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
|
|---|---|---|---|---|---|---|---|
19665617-DS-17
| 19,665,617 | 24,158,789 |
DS
| 17 |
2186-12-10 00:00:00
|
2186-12-10 14:40:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
Codeine / Statins-Hmg-Coa Reductase Inhibitors
Attending: ___
Chief Complaint:
dizziness, imbalance
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ woman with CAD s/p stent, HTN, hypothyroidism and history of
prior stroke in ___ (p/w dysarthria and right sided weakness at
that time) who presents today with "dizziness" that started upon
awakening and has now resolved.
As per the patient, she woke up at 0400 and as she got up to the
go to the bathroom she felt very dizzy. She does not describe
this feeling as the room spinning or being pushed in any
direction nor does she endorse light headedness. She says that
as
she walked to the bathroom, she felt like she would fall forward
and had to hold on to objects and the wall to keep from falling.
When she finally got to the toilet, she in fact had to fall down
on the toilet since she was unable to turn and balance herself.
The dizziness remained the same while on the toilet but when she
got up to go back to bed, it felt even worse. She went back to
her bedroom but soon after had to get up and go to the bathroom
again. When she finished using the toilet, she got up to wash
her
hands and noted that the feeling was starting to dissappate. She
went back to bed.
She then called her PCP and went in to see him at around 1400.
She reports being uncomfortable there but does not endorse rthe
dizziness she was experiencing this morning. Her daughter noted
though that she was preferentially keeping her eyes closed
there.
When enquired why, she does not endorse any improvement or
worsening of her symptoms with eye closure/ opening.
In the ER, her SBP was noted to be in the 200s. In the ER, she
denies any dizziness, and while she did endorse photophobia to
the ER staff, she denies this to me. She says her vision feels
off but does not endorse blurry vision or diplopia. She denies
tinnitus, dysarthria or dysphagia. She denies nausea or
vomiting.
On neuro ROS, the pt denies headache, loss of vision, blurred
vision, diplopia, dysarthria, dysphagia, lightheadedness,
tinnitus or hearing difficulty. Denies difficulties producing or
comprehending speech. Denies focal weakness, numbness,
parasthesiae. No bowel or bladder incontinence or retention.
On general review of systems, the pt denies recent fever or
chills. No night sweats or recent weight loss or gain. Denies
cough, shortness of breath. Denies chest pain or tightness,
palpitations. Denies nausea, vomiting, diarrhea, constipation
or
abdominal pain. No recent change in bowel or bladder habits.
No
dysuria. Denies arthralgias or myalgias. Denies rash.
Past Medical History:
HTN
CAD s/p stent placement
Hypothyroid
Prior CVA in ___ as per daughters (patient does not remember
this)
Anxiety
Social History:
___
Family History:
noncontributory
Physical Exam:
Physical Exam on Admission:
Vitals: T:97.2 P:69 R: 18 BP: 211/92 SaO2: 100%
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple
Pulmonary: Lungs CTA bilaterally
Cardiac: RRR, no murmurs
Abdomen: soft, NT/ND
Extremities: warm and well perfused. toe deformities bilaterally
Skin: no rashes.
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. The pt had good
knowledge of current events. There was no evidence of apraxia or
neglect.
-Cranial Nerves:
II: PERRL 2.5 to 2mm and brisk. VFF to confrontation.
Fundoscopic
exam with blurring of bilateral disc margins
III, IV, VI: EOMI without nystagmus. Normal saccades. Brief
diplopia on upgaze.
V: Facial sensation intact to light touch.
VII: Slight R facial droop at rest, no asymmetry on activation,
facial musculature symmetric.
VIII: Hearing intact grossly.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal bulk, tone throughout. Mild pronation of right
arm
but no drift bilaterally.
Delt Bic Tri IO IP Quad Ham TA Gastroc
L 5 ___ 5 5 5 5 5
R 5 ___ 5 5 5 5 5
-Sensory: No deficits to light touch throughout. No extinction
to
DSS.
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 3 3 1
R 2 2 2 2 1
Plantar response was flexor bilaterally.
-Coordination: No intention tremor, RAM slower on right than
left. No dysmetria on FNF bilaterally. Unterberger negative.
Head
thrust test negative.
-Gait: Good initiation. Narrow-based, normal stride and arm
swing. Unable to walk in tandem. Romberg absent.
Physical exam on discharge:
SBPs improved to 160s to 170s; otherwise, exam unchanged from
admission
Pertinent Results:
Labs
___ 04:02PM GLUCOSE-100 UREA N-19 CREAT-0.7 SODIUM-138
POTASSIUM-4.8 CHLORIDE-100 TOTAL CO2-27 ANION GAP-16
___ 04:02PM WBC-7.6 RBC-4.66 HGB-14.1 HCT-43.0 MCV-92
MCH-30.2 MCHC-32.8 RDW-13.5
___ 04:02PM PLT COUNT-156
___ 04:02PM ___ PTT-28.2 ___
___ 04:04PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.5
LEUK-NEG
___ 05:25PM BLOOD CK-MB-5 cTropnT-<0.01
___ 06:20AM BLOOD Triglyc-72 HDL-71 CHOL/HD-3.2
LDLcalc-141*
___ 06:20AM BLOOD TSH-0.67
Imaging:
CTA head/neck
1. No evidence of acute intracranial hemorrhage or mass effect.
2. Brain parenchymal volume loss and sequelae of chronic small
vessel ischemic
disease.
3. Scattered atheromatous vascular disease with approximately
50% narrowing of
the proximal left subclavian artery.
4. No evidence of pathologic large vessel occlusion, aneurysm,
or
hemodynamically significant stenosis within the head or neck.
5. Right maxillary sinus disease with hyperdense mucosal
thickening which
could represent inspissated secretions or fungal infection.
6. This report is provided without 3D and curved reformats.
When these
images are available, and if additional information is obtained,
then an
addendum may be given to this report.
MRI brain
1. No evidence of acute intracranial hemorrhage, mass effect, or
acute
ischemia.
2. Brain parenchymal volume loss and presumed sequelae of
chronic small vessel
ischemic disease.
3. Paranasal sinus disease, as described.
Chest xray
gs are grossly clear without focal consolidation, pleural
effusions, or
pneumothoraces. There is no pulmonary edema. Heart size and
mediastinal
structures are within normal limits. Bony structures are
intact.
Brief Hospital Course:
___ yo lady with vascular risk factor and prior ischemic stroke
in ___ who
presents with dizziness described as imbalance that she noticed
upon awakening this AM and has now spontaneously remitted. Her
exam is notable no nystagmus, no dysmetria, and negative
Romberg, head thrust and
Unterberger tests. She was orthostatic with SBP from 140 to 120
from laying to standing. MRI brain and CTA head/neck were
unremarkable, no evidence of stroke. It is possible that pt had
orthostasis or TIA as etiology of her symptoms. She is already
on aspirin for stroke prevention. LDL was 141. She has a
listed allergy to statins, but truly had mild myalgias with
rouvastatin. So, will try low dose pravastatin. She will
follow up in neurology stroke clinic.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. fluticasone-salmeterol 50 mcg inhalation daily
2. Labetalol 200 mg PO BID
3. Levothyroxine Sodium 50 mcg PO DAILY
4. Aspirin 325 mg PO DAILY
5. Fish Oil (Omega 3) 1000 mg PO DAILY
Discharge Medications:
1. fluticasone-salmeterol 50 mcg inhalation daily
2. Fish Oil (Omega 3) 1000 mg PO DAILY
3. Aspirin 325 mg PO DAILY
4. Labetalol 200 mg PO BID
5. Levothyroxine Sodium 50 mcg PO DAILY
6. Pravastatin 20 mg PO DAILY
RX *pravastatin 20 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*3
Discharge Disposition:
Home
Discharge Diagnosis:
orthostasis vs TIA
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 dizziness. We evaluated
___ for a stroke, but we did not see any sign that ___ have had
one. We think that ___ may have had a change in your blood
pressure which brought on your symptoms.
While ___ were in the hospital we saw that your blood pressure
dropped when ___ stood up. This can happen sometimes, especially
if ___ have not been eating and drinking well. It can also be
exacerbated by blood pressure medications. Your blood pressure
improved and your symptoms improved after we gave ___ some
fluids through your IV. It is important that while ___ are at
home ___ drink enough water and eat a healthy diet with regular
meals. ___ can also help prevent dizziness by making changes in
position slowly.
However, it is important to think about reducing your risk for
stroke in the future. 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
- high cholesterol
We are changing your medications as follows:
- adding pravastatin, a medication to lower your cholesterol
Please take your other medications as prescribed.
Please followup with Neurology and your primary care physician
as listed below.
If ___ experience any of the symptoms below, please seek
emergency medical attention by calling Emergency Medical
Services (dialing 911). In particular, since stroke can recur,
please pay attention to the sudden onset and persistence of
these symptoms:
- sudden partial or complete loss of vision
- sudden loss of the ability to speak words from your mouth
- sudden loss of the ability to understand others speaking to
___
- sudden weakness of one side of the body
- sudden drooping of one side of the face
- sudden loss of sensation of one side of the body
- sudden difficulty pronouncing words (slurring of speech)
- sudden blurring or doubling of vision
- sudden onset of vertigo (sensation of your environment
spinning around ___
- sudden clumsiness of the arm and leg on one side or sudden
tendency to fall to one side (left or right)
- sudden severe headache accompanied by the inability to stay
awake
It was a pleasure providing ___ with care during this
hospitalization.
Followup Instructions:
___
|
19665617-DS-18
| 19,665,617 | 28,374,225 |
DS
| 18 |
2188-03-07 00:00:00
|
2188-03-08 16:51:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Codeine / Statins-Hmg-Coa Reductase Inhibitors
Attending: ___.
Chief Complaint:
hypertension
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ woman with CAD s/p stent, HTN, hypothyroidism and history of
prior stroke in ___ (p/w dysarthria and right sided weakness
at
that time) who presents today p/w HTN urgency with SBP 200s.
Per patient / grandson report, pt was in USOH when patient's
granddaughter noticed conjunctival injection and checked a blood
pressure, finding it to be elevated. After calling PCP's office,
advised to come in. No cp sob dizziness HA or change in vision.
Reports took her usually 200 mg labetalol this am.
In the ED, initial VS were:
97.3 76 ___ RA
Labs including CBC, BMP, UA unremarkable. Trop negative.
Pt given:
___ 19:19 PO/NG Labetalol 200 mg
___ 22:20 PO/NG Labetalol 100 mg
Per ED report, required admission for HTN urgency. No sign of
end organ damage but uncontrolled on her usual labetalol dose.
Pt also noted to have fall in bathroom while giving urine sample
prompting NCHCT which was negative for acute pathology.
After paged her covering PCP twice with no response, determined
she was unsafe to go home with uncontrolled HTN and now fall.
Vitals prior to transfer: 98.1 91 173/95 17 99% RA
On arrival to the floor, patient reports feeling well w/o acute
complaint. Denies dizziness. Reports mild occipital headache
before which has resolved. Per grandson, fallen ___ times this
past year, supposedly mechanical.
REVIEW OF SYSTEMS:
Denies fever, chills, night sweats, headache, vision changes,
rhinorrhea, congestion, sore throat, cough, shortness of breath,
chest pain, abdominal pain, nausea, vomiting, diarrhea,
constipation, BRBPR, melena, hematochezia, dysuria, hematuria.
Past Medical History:
HTN
CAD s/p stent placement
Hypothyroid
Prior CVA in ___ as per daughters (patient does not remember
this)
Anxiety
Social History:
___
Family History:
noncontributory
Physical Exam:
ADMISSION PHYSICAL EXAM
VS: 97.8 195>187/93 66 18 98%RA
wt 60.6 kg
GENERAL: NAD
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, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: no cyanosis, clubbing or edema, moving all 4
extremities with purpose
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
DISCHARGE PHYSICAL EXAM
VS: 97.8 140/69 69 18 98%RA
wt 60.6 kg
GENERAL: NAD
HEENT: 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: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: no cyanosis, clubbing or edema, moving all 4
extremities with purpose
PULSES: 2+ DP pulses bilaterally
NEURO: grossly intact
Pertinent Results:
ADMISSION LABS
___ 06:35PM BLOOD WBC-8.9 RBC-4.11 Hgb-12.5 Hct-37.9 MCV-92
MCH-30.4 MCHC-33.0 RDW-13.0 RDWSD-43.5 Plt ___
___ 06:35PM BLOOD Neuts-61.5 ___ Monos-5.5 Eos-5.4
Baso-0.3 Im ___ AbsNeut-5.46 AbsLymp-2.40 AbsMono-0.49
AbsEos-0.48 AbsBaso-0.03
___ 06:35PM BLOOD Plt ___
___ 06:35PM BLOOD Glucose-103* UreaN-21* Creat-0.7 Na-140
K-3.9 Cl-104 HCO3-27 AnGap-13
___ 06:35PM BLOOD cTropnT-<0.01
OTHER STUDIES
___ CT Head w/o contrast
No evidence of hemorrhage, fracture or infarction Volume loss
and likely
sequela of chronic small vessel ischemia is unchanged.
High density mucous retention cyst within the right maxillary
sinus is likely inspissated secretions though fungal infection
cannot be entirely excluded, present on examination dated ___.
Brief Hospital Course:
___ woman with CAD s/p stent, HTN, hypothyroidism and history of
prior stroke in ___ (p/w dysarthria and right sided weakness at
that time) who presents today p/w HTN urgency with SBP 200s.
#Hypertensive urgency
Patient was given PO labetalol in the ED w/ improvement to SBP
140s. Patient will need close f/u with PCP to monitor BP.
Patient advised to use home blood pressure cuff as well. Patient
was also reported to have a fall in the emergency department.
#Fall
She reported ___ falls over past year without prodromal symptoms
which appear mechanical in nature. Orthostatics negative.
Patient evaluated by ___ and cleared for home.
#Hypothyroidism
Cont home levothyroixine
Transitional Issues
- follow up with PCP in the next ___ weeks for BP monitoring and
antihypertensive titration
- patient should monitor BP at home daily and call PCP if
SBP>180
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Fish Oil (Omega 3) 1000 mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Labetalol 200 mg PO BID
4. Levothyroxine Sodium 50 mcg PO DAILY
5. Vitamin D 1000 UNIT PO DAILY
6. Calcium Carbonate Dose is Unknown PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Fish Oil (Omega 3) 1000 mg PO DAILY
3. Levothyroxine Sodium 50 mcg PO DAILY
4. Vitamin D 1000 UNIT PO DAILY
5. Calcium Carbonate 500 mg PO DAILY
6. Labetalol 300 mg PO QAM
RX *labetalol 300 mg 1 tablet(s) by mouth every morning Disp
#*30 Tablet Refills:*0
7. Labetalol 200 mg PO QPM
RX *labetalol 200 mg 1 tablet(s) by mouth every evening Disp
#*30 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary: hypertensive urgency, mechanical fall
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were admitted for very high blood pressure and a fall that
you had while in the emergency department. You were given
additional blood pressure medications and monitored overnight.
Your blood pressure improved.
Please monitor your blood pressure at home using your cuff.
Remember to avoid high sodium foods (deli meat, packaged foods,
soups).
Please make an appointment with your primary care physician for
the next week.
It was a pleasure to care for you!
-Your ___ Team
Followup Instructions:
___
|
19665617-DS-21
| 19,665,617 | 20,726,625 |
DS
| 21 |
2190-02-25 00:00:00
|
2190-02-25 15:02:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Codeine / Statins-Hmg-Coa Reductase Inhibitors
Attending: ___.
Chief Complaint:
back pain
Major Surgical or Invasive Procedure:
NONE
History of Present Illness:
___ y/o female with a history of HTN, CAD s/p stent,
hypothyroidism, dementia, stroke in ___ and again ___
presents 3 days after fall.
Patient lives at home with her 2 caregivers, daughter and son.
Fell 3 days ago at approx. 3 AM, found on her backside by
daughter. Family thought fall likely due to walking without
walker in the dark. She denies amnesia, head strike w/ fall,
loss
of consciousness after the fall, tongue biting, bowel/bladder
incontinence. Endorsed diffuse body pain not localized to a
specific part of the body.
Pertinent ED course:
VS: T 98 HR 74 BP 178/94 RR 18 O2 94% RA
Exam in the ED:
---------------
Nervous appearing woman in no distress. Alert and oriented to
self and to the fact that she is in the hospital. She complains
of pain "all over" exacerbated by logroll.
Pulm: CTA bl
Cor NRRR. Normal S1 and S2
Abd soft, nontender, nondistended.
Ext/MSK No edema noted. Hips stable but patient complains of
significant pain on external rotation of the hip.
Back: Some tenderness over right flank but no overt CVA
tenderness. No tenderness over central spinous processes from C
to L spine.
Labs:
-----
11.0 WBC
15.2 Hgb
44.8 Hct
___ Plt
Chem 7: ___
UA: 1 WBC, Neg ___, Neg NITR, trace protein
INR 1.0
Trop <0.01
Studies done in the ED:
CT HEAD WO CONTRAST:
1. No acute intracranial process or acute fracture.
2. Similar appearance of extensive periventricular and
subcortical white matter hypodensities, likely reflecting
chronic
small-vessel ischemic changes.
3. Near complete opacification of the visualized right maxillary
sinus.
CT C SPINE W/O CONTRAST:
1. No acute fracture or traumatic malalignment of the cervical
spine. Moderate to severe compression deformities from C5-C7 are
likely secondary to advanced degenerative changes, not
significantly changed compared to the prior exam.
2. No significant change in moderate to severe multilevel
degenerative changes.
CT ABD WITH CONTRAST:
Anterior compression deformity of L1, likely acute, without
traumatic
malalignment.
CXR:
IMPRESSION:
Increasing right upper lobe opacity, which may represent
enlarged
brachiocephalic vein. However, if clinically indicated, chest CT
may be helpful.
In the ED, she was given:
acetaminophen, trazodone, metoprolol succinate 25 mg, sertraline
25 mg, levothyroxine 50 mcg, amlodipine 5 mg, ASA 81 mg.
Consults in the ED:
-------------------
Spine consult:
- Activity as tolerated
- TLSO for comfort only
- Follow-up in Ortho Spine Clinic in ___
___ consult:
___ attempted evaluation, however pt unable to tolerate even
sitting up due to bilateral flank pain and high fear of pain.
Resistant to all mobility and very tearful. ___ will follow up to
complete evaluation once pt has improved pain control and able
tolerate sitting upright. -___ ___ ___
Upon arrival to the floor, the patient reports feeling well,
denies any pain. Previous pain reported to be better lying prone
and associated at times with pain traveling down her leg. She
denies any SOB, chest pain, abd pain, bowel/bladder
incontinence.
Notes pain in her hands.
Past Medical History:
HTN
CAD s/p stent placement
Hypothyroid
Prior CVA in ___ as per daughters (patient does not remember
this)
Anxiety
Dementia
Social History:
___
Family History:
Reviewed with family. None pertinent
Physical Exam:
ADMISSION PHYSICAL EXAM:
VITALS:
___ 1805 Temp: 97.2 PO BP: 153/69 HR: 77 RR: 18 O2 sat: 94%
O2 delivery: Ra Dyspnea: 0 RASS: 0 Pain Score: ___
GENERAL: NAD, lying comfortably in bed
EYES: EOMI, Sclera anicteric
ENT: Neck supple, MMM
CV: RRR, no m/r/g
RESP: Soft breath sounds but CTAB
GI: obese abdomen, non-tender, non-distended.
GU: deferred
MSK: WWP, 2+ distal pulses
SKIN: No rashes noted
NEURO: CN II-XII intact, symmetric ___ strength b/l upper and
lower extremities. Sensation intact to light touch.
PSYCH: normal mood and affect
DISCHARGE PHYSICAL EXAM:
PHYSICAL EXAM:
VITALS:
___ 0712 Temp: 98.1 PO BP: 121/72 L Lying HR: 69 RR: 18 O2
sat: 93% O2 delivery: RA
GENERAL: NAD, lying comfortably in bed
EYES: EOMI, Sclera anicteric
ENT: Neck supple, MMM
CV: RRR, no m/r/g
RESP: Soft breath sounds but CTAB
GI: obese abdomen, nontender, nondistended.
BACK: Tenderness to R lumbar paraspinal muscles
GU: deferred
MSK: WWP, 2+ distal pulses
SKIN: No rashes noted
NEURO: A&Ox1 CN II-XII intact, symmetric ___ strength b/l upper
and lower extremities. Sensation intact to light touch.
PSYCH: normal mood and affect appeared worried.
Pertinent Results:
ADMISSION LABS:
___ 12:30PM BLOOD WBC-11.3* RBC-4.92 Hgb-14.7 Hct-44.3
MCV-90 MCH-29.9 MCHC-33.2 RDW-13.2 RDWSD-43.5 Plt ___
___ 12:30PM BLOOD Neuts-77.1* Lymphs-15.4* Monos-5.2
Eos-1.4 Baso-0.4 Im ___ AbsNeut-8.69* AbsLymp-1.73
AbsMono-0.58 AbsEos-0.16 AbsBaso-0.04
___ 12:30PM BLOOD ___ PTT-26.6 ___
___ 12:30PM BLOOD Glucose-177* UreaN-21* Creat-0.6 Na-144
K-4.0 Cl-105 HCO3-25 AnGap-14
___ 12:30PM BLOOD CK-MB-2 cTropnT-<0.01
___ 12:30PM BLOOD Calcium-9.5 Mg-2.4
PERTINENT/DISCHARGE LABS:
___ 07:00AM BLOOD Albumin-3.9
___ 07:00AM BLOOD WBC-8.8 RBC-4.97 Hgb-14.7 Hct-43.8 MCV-88
MCH-29.6 MCHC-33.6 RDW-13.2 RDWSD-42.4 Plt ___
___ 07:00AM BLOOD Glucose-145* UreaN-29* Creat-0.7 Na-141
K-4.1 Cl-104 HCO3-23 AnGap-14
IMAGING REPORTS:
___ HIP XR:
IMPRESSION:
No acute fractures or dislocations are seen. There are moderate
degenerative changes of both hips with joint space narrowing
minimal acetabular spurring. There is generalized
demineralization. There is a prominence of soft tissues which
limits fine bony detail. If there is high concern for occult
fracture, MRI could be performed.
___ CXR:
IMPRESSION:
Increasing right upper lobe opacity, which may represent
enlarged
brachiocephalic vein. However, if clinically indicated, chest
CT may be
helpful.
___ CT C SPINE WO CONTRAST:
IMPRESSION:
1. No acute fracture or traumatic malalignment of the cervical
spine.
Moderate to severe compression deformities from C5-C7 are likely
secondary to advanced degenerative changes, not significantly
changed compared to the prior exam.
2. No significant change in moderate to severe multilevel
degenerative
changes.
___ CT HEAD WO CONTRAST:
IMPRESSION:
1. No acute intracranial process or acute fracture.
2. Similar appearance of extensive periventricular and
subcortical white
matter hypodensities, likely reflecting chronic small-vessel
ischemic changes.
3. Near complete opacification of the visualized right
maxillary sinus.
___ CT ABD/PELVIS WO CONTRAST:
IMPRESSION:
1. Acute compression deformity of L1, without retropulsion or
malalignment.
2. Moderate hiatal hernia.
MICROBIOLOGY STUDIES:
NONE POSITIVE
Brief Hospital Course:
___ y/o female with a history of HTN, CAD s/p stent,
hypothyroidism, dementia, stroke in ___ and again ___
presented 3 days after fall. Found to have L1 vertebral
compression fracture. No intervention required by orthopedic
surgery spine. Treated with LSO brace, Tylenol, lidocaine,
low-dose oxycodone PRN. Evaluated by ___ and recommended
discharge to rehab.
ACUTE/ACTIVE PROBLEMS:
#Fall
Occurred 3 days PTA. Head imaging negative for acute process.
Has history of numerous falls, including an admission in ___t night as well, where she was found to be
orthostatic. No orthostatic hypotension noted on this admission.
Fall was deemed to be mechanical. Complicated by fracture below.
Evaluated by ___, recommended ___ rehab and family was
agreeable.
#Acute L1 Vertebral Compression Fracture
Seen by ortho spine in the ED. Recommended non-operative
management with follow up in ___ weeks. She was also fitted with
discunloader orthotic LSO. Her pain was managed with 1 gram
Tylenol TID, lidocaine patch over lumbar region, and oxycodone
2.5 mg. She should take oxycodone prior to ___ sessions or PRN
Q6h. She will follow up with orthopedic surgery spine in ___
weeks.
#Hypertension.
On chart review, has had multiple instances of hypertensive
urgency, resulting in observations and treatment with labetalol.
During her admission she remained normotensive. She should
continue on her amlodipine 5 mg and metoprolol succinate 25 mg
daily.
#History of Stroke.
History of stroke in ___ (presented with dysarthria, R sided
weakness), and again in ___ (presented with dysarthria, facial
droop, R sided weakness). Thought to be small vessel ischemia
rather than cardioembolic. She was reportedly started on
lovastatin last year but this does not appear on her medication
list at ___ and daughter corroborates this.
- continue ASA 81 mg daily
#Hypothyroidism
- continue levothyroxine 75 mcg M-F, 50 mcg ___
#Depression
- continue sertraline 25 mg BID
TRANSITIONAL ISSUES:
[ ] Please ensure patient goes to follow up orthopedic surgery
appointment
[ ] Please assess pain control for L1 fracture and continued use
of oxycodone. If pain is severe and persistent, may consider ___
___, MD) referral for possible vertebroplasty if within
family's goals of care.
CODE STATUS: DNR/DNI (MOLST FORM IN CHART)
EMERGENCY CONTACT: HEALTH CARE PROXY-- ___ ___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Levothyroxine Sodium 75 mcg PO 5X/WEEK (___)
3. Sertraline 50 mg PO DAILY
4. TraZODone 25 mg PO TID
5. Metoprolol Succinate XL 25 mg PO DAILY
6. amLODIPine 5 mg PO DAILY
7. Levothyroxine Sodium 50 mcg PO 2X/WEEK (___)
8. Multivitamins W/minerals 1 TAB PO DAILY
9. Triamcinolone Acetonide 0.1% Cream 1 Appl TP TID
Discharge Medications:
1. Acetaminophen 1000 mg PO TID
2. Docusate Sodium 100 mg PO BID
3. OxyCODONE (Immediate Release) 2.5 mg PO Q6H:PRN Pain -
Moderate
Please take 30 minutes before working with physical therapy or
as needed
RX *oxycodone 5 mg 0.5 (One half) tablet(s) by mouth q6h PRN
Disp #*30 Tablet Refills:*0
4. Senna 17.2 mg PO HS
5. amLODIPine 5 mg PO DAILY
6. Aspirin 81 mg PO DAILY
7. Levothyroxine Sodium 75 mcg PO 5X/WEEK (___)
8. Levothyroxine Sodium 50 mcg PO 2X/WEEK (___)
9. Metoprolol Succinate XL 25 mg PO DAILY
10. Multivitamins W/minerals 1 TAB PO DAILY
11. Sertraline 50 mg PO DAILY
12. TraZODone 25 mg PO TID
13. Triamcinolone Acetonide 0.1% Cream 1 Appl TP TID
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS
=================
FALL
L1 VERTEBRAL COMPRESSION FRACTURE
HYPERTENSION
HISTORY OF STROKE
HYPOTHYROIDISM
DEPRESSION
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 in the hospital.
You had a bad fall at home and were having back pain. Your
family was concerned about your back pain and brought you into
the hospital.
In the emergency room you had a CT scan of your back which
showed a small fracture in one of the bones in your spine. Our
orthopedic surgeons saw you and thought you did not need
surgery. You were given medications to treat the pain in your
back. You also worked with our physical therapists who
recommended that you spend time in a rehabilitation facility
before going home.
Please continue taking your medications as listed below and
follow up with your primary care provider as listed. You also
have an orthopedic surgery follow up for your back as well.
We wish you all the best,
Your ___ Care team
Followup Instructions:
___
|
19665644-DS-12
| 19,665,644 | 24,789,649 |
DS
| 12 |
2151-03-08 00:00:00
|
2151-03-10 16:41:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Sulfur-8
Attending: ___.
Chief Complaint:
Incontinence and lower back pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
HISTORY OF PRESENT ILLNESS:
Ms. ___ is a ___ year old woman with history of herniated
disc in L4, L5, S1, hypothyroidism, and asthma, who is
presenting with two weeks of lower back pain and incontinence.
The patient shares two weeks ago she was pushing a car, and
shortly after developed low back pain. She has constant lower
back pain that radiates down both legs, with no lower extremity
numbness or tingling. In addition, she has since been
incontinent of both urine and stool. She called PCP today, who
recommended ED evaluation for spinal cord issue. She has had no
fevers, chills, altered mental status. She has no history of
IVDU or known malignancy.
In the ED, VS 96.9 82 149/107 18 99% RA. Her exam was notable
for 'mild lumbar spine tenderness to palpation, strength ___ all
extremities, sensation intact extremities, genital area, rectal
tone intact.' Labs were notable for WBC 8.3, Hb 13.8, Cr 0.6, UA
withtrace ___, 10 Epis. A code cord was called, and MRI L spine
showed: L4-L5 moderate to severe bilateral neural foraminal
narrowing secondary to disc bulge and L5-S1 central disc
protrusion without significant foraminal narrowing. Spine was
consulted and said no urgent or emergent neurosurgical
intervention indicated at this time; they recommended medicine
admission for pain control and further workup by neurology. They
added that she may need surgical intervention in the near
future. She was given 0.5 mg IV dilaudid in the ED, but was also
noted to be taking her own vicodin.
On the floor, patient reports that she is still in significant
pain but is primarily concerned about her fecal incontinence as
it is emabarassing and has been an issue at work and home.
Past Medical History:
- Hypothyroidism
- Anxiety
- HTN
- COPD v Asthma
- H/o left leg stress fracture
- Right sided lumbosacral radiculopathy ___ L5-S1 disc bulge,
followed in pain clinic, L4-L5 disc bulge with mild bilateral
neural foraminal narrowing
Social History:
___
Family History:
- Mother with HTN, HCC, CAD and RA.
Physical Exam:
ADMISSION EXAM
==============
VS: 98.2 118/82 66 18 96RA
Gen: Very well appearing. No distress.
HEENT: OP clear, PERRL.
CV: RRR, normal S1/S2. No m/r/g
Pulm: CTAB
Abd: Soft, NT/ND
GU: no foley. Normal anal sphincter tone
Ext: warm, well perfused
Skin: intact
Spine: No stepoffs or focal vertebral tenderness. significant
paraspinal/sacral tenderness
Neuro: MAE without significant pain while talking. Straight leg
rise with good effort and normal hip and knee ROM. ___ strength
and normal sensation. Normal coordination.
Psych: Pleasant.
DISCHARGE EXAM
==============
VITALS: Tmax 98.2 BP 90-130/60-80s HR 60-70s RR 18 ___ on
RA
Gen: Well appearing. No distress.
HEENT: OP clear, PERRL.
CV: RRR, normal S1/S2. No m/r/g
Pulm: CTAB
Abd: Soft, NT/ND
GU: No foley.
Ext: warm, well perfused
Skin: intact
Spine: No stepoffs or focal vertebral tenderness. significant
paraspinal/sacral tenderness
Neuro: 4+/5 strength and normal sensation bilaterally. Normal
coordination.
Pertinent Results:
ADMISSION LABS
==============
___ 08:30PM BLOOD WBC-8.3 RBC-4.67 Hgb-13.8 Hct-42.9 MCV-92
MCH-29.6 MCHC-32.2 RDW-13.1 RDWSD-44.1 Plt ___
___ 08:30PM BLOOD Neuts-42.7 ___ Monos-8.0 Eos-5.3
Baso-1.0 Im ___ AbsNeut-3.53 AbsLymp-3.55 AbsMono-0.66
AbsEos-0.44 AbsBaso-0.08
___ 08:30PM BLOOD Plt ___
___ 08:30PM BLOOD Glucose-88 UreaN-9 Creat-0.6 Na-140 K-3.6
Cl-104 HCO3-24 AnGap-16
___ 08:30PM BLOOD Calcium-9.3 Phos-4.1 Mg-2.1
MICRO
=====
___ CULTURE-FINALEMERGENCY WARD
IMAGING
=======
___ MR ___
IMPRESSION:
Mild degenerative changes in the lumbar spine, with increased
left sided disc
protrusion in L5-S1 impinging on the left S1 nerve root.
___ MR ___ and T SPINE
IMPRESSION:
1. Mild degenerative changes in the cervical spine.
2. Normal thoracic spine.
DISCHARGE LABS
==============
___ 06:22AM BLOOD WBC-7.0 RBC-4.18 Hgb-12.9 Hct-39.7 MCV-95
MCH-30.9 MCHC-32.5 RDW-13.0 RDWSD-44.8 Plt ___
___ 06:22AM BLOOD Plt ___
___ 06:22AM BLOOD Glucose-93 UreaN-12 Creat-0.6 Na-137
K-4.0 Cl-104 HCO3-23 AnGap-14
___ 06:22AM BLOOD Calcium-8.3* Phos-3.5 Mg-2.0
Brief Hospital Course:
HOSPITAL COURSE
===============
Ms. ___ is a ___ year old woman with history of herniated
disc in L4, L5, S1, hypothyroidism, and asthma, who presented
with two weeks of worsening lower back pain and fecal/urinary
incontinence after pushing her car along the road. MRI spine was
negative for any cord compression. She was evaluated by
neurosurgery who did not recommend acute intervention. She was
admitted for pain control. Her incontinence had resolved for the
past 2 days and her pain returned to her baseline ___.
Neurosurgery recommended she may follow up in clinic as needed.
Patient was able to ambulate and was discharged home and to
follow up with PCP for further outpatient workup.
ACUTE ISSUES
============
# Acute on Chronic Back Pain: Patient with long standing history
of back pain since age ___, presenting with acute exacerbation
with associated shooting leg pain/parasthesias, fecal and
urinary incontinence in setting of pushing her car two weeks
prior to admission. Now s/p MRI spine in the ED without evidence
of acute cord or focal nerve compression. Per neurosurgery no
acute intervention required and no precautions required. She was
admitted for pain control. Her incontinence had resolved for the
past 2 days and her pain returned to her baseline ___.
Discharged with ibuprofen, gabapentin, lidocaine, and home
Vicodin.
# Fecal/Urinary Incontinence: Patient presenting with acute back
pain and fecal/urinary incontinence. No acute nerve compression
identified on MRI to explain symptoms. At this point favor pain
and extra-axial nerve compression as etiology. None in past 48
hours prior to discharge. Patient to f/u with PCP for further
workup and treatment.
CHRONIC ISSUES
==============
# Hypothyroidism: Continued levothyroxine.
# Anxiety/Depression: Continued sertraline, clonazepam.
TRANSITIONAL ISSUES
===================
[] New medications
- Gabapentin 300 mg PO/NG TID
- Lidocaine 5% Patch 1 PTCH TD QPM
[] Follow up appointment with PCP and neurosurgery as above
[] Patient to call PCP or return to ED if develops an worsening
pain, weakness, or incontinence
# CODE: Full
# CONTACT: ___ /___ OR
___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. ClonazePAM 0.5 mg PO Q8H:PRN anxiety
2. HYDROcodone-Acetaminophen (5mg-325mg) 1 TAB PO Q8H:PRN Pain -
Moderate
3. Levothyroxine Sodium 88 mcg PO DAILY
4. Sertraline 50 mg PO DAILY
Discharge Medications:
1. Gabapentin 300 mg PO TID
RX *gabapentin 300 mg 1 capsule(s) by mouth Three times a day
Disp #*90 Capsule Refills:*0
2. Lidocaine 5% Patch 1 PTCH TD QPM
RX *lidocaine [Lidoderm] 5 % Daily Disp #*30 Patch Refills:*0
3. HYDROcodone-Acetaminophen (5mg-325mg) 1 TAB PO Q4H:PRN Pain
- Moderate
4. ClonazePAM 0.5 mg PO Q8H:PRN anxiety
5. Levothyroxine Sodium 88 mcg PO DAILY
6. Sertraline 50 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis
- Urinary and fecal incontinence
- Acute back pain
Secondary diagnosis
- Chronic back pain
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were admitted to the hospital because you were having back
pain and incontinence for the past two weeks. We did an MRI of
your spine which did not show any compression of your spinal
cord or other dangerous causes for the incontinence. You were
able to walk and your incontinence improved. We treated your
pain and felt you were safe for discharge.
Continue taking your home Vicodin and ibuprofen. Do NOT take any
Tylenol, as that is contained in your Vicodin. You may take more
Vicodin (up to 6 times per day) if you need it to control your
pain.
Please contact your PCP (___) to arrange follow up and
to work up your symptoms within the next week.
If you develop any worsening leg pain, leg weakness, or
worsening incontinence, please call your PCP or return to the ER
immediately.
Please call the spine clinic (___) to schedule an
appointment within the next two weeks.
It was a privilege caring for you in the hospital, and we wish
you all the best.
Sincerely,
Your ___ Health Team
Followup Instructions:
___
|
19666282-DS-5
| 19,666,282 | 22,420,104 |
DS
| 5 |
2154-01-01 00:00:00
|
2154-01-01 20:50:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
syncope
Major Surgical or Invasive Procedure:
___ - ___ pacemaker interrogation
History of Present Illness:
This is a an ___ year-old Male with a PMH significant for
hypertension, hyperlipidemia, seizure disorder, sick sinus
syndrome (with permanent pacemaker), s/p MVR with left atrial
appendage resection or Maze procedure (for atrial fibrillation,
complicated by occluded coronary vessel with bypass grafting)
who presents following a syncopal episode.
.
The patient presents after "falling asleep" while in the
restroom this AM. He awoke around 6AM and went to use the
restroom and while on the commode, his head nodded and he felt
tired. He caught himself from falling asleep and thought he
should return to bed. His wife notes that he has been falling
asleep during the day at times; maybe ___ times weekly. He
reports getting ___ hours of sleep at nighttime. He has no
nighttime awakenings, wife reports minimal snoring or apneic
episodes. He reportedly has a history of syncope while driving,
but this has not occurred for many years. He had no pre-syncope
features of note. He denies chest pain, shortness of breath,
headache or vision changes. He denies lightheadedness, dizziness
or aura features prior to the event. He had no facial droop,
extremity weakness (outside his known bilateral foot drop) and
denied focal deficits. He was using the restroom, syncopized and
awoke with his head against the all with some superficial
bleeding. He did experience loss of consciousness for minutes
(he thinks), but this is unclear and was unwitnessed. He awoke
and was oriented enough to phone his wife regarding the
incident. His prior falls in ___ of this year
appear to have been mechanical, when he fails to utilize his
walker or cane.
.
In the ED, initial VS 97.1 80 140/78 22 100% RA. Laboratory
studies notable for WBC 7.0, hematocrit 36.3%, platelets 260.
INR 2.6 (on Coumadin). Creatinine 0.7. Troponin < 0.01. Lactate
1.5 and negative urinalysis. EKG demonstrated A-paced rhythm @
80 bpm, LAD, RBBB and non-specific ST changes. A CXR was without
focal consolidation. CT C-spine and head imaging were negative
for fracture or intracranial bleeding, respectively. Head CT did
show a moderate-sized posterior vertex subgaleal hematoma and
scalp laceration with stable, old SDH.
.
On arrival to the floor, he appears comfortable and is mentating
well.
Past Medical History:
PAST MEDICAL & SURGICAL HISTORY:
1. Hypertension
2. Hyperlipidemia
3. Seizure disorder (petit mal seizures have not occurred for
many years; complex partial seizures with behavior patterns have
not occurred for ___ years)
4. Sick sinus syndrome ___ pacemaker placed on right
side; interrogated ___
5. s/p mitral valve repair with MAZE procedure (atrial
fibrillation) complicated by total occlusion of coronary artery
- artery over-sewn during procedure and resulting CABG (RSVG
from aorta to OM2) x 1-vessel and left femoral artery
pseudoaneurysm (with thrombin injection).
6. Bilateral foot drop (resulting from coronary bypass surgery)
7. Left anterior wall acetabular fracture (___)
8. Prostate adenocarcinoma
9. Colonic adenoma
10. Rheumatoid arthritis
11. Chronic anemia
12. Gout
13. Prior subdural hematoma (required Burr hole placement)
14. Lichen simplex chronicus
Social History:
___
Family History:
non-contributory.
Physical Exam:
ADMISSION EXAM:
.
VITALS: 97.8 121/79 80 16 99% RA
GENERAL: Appears in no acute distress. Alert and interactive.
HEENT: Normocephalic, subgaleal hematoma palpable on posterior
scalp. Staples in place over circumferential skin laceration on
posterior scalp. EOMI. PERRL. Nares clear. Mucous membranes
moist. Poor dentition.
NECK: supple without lymphadenopathy. JVD not elevated.
___: Regular rate and paced rhythm, without murmurs, rubs or
gallops. S1 and S2 normal. Sternotomy incision is well-healed.
Right pacer pocket clean, dry and well-healed.
RESP: Clear to auscultation bilaterally without adventitious
sounds. No wheezing, rhonchi or crackles. Stable inspiratory
effort.
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.
.
DISCHARGE EXAM:
.
VITALS: 98.7 98.7 111/65 ___ 18 100% RA
I/Os: 730 (60) | 700 +
GENERAL: Appears in no acute distress. Alert and interactive.
HEENT: Normocephalic, subgaleal hematoma palpable on posterior
scalp. Staples in place over circumferential skin laceration on
posterior scalp, mild serosanguinouos oozing noted. EOMI. PERRL.
Nares clear. Mucous membranes moist. Poor dentition.
NECK: supple without lymphadenopathy. JVD not elevated.
___: Regular rate and paced rhythm, without murmurs, rubs or
gallops. S1 and S2 normal. Sternotomy incision is well-healed.
Right pacer pocket clean, dry and well-healed.
RESP: Clear to auscultation bilaterally without adventitious
sounds. No wheezing, rhonchi or crackles. Stable inspiratory
effort.
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 & PERTINENT LABS:
.
___ 07:53AM BLOOD WBC-7.0 RBC-3.83* Hgb-11.6* Hct-36.3*
MCV-95 MCH-30.4 MCHC-32.0 RDW-14.6 Plt ___
___ 07:53AM BLOOD ___ PTT-34.2 ___
___ 07:53AM BLOOD Glucose-106* UreaN-19 Creat-0.7 Na-138
K-4.0 Cl-105 HCO3-25 AnGap-12
___ 07:53AM BLOOD CK(CPK)-51
___ 07:53AM BLOOD cTropnT-<0.01
___ 05:00PM BLOOD CK-MB-3 cTropnT-<0.01
___ 07:53AM BLOOD Albumin-3.9 Calcium-8.7 Phos-3.8 Mg-2.1
___ 07:53AM BLOOD TSH-7.1*
___ 07:53AM BLOOD Phenyto-20.1*
___ 08:11AM BLOOD Glucose-96 Lactate-1.5
.
DISCHARGE LABS:
.
___ 05:50AM BLOOD WBC-7.9 RBC-3.73* Hgb-11.2* Hct-35.6*
MCV-96 MCH-30.2 MCHC-31.5 RDW-14.6 Plt ___
___ 05:50AM BLOOD ___ PTT-34.2 ___
___ 05:50AM BLOOD Glucose-97 UreaN-24* Creat-0.7 Na-140
K-4.3 Cl-103 HCO3-29 AnGap-12
___ 05:50AM BLOOD Calcium-8.5 Phos-4.0 Mg-2.2
.
URINALYSIS: clear, negative for ___, negative for Nitr, no
protein
.
MICROBIOLOGY DATA:
___ Blood cultures - pending
.
IMAGING:
___ CHEST (PORTABLE AP) - Single AP upright portable view of
the chest demonstrates no acute cardiopulmonary process.
Cardiomediastinal, pleural and pulmonary structures are
unremarkable. A right-sided pacemaker with leads terminating in
the right atrium, right ventricle is again noted. Median
sternotomy wires are unchanged. No pleural effusion or
pneumothorax. Degenerative changes of the cervical spine, left
acromioclavicular and left glenohumeral joint are noted.
.
___ CT C-SPINE W/O CONTRAST - There is no acute fracture or
prevertebral soft tissue swelling. Again noted is an old
fracture of the left first rib (601b:16). There is unchanged
slight anterolisthesis of C7 on T1. There are degenerative
changes again noted, greatest at C5-C6. Visualized lung apices
are unremarkable. A right side pacer is present. The thyroid is
unremarkable. The intracranial contents are better evaluated on
concurrent head CT.
.
___ CT HEAD W/O CONTRAST - No acute intracranial hemorrhage.
Moderate-sized posterior vertex subgaleal hematoma and scalp
laceration. No underlying fracture. A small chronic left frontal
subdural hematoma is unchanged since prior study.
Brief Hospital Course:
IMPRESSION: ___ with a PMH significant for HTN, HLD, seizure
disorder, sick sinus syndrome (with permanent pacemaker), s/p
MVR with left atrial appendage resection or Maze procedure (for
atrial fibrillation, complicated by occluded coronary vessel
with bypass grafting) who presented following a syncopal
episode, most consistent with fatigue and hypersomnia in the
setting of polypharmacy.
# SYNCOPE: EPISODIC HYPERSOMNIA - Patient has a history of
mechanical falls promting ED evaluation, with evidence of
chronic left frontal SDH with has remained stable on serial
imaging. Physical therapy has recommended a walker with
___ rehab needs in the past. Neurologic exam has been
reassuring without focal deficits, despite stable bilateral foot
drop. No concern for hypo- and hyperglycemia episodes. He has no
active chest pain or dyspnea; no lightheadedness or dizziness.
Pacer appears to be working well and interrogation this
admission was reassuring. There was some concern given his prior
petit mal and complex partial seizure history, but he has had no
seizures for many years and has been maintained on phenytoin
without issue. His phenytoin (corrected) level this admission
was 22.1 and we decreased his evening dose to 150 mg PO at
bedtime, in discussion with Neurology. A prior 2D-Echo (___)
showed some evidence of moderate aortic insufficiency but no
pre-syncope features were noted on this admission, and review of
his telemetry was reassuring and without cause for concern. CT
head imaging was reassuring and without acute hemorrhage. There
was note of an old subdural hematoma, which appeared stable.
There was limited concern for ACS/MI given negative cardiac
biomarkers and reassuring EKG. Overall, his work-up points
towards polypharmacy which may be contributing to episodic
fatigue and hypersomnia, most probably related to his phenytoin
dosing (possible sources: phenytoin, beta-blockers, Amiodarone,
Digoxin or SSRIs). ___ also evaluated him and felt he was safe
for home with home ___. He is being discharged with a decreased
evening dose of phenytoin and close outpatient follow-up with
his PCP, ___ and Cardiology.
# TRAUMATIC SCALP LACERATION - Evidence of 4-5 cm posterior
scalp laceration with hemostasis achieved. He was dosed Tetanus
booster vaccination in the ED. No evidence of purulence or
drainage. Staples placed in the ED and will need removal in
2-weeks. No indication for antibiotics at this time.
# PRIOR HISTORY OF CONGESTIVE HEART FAILURE - Known symmetric LV
hypertrophy with LVEF 45-50% in ___ in the setting of his
___ MI from valvular surgery. Moderate 2+ AI noted
and bioprosthetic mitral valve prosthesis noted. Outpatient
regimen has included beta-blocker, digoxin, furosemide; without
ACEI. Given his ischemic cardiomyopathy was ___, we
assume his cardiac function has steadily improved. He had no
exam evidence of volume overload of congestive heart failure. He
only requires intermittent PO Lasix and daily Digoxin dosing at
this time. He has close Cardiology follow-up established.
# ATRIAL FIBRILLATION - Atrially paced rhythm with pacemaker.
Underwent MAZE procedure for atrial fibrillation with left
atrial appendage resection in ___. Currently on Amiodarone.
Telemetry reveals demand pacing; minimal PVCs. We continued her
current regimen and his anticoagulation with Coumadin. His INR
on discharge was 2.7 and he received Coumadin 3 mg PO. He will
be followed by Cardiology regarding his anticoagulation needs.
# SEIZURE DISORDER - Prior history of petit mal seizures and
complex partial seizures which have been managed on Phenytoin.
Level on admission 22.1, mildly supratherapeutic. Low clinical
suspicion that this episode of 'syncope' reflects his known
seizure concerns. In discussion with Neurology, his phenytoin
dosing was adjusted (see above).
# HYPERTENSION - Remote history of hypertension following his
cardiac surgery. Blood pressure has been controlled in the
120-130 mmHg systolic range. No current anti-hypertensive
medications dosed at this time.
# SICK SINUS SYNDROME - Dual chamber pacemaker in place. Last
interrogation was in ___ with Dr. ___ was reassuring.
No indication of PPM malfunction. Interrogation by
electrophysiology this admission was reassuring.
# HYPOTHYROIDISM - We continued his home dose of Levothyroxine
25 mcg PO daily. A TSH on admission was 7.1 and we added thyroid
function tests. These will be followed-up by her outpatient
primary care physician and ___ decide if dose adjustment is
appropriate.
# HYPERLIPIDEMIA - We continued Pravastatin 20 mg PO QHS.
TRANSITION OF CARE ISSUES:
1. Assistance with medication administration with home ___
services.
2. Given recent mechanical falls, with need home physical
therapy and encourage strict adherence to walker or cane use.
3. Given recent hypersomnia and fatigue during the day,
decreased evening dose of Phenytoin ER to 150 mg at nighttime,
in discussion with Neurology. Will need phenytoin and albumin
level checked in 1-week (around ___. This will be followed
by Dr. ___.
4. Will need digoxin level checked as outpatient in ___ weeks.
Again, Dr. ___ will follow-up this laboratory value.
5. TSH was 7.1 this admission. Called PCP who can determine
appropriate adjustment in Levothyroxine dosing. Note left in
OMR.
6. Follow-up INR (goal ___. Remains on Coumadin ___ mg PO
daily as outpatient. Last INR 2.7 on ___.
7. At the time of discharge, blood cultures from admission were
still pending.
8. Will need staple removal on back of scalp in 2-weeks (around
___.
Medications on Admission:
HOME MEDICATIONS (confirmed with patient's wife)
1. Amiodarone 200 mg PO daily
2. Digoxin 125 mcg PO daily
3. Fluoxetine 10 mg PO daily
4. Furosemide 20 mg PO QOD
5. Levothyroxine 25 mcg PO daily
6. Phenytoin sodium EX ___ mg PO QAM, 200 mg PO QHS
7. Pravastatin 20 mg PO QHS
8. Coumadin 1 mg ___ tablets) PO daily (INR goal ___
9. Calcium carbonate 500 (1250 mg) 3 tablets PO BID
10. Cholecalciferol-D3 1000 units PO daily
11. Multivitamin 1 tablet PO daily
12. Aspirin 81 mg PO daily
Discharge Medications:
1. amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. fluoxetine 10 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
4. furosemide 20 mg Tablet Sig: One (1) Tablet PO EVERY OTHER
DAY (Every Other Day).
5. levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. phenytoin sodium extended 100 mg Capsule Sig: One (1) Capsule
PO QAM (once a day (in the morning)).
7. phenytoin sodium extended 100 mg Capsule Sig: 1.5 Capsules PO
QPM (once a day (in the evening)).
8. pravastatin 20 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
9. warfarin 1 mg Tablet Sig: Three (3) Tablet PO Once Daily at 4
___: dose adjust to maintain INR of ___.
10. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
Sig: Three (3) Tablet, Chewable PO BID (2 times a day).
11. cholecalciferol (vitamin D3) 1,000 unit Tablet Sig: One (1)
Tablet PO once a day.
12. multivitamin Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
14. Outpatient Lab Work
Please check phenytoin, digoxin and albumin level.
.
FAX TO: ___. ___ - ___
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnoses:
1. Hypersomnia episodes in the setting of polypharmacy
2. Acute syncope episode
3. Mechanical falls
.
Secondary Diagnoses:
1. Hypertension
2. Seizure disorder
3. Sick sinus syndrome with permanent pacemaker
4. Bilateral foot drop and peroneal nerve palsy
5. Prior mitral valve repair and resulting ___
myocardial ischemia with emergent coronary bypass grafting with
residual ischemic cardiomyopathy
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:
Patient Discharge Instructions:
.
You were admitted to the Internal Medicine service at ___
___ on ___ regarding management of
your recent spells of 'falling asleep' or hypersomnia. After a
thorough investigation into your passing out, we attributed this
to sleeping spells in relation to your medications. We lowered
the dose of your anti-seizure medication in discussion with
Neurology. You will follow-up outpatient regarding this issue.
You also had a pacemaker interrogation which was reassuring and
your cardiac monitor was reviewed and was reassuring. The
physical therapist's felt you would benefit from home physical
therapy and visiting nurse services. You were feeling well at
the time of discharge.
.
Please call your doctor or go to the emergency department if:
* You experience new chest pain, pressure, squeezing or
tightness.
* You develop new or worsening cough, shortness of breath, or
wheezing.
* You are vomiting and cannot keep down fluids, or your
medications.
* If 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 an unusual discharge.
* You have pain that is not improving within 12 hours or is not
under control within 24 hours.
* Your pain worsens or changes location.
* You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
* You develop any other concerning symptoms.
.
CHANGES IN YOUR MEDICATION RECONCILIATION:
.
* Upon admission, we ADDED: NONE
.
* This admission, we CHANGED:
DECREASE: Phenytoin sodium ER from 200 mg to 150 mg by mouth at
bedtime in discussion with Neurology.
.
* The following medications were DISCONTINUED on admission and
you should NOT resume: NONE
.
* You should continue all of your other home medications as
prescribed, unless otherwise directed above.
Followup Instructions:
___
|
19666282-DS-6
| 19,666,282 | 25,046,988 |
DS
| 6 |
2154-01-12 00:00:00
|
2154-01-12 15:15:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Syncope
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old man with h/o seizures, sick sinus syndrome s/p
pacer, s/p MVR and CABG, who presents after a syncopal episode.
He was standing by the car unloading groceries when the next
thing he remembers, he was in the ambulance on the way to the
hospital. He denies any preceeding dizziness, lightheadedness,
CP, SOB, palpitations, cough, or any other symptoms. He did lose
consciousness but is unsure for what duration. He states that
his wife was present and did not witness him having any seizure
activity, tongue biting, or loss of bladder/bowel function.
Though he does have a history of seizures, he has been
seizure-free for the past few years since being on the Dilantin.
When he fell he struck the back of his head which began
bleeding.
.
Of note, the patient has a h/o several recent falls and was seen
in the ED twice previously with head lacerations requiring
suturing/staples. He was admitted from ___ for a syncopal
episode and his sycope was felt to be secondary to polypharmacy
leading to episodic fatigue and hypersomnia. He was discharged
with neurology f/u and has an appt on ___.
.
In the ED, initial vitals were: 97.2, 80, 158/80, 20, 100% on
4L. Labs unremarkable (including neg trop and neg UA). CT head
showed old stable vertex subgaleal hematoma, an old stable left
frontal subdural, and a new large right parieto-occipital
subgaleal hematoma containing locules of gas. CT C-spine with
DJD but neg for fx. His head laceration was stapled. Transfer
vitals were: 98.0, 80 NSR, 16, 138/75, 100% RA.
.
On the floor, he continues to have a small amount of bleeding
from the head laceration but staples are in place. Patient is
comfortable.
.
ROS: As noted in HPI. In addition, denies recent fevers, chills,
night sweats, headaches, vision changes, cough, shortness of
breath, chest pain, abdominal pain, nausea, vomiting, diarrhea,
constipation, BRBPR, melena, hematochezia, dysuria, hematuria.
The ten point review of systems is otherwise negative.
Past Medical History:
PAST MEDICAL & SURGICAL HISTORY:
1. Hypertension
2. Hyperlipidemia
3. Seizure disorder (petit mal seizures have not occurred for
many years; complex partial seizures with behavior patterns have
not occurred for ___ years)
4. Sick sinus syndrome ___ pacemaker placed on right
side; interrogated ___
5. s/p mitral valve repair with MAZE procedure (atrial
fibrillation) complicated by total occlusion of coronary artery
- artery over-sewn during procedure and resulting CABG (RSVG
from aorta to OM2) x 1-vessel and left femoral artery
pseudoaneurysm (with thrombin injection).
6. Bilateral foot drop (resulting from coronary bypass surgery)
7. Left anterior wall acetabular fracture (___)
8. Prostate adenocarcinoma
9. Colonic adenoma
10. Rheumatoid arthritis
11. Chronic anemia
12. Gout
13. Prior subdural hematoma (required Burr hole placement)
14. Lichen simplex chronicus
Social History:
___
Family History:
non-contributory.
Physical Exam:
ADMISSION EXAM:
VS: 97.9, 152/94, 70, 14, 95% RA
GENERAL: A&Ox3, in NAD.
HEENT: Large laceration over right posterior scalp with staples
in place, sm amt of bleeding present.
NECK: Supple, no thyromegaly, no JVD, no carotid bruits.
HEART: RRR, no MRG, nl S1-S2.
LUNGS: CTA bilat, no ronchi/rales/wheezes, good air movement,
resp unlabored.
ABDOMEN: Soft/NT/ND, no masses or HSM, no rebound/guarding.
EXTREMITIES: WWP, no c/c/e, 2+ peripheral pulses.
SKIN: No rashes or lesions.
LYMPH: No cervical LAD.
NEURO: Awake, A&Ox3, normal speech, able to recall ___ objects
at 3 minutes, CNs II-XII intact, muscle strength ___ throughout,
except for decreased strength in feet (chronic per pt),
sensation grossly intact throughout, DTRs 2+ and symmetric,
cerebellar exam intact, gait not tested.
DISCHARGE EXAM:
O:98.6, 134/82 (100-150/50-70), 77 (70-80), 18, 98% RA
GENERAL: AAOx3, in NAD.
HEENT: Hematoma at right posterior scalp with dried blood and
healing well without more drainage. Hematoma adjacent to
laceration tracking down right side of neck. Neck is supple
with no tenderness and full range of motion. Prior laceration on
superior prortion of scalp with swelling but no active bleeding,
staples intact.
NECK: Supple, no JVD, no LAD.
HEART: RRR, split S2 at LLSB, ___ systolic murmur at the LUSB
LUNGS: Soft crackles at the right lung base, no wheezes,
unlabored.
ABDOMEN: Soft/NT/ND, no masses or HSM, no rebound/guarding.
EXTREMITIES: WWP, 2+ edema at the feet, 2+ peripheral pulses.
SKIN: No rashes or lesions.
NEURO: Awake, A&Ox3, CNs II-XII intact, strength ___ throughout
except for dorisflexion of feet (___), sensation grossly intact
throughout except decreased sensation in bilateral feet with
greatly diminished proprioception and vibration sense to the
ankles bilaterally.
Pertinent Results:
ADMISSION LABS:
___ 07:22PM BLOOD WBC-9.0 RBC-3.86* Hgb-11.4* Hct-37.0*
MCV-96 MCH-29.5 MCHC-30.8* RDW-14.8 Plt ___
___ 07:22PM BLOOD Neuts-83.9* Lymphs-10.6* Monos-4.3
Eos-0.9 Baso-0.3
___ 01:45PM BLOOD ___ PTT-35.5 ___
___ 07:22PM BLOOD Glucose-109* UreaN-23* Creat-0.9 Na-140
K-4.8 Cl-104 HCO3-24 AnGap-17
___ 06:30AM BLOOD CK(CPK)-59
___ 07:22PM BLOOD cTropnT-<0.01
___ 06:30AM BLOOD CK-MB-3 cTropnT-<0.01
___ 06:30AM BLOOD Calcium-8.7 Phos-3.4 Mg-2.1
DISCHARGE LABS:
___ 08:50AM BLOOD WBC-8.8 RBC-3.73* Hgb-11.1* Hct-35.2*
MCV-94 MCH-29.6 MCHC-31.4 RDW-14.6 Plt ___
___ 08:50AM BLOOD Plt ___
___ 08:50AM BLOOD Glucose-153* UreaN-17 Creat-0.8 Na-138
K-4.1 Cl-103 HCO3-24 AnGap-15
___ 08:50AM BLOOD TotProt-6.2* Calcium-8.8 Phos-3.4 Mg-2.1
MICRO:
URINE CULTURE (Final ___: <10,000 organisms/ml.
URINE:
___ 09:08PM URINE Color-Yellow Appear-Clear Sp ___
___ 09:08PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
IMAGING:
CXR SUPINE AP VIEW OF THE CHEST: The patient is status post
median sternotomy and CABG. Right-sided pacemaker device is
noted with leads terminating in the right atrium and right
ventricle, unchanged. Mild cardiomegaly with a left ventricular
predominance is re-demonstrated. The mediastinal and hilar
contours are unchanged. The pulmonary vascularity is not
engorged. Lungs are clear without focal consolidation. No
pleural effusion or pneumothorax is
visualized. No acute osseous abnormalities are visualized.
IMPRESSION: No acute cardiopulmonary process.
___
CT Head without Contrast: FINDINGS: There is a new large right
parieto-occipital subgaleal scalp hematoma as well as an
adjacent hematocrit level representing a second, more focal
hemorrhage. Staples and posterior midline vertex subgaleal
scalp hematoma again noted, unchanged from ___.
There is no acute intracranial hemorrhage, edema, mass effect,
or large
territorial infarction. The ventricles and sulci are prominent,
consistent with age-related atrophy. Right inferior frontal
lobe hypodensity is unchanged, likely due to prior trauma. The
basal cisterns are patent and there is preservation of the
gray-white matter differentiation. Small left frontal chronic
subdural hematoma is again noted.
No fracture is seen. The visualized paranasal sinuses, mastoid
air cells, and middle ear cavities are clear. Several burr
holes are again noted.
IMPRESSION:
1. New large right parieto-occipital subgaleal scalp hematoma
containing foci of gas.
2. Stable midline posterior vertex subgaleal scalp hematoma.
3. No acute intracranial hemorrhage or mass effect. Old left
frontal
subdural hematoma.
___ CT C-spine without Contrast:
FINDINGS: There is no fracture or malalignment of the cervical
spine. Again seen is a grade 1 anterolisthesis of C7 on T1.
Multilevel degenerative changes are again seen, worse at C5-6
and C6-7 with moderate central canal narrowing. Multilevel mild
to moderate neural foraminal narrowing is also noted
bilaterally. Old left first rib fracture is again noted. There
is no prevertebral soft tissue swelling. The thyroid gland is
unremarkable. The lung apices are clear.
IMPRESSION:
1. No acute fracture or malalignment.
2. Multilevel degenerative changes in the cervical spine,
unchanged.
EEG:
FINDINGS:
ABNORMALITY #1: The background was disorganized and mildly slow
with
frequencies typically in the range of 6.5-7.5 Hz
HYPERVENTILATION: Could not be performed.
INTERMITTENT PHOTIC STIMULATION: Produced no activation of the
record.
SLEEP: The patient progressed from wakefulness to drowsiness and
stage
II sleep with no additional findings.
CARDIAC MONITOR: Showed a generally regular rhythm with a rate
of
about 80.
IMPRESSION: Abnormal EEG due to a mildly slow and disorganized
background. Although this background activity is relatively
common at
this age, it suggests a mild encephalopathy. Medications,
infection,
and metabolic disturbances are among the most common causes.
There were
no focal abnormalities or epileptiform features.
Brief Hospital Course:
ASSESSMENT & PLAN: ___ with h/o seizures (petit mal, complex
partial on dilantin), sick sinus syndrome s/p pacer (interogated
___, replaced last year), s/p MVR and CABG, h/o bilateral
foot drop, and h/o several recent falls who presented after a
syncopal episode, found to have a large right parieto-occipital
subgaleal hematoma.
.
# Syncope -> Patient has presented with numerous falls over the
past months. Now with second fall over the past week with
significant soft tissue head injury requiring staples. He was
recently admitted for syncope work-up last week that was
ultimately felt to related to hypersomnolence in the setting of
polypharmacy and a slightly supertherapeutic dilantin level. On
this admission, his pacemaker was interogated and was found to
be functioning normally with no tachy or bradyarrythmia.
Neurology was consulted due to concern for possible seizure
etiology. EEG was done which showed no seizure activity.
Orthostatics were checked and patient was noted to be
persistently orthostatic without any symptoms. He was felt to
be volume depleted on admission with elevated BUN:cre ratio, and
was treated with IVF without much improvement in orthostasis.
Medications were considered as a possible cause of orthostasis
and lasix was stopped, without much improvement in orthostasis.
Autonomics was consulted and felt that he likely has autonomic
dysfunction leading to his orthostasis. He was started on
midodrine 2.5 mg BID for persistent orthostasis. B12,
UPEP/SPEP, HbA1c were pending at discharge.
He will benefit from outpatient follow-up with neurology and
___ clinic for further management.
# Subgaleal hematoma -> Patient with new hemtoma from ___ now
s/p staples. CT head without evidence of intracranial bleed.
Patient did not demonstrate any neurologic changes while in
___. Neuro exam was stable. He did have some initial bleeding
from the wound with an associated Hct drop, but his Hct then
remained stable with no further serosanguinous drainage. Patient
will need staples removed from new wound in 2 weeks, around
___. Staples will need to be removed from the prior head
wound on ___.
# Cardiomyopathy -> ECHO in ___ showed EF 45-50% with mild
left global hypokinesis. No evidence of volume overload on
exam. Previously managed on lasix, ASA. Lasix held as was
volume depleted, but then developed mild crackles at the bases
and ___ edema. Since he was still orthostatic and still
diuresing, we continued him on slow fluids while closely
monitoring volume status. Orthostasis did not improve much with
fluids. Will need to closely monitor volume status. Will
restart lasix 20 mg PO on ___ and ___ at discharge.
# H/o seizures -> History of seizures ___ years ago. Dilantin
level checked and was 13.6, which is therapeutic. Rechecked
level and was 10.6 with albumin 3.6. EEG showed no evidence of
seizure activity. Dilantin level rechecked and was 12.6.
Phenytoin increased to 100 mg AM and 160 mg ___ dose. Will need
neurology follow-up.
.
# Sick sinus syndrome s/p pacemaker -> Patient with history of
SSS s/p pacemaker placement ___, reportedly had generator
replaced last year. Pacemaker interogated and during this
admission and showed no abnormalities.
# Atrial Fibrillation -> History of atrial fibrillation s/p MAZE
procedure (___). Has been maintained on warfarin since
that time with goal INR ___. CHADS2 score is 3. He was
continued on amiodarone, digoxin, and warfarin while in ___.
.
# Hypothyroidism -> Recent TSH was 7.1 on last admission.
Currently on levoxyl supplementation. Will require outpatient
follow-up. Continued on current dose of levothyroxine now.
.
# Hyperlipidemia -> He was continued on pravastatin.
# Depression -> He was continued on fluoxetine.
.
TRANSITIONAL ISSUES:
1. Please check orthostatics twice daily. Ensure that patient
does not develop supine hypertension.
2. Ensure that patient wears soft helmet at all times.
3. Ensure that patient has a person monitoring him at all times
to prevent falls. Will likely require ___ care at home.
4. Monitor ___ edema and lungs for signs of volume overload. ___
tolerate mild volume overload to improve orthostasis, however,
if patient develops SOB, consider restarting lasix.
5. Pending studies at discharge include: B12, SPEP, UPEP
6. Patient may benefit from neuropsych testing in the near
future as he demonstrated significant short term memory loss
while in the hospital.
7. Will need staple removal on top of scalp in 2-weeks (around
___. Will need staples removed from the right lateral scalp
in 2 weeks (approx
___.
8. F/u INR in ___ days.
Medications on Admission:
1. amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
2. digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY
3. fluoxetine 10 mg Capsule Sig: One (1) Capsule PO DAILY
4. furosemide 20 mg Tablet Sig: One (1) Tablet PO EVERY OTHER
DAY
5. levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY
6. phenytoin sodium extended 100 mg Capsule Sig: One (1) Capsule
PO QAM.
7. phenytoin sodium extended 100 mg Capsule Sig: 1.5 Capsules PO
QPM.
8. pravastatin 20 mg Tablet Sig: One (1) Tablet PO HS
9. warfarin 1 mg Tablet Sig: Three (3) Tablet PO Once Daily at 4
___: dose adjust to maintain INR of ___.
10. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
Sig: Three (3) Tablet, Chewable PO BID (2 times a day).
11. cholecalciferol (vitamin D3) 1,000 unit Tablet Sig: One (1)
Tablet PO once a day.
12. multivitamin Tablet Sig: One (1) Tablet PO DAILY
13. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet daily
Discharge Medications:
1. amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. fluoxetine 10 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
4. levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. phenytoin sodium extended 100 mg Capsule Sig: One (1) Capsule
PO QAM (once a day (in the morning)).
6. phenytoin sodium extended 30 mg Capsule Sig: Five (5) Capsule
PO QPM (once a day (in the evening)).
Disp:*150 Capsule(s)* Refills:*2*
7. pravastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. warfarin 1 mg Tablet Sig: Three (3) Tablet PO Once Daily at 4
___.
9. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
Sig: Three (3) Tablet, Chewable PO BID (2 times a day).
10. cholecalciferol (vitamin D3) 1,000 unit Tablet Sig: One (1)
Tablet PO once a day.
11. multivitamin Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. midodrine 5 mg Tablet Sig: 0.5 Tablet PO BID (2 times a
day).
Disp:*30 Tablet(s)* Refills:*0*
13. Lasix 20 mg Tablet Sig: One (1) Tablet PO Two times per week
___ and ___: Take on ___ and ___.
Disp:*8 Tablet(s)* Refills:*0*
Discharge Disposition:
Extended Care
Facility:
___
for Rehabilitation and Sub-Acute Care)
Discharge Diagnosis:
Syncope due to autonomic dysfunction
Subgaleal Hematoma
Secondary Diagnoses:
Seizures
Sick Sinus Syndrome
Atrial Fibrillation
Discharge Condition:
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Level of Consciousness: Alert and interactive.
Mental Status: Clear and coherent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure participating in your care. You were admitted
after you passed out and hit your head. We checked your
pacemaker, and it is functioning well. You were seen by
neurology who did not think you had a seizure. You most likely
passed out because your blood pressure becomes low when you
stand up. You were started on a new medication to help prevent
your blood pressure from decreasing when you stand up.
You also had a new injury to your scalp. You received staples
to close the injury. You also had staples on your scalp from a
previous head injury. You will need to follow-up with your
primary care doctor or rehab facility to remove the old staples
on ___ and the new staples on ___.
You are at a high risk of falling. It is important that you
wear a helmet at all times to prevent head injury if you do
fall. It is important that someone help you while you walk at
all times.
Please continue to take your home medications as previously
prescribed. We made the following changes to your medications:
START taking Midodrine 2.5 mg twice daily
STOP taking Aspirin
CHANGE take Furosemide 20 mg twice a week ___ and ___
instead of three times a week.
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs. Please call your doctor if you notice that you are
having trouble breathing or your legs are swelling.
Followup Instructions:
___
|
19666282-DS-8
| 19,666,282 | 22,541,352 |
DS
| 8 |
2157-10-31 00:00:00
|
2157-11-01 05:58:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
s/p Falls
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This patient is a ___ year old male with history of mitral valve
replacement, sick sinus syndrome (s/p PPM), atrial fibrillation
(s/p maze procedure), CABG,who complains of R Leg pain and
lower back pain. He states he fell several weeks ago. He saw his
PCP and underwent lumbar plain films an outpatient that did not
show any fracture. The pain radiates down his right leg. He has
been trying Tylenol with codeine at home with minimal relief.
The pain has gotten progressively worse to the point where he
cannot ambulate at home. He was sent in by his PCP for CT scan
and placement in an extended care facility. He denies any
numbness or weakness, bladder or bowel incontinence. He denies
any headache, fevers, nausea, vomiting, chest pain, shortness of
breath. He otherwise feels well. He is not on anticoagulation.
In the ED, initial VS were 98.9 HR 81 BP 108/73 RR 16 96 RA
Exam notable for possible instability fracture, tenderness in
lower back
Labs showed normal BMP, CBC (Hgb 12.7, 73% neutrophils)
Imaging showed L4 vertebral body fracture, no height loss, no
retropulsion. T12 compression deformity (chronic)
Received Tylenol with Codeine, IV morphine 2mg x2, PO Amiodarone
200 mg, Aspirin 81, Digoxin 0.125, Pravastatin 40, Phenytoin 100
mg, 4L Fluids, 20 mg furosemide
Transfer VS were 98.2 BP 109/68 HR 82 RR16 97RA
Ortho spine was consulted and suggested admission to medicine
given medically complex history with plan for surgery tomorrow
Decision was made to admit to medicine for further management.
On arrival to the floor, patient reports no pain and feeling
well. He states he falls often, always "mechanical falls". This
time, he thinks he fell about a week ago, was walking holding
furniture, and missed holding a bookshelf. He denies presyncopal
event, was able to lower himself to the ground, no head strike,
no LOC. He says pain was worsening thus he came to seek further
care. He had a severe fall in ___ from a step stool, and had
intracranial hemorrhage and neurosurgery intervention, and since
then he wears a helmet.
REVIEW OF SYSTEMS:
Denies fever, chills, night sweats, headache, vision changes,
rhinorrhea, congestion, sore throat, cough, shortness of breath,
chest pain, abdominal pain, nausea, vomiting, diarrhea,
constipation, BRBPR, melena, hematochezia, dysuria, hematuria.
All other 10-system review negative in detail.
Past Medical History:
1. Hypertension
2. Hyperlipidemia
3. Seizure disorder (petit mal seizures have not occurred for
many years; complex partial seizures with behavior patterns have
not occurred for ___ years)
4. Sick sinus syndrome ___ pacemaker placed on right
side; interrogated ___
5. s/p mitral valve repair with MAZE procedure (atrial
fibrillation) complicated by total occlusion of coronary artery
- artery over-sewn during procedure and resulting CABG (RSVG
from aorta to OM2) x 1-vessel and left femoral artery
pseudoaneurysm (with thrombin injection).
6. Bilateral foot drop (resulting from coronary bypass surgery)
7. Left anterior wall acetabular fracture (___)
8. Prostate adenocarcinoma
9. Colonic adenoma
10. Rheumatoid arthritis
11. Chronic anemia
12. Gout
13. Prior subdural hematoma (required Burr hole placement)
14. Lichen simplex chronicus
Social History:
___
Family History:
non-contributory.
Physical Exam:
ADMISSION PHYSICAL EXAM:
=========================
VS 97.5F BP 107/62 HR 81 RR20 97RA
GENERAL: elderly gentleman, in no acute distress, lying down
flat, wearing helmet
HEENT: AT/NC, palpable 2 burr holes from prior procedure, EOMI,
PERRL, anicteric sclera, pink conjunctiva, MMM, good dentition
NECK: nontender supple neck, no LAD, no JVD
CARDIAC: distant heart sounds, soft systolic murmur at LUSB and
Mitral region, S1/S2, paced rhythm,
LUNG: largely clear to auscultation, trace crackles at L.base,
no wheezes, breathing comfortably without use of accessory
muscles
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding
BACK: No tenderness to palpation
EXTREMITIES: no edema, moving all 4 extremities with purpose
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact, Sensation intact to light throughout
bilateral lower extremities.
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
DISCHARGE PHYSICAL EXAM:
============================
VS 97.6 BP 95-107/56-66 HR 80 RR18 96RA
GENERAL: elderly gentleman, in no acute distress, lying down
flat, AOOX3 but still appears confused, brace not on when lying
down
HEENT: AT/NC, palpable 2 burr holes from prior procedure, MMM
NECK: nontender supple neck, no LAD, no JVD
CARDIAC: distant heart sounds, soft systolic murmur at LUSB and
Mitral region, S1/S2
LUNG: largely clear to auscultation, trace crackles at L.base
ABDOMEN: nondistended, +BS, nontender in all quadrants
BACK: No tenderness to palpation
EXTREMITIES: no edema, moving all 4 extremities with purpose
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact, Sensation intact to light throughout
bilateral lower extremities.
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
Pertinent Results:
ADMISSION LABS:
===============
___ 12:41AM BLOOD WBC-8.4 RBC-4.13* Hgb-12.7* Hct-40.5
MCV-98 MCH-30.8 MCHC-31.4* RDW-13.5 RDWSD-48.8* Plt ___
___ 12:41AM BLOOD Glucose-111* UreaN-25* Creat-0.9 Na-142
K-4.1 Cl-105 HCO3-25 AnGap-16
___ 05:56AM BLOOD Calcium-8.4 Phos-2.9 Mg-2.0
DISCHARGE LABS:
==================
___ 07:00AM BLOOD WBC-7.9 RBC-3.88* Hgb-12.1* Hct-37.2*
MCV-96 MCH-31.2 MCHC-32.5 RDW-13.6 RDWSD-47.9* Plt ___
___ 07:00AM BLOOD Glucose-105* UreaN-32* Creat-1.0 Na-141
K-4.0 Cl-104 HCO3-26 AnGap-15
___ 07:00AM BLOOD Calcium-9.1 Phos-3.1 Mg-2.
MICRO:
========
UA:
___ 02:10PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
IMAGING:
============
___ Lumbar Xray:
Again seen is the T12 compression fracture with unchanged loss
of vertebral body height. There is also mild compression of the
L4 vertebral body which is similar. Moderate to severe
lumbosacral degenerative changes are re-identified. There is
significant facet arthropathy. An overlying brace is
appreciated. There is fecal loading within the colon.
___ CT Head non contrast: Chronic right frontal lobe
infarct. No evidence of acute hemorrhage or other significant
intracranial abnormality
___ MRI Thoracic:
Chronic appearing compression fractures of the T1, T4 and T8-12
vertebral bodies with no osseous retropulsion at these levels.
Re- demonstration of the fracture in the L4 vertebral body with
diffuse bone marrow edema and no osseous retropulsion. Minimal
prevertebral edema at this level.
No evidence for ligamentous injury.
Degenerative changes throughout the spine, as described above,
worse at L4-5 resulting in moderate to severe spinal canal
stenosis and severe right neural foraminal stenosis.
___ CXR: Dual lead right-sided pacemaker is seen with lead
extending the expected positions of the right atrium and right
ventricle. Oblong radiopaque structure projects over the left
lower hemi thorax which has the appearance of a pen and is most
likely external to the patient. Correlate with direct
visualization. No focal consolidation is seen. There is no
pleural effusion or pneumothorax. The cardiac silhouette is
top-normal to mildly enlarged. Mediastinal contours are stable.
___ CT L-spine:
1. There is a transversely oriented fracture of the L4 vertebral
body, new since ___. Fracture line seen to involve
the anterior posterior aspects of the vertebral body as well as
a superior endplate. No significant height loss nor
retropulsion.
2. There is compression deformity of T12, with no CT findings to
suggest that it is acute.
Ortho impression:
CT of the lumbar spine demonstrates an acute fracture of the L4
vertebral body extending from anterior to posterior across the
lower aspect of the body as well as extending to the superior
endplate. There is significant degenerative change posteriorly
between the facets and spinous processes of L2-L4 with
significant fusion. The major fracture line through the L4
vertebral body is leading to an extension deformity of the
vertebra. The fracture line does not appear to clearly extend to
the posterior elements
Brief Hospital Course:
Mr. ___ is an ___ gentleman who sustained a
mechanical fall approximately 2 weeks prior with insidious onset
of now progressive low back pain with T4 vertebral body
fracture.
#Acute L4 Vertebral Fracture / Chronic T12 compression fx: On
admission, he appeared to be at his neurologic baseline, with
imaging showing fracture along with diffuse degenerative disease
throughout his lumbar spine posteriorly, that could have
resulted in this fracture through a hyperextension mechanism.
There was no clear ligamentous injury on MRI. Orthopedics
recommended TSLO brace. He was fitted for the brace in house
with recommendations to ___ brace at edge of bed and with any
movement when not lying down. Recommend consideration of
outpatient DEXA and osteoporosis work-up.
#Encephalopathy, suspect delirium ___ hospitalization: Patient
appeared oriented on initial exam, but over the course of the
hospitalization, he was increasingly confused, with no focal
signs. Differential delirium with waxing and waning features, vs
infection, vs pain. Patient was re-directable on conversational,
but somewhat agitated and hyperactive. Pain medications were
scheduled to assure adequate pain control. UA did not reveal any
infection and recent CT head did not show any new bleed. Per
collateral from wife, patient has history of getting
intermittently confused. He also drinks alcohol daily, but did
not score high on the CIWA scale. Patient was discharged and was
oriented x3.
#Alcohol use: Patient reports drinking daily, ___ drinks, no
known liver disease, no known history of withdrawal.
#Atrial fibrillation: Patient has chronic history of afib s/p
MAZE procedure, stable on home regimen rate controlled, with
amiodraone and digoxin. He is not on coumadin due to SDH's. He
is on amiodarone which was decreased by Dr. ___ to 100 mg
daily on ___. He was continued on Amiodarone 100 mg daily
and Digoxin 0.125 mcg daily.
#Sick Sinus syndrome, prior syncope: s/p PPM placement ___,
had post MRI check with sinus rhythm with intact AV conduction,
rate ~60 bpm.
#CAD: Patient had complicated admission in ___ for increasing
shortness of breath and underwent intraaortic balloon pump
placement, mitral valve replacement with a bioprosthesis.
Transesophageal echocardiography had been performed in the
operating room and revealed a preop LVEF of greater than 55%,
Postoperatively, EKG changes suggested an ST elevation
myocardial infarction and TEE revealed a new inferior WMA, and
he underwent selective coronary angiography of his left dominant
system, which revealed total occlusion of the left circumflex
after OM1.Patient had no chest pain during stay, was continued
on ASA and Atorvastatin.
#Gait instability: Patient has known gait instability, thought
to be a combination of bilateral compressive peroneal
compression neuropathies, perhaps cerebellar degeneration and
impulsiveness perhaps secondary to right frontal contusion. No
acute neurological problems noted. Physical Therapy recommended:
#Hypothyroidism: Continued home Levothyroxine 25 mcg daily.
#Code status: per ___ notes, patient does not want to persist
in a vegetative or demented state. We reviewed that his
likelihood of surviving CPR is very limited, but he has returned
from an encephalopathy (post-balloon pump, post by-pass x 2) now
with minimal residual damage. Therefore, he is not inclined to
be DNR at this time. He states he would like a "reasonable
trial" of CPR and intubation, but not prolonged care if futile.
TRANSITIONAL ISSUES:
====================
- Spine follow up in two weeks with Dr. ___
- patient to ___ TLSO brace at edge of bed and wear at all times
when not in bed
- Pain control has been sufficient with Tylenol but may require
prn Tramadol to adequately work with physical therapy
-Consider follow up with neurology to assess gait instability
- Recommend DEXA scan and outpatient workup of osteroporosis
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Digoxin 0.125 mg PO DAILY
3. Levothyroxine Sodium 25 mcg PO DAILY
4. Amiodarone 100 mg PO DAILY
5. Furosemide 40 mg PO BID
6. Atorvastatin 80 mg PO QPM
7. Phenytoin (Suspension) 200 mg PO DAILY
Discharge Medications:
1. Amiodarone 100 mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 80 mg PO QPM
4. Digoxin 0.125 mg PO DAILY
5. Furosemide 40 mg PO BID
6. Levothyroxine Sodium 25 mcg PO DAILY
7. Phenytoin (Suspension) 200 mg PO DAILY
8. Acetaminophen 1000 mg PO TID
Please taper as tolerated at rehab.
9. TraMADOL (Ultram) 25 mg PO Q6H:PRN Physical Therapy/Exertion
RX *tramadol 50 mg 0.5 (One half) tablet(s) by mouth every six
(6) hours Disp #*20 Tablet Refills:*0
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary Diagnosis:
-L4 lumbar fracture
Secondary Diagnosis:
-Atrial Fibrillation
-Coronary Artery Disease
-Sick sinus syndrome s/p pacemaker placement
Discharge Condition:
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Mental Status: Clear and coherent.
Discharge Instructions:
Dear Mr. ___,
You were admitted to ___ on ___ after you had fallen
and had worsening hip pain.
What was done?
===============
You were found to have a fracture in the lower part of your
spine. Orthopedic doctors recommended ___ have a brace placed
and not have surgery at this time.
What to do next?
================
Please ensure you are wearing your brace whenever you are out of
the bed.
Please follow up with spine clinic as listed below in 2 weeks.
It was a pleasure taking care of you
Your ___ team
Followup Instructions:
___
|
19666359-DS-6
| 19,666,359 | 25,251,935 |
DS
| 6 |
2184-02-04 00:00:00
|
2184-02-04 20:51:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
codeine
Attending: ___.
Chief Complaint:
Hypotension
Major Surgical or Invasive Procedure:
ERCP with stent placement
History of Present Illness:
Ms. ___ is a ___ year old female with PMH significant for
HTN, HLD, DMII who presented to ___ with nausea,
vomiting, diarrhea, abdominal pain, hypotensive, found to be
septic ___ cholangitis now transferred for further management of
sepsis and possible ERCP.
Pt. had been in her usual state of health until the evening of
___ when she noted the acute onset of nausea, vomiting, large
well-formed bowel movements, and diffuse mild abdominal pain.
Pt. also endorses associated worsening of her mid back pain,
chills, malaise, and generalized weakness but denies any
subjective fever, , rigors, or sick contacts. Per pt's daughter
who she ___ with, no evidence of coffee ground emesis or
blood in On the morning of ___, pt. presented to ___
___. At this time, her initial VS T 98.5, Tmax102.5, HR
105, BP 131/85, RR 18, Sat 97% on RA. She was noted to be in
NAD and was given 1L NS, zofran, protonix, and pepcid. CXR
revealed a possible infiltrate in the left lower lobe. She was
later admitted to medicine where a Abdominal ultrasound revealed
choledocholithiasis, mild intrahepatic biliary dilation, stones
in the gallbladder neck, and dilation of common left hepatic
duct. An MRCP was later done which confirmed
choledocholithiasis, cholelithiasis, 3 calculi in the common
bile duct, intra/extra hepatic biliary duct dilation. A HIDA
scan was then performed which showed likely cystic duct
obstruction and partial CBD obstruction. Pt. was initially
started on cefazolin. Her blood cultures from ___ later
grew GNRs. She was transferred to ___ for further management.
On arrival to the ___ ED, pt's VS were 98.6, 155/97, 82, RR
18, Sat 100% on 2L NC. Pt. received 1L NS and Zosyn 4.5G IV x1.
She was transferred to the ___ at that time.
On arrival to the ___, pt. was noted to be in NAD,
hemodynamically stable, and alert/oriented partially to place,
fully to person and time. Pt. denies any current nausea,
vomiting, abdominal pain, diarrhea, CP, SOB, lightheadedness,
dizziness, fevers, chills, or rigors.
Past Medical History:
- Diabetes
- HTN
- HLD
- GERD
Social History:
___
Family History:
No family hx. of GI illnesses, cancers, gallstone disease.
Physical Exam:
ADMISSION PHYSICAL EXAM
=======================
Vitals: T98.5, 90, 120/89, 17, 98% on RA
General- Alert, oriented, no acute distress
HEENT- Sclera mildly icteric, white plaques on tongue, MMM,
oropharynx clear
Neck- supple, JVP not elevated, no LAD
CV- Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs- Anterior lung fields are clear to auscultation
bilaterally, no wheezes, rales, ronchi
Abdomen- soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly, negative
___ sign
GU- foley in place
Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis
Neuro- CNs2-12 grossly intact, motor function grossly normal
DISCHARGE PHYSICAL EXAM:
==============================
Vitals:
T98.3 BP: 142/57 HR:88 R: 18 O2: 97% RA
General- Alert, oriented, no acute distress
HEENT- MMM, oropharynx clear
Neck- supple, JVP not elevated, no LAD
CV- Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs- Anterior lung fields are clear to auscultation
bilaterally, no wheezes, rales, ronchi
Abdomen- soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly, negative
___ sign
Ext- warm, well perfused, 2+ pulses B/L, Mild B/L edema and some
limitation in ROM due to pain
Pertinent Results:
ADMISSION LABS
================
___ 04:30PM BLOOD WBC-14.0* RBC-3.25* Hgb-10.0* Hct-29.7*
MCV-91 MCH-30.8 MCHC-33.7 RDW-13.5 Plt ___
___ 04:30PM BLOOD Neuts-84* Bands-10* Lymphs-2* Monos-1*
Eos-0 Baso-0 ___ Metas-3* Myelos-0
___ 04:30PM BLOOD ___ PTT-39.3* ___
___ 04:30PM BLOOD Glucose-68* UreaN-37* Creat-1.3* Na-141
K-3.7 Cl-107 HCO3-22 AnGap-16
___ 07:43PM BLOOD ALT-151* AST-291* LD(LDH)-226 AlkPhos-79
TotBili-1.6*
___ 04:30PM BLOOD Calcium-8.5 Phos-2.2* Mg-1.8
___ 04:55PM BLOOD Lactate-2.0
___ 07:41PM BLOOD O2 Sat-68
MICRO:
Blood cutures: ___ ___:
E. Coli- pan-sensitive
Blood culture: ___ No growth
STUDIES
========
PORTABLE CXR ___ post line placement
There is a right IJ central venous catheter with its tip in the
region of the right atrium. The heart size is difficult to
assess. There is probable mitral annular calcification. Lung
volumes are low. Evaluation of the left lower lobe is limited
due to patient's leftward rotation. No definite opacification
is seen in the right lung. Bony structures appear intact,
though demineralized. There is a sclerotic focus in the right
humeral head/neck, likely an enchondroma or medullary infarct.
ERCP (___):
Impression:
Small possible laceration of the major papilla, suggestive of a
recently passed stone. Successful pancreatic duct cannulation
using the sphincterotome. Normal limited pancreatogram in the
head of the pancreas.
Successful biliary duct cannulation using the sphincterotome.
Approximately three 5-10 mm stones causing partial obstruction
were seen in the common bile duct. There was mild diffuse
post-obstructive dilation of the common bile duct, common
hepatic duct, and right and left main hepatic ducts with the CBD
measuring 10 mm. Care was taken not to inject the intrahepatic
ducts given the clinical concern for cholangitis. Given the
concern for cholangitis and biliary sepsis, the decision was
made not to perform sphincterotomy and stone extraction. A 5cm
by ___ double pigtail plastic biliary stent was placed
successfully into the common bile duct.
There was excellent flow of bile and contrast through the stent
at the end of the procedure. Otherwise normal ERCP to third
part of the duodenum.
Recommendations: return to ICU for further management of
cholangitis and biliary sepsis. Continue antibiotics. NPO
overnight with aggressive IV hydration as tolerated. Follow for
response and complications. If any abdominal pain, fever,
jaundice, gastrointestinal bleeding please call ERCP fellow on
call (___). Repeat ERCP in 4 weeks for stent pull,
sphincterotomy, stone extraction. Follow-up with Dr. ___ as
scheduled.
Follow-up with Dr. ___ as necessary.
Brief Hospital Course:
Ms. ___ is a ___ year old female with PMH significant for
HTN, HLD, DMII who presented to ___ with nausea,
vomiting, diarrhea, abdominal pain, hypotensive, found to be
septic with cholangitis transferred for further management of
sepsis and possible ERCP.
# Sepsis, cholangitis, bacteremia. Pt. with acute onset of
nausea/vomiting. Presented to OSH with elevated LFTs, TBili,
lipase later found to have evidence of cholelithiasis,
choledocholethiasis, and likely cholangitis on abdominal
ultrasound, MRCP, and HIDA scan. Pt. was placed on cefazolin at
the outside hospital and given several liters of IVF. OSH Blood
cultures later pan-sensitive Ecoli. Antibiotics will continue
for a 14 day course(day #1 ___. Patient was on IV
antibiotics (Zosyn) initially, and then transitioned to cipro
last day of antibiotics ___. Patient will need repeat ERCP
in 4 weeks for stent removal. Dr. ___ will contact
the patient with an appointment.
#Pancreatitis: Pt. with acute worsening of chronic back pain
located in middle of back at midline later found to have an
elevated lipase to 2000s at OSH. Likely ___ gallstone
pancreatitis. Pt received upportive treatment with IV fluids,
bowel rest and pain management. The patient was tolerating a
regular diet prior to discharge.
# Left lower lobe infiltrate: Pt. with evidence of LLL
infiltrate at OSH. Pt. without evidence of cough, SOB, or other
symptoms suggestive of pneumonia. She was not given antibiotics
for pneumonia while hospitalized.
# Anemia: Pt. with normocytic anemia. Last hct at PCP office
was in ___ (34). Recommend repeat CBC next week. HCT on
discharge 27.4.
# ___: Pt. with evidence of elevated creatinine and elevated
BUN/Creatinine ratio, likely pre-renal. Improved with IV fluids.
Creatinine on discharge 1.3. Recommend repeat BUN/Cr check next
week.
#Hypertension, benign
Patient with history of hypertension, antihypertensives were
held on admission in the setting of sepsis and cholangitis.
Recommend resuming Amlodipine and Metoprolol. IF blood pressure
tolerates, can resume additonal blood pressure medications.
#B/L foot pain
Patient had complaints of B/L foot pain on the day prior to
discharge. She underwent xrays which were negative for fracture.
It is possible her foot pain represents neuropathy given that it
is bilateral and burning in nature. Could consider trial of
gabapentin if persits.
Transitional issues:
- FULL CODE
- Needs repeat ERCP In 4 weeks for stent pull
- Recommend rechecking CBC and Chem-7 this week
- Anti-hypertensives were held while hospitalized. Recommend
resuming amlodipine and metoprolol. Resume additional BP meds as
blood pressure tolerates.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Rosuvastatin Calcium 20 mg PO DAILY
2. Metoprolol Tartrate 25 mg PO BID
3. CloniDINE 0.1 mg PO DAILY
4. CloniDINE 0.5 mg PO HS
5. Hydrochlorothiazide 50 mg PO DAILY
6. fenofibrate 134 mg oral Daily
7. Omeprazole 20 mg PO DAILY
8. Amlodipine 10 mg PO DAILY
Discharge Medications:
1. Omeprazole 20 mg PO DAILY
2. Acetaminophen 1000 mg PO TID
3. TraMADOL (Ultram) 12.5 mg PO Q6H:PRN pain
4. Ciprofloxacin HCl 750 mg PO Q12H
Last dose ___
5. Amlodipine 10 mg PO DAILY
6. fenofibrate 134 mg oral Daily
7. Metoprolol Tartrate 25 mg PO BID
8. Rosuvastatin Calcium 20 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Cholangitis
Choledocholithiasis
Bacteremia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
You were admitted with a blood stream infection related to a
biliary blockage. You had an ERCP that showed a blocked duct,
and a stent was placed. The stent will need to be removed in
four weeks. You were started on antibiotics and will need to
continue these antibiotics for 2 weeks in total. The last day
___.
You also had complaints of foot pain, this may be due to
neuropathy. An xray was checked and did not show a fracture.
Followup Instructions:
___
|
19666512-DS-14
| 19,666,512 | 26,077,759 |
DS
| 14 |
2155-10-16 00:00:00
|
2155-10-30 10:51:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
horse serum tetanus / Banana
Attending: ___.
Chief Complaint:
Fever
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This patient is a ___ w/ hx of alcoholic/autoimmune hepatitis on
immunosuppressive therapy who presents with fever. Fever began
yesterday and spiked to 104 at home. Endorses urinary frequency
and urgency. Denies dysuria, hematuria. Pt denies chills,
rigors, HA, CP, SOB/cough, abdominal pain, diarrhea, melena. No
rash, sick contacts, recent travel.
In ED, pt febrile to 102.0, tachy to 102 w/ BP 130/56. Labs
notable for WBC 2.0, Hct 23 (baseline), lactate 2.1, Cr 1.4
(baseline 0.8). LFTs signif for Tbili 1.6. UA w/ many WBC and
bacteria. CXR with possible infiltrate. Pt received 400mg IV
ciprofloxacin and 2L NS in ED, Upon transfer vitals were 97.6
97/51 88 14 100%
On floor, abx changed to IV ceftriaxone. Pt remained afebrile
and is currently comfortable.
Past Medical History:
1. ETOH and autoimmune hepatitis - on immunosuppression since
___. Child's A cirrhosis.
3. HTN
4. COPD
5. Gout
6. Bladder cancer s/p 3 resections
7. BPH
Social History:
___
Family History:
Father with carotid artery disease, mother died of ___,
sister died of colon cancer
Physical Exam:
VITALS: 97.7 104/57 78 20 97% RA
GENERAL: well appearing
HEENT: EOMI, sclera non-icteric
NECK: no carotid bruits, no LAD
LUNGS: CTAB no W/R/R
HEART: RRR, normal S1 S2, no MRG
ABDOMEN: Soft, NT, NABS, no organomegaly, no fluid wave
EXTREMITIES: 2+ pitting ___ edema bilaterally, palmar erythema,
spiders on chest
NEUROLOGIC: A+OX3, normal mentation, ___ strength throughout,
preserved sensation
Pertinent Results:
___ 07:48PM LACTATE-2.1*
___ 07:40PM GLUCOSE-122* UREA N-41* CREAT-1.4*
SODIUM-129* POTASSIUM-4.4 CHLORIDE-96 TOTAL CO2-23 ANION GAP-14
___ 07:40PM CALCIUM-7.9* PHOSPHATE-2.9 MAGNESIUM-2.0
___ 07:40PM WBC-2.0* RBC-1.92* HGB-7.8* HCT-23.1*
MCV-121* MCH-40.6* MCHC-33.7 RDW-25.2*
___ 07:40PM NEUTS-73* BANDS-3 LYMPHS-12* MONOS-9 EOS-0
BASOS-0 ___ METAS-3* MYELOS-0
___ 07:40PM ___ PTT-28.3 ___
___ 07:40PM URINE COLOR-Yellow APPEAR-Hazy SP ___
___ 07:40PM URINE RBC-4* WBC-42* BACTERIA-MANY YEAST-NONE
EPI-0 TRANS EPI-<1
URINE CULTURE (Final ___:
ESCHERICHIA COLI. PRESUMPTIVE IDENTIFICATION.
>100,000 ORGANISMS/ML..
Piperacillin/tazobactam sensitivity testing available
on request.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ <=2 S
AMPICILLIN/SULBACTAM-- <=2 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
Blood Culture, Routine (Final ___:
ESCHERICHIA COLI. FINAL SENSITIVITIES.
Piperacillin/Tazobactam sensitivity testing performed
by ___
___.
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----- S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
TTE ___:
IMPRESSION: Mild mitral regurgitation without discrete
vegetation. Mild symmetric left ventricular hypertrophy with
preserved global and regional biventricular systolic function.
Pulmonary artery hypertension. Dilated ascending aorta.
___ 06:35AM BLOOD WBC-3.8* RBC-2.23* Hgb-8.7* Hct-27.4*
MCV-123* MCH-38.9* MCHC-31.6 RDW-24.5* Plt Ct-93*
___ 06:35AM BLOOD Glucose-113* UreaN-30* Creat-0.8 Na-137
K-4.1 Cl-104 HCO3-29 AnGap-8
___ 06:40AM BLOOD ALT-38 AST-37 LD(LDH)-215 AlkPhos-100
TotBili-1.5
Brief Hospital Course:
#Septicemia: Blood cultures grew pan-sensitive GNRs. Urine
culture was positive for E. coli sensitive to ceftriaxone. The
likely source of Mr. ___ septicemia was thought to be his
urinary tract infection, but given his immunocompromised status,
PNA, SBP, and ABE were also considered. Endocarditis thought
unlikely as GNRs do not usually cause ABE, and TTE did not show
vegetations. PNA also unlikely as Mr. ___ was without
respiratory symptoms and his lung exam was normal. He had no
symptoms of gastroenteritis, meningitis, or acute hepatitis.
Patient remained afebrile on ceftriaxone and was discharged home
on ciprofloxacin x 10d.
# ETOH/autoimmune cirrhosis: No evidence of acute
decompensation. ALT and Tbili slightly elevated upon admission,
likely due to SIRS, but later returned to normal. Azathioprine
and budesonide were continued.
# Anemia/pancytopenia: Anemia and leukopenia were likely
secondary to bone marrow suppression from azathioprine. Low
platelts secondary to cirrhosis. Hematocrit was at pt's
baseline. Pt was scheduled for transfusion as an outpatient that
was missed due to his admission. Transfusion was not performed
in house due to bacteremia, but Hct remained stable.
# ___: Cr elevated to 1.4 on admission and was likely prerenal.
Returned to baseline of 0.8 with rehydration with hydration.
# ___ edema: Significant ___ edema, above pt's baseline. He
received 2L NS in ED. Recently d/c'ed all diuretics per Dr.
___. Pt was diuresed with boluses of IV Lasix with some
improvement.
# Gout: Stable. Continued renally dosed allopurinol.
# BPH: Stable. Continued doxazosin.
TRANSITIONAL ISSUES:
# Surveillance blood cultures pending
# Discuss need for outpatient diuresis for ___ edema.
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from webOMR.
1. Allopurinol ___ mg PO DAILY
2. Azathioprine 100 mg PO DAILY
3. Budesonide 9 mg PO DAILY
4. Doxazosin 8 mg PO HS
5. Aspirin 81 mg PO DAILY
6. saw ___ *NF* 160 mg Oral daily
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Azathioprine 100 mg PO DAILY
3. Budesonide 9 mg PO DAILY
4. Doxazosin 8 mg PO HS
5. saw ___ *NF* 160 mg Oral daily
6. Ciprofloxacin HCl 500 mg PO Q12H Duration: 10 Days
RX *ciprofloxacin 500 mg 1 tablet(s) by mouth twice a day Disp
#*14 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Urinary tract infection, septicemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. ___,
You were ___ to the hospital for a fever and found to have
a urinary tract infection and an infection in your blood. We
treated your infections with IV antibiotics, and your fever
never returned. We performed an echocardiography (ultrasound of
the heart), which did not show any infection in your heart.
We believe that an interaciton between two of your medications
(allopurinol and azathioprine) caused a weakening of your immune
system that may have lead to infection. We have made the
following changes to your medications:
1. allopurinol - we have STOPPED this medication.
2. ciprofloxacin - we have added this medication to treat your
infections.
Please take all medications as prescribed, and please keep all
follow-up appointments.
We wish you a quick recovery.
Followup Instructions:
___
|
19666541-DS-10
| 19,666,541 | 22,248,631 |
DS
| 10 |
2113-09-25 00:00:00
|
2113-09-26 18:42:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
diarrhea
Major Surgical or Invasive Procedure:
Sigmoidoscopy
Ureteral stent placement
Right tunneled line placement
History of Present Illness:
___ admitting MD
HPI: The patient is a ___ y/o M with PMHx of colonic polyps,
kidney stones, anemia, who presented with persistent diarrhea.
The reports 2 months of persistent watery diarrhea. He endorses
associated periumbilical prior to having BM's, which improves
after having BMs. He endorses up to 10 BM's a day (he told the
ED
___ BMs a day). He initially describes the stool as watery and
non-bloody. However, he later tells me that his stools today
have had mucous and blood (not saved per RN). He endorses LOA
and weight loss (20 lbs since ___, 4 lbs in the last month). He
does endorse associated pruritus as well. No nausea. He denies
fevers, chills, night sweats. He did travel to ___ for a month
last ___. Has been taking Lomotil at home for these s/s.
In addition to these symptoms, he also have noted that he has
been urinating less, which he attributes to decreased PO intake.
No dysuria, hematuria, or back pain. He reports that current
pain is not similar to prior pain that he had with kidney
stones.
Of note, the patient also endorses frequent cold-like symptoms
(rhinorrhea, sneezing, fevers, fatigue). Last 1 month ago. He
takes amoxicillin and an unspecified ___ medication for
these symptoms. He also endoreses difficulty sleeping, for which
he takes a medication that was prescribed by a doctor in ___.
ED Course:
Initial VS: 99.6 107 125/69 18 99% RA
Tm 100.0
Labs significant for mild leukocytosis (10.3, 10.6). H/H
7.9/27.1
-> 7.5/25.2. Cr 1.7->1.3. Lactate 1.1. CRP 15.2. UA with small
leuks and small blood, no bacteria.
Imaging: CT A/P showed severe colonic wall thickening of the
sigmoid colon with mild surrounding fat stranding, as well as
moderate left hydroureteronephrosis leading up to a 1.1 cm stone
in the left mid ureter.
Meds given:
___ 23:56 IVF LRLR 1000 mL
___ 00:37 IV Ondansetron 4 mg
___ 03:30 IV CefTRIAXone 1 g
___ 05:05 IV MetroNIDAZOLE 500 mg
VS prior to transfer: 98.4 105 126/70 18 99% RA
ED Exam:
Gen: Comfortable, No Acute Distress
HEENT: NC/AT. EOMI.
Neck: No swelling. Trachea is midline.
Cor: RRR. No m/r/g.
Pulm: CTAB, Nonlabored respirations.
Abd: Soft, nondistended, mild epigastric tenderness. No CVA
tenderness.
Ext: No edema, cyanosis, or clubbing.
Skin: No rashes. No skin breakdown
Neuro: AAOx3. Gross sensorimotor intact.
Psych: Normal mentation.
Heme: No petechia. No ecchymosis.
GU: No scrotal tenderness or mass. No gross blood. Guaiac
positive watery stool.
He underwent L ureteral stent placement by urology prior to
admission to the floor. His blood cx also returns with GPC's for
which he was started on vancomycin.
On arrival to the floor, the patient reports the story as above.
The patient also endorses taking several ___ medications and
herbs which he is unable to name.
Past Medical History:
-Hydronephrosis ___ nephrolithiasis s/p nephroureteral stent c/b
hematuria
-PVC
-Hemorrhoid
-B cell lymphoma (c/b colonic ulceration, contained perforation,
and fistula to ileum)
-Chronic diarrhea ___ fistula
-Strep Bacteremia
-Anemia
-Severe malnutrition
-Zinc Deficiency
Social History:
___
Family History:
As per admitting MD:
Reports that his father died after getting sick with diarrhea.
Denies other FHX of GI illness.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS - ___ Temp: 98.6 PO BP: 138/65 R Lying HR: 102 RR:
18 O2 sat: 99% O2 delivery: RA
GEN - Alert, NAD, mildly cachectic
HEENT - NC/AT, MMM, mild oropharyngeal erythema without exudates
noted
NECK - Supple, no cervical LAD noted
CV - RRR, no m/r/g
RESP - CTA B, breathing appears comfortable
BACK - no CVAT
ABD - S/ND, BS present, mild tenderness to deep palpation
underlying the umbilicus without any r/g
EXT - No ___ edema or calf tenderness
SKIN - No apparent rashes
NEURO - ___ strength in all 4 extremities; face symmetric
PSYCH - Calm, appropriate
DISCHARGE PHYSICAL EXAM:
GENERAL: Sitting comfortably in bed, NAD, pleasant, calm
EYES: PERRL, anicteric
HEENT: MMM, no lesions
NECK: supple, normal ROM
___: Regular, no MRG, normal distal perfusion without edema
RESP: CTAB, no wheezing, rhonchi or crackles
GI: Soft, no rebound or guarding, non-tender. No CVAT
EXT: warm, no edema, decreased muscle bulk, no deformity
SKIN: dry, no obvious rashes, warm
NEURO: AOx3, fluent speech
ACCESS: POC c/d/i
Pertinent Results:
CT ABD/PELVIS ___:
1. Severe colonic wall thickening of the sigmoid colon with mild
surrounding fat stranding and prominent mesenteric and
retroperitoneal lymph nodes which could be infectious (eg TB),
inflammatory (eg IBD), or neoplastic (eg lymphoma) in etiology.
2. Moderate left hydroureteronephrosis leading up to a 1.1 cm
stone in the left mid ureter. Additional bilateral
nonobstructive renal calculi.
Transthoracic Echo ___:
Normal biventricular cavity sizes and regional/global
biventricular systolic function.
No valvular pathology or pathologic flow identified. Borderline
elevated estimated pulmonary
artery systolic pressure. No 2D echocardiographic evidence for
endocarditis.
CXR ___:
No radiographic evidence of active tuberculosis infection. No
acute cardiopulmonary process.
CT ABD/PELVIS WITH RECTAL CONTRAST ___:
1. Contained thick walled, likely chronic perforation measuring
3.7 x 10.2 cm on sagittal dimension located anterior to the
upper rectum with fistulous tracts connecting to distal ileum
and distal jejunum/proximal ileum. No evidence of extravasated
or extraluminal contrast.
2. Stable retroperitoneal lymphadenopathy measuring up to 1 cm.
3. Status post new left nephroureteral stent with interval
resolution of
left-sided hydronephrosis. A 8 mm calculus is still seen within
the mid left distal ureter adjacent to the stent.
4. Stable grade 1 anterolisthesis of L4 on L5.
CT ABD & PELVIS WITH CONTRAST Study Date of ___ 1:34 ___
1. Large fistulous tract between the rectosigmoid junction and a
distal ileal loop is again noted. A small sinus tract is also
unchanged.
2. No focal abscess.
3. Left nephroureteral stent in place with no hydronephrosis.
Nonobstructive 7 mm stone within the mid left ureter is again
noted.
4. Bilateral nonobstructive kidney stones.
___: ulcerated lesion 3cm in the rectosigmoid
jxn with suspected underlying chronic perforation, biopsied
CT A/P ___:
1. Large fistulous tract between the rectosigmoid junction and a
distal ileal loop is again noted. A small sinus tract is also
unchanged.
2. No focal abscess.
3. Left nephroureteral stent in place with no hydronephrosis.
Nonobstructive 7 mm stone within the mid left ureter is again
noted.
4. Bilateral nonobstructive kidney stones.
CT A/P ___:
1. Unchanged large caliber fistula from the rectosigmoid
junction to ileal
small bowel loops with a superiorly projecting sinus tract. No
evidence of extraluminal contrast. No focal fluid collections.
2. Left nephroureteral stent appears appropriate without
evidence of
hydronephrosis. 11 mm mid left ureteral stone is unchanged.
Duplex ___:
No evidence of deep venous thrombosis in the left lower
extremity veins.
=========================
LABS ON ADMISSION:
___ 10:20PM BLOOD WBC-10.3* RBC-3.31* Hgb-7.9* Hct-27.1*
MCV-82 MCH-23.9* MCHC-29.2* RDW-19.9* RDWSD-58.0* Plt ___
___ 10:20PM BLOOD Glucose-125* UreaN-19 Creat-1.7* Na-139
K-4.5 Cl-104 HCO3-24 AnGap-11
___ 10:20PM BLOOD ALT-15 AST-23 AlkPhos-39* TotBili-0.4
___ 06:00AM BLOOD LD(LDH)-342*
___ 10:20PM BLOOD Albumin-3.5 Calcium-8.8 Phos-3.4 Mg-1.7
___ 10:20PM BLOOD Lipase-13
___ 10:20PM BLOOD CRP-15.2*
___ 10:22PM BLOOD Lactate-1.1
___ 02:55AM URINE Color-Straw Appear-Clear Sp ___
___ 02:55AM URINE Blood-SM* Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-SM*
___ 02:55AM URINE RBC-1 WBC-5 Bacteri-NONE Yeast-NONE Epi-0
=========================
MICRO:
URINE CULTURE ___: NO GROWTH (FINAL)
STOOL CULTURE ___: NEGATIVE
C DIFFICILE ___: NEGATIVE
BLOOD CULTURE ___: PENDING - NO GROWTH TO DATE
BLOOD CULTURE ___: PENDING - NO GROWTH TO DATE
Time Taken Not Noted Log-In Date/Time: ___ 3:17 am
BLOOD CULTURE
Blood Culture, Routine (Preliminary):
STREPTOCOCCUS GALLOLYTICUS SSP. PASTEURIANUS
(STREPTOCOCCUS BOVIS).
FINAL SENSITIVITIES. CLINDAMYCIN MIC OF > 2 MCG/ML.
ERYTHROMYCIN MIC OF > 4 MCG/ML.
test result performed by Sensititre.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STREPTOCOCCUS GALLOLYTICUS SSP.
PASTEURIANUS (STR
|
CLINDAMYCIN----------- R
ERYTHROMYCIN---------- R
PENICILLIN G----------<=0.06 S
VANCOMYCIN------------ <=1 S
Anaerobic Bottle Gram Stain (Final ___:
GRAM POSITIVE COCCI IN PAIRS AND CHAINS.
Reported to and read back by ___ (___) ON
___ AT
15:56.
Aerobic Bottle Gram Stain (Final ___:
GRAM POSITIVE COCCI IN PAIRS AND CHAINS.
___ 3:06 am BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___:
STREPTOCOCCUS GALLOLYTICUS SSP. PASTEURIANUS
(STREPTOCOCCUS BOVIS).
Identification and susceptibility testing performed on
culture #
___ ___.
Anaerobic Bottle Gram Stain (Final ___:
GRAM POSITIVE COCCI IN PAIRS AND CHAINS.
Reported to and read back by ___ (___) ON
___ AT
15:56.
Aerobic Bottle Gram Stain (Final ___:
GRAM POSITIVE COCCI IN PAIRS AND CHAINS.
Brief Hospital Course:
___ with recent diagnosis of B cell lymphoma (c/b colonic
ulceration, contained perforation, and fistula to ileum) is s/p
C2 of CHP (vincristine removed) on ___, with hospital course c/b
strep bovis bacteremia (s/p 21 day CTX) and ___
___ obstructive stone, s/p nephroureteral stent), now s/p nadir
with improvement in counts, discharged home with outpatient
oncology followup next week
#LYMPHOMA
#ENCOUNTER FOR CHEMOTHERAPY:
Lymphoma diagnosed this admission. Most recently, pt is s/p C2
(___) of modified CHOP (vincristine removed for concern could
precipitate perforation) and tolerated it well. Per discussion
with ___, patient was monitored through nadir prior to discharge
given high risk for bowel perforation or infectious
complication. He was continued on neupogen until counts
recovered on D13. He was discharged with outpatient followup on
___ when he will receive his next cycle of chemotherapy.
Acyclovir/allopurinol ppx continued on discharge
#RECTOSIGMOID ULCERATION
#COLONIC FISTULA
#DIARRHEA:
On imaging, patient found to have thick walled, likely chronic
perforation measuring 3.7 x 10.2 cm on sagittal dimension
located anterior to the upper rectum with fistulous tracts
connecting to distal ileum and distal jejunum/proximal ileum. GI
complications ___ lymphoma with profound diarrhea thought to be
___ large ileal/sigmoid fistula. C. diff negative. Diarrhea has
lessened in frequency with lamotil/loperamide/tincture of opium.
PA for tincture of opium was pending on discharge but patient
given 1 week supply in meantime.
Patient monitored s/p 2 cycles of chemo given risk for
perforation as tumor shrinks from chemotherapy but had no
adverse events.
#STREP BACTEREMIA:
Due to gut translocation due to colonic ulceration. s/p 21 days
CTX (last day ___. At risk for re-infection given known
fistula. Accordingly, as per Dr ___ was continued
on ceftriaxone while neutropenic to prevent recurrent bacteremia
and was discharged on Augmentin ppx. Outpatient team to arrange
ID followup appointment.
#GROSS HEMATURIA
#NEPHROLITHIASIS:
___
Patient found to have ___ ___ mm calculus
within the mid left distal ureter, so had cystoscopy and
placement of left nephroureteral stent. Bladder stone was
removed during procedure. Patient had hematuria following
procedure which remained low level and stable throughout rest of
hospital course. As per urology, stenting causes chronic low
level irritation of bladder leading to hematuria which they do
not expect to resolve until his stent is removed. As for stent
removal they recommend outpatient followup at the beginning of
___ to determine timing of stent removal. Patient was counseled
regarding contingencies for worsening hematuria.
#ANEMIA IN MALIGNANCY:
#ACUTE BLOOD LOSS ANEMIA:
Complicated by GI losses from colonic ulceration + hematuria as
above. As counts improved his anemia stabilized. Transfusions
given as needed during stay. Counts to be trended by outpatient
team with next cycle of chemotherapy.
#SEVERE PROTEIN CALORIE MALNUTRITION
As above patient with severe diarrhea which improved with
anti-diarrheals but was a major factor in malnutrition. Patient
also had decreased appetite due to chemotherapy. TPN was used
temporarily, discontinued on discharge as appetite/intake had
improved. Weight and nutritional status will need to be trended
on discharge.
#Zinc Deficiency
Started on supplementation on discharge. Will need zinc levels
trended in outpatient setting to assess response to therapy
Transitional Issues:
1. Next chemo on ___. Outpatient team to determine when tunneled central line to be
removed and port placed
3. CBC to be trended with next cycle of chemotherapy
4. Augmentin ppx started on discharge. Pt will need to followup
in ___ clinic as scheduled
5. Diarrhea to be trended by outpatient team, and
anti-diarrheals adjusted as necessary.
6. Patient will need to attend outpatient urology followup to
assess when ureteral stent can be removed, and to trend his
hematuria.
7. Weight/nutritional status will need to be closely monitored.
I personally spent 74 minutes preparing discharge paperwork,
educating patient/family, answering questions, and coordinating
care with outpatient providers
___ on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Multivitamins Dose is Unknown PO Frequency is Unknown
2. Fish Oil (Omega 3) Dose is Unknown PO Frequency is Unknown
3. Amoxicillin Dose is Unknown PO Frequency is Unknown
4. Glucosamine (glucosamine sulfate) 0 mg oral unknown
5. coenzyme Q10 0 mg oral unknown
6. Amino Acid (amino acids) 0 mg oral unknown
7. ginseng 0 mg oral unknown
Discharge Medications:
1. Acyclovir 400 mg PO Q12H
RX *acyclovir 400 mg 1 capsule(s) by mouth every twelve (12)
hours Disp #*60 Tablet Refills:*1
2. Allopurinol ___ mg PO DAILY
RX *allopurinol ___ mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
3. Amoxicillin-Clavulanic Acid ___ mg PO Q12H
RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tablet(s) by
mouth every twelve (12) hours Disp #*60 Tablet Refills:*1
4. Diphenoxylate-Atropine 2 TAB PO Q6H diarrhea
RX *diphenoxylate-atropine 2.5 mg-0.025 mg 2 tablet(s) by mouth
every six (6) hours Disp #*240 Tablet Refills:*1
5. Heparin Flush (10 units/ml) 2 mL IV DAILY and PRN, line
flush
6. LOPERamide 4 mg PO Q6H
RX *loperamide 2 mg 2 tablet by mouth every six (6) hours Disp
#*240 Tablet Refills:*1
7. Ondansetron ODT 8 mg PO Q8H:PRN Nausea/Vomiting - First Line
RX *ondansetron 8 mg 1 tablet(s) by mouth every eight (8) hours
Disp #*30 Tablet Refills:*1
8. Opium Tincture (morphine 10 mg/mL) 9 mg PO Q4H:PRN diarrhea
RX *opium tincture 10 mg/mL (morphine) 1 ml by mouth every four
(4) hours Refills:*0
9. Prochlorperazine 10 mg PO Q6H:PRN Nausea/Vomiting - Second
Line
RX *prochlorperazine maleate 10 mg 1 tablet(s) by mouth every
six (6) hours Disp #*30 Tablet Refills:*1
10. Sodium Chloride 0.9% Flush 10 mL IV DAILY and PRN, line
flush
11. Zinc Sulfate 220 mg PO DAILY
RX *zinc sulfate 220 mg (50 mg zinc) 1 capsule(s) by mouth once
a day Disp #*30 Capsule Refills:*1
12. Multivitamins 1 TAB PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
#LYMPHOMA
#ENCOUNTER FOR CHEMOTHERAPY:
#RECTOSIGMOID ULCERATION
#COLONIC FISTULA
#DIARRHEA:
#STREP BACTEREMIA:
#GROSS HEMATURIA
#NEPHROLITHIASIS:
___
#ANEMIA IN MALIGNANCY:
#ACUTE BLOOD LOSS ANEMIA:
#SEVERE PROTEIN CALORIE MALNUTRITION
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were admitted because:
=====================
- You had diarrhea and were found to have a chronic perforation
of your intestine with fistulas.
-You were also found to have a mild kidney injury and an
obstructing stone, so you had a ureteral stent placed by urology
During your stay:
=============
-You were seen by GI, infectious disease, urology and surgery
doctors.
-___ were found to have a bacterial blood infection, for which
you were treated with IV antibiotics and seen by infectious
disease specialists.
-A biopsy of your colon found new lymphoma, for which you
received chemotherapy.
-You received nutrition through the IV for a while to give your
bowel some rest
-After your first round of chemotherapy, you resumed a normal
diet without issues
-A repeat CAT scan after your first round of chemotherapy showed
stable fistulas.
After you leave:
===========
-Please take your antibiotics twice daily, it will prevent you
from having a recurrence of bacterial infection. Please followup
with the infectious disease providers in clinic
-Please ensure to eat as much as possible because you loose a
lot of calories from your diarrhea
-Please continue to increase your tincture of opium until your
diarrhea is resolved
-Please be sure to attend your upcoming oncology appointment
where you will receive chemo
-Please be sure to attend your outpatient urology appointment
where stent removal and bleeding in your urine will be
discussed.
It was a privilege participating in your care! We wish you the
very best!
Sincerely,
Your ___ Healthcare Team
Followup Instructions:
___
|
19666602-DS-20
| 19,666,602 | 24,783,401 |
DS
| 20 |
2192-11-03 00:00:00
|
2192-12-27 10:12:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins / Latex
Attending: ___.
Chief Complaint:
L ear pain, headache
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ y/o with h/o HIV on HAART (per patient, last CD4 500, viral
load undetectable 3 months ago), p/w left ear pain x 5 days. He
was feeling fine until 5 days ago when he suddenly developed L
ear pain that's been getting worse. He describes the pain as
___, throbbing in nature, and affecting the ear and L side of
his head. He notes subjective fevers and chills at home. He
denies otorrhea, hearing loss, nasal congestion, sore throat,
neck stiffness, productive cough, chest pain, abd pain, n/v,
urinary sx. Of note, pt says that he has not been taking his
HAART as prescribed. He also reports that he fell and hit his
head 2 weeks ago with LOC but did not get evaluated at that
time.
In the ED, he was complaining of severe L-sided headache.
Non-con CT Head showed no acute intracranial process, but
opacification of the left mastoid air cells and left middle air
cavity consistent with otomastoiditis. ENT saw the patient and
recommended unasyn x24 h with transition to amoxicillin for
total ___ days, pseudophed, flonase, medrol dosepak.
In the ED, initial vitals- T: 98.9 97 132/69 18 99%
Labs showed WBC 8.6, lactate 1.5, negative UA. BCx x2 pending.
Vitals prior to transfer: 98.6 78 130/68 17 100% RA.
Currently, he continues to complain of ___ throbbing L-sided
headache and ear pain. He notes photosensitivity but denies
blurry vision.
Past Medical History:
- HIV Dx ___ (CD4 495 with undetectable viral load on ___
- Lipodystrophy
- HSV
- HBV exposure
- testicular hypofunction (on testosterone)
- oral hairy leukoplakia
- h/o B12 deficiency (repleted; greater than assay in ___
- HTN
- Depression/Anxiety/panic attacks
- asthma
- gerd
- headaches, migraine
- warts
- external hemorrhoids
- s/p appy
- s/p circumcision
Social History:
___
Family History:
Significant for multiple members with anxiety, depression and
bipolar disorder. Also several cancers including brain cancer
Physical Exam:
ON ADMISSION:
===========
VS: 98.6 78 130/68 17 100% RA
GEN: Alert, lying in bed with eyes closed, holding his head in
pain
HEENT: Moist MM, anicteric sclerae, ttp posterior to pinna, left
TM is bulging and erythematous, no blood or drainage.
NECK: Supple without LAD, no nuchal rigidity
PULM: Generally CTA b/l without wheeze or rhonchi
COR: RRR (+)S1/S2 no m/r/g
ABD: Soft, non-tender, non-distended
EXTREM: Warm, well-perfused, no edema
NEURO: CN II-XII intact, motor function grossly normal
ON DISCHARGE:
============
Vitals: 98.8 142/72 83 18 98% RA
General: alert, oriented, no acute distress
HEENT: PERRL, EOMI, sclera anicteric, MMM, oropharynx clear. ttp
over mastoid process.
Lungs: clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused,
Neuro: CNs2-12 intact, motor function grossly normal, F->N
testing normal. slight pronator drift.
Pertinent Results:
ON ADMISSION:
============
___ 10:44AM BLOOD WBC-8.9# RBC-3.94* Hgb-11.3*# Hct-36.1*#
MCV-92 MCH-28.7 MCHC-31.3* RDW-17.8* RDWSD-59.7* Plt ___
___ 07:11AM BLOOD WBC-8.4 Lymph-35 Abs ___ CD3%-75
Abs CD3-2213* CD4%-27 Abs CD4-795 CD8%-47 Abs CD8-1383*
CD4/CD8-0.57*
___ 10:44AM BLOOD ___ PTT-29.0 ___
___ 10:44AM BLOOD Glucose-120* UreaN-16 Creat-0.7 Na-137
K-4.4 Cl-102 HCO3-24 AnGap-15
___ 10:55AM BLOOD Lactate-1.5
ON DISCHARGE:
===========
___ 08:00AM BLOOD WBC-7.9 RBC-3.54* Hgb-10.1* Hct-32.9*
MCV-93 MCH-28.5 MCHC-30.7* RDW-17.6* RDWSD-60.2* Plt ___
___ 08:00AM BLOOD Glucose-102* UreaN-23* Creat-0.8 Na-137
K-4.7 Cl-100 HCO3-27 AnGap-15
IMAGING:
======
Non-contrast CT Head, ___-
No acute intracranial process. Opacification of the left mastoid
air cells and left middle air cavity
worrisome for otomastoiditis. Correlate clinically.
MICRO:
=====
HIV-1 RNA is not detected.
Brief Hospital Course:
___ y/o with h/o HIV on HAART who p/w left ear pain x 5 days
likely due to acute otitis media; course below:
#Left ear pain: Pt received CT Head in ED which should
radiographic evidence of otomastoiditis. Initially, he was
started on ceftriaxone 2g IV given concern for otomastoiditis.
He received two doses. ENT evaluated the patient and diagnosed
acute otitis media without associated mastoiditis. He was
transitioned to PO antibiotics (Cefpodoxime 200 mg BID) for a
total of 10 days. He also received Prednisone 5mg x 5 days,
along with Flonase and pseudophedrine prn for decongestion. He
remained afebrile and hemodynamically stable throughout the
admission.
# HIV: Continued on home regimen truvada, ritonavir, darunavir.
He says he has not been taking his HAART consistently. CD4 795,
viral load undetectable during this admission.
CHRONIC PROBLEMS:
# Depression: He was continued on bupropion and venlafaxine
# Asthma: He was continue home fluticasone, albuterol prn
# Anxiety: He was anxious about a variety of medical conditions
during hospitalization, despite reassurance. He was continued
home clonazepam.
# GERD: He was continued on home medication, omeprazole
TRANSITIONAL ISSUES:
# Reports frequent falls over the last few months. ___ benefit
from workup of these. No falls, steady gait here
# ENT felt that he has evidence of TMJ, may benefit from mouth
guard/outpatient OMFS
#CODE Status: Full
#Contact: none listed
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amphetamine-Dextroamphetamine 15 mg PO BID
2. Albuterol Inhaler 2 PUFF IH BID
3. Darunavir 800 mg PO DAILY
4. OxyCODONE--Acetaminophen (5mg-325mg) 1 TAB PO TID
5. RiTONAvir 100 mg PO DAILY
6. Multivitamins 1 TAB PO DAILY
7. Fluticasone Propionate 110mcg 2 PUFF IH BID
8. Docusate Sodium 100 mg PO BID
9. DiphenhydrAMINE 25 mg PO Frequency is Unknown
10. ClonazePAM 1 mg PO TID
11. QUEtiapine Fumarate 25 mg PO QHS
12. Omeprazole 20 mg PO DAILY
13. Venlafaxine XR 75 mg PO DAILY
14. Emtricitabine-Tenofovir (Truvada) 1 TAB PO DAILY
15. Lisinopril 40 mg PO DAILY
16. Ibuprofen 600 mg PO Q8H:PRN Pain - Moderate
17. HydrOXYzine 25 mg PO BID
18. Gabapentin 800 mg PO TID
19. BuPROPion XL (Once Daily) 150 mg PO DAILY
Discharge Medications:
1. Cefpodoxime Proxetil 200 mg PO Q12H
RX *cefpodoxime 200 mg 1 tablet(s) by mouth twice a day Disp
#*20 Tablet Refills:*0
2. Fluticasone Propionate NASAL 1 SPRY NU BID
RX *fluticasone 50 mcg/actuation 1 SPRY NAS twice a day Disp #*1
Spray Refills:*0
3. PredniSONE 5 mg PO DAILY Duration: 3 Days
RX *prednisone 5 mg 1 tablet(s) by mouth daily Disp #*3 Tablet
Refills:*0
4. Pseudoephedrine 30 mg PO Q6H:PRN congestion
RX *pseudoephedrine HCl 30 mg 1 tablet(s) by mouth every six (6)
hours Disp #*24 Tablet Refills:*0
5. Albuterol Inhaler 2 PUFF IH BID
6. Amphetamine-Dextroamphetamine 15 mg PO BID
7. BuPROPion XL (Once Daily) 150 mg PO DAILY
8. ClonazePAM 1 mg PO TID
9. Darunavir 800 mg PO DAILY
10. DiphenhydrAMINE 25 mg PO QHS:PRN insomnia
11. Docusate Sodium 100 mg PO BID
12. Emtricitabine-Tenofovir (Truvada) 1 TAB PO DAILY
13. Fluticasone Propionate 110mcg 2 PUFF IH BID
14. Gabapentin 800 mg PO TID
15. HydrOXYzine 25 mg PO BID
16. Ibuprofen 600 mg PO Q8H:PRN Pain - Moderate
17. Lisinopril 40 mg PO DAILY
18. Multivitamins 1 TAB PO DAILY
19. Omeprazole 20 mg PO DAILY
20. OxyCODONE--Acetaminophen (5mg-325mg) 1 TAB PO TID
21. QUEtiapine Fumarate 25 mg PO QHS
22. RiTONAvir 100 mg PO DAILY
23. Venlafaxine XR 75 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: acute otitis media
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You came in with ear pain. We found that you have an infection
in your ear. We treated you with IV antibiotics, and are sending
you home on oral antibiotics. You should take this antibiotic
(Cefpoxidime) with breakfast and dinner for 10 days. You should
also take Prednisone for 3 more days for the ear infection. You
can continue to take Flonase and pseudoephedrine as needed to
help with congestion.
If you develop fevers or chills, please call your doctor or come
back to the Emergency Department.
It was a pleasure taking care of you, and we are happy that you
are feeling better!
Followup Instructions:
___
|
19666743-DS-7
| 19,666,743 | 21,595,401 |
DS
| 7 |
2151-01-15 00:00:00
|
2151-01-24 15:09:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
Bronchoscopy
History of Present Illness:
___ female nursing home resident, history of CHF, COPD, anemia,
CAD, DM and HTN presenting with shortness of breath since
yesterday with O2 sats ___ the ___ per first responders, up to
100% on non-rebreather, brought ___ by ambulance to ___ ED. She
was noted to be confused but denied abdominal pain or chest pain
at the time. CXR at the nursing home showed pulmonary vascular
congestion, Hct 22.8 and hgb 6.6, Cr 1.6. Exam showed mildly
guaiac positive stools. She was transferred to ___ ED for
further care.
Initial vitals ___ the ED were T97.6F, HR 80, BP 128/58, RR 32,
100% on NRB. Lung exam without rales, no edema, guaiac positive
brown stool. Labs confirmed anemia with Hgb 6.3, Hct 21.7, INR
1.0, BNP 2984, BUN/Cr 69/1.6, negative D-dimer. CXR again
showed evidence of pulmonary congestion, CTPA showed collapsed
RML. She was started on Vanc/Zosyn for possible HCAP ___ RML,
given ASA and 40mg IV lasix, foley was placed. She continued to
be tachypneic to the ___ and dependent on NRB, was noted to be
tripoding and speaking only 1 word at a time, initially improved
on BiPAP but then appeared to be tiring out so was itubated with
etomidate/succ with ___ (so bronchoscopy can be done for RML
collapse), sedated with fentanyl/midazolam, CXR confirmed chest
tube placement. Subsequent vitals BP 148/70, HR 71, RR 16 100%
on 60 FiO2, PEEP 8. Blood pressures trended down just prior to
transfer to ___ ___.
On arrival to the MICU patient is intubated and sedated, with a
unit of blood hanging. Family members had been ___ ED (sister and
niece) said patient was at baseline mental status on
presentation to ED and then became more altered. Sister who is
HCP was called and says other sister and niece went to visit 2d
prior to admission and pt was complaining of URI symptoms,
general malaise, looked pale, brother went yesterday and said
she looked "terrible", pale and "swollen", seemed to be having
trouble breathing. No f/c, cough, n/v/d, no chest pain,
abdominal pain but did complain of decreased appetite. Has
required blood transfusions ___ past for "anemia" no source of
bleeding found, most recent about ___ ago. Past (last ___ ago)
colonoscopies have showed many polyps ___ at a time) but poor
prep. Thinks last colonoscopy at ___.
Review of systems:
unable to obtain
Past Medical History:
CHF (no echo currently available)
COPD (unknown PFTs), ?no home O2
Anemia unknown baseline
CAD unknown details
DM
HTN
colonic polyps (about a dozen small polyps on last colonoscopy
___ ago at ___ per sister)
Social History:
___
Family History:
Non-contributory
Physical Exam:
Admission Physical Exam:
Vitals: T:98.5 BP:94/45 P: 61 R:16 O2: 95% on CMV PEEP 5, TV
450, FiO2 60%
General: Intubated and sedated
HEENT: Sclera anicteric, pupils pinpoint and minimally reactive,
MMM, ET tube ___ place
Neck: supple, JVP not elevated, firm submandibular ?mass on
right
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally with coarse breath
sounds, no wheezes, rales, ronchi
Abdomen: soft, non-tender, obese, non-distended, bowel sounds
present, no organomegaly
GU: foley ___ place with yellow urine
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: exam limited by sedation
Discharge Exam
VS - 98.4 144/63 93 22 100% 2L
GEN - Alert and oriented x 0. Very pleasant
HEENT - NCAT, MMM, EOMI, sclera anicteric, OC/OP clear
NECK - supple, no JVD, no LAD
PULM - much more clear today, minimal rhonchi
CV - RRR, S1/S2, no m/r/g
ABD - soft, NT/ND, normoactive bowel sounds, no guarding or
rebound
EXT - WWP, no c/c/e, 2+ pulses palpable bilaterally
NEURO - CN II-XII intact, motor function grossly normal
SKIN - no ulcers or lesions
Pertinent Results:
Admission labs:
___ 05:35PM BLOOD WBC-7.0 RBC-2.59* Hgb-6.3* Hct-21.7*
MCV-84 MCH-24.3* MCHC-29.1* RDW-17.4* Plt ___
___ 05:35PM BLOOD Neuts-80* Lymphs-12* Monos-7 Eos-1 Baso-0
___ 05:35PM BLOOD Hypochr-2+ Anisocy-2+ Poiklo-1+
Macrocy-NORMAL Microcy-1+ Polychr-1+
___ 05:35PM BLOOD ___ PTT-30.5 ___
___ 05:35PM BLOOD Glucose-161* UreaN-69* Creat-1.6* Na-138
K-4.9 Cl-101 HCO3-24 AnGap-18
___ 05:35PM BLOOD ALT-59* AST-70* LD(LDH)-293* AlkPhos-75
TotBili-0.2
___ 05:35PM BLOOD Calcium-8.5 Phos-5.2* Mg-2.4 Iron-16*
___ 05:35PM BLOOD calTIBC-415 Hapto-254* Ferritn-36 TRF-319
___ 06:02PM BLOOD Type-ART pO2-266* pCO2-46* pH-7.33*
calTCO2-25 Base XS--1 Intubat-NOT INTUBA
___ 06:02PM BLOOD Lactate-1.6
___ 06:02PM BLOOD freeCa-1.08*
___ 05:35PM BLOOD Digoxin-1.1
___ 05:35PM BLOOD proBNP-2984*
___ 05:35PM BLOOD cTropnT-<0.01
___ 06:40PM URINE Color-Straw Appear-Clear Sp ___
___ 06:40PM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
___ 06:40PM URINE RBC-<1 WBC-<1 Bacteri-NONE Yeast-NONE
Epi-1
Discharge Labs
___ 05:34AM BLOOD WBC-7.2 RBC-2.93* Hgb-7.2* Hct-24.9*
MCV-85 MCH-24.6* MCHC-29.0* RDW-16.8* Plt ___
___ 05:34AM BLOOD Glucose-127* UreaN-33* Creat-1.0 Na-144
K-4.2 Cl-101 HCO3-36* AnGap-11
___ 05:34AM BLOOD CK(CPK)-71
___ 05:34AM BLOOD Calcium-9.5 Phos-3.3 Mg-2.3
MICRO:
Blood Culture, Routine (Final ___:
ENTEROCOCCUS FAECIUM. FINAL SENSITIVITIES.
Tigecycline Sensitivity testing per ___ ___.
HIGH LEVEL GENTAMICIN SCREEN: Susceptible to 500 mcg/ml
of
gentamicin. Screen predicts possible synergy with
selected
penicillins or vancomycin. Consult ID for details.
HIGH LEVEL STREPTOMYCIN SCREEN: Resistant to 1000mcg/ml
of
streptomycin. Screen predicts NO synergy with
penicillins or
vancomycin. Consult ID for treatment options. .
Daptomycin = SENSITIVE (3 MCG/ML), Sensitivity testing
performed
by Etest.
Tigecycline = 0.094 MCG/ML , Susceptibility results
were obtained
by a procedure that has not been standardized for this
organism
Results may not be reliable and must be interpreted
with caution.
SENSITIVITIES: MIC expressed ___
MCG/ML
_________________________________________________________
ENTEROCOCCUS FAECIUM
|
AMPICILLIN------------ =>32 R
DAPTOMYCIN------------ S
LINEZOLID------------- 2 S
PENICILLIN G---------- =>64 R
VANCOMYCIN------------ =>32 R
Anaerobic Bottle Gram Stain (Final ___:
GRAM POSITIVE COCCI ___ CHAINS.
Reported to and read back by ___ AT 2PM ON
___.
**Other blood cultures are pending and have are no growth to
date**
___ 6:39 am SPUTUM Source: Endotracheal.
**FINAL REPORT ___
GRAM STAIN (Final ___:
___ PMNs and <10 epithelial cells/100X field.
2+ ___ per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS.
2+ ___ per 1000X FIELD): GRAM POSITIVE ROD(S).
2+ ___ per 1000X FIELD): GRAM NEGATIVE ROD(S).
2+ ___ per 1000X FIELD): GRAM NEGATIVE DIPLOCOCCI.
SMEAR REVIEWED; RESULTS CONFIRMED.
RESPIRATORY CULTURE (Final ___:
SPARSE GROWTH Commensal Respiratory Flora.
Legionella ag negative, urine culture negative.
IMAGING:
___ CXR
IMPRESSION:
Mild pulmonary edema.
___ CTPA
IMPRESSION:
1. No acute aortic pathology or pulmonary embolism.
2. Interlobular septal thickening and ground-glass opacities
likely represent congestive heart failure ___ the setting of
cardiomegaly, right atrial enlargement and small right pleural
effusion.
3. Right middle lobe collapse with occlusion of the right
bronchus
intermedius. Markedly narrowed mainstem bronchi. No obvious
endobronchial
lesion seen, but correlation with bronchoscopy is suggested.
4. Enlarged mediastinal lymph nodes and hilar lymph nodes.
Echocardiogram
The left atrium is mildly dilated. The right atrium is
moderately dilated. No atrial septal defect or patent foramen
ovale is seen by 2D, color Doppler or saline contrast at rest.
There is mild symmetric left ventricular hypertrophy. The left
ventricular cavity size is normal. Due to suboptimal technical
quality, a focal wall motion abnormality cannot be fully
excluded. Overall left ventricular systolic function is low
normal (LVEF 50%). The right ventricular free wall thickness is
normal. The right ventricular cavity is dilated with borderline
normal free wall function. The aortic valve leaflets (3) are
mildly thickened. The mitral valve leaflets are mildly thickened
(mild posterior leaflet MVP may be present). Mild to moderate
(___) mitral regurgitation is seen. There is borderline
pulmonary artery systolic hypertension. There is a small
pericardial effusion. There are no echocardiographic signs of
tamponade.
Due to the technically suboptimal nature of this study, the
severity of mitral regurgitation is probably significantly
underestimated by the color-flow imaging. Transesophageal
echocardiography is recommended if clinically indicated.
Brief Hospital Course:
___ female nursing home resident, history of CHF, COPD, anemia,
CAD, DM and HTN presenting with shortness of breath, respiratory
failure and anemia ___ setting of recent URI symptoms, found to
have RML collapse and requiring intubation ___ the setting of
concern for tiring out ___ the ED, admitted to the MICU.
# Hypoxia: Presented with sats ___ ___ requiring NRB, and
required intubation when appeared to be tiring out ___ the ED.
Most concerning for CHF exerbation as discussed below, possibly
triggered by URI. Vent measurements were not consistent with
COPD exacerbation. Pulmonary embolism effectively ruled out ___
patient with low Wells score, neg d-dimer, and negative CTPA.
She was successfully extubated prior to being called out from
the MICU, but was still requiring supplemental O2. She was
given a few doses of IV lasix ___ the MICU as well, which may
have contributed to her approval. While on the floor, she
continued to require 2L O2 and desatted to the upper ___ on room
air. The thought was she likely has both a COPD and CHF
component contributing to her increased O2 requirement
# RML collapse: CT showed RML collapse and narrowed airways,
bronchoscopy showed only narrowed airways, and scoped could not
be passed into the RML brochus. No fevers or leukocytosis on
initial presentation but was initially treated empirically for
HCAP with vanc/zosyn/azitho (day 1 ___, but these were
switched to daptomycin/zosyn when blood cultures grew VRE as
discussed below and ID was consulted. Daptomycin was started
instead of linezolid because she is on citalopram and there is a
black box contraindication. Sputum cultures grew only
respiratory flora, however she did spike fevers and source of
VRE was not identified, so broad antibiotic coverage was
continued upon being called out of the MICU. Urine legionella
was negative, as was flu swab. Zosyn was later discontinued as
patient did not clinically look like she had pneumonia. Her
clinical status did not change off of zosyn.
#VRE ___ blood culture: Unclear source, no indwelling lines,
urine cultures were negative. Discontinued vancomycin (had been
febrile on this), consulted ID, changed coverage to zosyn and
daptomycin. TEE was negative for vegetations, but suboptimal
image quality commented on ___ report. Daily surveillance
cultures were negative. ID planned for a 2 week course of
dapto. Her CK was monitored. A PICC line was placed for plans
to complete her course on ___
# Acute on chronic heart failure: TTE this admission with EF of
50%, so likely mostly diastolic etiology. Presented with
dysnpea, hypoxia, pulmonary edema on imaging, elevated BNP,
suggestive of left sided failure. Minimal lower extremity edema
appreciated. She was diuresed with IV furosemide boluses while
PO daily dose was held, and was net negative 3L at time of
transfer from MICU. Digoxin level was 1.1 on admission, this was
rechecked and restarted. Lisinopril was held for acute kidney
injury, and metoprolol was converted to shorter acting while ___
the MICU. On the floor, we tried to diurese her more with IV
lasix but her Cr bumped, indicating she may be at her baseline
with 2L of O2. We then resumed her home dose oral lasix. We
also discontinued her digoxin as there was no clear systolic
component to her heart failure per her echo. Her lisinopril was
restarted at discharge
# Dementia with superimposed dementia: Oriented to person and
place at baseline, usually not date. More acutely confused ___ ED
as respiratory status decompensated, with escalating agitation
following extubation. Continued donepezil, buspirone,
citalopram, standing seroquel. Re-added home agitation prn
medications as needed (seroquel, trazodone, ativan). She had a
great deal of agitation and confusion following extubation,
easily managed with soft restraints to avoid interference with
care and with intermittent seroquel and haldol. On the floor
she was very sedated, so trazadone, ativan, and seroquel were
all held. As she continued to be agitated at night, her PCP
recommended that the seroquel be added back for a night time
dose.
# Normocytic Anemia: Presented with Hgb 6.3, Hct 21.7 with labs
3wk prior showing hct 27, and ___ showing hct 30, symptomtic
with SOB but with expanded differential as discussed above,
otherwise asymptomatic. Most likely explanation is slow GI
bleeding from known polyps seen on colonoscopy ___ ___ or
esophagitis seen on EGD ___ ___. Hemolysis labs were negative,
iron studies showed significant iron deficiency. She received 1
unit pRBC transfusion ___ the ED this admission and was
hemodynamically stable with stable hematocrits thereafter. GI
was consulted but there was no indication for urgent endoscopy.
Colonoscopy was recommended as an outpatient as Hct was stable
here
# Acute kidney injury: Creatinine elevated to 1.6 on admission
with BUN 69 suggestive of prerenal etiology. Baseline creatinine
1.1 ___ late ___. Most likely due to volume depletion ___
setting of acute illness and possible subacute GI bleeding, as
well as renal vascular congestion from heart failure. Improved
with blood transfusion as well as diuresis, likely due to
improved renal perfusion. Urine lytes were not exceptionally low
___ sodium but were obtained while patient taking furosemide.
ACEI was held until discharge when creatinine improved
# Paroxysmal atrial fibrillation: Formerly on coumadin, but no
long anticoagulated because of history of GI bleeding, confirmed
with PCP ___. Had Afib with RVR while ___ the MICU,
maintained blood pressures, acheived rate control with
metoprolol, diltiazem, digoxin. Pt went back into sinus on the
floor. Dig was stopped as above.
CHRONIC ISSUES
# COPD: We did not suspect exacerbation triggered by URI at this
time as patient without wheezing, has good air movement,
measurements on ventilator including plateau pressures and PIP
not consistent with COPD flair. Continued
Fluticasone-Salmeterol, tiotropium, added prn albuterol.
# HTN: Borderline low blood pressures on admission to MICU,
metoprolol was continued but converted to short acting,
diltiazem initially held but then gradually restarted for rate
control ___ short acting form, lisinopril held for ___, PO
furosemide held for diuresis with IV furosemide, and then
restarted on the floor. She was kept on short acting metoprolol
and diltizem on the floor and discharged with her home doses
# CAD: continued ASA 81mg
# DM: Held metformin, glipizde, used ISS and 70/30 at home
doses, adjusted for NPO
# Hyperlipidemia: held ___ Calcium 20 mg PO DAILY once
started daptomycin for risk of myopathy
# GERD: continued omeprazole 20 mg PO DAILY, Sucralfate 1 gm PO
TID
# Vit D deficiency: continued Vitamin D 50,000 UNIT PO 1X/WEEK
(WE)
TRANSITIONAL ISSUES:
#Patient underwent bronchoscopy and was noted to have right
middle lobe collapse with narrowing of her bronchus. The
etiology of this is unclear and needs to be addressed with her
PCP
___ was held while on daptomycin. Patient
will need CKs weekly, and will also need to have statin
restarted once daptomycin course completed
#Patient's seroquel dose was changed to qHS from BID and we d/c
the prn dose as she was over sedated. We also stopped her
trazadone and ativan. These med changes need to be readdressed.
Should her agitation continue or worsen, trazadone may need to
be restarted.
#Digoxin was stopped as patient was noted to only have
paroxysmal, not chronic afib. She remained ___ sinus rhythm on
the floor. Additionally, an echo was performed which did not
show any systolic heart failure, precluding it's need for CHF
#Pt was also noted to have FOBT+ blood ___ stool with a
normocytic anemia. GI was consulted, and given her history of
polyps, they recomended she undergo a colonoscopy as an
outpatient
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Digoxin 0.125 mg PO DAILY
2. Diltiazem Extended-Release 180 mg PO DAILY
3. Docusate Sodium 100 mg PO BID
4. Donepezil 10 mg PO HS
5. Furosemide 40 mg PO DAILY
6. GlipiZIDE 5 mg PO BID
7. Lisinopril 2.5 mg PO DAILY
8. MetFORMIN (Glucophage) 500 mg PO BID
9. 70/30 50 Units Breakfast
70/30 45 Units Dinner
Insulin SC Sliding Scale using Aspart Insulin
10. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
11. BusPIRone 10 mg PO TID
12. ___ Calcium 20 mg PO DAILY
13. Citalopram 10 mg PO DAILY
14. Acetaminophen 650 mg PO Q6H:PRN pain
15. Bisacodyl 10 mg PR HS:PRN constipation
16. Fleet Enema ___AILY:PRN constipation
17. Milk of Magnesia 30 mL PO DAILY:PRN constipation
18. Quetiapine Fumarate 12.5 mg PO BID:PRN agitation
19. traZODONE 25 mg PO Q4H:PRN agitation
20. Lorazepam 0.5 mg PO DAILY:PRN anxiety
21. Aspirin 81 mg PO DAILY
22. Metoprolol Succinate XL 50 mg PO DAILY
23. Omeprazole 20 mg PO DAILY
24. Polyethylene Glycol 17 g PO EVERY OTHER DAY constipation
25. Quetiapine Fumarate 12 mg PO BID
___ addition to prn
26. Tiotropium Bromide 1 CAP IH DAILY
27. Sucralfate 1 gm PO TID
28. traZODONE 25 mg PO HS
___ addition to prn order
29. Vitamin D 50,000 UNIT PO 1X/WEEK (WE)
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Aspirin 81 mg PO DAILY
3. Bisacodyl 10 mg PR HS:PRN constipation
4. BusPIRone 10 mg PO TID
5. Citalopram 10 mg PO DAILY
6. Docusate Sodium 100 mg PO BID
7. Donepezil 10 mg PO HS
8. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
9. Furosemide 40 mg PO DAILY
10. 70/30 50 Units Breakfast
70/30 45 Units Dinner
Insulin SC Sliding Scale using Aspart Insulin
11. Lisinopril 2.5 mg PO DAILY
12. Omeprazole 20 mg PO DAILY
13. Polyethylene Glycol 17 g PO EVERY OTHER DAY constipation
14. Sucralfate 1 gm PO TID
15. Vitamin D 50,000 UNIT PO 1X/WEEK (WE)
16. Daptomycin 450 mg IV Q24H
RX *daptomycin [CUBICIN] 500 mg 450 mg q 24 hrs Disp #*9 Bottle
Refills:*0
17. Diltiazem Extended-Release 180 mg PO DAILY
18. Fleet Enema ___AILY:PRN constipation
19. GlipiZIDE 5 mg PO BID
20. MetFORMIN (Glucophage) 500 mg PO BID
21. Metoprolol Succinate XL 50 mg PO DAILY
22. Milk of Magnesia 30 mL PO DAILY:PRN constipation
23. Tiotropium Bromide 1 CAP IH DAILY
Discharge Disposition:
Extended Care
Facility:
___
___ Diagnosis:
Primary
-Right middle lobe collapse, bronchial narrowing
-Congestive Heart failure
-Chronic obstructive pulmonary disease
-Delirium
Secondary
-Dementia with superimposed delirium
-Coronary artery disease
-Diabetes Mellitus
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Mrs. ___,
___ were admitted to ___ for shortness of
breath. ___ were found to have low oxygen levels and sent to
the ICU where they put ___ on mechanical ventilation. ___ were
given antibiotics for a possible pneumonia and also blood stream
infection. Once stabilized, ___ were sent to the floor where
your medical issues were stable
Please STOP the following medications
-Digoxin
-Ativan
-Trazadone
-___ (This interaction interacts with your current
antibiotic, please address this after ___ are done taking your
antibiotic)
We have CHANGED the following medications:
-Seroquel twice a day to just taking it at night before bed
Followup Instructions:
___
|
19666743-DS-9
| 19,666,743 | 20,245,349 |
DS
| 9 |
2151-01-26 00:00:00
|
2151-01-27 18:40:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Blood in diaper
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Patient is a ___ female with PMH of COPD on 2L home O2, dCHF,
OSA on 4L NC at night, chronic LGIB, anemia, HTN, T2DM, and
dementia (A+Ox2 at baseline), s/p several recent
hospitalizations, presenting with blood in diaper. It was
discovered this AM, after her diaper was changed, unclear if
blood was from GI or GU source. She was sent back to ___ for
evaluation.
She has had two recent complicated hospitalizations:
From ___, she was admitted to the ICU with acute
respiratory failure requiring intubation, thought to be related
to heart failure. She was diuresed 3L with good effect. She was
also treated for HCAP after bronchoscopic eval did not allow
passage into a collapsed RML, treated with vanc/zosyn/azitho,
subsequently switched to daptomycin/zosyn when blood cultures
grew VRE. She was discharged on daptomycin only. TEE
unremarkable. Hospitalization complicated by agitation and
confusion s/p extubation, responsive to seroquel and haldol. She
has presented with Hgb 6.3, Hct 21.7, compared to 3 weeks prior
showing Hct 27. FOBT positive with brown stool. Acute kidney
injury improved with diuresis and blood products.
She was re-admitted to the ICU during ___ for a new onset
anemia (HCT of 20.6) and hypoxemia on 2L O2 to the ___ with
transient hypotension. She was quickly weaned from 5L to 2L NC,
remaining stable on ___ NC with O2 sats in low ___ (baseline).
Her hypoxia appeared to be related to hypoventilation as she was
somnolent on arrival to the floor with shallow inspirations.
When awake she ventilates and oxygenates well. Due to her
underlying OSA, and inability to tolerate CPAP, she requires 4L
O2 at night for sleep. She was initially covered with vancomycin
and Zosyn for HCAP, though given fast clinical improvement and
lack of objective evidence in support of pneumonia, they were
both discontinued shortly thereafter. She was treated with 1
unit of PRBCs for her anemia, and again found to have heme
positive stool on admission, followed by GI previously who
require an outpatient colonoscopy.
In the ED, initial VS were: 98.5 85 116/56 18 92% 2L Nasal
Cannula
Mental Status: Oriented to self only. On exam denies abdominal
pain, SOB, chest pain, no complaints. She has not seen blood
from vagina or rectum. Stool was brown and guiac positive.
VS on arrival to the floor were T98.9, BP122/58, HR98, RR20,
O2sat 94% on 4___. She was A+Ox1 and in NAD with pan-negative
ROS. She is not aware that she had been in the ED or why she is
here
Past Medical History:
CHF EF 55%
COPD (unknown PFTs), on 2L home O2 (4L at night)
Anemia baseline
CAD unknown details
T2DM
HTN
colonic polyps and diverticulosis, hemorrhoids on colonoscopy
___
Social History:
___
Family History:
No history significant to this medication.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: T98.9, BP122/58, HR98, RR20, O2sat 94% on ___
GENERAL: well appearing
HEENT: NC/AT, PERRLA, EOMI, sclerae anicteric, MMM
NECK: supple, obese
LUNGS: CTA bilat, no r/rh/wh, diminished air movement, rhonchi
on R, resp unlabored, no accessory muscle use
HEART: RRR, no MRG, nl S1-S2
ABDOMEN: normal bowel sounds, soft, non-tender, non-distended,
no rebound or guarding, no masses
EXTREMITIES: 1+ pitting edema ___ bilaterally, 2+ pulses radial
and dp
NEURO: awake, A&Ox1, CNs II-XII grossly intact, muscle strength
___ throughout, sensation grossly intact throughout
GU: manual vaginal exam: clear discharge on glove. No blood.
DISCHARGE PHYSICAL EXAM:
VS: T98.7F, 103/61, HR 89, RR 20, 97%2L
GENERAL: well appearing elderly overweight woman in no distress
HEENT: NC/AT, PERRL, EOMI, OP clear, MMM
LUNGS: CTAB.
HEART: RRR, no MRG, nl S1-S2
ABDOMEN: normal bowel sounds, soft, non-tender, non-distended,
no rebound or guarding, no masses
EXTREMITIES: warm, 2+ radial, 1+ DP pulses bilat, trace pitting
edema in BLE.
NEURO: A&O to person, did not know place or year, moving all
extremities with purpose, steady gait.
Pertinent Results:
ADMISSION LABS:
___ 05:05PM BLOOD WBC-10.1# RBC-2.68* Hgb-7.2* Hct-23.3*
MCV-87 MCH-26.7* MCHC-30.7* RDW-18.6* Plt ___
___ 05:05PM BLOOD Neuts-77.2* Lymphs-14.2* Monos-5.0
Eos-2.6 Baso-0.9
___ 06:55AM BLOOD Ret Aut-4.7*
___ 05:05PM BLOOD Glucose-123* UreaN-43* Creat-1.4* Na-139
K-5.0 Cl-99 HCO3-32 AnGap-13
___ 06:55AM BLOOD CK(CPK)-1419*
___ 06:55AM BLOOD proBNP-701*
___ 06:55AM BLOOD Calcium-8.9 Phos-5.4* Mg-2.3
___ 09:18AM BLOOD Type-ART pO2-134* pCO2-67* pH-7.33*
calTCO2-37* Base XS-6
___ 05:30PM URINE Color-Yellow Appear-Clear Sp ___
___ 05:30PM URINE Blood-MOD Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-LG
___ 05:30PM URINE RBC-58* WBC-15* Bacteri-NONE Yeast-NONE
Epi-3
___ 05:30PM URINE Color-Yellow Appear-Clear Sp ___
___ 05:30PM URINE Blood-MOD Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-LG
___ 05:30PM URINE RBC-58* WBC-15* Bacteri-NONE Yeast-NONE
Epi-3
DISCHARGE LABS:
___ 05:15AM BLOOD WBC-6.0 RBC-2.92* Hgb-7.8* Hct-25.1*
MCV-86 MCH-26.8* MCHC-31.1 RDW-17.6* Plt ___
___ 05:15AM BLOOD Glucose-174* UreaN-33* Creat-1.2* Na-141
K-4.4 Cl-99 HCO3-33* AnGap-13
___ 05:15AM BLOOD Calcium-9.3 Phos-4.1 Mg-2.2
MICRO:
___ URINE CULTURE (Final ___: <10,000
organisms/ml.
IMAGING:
CXR ___
FINDINGS: As compared to the previous radiograph, there is no
relevant change. On the current image, there is no
visualization of a PICC line. Moderate cardiomegaly, tortuosity
of the thoracic aorta. Minimal fluid overload. No pleural
effusions, no pneumonia.
EKG ___: Sinus rhythm and frequent atrial ectopy in a
trigeminal pattern. Left atrial abnormality. Compared to the
previous tracing of ___ the rate has slowed. Atrial ectopy
persists without diagnostic interim change. Read by: ___
___
___ Axes
Rate PR QRS QT/QTc P QRS T
77 148 ___
Brief Hospital Course:
Patient is a ___ female with history of intermittant GIB
requiring blood transfusion, COPD, CAD, diastolic CHF and OSA
who presents to the hospital with a new episode of bright red
blood found on her diaper and downtrending hematocrit.
ACTIVE ISSUES:
======================
#LGIB: Patient presented with a history of blood on diaper:
Given patient's history of LGIB with recent admissions and
multiple polyps on recent colonoscopy this likely a recurrence
of lower GI bleed. In the ED she again had brown guiac positive
stool and was hemodynamically stable, making brisk GIB unlikely.
Recent baseline hematocrit has been ___ in the setting of
presumed chronic LGIB, and was stable on admission from last
discharge 3 days prior. Vaginal exam showed no blood, urine
showed only microscopic hematuria. She was monitored with serial
hematocrits which remained stable, and she remained
hemodynamically stable. She was transfused 1 unit pRBC for
Hgb<7. After extensive discussion with her family, the plan is
for weekly CBC at nursing home with transfusion as needed
(supportive care), with no plan for endoscopy or more aggressive
investigation, as therapeutic options could be limited and
family would like to preserve patient's quality of life as much
as possible at this time. Goals of care should continue to be
addressed after discharge.
# Dementia and superimposed delerium: Oriented to person and
place at baseline. Her home regimen is donepezil, buspirone,
citalopram, and standing seroquel which was increased to 25mg at
night, which were continued. She did require prn seroquel haldol
and soft restraints on night of admission for agitation and risk
of self-injury.
# Acute on chronic kidney injury: Baseline creatinine 1.0-1.2,
presented with Cr 1.4 and BUN elevated to 43, quickly
downtrended with minimal hydration in the ED and encouragement
of PO. Ratio consistent with prerenal etiology, though patient
appeared euvolemic on exam.
# Leukocytes on urinalysis: Given agitation/acute delirium was
initially treated empirically as UTI (did get one dose of CTX
___, though AMS could also be from being in hospital
setting. Further antibiotics were held and culture returned
negative.
# VRE bacteremia: Unclear source from prior admission, TEE was
negative as were surveillance cultures. On admission she was on
2 week course of daptomycin through her midline PICC. CK was
checked on admission which was elevated to 1419 from 45 one week
prior, so daptomycin was held and patient finished antibiotic
course with linezolid. The risk of serotonin syndrom was
discussed at length with pharmacy and it was felt that the risk
was low in patient on very low dose SSRI for short (2 day)
course of linezolid. Midline PICC was discontinued prior to
discharge.
# Diabetes: Held metformin, glipizde while admitted used ISS and
70/30 at first, but had FSGs in the ___, documented hypoglycemia
in nursing home labs as well. Changed to 44u QHS glargin +
sliding scale humalog, with some permissive hyperglycemia while
titrating in effort to avoid hypoglycemia. This will need to be
readdressed in out patient setting. She is being discharge on
glargine in effort to avoid further hypoglycemic episodes on
discharge that could increase fall risk and mortality.
CHRONIC ISSUES:
==================
# Chronic diastolic heart failure: EF 55% in ___. Euvolemic
to hypervolemic at presentation, and hemodynamically stable.
Very mild pulmonary congestion on admission CXR and BNP 701,
lower than on prior admissions. Physical exam and O2 saturation
not consistent with CHF exacerbation. She continued her
metoprolol and furosemide, lisinopril was restarted when
hematocrits were found to be stable, and she received a dose of
IV furosemide with her blood transfusion.
#HTN: Continued metoprolol, lisinopril. Diltiazem was held on
admission until hemodynamic stability confirmed, and patient was
not hypertensive or tachycardic. Consider restarting diltiazem
as outpatient.
#COPD: continued spiriva and salmetrol/fluticasone, supplemental
O2 and prn albuterol.
# CAD: restarted aspirin 81 when hematocrits proved to be
stable.
# Hyperlipidemia: Rosuvastatin 20 mg daily had been held while
on daptomycin for risk of myopathy. This should be restarted if
CK is normal in 1 week.
# GERD: continued omeprazole 20 mg PO DAILY, Sucralfate 1 gm PO
TID
# Vit D deficiency: continued Vitamin D 50,000 UNIT PO once a
week (___)
TRANSITIONAL ISSUES:
- If CK normalizing in 1 week, can restart rosuvastatin 20mg
- Restart diltiazem ER 180mg daily if pressures allow after
discharge
- Monitor sugars and adjust insulin accordingly
- Check CBC weekly, patient may need outpatient blood
transfusions as discussed with Dr. ___
- ___ amount of blood spotting on diaper may be expected given
suspected chronic low grade GI bleeding from colonic polyps
- Goals of care discussion with HCP should be continued with
outpatient providers
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Aspirin 81 mg PO DAILY
3. BusPIRone 10 mg PO TID
4. Citalopram 10 mg PO DAILY
5. Daptomycin 450 mg IV Q24H
6. Docusate Sodium 100 mg PO BID
7. Donepezil 5 mg PO HS
8. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
9. Furosemide 40 mg PO DAILY
10. 70/30 50 Units Breakfast
70/30 45 Units Dinner
Insulin SC Sliding Scale using Aspart Insulin
11. Sucralfate 1 gm PO TID
12. Bisacodyl ___AILY:PRN constipation
13. Diltiazem Extended-Release 180 mg PO DAILY
14. Fleet Enema ___AILY:PRN constipation
15. GlipiZIDE 5 mg PO BID
16. Lisinopril 2.5 mg PO DAILY
17. MetFORMIN (Glucophage) 500 mg PO BID
18. Metoprolol Succinate XL 50 mg PO DAILY
19. Milk of Magnesia 30 mL PO DAILY:PRN constipation
20. Omeprazole 20 mg PO DAILY
21. Polyethylene Glycol 17 g PO EVERY OTHER DAY constipation
22. Tiotropium Bromide 1 CAP IH DAILY
23. Vitamin D 50,000 UNIT PO 1X/WEEK (WE)
24. Quetiapine Fumarate 25 mg PO QHS agitation
25. Quetiapine Fumarate 12.5 mg PO DAILY:PRN agitation
26. Senna 1 TAB PO BID
27. Ferrous Sulfate 325 mg PO DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Bisacodyl ___AILY:PRN constipation
3. BusPIRone 10 mg PO TID
4. Citalopram 10 mg PO DAILY
5. Docusate Sodium 100 mg PO BID
6. Donepezil 5 mg PO HS
7. Fleet Enema ___AILY:PRN constipation
8. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
9. Furosemide 40 mg PO DAILY
10. Milk of Magnesia 30 mL PO DAILY:PRN constipation
11. Omeprazole 20 mg PO DAILY
12. Quetiapine Fumarate 25 mg PO QHS
13. Quetiapine Fumarate 12.5 mg PO DAILY:PRN agitation
14. Sucralfate 1 gm PO TID
15. Tiotropium Bromide 1 CAP IH DAILY
16. Vitamin D 50,000 UNIT PO 1X/WEEK (WE)
17. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN SOB/Wheeze
18. Aspirin 81 mg PO DAILY
19. Ferrous Sulfate 325 mg PO DAILY
20. Senna 1 TAB PO BID
21. Metoprolol Succinate XL 50 mg PO DAILY
22. MetFORMIN (Glucophage) 500 mg PO BID
23. Lisinopril 2.5 mg PO DAILY
24. Glargine 50 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
25. Polyethylene Glycol 17 g PO EVERY OTHER DAY constipation
26. Linezolid ___ mg PO Q12H Duration: 2 Days
Final day is ___
Discharge Disposition:
Extended Care
Facility:
___
___ Diagnosis:
primary: lower gastrointestinal bleeding
secondary: dementia, chronic obstructive pulmonary disease
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Lethargic but arousable.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear ___ was a pleasure caring for you during your hospitalization at
___. You were admitted out of concern for lower
gastrointestinal bleeding, most likely from polyps in your
colon. We followed your blood counts closely, and these were
stable, so the bleeding was most likely a ___ amount over a
long period of time, and not a rapid bleed. You had blood
transfusion while you were here. After discussion with your
family, no further investigation was started for the cause of
the bleeding as it was felt that the risk of treatment for the
cause of bleeding could likely outweight any benefit. You will
continue to have your blood checked at your nursing home, and
can have transfusions as needed as an outpatient, as we have
discussed with Dr. ___ at ___.
.
You were discharged back to your nursing facility. We added
rescue inhalers (albuterol) for your COPD to your medication
list and adjusted your insulin.
.
Please weigh yourself daily and call your doctor if your weight
increases by more than 3 pounds.
Followup Instructions:
___
|
19666749-DS-6
| 19,666,749 | 25,153,962 |
DS
| 6 |
2145-05-16 00:00:00
|
2145-05-16 16:34:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
polytrauma
Major Surgical or Invasive Procedure:
Left femur retrograde IMN ___ ___
History of Present Illness:
___ s/p MVC with anterior arch C1 fx, non-displaced Right
nightstick fx and left midshaft femur fx s/p retrograde nail
___ ___.
Past Medical History:
None
Social History:
___
Family History:
non-contributory
Physical Exam:
General: no acute distress
HEENT: C-collar in place
CV: well-perfused
Resp: non-labored
Abd: non-distended
Moves all extremities spontaneously and to command. No N/T/P.
RUE:
wrist splint in place
Fires EDC, FDS/FDP, ___, EPL/FPL
well-perfused
LLE:
incisional dressings c/d/I
Sensation intact to light touch
Fires TA, ___, ___, EDL/FDL
dp 2+
Pertinent Results:
Please see OMR for pertinent lab/radiology data.
Brief Hospital Course:
The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have C1 fracture, Left midshaft femur fracture, and
non-displaced Right ulna shaft fracture and was admitted to the
orthopedic surgery service. The patient was taken to the
operating room on ___ for Left femur retrograde IMN
(___), which the patient tolerated well. For full details
of the procedure please see the separately dictated operative
report. The patient was taken from the OR to the PACU in stable
condition and after satisfactory recovery from anesthesia was
transferred to the floor. Of note, a C-collar was placed in the
ED per standard protocol and was C-spine precautions were
maintained in OR and throughout inpatient stay. The patient was
initially given IV fluids and IV pain medications, and
progressed to a regular diet and oral medications by POD#1. The
patient was given ___ antibiotics and anticoagulation
per routine. The patient's home medications were continued
throughout this hospitalization. The patient worked with ___ who
determined that discharge to rehab was appropriate. The
___ hospital course was otherwise unremarkable.
Per Neurosurgery Spine recs, patient was advised to remain in
C-collar at all times. They did advise that it is ok to remove
for brief skin care. He should follow-up with them in 4 weeks.
At the time of discharge the patient's pain was well controlled
with oral medications, incisions were clean/dry/intact, and the
patient was voiding/moving bowels spontaneously. The patient is
WBAT in the Left lower extremity, and will be discharged on
Lovenox for DVT prophylaxis. The patient will follow up with Dr.
___ (2 weeks) per routine in addition to Dr. ___
(4 weeks). A thorough discussion was had with the patient
regarding the diagnosis and expected post-discharge course
including reasons to call the office or return to the hospital,
and all questions were answered. The patient was also given
written instructions concerning precautionary instructions and
the appropriate follow-up care. The patient expressed readiness
for discharge.
Medications on Admission:
None
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
Take for baseline pain ctrl and use Oxycodone for moderate pain
not relieved by Acetaminophen.
RX *acetaminophen 500 mg 2 tablet(s) by mouth every 8 hours as
needed Disp #*100 Tablet Refills:*1
2. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation
Use daily as needed for constipation not relieved by Senna and
Colace.
RX *bisacodyl 5 mg 2 tablet(s) by mouth daily as needed Disp
#*10 Tablet Refills:*0
3. Docusate Sodium 100 mg PO BID
Take to prevent post-operative constipation. Hold for diarrhea
or loose stools.
RX *docusate sodium [Colace] 100 mg 2 capsule(s) by mouth twice
daily Disp #*80 Capsule Refills:*0
4. Enoxaparin Sodium 40 mg SC DAILY
Start: ___, First Dose: Next Routine Administration Time
Use for 4 weeks post-operatively to prevent blood clots.
RX *enoxaparin 40 mg/0.4 mL 1 syringe subcutanesouly daily Disp
#*26 Syringe Refills:*0
5. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain
Don't take before driving, operating machinery, or with alcohol.
RX *oxycodone 5 mg ___ tablet(s) by mouth every 4 hours as
needed Disp #*50 Tablet Refills:*0
6. Senna 8.6 mg PO BID
Take to prevent post-operative constipation. Hold for diarrhea
or loose stools.
RX *sennosides [senna] 8.6 mg 2 tablets by mouth every evening
Disp #*40 Tablet Refills:*0
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Left midshaft femur fracture
C1 anterior arch fracture
Right non-displaced ulna fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY:
- You were in the hospital for orthopedic surgery. It is normal
to feel tired or "washed out" after surgery, and this feeling
should improve over the first few days to week.
- Resume your regular activities as tolerated, but please follow
your weight bearing precautions strictly at all times.
ACTIVITY AND WEIGHT BEARING:
- Weightbearing as tolerated/full weightbearing Left lower
extremity; platform weightbearing in forearm/wrist splint for
Right upper extremity; C-collar should remain in place AT ALL
TIMES. Per our Spine team, you may remove it BRIEFLY for skin
care.
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 use Lovenox daily for 4 weeks post-operatively to
prevent blood clots.
WOUND CARE:
- You may shower. No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- Please remain in your dressing and do not change unless it is
visibly soaked or falling off.
DANGER SIGNS:
Please call your PCP or surgeon's office and/or return to the
emergency department if you experience any of the following:
- Increasing pain that is not controlled with pain medications
- Increasing redness, swelling, drainage, or other concerning
changes in your incision
- Persistent or increasing numbness, tingling, or loss of
sensation
- Fever > 101.4
- Shaking chills
- Chest pain
- Shortness of breath
- Nausea or vomiting with an inability to keep food, liquid,
medications down
- Any other medical concerns
FOLLOW UP:
Please follow up with your Orthopaedic Surgeon, Dr. ___.
You will have follow up with ___, NP in the
Orthopaedic Trauma Clinic 14 days post-operation for evaluation.
Call ___ to schedule appointment upon discharge.
Please follow up with your primary care doctor regarding this
admission within ___ weeks and for and any new
medications/refills.
Physical Therapy:
Weightbearing as tolerated/full weightbearing Left lower
extremity; platform weightbearing in forearm/wrist splint for
Right upper extremity; C-collar should remain in place AT ALL
TIMES. Per our Spine team, pt may remove it BRIEFLY for skin
care--should remain in place for out of bed and showering.
Treatments Frequency:
Dressings may be changed on arrival to rehab. Change as needed
thereafter with sterile dressing and tape. ___ be left open to
air on and after POD6.
Followup Instructions:
___
|
19666878-DS-20
| 19,666,878 | 22,895,519 |
DS
| 20 |
2186-08-20 00:00:00
|
2186-08-24 11:42:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Nsaids
Attending: ___.
Chief Complaint:
Nausea, vomiting, mechanical fall
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ M PMhx angiosarcoma of the jejunum s/p resection in ___,
Stage IIa prostate cancer s/p IMRT and fiducial placement c/b
recurrent urethral bleeding, who presented to ___ ED with 7
episodes of NBNB emesis. On the day of admission at 12:30pm,
patient reported experiencing some diffuse abdominal discomfort
followed by 7 NBNB emesis. Patient reports that following this,
had a mechanical fall, landing on his R hip without head strike
or LOC. He presented to the ED for further evaluation of his
abdominal pain.
Past Medical History:
1. Peptic Ulcer disease (secondary to NSAIDs) s/p
hemigastrectomy/vagotomy in ___
2. Irritable Bowel Syndrome
3. Hepatitis- unknown type
4. Osteopenia
5. Bronchitis
Social History:
___
Family History:
Father- died of esophageal cancer. No history of colon cancer,
GI bleed, heart disease
Physical Exam:
ADMISSION PHYSICAL EXAM
PHYSICAL EXAM:
Vitals 98.5 144/78 64 20 98%RA
GENERAL: elderly male, NAD
HEENT: AT/NC, PERRL, nontender supple neck, no LAD, no JVD
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs
LUNG: CTA b/l, no wheezes, rales, rhonchi
ABDOMEN: nondistended, naBS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly, no CVA tenderness
EXTREMITIES: Full RoM at hips bilaterally, no edema
PULSES: 2+ radial/DP pulses bilaterally
NEURO: CN II-XII intact
SKIN: WWP
DISCHARGE PHYSICAL EXAM
Vitals - Tc 98.6 BP 100s/50-60s HR 50-60s 97-98RA
GENERAL: NAD
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
HEENT: AT/NC, EOMI, PERRLA, anicteric sclera, pink conjunctiva,
patent nares, MMM, good dentition
NECK: nontender supple neck, no LAD, no JVD
CARDIAC: RRR, S1/S2, no mrg
LUNG: CTAB, no w/r/r
ABDOMEN: nondistended, nontender in all quadrants, no
rebound/guarding,
PULSES: 2+ DP pulses bilaterally. RLE w/ trace pitting edema,
LLE nonedematous
NEURO: CN II-XII intact, strength ___ in all 4 ext, sensation
grossly intact
Pertinent Results:
ADMISSION LABS
___ 03:55PM BLOOD WBC-18.5* RBC-3.01* Hgb-8.1* Hct-25.6*
MCV-85 MCH-26.9* MCHC-31.6 RDW-15.9* Plt ___
___ 03:55PM BLOOD Neuts-93.1* Lymphs-3.8* Monos-2.6 Eos-0.2
Baso-0.2
___ 03:55PM BLOOD Plt ___
___ 03:55PM BLOOD Glucose-124* UreaN-21* Creat-0.9 Na-133
K-4.5 Cl-94* HCO3-28 AnGap-16
___ 03:55PM BLOOD ALT-22 AST-23 AlkPhos-145* TotBili-0.2
___ 03:55PM BLOOD Lipase-32
___ 03:55PM BLOOD cTropnT-<0.01
___ 08:12AM BLOOD cTropnT-<0.01
___ 03:55PM BLOOD Albumin-3.2* Calcium-9.1 Phos-3.6 Mg-2.1
DISCHARGE LABS
___ 08:05AM BLOOD WBC-17.7* RBC-3.18* Hgb-8.4* Hct-26.2*
MCV-82 MCH-26.4* MCHC-32.0 RDW-16.4* Plt ___
___ 08:05AM BLOOD WBC-17.7* RBC-3.18* Hgb-8.4* Hct-26.2*
MCV-82 MCH-26.4* MCHC-32.0 RDW-16.4* Plt ___
___ 08:05AM BLOOD ___ PTT-33.1 ___
___ 08:05AM BLOOD Glucose-111* UreaN-16 Creat-0.9 Na-136
K-4.4 Cl-96 HCO3-31 AnGap-13
___ 07:35AM BLOOD Amylase-73
___ 07:35AM BLOOD Lipase-19
___ 08:05AM BLOOD Calcium-9.5 Phos-3.4 Mg-1.___BD PELVIS ___:
IMPRESSION:
1. New mass in the retroperitoneum posterior to the splenic
vein is concerning for recurrent malignancy and could reflect an
enlarged, malignant lymph node conglomerate. There is adjacent
lymphadenopathy in the mesentery.
2. New heterogeneous ill-defined hypodense mass within an
enlarged right psoas muscle may represent a neoplastic process,
such as a necrotic metastasis, or infection with possible
abscess. An MRI is recommended for further distinction, and to
assess for any focal fluid collection. Adjacent right pelvic
lymphadenopathy is also new.
XRAY HIP ___:
REASON FOR EXAM: Trauma.
There is no evidence of fracture or dislocation. There are mild
degenerative changes in the hip joints bilaterally with
sclerosis of the acetabulum, osteophytes and mild decrease in
the joint space. Metallic clips project in the lower pelvis.
Residual dense barium projects over the right iliac wing in
the ascending colon and obscures the bone.
___ DOPPLER ___:
IMPRESSION: No evidence of deep vein thrombosis.
___:
MR ABDOMEN PELVIS:
IMPRESSION:
1. 5.8 x 5.7 x 4.7 cm metastatic retroperitoneal nodal mass
between the left renal vein and splenic vein. The mass is
compressing the left renal and splenic veins but both veins
remain patent.
2. 7.7 x 5.4 x 8.3 cm intramuscular metastasis within the right
psoas muscle.
3. Extracapsular extension of tumor from the left-side of the
prostate gland into the left seminal vesicle.
4. Four osseous metastases within the pelvis involving the left
iliac bone, right acetabulum and right pubic bone.
5. Left para-aortic and right external iliac adenopathy.
CT GUIDED CORE BIOPSY ___:
Successful CT-guided core biopsy of a right psoas mass. No
immediate post-procedural complications.
PATHOLOGY R PSOAS MASS: NEOPLASTIC CELLS PRESENT, consistent
with epithelioid neoplasm.
Brief Hospital Course:
___ yo M w/h/o angiosarcoma of the jejunum s/p resection, stage
IIa prostate cancer complicated by recurrent urethral bleeding,
admitted for nausea, vomiting and mechanical fall w/ no LOC.
On arrival to the ED, vital signs were stable, R hip pain ___.
Abdomen was soft without rebound or guarding. Labs were notable
for WBC 18.5, Hct 25.6 (both stable from 1 week prior). UA
showed >182 RBCs, 10 WBC, few bacteria. Cardiac biomarkers were
negative, EKG unchanged. Plain films of pelvis and hips showed
no fracture. CT abd pelvis revealed new masses in the
retroperitoneum, one posterior to the splenic vein and one
adjacent to the right psoas muscle, concerning for malignancy vs
abscess. Pt sent to OMED for further management.
Pt initially made NPO and his nausea/vomiting treated w/
antiemetics, diet advanced w/ continued resolution of sxs; pt
passing flatus, and imaging reassuring for obstruction, lipase
and amylase w/n/l. Judged likely viral in origin.
MRI performed to further evaluate masses; imaging revealed
metastatic disease in the retroperitoneum partially compressing
the L renal and splenic veins, a large metastatic mass w/in the
right psoas muscle, extension of prostatic tumor into L seminal
vesicle, and ___ metastases in the pelvis and R acetabulum. Pt
underwent CT-guided biopsy of R psoas mass; cytology was
consistent with epithelial neoplasm.
Pt remained afebrile and without signs of infection aside from a
chronically elevated ___ count of uncertain etiology. He was
sent home in stable condition to follow up with his outpatient
oncologist for further management and treatment.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Doxazosin 2 mg PO HS
2. Hydrochlorothiazide 12.5 mg PO DAILY
3. Omeprazole 20 mg PO DAILY
4. Vitamin D Dose is Unknown PO DAILY
5. Calcium Carbonate Dose is Unknown PO Frequency is Unknown
6. Vitamin B Complex 1 CAP PO DAILY
7. Lorazepam Dose is Unknown PO HS:PRN insomnia
8. Prochlorperazine Dose is Unknown PO Frequency is Unknown
Discharge Medications:
1. Calcium Carbonate 500 mg PO DAILY
2. Doxazosin 2 mg PO HS
3. Hydrochlorothiazide 12.5 mg PO DAILY
4. Lorazepam 0.5 mg PO HS:PRN insomnia
5. Omeprazole 20 mg PO BID
6. Prochlorperazine ___ mg PO Q8H:PRN nausea
7. Vitamin B Complex 1 CAP PO DAILY
8. Vitamin D 800 UNIT PO DAILY
9. Senna 1 TAB PO BID:PRN constipation
RX *sennosides [senna] 8.6 mg 1 tab by mouth twice a day Disp
#*60 Capsule Refills:*0
10. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice daily
Disp #*60 Capsule Refills:*0
11. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
RX *oxycodone 5 mg 1 capsule(s) by mouth every 4 hour Disp #*45
Capsule Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis:
Mechanical fall
Nausea/vomiting, likely gastroenteritis
Secondary diagnoses:
Angiosarcoma
Prostate cancer
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you during your stay at ___
___. You were admitted with a fall,
with nausea and vomiting. We ruled out dangerous causes of your
fall (seizure, cardiac problems), and we gave you medications
for your nausea. You were imaged, and were found to have some
new masses in your abdomen. You got an MRI to further evaluate
these, and you were also taken for biopsy to evaluate the mass.
You were discharged in stable condition to follow up with your
primary oncologist, Dr. ___. You primary oncologist will
receive the results of the biopsy.
Please make sure to avoid aspirin, NSAIDs, and any other
anticoagulant medications for 2 days after your biopsy. It will
be permitted to shower on the day after discharge, on ___.
Followup Instructions:
___
|
19666878-DS-22
| 19,666,878 | 27,290,526 |
DS
| 22 |
2186-10-04 00:00:00
|
2186-10-04 15:29:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Nsaids
Attending: ___
Chief Complaint:
AMS, emesis, dark urine
Major Surgical or Invasive Procedure:
placement of R IJ CVL
History of Present Illness:
___ w/ hx metastatic angiosacrcoma, prostate cancer and GI bleed
from rehab with generalized weakness, nausea, dark emesis.
Patient noted to have altered mental status per his family with
hallucinations for the past three days. Per EMS note, patient
was found with 500 cc brown emesis on his bed. Apparently had
increased lethargy and weakness today and started vomiting dark
emesis. He was founnd not responsive to verbal stimulus, but
responded with moaning to painful stimuli. He continued to
vomit while being moved to the stretcher and intermittently
vomited in the ambulence. O2 sats were 84% on room air and he
was put on 12 L NC.
Of note, the patient was admitted ___ due to GI
symptoms and found to have recurrence of his angiosarcoma.
Discharged at that
time and followed-up with oncology ___ with plans to start
taxol therapy. Readmitted ___ admitted with malaise,
dehydration and leukocytosis. Leukocytosis was most likely
related to progression of metastatic disease; he was found to
have progression of disease including a new metastatic lesion
around the base of the penis causing urinary retention. Urology
was consulted and placed a foley which should be in place for 6
weeks. He also had brief episodes of atrial flutter and atrial
fibrillation, but self converted into sinus (with frequent
PACs). Cardiology was consulted for question of electrical
cardioversion given poor candidacy for lifelong anticoagulation,
but as noted he self converted. He underwent a round of taxol
palliative chemotherapy on ___, which he tolerated well.
Most recent chemo was ___ and is currently at C1D13.
In the ED, initial VS were: T 99.8 P ___, BP 55/44 22 80% on RA.
patient received 4L NS and put on neo and levophed with BPs up
to the ___ systolic, Labs were notable for WBC 44.4, Lactate
5.1, received Vanc, Cefepime, protonix, UA grossly + with large
Leuks, 182 WBCs, and many bacteria. Patient was intubated for
hypoxia and altered mental status. Stool was trace guaiac
positive and OG tube w dark liquid, more consistent with gastric
content not gross blood- hct @ baseline. Currently on
versed/fent, levo 0.3 (weaned from 0.5) never started neo. He
also received IV ppi- gi aware, typed and screened but not
transfused. His CVPs were ___ and current access is a R IJ CVL,
R IJ, 2 PIV- ___.
On arrival to the MICU, patient is intubated and sedated.
Past Medical History:
PAST MEDICAL HISTORY:
# Duodenal ulcer w/ hemorrhage requiring hemigastrectomy
# Chronic obscure GI bleeding, w/ lesion in distal jejunum -
found to be jejunal mass
- s/p resection of jejunal mass found to be poorly
differentiated malignant tumor most consistent with epithelioid
angiosarcoma
# H/o colonoscopy showing diverticulosis
# CT scan showed new RP mass in ___ (see OMR for details of
scan) that was dignoased as angiosarcoma
# stage IIA prostate cancer s/p IMRT and fiducial placement c/b
recurrent urethral bleeding. He received IMRT with IGRT guidance
to fiducials of Prostate and seminal vesicle, 4500 cGy from
___ IMRT with IGRT guidance to fiducials of
Prostate, 3420 cGy from ___ and a Boost of 7920
cGy from ___- PUD ___ NSAIDs s/p
hemigasterectomy/vagotomy (___)
# Irritable Bowel Syndrome
# Hepatitis unkonwn type
# Osteopenia
# Bronchitis
Angiosarcoma History
ONCOLOGIC HISTORY:
- early ___: presented with GI bleeding and Hct in ___.
Underwent work-up including endoscopy, capsule endoscopy and
push
enteroscopy with bleeding lesion in jejunum and initially
inconclusive results.
- ___: laparotomy and segmental resection of jejunum with
poorly differentiated tumor consistent with epitheloid
angiosarcoma. Tumor was 2.5cm in diameter with negative
margines.
LN X 1 was negative.
- ___: admitted with abdominal discomfort and emesis as
well
as fall with CT scan identifying new masses in the
retroperitoneum, one posterior to the splenic vein and one
adjacent to the right psoas muscle and MRI revealing metastatic
disease in the retroperitoneum partially compressing the L renal
and splenic veins, a large metastatic mass w/in the right psoas
muscle, extension of prostatic tumor into L seminal vesicle, and
___ metastases in the pelvis and R acetabulum. Pt underwent
CT-guided biopsy of R psoas mass; consistent with angiosarcoma.
Social History:
___
Family History:
Father- died of esophageal cancer. No history of colon cancer,
GI bleed, heart disease
Physical Exam:
Admission exam:
Vitals: T:98 BP:101/52 P:79 R: 18 11 O2:100%
General: Intubated, sedated, appears cachectic
HEENT: Sclera anicteric, MMM, oropharynx clear
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,
ronchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: no foley
Ext: 3+ pitting edema throughout entire RLE, no edema on left.
Drastic difference in circumference between RLE and LLE
Neuro: PERRLA although constricted pupils
Pertinent Results:
Admission labs:
___ 10:15AM BLOOD WBC-44.4*# RBC-3.14* Hgb-8.4* Hct-27.8*
MCV-89 MCH-26.9* MCHC-30.3* RDW-17.1* Plt ___
___ 10:15AM BLOOD Neuts-96.1* Lymphs-1.9* Monos-1.7*
Eos-0.1 Baso-0.2
___ 10:57AM BLOOD ___ PTT-30.9 ___
___ 10:15AM BLOOD Glucose-99 UreaN-29* Creat-1.3* Na-139
K-4.9 Cl-102 HCO3-21* AnGap-21*
___ 04:26PM BLOOD ALT-15 AST-28 AlkPhos-128 TotBili-0.3
___ 04:26PM BLOOD Albumin-2.3* Calcium-7.2* Phos-3.1 Mg-1.9
___ 03:48AM BLOOD calTIBC-155* Ferritn-1196* TRF-119*
___ 04:26PM BLOOD TSH-3.0
___ 11:46AM BLOOD Type-ART ___ Tidal V-400 PEEP-5
FiO2-100 pO2-309* pCO2-39 pH-7.42 calTCO2-26 Base XS-1 AADO2-351
REQ O2-65 -ASSIST/CON Intubat-INTUBATED
___ 10:07AM BLOOD Glucose-106* Lactate-5.1* Na-135 K-4.0
Cl-105 calHCO3-21
MICROBIOLOGY
============
___ MRSA SCREEN-FINAL
URINE CULTURE (Final ___:
CITROBACTER ___. >100,000 ORGANISMS/ML..
SENSITIVE TO Cefepime (<=2MCG/ML).
SENSITIVE TO MEROPENEM (<=1MCG/ML).
sensitivity testing performed by Microscan.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
CITROBACTER ___
|
CEFEPIME-------------- S
CEFTAZIDIME----------- <=1 S
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ <=1 S
MEROPENEM------------- S
NITROFURANTOIN-------- 128 R
PIPERACILLIN/TAZO----- <=8 S
TOBRAMYCIN------------ 2 S
TRIMETHOPRIM/SULFA---- <=2 S
___ BLOOD CULTURE -FINAL
___ BLOOD CULTURE -FINAL
URINE STUDIES
=============
___ 10:40AM URINE Color-DkAmb Appear-Cloudy Sp ___
___ 10:40AM URINE Blood-LG Nitrite-NEG Protein-100
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-LG
___ 10:40AM URINE RBC-60* WBC->182* Bacteri-MANY Yeast-NONE
Epi-0
___ 10:40AM URINE AmorphX-FEW CaOxalX-FEW
___ 10:40AM URINE WBC Clm-FEW Mucous-FEW
OTHER PERTINENT LABS
=====================
___ 03:48AM BLOOD calTIBC-155* Ferritn-1196* TRF-119*
___ 04:26PM BLOOD TSH-3.0
___ 10:07AM BLOOD Glucose-106* Lactate-5.1* Na-135 K-4.0
Cl-105 calHCO3-21
LACTATE TREND
=============
___ 11:46AM BLOOD Lactate-1.8
___ 02:19PM BLOOD Lactate-1.7
STUDIES
=======
EKG ___
Sinus rhythm. Sinus arrhythmia. Atrial premature contractions.
Non-specific ST-T wave abnormalities. Compared to the previous
tracing of ___ no significant changes are noted.
Rate PR QRS QT/QTc P QRS T
92 0 86 ___ BILATERAL LENIs
IMPRESSION:
1. Occlusive thrombus of the right common femoral vein with
nonocclusive
extension into the right superficial femoral and deep femoral
veins.
2. No evidence of deep vein thrombosis in the left lower
extremity. Deep
peroneal veins are not visualized.
___ RENAL U/S
IMPRESSION:
1. Mild left hydronephrosis, allowing for differences in
technique, little change from CT of ___.
2. Mildly thickened bladder wall with minimal retained urine
and a Foley in place.
___ CXR
CONCLUSION: Stable right lower lung focal consolidation with
left lower lung consolidation and small pleural effusion could
be due to pneumonia or aspiration
Brief Hospital Course:
BRIEF HOSPITAL COURSE:
======================
___ year old gentleman with metastatic angiosarcasoma, locally
invasive prostate cancer currently undergoing palliative taxol
therapy (C1D13 on admission) presents with AMS found to be
hypotensive and hypoxic in septic shock.
ACTIVE ISSUES:
==============
#) Septic shock due to urosepsis- Given suspicious urinalysis
and history of retention with chronic indwelling foley, this was
most likely source. Urine grew out citrobacter, sensitive to
cefepime. Chest x-ray was without infiltrate. Gsatrointestinal
source was also be considered given known intraabdominal
metastatic disease. He was started on vancomycin, cefepime,
metronidazole; vanc and Flagyl were D/C'd, and the patient
received a full course of cefepime for citrobacter UTI. Blood
cultures remained negative. He was started on pressors in the
emergency department and intubated. Once he was stabilized in
the ICU, he was extubated and weaned off of pressors. He
remained hemodynamically stable once transferred to the medicine
floor.
#) LLE/Scrotal swelling- It was documented on previous imaging
that he has slow flow through his right femoral vein due to
right psoas mass. Given low flow state, cancer, and
unnevenness, he underwent ___ which showed occlusive thrombus
of the right common femoral vein with nonocclusive extension
into the right superficial femoral and deep femoral veins. He
was started on a heparin drip and then transitioned to Lovenox.
He also had severe scrotal edema likely related to lymphatic
obstruction. This was treated with elevation and topical
lidocaine, given associated scrotal tenderness.
#) Atrial fibrillation and Atrial flutter: He had brief episodes
of both rhythms while in house (with some episodes of a-flutter
w/ RVR). On last admission, cardiology was consulted to explore
electrical cardioversion to avoid lifelong anticoagulation, but
because he spontaneously converted back into sinus rhythm (with
PACs) during their consultation, further workup was
discontinued. He did have TTE, which was without significant
structural and valvular findings. We did not start 325mg daily
aspirin, as given his life expectancy, this is unlikely to
provide benefit.
#) Angiosarcoma: He had been undergoing palliative taxol
chemotherapy, C1D13 on day of admission. He had extensive mets
to abdomen, bone, lymph nodes. His code status was changed to
DNR/DNI in the ICU after a family meeting. Re-staging MRI was
done while on the Oncology service, which showed rapid tumor
progression. A thorough discussion was undertaken between the
managing oncology attending and team and it was discussed that
his prognosis was grave and there was unfortunately not any
possibility to control tumor growth with any known treatment,
especially given the patient's poor performance status. As
such, patient was made CMO with a focus to provide palliative
treatment. The inital plan was for him to go to a skilled
nursing facility with hospice care, but he began to decline
further and was laced on a morphine gtt. He passed away
peacefully at 11:18AM on ___.
ISSUES WHICH RESOLVED DURING ICU COURSE:
========================================
#) Hypoxia- Likely due to hypoventilation in the setting of
altered mental status. Patient's ABG in the ED showed
appropriate ventilation and oxygenation with normal pH following
intubation. No consolidation, pneumothorax, effusion on CXR and
not hypercarbic (but done after intubation, so unclear what
initial presenting PaCO2 was). In addition, given known low
flow in RLE secondary to tumor compression of vasculature and
underlying malignancy, he was at significant risk of DVT with
subsquent pulmonary embolism. Given ___ was performed
rather than CT and showed an occlusive thrombus of the right
common femoral vein with nonocclusive extension into the right
superficial femoral and deep femoral veins. He was subsequently
started on heparin gtt. His respiratory status continued to
improve and he was extubated on ___ w/o complication, repeat
ABG was normal. He had no respiratory issues while on the
Oncology floor.
#) Altered Mental Status- likely from hypoxia with associated
sepsis. He was continued on O2 therapy and sepsis was treated
as above. He was at his baseline prior to transfer out of the
ICU and continued to do well on the Oncology floor.
#) GIB- He was guaiac trace positive in the ED with gastric
contents in OG somewhat concerning for coffee-grounds. Hct at
presentation was at baseline. GI was not officially consulted,
and given his stable hematocrit he did not require EGD. His HCT
trended down to 24.4 from 27.8 on admission and he was
transfused 2U PRBCs. His HCT increased appropriately to
transfusion and remained stable afterwards.
#) ___- likely pre-renal given hypotensive with sepsis and
post-renal, as he was found to have urinary obstruction, which
resolved when urology placed a firm Foley, which he will likely
need on an ongoing basis; urology felt tumor growing into his
urethra. Also with known tumor burden in abdomen, at risk for
more proximal GU obstruction with hydronephrosis. Renal
ultrasound showed mild left hydronephrosis unchanged from prior
CT on ___. His Cr improved with fluid resuscitation and
Foley placement and was at baseline before leaving the ICU. It
remained stable on the Oncology floor.
CHRONIC ISSUES
==============
#. Hypertension: Home metoprolol was continued.
#. Prostate Cancer: Stage IIa, s/p XRT and fiducials. Not active
during this admission. Continued doxazosin. Foley placed; he
will follow up with Urology as an outpatient.
TRANSITIONAL ISSUES
===================
- Code status: DNR/DNI/CMO
- Emergency contact: ___, wife ___
___.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Calcium Carbonate 500 mg PO DAILY
2. Docusate Sodium 100 mg PO BID
3. Doxazosin 2 mg PO HS
4. Lorazepam 0.5 mg PO HS:PRN insomnia
5. Omeprazole 20 mg PO BID
6. Ondansetron 8 mg PO Q8H:PRN nausea
7. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
8. Polyethylene Glycol 17 g PO DAILY:PRN constipation
9. Prochlorperazine 10 mg PO Q6H:PRN nausea
10. Senna 1 TAB PO BID constipation
11. Vitamin B Complex 1 CAP PO DAILY
12. Vitamin D 800 UNIT PO DAILY
13. Zolpidem Tartrate 5 mg PO HS:PRN insomnia
14. Metoprolol Tartrate 25 mg PO BID
15. Mirtazapine 15 mg PO HS
16. Gaviscon Extra Strength *NF* (aluminum hydrox-magnesium
carb) 160-105 mg Oral daily with meals
17. Acetaminophen 325 mg PO Q4H:PRN pain/fever
18. Milk of Magnesia 30 mL PO DAILY:PRN constipation
19. Bisacodyl 10 mg PR HS:PRN constipation
20. Multivitamins 1 TAB PO DAILY
21. Metoclopramide 2.5 mg PO TID w meals
22. Guaifenesin ER 600 mg PO Q12H:PRN cough/congestion
Discharge Medications:
Pt expired
Discharge Disposition:
Expired
Discharge Diagnosis:
Primary: Urosepsis
Secondary:
Metastatic angiosarcoma
GI bleed
DVT
Scrotal edema
Discharge Condition:
pt expired
Discharge Instructions:
Mr. ___ was admitted to the hospital with altered mental
status, GI bleed, and sepsis due to a urinary source. He had
advanced angiosarcoma and a blood clot in your leg.
The patient continued to decline, and the family decided to make
him CMO. He was placed on a morphine gtt, and passed away
peacefully the morning of ___.
Followup Instructions:
___
|
19667160-DS-2
| 19,667,160 | 26,358,657 |
DS
| 2 |
2129-06-15 00:00:00
|
2129-06-15 20:50:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Allergies/ADRs on File
Attending: ___.
Chief Complaint:
Found down unresponsive
Major Surgical or Invasive Procedure:
Intubation and extubation
History of Present Illness:
___ with hx of a-fib found down at home, and admitted with R MCA
infarct with hemorrhagic conversion, intubated for airway
protection, a-fib/a-tach RVR refractory to cardioversion.
He was found at home by his neighbor who was doing a well check.
He had not been seen for prior 2 weeks. Patient has limited
social contacts and no known family. He was found lying on left
side, speaking but confused. FSBS 153. A-fib with HR 200-230 and
brought to ___ ___ at 7pm. There, GCS 9, BP
90/33, HR 180, LUE weakness. CT head showed large subacute
stroke R MCA distribution with secondary hemorrhagic
transformation. He was intubated and started on dilt gtt, 100g
IV mannitol, 3.5L IVF. Transferred to ___
In ED initial VS: 97.6 188 ___ 100% Intubation
- Labs notable for CK 5965, lactate 2.9, ABG ___
- Vent settings: PSV ___, 40%
- Cards was consulted. He received synchronized cardioversion x
2 without success. He was started on amiodarone bolus and gtt,
continued dilt gtt at 5/hr, and continued to be in rapid a-fib
up to 180.
- Neurology and neurosurgery were consulted who recommended no
acute intervention.
- CTA chest showed segmental PE of RML and RLL; CT/CTA head
showed Large right MCA territory hemorrhagic infarction
measuring 5.3 x 3.4 cm; Cutoff of the proximal right M2 branch
of the MCA
- Decision made to admit to MICU for control of rapid a-fib
VS prior to transfer: 99.8 160 105/65 20 100% Intubation
On arrival to the MICU, he is intubated and sedated.
Past Medical History:
atrial fibrillation
Social History:
___
Family History:
Unknown
Physical Exam:
ADMISSION
=========
VITALS: 99 150-180 ___ 18 96% vent
GENERAL: intubated, no gag reflex
HEENT: Sclera anicteric, pupils 1-2mm and non-reactive
bilaterally
NECK: supple, JVP not elevated, no LAD
LUNGS: bilateral breath sounds, Clear anteriorly
CV: tachycardic
ABD: soft, non-tender, non-distended
EXT: cool distally, no peripheral edema
SKIN: numerous skin blisters in L chest, flank, and leg
NEURO: extremities are not rigid; does not withdraw to pain;
toes downgoing b/l; patella reflexes present b/l; no clonus
DISCHARGE
=========
VITALS: 99.0, 21
GENERAL: Resting comfortably, asleep.
Respiratory: Mouth partially open with stable rate
Pertinent Results:
ADMISSION
=========
___ 11:15PM BLOOD WBC-15.1* RBC-5.03 Hgb-15.4 Hct-44.3
MCV-88 MCH-30.6 MCHC-34.8 RDW-13.1 RDWSD-42.1 Plt ___
___ 11:15PM BLOOD Neuts-85.6* Lymphs-6.2* Monos-7.2
Eos-0.0* Baso-0.1 Im ___ AbsNeut-12.91* AbsLymp-0.93*
AbsMono-1.09* AbsEos-0.00* AbsBaso-0.02
___ 11:15PM BLOOD ___ PTT-20.3* ___
___ 11:15PM BLOOD Glucose-142* UreaN-41* Creat-0.9 Na-140
K-3.8 Cl-107 HCO3-21* AnGap-16
___ 11:15PM BLOOD ALT-79* AST-150* CK(CPK)-5965* AlkPhos-72
TotBili-1.0
___ 11:15PM BLOOD cTropnT-0.01
___ 11:15PM BLOOD Albumin-3.0* Calcium-7.3* Phos-2.5*
Mg-2.0
___ 03:15AM BLOOD Osmolal-313*
___ 11:33PM BLOOD Lactate-2.9*
___ 12:17AM BLOOD Type-ART pO2-147* pCO2-28* pH-7.42
calTCO2-19* Base XS--4
PERTINENT
=========
___ 10:52AM BLOOD ___ 03:43AM BLOOD Glucose-240* UreaN-22* Creat-0.7 Na-131*
K-4.4 Cl-96 HCO3-27 AnGap-12
___ 11:15PM BLOOD ALT-79* AST-150* CK(CPK)-5965* AlkPhos-72
TotBili-1.0
___ 03:15AM BLOOD ALT-78* AST-152* LD(LDH)-595*
CK(CPK)-5783* AlkPhos-73 TotBili-1.1
___ 03:11AM BLOOD CK(CPK)-1865*
___ 11:15PM BLOOD Lipase-35
___ 03:15AM BLOOD CK-MB-47* MB Indx-0.8 cTropnT-0.01
___ 08:36AM BLOOD CK-MB-27* cTropnT-0.01 proBNP-1285*
___ 03:11AM BLOOD CK-MB-7 cTropnT-0.01
___ 04:01AM BLOOD VitB12-547 Folate-13
___ 10:52AM BLOOD Hapto-280*
___ 04:27AM BLOOD %HbA1c-6.1* eAG-128*
___ 08:36AM BLOOD Osmolal-308
___ 03:52PM BLOOD Osmolal-292
___ 03:15AM BLOOD TSH-3.5
___ 03:15AM BLOOD Free T4-1.4
___ 03:15AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 12:10AM URINE Color-Straw Appear-Clear Sp ___
___ 12:10AM URINE Blood-SM Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG
___ 12:10AM URINE RBC-5* WBC-1 Bacteri-NONE Yeast-NONE
Epi-<1
___ 03:15AM URINE bnzodzp-POS* barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG oxycodn-NEG mthdone-NEG
MICROBIOLOGY
============
> BLOOD CULTURE Final
___
After less than 24 hours From one bottle
GRAM POSITIVE COCCI IN CHAINS
GRAM POSITIVE COCCI IN PAIRS
GRAM POSITIVE COCCI, CLUSTERS
Critical value called to ED NURSE , ___
on ___ at 1147 by MIC.TB
After less than 24 hours ___ bottle
GRAM POSITIVE COCCI, CLUSTERS
Subsequent critical value
From both bottles
COAG NEG STAPHYLOCOCCUS
COAG NEG ___
mixed morphotype with same sensitivity pattern.
From one bottle : ENTEROCOCCUS FAECALIS
COAG-STAPH COAG-STAPH E
FAECALIS
M.I.C. RX M.I.C. RX M.I.C.
RX
------- ------ ------- ------ -------
------
AMPICILLIN <=2
S
CEFAZOLIN <=4 S <=4 S
CLINDAMYCIN <=0.25 S <=0.25 S
DAPTOMYCIN 0.5
S
ERYTHROMYCIN <=0.25 S <=0.25 S
LEVOFLOXACIN <=0.5 S <=0.5 S
OXACILLIN <=0.25 S <=0.25 S
TETRACYCLINE <=1 S <=1 S
TRIM/SULFA ___ S ___ S
VANCOMYCIN 1 S 1 S 2
S
GENTAMICIN SYN <=500
S
4. COAG NEG STAPHYLOCOCCUS
Target Route Dose RX AB
Cost M.I.C. IQ
------ ----- ------------------ ------ --
------ --------- ------
CEFAZOLIN S
<=4
CLINDAMYCIN SERUM X S
<=0.25
ERYTHROMYCIN SERUM X S
<=0.25
LEVOFLOXACIN SERUM X S
<=0.5
BLOOD CULTURE Final (continued)
___
4. COAG NEG STAPHYLOCOCCUS (continued)
Target Route Dose RX AB
Cost M.I.C. IQ
------ ----- ------------------ ------ --
------ --------- ------
OXACILLIN SERUM X S
<=0.25
TETRACYCLINE SERUM X S
<=1
TRIM/SULFA SERUM X S
<=0.5/9.5
VANCOMYCIN SERUM X S
1
5. COAG NEG ___
Target Route Dose RX AB
Cost M.I.C. IQ
------ ----- ------------------ ------ --
------ --------- ------
CEFAZOLIN S
<=4
CLINDAMYCIN SERUM X S
<=0.25
ERYTHROMYCIN SERUM X S
<=0.25
LEVOFLOXACIN SERUM X S
<=0.5
OXACILLIN SERUM X S
<=0.25
TETRACYCLINE SERUM X S
<=1
TRIM/SULFA SERUM X S
<=0.5/9.5
VANCOMYCIN SERUM X S
1
6. ENTEROCOCCUS FAECALIS
Target Route Dose RX AB
Cost M.I.C. IQ
------ ----- ------------------ ------ --
------ --------- ------
AMPICILLIN SERUM X S
<=2
DAPTOMYCIN S
0.5
VANCOMYCIN SERUM X S
2
GENTAMICIN SYN S
<=500
___ 11:10 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___:
STAPHYLOCOCCUS, COAGULASE NEGATIVE.
Isolated from only one set in the previous five days.
SENSITIVITIES PERFORMED ON REQUEST..
Aerobic Bottle Gram Stain (Final ___:
GRAM POSITIVE COCCI IN CLUSTERS.
___ 12:30 pm SPUTUM Site: ENDOTRACHEAL
Source: Endotracheal.
**FINAL REPORT ___
GRAM STAIN (Final ___:
>25 PMNs and <10 epithelial cells/100X field.
1+ (<1 per 1000X FIELD): MULTIPLE ORGANISMS
CONSISTENT WITH
OROPHARYNGEAL FLORA.
RESPIRATORY CULTURE (Final ___:
SPARSE GROWTH Commensal Respiratory Flora.
IDENTIFICATION END SENSITIVITIES PER ___ ___.
PROTEUS MIRABILIS. SPARSE GROWTH.
KLEBSIELLA PNEUMONIAE. RARE GROWTH.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
SENSITIVITIES: MIC expressed in
MCG/ML
________________________________________________________
PROTEUS MIRABILIS
| KLEBSIELLA PNEUMONIAE
| |
AMPICILLIN------------ <=2 S
AMPICILLIN/SULBACTAM-- <=2 S 8 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S <=1 S
CEFTAZIDIME----------- <=1 S <=1 S
CEFTRIAXONE----------- <=1 S <=1 S
CIPROFLOXACIN---------<=0.25 S <=0.25 S
GENTAMICIN------------ <=1 S <=1 S
MEROPENEM-------------<=0.25 S <=0.25 S
PIPERACILLIN/TAZO----- <=4 S <=4 S
TOBRAMYCIN------------ <=1 S <=1 S
TRIMETHOPRIM/SULFA---- <=1 S <=1 S
Test Result Reference
Range/Units
S. PNEUMONIAE ANTIGENS, Not Detected Not Detected
URINE
___ 3:26 am URINE CHEM ___ ___.
**FINAL REPORT ___
Legionella Urinary Antigen (Final ___:
NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN.
___ 3:36 pm CATHETER TIP-IV Source: R PICC line.
**FINAL REPORT ___
WOUND CULTURE (Final ___: No significant growth.
IMAGING
=======
CTA head ___:
1. Large left acute/subacute MCA territory infarct with
hemorrhagic
transformation and extensive mass effect on the right lateral
ventricle and 8 mm shift of normally midline structures to the
left as described above.
2. Abrupt cut off of the distal M1 segment of the right middle
cerebral artery with markedly diminished flow in the more distal
right MCA branches.
3. Unremarkable neck CTA aside from moderate atherosclerotic
calcifications at the carotid bifurcations. There is no
internal carotid artery stenosis by NASCET criteria.
Repeat CT head ___. Evolving large right MCA territory infarct. Hemorrhage
within the infarct centered within the basal ganglia is not
significantly changed compared to the prior study.
2. Effacement of the sulci and the right lateral ventricle as
well as leftward midline shift, unchanged when compared to the
prior study.
CT torso:
1. Segmental pulmonary emboli involving the right upper, middle
and lower
lobe.
2. Left greater than right basilar opacity, likely a combination
of
atelectasis and aspiration.
3. No sequela of trauma in the chest, abdomen, or pelvis.
___:
There is limited visualization of the left peroneal veins.
Otherwise, no
evidence of deep venous thrombosis in the remaining right or
left lower
extremity veins
TTE:
The left atrium is mildly dilated. The right atrium is
moderately dilated. No atrial septal defect is seen by 2D or
color Doppler. Left ventricular wall thicknesses and cavity size
are normal. The moderate focal hypokinesis of the inferior and
septal walls with mild hypokinesis of the remaining segments
(LVEF= 35%). There is considerable beat-to-beat variability of
the left ventricular ejection fraction due to an irregular
rhythm/premature beats. 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
(3) are mildly thickened but aortic stenosis is not present. No
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. No discrete vegetation/mass is seen. Moderate
(2+) mitral regurgitation is seen. The estimated pulmonary
artery systolic pressure is high normal. There is no pericardial
effusion.
IMPRESSION: Normal biventricular cavity size with regional and
global systolic dysfunction c/w diffuse process. Moderate mitral
regurgitation without discrete vegetation. Biatrial dilation.
Mildly dilated ascending aorta.
Brief Hospital Course:
This is a ___ year old male with past medical history of atrial
fibrillation, admitted ___ with acute R MCA stroke with
hemorrhagic conversion, acute hypoxic respiratory failure
secondary to pulmonary embolism, course complicated by
persistent atrial fibrillation with RVR, subsequently with
family deciding
on comfort measures management, subsequently enrolled in hospice
and able to be discharged to ___ facility
ACTIVE ISSUES
=============
# Acute R MCA stroke - Patient found down at home, with imaging
on presentation demonstrating large R with hemorrhagic
conversion, 11mm midline shift to left. He briefly received
mannitol and was subsequently weaned due to stability of head
imaging. He was initially unresponsive but a week into his
course started following commands, and was able to verbalize a
few words once extubated. He subsequently remained largely
hemiparetic on the left side without additional improvement.
Given likely complete, permanent dependence on care for ADLs,
decision was made my family in accordance with patients prior
wishes to transition to comfort measures. Transitioned patient
to symptom oriented medications and patient was discharged to
___ facility closer to family.
# Atrial fibrillation with RVR:
Patient with known history of atrial fibrillation who was noted
to have RVR on presentation. Cardioversion was attempted twice
without obtaining sinus rhythm. He was treated with for rate
control with metoprolol, diltiazem, and digoxin, with initial
response, but course was complicated by progressively worsening
heart rate control as well as hypotension. No anticoagulation
was given due to large hemorrhagic stroke conversion as above.
Subsequently, he was transferred to the ICU on ___ given
afib with RVR rates in the 150s with associated hypotension.
After discussion with family, patient was made CMO and all rate
control agents were discontinued.
# Acute hypoxic Respiratory failure:
# Acute bacterial pnuemonia
Patient intubated on presentation in the setting of above stroke
and hypoxia. Found to have L basilar opacity on presentation
for which he was treated with broad spectrum antibiotics.
Patient successfully extubated on ___. His respiratory status
remained stable on 2L 35% humidified o2 during the rest of his
hospitalization. Further management deferred in setting of
decision to transition to CMO as above and respiratory distress
was treated with morphine prn.
# Acute blood stream infection secondary to Coag negative staph
and enterococcus
Patient found to have Coag neg staph in 2 bottles and
enterococcus faecalis in 1 bottle, both pan-sensitive. ___ be in
setting of prolonged downtime for likely days, numerous left
sided skin wounds. TTE showed no vegetations. Patient was
Treated with vancomycin, for planned 14 day course, which was
stopped on transition to comfort measures.
# Acute segmental PE:
Found on admission CTA. No significant R heart strain on TTE.
Anticoagulation and thrombolysis deferred in the setting of
recent stroke with hemorrhagic conversion. Further management
deferred in setting of decision to transition to CMO as above.
TRANSITIONAL ISSUES
=================
- Medications, including morphine and Ativan provided on
discharge for comfort en route to hospice house.
- ___ in ___ to provide remainder of
medications such as scopolamine/glycopyrolate or additional pain
medications pending patient needs for comfort
- Multiple attempts were made to identify patients primary care
physician, to notify regarding above information, but they were
not able to be identified
#CODE: DNR/DNI, CMO
#COMMUNICATION: HCP: ___ (brother): ___
___ (sister): ___
Medications on Admission:
Unknown
Discharge Medications:
1. LORazepam 0.5-2 mg IV Q2H:PRN anxiety/distress
RX *lorazepam 2 mg/mL 0.5 (One half) mL IV every 2 hours as
needed for anxiety or distress Disp #*5 Vial Refills:*0
2. Morphine Sulfate ___ mg IV Q15MIN:PRN Pain or respiratory
distress
RX *morphine (PF) in dextrose 5 % 100 mg/100 mL (1 mg/mL) 2 mL
IV every 15 minutes as needed for sever pain or distress Disp
#*1 Bag Refills:*0
3. Morphine Sulfate 2 mg IV Q6H
RX *morphine (PF) in dextrose 5 % 100 mg/100 mL (1 mg/mL) 2 mL
IV every 6 hours Disp #*1 Bag Refills:*0
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
# Acute R MCA stroke
# Atrial fibrillation with RVR:
# Acute hypoxic Respiratory failure:
# Acute bacterial pnuemonia
# Acute blood stream infection secondary to Coag negative staph
and enterococcus
# Acute segmental PE:
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Lethargic but arousable.
Activity Status: Bedbound.
Discharge Instructions:
Dear Mr. ___,
You were initially admitted after have a large stroke. This
stroke was in the right side of your brain, which prohibited you
from moving the left side of your body very well and also from
speaking well. You were initially in the ICU. Throughout the
rest of your hospitalization, your heart rates were difficult to
control and you had to be put on high doses of medications to
decrease your heart rate. These medications sometimes decreased
your blood pressure. You were also found to have a blood clot in
your lung. This was unable to be treated with blood thinners due
to the stroke and bleeding in your brain. After discussion with
your family, the decision was made to focus on your comfort in
line with your goals of care. You were discharged from the
hospital to a hospice house in order to be more comfortable and
closer to your family. We wish you the best.
Your ___ Treatment Team
Followup Instructions:
___
|
19667252-DS-3
| 19,667,252 | 22,292,110 |
DS
| 3 |
2171-01-20 00:00:00
|
2171-01-20 15:01:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
Sulfa (Sulfonamide Antibiotics)
Attending: ___
Chief Complaint:
Left basal gnaglia ICH
Major Surgical or Invasive Procedure:
NGT
History of Present Illness:
Time (and date) the patient was last known well:yesterday
unknown
time
(24h clock)
GCS Score at the Scene: 15
ICH volume by ABC/2 method: 4 cc
ICH Score:1
Pre-ICH mRS ___ social history for description):3
REASON FOR CONSULTATION: Left basal gnaglia ICH
HPI:
The patient is a ___ very pleasant woman with hx of
migraine, hyperparathyroidism secondary to CKD and
hypothyroidism, CKD stage IV, osteoarthritis, and history of
left
cavernous carotid artery aneurysm status post neuroform stent
and
coiling in ___ on aspirin who presents after an unwitnessed
fall
at home. Briefly, she lives in assisted living and this morning
she wok up on the floor. She does not recall what happened but
felt weak all over and had trouble getting up so she called EMS.
She was brought to OSH where CT head showed left basal ganglia
bleed with compression of the left lateral ventricle. She was
given 1 g keppra an transferred here for further management.
She
denies any recent fevers, unintentional weight loss, no history
of seizures, no focal weakness or numbness, no diplopia, nausea
or vomiting. She said recently her blood pressure medications
have been reduced as she was noted to be hypotensive. She is in
charge of taking all her medication and is very good with it.
At
baseline she uses a walker to get around. Gets help with all
her
ADLs in her assisted living facility.
Past Medical History:
BILATERAL RENAL ARTERY STENOSIS
Cavernous sinus CAROTID aneurysm s/p stent and coil in ___
CHRONIC OBSTRUCTIVE PULMONARY DISEASE
CKD stage IV
ELEVATED CHOLESTEROL
HYPERTENSION
OSTEOARTHRITIS
OSTEOPOROSIS
PEPTIC ULCER DISEASE
RECURRENT URINARY TRACT INFECTION
ORTHOSTATIC HYPOTENSION
HEADACHE
Surgical History:
COLECTOMY
___
SKIN CANCERS
Cavernous sinus CAROTID aneurysm s/p stent and coil in ___
Social History:
___
Family History:
Non-contributory
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: T: P:58 R: 16 BP:162/79 SaO2:
- General: Awake, cooperative, NAD.
- HEENT: NC/AT
- Neck: Supple
- Pulmonary: no increased WOB
- Cardiac: well perfused
- Abdomen: soft, nontender, nondistended
- Extremities: no edema, pulses palpated
- Skin: Bruising on right lateral knee and right upper extremity
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:
I: Olfaction not tested.
II: PERRL 3 to 2mm and brisk. VFF to confrontation.
III, IV, VI: EOMI with bilateral end gaze nystagmus
extinguishable
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: No pronator drift bilaterally.
No adventitious movements, such as tremor, noted. No asterixis
noted.
Delt Bic Tri WrE FFl FE IP Quad Ham TA ___
L 5 ___ 5 5 5 5 5 *3 *3 *3 *3
R 4+ ___ 5 5 5 5 5 5 5 5 5
*baseline fro OA
-DTRs:
Plantar response up on right and down on left
-Sensory: No deficits to light touch, pinprick throughout. No
extinction to DSS.
-Coordination: No intention tremor. No dysmetria on FNF
bilaterally.
-Gait: Deferred
==========================================
DISCHARGE PHYSICAL EXAM:
24 HR Data (last updated ___ @ 445)
Temp: 98.1 (Tm 98.9), BP: 159/74 (120-163/53-75), HR: 74
(61-74), RR: 16, O2 sat: 97% (95-98), O2 delivery: Ra
General: Awake, frail appearing
HEENT: NC/AT, dry MM
Pulmonary: Normal work of breathing
Cardiac: RRR, warm, well-perfused
Abdomen: soft, non-distended
Extremities: No ___ edema.
Skin: scattered ecchymosis noted on arms and legs
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 comprehension. Speech
was not dysarthric. Able to follow both midline and appendicular
commands.
-Cranial Nerves:
I: Olfaction not tested.
II: B/L pupils reactive brisk, VFF to confrontation.
III, IV, VI: EOMI without nystagmus
V: Facial sensation intact to light touch.
VII: No facial droop
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Good movement bilaterally
-Motor: No pronator drift bilaterally. No adventitious
movements,
such as tremor, noted. No asterixis
noted. Mild bilateral deltoid weakness, otherwise full strength.
-DTRs: ___
-___: Intact to LT.
-Coordination: No intention tremor. No dysmetria on FNF
bilaterally.
-Gait: Deferred
Pertinent Results:
ADMISSION LABS:
================
___ 02:23PM BLOOD WBC-10.9* RBC-3.18* Hgb-9.8* Hct-30.8*
MCV-97 MCH-30.8 MCHC-31.8* RDW-13.9 RDWSD-49.2* Plt ___
___ 02:23PM BLOOD Neuts-81.4* Lymphs-9.5* Monos-7.5
Eos-0.9* Baso-0.4 Im ___ AbsNeut-8.87* AbsLymp-1.04*
AbsMono-0.82* AbsEos-0.10 AbsBaso-0.04
___ 02:23PM BLOOD ___ PTT-28.3 ___
___ 02:23PM BLOOD Glucose-58* UreaN-19 Creat-0.7 Na-147
K-3.1* Cl-118* HCO3-19* AnGap-10
___ 09:15AM BLOOD ALT-14 AST-36 CK(CPK)-296* AlkPhos-74
TotBili-0.6
___ 09:15AM BLOOD CK-MB-4 cTropnT-0.01
___ 07:52PM BLOOD Calcium-9.6 Phos-3.4 Mg-3.0*
___ 06:25AM BLOOD %HbA1c-6.0 eAG-126
___ 09:15AM BLOOD Triglyc-54 HDL-98 CHOL/HD-1.7 LDLcalc-57
___ 09:15AM BLOOD TSH-1.1
___ 02:23PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Tricycl-NEG
DISCHARGE LABS
===============
___ 04:30AM BLOOD WBC-8.6 RBC-3.24* Hgb-9.9* Hct-31.4*
MCV-97 MCH-30.6 MCHC-31.5* RDW-13.8 RDWSD-49.0* Plt ___
___ 04:30AM BLOOD ___ PTT-40.6* ___
___ 04:30AM BLOOD Glucose-91 UreaN-25* Creat-0.9 Na-145
K-5.2 Cl-109* HCO3-24 AnGap-12
___ 04:30AM BLOOD Calcium-8.6 Phos-3.6 Mg-2.1
IMAGING:
CTA H&N ___:
1. With left globus pallidus and putaminal hematoma with
surrounding edema and mass-effect on the adjacent left lateral
ventricle.
2. Coil pack in place appears unchanged since ___, although
artifact from the coils obscures imaging at this level.
3. No evidence of aneurysm or arteriovenous malformation.
4. No evidence of infarction.
5. Pulmonary apex findings suggest infection or aspiration.
CXR ___:
Lungs are low volume otherwise clear. There is minimal
bibasilar fibrosis
which is age related. Moderate cardiomegaly is again seen. No
new
consolidations concerning for pneumonia. There is no pleural
effusion. No pneumothorax is seen.
MRI BRAIN WITH AND WITHOUT CONTRAST ___:
1. Study is mildly degraded by motion.
2. No significant change in acute intraparenchymal hemorrhage
centered in the left basal ganglia with mild mass effect on the
adjacent frontal horn of the left lateral ventricle. No midline
shift.
3. No evidence of underlying mass lesion.
4. Extensive chronic microvascular ischemic changes.
5. There is susceptibility artifact in the region of the left
cavernous
internal carotid artery due to an aneurysm coil.
LEFT ANKLE X-RAY ___:
No acute fracture or dislocation. Chronic degenerative changes
around the
ankle joint and findings suggestive of prior injury.
VIDEO SWALLOW ___:
Aspiration of thin and nectar liquids.
Brief Hospital Course:
Ms. ___ is an ___ woman with hx of migraine,
hyperparathyroidism secondary to CKD stage IV, hypothyroidism,
osteoarthritis, and history of left
cavernous carotid artery aneurysm status post stent and coiling
in ___ on aspirin who presented on ___ after an unwitnessed
fall at home found to have a left basal ganglia intraparenchymal
hemorrhage thought to be secondary to hypertension.
#Left basal ganglia IPH:
Her exam was notable for mild right arm weakness which improved
to pronation of the right hand, but was otherwise intact.
Etiology of the bleed was thought to be hypertensive. Her blood
pressure was controlled with her home antihypertensive regimen,
with additional prns, with goal normotension. She was noted to
have orthostatic hypotension and supine hypertension, concerning
for underlying autonomic dysfunction. Her BP medication were
therefore changed to be given at night and head of bed was
elevated to > 45 degrees. Aspirin and other anti-platelets were
held. A1c 6.0. LDL 57. She was evaluated by speech and swallow
therapy, who recommended NGT placement and TFs due to aspiration
with thin liquids. She was subsequently upgraded to pureed
solids and honey prethickened liquids. ___ recommended acute
rehab.
#HTN:
As above, her BP was controlled with: clonidine 0.1mg daily,
losartan 100gm qhs, Lopressor tartate 12.5 BID, and amlodipine
10mg qhs.
#Hypothyroidism:
She was kept on home levothyroxine 75mcg daily.
#Glaucoma:
She was kept on home eye drops.
#UTI
Patient had a new white count with UA c/w CAUTI for which she
was started on 7 day course of CTX (___).
Transitional issues:
[ ] BP goal normotensive
[ ] Clonidine dose changeD to 0.1 mg daily.
[ ] Lopressor dose changed to Lopressor tararate 12.5 mg BID and
Lopressor succinate was stopped.
[ ] Amlodipine dose increased to 10 mg QHS.
[ ] Monitor for standing hypotension and supine hypertension.
Manage BP by dosing meds at night and keeping head of bed
elevated while sleeping.
[ ] Continue to assess and advance diet.
[ ] Continue 1g Q24H CTX course until ___ for CAUTI.
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? (x) 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 1000 mg PO Q6H:PRN Pain - Mild
2. amLODIPine 5 mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. Atorvastatin 20 mg PO QPM
5. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES DAILY
6. Celecoxib 200 mg oral DAILY
7. Citalopram 20 mg PO DAILY
8. CloNIDine 0.1 mg PO BID
9. Denosumab (Prolia) 60 mg SC ONCE A MONTH
10. diclofenac sodium 1 % topical BID
11. Docusate Sodium 100 mg PO DAILY
12. Estradiol 0.1 mg PO 3X/WEEK (___)
13. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH DAILY
14. Levothyroxine Sodium 75 mcg PO DAILY
15. lidocaine HCl-hydrocortison ac 5% rectal DAILY
16. Losartan Potassium 100 mg PO DAILY
17. Metoprolol Succinate XL 100 mg PO DAILY
18. Multivitamins 1 TAB PO DAILY
19. Pantoprazole 20 mg PO Q24H
20. Polyethylene Glycol 17 g PO DAILY
21. Senna 8.6 mg PO DAILY
22. Zioptan (PF) (tafluprost (PF)) 0.0015 % ophthalmic (eye) BID
23. Timolol Maleate 0.5% 1 DROP BOTH EYES DAILY
24. Tiotropium Bromide 1 CAP IH DAILY
25. Trimethoprim 100 mg PO 3X/WEEK (___)
26. Zolpidem Tartrate 10 mg PO QHS
Discharge Medications:
1. CefTRIAXone 1 gm IV Q24H Duration: 1 Dose
2. Metoprolol Tartrate 12.5 mg PO BID
3. Multivitamins W/minerals 1 TAB PO DAILY
4. amLODIPine 10 mg PO QHS
5. CloNIDine 0.1 mg PO DAILY
6. Losartan Potassium 100 mg PO QHS
7. Polyethylene Glycol 17 g PO DAILY:PRN constipation
8. Senna 8.6 mg PO BID:PRN Constipation
9. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild
10. Atorvastatin 20 mg PO QPM
11. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES DAILY
12. Citalopram 20 mg PO DAILY
13. Denosumab (Prolia) 60 mg SC ONCE A MONTH
14. diclofenac sodium 1 % topical BID
15. Docusate Sodium 100 mg PO DAILY
16. Estradiol 0.1 mg PO 3X/WEEK (___)
17. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH DAILY
18. Levothyroxine Sodium 75 mcg PO DAILY
19. lidocaine HCl-hydrocortison ac 5% rectal DAILY
20. Multivitamins 1 TAB PO DAILY
21. Pantoprazole 20 mg PO Q24H
22. Timolol Maleate 0.5% 1 DROP BOTH EYES DAILY
23. Tiotropium Bromide 1 CAP IH DAILY
24. Trimethoprim 100 mg PO 3X/WEEK (___)
25. Zioptan (PF) (tafluprost (PF)) 0.0015 % ophthalmic (eye)
BID
26. Zolpidem Tartrate 10 mg PO QHS
27. HELD- Aspirin 81 mg PO DAILY This medication was held. Do
not restart Aspirin until you speak with your doctor.
28. HELD- Celecoxib 200 mg oral DAILY This medication was held.
Do not restart Celecoxib until you speak with your doctor.
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Left basal ganglia intraparenchymal hemorrhage
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were hospitalized due to symptoms of right sided weakness
resulting from an ACUTE HEMORRHAGIC STROKE, a condition where a
blood vessel providing oxygen and nutrients to the brain is
damaged from bleeding. The brain is the part of your body that
controls and directs all the other parts of your body, so damage
to the brain from being deprived of its blood supply can result
in a variety of symptoms.
Stroke can have many different causes, so we assessed you for
medical conditions that might raise your risk of having stroke.
In order to prevent future strokes, we plan to modify those risk
factors. Your risk factors are:
-high blood pressure
We are changing your medications as follows:
-Stop aspirin
Please take your other medications as prescribed.
Please follow up with Neurology and your primary care physician
as listed below.
If you experience any of the symptoms below, please seek
emergency medical attention by calling Emergency Medical
Services (dialing 911). In particular, since stroke can recur,
please pay attention to the sudden onset and persistence of
these symptoms:
- Sudden partial or complete loss of vision
- Sudden loss of the ability to speak words from your mouth
- Sudden loss of the ability to understand others speaking to
you
- Sudden weakness of one side of the body
- Sudden drooping of one side of the face
- Sudden loss of sensation of one side of the body
Sincerely,
Your ___ Neurology Team
Followup Instructions:
___
|
19667420-DS-16
| 19,667,420 | 23,708,994 |
DS
| 16 |
2169-05-08 00:00:00
|
2169-05-08 15:38:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Bactrim DS / Zosyn
Attending: ___.
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
Central line placement
History of Present Illness:
Mr. ___ is a ___ history of AF, complete heart block s/p
PPM, CAD s/p prior CABG, ESRD on HD MWF, recurrent right PLEFF
s/p TPC placement, chronic decubitus ulcer, recent admission for
septic shock from UTI/pyocystitis and symptomatic bradycardia
from failed pacemaker lead capture, presenting to ___
with
worsening shortness of breath, found to have multifocal PNA and
septic shock transferred for further management.
Limited history able to be obtained from patient given pooor
historian, however presented from nursing home with several days
worsening shortness of breath and productive cough. At
___ 13.5, BNP 64,000, troponin 0.32. Had CXR showing RUL patchy
opacification, flu negative. Was started on vancomycin, CTX,
azithromycin there, also given 500cc IVF given became
hypotensive. Per family request, was transferred here. En route
with EMS, was hypotensive and started on dopamine.
Of note, patient with recent admission ___ after
presenting with symptomatic bradycardia found to have failed
pacemaker lead capture and septic shock from UTI/pyocystitis.
With history of ESBL UTIs, initially started on vanc/meropenem,
however urine culture ultimately grew proteus and klebsiella.
Thought to have had pyocystitis, antibiotics de-escalated to
cefepime. Also treated for PNA, thought to be HAP or aspiration
with gross witnessed aspiration during hospitalization.
Regarding
his bradycardia, had symptomatic bradycardia to HR ___. Per EP
thought to have had partial lead fracture, however did not feel
urgent revision was needed, favoring PPM revision until
infection
treated.
In the ED here,
Initial Vitals: T 99.2 HR 72 BP 95/47, RR 18, O2 95% on RA
Exam: Not documented
Labs:
- WBC 11.7, Hb 9.9, PLT 200
- Na 137, K 5.2, BUN 33, Cr 4.5, glucose 104
- ___ 27, PTT 35.2, INR 2.5
- LFTs WNL
- Lactate 1.4
- VBG 7.38/___
Imaging:
CTA Chest, CT A/P WC:
1. Multifocal consolidative opacities likely represent
infectious
process, with numerous bilateral ground-glass and ___
opacities, which are new from prior.
2. Interval worsening of bilateral pleural effusions, now large
on the right and small on the left. Right pleural drainage
catheter appears to terminate anteriorly, however the drain
demonstrates sideholes which are within the effusion.
3. Moderate-severe cardiomegaly with reflux of contrast into the
hepatic vasculature on the CTA images is worrisome for poor
cardiac output. There is new diffuse anasarca and
pericholecystic
fluid, which may be a component of third-spacing or fluid
overload.
4. New low-density intra-abdominal ascites.
5. Cystic, macrolobulated pancreatic head/neck mass again
demonstrated, if deemed clinically appropriate, an MRCP may be
obtained to further evaluate. Heterogeneous appearance of the
distal pancreas, felt to exclude component of
pancreatic ductal dilatation or parenchymal abnormality, however
this appears to have been present on the prior study from
___.
6. Intermediate density right renal cortical cyst would be
amenable to further evaluation if an MRCP is obtained.
7. No pulmonary embolism.
- Administered:
___ 19:00 IV DRIP NORepinephrine (0.03-0.25 mcg/kg/min
ordered) Started 0.03 mcg/kg/min
___ 19:54 IV Piperacillin-Tazobactam
___ 20:39 IV Vancomycin
___ 00:16 IV CefePIME (2 g ordered)
___ 00:19 IV DRIP NORepinephrine ___ Confirmed
Rate Changed to 0.05 mcg/kg/min
ED Course: Shock ultrasound was obtained showing possible free
fluid in RUQ, therefore was ordered for CT A/P. CT showing small
volume ascites, on bedside US no tappable fluid pocket.
Requiring
6L O2 on transfer to MICU.
Past Medical History:
- CAD s/p CABG x4 in ___
-----> 1. Coronary artery bypass graft x4: Left internal mammary
artery to left anterior descending artery and saphenous vein
grafts to obtuse marginal, diagonal and distal right coronary
artery.
- Aortic valve replacement with a size 23 ___ tissue
valve ___ with CABG)
- CKD on MWF HD
- BPH s/p TURP, daily straight cath
- Cystic tumor of pancreas
- Heart failure with reduced ejection fraction
- CVA in ___
- Atrial fibrillation
- Complete heart block with pacemaker ___ or ___ at ___
- Chronic recurrent pleural effusion s/p TPC
Social History:
___
Family History:
There is no family history of kidney disease. His father died at
age ___ from heart disease. His mother died at age ___ longevity
runs in his family.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: Reviewed in metavision
GEN: Comfortable, in NAD, speaking in full sentences
HENNT: NC/AT, PERRL, EOMI
Chest: R TPC drain in place, minimal surrounding erythema. No
tenderness to palpation surrounding drain site
CV: Regular rate and rhythm, no murmurs, rubs, or gallops
RESP: Bibasilar rales, no wheezes or rhonchi
GI: Soft, NT/ND. Normoactive bowel sounds, no e/o organomegaly
MSK: 2+ peripheral pulses, no c/c/e
SKIN: 10x10cm area stage 2 sacral ulcer some scant bloody
drainage, no purulent drainage
NEURO: CN II-XII grossly intact. No focal neurological deficits
DISCHARGE PHYSICAL EXAM:
VITALS: 24 HR Data (last updated ___ @ 957)
Temp: 97.3 (Tm 99.1), BP: 100/61 (93-133/45-68), HR: 88
(74-88), RR: 20 (___), O2 sat: 95% (95-99), O2 delivery: Ra
GENERAL: Alert, NAD, sitting up in bed
HEENT: Atraumatic, normocephalic
CARDIAC: RRR, no m/r/g
LUNGS: clear to auscultation bilaterally, no increased work of
breathing, no accessory muscle use
ABDOMEN: NABS, soft, NT, ND, no rebound or guarding
EXTREMITIES: wwp, no clubbing, cyanosis or edema
NEUROLOGIC: CN grossly intact, moving all extremities with
purpose, symmetric smile, speech fluent
Pertinent Results:
ADMISSION LABS:
================
___ 05:50PM BLOOD WBC-11.7* RBC-3.29* Hgb-9.9* Hct-32.5*
MCV-99* MCH-30.1 MCHC-30.5* RDW-20.0* RDWSD-70.2* Plt ___
___ 05:50PM BLOOD ___ PTT-35.2 ___
___ 05:50PM BLOOD Glucose-104* UreaN-33* Creat-4.5* Na-137
K-5.2 Cl-95* HCO3-26 AnGap-16
___ 05:50PM BLOOD Albumin-2.8* Calcium-9.9 Phos-5.6* Mg-2.0
___ 01:00PM BLOOD Vanco-15.9
OTHER PERTINENT LABS:
======================
___ 05:53AM PLEURAL TNC-171* RBC-3834* Polys-8* Lymphs-77*
___ Macro-15*
___ 05:53AM PLEURAL TotProt-1.8 Glucose-78 LD(LDH)-225
Cholest-23
MICRO/PATHOLOGY:
=================
___ BCx x2: No growth to date
___ MRSA: Positive
___ 5:53 am PLEURAL FLUID
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final ___: NO GROWTH.
ANAEROBIC CULTURE (Preliminary): NO GROWTH.
___ UCx: No growth to date
___ Urine Legionella: Negative
IMAGING
=======
___ CXR: Again seen right upper and lower lung pulmonary
opacities and associated
moderate to large right pleural effusion. Bilateral perihilar
opacities may
relate to pulmonary edema.
___ CTA A/P: 1. Multifocal consolidative opacities likely
represent infectious process,
with numerous bilateral ground-glass and ___ opacities,
which are new
from prior.
2. Interval worsening of bilateral pleural effusions, now large
on the right
and small on the left. Right pleural drainage catheter appears
to terminate
anteriorly, however the drain demonstrates sideholes which are
within the
effusion.
3. Moderate-severe cardiomegaly with reflux of contrast into the
hepatic
vasculature on the CTA images is worrisome for poor cardiac
output. There is
new diffuse anasarca and pericholecystic fluid, which may be a
component of
third-spacing or fluid overload.
4. New low-density intra-abdominal ascites.
5. Cystic, macrolobulated pancreatic head/neck mass again
demonstrated, if
deemed clinically appropriate, an MRCP may be obtained to
further evaluate.
Heterogeneous appearance of the distal pancreas, felt to exclude
component of
pancreatic ductal dilatation or parenchymal abnormality, however
this appears
to have been present on the prior study from ___.
6. Intermediate density right renal cortical cyst would be
amenable to further
evaluation if an MRCP is obtained.
7. No pulmonary embolism.
CXR ___:
Heart size and mediastinum are stable in appearance. Hardware
projecting over
the spine is unchanged. Pacemaker leads terminate in right
ventricle.
Right apical pneumothorax is small but new. Small right pleural
effusion is
demonstrated. Right chest tube is in place in slightly
different position, in
right lung base. Opacities in the right upper lobe are similar
to previous
examination or minimally improved. Vascular congestion is mild
to moderate,
unchanged.
KUB ___:
Ascites and right pleural effusion. No signs of bowel
obstruction.
CT PELVIS WITHOUT CONTRAST ___:
1. Stable degenerative change and postoperative change without
acute fracture,
suspicious osseous lesion, or hardware complication.
2. Partial visualization of large volume ascites. Widespread
anasarca.
3. Findings consistent with ankylosing spondylitis.
4. Overall no significant change from ___.
DISCHARGE LABS:
================
___ 03:29AM BLOOD WBC-7.7 RBC-2.83* Hgb-8.8* Hct-28.3*
MCV-100* MCH-31.1 MCHC-31.1* RDW-20.7* RDWSD-73.7* Plt ___
___ 03:29AM BLOOD ___ PTT-39.3* ___
___ 03:29AM BLOOD Glucose-85 UreaN-24* Creat-2.9*# Na-136
K-4.2 Cl-93* HCO3-31 AnGap-12
___ 03:29AM BLOOD Calcium-9.4 Phos-4.6* Mg-1.9
Brief Hospital Course:
Mr. ___ is a ___ history of AF, complete heart block s/p PPM,
CAD s/p prior CABG, ESRD on HD MWF, recurrent right PLEFF s/p
TPC placement, chronic decubitus ulcer, recent admission for
septic shock from UTI/pyocystitis and symptomatic bradycardia
from failed pacemaker lead capture, who initially presented to
___ with worsening shortness of breath, found to have
multifocal PNA and worsening hypotension, transferred to ___
for further management initially in the MICU before eventual
transfer to the floor.
ACUTE ISSUES
===========
#Aspiration. He is followed by S&S at his rehab, with concern on
prior assessments of ongoing vs worsening aspiration, likely
contributing to his pneumonia. Video swallow obtained on this
hospitalization revealed: moderate oropharyngeal dysphagia. His
swallow is most notable for a swallow delay, but with fairly
good clearance of both solids and liquids through the
oropharynx. Due
to his swallow delay, he had penetration of honey thick liquids
and aspiration of nectar thick liquids. Aspiration was initially
silent, although he had a cough response approximately 2 minutes
after. Cough was not effective to clear aspiration from the
airway. While the patient is safe to have chewable solids, he is
at high risk for aspiration with all liquids given his swallow
delay. As a result, goals of care discussion was held with the
patient where he has accepted the risk of aspiration and feels
that modified diet or NPO would not be within his goals of care.
He was continued on regular diet prior to discharge.
#Multifocal Pneumonia
#Concern for developing parapneumonic effusion (from chronic R
effusion)
#Septic Shock. Patient with recent admission for UTI/pyocystitis
and right sided PNA on previous admission previously on
vancomycin/meropenem, subsequently narrowed to cefepime, who
presented with worsening shortness of breath, cough and
worsening hypotension requiring vasopressor support. CTA chest
obtained showed multifocal pneumonia. His shock was likely due
to sepsis from PNA. He also has a chronic right sided pleural
effusion with chronic TPC. CT A/P showed small volume new
ascites with no tappable pocket on US. Of note, there was
concern for a parapneumonic effusion development given
multifocal PNA. He did have regular drainage documented on
previous admission to be draining 500cc every other day, s/p
attachment of pleurx to pleurovac. He was able to be weaned off
pressors on ___. Unfortunately, the MICU was unable to obtain
sputum sample to guide antibiotic administration. Given that he
presented in septic shock and has had multiple hospital
exposures recently with possible acquisition of resistant
organisms the decision was made to double cover him for
pseudomonas with meropenem and levofloxacin in addition to
vancomycin for MRSA (+swab) x7 days (D1 ___ with end date
being ___. Pleural cultures demonstrated an exudative effusion
but no growth. UCx negative, BCx NGTD. His Midodrine was also
increased to 20mg TID in the setting of hypotension.
#Hypoxemic Respiratory Failure. Patient with history of HFrEF
with recovered EF and chronic right pleural effusion per above.
Etiology of his failure was likely multifactorial given evidence
of multifocal PNA, history of chronic R pleural effusion with
TPC with CTA showing interval worsening bilateral pleural
effusion (large on right). BNP elevation also noted at 64,000,
possibly acute on chronic HFpEF, triggered possibly by
multifocal PNA. No evidence PE was witnessed on CTA. He was
treated with antibiotics per above and iHD for volume
management. His supplemental O2 was weaned as tolerated and he
was on RA prior to discharge.
#Pelvic pain.
#Ankylosing spondylitis. Patient endorses pelvic and back pain,
especially aggravated given recent fall on buttocks on ___. He
does endorse a history of chronic back pain. Pelvic CT obtained
did not reveal acute fracture but it did show findings
consistent with ankylosing spondylitis. His pain was managed
with APAP and oxycodone PRN as well as lidocaine patch and he
worked with ___ and OT during his hospitalization.
#Atrial flutter
#CHB s/p PPM
#Elevated INR.
History of A-flutter, also s/p PPM. He is on Coumadin for
anticoagulation which was dosed daily as per INR. Of note, INRs
fluctuated greatly throughout his hospitalization with INR on
day of discharge being 2.6. It is unclear why there was so much
variability. In discussion with pharmacy, he received 2 mg
Coumadin on day of discharge. He should have INRs monitored
daily until his Coumadin regimen is stabilized. Per pharmacy, he
should continue with ___ mg Coumadin moving forward given
tendency to be supratherapeutic.
#Hemoptysis. First episode of hemoptysis was noted around 2 AM
on ___ with evidence of small dark red blood with clots. Chest
x-ray, CBC, and blood gas were normal at that time. Recurrence
of approximately 50-75 cc of bright red blood without clots then
occurred. He was started on PPI IV twice daily, with repeat CBC
being stable. Hemoptysis was potentially related to mucosal
bleeding in the setting of anticoagulation (warfarin) as
evidenced by a few punctate lesions on the hard/soft palate and
a small amount of blood in the anterior oropharynx without
evidence of active nasopharyngeal bleed or oropharyngeal bleed.
As such, his Coumadin was continued when indicated and CBC
trends showed stability.
#BPH
#Penile Edema. Removed chronic foley per patient request, and
instead performed bladder scan and straight cathed daily as
needed. Wound care was consulted for penile edema, and he had
his paraphimosis reduced.
#Elevated troponin. History of CAD s/p CABG, with troponin
elevation 0.32 at OSH. He denied evidence of chest pain while at
___. EKG showed V-paced. Troponin elevation was likely in the
setting of pulmonary edema and ESRD. His home ASA 81mg daily and
Simvastatin 20mg daily were continued.
#Anemia. Hb 9.9 on admission, with recent baseline ___.
Suspect his anemia is related to CKD. CBC was trended daily and
showed stability up to discharge.
CHRONIC ISSUES
=============
#Previous symptomatic bradycardia
#Failed pacemaker lead capture. Previously with HRs in the ___,
with previous interrogation of pacer in consultation with EP
thought to have partial lead fracture. During his last
admission, an urgent revision was not felt to be necessary given
underlying UTI. The initial plan was for consideration of PPM
revision after the infection was treated, with plan for
follow-up in 1 month with EP. Currently, upon most recent
interrogation, there is no evidence of failure of pacemaker
capture.
#HFpEF. Patient with history of HFrEF (EF 35% in ___ thought
to be ___ pacing-induced dyssnchrony. Repeat TTE showing
recovered EF 55%, with well seated bioprosthetic aortic valve.
He is not on home preload agent given minimal urine output and
ESRD. His metoprolol was previously
discontinued in the setting of bradycardia. He is also not on
afterload agents given his need for midodrine. Preload
management is with volume management as per HD.
#ESRD on HD MWF. Volume management per above with intermittent
HD. Continued home Sevelamer and Nephrocaps.
#Decubitus Ulcer. Patient with known chronic decubitus stage 2
ulcer. Wound care was consulted. Continued home APAP and
Lidocaine patch.
#Neurogenic bladder
#BPH. Prior TURP. Per previous urology notes, he has a hx/o
bladder outlet obstruction and neurogenic acontractil bladder.
Continued home Finasteride and removed chronic Foley per patient
preference as per above.
TRANSITIONAL ISSUES
==================
[ ] EP f/up scheduled in ___, has PPM given SSS
[ ] MICU team had several discussions on code status, but
ultimately after discussions with son decision was made to have
him be full code. Brief discussion with patient ___ revealed he
is actively thinking about his preferences, including framing
his care in setting of likely deterioration that may require
repeat hospitalizations.
[ ] high aspiration risk which is likely contributing to PNA.
Discussed with patient different options regarding nutrition
include NPO being safest option, as well as modified diets that
can reduce risk of aspiration. Patient determined that modified
diet/NPO would not be within his goals of care and accepts risk
of aspiration on regular diet, without modifications
[ ] INR with variable fluctuations when dosed for Coumadin,
found to be 2.6 on day of discharge. Received 2 mg Coumadin on
day of discharge. He should have INRs checked daily and should
not receive more than 3 mg Coumadin at a time given that his INR
has been easily supratherapeutic while hospitalized.
[ ] Reported ongoing pelvic pain which was aggravated by fall on
buttocks while hospitalized. Pelvic CT did not show acute
fracture, but did show ankylosing spondylitis. Pain was best
controlled with standing APAP and PRN oxycodone.
#CODE STATUS: Full code
#CONTACT: ___
Relationship: son
Phone number: ___
.
.
.
.
.
-------------------
Attending addendum
Greater than 30 minutes were spent providing and coordinating
care for this patient on day of discharge.
___ MD
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
2. Aspirin 81 mg PO DAILY
3. Bisacodyl ___AILY:PRN Constipation - Second Line
4. Cyanocobalamin 500 mcg PO DAILY
5. Docusate Sodium 100 mg PO BID
6. Finasteride 5 mg PO DAILY
7. Ipratropium-Albuterol Neb 1 NEB NEB Q6H:PRN SOB/wheeze
8. Lidocaine 5% Patch 1 PTCH TD QAM
9. Midodrine 5 mg PO TID
10. Mirtazapine 7.5 mg PO QHS
11. Polyethylene Glycol 17 g PO DAILY
12. Senna 17.2 mg PO BID
13. sevelamer CARBONATE 1600 mg PO TID W/MEALS
14. Simvastatin 20 mg PO QPM
15. Calcium Carbonate 1000 mg PO TID:PRN Dyspepsia
16. FoLIC Acid 1 mg PO DAILY
17. ___ Caps (B complex with C#20-folic acid) 1 mg oral DAILY
18. Omeprazole 40 mg PO Q12H
19. Milk of Magnesia 30 mL PO DAILY:PRN Constipation - First
Line
20. Acetylcysteine 20% ___ mL NEB Q6H:PRN with nebs if lots of
plugging
21. Cetirizine 5 mg PO DAILY:PRN Itching
22. Simethicone 40-80 mg PO QID:PRN Gas, abdominal cramping
23. Warfarin 3 mg PO DAILY16
Discharge Medications:
1. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain -
Moderate
Reason for PRN duplicate override: Alternating agents for
similar severity
RX *oxycodone 5 mg 1 tablet(s) by mouth every six (6) hours Disp
#*8 Tablet Refills:*0
2. Midodrine 20 mg PO TID orthostatic hypotension
3. ___ MD to order daily dose PO DAILY16
4. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
5. Acetylcysteine 20% ___ mL NEB Q6H:PRN with nebs if lots of
plugging
6. Aspirin 81 mg PO DAILY
7. Bisacodyl ___AILY:PRN Constipation - Second Line
8. Calcium Carbonate 1000 mg PO TID:PRN Dyspepsia
9. Cetirizine 5 mg PO DAILY:PRN Itching
10. Cyanocobalamin 500 mcg PO DAILY
11. Docusate Sodium 100 mg PO BID
12. Finasteride 5 mg PO DAILY
13. FoLIC Acid 1 mg PO DAILY
14. Ipratropium-Albuterol Neb 1 NEB NEB Q6H:PRN SOB/wheeze
15. Lidocaine 5% Patch 1 PTCH TD QAM
16. Milk of Magnesia 30 mL PO DAILY:PRN Constipation - First
Line
17. Mirtazapine 7.5 mg PO QHS
18. Omeprazole 40 mg PO Q12H
19. Polyethylene Glycol 17 g PO DAILY
20. ___ Caps (B complex with C#20-folic acid) 1 mg oral DAILY
21. Senna 17.2 mg PO BID
22. sevelamer CARBONATE 1600 mg PO TID W/MEALS
23. Simethicone 40-80 mg PO QID:PRN Gas, abdominal cramping
24. Simvastatin 20 mg PO QPM
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSES
================
ASPIRATION
MULTIFOCAL PNEUMONIA
SEPTIC SHOCK
HYPOTENSION
PLEURAL EFFUSION
HYPOXEMIC RESPIRATORY FAILURE
PELVIC PAIN
HEMOPTYSIS
BPH
TROPONINEMIA
ANEMIA
SECONDARY DIAGNOSES
===================
HFpEF
ESRD on HD
DECUBITUS ULCER
ATRIAL FLUTTER
COMPLETE HEART BLOCK S/P PPM
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. ___,
You were hospitalized at ___ after developing shortness of
breath which was due to a significant pneumonia that required
three antibiotics for treatment. Your breathing improved with
antibiotics and dialysis to remove excess fluid from your body.
Your illness also improved with oral and IV medications to keep
your blood pressure within normal range. You were noted to have
difficulty swallowing during your hospitalization for which you
underwent an evaluation that showed you have a delayed swallow
that puts you at risk for aspirating food into your lungs. We
discussed what your goals of care preferences would be when it
comes to your nutrition and you decided that eating a regular
diet without modifications is consistent with your preferences,
accepting this risk of aspiration.
It is very important that you keep your follow-up appointments
and take your medications as listed below.
It was a pleasure taking care of you!
We wish you the best!
Your ___ Team
Followup Instructions:
___
|
19667819-DS-10
| 19,667,819 | 27,807,786 |
DS
| 10 |
2124-04-25 00:00:00
|
2124-04-29 13:39:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
ampicillin
Attending: ___.
Chief Complaint:
Nephrostomy tube displacement
Major Surgical or Invasive Procedure:
___: ___ replacement of nephrostomy tube
___: Cystoscopy, Left Ureteroscopy with Laser Lithotripsy
History of Present Illness:
Ms. ___ is a ___ year-old female with history of aortic
stenosis s/p porcine valve replacement, atrial fibrillation on
Coumadin, recent ___ perc nephrostomy placement due to left
obstructing stone who initially presented to ___ after
dislodging her nephrostomy tube now transferred to ___ for
nephrostomy tube replacement by ___. Patient was observed in the
ED overnight, however, ___ was unable to perform the procedure
today. Therefore, she is admitted to medicine for observation
until her procedure is able to be performed.
In regards to her recent history, the patient was admitted in
___ after suffering a fall found to have a right
comminuted
humerus fracture and right hip hematoma without fracture. During
that admission she was found to have positive UA with CT torso
revealing
0.6 cm obstructing stone causing hydronephrosis. She underwent
nephrostomy tube placement on ___ with urine culture
positive for pansensitive enterobacter. She was initially on CTX
later transitioned to cefpoxidime for ___ course. Plan was to
follow-up with Urology for lithotripsy on ___. Since her
discharge, her nephrostomy tube has become dislodged twice and
she was taken to ___ for management when it fell out a
couple of days ago. She was subsequently transferred to ___
for
___ evaluation. Upon arrival here, Urology was consulted
and recommended replacement with ___ with planned lithotripsy on
___. She was in observation in the ED overnight, however,
they were unable to take her today. Therefore, she was admitted
to medicine for further management.
In the ED, initial vital signs were: 97.1 86 136/74 18 94% RA
- Exam notable for: CBC 7.3/11.0/365, Cr 0.8, K 4.4 ___ 15.5,
INR
1.4, UA with large leuk, neg nit, 12 WBC, no RBC
- Labs were notable for
- Studies performed include KUB which showed The tip of the
left
percutaneous nephrostomy tube projects over the expected
location
of the left kidney. The pigtail is uncurled. Nonobstructive
bowel
gas pattern.
- Patient was given home meds, 1L NS
Transfer vitals: 98.2 75 133/66 20 100% RA
On arrival to the floor patient reports pain in her shoulders
but
denies any abdominal pain, fevers, chills, or urinary symptoms.
Past Medical History:
Aortic stenosis
Rheumatoid arthritis
Hypertension
Osteoporosis
Cervical spine "operation for broken neck" ___
Spine compression fx s/p kyphoplasty ___ ___
Bilateral cataract removal
Tonsillectomy
Hysterectomy
Bilateral vein stripping
Social History:
___
Family History:
Premature coronary artery disease- Father died from an MI.
Oldest
son has had two heart attacks (age ___ now, had them within last
___ years).
Physical Exam:
ADMISSION PHYSICAL EXAM
========================
Vitals: 98.5 PO 134 / 82 78 16 94 Ra
GENERAL: AOx3, NAD
HEENT: NC/AT, EOMI, PERRL
CARDIAC: RRR, no murmurs/rubs/gallops.
LUNGS: CTAB, no r/r/w
ABDOMEN: Soft, ND, NTTP, +BS throughout. Nephrostomy tube
sutured in place.
EXTREMITIES: No clubbing, cyanosis, or edema. + chronic venous
stasis changes
SKIN: venous stasis changes
NEUROLOGIC: CNII-XII grossly intact. Moving all 4 extremities
symmetrically and with purpose.
DISCHARGE PHYSICAL EXAM
========================
Vitals: 98.0, 110/59, 81, 18, 95% Ra
GENERAL: AOx3, thin appearing woman, NAD
HEENT: NC/AT, EOMI, PERRL
CARDIAC: RRR, II/IV diastolic murmur best heard at left sternal
border
LUNGS: Bibasilar crackles, breathing comfortably on room air
ABDOMEN: Soft, ND, NTTP, +BS throughout. Nephrostomy tube
sutured in place with dressing covered, and tube capped, non
tender to palpation around nephrostomy tube
EXTREMITIES: No clubbing, cyanosis, or edema. + chronic venous
stasis changes
SKIN: venous stasis changes
NEUROLOGIC: AAOx3. Moving all 4 extremities with purpose.
Pertinent Results:
ADMISSION LABS
==============
___ 10:40PM BLOOD WBC-7.3 RBC-3.66* Hgb-11.0* Hct-35.8
MCV-98 MCH-30.1 MCHC-30.7* RDW-13.6 RDWSD-49.2* Plt ___
___ 10:40PM BLOOD Neuts-56.6 ___ Monos-7.2 Eos-6.3
Baso-1.4* Im ___ AbsNeut-4.16 AbsLymp-2.07 AbsMono-0.53
AbsEos-0.46 AbsBaso-0.10*
___ 10:40PM BLOOD Glucose-100 UreaN-20 Creat-0.8 Na-142
K-4.4 Cl-104 HCO3-23 AnGap-15
___ 08:09AM BLOOD Calcium-10.3 Phos-3.7 Mg-2.0
DISCHARGE LABS
==============
___ 07:45AM BLOOD WBC-6.3 RBC-3.57* Hgb-10.7* Hct-35.4
MCV-99* MCH-30.0 MCHC-30.2* RDW-13.3 RDWSD-48.3* Plt ___
___ 07:45AM BLOOD Plt ___
___ 07:45AM BLOOD ___
___ 07:45AM BLOOD Glucose-102* UreaN-19 Creat-0.9 Na-140
K-4.7 Cl-100 HCO3-27 AnGap-13
MICRO
=====
___ Urine culture: negative
IMAGING
========
___ KUB:
IMPRESSION:
1. The tip of the left percutaneous nephrostomy tube projects
over the expected location of the left kidney. The pigtail is
uncurled.
2. Nonobstructive bowel gas pattern.
___ ___ Nephrostomy exchange
1. Nephrostogram demonstrates retracted and malposition
indwelling left
nephrostomy tube. Proximal ureteral renal calculus is again
identified with mild hydronephrosis.
IMPRESSION:
Successful exchange of a 8 ___ nephrostomy on the left.
Brief Hospital Course:
___ year-old female with history of aortic stenosis s/p porcine
valve repair, atrial fibrillation on Coumadin, recent ___ perc
nephrostomy placement due to left obstructing stone presented to
___ after dislodging her nephrostomy tube.
Hospital Course:
Ms. ___ was admitted to the hospital for dislodgement of
nephrostomy tube and mild Cr bump to 1.04. She went to ___ and
had nephrostomy tube replaced. Cr improved and was 0.9. She went
to OR with urology for lithotripsy and placement of ureteral
stent for obstructive renal stone. She did well during
procedure. Her nephrostomy tube was capped. Her warfarin was
held prior to procedure and restarted after it was completed.
She also had an episode of coughing/wretching while eating and
there was some concern for oropharyngeal dysphagia. She was
evaluated by speech and swallow who suggested a ground dysphagia
diet and nectar thickened liquids.
TRANSITIONAL ISSUES
===================
[] Follow up with urology within ___ weeks(urology to arrange
follow up and contact patient)
[] Keep nephrostomy tube capped, monitor Cr while in rehab twice
a week. If increasing can attach nephrostomy tube to bag for
drainage.
[] Monitor INR while in rehab. Discharged on her pre-admission
Coumadin dose.
[] Consider reevaluation by speech and swallow to see if able to
tolerate a regular diet
#CODE: full code (presumed)
#COMMUNICATION: ___ Husband ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO Q6H
2. Bisacodyl 10 mg PO DAILY:PRN constipation
3. Docusate Sodium 100 mg PO BID
4. Senna 8.6 mg PO BID
5. TraMADol ___ mg PO Q6H:PRN Pain - Moderate
6. Warfarin 6 mg PO DAILY
7. Amiodarone 200 mg PO DAILY
8. Atorvastatin 10 mg PO QPM
9. BuPROPion 100 mg PO BID
10. Calcium Carbonate 500 mg PO QID:PRN heartburn
11. FLUoxetine 20 mg PO DAILY
12. Gabapentin 300 mg PO TID
13. Vitamin D 1000 UNIT PO DAILY
14. Carvedilol 3.125 mg PO BID
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H
2. Amiodarone 200 mg PO DAILY
3. Atorvastatin 10 mg PO QPM
4. Bisacodyl 10 mg PO DAILY:PRN constipation
5. BuPROPion 100 mg PO BID
6. Calcium Carbonate 500 mg PO QID:PRN heartburn
7. Carvedilol 3.125 mg PO BID
8. Docusate Sodium 100 mg PO BID
9. FLUoxetine 20 mg PO DAILY
10. Gabapentin 300 mg PO TID
11. Senna 8.6 mg PO BID
12. TraMADol ___ mg PO Q6H:PRN Pain - Moderate
13. Vitamin D 1000 UNIT PO DAILY
14. Warfarin 5 mg PO 5X/WEEK (___)
15. Warfarin 2.5 mg PO 2X/WEEK (MO,FR)
Discharge Disposition:
Extended Care
Facility:
___
___ Diagnosis:
Primary Diagnosis
=================
Dislodged pec nephrostomy tube
Obstructive Renal Stone
Secondary Diagnosis
===================
HTN
A fib
AS s/p porcine valve repair
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 at ___.
WHY WAS I HERE?
You were admitted to the hospital because your nephrostomy tube
became dislodged.
WHAT WAS DONE WHILE YOU WERE IN THE HOSPITAL
- While you were in the hospital you had nephrostomy tube
replaced
- You also received lithotripsy to break up your kidney stone.
WHAT SHOULD I DO WHEN I GET HOME?
1) Follow up with your Primary Care Doctor.
2) Follow up with Urology
We wish you the best!
Your ___ Care Team
Followup Instructions:
___
|
19667819-DS-8
| 19,667,819 | 20,264,011 |
DS
| 8 |
2124-03-17 00:00:00
|
2124-03-18 00:48:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
ampicillin
Attending: ___.
Chief Complaint:
trauma s/p fall
Major Surgical or Invasive Procedure:
___- Left nephrostomy placed for obstructing proximal ureteral
stone.
Sample sent for culture.
History of Present Illness:
___ year-old female with history of aortic stenosis s/p porcine
valve repair, atrial fibrillation on Coumadin presenting after a
fall from standing. She denies LOC and reports no preceding
lightheadedness/dizziness however did not trip; she is unable to
specify definitively if she syccopized. Reports she fell and hit
her right head, shoulder/upper arm, and hip. She initially
presented to ___ where she underwent imaging
demonstrating a right comminuted humerus fracture and right hip
hematoma without fracture; CT head and c-spine were negative.
She was found to have an INR of 2.3 and a Hct of 34. She
received 1L fluid bolus for low SBP with good response. At time
of evaluation here, she currently currently complains only of
pain at the right arm/shoulder. Denies head pain or abdominal
pain.
Past Medical History:
Aortic stenosis
Rheumatoid arthritis
Hypertension
Osteoporosis
Cervical spine "operation for broken neck" ___
Spine compression fx s/p kyphoplasty ___ ___
Bilateral cataract removal
Tonsillectomy
Hysterectomy
Bilateral vein stripping
Social History:
___
Family History:
Premature coronary artery disease- Father died from an MI.
Oldest son has had two heart attacks (age ___ now, had them
within last ___ years).
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals-97.5 ___ 95RA
General- uncomfortable-appearing, non-toxic
HEENT- PERRL, EOMI, sclera anicteric, moist mucus membranes,
oropharynx clear, no hemotympanum, no oto/rhinorrhea
Neck- no midline spinal tenderness, full ROM
Cardiac- RRR
Chest- CTAB. No chest wall deformities or flail chest. No
sternal
tenderness. Midline sternotomy scar well-healed.
Abdomen- soft, nontender, nondistended. No rebound or guarding.
Flank- Right flank with soft hematoma, not expanding, TTP.
Back- No spinal tenderness or stepoffs. No CVAT.
Ext- Right upper arm with large, stable hematoma- TTP.
Neurovascularly intact ___ bilatearlly. Pelvis stable. Tender
to palpation over right hip with tense hematoma, stable.
Neuro- Motor/sensation grossly intact upper and lower
extremities
bilaterally.
DISCHARGE PHYSICAL EXAM:
Vitals: 97.8 PO 119/69 L Lying 90 16 94% Ra
IN: 1130 OUT: 675 urine/380 mL nephro
General: Alert, oriented, ___ pain
HEENT: Sclerae anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: unable to fully assess given ___ postion
CV: RRR, S1/S2, no m/r/g
Abdomen: soft, mildly distended tender with bruising, no
rebound, no guarding. BS+.
Ext: RUE with brace, dark pink/purple down to wrist with
palpable radial pulse--Moving fingers, sensation intact and
warm.. Right lower extremity with bruising tracking down the
posterior leg, soft, non tender. No perpherial edema.
Neuro: CN2-12 intact, no focal deficits
Pertinent Results:
========================
LABS ON AMDISSION
========================
___ 08:50PM BLOOD WBC-15.4* RBC-2.97* Hgb-9.0* Hct-29.1*
MCV-98 MCH-30.3 MCHC-30.9* RDW-13.2 RDWSD-46.7* Plt ___
___ 08:50PM BLOOD Neuts-85.2* Lymphs-7.6* Monos-6.1
Eos-0.1* Baso-0.5 Im ___ AbsNeut-13.09* AbsLymp-1.17*
AbsMono-0.93* AbsEos-0.02* AbsBaso-0.07
___ 08:50PM BLOOD ___ PTT-36.2 ___
___ 08:50PM BLOOD Glucose-190* UreaN-19 Creat-1.0 Na-140
K-5.0 Cl-106 HCO3-20* AnGap-14
___ 04:40AM BLOOD ALT-11 AST-12 LD(LDH)-177 AlkPhos-45
TotBili-0.9
___ 03:39AM BLOOD Calcium-8.7 Phos-3.7 Mg-1.7
=================
PERTIENT LABS
=================
___ 05:30AM ___
___ 04:45AM Ret Aut-2.8* Abs Ret-0.08
___ 04:45AM proBNP-6508*
___ 04:40AM CK-MB-2 cTropnT-<0.01
___ 05:10PM CK-MB-2 cTropnT-<0.01
___ 04:45AM calTIBC-176* Ferritn-232* TRF-135*
___ 04:45AM TSH-2.5
___ 04:45AM Free T4-1.3
=======
MICRO
=======
URINE CULTURE (Final ___:
ENTEROBACTER AEROGENES. >100,000 CFU/mL.
SENSITIVITIES: MIC expressed in
MCG/ML
ENTEROBACTER AEROGENES
|
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
URINE CULTURE (Final ___:
ENTEROBACTER AEROGENES. 1,000-10,000 CFU/ML.
IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE #
___
___.
Blood Culture, Routine (Final ___: NO GROWTH.
Blood Culture, Routine (Final ___: NO GROWTH.
URINE CULTURE (Final ___: NO GROWTH.
================
IMAGING
================
___ ___
Well-seated, normally functioning aortic bioprosthesis.
Preserved biventricular systolic function. Mildly dilated
ascending aorta. Mild pulmonary artery systolic hypertension.
___ CXR
Lordotic positioning could be responsible apparent, heart size
is normal.
Lungs are clear. No pleural abnormality. Mild widening of the
upper
mediastinum.
___ HUMERUS (AP & LAT) RIGHT
The patient has a known comminuted fracture of the proximal
humeral diaphysis with displacement of the fracture fragments.
This appears essentially unchanged when compared to the prior
study from ___. ___ is a comminuted
fracture of the humeral diaphysis.
SHOULDER (AP, NEUTRAL & AXILLARY) TRAUMA LEFT ___
No previous images. No evidence of acute fracture or
dislocation. The AC joint is poorly seen on views presented.
There are degenerative changes in the glenohumeral joint with
narrowing and spurring from the medial and inferior portion of
the humeral head.
HUMERUS (AP & LAT) RIGHT
Redemonstration of known right spiral comminuted proximal
diaphyseal for fracture of the right humerus with approximately
2.2 cm of lateral and 1.1 cm of anterior displacement of the
distal segment.
___ CT TORSO
1. Partially visualized acute comminuted proximal right humeral
fracture with large surrounding hematoma.
2. 4.5 x 2.8 cm right flank hematoma and 5.7 x 3.6 cm right hip
hematoma, both with foci of active contrast extravasation.
3. Obstructing 0.6 cm calculus in the proximal left ureter
causing mild
upstream hydroureteronephrosis.
4. Enlarged main pulmonary artery, which can be seen in patients
with
pulmonary arterial hypertension.
5. Probable hepatic steatosis.
6. Colonic diverticulosis.
7. Chronic appearing bilateral rib fractures, right-sided pelvic
fractures, and compression deformities within the thoracic and
lumbar spine.
==================
PCN PLACEMENT NOTE
===================
PROCEDURE DETAILS:
After the injection of 5 cc of 1% lidocaine in the subcutaneous
soft tissues, the left renal collecting system was accessed
through a posterior lower pole calyx under ultrasound guidance
using a 21 gauge Cook needle. Ultrasound images of the access
were stored on PACS. Prompt return of urine confirmed
appropriate positioning. Injection of a small amount of contrast
outlined a dilated renal collecting system. Under fluoroscopic
guidance, a Headliner wire was advanced into the renal
collecting system. After a skin ___, the needle was exchanged
for an Accustick sheath. Once the tip of the sheath was in the
collecting system; the sheath was advanced over the wire, inner
dilator and metallic stiffener. The wire and inner dilator were
then removed and diluted contrast was injected into the
collecting system to confirm position. A ___ wire was advanced
through the sheath and coiled in the collecting system. The
sheath was then removed and a 8 ___ nephrostomy tube was
advanced into the renal collecting system. The wire was then
removed and the pigtail was formed
in the collecting system. Contrast injection confirmed
appropriate positioning. The catheter was then flushed, 0 silk
stay sutures applied and the catheter was secured with a Stat
Lock device and sterile dressings. The catheter was attached to
a bag.
Obstructing stone in the proximal ureter. Successful placement
of 8 ___ nephrostomy on the left. Follow up with urology for
lithotripsy
Brief Hospital Course:
___ year-old female with history of aortic stenosis s/p porcine
valve repair, atrial fibrillation on Coumadin presenting after a
fall from standing.
# Trauma Survey
On ___ the patient was seen and evaluated by the ___ service
as a trauma consult. She was admitted to the trauma/surgery ICU
for serial hematocrit checks every ___s continuous
hemodynamic monitoring. Orthopaedic surgery was consulted, and
on the same day they splinted her right upper extremity. A CT
scan of the abdomen and pelvis revealed active extravasation in
the Right flank/hip. ___ was consulted and they determined there
was nothing to be done. In terms of blood products, she received
1U pRBC, 1U FFP. A percutaneous nephrostomy tube was placed
obstructing 0.6 cm calculus in the proximal left ureter causing
mild upstream hydroureteronephrosis.
On ___ she received an additional unit of packed red cells
and 1 of FFP for a systolic blood pressure in the ___ mmHg. Her
hematocrit bumped up from 23 to 25. Her INR was 1.9 and she had
no further events. On ___ her hematocrit was stable, she
remained hemodynamically stable, and subcutaneous heparin twice
per day was restarted. At this time she was transferred to the
floor in stable condition. On ___, she was transferred to the
medicine service for syncope workup.
# Syncope:
Causes include mechanical given previous back injury and
instability with ambulation requiring a walker vs. medication
induced given patient is taking a number of blood pressure
lowering medications including entreso, 2 mg Ativan at night,
narcotics and tramadol prn. Additionally, patient was found to
have a UTI so infection likely contributing. C/f valvuar
pathology given history of tissue valve replacement and history
of aortic stenosis; patient follows with cardiology at ___
___ Dr. ___ last ___ with normal aortic gradient
LEVF 50-55% and EKG with sinus rhythms. Less likely vasovagal or
seizure. EKG at ___ with incomplete LBBB in sinus rhythm with
normal QTc interval. ___ with mild pulmonary artery
hypertension, normal EF, normal aortic gradients. Not
orthostatic when working with ___ and no arrhythmias on
telemetry.
# Hypoxemia (resolving): Patient initially hypoxia after trauma
to 3L, CXR without evidence of infection, likely from volume
overload and splinting from pain. Enlarged main pulmonary
artery, which can be seen in patients with pulmonary arterial
hypertension seen on CT Torso. Patient requiring ___ L O2 likely
in the setting of volume overload. Low concern for BP given
patient is normotensive and not tachycardiac with the O2
requirement improving. No murmur on exam. C/f pleural effusion
or hemothroax given recent trauma, CT torso on ___ with
out effusions, no mediastinal mass or hematoma and O2
requirement stable. No evidence of PE on CT torso. CXR on ___
without effusion, edema or infection. On ___, Net negative 2L
in response to 20 mg IV Lasix and complete resolution of
shortness of breath. Moving and talking comfortably on room air
with good breath sounds. Patient will follow with outpatient
cardiology Dr. ___: starting home dose Lasix.
# R humeral fracture, non operative: Ortho placed ___
brace on ___ to be potentially removed in ___ days. Pain
controlled with oxycodone ___ mg q4hr with good response.
Patient is working successfully with ___. Nursing to tighten
brace daily as swelling decreasing. She should follow up with
___ clinic in one week.
# R flank hematoma, non operative: Patient with evidence of a .5
x 2.8 cm right flank hematoma and 5.7 x 3.6 cm right hip
hematoma, both with foci of active contrast extravasation
reviewed by ___ with no area amenable to embolization. Patient
was initially in the TSICU for serial H/H and patient is now
hemodynamically stable with stable h/h and free from flank pain.
Stable h/h for several days. Patient does have significant
bruising down hip, thigh and down her leg that is non-tender and
she is neurovascularly intact.
# Obstructing nephrolithiasis
# Enterbacter UTI
# S/P left nephrosotomy tube
Patient presented s/p fall with positive UA and CT torso with
0.6 cm obstructing stone causing hydronephrosis; infection
potentially contributing to dizziness. Nephrosotomy tube placed
___ now draining yellow urine. Patient making good urine.
UCx ___ growing enterbacter sensitive to CTX. Currently
afebrile with normal white count. Perc nephrostomy tube per
urology recs, lithotripsy and date of removal to be determined
in outpatient follow up. On day of discharge, patient
transitioned from CTX to cefpoxidime total to continue ___
days (___). Patient will follow up with ___ in 3
months for nephrosotomy tube exchange and urology follow up in
___ weeks for lithotripsy.
# Hepatosteatosis
Incidentally seen on CT torso. No history of EtOH abuse or
cirrhosis. LFTs since admission normal.
# Aortic tissue valve replacement
# H/O aortic stenosis
Currently requiring oxygen. Follows with Dr. ___ at ___
___, last ___ in ___ system was prior to valve
replacement. Per ___ home medication list on entreso. No
evidence of volume overload on exam. Repeat ___ with normal EF,
normal aortic gradient.
# H/O Systolic CHF: When patient was with aortic stenosis ___,
LEVF 30% s/p tissue vavluar replacement on enrestro and
carvideolol and not on Lasix. Per outpatient provider last ___
___ with normal aortic gradient and LEVF 50-55%. Requiring
O2 however CXR without edema or effusion, JVD not elevated and
no peripheral edema. weights this admission despite orders. ___
___ well-seated, normally functioning aortic
bioprosthesis, preserved biventricular systolic function, mildly
dilated ascending aorta and mild pulmonary artery systolic
hypertension. She was restarted on home dosing of entresto 49/51
mg and continue carvdilol 3.125 mg BID
# Atrial Fibrillation CHADS score 4: On Coumadin at home, INR
therapeutic on admission with trauma and evidence of bleeding.
Rhythm on tele currently sinus. TSH/free T4 normal. She was
continued on amiodarone 200 mg (home dose) and remained in sinus
rhythm HR 90's. She was restarted on her warfarin 5 mg home
dose. She received two doses in house and INR of 1.2 on
discharge. The risks and benefit of long term anticoagulation
with outpatient provider given ___ frequent falls at home.
# Acute blood loss anemia
Likely secondary to hematomas around humeral fracture and right
flank hematoma. Trauma survey otherwise negative. Stable for 48
hr. Iron studies normal. Hgb 9.0 on discharge.
# Rheumatoid Arthritis: Previous on hydrochlorquine however most
recent medication list states it was discontinued. Pain control
with nacortics for now. Will need follow up with outpatient
provider.
====================
Transitional Issues:
=====================
TRAUMA INJURIES:
- Right communicated humeral fracture ___ brace in ___
days
- Right flank hematoma 4.5 x 2.8 cm right flank hematoma and 5.7
x 3.6 cm right hip hematoma, both with foci of active contrast
extravasation; stable no ___ intervention required
- Obstructing 0.6 cm calculus in the proximal left ureter
causing mild upstream hydroureteronephrosis s/p L PCN on
___
- On CT Torso ___: Chronic appearing bilateral rib
fractures, right-sided pelvic fractures and compression
deformities within the thoracic and lumbar spine
GENERAL
- Ortho to place ___ brace in ___ wks; NWB
- L PCN tube draining yellow urine for 3 months
- Will undergo lithotripsy for renal stone
IMPORTANT DISCHARGE LABS
- INR 1.2 (___)
- hgb 9.0 (___)
- BUN/Cr ___
FOLLOW UP
- urology follow up in ___ weeks ___: lithotripsy with Dr. ___ follow up ___ weeks ___ brace Dr. ___
- ___ follow up 2 months for PCN drain replacement
- cardiology follow up with Dr. ___
NEW MEDICATIONS:
- Cefpoxidime 200 mg BID until ___ (2 days)
HOME MEDICATIONS:
- Restarted warfarin 5 mg on ___ needs dose ___.
INR, coags and CBC should be checked on ___ Range
___ for atrial fibrillation.
- Restarted heart failure medications at home dose: entresto
49/51 mg BID; carvedilol 3.125 mg BID. Please check heart rate
and blood pressure at least twice daily or per protocol.
Medications on Admission:
Ativan 1 mg tablet qhs
Colace 200 BID
Flonase 2 sprays qd
Miralax 17 gram/dose oral powder qd
Wellbutrin 100 mg tablet BID
amiodarone 200mg qd
asa 81mg daily
captopril 6.25 mg tablet TID
furosemide 20 mg tablet qd
hydroxychloroquine 200 mg tablet BID
ipratropium bromide 0.02 % solution for inhalation q6
methotrexate sodium 10mg BID ___
oxycodone 2.5 q4
ranitidine 75mg BID
Discharge Medications:
1. Bisacodyl ___AILY:PRN constipation
2. Cefpodoxime Proxetil 200 mg PO Q12H
3. Docusate Sodium 100 mg PO BID
4. Senna 8.6 mg PO BID constipation
5. Acetaminophen 1000 mg PO Q8H
6. LORazepam 1 mg PO QHS:PRN insomnia
RX *lorazepam [Ativan] 1 mg 1 mg by mouth nightly Disp #*15
Tablet Refills:*0
7. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain -
Severe
RX *oxycodone 5 mg ___ tablet(s) by mouth every four hours Disp
#*30 Tablet Refills:*0
8. Amiodarone 200 mg PO DAILY
9. Atorvastatin 10 mg PO QPM
10. BuPROPion 100 mg PO BID
11. Calcium Carbonate 500 mg PO QID:PRN acid reflux
12. Carvedilol 3.125 mg PO BID
13. Cyanocobalamin 500 units PO DAILY
14. FLUoxetine 20 mg PO DAILY
15. Gabapentin 200 mg PO BID
16. Multiple Vitamin, Womens (multivitamin-Ca-iron-minerals) 1
tab oral DAILY
17. Polyethylene Glycol 17 g PO DAILY:PRN constipation
18. Sacubitril-Valsartan (49mg-51mg) 1 TAB PO BID
19. Vitamin D 1000 UNIT PO DAILY
20. Warfarin 5 mg PO 5X/WEEK (___)
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Right comminuted humeral fracture
Right hip/flank hematoma
history of falls
nephrolithiasis
Urinary tract infection/pyelonephritis
Aortic stenosis s/p valve replacement
Rheumatoid arthritis
Hypertension
Systolic CHF
Atrial Fibrillation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. ___,
You were admitted to the Acute Care Surgery Service on ___
after a fall from standing sustaining a right humerus fracture,
and a right flank hematoma. You were found to have a kidney
stone obstructing the flow of urine from the left kidney and a
urinary tract infection. You had a nephrostomy tube placed to
allow the urine to drain out of the kidney. You will need a
procedure in the future the break up the stone and allow it to
pass. After urine is passing, the nephrostomy tube will be
removed. You were given antibiotics to treat the urinary tract
infection.
Your humerus fracture was evaluated by the orthopedic surgery
team who placed a spint, recommended not weight bearing on the
right upper extremity, and you will transition to ___
brace in the next ___ weeks.
Your blood thinner, Coumadin, was held and your blood counts
were monitored for signs of bleeding. Your blood levels
stabilized without any intervention. Your blood thinner was then
restarted.
You were discharged to a rehab facility. Ensure you attend your
follow up appointments at home and follow the discharge
instructions given from the rehab.
It was a pleasuring caring for you.
___ care team
Followup Instructions:
___
|
19668080-DS-16
| 19,668,080 | 24,329,411 |
DS
| 16 |
2177-09-18 00:00:00
|
2177-09-19 11:21:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics)
Attending: ___
Chief Complaint:
palpitations
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms. ___ is a ___ female with breast cancer
(s/p mastectomy, on exemastane), MGUS (not treated),
hypertension, and hyperlipidemia who presents with dizziness,
nausea, and atrial fibrillation.
Patient reports that on ___ morning she awoke with foot
weakness, nausea without vomiting, and palpitations. This
worsened during the day and she developed episodes of "black
outs" where she saw black spots. She denies any falls or loss of
consciousness. Her symptoms lasted throughout the night and on
___ morning she had worsened nausea and felt very weak and
dizzy. She the presented to her PCP for evaluation of her
symptoms. Her HR was 120s and ECG demonstrated atrial
fibrillation which was new for her. She was referred to ED for
further evaluation.
In the ED, initial vital signs were: 97.8 120 137/84 16 99% RA.
Labs were notable for WBC 6.5, H/H 10.3/34.0, Plt 360, Na 137, K
4.6, BUN/Cr ___, Mg 2.7, BNP 2868, trop < 0.01, and UA with
large leuks, 58 WBCs, and few bacteria. CXR showed no acute
process. ECG showed AFRVR with LVH and repolarization
abnormalities. Bedside TTE by ED providers showed trace effusion
with no other gross abnormalities. The patient was given 1L NS
and 1g IV ceftriaxone. Admitted to Medicine for diagnosis and
management of new atrial fibrillation and UTI. Vitals prior to
transfer were: 98.9 107 111/70 17 100% RA.
On arrival to the floor, she reports nausea and mild left breast
pain. She denies shortness of breath, cough, abdominal pain,
diarrhea, fevers/chills, dysuria, hematuria, and increased
urinary frequency.
REVIEW OF SYSTEMS: Per HPI.
Past Medical History:
- Left Breast Cancer s/p mastectomy ___
- Mitral Regurgitation
- Hypertension
- Hyperlipidemia
- MGUS
- Back Pain
- Knee Pain
- Anemia
- s/p appendectomy
Social History:
___
Family History:
She has no family history of breast or ovarian cancer nor she is
___. She is from ___.
Physical Exam:
ADMISSION PHYSICAL EXAM
VITALS: Temp 97.8, BP 126/80, HR 121, RR 20, O2 sat 100% RA
GENERAL: Pleasant, well-appearing, in no apparent distress.
HEENT: Normocephalic, atraumatic, no conjunctival pallor or
scleral icterus, PERRLA, EOMI, OP clear.
NECK: Supple, no LAD, no thyromegaly, JVP not elevated.
CARDIAC: Irregularly irregular rhythm, tachycardic, normal
S1/S2, no murmurs rubs or gallops.
PULMONARY: Clear to auscultation bilaterally, without wheezes or
rhonchi.
ABDOMEN: Normal bowel sounds, soft, non-tender, non-distended,
no organomegaly.
EXTREMITIES: Warm, well-perfused, no cyanosis, clubbing or
edema.
NEUROLOGIC: A&Ox3, CN II-XII grossly normal, normal sensation,
with strength ___ throughout.
DISCHARGE PHYSICAL EXAM
Exam: T97.7 BP119/74 HR128 RR18 99%RA
GENERAL: Pleasant, well-appearing, in no apparent distress.
HEENT: Normocephalic, atraumatic, no conjunctival pallor or
scleral icterus, PERRLA, EOMI, OP clear.
NECK: Supple, no LAD, no thyromegaly, JVP not elevated.
CHEST: left breast mastectomy surgical scar well healed with
mild ttp, no overlying erythema or fluctuance
CARDIAC: Irregularly irregular rhythm, tachycardic, normal
S1/S2, no murmurs rubs or gallops.
PULMONARY: Clear to auscultation bilaterally, without wheezes or
rhonchi.
ABDOMEN: Normal bowel sounds, soft, non-tender, non-distended,
no organomegaly.
EXTREMITIES: Warm, well-perfused, no cyanosis, clubbing or
edema.
NEUROLOGIC: A&Ox3, CN II-XII grossly normal, normal sensation,
with strength ___ throughout.
Pertinent Results:
ADMISSION LABS
___ 08:08PM BLOOD WBC-6.5 RBC-3.39* Hgb-10.3* Hct-34.0
MCV-100* MCH-30.4 MCHC-30.3* RDW-14.6 RDWSD-53.9* Plt ___
___ 08:08PM BLOOD Neuts-46.2 ___ Monos-9.2 Eos-0.9*
Baso-0.5 Im ___ AbsNeut-3.01 AbsLymp-2.80 AbsMono-0.60
AbsEos-0.06 AbsBaso-0.03
___ 08:08PM BLOOD Glucose-102* UreaN-24* Creat-1.1 Na-137
K-5.2* Cl-101 HCO3-21* AnGap-20
___ 08:08PM BLOOD cTropnT-<0.01 proBNP-2868*
___ 10:05AM BLOOD cTropnT-<0.01
___ 08:08PM BLOOD Calcium-9.7 Phos-4.4 Mg-2.7*
___ 08:08PM BLOOD TSH-2.3
___ 09:13PM BLOOD K-4.6
URINE
___ 05:50PM URINE Color-Yellow Appear-Clear Sp ___
___ 05:50PM URINE Blood-NEG Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-LG
___ 05:50PM URINE RBC-4* WBC-58* Bacteri-FEW Yeast-NONE
Epi-<1
___ 05:50PM URINE CastHy-31*
___ URINE CULTURE CONTAMINATED
EKG
___
Atrial fibrillation with a rapid ventricular response. Diffuse
ST-T wave
changes. Compared to the previous tracing of the same date,
ventricular
ectopy versus aberrant conduction is no longer present.
TRACING #2
Read by: ___.
Intervals Axes
Rate PR QRS QT QTc (___) P QRS T
127 78 ___ 56 ___ EKG
Sinus rhythm. Premature atrial complex. Non-specific ST segment
changes.
Compared to the previous tracing of ___ atrial fibrillation
with a rapid ventricular response rate is no longer appreciated
and the inferolateral ST segment changes are less pronounced.
TRACING #2
Read by: ___.
Intervals Axes
Rate PR QRS QT QTc (___) P QRS T
76 170 70 390 418 39 20 79
PERTINENT IMAGING
___ CXR
No acute cardiopulmonary process.
DISCHARGE LABS
___ 10:30AM BLOOD WBC-6.8 RBC-3.08* Hgb-9.2* Hct-30.7*
MCV-100* MCH-29.9 MCHC-30.0* RDW-14.4 RDWSD-51.7* Plt ___
___ 10:30AM BLOOD Glucose-124* UreaN-12 Creat-0.9 Na-141
K-3.7 Cl-104 HCO3-24 AnGap-17
Brief Hospital Course:
Ms. ___ is a ___ female with breast cancer
(s/p mastectomy ___, on exemastane), MGUS (not treated),
hypertension, and hyperlipidemia who presents with dizziness,
nausea, and new atrial fibrillation.
# New atrial Fibrillation: No prior history. CHADS2 = 3, TTE
___ wnl. TSH wnl as
well. Patient does report ongoing stressors since the start of
the year in the setting of recent mastectomy. Life stressors and
decreased po intake were thought to have acted as possible
triggers of atrial fibrillation. Patient was trialed on various
doses of metoprolol and diltiazem and ultimately achieved rate
control on metop 50mg BID and dilt ER 240mg daily. Metoprolol
was maintained as fractionated on discharge given concern for
hypotension with AM dosing of both metoprolol and diltiazem.
Patient was also started on apixiban and counseled on
risks/benefits of anticoagulation for atrial fibrillation.
# Breast Cancer s/p mastectomy ___: no evidence of infection on
skin exam. Pain was well controlled with Tylenol. She was
maintained on xemestane.
# Positive u/a. Patient asymptomatic and urine culture was
contaminated. Antibiotics were not thought to be indicated as
UTI unlikely.
# Hypertension: Home amlodopine, atenolol, and losartan-hctz
were discontinued given adequate blood pressure control with
metop/dilt.
# Hyperlipidemia: Continued simvastatin.
TRANSITIONAL ISSUES
- please consider referral to social work given numerous
multiple recent life stressors
- please follow-up heart rate control on po diltiazem and
metoprolol
- amlodopine, atenolol, and losartan-hctz were discontinued
given adequate blood pressure control with metop/dilt
- simvastatin was held due to interaction with apixiban
- CONTACT: ___ (husband) ___
- CODE STATUS: Full Code
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB or wheezing
2. Amlodipine 5 mg PO DAILY
3. Atenolol 50 mg PO DAILY
4. Multivitamins 1 TAB PO DAILY
5. Simvastatin 20 mg PO QPM
6. Exemestane 25 mg PO DAILY
7. losartan-hydrochlorothiazide 100-25 mg oral DAILY
8. Oxycodone-Acetaminophen (5mg-325mg) 1 TAB PO Q6H:PRN pain
Discharge Medications:
1. Apixaban 5 mg PO BID
RX *apixaban [Eliquis] 5 mg 1 tablet(s) by mouth twice daily
Disp #*60 Tablet Refills:*0
2. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB or wheezing
3. Exemestane 25 mg PO DAILY
4. Multivitamins 1 TAB PO DAILY
5. Diltiazem Extended-Release 240 mg PO DAILY
RX *diltiazem HCl [Cardizem CD] 240 mg 1 capsule(s) by mouth
daily Disp #*30 Capsule Refills:*0
6. Metoprolol Tartrate 50 mg PO BID
RX *metoprolol tartrate [Lopressor] 50 mg 1 tablet(s) by mouth
twice daily Disp #*60 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis: new onset atrial fibrillation
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 here at ___. You
were found to have high fast rates and an abnormal heart rhythm
for which you were started on a medication called metoprolol and
diltiazem. you were also started on a blood thinner called
apixiban to prevent blood clots from forming in your heart.
We wish you all the best in your recovery.
Sincerely,
Your ___ team
Followup Instructions:
___
|
19668518-DS-4
| 19,668,518 | 26,190,774 |
DS
| 4 |
2123-08-17 00:00:00
|
2123-08-17 14:02:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
latanoprost / oxycodone
Attending: ___.
Chief Complaint:
Left periprosthetic hip fracture
Major Surgical or Invasive Procedure:
Left dynamic hip screw, Dr. ___, ___
History of Present Illness:
HPI: Patient seen and examined, ___ woman history of
___ disease and left hip replacement status post fall back
in ___nd periprosthetic
fracture
status post revision by Dr. ___ in ___ here today
with a mechanical fall when getting out of bed striking her head
unclear loss of consciousness with immediate left leg pain
inability to bear weight. At baseline she is ambulatory uses a
cane approximately 25% of the time while in house
Past Medical History:
PMH/PSH:
___ disease with deep brain stimulator
Left periprosthetic hip fracture back in ___
Social History:
___
Family History:
Noncontributory
Physical Exam:
On admission:
left lower extremity:
- Skin intact
- No deformity, edema, ecchymosis, erythema, induration
- Soft, non-tender leg
-Mild tenderness to palpation over the proximal mid femur
- Fires ___
- SILT S/S/SP/DP/T distributions
- 1+ ___ pulses, WWP
On discharge:
Exam:
24 HR Data (last updated ___ @ 717)
Temp: 98.0 (Tm 98.4), BP: 135/79 (116-136/66-83), HR: 80
(69-84), RR: 18 (___), O2 sat: 99% (98-100), O2 delivery: Ra
General: Alert and oriented x2.
MSK: Left hip with large clean dry and intact dressing without
surrounding skin changes. Left foot warm and well perfused with
sensation and motor function grossly intact.
Pertinent Results:
See OMR
___ 04:33AM BLOOD WBC-6.4 RBC-3.25* Hgb-9.4* Hct-28.4*
MCV-87 MCH-28.9 MCHC-33.1 RDW-15.0 RDWSD-48.6* Plt ___
___ 06:44AM BLOOD Glucose-157* UreaN-19 Creat-0.7 Na-139
K-4.3 Cl-105 HCO3-24 AnGap-10
Brief Hospital Course:
The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have a left periprosthetic hip fracture And was admitted to
the orthopedic surgery service. The patient was taken to the
operating room on ___ for ORIF of left hip periprosthetic
fracture., which the patient tolerated well. For full details of
the procedure please see the separately dictated operative
report. The patient was taken from the OR to the PACU in stable
condition and after satisfactory recovery from anesthesia was
transferred to the floor. The patient was initially given IV
fluids and IV pain medications, and progressed to a regular diet
and oral medications by POD#1. ___ hospital course was
complicated by delirium. Geriatrics was consulted for delirium
management. Patient was placed on atypical antipsychotics for
the treatment of delirium. Medications were optimized to reduce
delirium. The patient required 2 units PRBCs of transfusion.
The patient was given ___ antibiotics and
anticoagulation per routine. The patient's home medications were
continued throughout this hospitalization. Geriatric
consultation was obtained during this hospitalization, who made
recommendations to help with agitation and delirium.
Additionally neurology was consulted, and after discussion with
the patient no changes were made to the patient's medications as
the patient was stable on her medication regimen prior, and it
seemed that she had returned to baseline. The patient worked
with ___ who determined that discharge to extended care facility
was appropriate. The ___ hospital course was otherwise
unremarkable.
At the time of discharge the patient's pain was well controlled
with oral medications, incisions were clean/dry/intact, and the
patient was voiding/moving bowels spontaneously. The patient is
weightbearing as tolerated in the left lower extremity, and will
be discharged on Lovenox for DVT prophylaxis. The patient will
follow up with Dr. ___ routine. A thorough discussion
was had with the patient regarding the diagnosis and expected
post-discharge course including reasons to call the office or
return to the hospital, and all questions were answered. The
patient was also given written instructions concerning
precautionary instructions and the appropriate follow-up care.
The patient expressed readiness for discharge.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amantadine 100 mg PO BID
2. BuPROPion 75 mg PO BID
3. Timolol Maleate 0.25% 1 DROP BOTH EYES BID
4. Carbidopa-Levodopa (___) 0.5 TAB PO TID
5. Pravastatin 20 mg PO QPM
6. Donepezil 5 mg PO QHS
7. Citalopram 40 mg PO DAILY
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
2. Bisacodyl 10 mg PO DAILY:PRN Constipation - Second Line
3. Codeine Sulfate 15 mg PO Q4H:PRN brakthrough pain
4. Docusate Sodium 100 mg PO BID
5. Enoxaparin Sodium 40 mg SC QHS
RX *enoxaparin 40 mg/0.4 mL 40 mg SC once a day Disp #*30
Syringe Refills:*0
6. Multivitamins 1 TAB PO DAILY
7. Polyethylene Glycol 17 g PO DAILY
8. Carbidopa-Levodopa (___) 0.5 TAB PO BID ___, 1200
9. Carbidopa-Levodopa (___) 1 TAB PO DAILY at 1800
10. Donepezil 5 mg PO DAILY
11. Pravastatin 40 mg PO QPM
12. Amantadine 100 mg PO BID
13. BuPROPion 75 mg PO BID
14. Citalopram 40 mg PO DAILY
15. Timolol Maleate 0.25% 1 DROP BOTH EYES BID
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Left periprosthetic femur fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY:
- You were in the hospital for orthopedic surgery. It is normal
to feel tired or "washed out" after surgery, and this feeling
should improve over the first few days to week.
- Resume your regular activities as tolerated, but please follow
your weight bearing precautions strictly at all times.
ACTIVITY AND WEIGHT BEARING:
-Weightbearing as tolerated left lower extremity next field
MEDICATIONS:
1) Take Tylenol ___ every 6 hours around the clock. This is
an over the counter medication.
2) Add codeine as needed for increased pain. Aim to wean off
this medication in 1 week or sooner. This is an example on how
to wean down:
Take 1 tablet every 3 hours as needed x 1 day,
then 1 tablet every 4 hours as needed x 1 day,
then 1 tablet every 6 hours as needed x 1 day,
then 1 tablet every 8 hours as needed x 2 days,
then 1 tablet every 12 hours as needed x 1 day,
then 1 tablet every before bedtime as needed x 1 day.
Then continue with Tylenol for pain.
3) Do not stop the Tylenol until you are off of the narcotic
medication.
4) Per state regulations, we are limited in the amount of
narcotics we can prescribe. If you require more, you must
contact the office to set up an appointment because we cannot
refill this type of pain medication over the phone.
5) Narcotic pain relievers can cause constipation, so you
should drink eight 8oz glasses of water daily and continue
following the bowel regimen as stated on your medication
prescription list. These meds (senna, colace, miralax) are over
the counter and may be obtained at any pharmacy.
6) Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
7) Please take all medications as prescribed by your
physicians at discharge.
8) Continue all home medications unless specifically
instructed to stop by your surgeon.
ANTICOAGULATION:
- Please take Lovenox daily for 4 weeks
WOUND CARE:
- You may shower. No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- Incision may be left open to air unless actively draining. If
draining, you may apply a gauze dressing secured with paper
tape.
- Splint must be left on until follow up appointment unless
otherwise instructed.
- Do NOT get splint wet.
DANGER SIGNS:
Please call your PCP or surgeon's office and/or return to the
emergency department if you experience any of the following:
- Increasing pain that is not controlled with pain medications
- Increasing redness, swelling, drainage, or other concerning
changes in your incision
- Persistent or increasing numbness, tingling, or loss of
sensation
- Fever ___ 101.4
- Shaking chills
- Chest pain
- Shortness of breath
- Nausea or vomiting with an inability to keep food, liquid,
medications down
- Any other medical concerns
THIS PATIENT IS EXPECTED TO REQUIRE ___ DAYS OF REHAB
Physical Therapy:
See OMR for physical therapy plan and disposition.
Treatments Frequency:
Physical therapy: Weightbearing as tolerated
Daily wound checks.
Assistance with ADLs
Followup Instructions:
___
|
19668737-DS-14
| 19,668,737 | 22,370,489 |
DS
| 14 |
2183-12-10 00:00:00
|
2183-12-10 20:54:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
erythromycin base
Attending: ___.
Chief Complaint:
Back pain, lower extremity weakness
Major Surgical or Invasive Procedure:
___ L1-L2 laminectomies and microdiskectomy
History of Present Illness:
___ yo M with new onset lower back pain 3 days ago. Since
that time he has had intermittent weakness in his legs while
walking upstairs or short distances. He notes that both his
legs
"give out" on him and he must hold on to things in order not to
fall. When he sits down all symptoms are relieved. His PCP
sent
him for an MRI through the ED tonight so that he could be
premedicated as he is unable to tolerate lying on his back
without significant pain. Denies numbness. Denies bowel or
bladder incontinence.
Past Medical History:
KIDNEY STONES
ATYPICAL CHEST PAIN
CATARACTS
CERVICAL RADICULOPATHY
COLONIC POLYPS
ELEVATED BLOOD PRESSURE
GASTROESOPHAGEAL REFLUX
HEALTH MAINTENANCE
HERNIA
HYPERTRIGLYCERIDEMIA
LACERATION
OCCUPATIONAL EXPOSURE
PROCTALGIA
RENAL INSUFFICIENCY
RESPIRATORY TRACT INFECTION
ROSACEA
URINARY FREQUENCY
H/O HERPES ZOSTER
Social History:
___
Family History:
Non-contributory
Physical Exam:
ADMISSION EXAM (neurosurgery)
==============
O: T:97.9 HR:66 BP:150/87 RR:16 Sat:98% RA
Gen: WD/WN, comfortable, NAD.
HEENT:normocephalic, atraumatic
Neck: Supple.
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Motor:
IP Q H AT ___ G
R 5 ___ 5 5
L 5 ___ 5 5
Sensation: Intact to light touch, propioception, pinprick and
vibration bilaterally.
Reflexes: Pa Ac
Right 2+ 2+
Left 2+ 2+
Propioception intact
Toes downgoing bilaterally
Rectal exam - patient refuses
DISCHARGE EXAM
==============
Vitals: 98.1 122/70-142/87 ___ 97% RA
General: pleasant male in NAD
HEENT: MMM, EOMI, PERRL
Neck: Supple, no LAD, no bruits, no JVD elevation
CV: RRR, no murmurs or extra heart sounds
Lungs: CTAB, no w/r/rh
Abdomen: +BS, soft, mildly distended, nontender
Ext: ___ strength in bilateral lower extermities
Neuro: CN ___ grossly intact
Psych: Normal affect
Pertinent Results:
ADMISSION LABS
==============
___ 06:10AM BLOOD WBC-11.9* RBC-4.70 Hgb-15.1 Hct-43.1
MCV-92 MCH-32.0 MCHC-34.9 RDW-12.9 Plt ___
___ 06:10AM BLOOD Neuts-92.5* Lymphs-6.1* Monos-1.1*
Eos-0.2 Baso-0.1
___ 06:10AM BLOOD ___ PTT-29.1 ___
___ 06:10AM BLOOD Glucose-100 UreaN-25* Creat-1.3* Na-138
K-4.9 Cl-102 HCO3-24 AnGap-17
INTERIM LABS
============
___ 02:56PM BLOOD cTropnT-<0.01
___ 03:35PM URINE Color-Yellow Appear-Clear Sp ___
___ 03:35PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-300 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
IMAGING/STUDIES
===============
___ MRI L spine with and without contrast:
1. L1-L2 disc protrusion with caudal migration, severely
narrowing the spinal canal, and compressing the distal conus
medullaris and nerve roots. There is no clear evidence of spinal
cord edema.
2. Additional multilevel lumbar spondylosis, greatest from the
L3-L4 through L5-S1 levels, including moderate spinal canal
narrowing at the L3-L4 level, likely affecting the traversing L4
nerve roots, and moderate to severe bilateral neural foraminal
narrowing at the L5-S1 levels, likely compressing the exiting
bilateral L5 nerve roots.
3. Multiple bilateral renal cystic structures as described, the
some of which are noted to be present on the. While these
findings may represent renal cysts, other etiologies cannot be
excluded on the basis of this noncontrast examination. Recommend
clinical correlation. If clinically indicated, further
evaluation may be obtained via renal ultrasound.
___ CXR
Heart size is normal. Mediastinum is normal. Lungs are clear.
There is no pleural effusion or pneumothorax. Overall normal
chest radiograph.
___ LUMBAR FILM
Posterior probe is seen at the upper aspect of what appears to
be the L2
vertebral body. Further information can be gathered from the
operative report.
___ PORTABLE ABD
Dilated cecum up to 12 cm with air diffusely throughout the
colon and no
evidence of small bowel dilation or air-fluid levels. Findings
are consistent with ileus.
DISCHARGE LABS
==============
___ 05:00AM BLOOD WBC-12.9* RBC-4.23* Hgb-13.4* Hct-39.5*
MCV-94 MCH-31.8 MCHC-34.0 RDW-12.9 Plt ___
___ 05:00AM BLOOD Glucose-104* UreaN-26* Creat-1.1 Na-135
K-4.0 Cl-97 HCO3-27 AnGap-15
___ 05:00AM BLOOD Calcium-8.3* Phos-2.3* Mg-2.7*
Brief Hospital Course:
BRIEF SUMMARY
==============
___ year old man with HTN, CKD, who presented with new onset
lower back pain, and weakness. He went to his PCP and received
MRI, which showed L1-2 central disc herniation and compression
of the conus. He received Decadron and he went to the OR on ___
for a L1-2 laminectomy/microdiskectomy, without surgical
complications. On ___ he had 3 events that were concerning for
syncopal events and the patient was subsequently transferred to
medicine after being found with orthostatic hypotension.
ACTIVE ISSUES
=============
# L1-L2 herniated nucleus pulposus: Patient was found to have
L1-2 central disc herniation and compression of the conus on MRI
after presenting to his PCP with new onset low back pain. He was
immediately started on Decadron 10mg x 1 then 4 mg q6h from
___. He received L1-2 laminectomy/microdiskectomy on ___,
which he tolerated well. He was seen by physical therapy and
recommended to have outpatient physical therapy. He received
pain control with 1000 mg PO q8h and tramadol 75 mg q6h prn. He
was instructed to have a wound check at ___ days after discharge
and to ___ with neurosurgery in 4 weeks.
# Syncope
# Orthostatic Hypotension: On ___, the patient had 3 episodes
concerning for syncope. The patient did not recall some of the
events. One of the events occurred while standing and he was
assisted to a chair. The second occurrence was while sitting in
the chair where the nurse said his eyes seemed to "roll in the
back of his head." A trigger was called, fingerstick glucose was
normal, and vital stigns stable. EKG showed sinus bradycardia
with PACs with nonischemic pattern and troponin was negative. He
was placed on telemetry for closer monitoring with no events.
Medicine consult was called and initially believed this was due
to narcotic administration. The patient was found on ___ to be
orthostatic with systolic pressures in the ___. The patient was
given IV fluids and transferred to the medicine service. He had
repeat orthostatic vitals on ___, which were normal and showed
resolution of orthostatic hypotension. His home enalapril was
initially held but restarted prior to discharge. His home
tamsulosin was held on discharge and can be restarted as blood
pressure tolerates.
# Constipation/ileus: On ___, the patient had reported no bowel
movement since his surgery. He received a KUB, which was
consistent with ileus. Abdominal exam remained benign. He
receive senna, colace, bisacodyl, with magnesium citrate x 1. He
had a small bowel movement on ___ and was discharged with senna,
colace, Miralax.
# Leukocytosis: Patient with WBC of 18.3 on admission. This
continued to downtrend to 12.9. It was believed that there was
some component of acute inflammatory response in the setting of
surgery as well as recent brief steroids. He had no localizing
sources of infection.
CHRONIC ISSUES
==============
# Thrombocytopenia: Patient found to have low platelet count to
107, down from 151 on admission. However, it was noted that the
patient has had previously low platelets before this admission,
down to 140. His platelets were 127 on discharge.
# Hyperlipidemia: Continued on atorvastatin at discharge.
# Hypertension: Continued on enalapril at discharge once blood
pressure stabilized.
# Chronic kidney disease: Creatinine at baseline.
# Urinary frequency: Patient's home tamsulosin was held on
discharge due to orthostatic hypotension but can be restarted as
an outpatient as blood pressure tolerates.
TRANSITIONAL ISSUES
===================
# Home tamsulosin was held on discharge in the setting of
orthostatic hypotension. Consider restarting once blood pressure
stabilizes on discharge.
# Patient found to have mild thrombocytopenia (stable and likely
chronic). Please evaluate for possible causes. Also with
leukocytosis (likely due to brief Decadron during admission).
# CODE: Full (presumed)
# CONTACT: Wife/patient, Son: ___, ___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 10 mg PO QPM
3. Enalapril Maleate 2.5 mg PO DAILY
4. Tamsulosin 0.4 mg PO QHS
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 10 mg PO QPM
3. Enalapril Maleate 2.5 mg PO DAILY
4. TraMADOL (Ultram) 75 mg PO Q6H:PRN pain
RX *tramadol 50 mg 1.5 tablet(s) by mouth every 6 hours as
needed Disp #*30 Tablet Refills:*0
5. Acetaminophen 1000 mg PO Q8H:PRN pain
RX *acetaminophen 500 mg 2 tablet(s) by mouth every 8 hours as
needed Disp #*30 Tablet Refills:*0
6. Senna 8.6 mg PO BID:PRN constipation
RX *sennosides [senna] 8.6 mg 1 tab by mouth twice a day as
needed Disp #*30 Capsule Refills:*0
7. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*30 Capsule Refills:*0
8. Polyethylene Glycol 17 g PO DAILY:PRN constipation
RX *polyethylene glycol 3350 17 gram 1 powder(s) by mouth daily
as needed Disp #*15 Packet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS
==================
# L1-L2 herniated nucleus pulposus
# Syncope
# Orthostatic hypotension
# Constipation
SECONDARY DIAGNOSIS
===================
# Chronic kidney disease
# Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Dr. ___,
___ was a pleasure taking care of you during your hospitalization
at ___. You were admitted for L1-2 central disc herniation and
compression of the conus. You were seen by the neurosurgeons and
received a L1-2 laminectomy/microdiskectomy, which went well. We
have provided a script for you to have outpatient physical
therapy at ___.
You were transferred to the medicine service after having 3
events concerning for syncope, which we believe is from
orthostatic hypotension. This resolved after you received IV
fluids. We have held your tamsulosin on discharge, but this can
be restarted once your blood pressure normalizes.
You also had constipation, which was treated with stool
softeners and laxatives. We have provided you with stool
softeners to take once you leave the hospital as needed. You had
mildly decreased platelets and an elevated white blood cell
count, which we believe are due to receiving steroids. You also
make an appointment to see your primary care physician for
___.
For pain control, you may take Tylenol ___ mg every 8 hours and
tramadol 75 mg daily every 6 hours as needed. Please call
___ to make an appointment for a post-op wound check in
___ days. Additionally, please make a ___ appointment with
Dr. ___ in 4 weeks. You will not need any additional
imaging during these appointments.
We wish you the best,
Your ___ Care Team
Followup Instructions:
___
|
19668928-DS-6
| 19,668,928 | 28,315,326 |
DS
| 6 |
2116-11-28 00:00:00
|
2116-12-02 22:39:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
PCP: ___. MD
PRIMARY ONCOLOGIST: ___
PRIMARY DIAGNOSIS: ___
CHIEF COMPLAINT: nausea/vomiting
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. ___ is a ___ ___ with a history
of hepatitis B and stage I T1N0M0 hepatocellular carcinoma s/p
TACE/ablation ___ to the caudate lobe, then segmentectomy
___ with continued growth of venous tumor thrombosis and recent
admission with transaminitis/bilirubinemia and ascending colitis
started on flagyl/cipro, now presenting with nausea and blood
streaked emesis.
Patient states that since discharge from the hospital, he has
had 3 days of nausea and vomiting ___ a day, refractory to po
Zofran (BID), accompanied by continued abdominal pain in the RUQ
and RLQ. He rated his pain as constant, and notes that his
abdomen is slightly more distended. His nausea/vomiting and
abdominal pain was accompanied by with diarrhea two days prior
to presentation, in which he has had 5 loose stools, which he
characterized as non-bloody, which have since slowed. Pt notes
that he has had poor po intake as a result of his nausea, and
has not been able to tolerate solids and only minimal water. Pt
denies any fevers, chills, or urinary symptoms.
In the ED, initial vitals: T98.8 80 147/90 18 98% RA. Pt
received IVF 2L NS, IV Metoclopramide 10 mg and IV LORazepam 1
mg. Labs were notable for: New Na 130, HCO3 19, BUN/Cr: ___,
AG 22. ALT/AST was elevated but stable since discharge 65/119
(stable) and AP 445, Tbili 1.9 (slightly elevated from prior).
WBC was normal without left shift. H%H was stable at 11.7/35.3.
Of note, lactate was 2.1. UA was bland with trace ketones.
Imaging was notable for appendiceal ultrasound with small
ascites and liver U/S was notable for main portal vein with slow
flow, stable complete occlusion of right portal vein and patent
proximal left portal vein. Patient was given: 1.5L NS, 10mg IV
Metoclopramide 10 mg and IV LORazepam 1 mg.
Decision was made to admit to OMED for management of ongoing
nausea and poor PO intolerance. Vitals prior to transfer were 0
98.7 83 129/71 16 99% RA.
On arrival to the floor, patient endorsed continued nausea
mildly improved from medications in the ED, as well as continued
abdominal
pain.
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:
- Mr. ___ has had a past medical history of hepatitis B since
about ___ and was undergoing screening at ___ where
he was recently found to have imaging on an abdominal ultrasound
showing a 5.4 x 4.2 x 3.7 cm partially exophytic heterogeneous
mass in the right lobe of the liver. Color evaluation with
Doppler signals revealed that the portal veins and hepatic veins
were patent. Subsequently, he had an MRI scan dated ___ which showed two lesions: a 4.2 cm caudate lobe mass
consistent with HCC (OPTN 5B)and a 7 mm segment 5 lesion highly
suspicious for HCC. Imaging was reviewed at our liver tumor
conference with recommendation for treatment with TACE followed
by ablation.
He underwent trans-arterial DEB chemoembolization of the caudate
lobe tumor on ___. He was admitted for observation. He was
noted to have had mild abdominal pain quickly relieved with
oxycodone and he was discharged on Tylenol and oxycodone.
Received RFA on ___ to caudate lobe lesion. MRI on ___
revealed post treatment changes of the caudate lobe lesion with
expected post procedure appearance with no arterial enhancement
or other concerning features, similar appearance of sub
centimeter lesion in segment 5, which remains suspicious for
___, and two additional lesions highly suspicious for ___,
neither of which met OPTN criteria. On ___ he underwent
right posterior segmentectomy. There was a positive margin and
on follow-up imaging multiple sites of tumor thrombus.
PAST MEDICAL HISTORY:
1. Hepatitis B since ___
Social History:
___
Family History:
He has no known family history of malignancy. His father died at
the age ___. He has 10 siblings, some of whom are deceased, but
he does not know the full medical history of them.
Physical Exam:
ADMISSION PHYSICAL EXAM:
==========================
Vitals: 97.9 BP 118 / 70 HR 71 RR 18 97% RA
HEENT: oral thrush, no LAD, no thyromegaly
CV: RR, NL S1S2 no S3S4 MRG
PULM: CTAB
ABD: abdomen minimally distended, tender to light touch
diffusely throughout the RUQ and RLQ, well healed scar
LIMBS: No edema, clubbing, tremors, or asterixis; no inguinal
adenopathy
SKIN: No rashes or skin breakdown
NEURO: Intact, oriented to place, plan of care. MAE.
ACCESS: piv 20g left wrist
DISCHARGE PHYSICAL EXAM:
========================
Vitals: T98.8 BP 152 / 80 HR 106 RR 18 94% RA
HEENT: oral thrush, no LAD, no thyromegaly
CV: RR, NL S1S2 no S3S4 MRG
PULM: CTAB
ABD: abdomen moderately distended, tympanic to percussion, +
fluid wave, tenderness to palpation in RUQ and RLQ but improved,
with no rebound or guarding. well healed scar
LIMBS: No edema, clubbing, tremors, or asterixis; no inguinal
adenopathy
SKIN: No rashes or skin breakdown
NEURO: Intact, oriented to place, plan of care. MAE.
Pertinent Results:
ADMISSION LABS:
================
130* 94* 13
--------------< 111 AGap=22
4.5 19* 0.8
ALT: 65* AP: 445* Tbili: 1.9* Alb: 3.5
AST: 119* Lip: 21
89
7.3 \ 11.7 / 148
/ 35.3 \
N:78.4 L:10.2 M:10.2
___: 12.4 PTT: 31.1 INR: 1.1
Lactate:2.1
UA: ___ negative / Ketones trace / Epi 0
DISCHARGE LABS:
===============
___ 06:10AM BLOOD WBC-5.3 RBC-3.19* Hgb-9.5* Hct-28.6*
MCV-90 MCH-29.8 MCHC-33.2 RDW-17.4* RDWSD-56.6* Plt ___
___ 06:10AM BLOOD Glucose-93 UreaN-9 Creat-0.6 Na-132*
K-4.4 Cl-100 HCO3-27 AnGap-9
___ 06:10AM BLOOD ALT-33 AST-107* LD(LDH)-259* AlkPhos-336*
TotBili-2.7*
___ 06:10AM BLOOD Albumin-2.9* Calcium-8.2* Phos-3.3 Mg-2.1
___ 06:10AM BLOOD AFP-777.9*
MICROBIOLOGY:
================
___ URINE CULTURE-PENDING
___ Blood Culture, Routine
___ Blood Culture, Routine
___ URINE CULTURE-FINAL
STOOL C. difficile DNA amplification assay-FINAL;
FECAL CULTURE-FINAL
CAMPYLOBACTER CULTURE-FINAL;
FECAL CULTURE - R/O VIBRIO-FINAL;
FECAL CULTURE - R/O YERSINIA-FINAL;
FECAL CULTURE - R/O E.COLI 0157:H7-FINAL;
MICROSPORIDIA STAIN-FINAL;
CYCLOSPORA STAIN-FINAL;
Cryptosporidium/Giardia (DFA)-FINAL INPATIENT
STUDIES:
================
___: LIVER OR GALLBLADDER US (SINGLE ORGAN)
1. Patent main portal vein with reversed and slow flow, similar
to prior exam.
2. Non-visualization of the right and left portal veins are
compatible with tumor thrombus on the prior CT.
3. Patent splenic vein and SMV with reversal of SMV flow,
expected given portal vein thrombi.
4. Status-post right segmentectomy and persistent overall
similar 5.1-cm caudate mass and an 1.2-cm echogenic lesion in
the right hepatic lobe is unchanged from prior US and may
correspond to a lesion that did not demonstrate washout on the
prior CT.
6. Mild ascites. No splenomegaly.
___: CHEST PORT. LINE PLACEMENT
Right PICC terminates in the mid SVC. No pneumothorax. The
lungs are well expanded and clear. Mediastinum silhouette,
hila, and cardiac silhouette are normal. No pleural effusion.
Surgical clips in the right upper quadrant are unchanged.
___: US guided paracentesis, cancelled:
Small volume ascites with bowel limiting safe access for
paracentesis.
+ CT chest ___
Interval enlargement of multiple bilateral pulmonary nodules,
presumably metastases.
+ CT Abdomen ___:
1. Stable tumor thrombus burden in the right anterior and left
portal vein since ___, and markedly progressed since ___.
2. New small nonocclusive bland thrombus within the main portal
vein. Patent SMV.
3. Number of arterial enhancement measuring up to 7 mm in the
right lobe of the liver do not demonstrate clear washout.
4. Stable ascending colitis.
+ US Appendix (___):
1. Small amount of ascites in the right lower quadrant.
2. Appendix is not visualized.
+ Liver Or Gallbladder Us (___):
1. Patent main portal vein with slow, hepatofugal flow.
2. Stable, complete occlusion of the right portal vein.
3. Patent proximal left portal vein with non visualization of
the previously occluded segments of the distal left portal vein.
4. Unchanged appearance of the region of coagulation necrosis in
the caudate lobe.
Brief Hospital Course:
Mr. ___ is a ___ ___ with a history
of hepatitis B and stage I T1N0M0 hepatocellular carcinoma s/p
TACE ___ to the caudate lobe, then segmentectomy ___ with
continued growth of venous tumor thrombosis and recent admission
with transaminitis/bilirubinemia and ascending colitis started
on flagyl/cipro, now presenting with persistent nausea/vomiting
and R-sided abdominal pain.
# Abdominal pain: Patients pain was thought to be due to an
infectious etiology likely due to colitis seen on recent CT vs
tumor disease progression vs chronic portal vein tumor
thrombosis. Pt had re-assuring WBC (7.3 on admission), and was
afebrile throughout his hospital course, with recent extensive
stool workup 3 days prior to admission reassuring with negative
c-diff, campylobacter, vibrio, Yersinia, Ecoli ___:H7,
microsporidia, cyclospora and cryptosporidium/giardia. On
admission pt's liver U/S was notable for slow flow in the main
portal vein with slow, hepatofugal flow and stable complete
occlusion of the right portal vein, similar to previous imaging
findings. The left portal vein was not noted to be occluded on
this admission, changed from prior. On admission, pt was
started on IV Cipro / Flagyl on this admission to treat possible
infectious etiology. Repeat CT abdomen on this admission showed
stable tumor thrombus burden in the right anterior and left
portal vein since earlier in ___ but markedly progressed
since ___, with evidence of a new small nonocclusive
bland thrombus within the main portal vein, 7mm of arterial
enhancement in the R lobe of the liver without clear washout and
stable ascending colitis. Overall, there was concern for
worsening tumor thrombus in left and right portal veins with
concern for obstruction of flow and portal vein tumor thrombus
since earlier in ___. Patient was continued on IV
cipro/flagyl during this admission but had interval worsening of
abdominal pain and nausea. In light of pt's abdominal
distention, pt was assessed for U/S guided paracentesis which
was notable for small volume ascites with bowel limiting safe
access for paracentesis. Pt continued to have progressively
worsening pain relief, and in-patient team reached out to pt's
primary oncologist to initiate in-patient chemotherapy. In the
setting of patients poor po intake and general malaise, plan was
made for patients symptoms to be aggressively controlled and for
pt to receive IVF resuscitation before initiating FOLFOX as an
outpatient. Pt was discharged on increased pain medication
regimen of oxycontin 20MG BID / oxycodone ___ Q4H for
breakthrough, anti-emetics on metocloparmide, and IV fluid
therapy of 1L every other day for 2 weeks with a plan to receive
outpatient FOLFOX. Plan was further made for potential alcohol
ablation of celiac plexus as an outpatient. Pt finished his
antibiotic course as an inpatient.
#HCC: During this admission, patients progressive abdominal
pain symptoms, abdominal distention and new portal venous tumor
thrombus were most likely due to tumor disease progression.
Patient had been assessed in clinic with his primary oncologist
who noted no role for radiation given the extent of tumor
thrombus. Plan was made on this admission for patient to receive
IVF therapy via his PICC and aggressive symptom management so
patient would be able to be stably discharged and tolerate
FOLFOX therapy as an outpatient.
#Nausea/Vomiting: At the time of admission, patient had been
unable to tolerate any solids or liquids since his most recent
admission, resulting in poor po intake x3 days. Patients nausea
and vomiting were most likely due to patients infectious colitis
vs tumor progression. Pt had waxing/waning improvement of his
nausea symptoms, and was controlled with intermittent use of pro
anti-emetics as follows: Reglan 10 mg PO QID with meals, Zofran
8MG IV Q8h prn and Ativan 0.5mg IV Q4H prn.
#Hyperbilirubinemia, transaminitis: On admission, patient's AST
and ALT were elevated but stable since his previous discharge.
However, his elevated bilirubin continued to uptrend. While
vomiting and low po intake is known to cause cholestasis with
LFT pattern consistent with obstructive process, on U/S and CT
imaging, patient had no evidence of biliary dilatation and no
role for decompression of his biliary tract. In the setting of
pts known progressive disease burden, patient will be continued
to be monitored to ensure resolution of his elevated bilirubin
level and transaminitis.
#Oral thrush: on this admission, patient was not actively on
current chemotherapy regimen. However concern for
immune-compromise continued in the setting of persistent oral
thrush on exam. Patient was started on a nystatin oral wash on
this admission, with reduction of oral thrush on exam.
#Hyponatremia, resolved: on this admission, patient had low
serum Na values, likely due to low po intake and dehydration,
most likely consistent with hypovolemic hyponatremia although
further workup is warranted. Patients Na improved with IVF
resuscitation on this admission.
#Anion gap metabolic acidosis: In the setting of poor po intake,
possibly a starvation ketosis. UA is notable for +ketones, which
resolved with IVF resuscitation.
Chronic issues:
============
#Hep B: On this admission, patient was continued on home dose
Entecavir
TRANSITIONAL:
===============
- PICC placed for home IVF administration (1L every other day),
plan is to continue IVF administrations for total of two weeks.
- Patient will followup with outpatient oncologist Dr. ___
___ consideration of outpatient chemotherapy
- AFP sent for evidence of biochemical progression, was pending
at time of discharge.
- Staging CT obtained during admission with portal venous
thrombosis and pulmonary nodules concerning for metastases.
- Patient noted to have moderate amount of abdominal ascites,
however both bedside and ___ guided attempts did not identify
safe/tappable fluid pocket for diagnostic/therapeutic
paracentesis.
- He will be discharged to his daughter's home at ___,
___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO Q8H:PRN pain
2. Entecavir 1 mg PO DAILY
3. MethylPHENIDATE (Ritalin) 5 mg PO BID
4. Ondansetron ODT 4 mg PO Q8H:PRN nausea
5. Bisacodyl 10 mg PO DAILY
6. Docusate Sodium 100 mg PO BID
7. MetroNIDAZOLE 500 mg PO Q8H
8. Senna 8.6 mg PO DAILY
9. OxyCODONE SR (OxyconTIN) 10 mg PO Q12H
10. Polyethylene Glycol 17 g PO DAILY
11. Ciprofloxacin HCl 500 mg PO Q12H
12. Gabapentin 300 mg PO QHS
Discharge Medications:
1. Metoclopramide 10 mg PO QIDACHS
RX *metoclopramide HCl 10 mg 1 tablet by mouth QIDACHS Disp #*90
Tablet Refills:*0
2. Mirtazapine 15 mg PO QHS
RX *mirtazapine 15 mg 1 tablet(s) by mouth at bedtime Disp #*30
Tablet Refills:*0
3. Nystatin Oral Suspension 5 mL PO TID
RX *nystatin 100,000 unit/mL 5 ml by mouth three times a day
Refills:*0
4. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain -
Moderate
RX *oxycodone 5 mg ___ tablet(s) by mouth every 4 hours Disp
#*90 Tablet Refills:*0
5. Simethicone 120 mg PO QID nausea
RX *simethicone 80 mg ___ tabs by mouth four times a day Disp
#*90 Tablet Refills:*0
6. sodium chloride 0.9 % 0.9 % intravenous EVERY OTHER DAY
RX *sodium chloride 0.9 % 0.9 % 1000 ml IV every other day Disp
___ Milliliter Milliliter Refills:*0
7. OxyCODONE SR (OxyconTIN) 20 mg PO Q12H
RX *oxycodone [OxyContin] 20 mg 1 tablet(s) by mouth twice a day
Disp #*90 Tablet Refills:*0
8. Acetaminophen 650 mg PO Q8H:PRN pain
9. Bisacodyl 10 mg PO DAILY
10. Docusate Sodium 100 mg PO BID
11. Entecavir 1 mg PO DAILY
12. Gabapentin 300 mg PO QHS
13. MethylPHENIDATE (Ritalin) 5 mg PO BID
14. Ondansetron ODT 4 mg PO Q8H:PRN nausea
15. Polyethylene Glycol 17 g PO DAILY
16. Senna 8.6 mg PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY: Ascending colitis, portal vein thrombosis
SECONDARY: Progression of Metastatic Cholangiocarcinoma
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 meeting you and taking care for you. You were
admitted to ___ with abdominal pain, nausea and inability to
eat and drink. We were concerned because your symptoms did not
improve with the antibiotics you were prescribed at your last
admission. This made us concerned that this was because of
progression of your cancer. We saw that the clots in your portal
vein (a vein that comes from the intestines and goes to the
liver) had worsened. You were given an IV that your can take
home to get IV fluids to keep you hydrated until you can discuss
treatment options with Dr. ___. We now feel it is safe for
you to return home.
We wish you the best,
Your ___ team
Followup Instructions:
___
|
19669165-DS-19
| 19,669,165 | 27,150,261 |
DS
| 19 |
2167-06-04 00:00:00
|
2167-06-17 18:25:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
intoxication
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ year old male presents by ___ EMS with intoxication.
Patient was at a shelter all day today and had decreased
mentation. He was unable to answer questions at the time. He
does have a history of a recent trauma with injury above his
clavicles.
In the ED, initial vitals were 98.2 98 158/105 18 98%RA. Labs
showed Na or 132, hematocrit of 38.0, platelet count of 129K.
Serum toxicity was negative. Urine toxicology screen was
positive for cocaine. Lactate was 1.2. Lumbar puncture showed 2
WBC, 1 RBC, 15 protein, 70 glucose. UA showed was not suspicious
for infection. CT head showed no acute intracranial hemorrhage
and non-displaced bilateral nasal bone fracture of indeterminate
age. CT C-spine was unremarkable. CXR showed left lung opacities
consistent with infection or atelectasis. Blood cultures were
sent. Patient received ceftriaxone 2 mg IV x 1. ECG showed
normal sinus rhythm, no ST changes or QT abnormalities Naloxone
was not given, though it was shown on ED dashboard (was an
error). He also received ___cetaminophen. Vitals on
transfer were 98.6 84 116/87 16 100% RA.
On the floor, patient reports that he smoked crack cocaine on
the day before admission, and drank an unknown amount of vodka.
He admits to no other illicit drug use or pill use. He reports
headache, but no stiff neck. There is no cough or sputum
production. He reports no diarrhea or abdominal pain. Patient
reports that he has some urinary hesitancy, as well as some
bilateral wrist pain. He reports being beat up and urinated on
outside a club before coming into the hospital.
Review of systems:
(+) Per HPI
(-) Denies chills, night sweats, recent weight loss or gain.
Denies headache, sinus tenderness, rhinorrhea or congestion.
Denies shortness of breath, cough, dyspnea or wheezing. Denies
chest pain, chest pressure, palpitations. Denies constipation,
abdominal pain, diarrhea, dark or bloody stools. Denies dysuria,
frequency, or urgency. Denies arthralgias or myalgias. Denies
rashes or skin changes.
Past Medical History:
Substance Abuse
Psychiatric Illness
Social History:
___
Family History:
Not obtained
Physical Exam:
Physical Exam on Presentation:
Vitals: T: 97.4 BP: 110/64 HR: 90 RR: 16 02 sat: 99% on RA
GENERAL: NAD, intermittently awake, but often fails to finish
sentences and thoughts, constant shrugging of shoulders and
movement of legs
HEENT: AT/NC, , bruise over bridge of nose, EOMI, PERRL, pupils
3->2 mm, anicteric sclera, pink conjunctiva, MM dry
NECK: nontender and supple, no LAD, no meningismus
BACK: no spinal process tenderness, no CVA tenderness
CARDIAC: RRR, nl S1 S2, no MRG
LUNG: CTAB, no rales wheezes or rhonchi, no accessory muscle use
ABDOMEN: +BS, soft, non-tender, non-distended, no rebound or
guarding, no HSM
EXT: warm and well-perfused, no cyanosis, clubbing or edema
MSK: wrists bilaterally mildly erythematous, with full active
and passive range of motion, mild swelling bilaterally
NEURO: non-focal
SKIN: warm and well perfused, no excoriations or lesions, no
rashes, no track marks
Physical Exam on Discharge:
Vitals: T98.0 BP109/59, HR65, RR18, O2sat100%RA
Neuro:awake, alert, orientedx3, gait mildly ataxic
Exam otherwise unchanged from presentation
Pertinent Results:
LAB RESULTS ON PRESENTATION:
___ 04:55PM BLOOD WBC-10.4 RBC-4.06* Hgb-12.7* Hct-38.0*
MCV-94 MCH-31.4 MCHC-33.5 RDW-12.9 Plt ___
___ 04:55PM BLOOD Neuts-77.1* Lymphs-14.7* Monos-7.0
Eos-0.5 Baso-0.7
___ 04:55PM BLOOD Plt ___
___ 06:00AM BLOOD ___ PTT-31.3 ___
___ 04:55PM BLOOD Glucose-101* UreaN-15 Creat-0.9 Na-132*
K-3.9 Cl-93* HCO3-31 AnGap-12
___ 04:55PM BLOOD CK(CPK)-6185*
___ 04:55PM BLOOD Calcium-8.3* Phos-2.7 Mg-2.0
___ 11:25AM BLOOD HIV Ab-NEGATIVE
___ 04:55PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 05:10PM BLOOD Lactate-1.2
___ 06:30PM URINE Color-Straw Appear-Clear Sp ___
___ 06:30PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-40 Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG
___ 06:30PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-POS amphetm-NEG mthdone-NEG
___ 12:45AM CEREBROSPINAL FLUID (CSF) WBC-2 RBC-1* Polys-4
Bands-1 ___ Macroph-4
___ 12:45AM CEREBROSPINAL FLUID (CSF) TotProt-15 Glucose-70
MICROBIOLOGY:
___ 5:11 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
___ 12:45 am CSF;SPINAL FLUID
**FINAL REPORT ___
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
This is a concentrated smear made by cytospin method,
please refer to hematology for a quantitative white blood cell
count..
FLUID CULTURE (Final ___: NO GROWTH.
Time Taken Not Noted Log-In Date/Time: ___ 3:18 am
BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
___ 11:25 am IMMUNOLOGY
**FINAL REPORT ___
HIV-1 Viral Load/Ultrasensitive (Final ___:
HIV-1 RNA is not detected.
IMAGING:
Radiology Report CHEST (PORTABLE AP) Study Date of ___
5:51 ___
IMPRESSION:
Left lung base opacities could represent atelectasis or
infection.
Radiology Report CT HEAD W/O CONTRAST Study Date of ___
7:16 ___
IMPRESSION: No acute intracranial hemorrhage. Non-displaced
bilateral nasal bone fractures of indeterminate age.
Radiology Report CT C-SPINE W/O CONTRAST Study Date of
___ 7:17 ___
IMPRESSION:
No acute fracture or dislocation. Apparent rotation of C1 on C2
is most
likely related to patient position.
Radiology Report PELVIS (AP ONLY) Study Date of ___ 10:06
AM
IMPRESSION:
No fracture.
Radiology Report HIP UNILAT MIN 2 VIEWS LEFT Study Date of
___ 10:06 AM
IMPRESSION:
No fracture.
Radiology Report WRIST(3 + VIEWS) RIGHT Study Date of ___
10:06 AM
IMPRESSION:
No fracture.
Radiology Report L-SPINE (AP & LAT) Study Date of ___
10:07 AM
FINDINGS: There are five non-rib-bearing lumbar-type vertebral
bodies. There are no compression deformities or abnormal
___- or retrolisthesis. Mineralization is normal. The
sacroiliac joints and bilateral hip joints are relatively
preserved.
Radiology Report CHEST (PORTABLE AP) Study Date of ___
10:03 AM
There is resolution of left basal opacity with no new opacities
noted within the lungs. Heart size and mediastinum are stable.
No appreciable pleural effusion is seen. No pneumothorax is
seen.
ECG:
Cardiovascular Report ECG Study Date of ___ 1:12:42 AM
Sinus rhythm. Normal tracing. No previous tracing available for
comparison.
LAB RESULTS FOR DISCHARGE:
___ 11:25AM BLOOD WBC-5.4 RBC-3.82* Hgb-11.8* Hct-36.5*
MCV-95 MCH-30.9 MCHC-32.4 RDW-13.1 Plt ___
___ 11:25AM BLOOD Plt ___
___ 09:00AM BLOOD Glucose-118* UreaN-6 Creat-0.8 Na-140
K-3.6 Cl-106 HCO3-27 AnGap-11
___ 11:25AM BLOOD ALT-29 AST-39 LD(LDH)-247 CK(CPK)-1028*
AlkPhos-50 TotBili-0.2
___ 09:00AM BLOOD CK(CPK)-541*
___ 09:00AM BLOOD Calcium-8.2* Phos-3.0 Mg-1.9
___ 06:12AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-5*
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
Brief Hospital Course:
PRIMARY REASON FOR HOSPITALIZATION:
Mr. ___ is a ___ male with PMH of substance abuse and
mental illness who presented with intoxication and fever. Fever
resolved and LP was benign. He completed a course of
treatment-dose thiamine. Mental status improved and now with
ataxia remaining, likely due to leg pain. He was discharged to
___.
ACUTE CARE:
#Altered Mental Status: Mr. ___ presented somnolent and with
positive cocaine on tox screen. He reported having taken
suboxone in the ED and endorsed a 3-day alcohol binge leading up
to presentation. He was empirically treated for Wernicke's
encephalopathy with high-dose thiamine. With supportive care and
IV hydration, his somnolence resolved. His affect was odd, but
he was awake and alert. Most likely toxic effect from drug given
positive tox screen. Unlikely encephalomeningitis given bland LP
and HIV testing negative. CT head was without acute process. He
remained ataxic before discharge, reporting leg pain as limiting
factor. ___ cleared him for walking with assitive device.
# Toxidrome: On presentation, Mr. ___ had no anion gap, ECG
unremarkable, pupils normal reaction, extremities warm. No overt
stereotypic toxidrome, though most likely sympathetic based on
cocaine use vs alcohol withdrawal. Tox studies positive only for
cocaine in urine. Patient reports not taking diphenhydramine
excessively. He did experience urinary retention on presentation
which resolved with supportive care. Social work was consulted
for substance abuse, and he was placed in ___
___.
# Fever: Initial CSF studies showed 1 WBC, which is less
suspicious for infection. CXR with left lung opacity that
resolved on re-imaging and was likely an aspiration pneumonitis,
explaining the fever. UA with <1 WBC, 40 ketones, few bacteria,
trace protein. No report of diarrhea. Potential autonomic
instability/activation from toxidrome vs. withdrawal. Exactly
what substances were in his system before presentation is not
clear as he has told different providers different stories,
though we know cocaine is present. Fever ultimately resolved
with supportive care.
#Ataxia: Peristant despite clearing mental status but improving.
This may be related to limb pain vs. substance withdrawal,
though other symptoms have resolved. He was able to walk with
___ alone safely on discharge.
#Urinary Retention: His initial urine retention was question
anticholinergic poisoning such as from benadryl, hydroxyzine, or
other medication co-ingested with cocaine. Possible opiate
effect as well. This resolved with supportive care.
#Elevated CK: Likely from being down while intoxicated. He never
had renal dysfuction, and the CK resovled with IV fluid
hydration.
#Painful extremities: There were no gross bony deformities over
wrist, leg, or back where patient reports focal pain. These are
likely soft tissue injuries from assault vs. positional muscle
injury while intoxicated. No fractures seen on Xray. CK was
elevated on presentation, confirming muscle breakdown. He was
treated with acetaminophen.
# Thrombocytopenia: unknown chronicity. Possibly from alcohol
use, liver dysfunction vs. infection. HIV testing normal. HCV
testing should be considered on discharge.
TRANSITIONS IN CARE:
# Communication: patient, has a brother ___, but does not know
phone number
# Code: presumed full
He was discharged to ___ where he obtains his
primary medical care.
-HCV testing should be considered on discharged.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Mirtazapine Dose is Unknown PO HS
Discharge Medications:
none
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: Intoxication
Secondary: Ataxia, Myalgia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. ___,
You were admitted to the hospital because you were found
confused and not responding to people. You ingested one or more
of the following: cocaine, alcohol, suboxone, or another unknown
substance. We found cocaine in the urine but you were unable to
tell us what else you had taken. While in the hospital we found
that you had evidence of muscle breakdown, likely from an
altercation you were in vs. being unconcious and lying down with
pressure over a muscle. You had several areas that hurt
including your left leg, back, and right wrist. All of these and
your neck were visualized with x-ray and there were no
fractures. A CT of your head showed no fracture or bleed as
well. You had trouble walking as the intoxication resolved, but
you improved to the point where you could move safely with a
walker, but not so without a stable place to stay temporarily.
You were discharged to a bed in a shelter.
Please avoid using substances as you have been doing.
Followup Instructions:
___
|
19669298-DS-3
| 19,669,298 | 21,457,345 |
DS
| 3 |
2133-08-16 00:00:00
|
2133-08-16 15:55:00
|
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:
ERCP with biliary stent placement in common bile duct
CT-guided placement of a transhepatic drainage catheter to
gallbladder bed
History of Present Illness:
___ s/p laparoscopic cholecystectomy for biliary colic ___,
transfered from OSH with severe RUQ pain. Pt underwent elective
laparoscopic cholecystectomy at an OSH three prior to
presentation, which was uncomplicated according to the operative
report. The patient was discharged home from the PACU and
reports to have been recovering well, requiring only minimal
pain medications. On the morning prior to presentation,
however, patient began having intermittent episodes of severe
epigastric/RUQ pain with associated nausea, chills, and
diaphoresis. He returned to ___, where a CT
and HIDA scan were interpreted to be concerning for a bile leak.
He was subsequently transfered to ___ for further evaluation
and management.
Past Medical History:
-Laparoscopic cholecystectomy for biliary colic ___
-___ eye surgery
-Adenoidectomy
Social History:
___
Family History:
Denies history of IBD or GI cancers
Physical Exam:
On admission
Vitals: 99.8 89 124/78 16 97% 2L
GEN: NAD. Alert, oriented x3.
HEENT: No scleral icterus. Mucous membranes dry.
CV: RRR
PULM: Clear to auscultation b/l
ABD: Soft. Distended with mild RUQ/epigastric tendernes. No R/G.
Lap incision sites clean, intact with steri-stips and clear
dressings in place. No erythema.
EXT: Warm without ___ edema.
.
On discharge
Vitals: T 99.6F HR65 BP124/82 RR18 96%RA
GEN: comfortable
CV: RRR
PULM: CTAB
ABD: soft, ND. mild ttp on RUQ. Pigtail drain in R flank with
serosanguinous fluid. No erythema at entry site.
Ext: warm and well-perfused
Pertinent Results:
LABS:
___ 12:35AM BLOOD WBC-11.0 RBC-4.45* Hgb-12.7* Hct-39.8*
MCV-89 MCH-28.6 MCHC-32.0 RDW-13.2 Plt ___ PTT-24.3*
___
___ 12:35AM BLOOD Glucose-137* UreaN-17 Creat-1.0 Na-139
K-4.0 Cl-103 HCO3-27 ALT-47* AST-27 AlkPhos-53 TotBili-0.8
DirBili-0.2 IndBili-0.6 Lactate-2.7*
.
___ 04:40AM BLOOD WBC-7.1 RBC-4.03* Hgb-11.7* Hct-36.1*
MCV-90 MCH-29.0 MCHC-32.4 RDW-13.0 Plt ___ Glucose-99
UreaN-18 Creat-0.9 Na-139 K-4.2 Cl-106 HCO3-28 ALT-44* AST-28
AlkPhos-49 TotBili-0.9
.
___ 4:00 pm ABSCESS
SUBHEPATIC FLUID COLLECTION GALL BLADDER FOSSA, ? INFECTION.
GRAM STAIN (Final ___:
2+ ___ per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
WOUND CULTURE (Preliminary): NO GROWTH.
ANAEROBIC CULTURE (Preliminary): NO GROWTH.
.
___ ERCP Report Impression: Normal papilla. 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. The common bile duct,
common hepatic duct, right and left hepatic ducts, biliary
radicles and cystic duct were filled with contrast and well
visualized. The course and caliber of the structures are normal
with no evidence of extrinsic compression, no ductal
abnormalities, and no filling defects. Extravasation of contrast
was noted at the cystic duct stump consistent with post
operative bile leak. A 9cm by ___ Cotton ___ biliary stent
was placed successfully in the common bile duct.
Otherwise normal ercp to third part of the duodenum.
Brief Hospital Course:
___ was admitted to the Acute Care surgery service for
evaluation of Right Upper Quadrant pain and concern for bile
leak after a cholecystectomy. Patient was kept NPO with IV
hydration and started on empiric Unasyn. Patient underwent a CT
guided drain placement by interventional radiology into the
perihepatic fluid collection. Patient also had an ERCP for
evaluation of bile ducts and a stent was placed on the CBD to be
reevaluated in 4 weeks. Patient's diet was advanced and by the
time of discharge he was tolerating a regular diet, ambulating
without assistance, and voiding without difficulty. Patient was
discharged with the drain in place and given instructions on how
to care for this. Patient will follow-up in acute care clinic
for follow-up evaluation and complete a week course of PO
ciprofloxacin and Flagyl.
Medications on Admission:
-
Discharge Medications:
1. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO every six
(6) hours as needed for pain.
2. Augmentin 875-125 mg Tablet Sig: One (1) Tablet PO twice a
day for 5 days.
Disp:*10 Tablet(s)* Refills:*0*
3. oxycodone 5 mg Capsule Sig: ___ Capsules PO every four (4)
hours as needed for pain for 1 weeks.
Disp:*24 Capsule(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Post-operative bile leak
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the Acute Care surgery service for
evaluation and treatment of your abdominal pain after
gallbladder surgery. You were found to have a fluid collection
and were treated with antibiotics as well as the placement of a
drain. You also had a stent placed in your bile duct. You
recovered well and were able to be discharged home.
Please resume all regular home medications. Please take any new
medications as prescribed.
START augmentin 875mg twice a day for 5 days
Please take the prescribed analgesic medications as needed. You
may not drive or heavy machinery while taking narcotic analgesic
medications. You may also take acetaminophen (Tylenol) as
directed, but do not exceed 3000 mg in one day.
Please get plenty of rest, continue to walk several times per
day, and drink adequate amounts of fluids. Avoid strenuous
physical activity and refrain from heavy lifting greater than 20
lbs., until you follow-up with your surgeon, who will instruct
you further regarding activity restrictions. Please also
follow-up with your primary care physician.
Bulb Suction Drain Care:
*Please look at the drain site every day for signs of infection
(increased redness or pain, swelling, odor, yellow or bloody
discharge, warmth, and fever).
*Maintain the bulb on suction.
*Record the color, consistency, and amount of fluid in the
drain. Call the surgeon, nurse practitioner, or ___ nurse if
the amount increases significantly or changes in character.
*Empty the drain frequently.
*You may shower and wash the drain site gently with warm, soapy
water. You may also wash with half strength hydrogen peroxide
followed by saline rinse.
*Keep the insertion site clean and dry otherwise. Place a drain
sponge for cleanliness.
*Avoid swimming, baths, and hot tubs. Do not submerge yourself
in water.
*Attach the drain securely to your body to prevent pulling or
dislocation.
Followup Instructions:
___
|
19669446-DS-16
| 19,669,446 | 24,022,818 |
DS
| 16 |
2186-11-26 00:00:00
|
2186-11-26 14:05:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
Zithromax
Attending: ___.
Chief Complaint:
paraplegia
Major Surgical or Invasive Procedure:
1. Far lateral decompression L1.
2. Laminectomy T12 without facetectomy.
3. Posterior fusion T10 through L3.
4. Posterior instrumentation T10 through L3.
5. Open treatment lumbar fracture.
6. Allograft for fusion.
7. Local autograft for fusion.
History of Present Illness:
HPI: ___ with intellectual disability and mutism, baseline
walking with assistance, has had week of back and abdominal
pain,
previously evaluated at OSH ER for earlier this week. Has had
increasing ammounts of pain, increasing difficulty walking,
presumed last to be walking yesterday, and possibly today with
aid. Now refusing to walk. Accompanied by aid. Pt poor self
historian and cannot generally partake in HPI/ROS, or physical
exam.
PMH: unable to confirm with pt, but includes HTN, DM, and CKD
(baseline Cr: 2.3-2.5)
MED: loratadine daily, renvela 800mg TID, colace 100mg bid,
metamucil 2 caps bid, miralax prn, asa 81 q24, zoloft 75mg
daily,
vitd 800U daily, protonix 40mg daily
ALL: vomiting to azithromycin
SH: requires assistance to walk, but does walk at baseline.
No vices
PE: 98.2 110 ___ 96%
NAD, AOx3
BUE skin clean and intact
No tenderness, deformity, erythema, edema, induration or
ecchymosis
Arms and forearms are soft
No pain with passive motion
R M U SITLT
EPL FPL EIP EDC FDP FDI fire
2+ radial pulses
BLE skin clean and intact
No tenderness, deformity, erythema, edema, induration or
ecchymosis
Thighs and legs are soft
No pain with passive motion
Motor and sensory exam limited, essentially unable to assess,
due
to pt's disability and mutism.
Scant spontaneous movement of ___, R>L, notable for some plantar
and dorsal flexion, but generally cannot cooperate with exam.
Some response to painful pinprick stimuli on LLE below knee.
Some response to painful pinprick stimuli on RLE at level of
knee.
Normal rectal tone (per ER), no clonus.
Reflexes are ___ at patella and achilles b/l.
Past Medical History:
see HPi
Social History:
___
Family History:
nc
Physical Exam:
Neurological exam at discharge. (difficult to assess accurately)
Showing neurological improvement from preop examination.
Both quads fire.
Movement in ___ toes and ankles at least grade 2.
Pertinent Results:
___ 05:20PM GLUCOSE-125* UREA N-56* CREAT-2.1*
SODIUM-132* POTASSIUM-4.3 CHLORIDE-96 TOTAL CO2-20* ANION GAP-20
___ 05:20PM estGFR-Using this
___ 05:20PM WBC-9.4 RBC-3.67* HGB-11.4* HCT-34.5* MCV-94
MCH-31.1 MCHC-33.0 RDW-15.2
___ 05:20PM NEUTS-90.9* LYMPHS-6.3* MONOS-2.5 EOS-0.1
BASOS-0.1
___ 05:20PM PLT COUNT-232
___ 05:20PM ___ PTT-26.4 ___
Brief Hospital Course:
Patient was admitted to the ___ Spine Surgery Service and
taken to the Operating Room for the above procedure. Refer to
the dictated operative note for further details. The surgery
was without complication and the patient was transferred to the
PACU in a stable condition. TEDs/pnemoboots were used for
postoperative DVT prophylaxis. Intravenous antibiotics were
continued for 24hrs postop per standard protocol. Initial postop
pain was controlled with a PCA. Diet was advanced as tolerated.
The patient was transitioned to oral pain medication when
tolerating PO diet. Foley was removed on POD#3. Physical
therapy was consulted for mobilization OOB with brace.
Ankle boots were given.
Neurological improvement, although slight, was noted
postoperatively.
On the day of discharge the patient was afebrile with stable
vital signs, comfortable on oral pain control and tolerating a
regular diet.
Medications on Admission:
loratadine daily, renvela 800mg TID, colace 100mg bid,
metamucil 2 caps bid, miralax prn, asa 81 q24, zoloft 75mg
daily, vitd 800U daily, protonix 40mg daily
Discharge Medications:
1. Gabapentin 300 mg PO TID
RX *gabapentin 300 mg 1 capsule(s) by mouth three times a day
Disp #*90 Capsule Refills:*0
2. Acetaminophen 1000 mg PO Q8H
3. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*30 Capsule Refills:*0
4. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN pain
RX *hydromorphone 2 mg ___ tablet(s) by mouth every four (4)
hours Disp #*100 Tablet Refills:*0
5. Pantoprazole 40 mg PO Q24H
6. Sertraline 75 mg PO DAILY
7. sevelamer CARBONATE 800 mg PO TID W/MEALS
8. Vitamin D 800 UNIT PO DAILY
9. Psyllium 2 PKT PO BID
RX *psyllium 2 packets by mouth twice a day Disp #*120 Packet
Refills:*0
Discharge Disposition:
Extended Care
Facility:
___
___)
Discharge Diagnosis:
1. L1 burst fracture.
2. Spinal stenosis.
3. Traumatic spinal deformity, thoracolumbar.
Discharge Condition:
Activity Status: Bedboun due to paraparesis
Mental Retardation.
Discharge Instructions:
You have undergone the following operation: Lumbar Decompression
With Fusion
Immediately after the operation:
- Activity: As tolerated. Out of bed to chair with brace.
can ___ the brace in sitting position. Do not bend forward or do
any twisting activity.
- Rehabilitation/ Physical Therapy: To prevent joint
contractures. Stretching exercises and joint mobilization.
- Diet: Eat a normal healthy diet. You may have some
constipation after surgery. You have been given medication to
help with this issue.
- Brace: You have been given a brace. This brace is to
be worn when you are out of bed. You may take it off while lying
in bed.
- Wound Care: Remove the dressing in 2 days. If the
incision is draining cover it with a new sterile dressing. If
it is dry then you can leave the incision open to the air. Once
the incision is completely dry (usually ___ days after the
operation) you may take a shower. Do not soak the incision in a
bath or pool. If the incision starts draining at anytime after
surgery, do not get the incision wet. Cover it with a sterile
dressing. Call the office.
- You should resume taking your normal home medications.
- You have also been given Additional Medications to
control your pain. Please allow 72 hours for refill of narcotic
prescriptions, so please plan ahead. You can either have them
mailed to your home or pick them up at the clinic located on
___ 2. We are not allowed to call in or fax narcotic
prescriptions (oxycontin, oxycodone, percocet) to your pharmacy.
In addition, we are only allowed to write for pain medications
for 90 days from the date of surgery.
- Follow up:
o Please Call the office and make an appointment for 2 weeks
after the day of your operation if this has not been done
already.
o At the 2-week visit we will check your incision, take
baseline X-rays and answer any questions. We may at that time
start physical therapy.
o We will then see you at 6 weeks from the day of the
operation and at that time release you to full activity.
Please call the office if you have a fever>101.5 degrees
Fahrenheit and/or drainage from your wound.
Physical Therapy:
see discharge instructions.
The TLSO brace needs to be worn strictly when out of bed.
Treatments Frequency:
see discharge instructions
Followup Instructions:
___
|
19669688-DS-13
| 19,669,688 | 29,478,227 |
DS
| 13 |
2148-07-18 00:00:00
|
2148-07-19 11:59:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
___ Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ yo F with h/o asthma, HTN who p/w dyspnea, increased
wheezing.
She has noted wheezing above her baseline for asthma in the past
week and presented to ___ on ___ for SOB and wheezing. At
that time rapid flu negative and CXR concerning for RML
infiltrate so patient started on levofloxacin and discharged
home. Her symptoms have not been improving. Breathing feels OK
but wheezing is worse. No fevers/chills, CP, N/V/D. No myalgias.
She resides at an assisted living facility and states that other
residents have had URI symptoms. She has had a dry cough. Her
inhalers have not been helping much.
She returned for evaluation on ___
Initial vitals in the ___ 95.6 88 169/86 22 100% NRB.
Here was found to be positive for the flu.
She was given Oseltamavir, Duonebs, 2gm Mag, and 125mg
methylpred. Repeat CXR showed right basilar atelectasis, no
focal consolidation.
EKG NSR, LAD, STD in V5.
Labs otherwise notable for anemia, with H/H 10.8/32 (baseline
Hct of 37-40), normal WBC of 4.9 with monocyte percent 11.8.
Chem 7 panel wnl
Vitals prior to transfer 98.6 107 135/70 26 97% Nasal Cannula.
On the floor, she says whhezing has not improved but she is
having no trouble breathing. She is also bothered by her cough.
Denies chest pain
Review of Systems:
(+) per HPI
(-) fever, chills, night sweats, headache, vision changes,
rhinorrhea, congestion, sore throat, chest pain, abdominal pain,
nausea, vomiting, diarrhea, constipation, BRBPR, melena,
hematochezia, dysuria, hematuria.
Past Medical History:
- asthma
- HLD
- Osteoperosis
- HTN
- stroke
- depression
- Urinary incontinence
- Frequent falls
Social History:
___
Family History:
non-contributory
Physical Exam:
=======================
ADMISSION PHYSICAL EXAM
=======================
Vitals - 97.9 136/74 107 24 98%RA
GENERAL: Alert and oriented x 3. NAD
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: bilateral diffuse wheezing with appreciable air entry and
without use of accessory muscles
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: 1+ bilateral lower extremity 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: 98.9 144/64 70 22 96/1L
General: Sleeping but arousable, comfortable appearing, in NAD
HEENT: NCAT. Sclera anicteric, conjunctiva pink.
Lungs: CTAB, rare expiratory wheezes at base, rhonchi
CV: RRR, normal S1 and S2, II/VI systolc ejection murmur, no
rubs, gallops noted
Abdomen: Soft, nondistended, notender
GU: No foley
Ext: WWP. Trace bilateral lower extremity edema.
Neuro: MAEE. Grossly normal strength and sensation.
Pertinent Results:
ADMISSION LABS
==============
___ 05:10PM BLOOD WBC-4.9 RBC-3.87* Hgb-10.8* Hct-32.3*
MCV-84 MCH-27.9 MCHC-33.4 RDW-13.6 Plt ___
___ 05:10PM BLOOD Neuts-67.0 ___ Monos-11.8*
Eos-1.3 Baso-0.2
___ 05:10PM BLOOD Glucose-92 UreaN-19 Creat-0.7 Na-137
K-4.0 Cl-99 HCO3-23 AnGap-19
___ 05:10PM BLOOD Calcium-8.6 Phos-3.6 Mg-2.0
DISCHARGE LABS
==============
___ 06:50AM BLOOD WBC-5.4 RBC-3.50* Hgb-9.8* Hct-29.3*
MCV-84 MCH-28.0 MCHC-33.4 RDW-13.5 Plt ___
___ 06:50AM BLOOD Glucose-85 UreaN-32* Creat-0.7 Na-135
K-3.6 Cl-100 HCO3-27 AnGap-12
IMAGING
=======
CHEST (PA & LAT) Study Date of ___ 5:23 ___
IMPRESSION:
Subtle right basilar opacity may be due to atelectasis and
overlap of vascular structures. No definite focal consolidation
is seen.
Brief Hospital Course:
___ year old woman with history of HTN and asthma who presented
with dyspnea and found to have influenza and asthma exacerbation
after recent diagnosis of pneumonia.
ACTIVE ISSUES
-------------
1. Influenza: Patient admitted in setting of increased wheezing,
shortness of breath and nausea. She was positive for influenza A
and was treated with renally dosed oseltamavir (5 days) and
weaned off oxygen. She was afebrile through her hospitalization
and sating 97% on RA at time of discharge with improvement of
her wheezing and dyspnea.
2. Asthma exacerbation: Patient admitted with diffuse expiratory
wheezing in setting of influenza, thought to be due to asthma
exacerbation. Given IV solumedrol x 1, magnesium, followed by
prednisone burst for a 5 day total steroid course. She was also
treated with nebulizers (albuterol, ipratropium), fluticasone
inhaler, and weaned off oxygen. Her wheezing improved
significantly and she was sating 97 on RA at time of discharge.
3. CAP: Patient presented to ___ on ___ with increased
wheezing and dyspnea, with imaging notable for right lower lobe
consolidation. Patient was started on levofloxacin at ___
for 7 day treatment of CAP. There was no consolidation on
admission chest x-ray at ___. Levofloxacin was switched
to doxycycline out of concern for prolonged QTc and patient
completed 7 day course. She remained afebrile while
hospitalized.
4. Hyponatremia: Given poor PO intake prior to admission, this
was felt to be hypovolemic hyponatremia. Her sodium levels
resolved and remained stable in mid ___ through the remainder
of her hospitalization.
CHRONIC ISSUES
--------------
- Hypertension: Home losartan, amlodipine continued
- Hyperlipidemia: Home atorvastatin continued
- H/o Stroke: Clopidogrel, aspirin continued
- ?GERD: Omeprazole continued
TRANSITIONAL ISSUES
-------------------
-Follow up with PCP
-___ discharged with albuterol inhaler, consider setting her
up with nebulizer machine at home
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Clopidogrel 75 mg PO DAILY
2. Omeprazole 20 mg PO DAILY
3. Vitamin D ___ UNIT PO DAILY
4. Atorvastatin 20 mg PO QPM
5. Aspirin 325 mg PO DAILY
6. Flovent HFA (fluticasone) 110 mcg/actuation inhalation bid
7. Hydrocortisone Acetate Suppository ___ID
8. Losartan Potassium 25 mg PO QPM
9. Losartan Potassium 50 mg PO QAM
10. Amlodipine 5 mg PO DAILY
11. Docusate Sodium 100 mg PO BID
12. Senna 8.6 mg PO QHS
13. Polyethylene Glycol 17 g PO DAILY:PRN constipation
14. Acetaminophen 650 mg PO Q6H:PRN pain
15. Preparation H(pe,cb) (phenylephrine-cocoa butter) 0.25-88.44
% rectal BID prn
Discharge Medications:
1. Amlodipine 5 mg PO DAILY
2. Aspirin 325 mg PO DAILY
3. Atorvastatin 20 mg PO QPM
4. Losartan Potassium 25 mg PO QPM
5. Losartan Potassium 50 mg PO QAM
6. Docusate Sodium 100 mg PO BID
7. Clopidogrel 75 mg PO DAILY
8. Omeprazole 20 mg PO DAILY
9. Senna 8.6 mg PO QHS
10. Acetaminophen 650 mg PO Q6H:PRN pain
11. Flovent HFA (fluticasone) 110 mcg/actuation inhalation bid
12. Hydrocortisone Acetate Suppository ___ID
13. Vitamin D ___ UNIT PO DAILY
14. Preparation H(pe,cb) (phenylephrine-cocoa butter) 0.25-88.44
% rectal BID prn
15. Polyethylene Glycol 17 g PO DAILY:PRN constipation
16. Albuterol Inhaler 2 PUFF IH Q4H:PRN shortness of breath or
wheezing
RX *albuterol sulfate [ProAir HFA] 90 mcg 2 puffs INH every 4
hours Disp #*1 Inhaler Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Influenza
Asthma exacerbation
Community Acquired Pneumonia
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 hospitalizaiton to
___. You were admitted with influenza and an asthma
exacerbation. You were also finishing treatment for a pneumonia
diagnosed at ___.
Your influenza was treated with oseltamavir (Tamiflu). Your
asthma exacerbation was treated with nebulizers and steroids. At
the time of discharge, your symptoms and oxygen levels were
significantly improved.
If you experience symptoms of fevers, chills, shortness of
breath, chest pain, please let your doctor know or return to the
___.
Once again, it was a pleaure caring for you.
Sincerely,
Your Medical Team
Followup Instructions:
___
|
19669708-DS-19
| 19,669,708 | 25,717,722 |
DS
| 19 |
2123-01-13 00:00:00
|
2123-01-17 18:49:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
rectal bleeding
Major Surgical or Invasive Procedure:
colonoscopy
History of Present Illness:
___ w/anemia, prior colonic adenomas presents with rectal
bleeding after colonoscopy with polypectomy. Pt presented ___
for routine colonoscopy, had 3 polyps removed. Pt reports that
post procedure she had at least 5 bloody BMs. The last 2 she was
dizzy, nauseated and diaphoretic which prompted her to call EMS.
On arrival to the ED pt triggered for hypotension 89/56. She was
given 1Lns with improvement in BP. 2u pRBC were ordered but not
given.
ROS: +as above, otherwise reviewed and negative
Past Medical History:
colonic adenomas
Iron defiency anemia
Social History:
___
Family History:
no GI malignancy or bleeding disorders
Physical Exam:
Vitals: T:98.3 BP:104/55 P:85 R:16 O2:100%ra
PAIN: 0
General: nad
EYES: anicteric
Lungs: clear
CV: rrr no m/r/g
Abdomen: bowel sounds present, soft, nt/nd
Ext: no e/c/c
Skin: no rash
Neuro: alert, follows commands
Pertinent Results:
___ 02:00AM GLUCOSE-116* UREA N-14 CREAT-0.8 SODIUM-142
POTASSIUM-4.3 CHLORIDE-108 TOTAL CO2-25 ANION GAP-13
___ 02:00AM ALT(SGPT)-15 AST(SGOT)-17 ALK PHOS-49 TOT
BILI-0.2
___ 02:00AM LIPASE-29
___ 02:00AM ALBUMIN-4.1
___ 02:00AM WBC-4.0 RBC-3.49* HGB-9.3* HCT-28.8* MCV-83
MCH-26.7* MCHC-32.4 RDW-15.6*
___ 04:10AM HCT-26.7*
Colonoscopy ___ Impression: Polyp in the cecum (polypectomy)
Polyp in the ascending colon (polypectomy)
Polyp in the ascending colon.10 ccs of methylene blue was
injected submucosally to lift the polyp successfully. A
piece-meal polypectomy was performed using a hot snare in the
ascending colon. One area of residual polyp at the edge of the
polypectomy site was removed with the cold forceps. The polyp
was completely removed. An Argon-Plasma Coagulator was applied
at the edges of the polypectomy site. 5 cc. of SPOT injection
was applied immediately distal to the polypectomy site in the
ascending colon for tattooing with success. A ___ net was used
to remove all of the polyp fragments from the polypectomy site.
Otherwise normal colonoscopy to cecum
Recommendations: Follow up with pathology reports. Please call
Dr. ___ office ___ in 7 days for the pathology
results.
If any fever, worsening abdominal pain, blood in your stools, or
post procedure symptoms, please call the advanced endoscopy
fellow on call ___/ pager ___.
NO ASPIRIN, PLAVIX, COUMADIN, NSAIDs (eg Advil, Motrin, Aleve)
for 7 days
Repeat colonoscopy in 6 months to assess EMR site.
Colonoscopy ___ Impression: The EMR site was identifed in
the ascending colon. Two visible vessels were seen. No active
bleeding identified.
Two endoclips were successfully applied to the EMR site to treat
the visible vessels and reduce the risk of re-bleeding.
Otherwise normal colonoscopy to cecum
Brief Hospital Course:
___ w/anemia, prior colonic adenomas presents with post
polypectomy bleed. Pt with continued bleeding with significant
Hgb drop. Repeat colonscopy found bleeding vessel and ulceration
at polypectomy site. Clip placed and bleeding controlled. Pt
given IV iron x1. Post procedure she had no bleeding, vitals
remained stable. Hgb at discharge 7.6
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Ferrous Sulfate 325 mg PO DAILY
Discharge Medications:
1. Ferrous Sulfate 325 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
post-polypectomy bleeding
acute blood loss anemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Ms. ___, you were admitted due to bleeding after a
colonosocpy. You had another colonoscopy which found the source
of bleeding and was able to stop it. You received a dose of IV
iron to help your blood counts recover more quickley.
Followup Instructions:
___
|
19669774-DS-13
| 19,669,774 | 23,092,452 |
DS
| 13 |
2134-11-18 00:00:00
|
2134-11-18 09:30:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
___
Major Surgical or Invasive Procedure:
___: Diagnostic cerebral angiogram
History of Present Illness:
___ is a ___ female who presents from OSH for
evaluation of ___. She states that at 7pm, she turned her head
to
the left and felt a "sudden pop with worst pain in her life,
felt
dizzy and the pain was so severe that she felt she was going to
poop and pee at the same time". She laid down in her car for two
hours, and then had someone drive her to the Emergency Room.
While at the OSH, the ___ showed subarachnoid blood and she
was
transferred to ___ for further evaluation.
Past Medical History:
Arthritis
HTN (was given medications for HTN, took for one month, and then
self discontinued because she "felt better")
Social History:
___
Family History:
Family Hx:
Is there a family history of Aneurysms?
[x]No
Physical Exam:
On admission PHYSICAL EXAM
___ and ___:
[ ]Grade I: Asymptomatic, mild headache, slight nuchal rigidity
[x]Grade II: Moderate to severe headache, nuchal rigidity, no
neurological deficit other than cranial nerve palsy.
[ ]Grade III: Drowsiness/Confusion, mild focal neurological
deficit.
[ ]Grade IV: Stupor, moderate-severe hemiparesis.
[ ]Grade V: Coma, decerebrate posturing.
Fisher Grade:
[ ]1 No hemorrhage evident
[x]2 Subarachnoid hemorrhage less than 1mm thick
[ ]3 Subarachnoid hemorrhage more than 1mm thick
[ ]4 Subarachnoid hemorrhage of any thickness with IVH or
parenchymal extension
WFNS ___ 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
___ Coma Scale:
[ ]Intubated [x]Not intubated
Eye Opening:
[ ]1 Does not open eyes
[ ]2 Opens eyes to painful stimuli
[ ]3 Opens eyes to voice
[x]4 Opens eyes spontaneously
Verbal:
[ ]1 Makes no sounds
[ ]2 Incomprehensible sounds
[ ]3 Inappropriate words
[ ]4 Confused, disoriented
[x]5 Oriented
Motor:
[ ]1 No movement
[ ]2 Extension to painful stimuli (decerebrate response)
[ ]3 Abnormal flexion to painful stimuli (decorticate response)
[ ___ Flexion/ withdrawal to painful stimuli
[ ]5 Localizes to painful stimuli
[x]6 Obeys commands
15 - Total
T: 98.0 BP: 134/68 HR: 78 R: 11 O2Sats:96% on RA
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: 3-2mm bilaterally EOMs intact - 3 beats
horizontal nystagmus to right
Extrem: Warm and well-perfused. No C/C/E.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 3mm to 2mm
bilaterally.
III, IV, VI: Extraocular movements intact bilaterally with 3
beats of horizontal nystagmus to the right
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 full power ___ throughout. No pronator drift
Sensation: Intact to light touch
On Discharge:
=============
Exam:
Opens eyes: [x]spontaneous [ ]to voice [ ]to noxious
Orientation: [x]Person [x]Place [x]Time
Follows commands: [ ]Simple [x]Complex [ ]None
Pupils: PERRL 3-2mm bilaterally
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
___
IPQuadHamATEHLGast
Right___
Left5 5 5 5 5 5
[x]Sensation intact to light touch
Pertinent Results:
Please see OMR for pertinent lab/imaging studies.
Brief Hospital Course:
___ is a ___ year old female who presented to OSH after
complaint of the sudden popping sensation when turning her neck
to the right and NCHCT was shown to have SAH. She was
transferred to ___ and admitted to the neuro ICU for
close monitoring in the setting of possible sentinel bleed of
aneurysm.
#___
Patient was admitted to neuro ICU and a Diagnostic angiogram was
performed on ___ which was negative for vascular malformation
or aneurysm. Patient developed a small groin hematoma post
operatively. Pressure was held and patient was kept on bedrest
and there was not further active bleeding. On ___, she was
transferred to the floor where she continued to be monitored,
she remained neurologically stable. On ___, she was assessed by
physical and occupational therapy, she was deemed stable for
discharge.
#Hypotension
Patient had an episode of symptomatic hypotension after
receiving dose of nimodipine on ___. Given the nimodipine
caused SBP drop, dosing was changed to 30mg Q2 hrs (from 60mg Q4
hrs). SBP improved over time and patient's symptoms resolved. On
___, her nimodipine was discontinued, as the cerebral angiogram
revealed that she had a non-aneurysmal subarachnoid hemorrhage.
AHA/ASA Core Measures for SAH/ ICH:
1. Dysphagia screening before any PO intake? [x]Yes []No
2. DVT prophylaxis administered? [x]Yes []No
3. Smoking cessation counseling given? []Yes [x]No [Reason:
(x)non-smoker ()unable to participate]
4. Stroke Education given in written form? [x]Yes []No
5. Assessment for rehabilitation and/or rehab services
considered? [x]Yes []No
Stroke Measures:
1.Was ___ performed within 6hrs of arrival? [x]Yes []No
2.Was a Procoagulant Reversal agent given? []Yes [x]No
[Reason:] Not on anticoagulants daily and had normal lab values
3.Was Nimodipine given? [x]Yes []No [Reason:] Given initially,
eventually discontinued after diagnostic cerebral angiogram
revealed she had a non-aneurysmal subarachnoid hemorrhage
Medications on Admission:
None
Discharge Medications:
1. Acetaminophen ___ mg PO Q8H:PRN Pain - Mild
2. Docusate Sodium 100 mg PO BID
3.Outpatient Physical Therapy
Evaluate and treat
Discharge Disposition:
Home with Service
Discharge Diagnosis:
Non-aneurysmal Subarachnoid Hemorrhage
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Activity
* You may gradually return to your normal activities, but we
recommend you take it easy for the next ___ hours to avoid
bleeding from your groin.
* Heavy lifting, running, climbing, or other strenuous exercise
should be avoided for ten (10) days. This is to prevent bleeding
from your groin.
* You make take leisurely walks and slowly increase your
activity at your own pace. ___ try to do too much all at once.
* Do not go swimming or submerge yourself in water for five (5)
days after your procedure.
* You make take a shower.
* No driving while taking any narcotic or sedating medication.
* If you experienced a seizure while admitted, you must refrain
from driving.
Medications
* Resume your normal medications and begin new medications as
directed.
* Please do NOT take any blood thinning medication (Aspirin,
Plavix, Coumadin) until cleared by the neurosurgeon.
* You may use Acetaminophen (Tylenol) for minor discomfort if
you are not otherwise restricted from taking this medication.
What You ___ Experience:
* Mild to moderate headaches that last several days to a few
weeks.
* Difficulty with short term memory.
* Fatigue is very normal
* Constipation is common. Be sure to drink plenty of fluids and
eat a high-fiber diet. If you are taking narcotics (prescription
pain medications), try an over-the-counter stool softener.
When to Call Your Doctor at ___ for:
* Severe pain, swelling, redness or drainage from the incision
site or puncture site.
* Fever greater than 101.5 degrees Fahrenheit
* Constipation
* Blood in your stool or urine
* Nausea and/or vomiting
* Extreme sleepiness and not being able to stay awake
* Severe headaches not relieved by pain relievers
* Seizures
* Any new problems with your vision or ability to speak
* Weakness or changes in sensation in your face, arms, or leg
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:
___
|
19669999-DS-7
| 19,669,999 | 20,005,479 |
DS
| 7 |
2148-06-07 00:00:00
|
2148-06-09 01:21:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Latex / Budesonide / Hydrocortisone Butyrate / Triamcinolone /
Desonide / Tape ___
Attending: ___.
Chief Complaint:
Altered mental status, lethargy, unresponsiveness
Major Surgical or Invasive Procedure:
___ PICC Line Placement
History of Present Illness:
___ with h/o CAD s/p CABG and stents, HTN, HL, hypothyroidism,
dementia, and frequent MDR (MRSA, VRE, ESBL) UTIs who was BIBA
from ___ of ___ for
altered mental status, including lethargy and minimal
responsiveness (only to sternal rub). On ___ a urine culture
was sent and patient was started on macrobid. On ___, culture
returned growing ESBL e.coli and another unidentified organism.
Patient was started on ertapenem. On ___, urine culture grew
VRE. She was found febrile to 100.7F and given tylenol ___nd transferred to ___. Per son ___, patient is
oriented, clear and coherent at baseline, able to answer
questions, but with memory loss. Son notes when she is infected,
she gets significantly altered.
.
In the ED, VS: 97 45 77/46 18 83% 2L NC. Per report, she was
hypoxic to the ___ on RA. Patient was noted to be responsive
only to pain. Tmax noted to be 102.8F, given tylenol PR. UA was
floridly positive (>182WBC, Mod bacteria, large leuks). WBC was
notable at 29.5 (N89%). Urine and blood cultures sent. CXR
suggestive of RML PNA. BP was in the 60-70s/40s so patient was
given 1.5L NS with improvement in BPs to 90-100s/30s, CVP
reportedly estimated to be ___ s/p 1.5L IVFs. Central venous gas
showed lactate 3.7, pH 7.37, pCO2 41, pO2 37, HCO3 25 on
nonrebreather. Patient was given IV Linezolid and meropenem 1g
IV and was admitted to the ICU for urosepsis and possible
pneumonia. Patient's VS were 83 91/33 20 100% on a nonrebreather
prior to transfer.
.
On arrival to the ICU, patient is moaning and not able to give
history.
Past Medical History:
- CAD, s/p 3-vessel CABG in ___ (SVG to LAD, SVG to Diagonal,
SVG to RCA) and bare metal stents in ___ (SVG to LAD in ___
and SVG to RCA in ___
- Hypertension
- Dyslipidemia
- L CEA ___
- PVD
- large hiatal hernia/esophageal stricture/GERD
- Behcets disease
- rectal prolapse
- hypothyroidism
- recurrent UTIs (ESBL e. coli, VRE)
Social History:
___
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.
Physical Exam:
Admission Exam:
T: 98.1, BP: 93/72, P: 97, R: 16, O2: 98% facemask at 40%
General: minimally responsive, opens eyes, facemask on
HEENT: Sclera anicteric, dry MM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD, chronic skin changes
around neck
CV: tachycardic, but regular rhythm, normal S1 + S2, no murmurs,
rubs, gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi. sternotomy scar
Abdomen: soft, minimally tender suprapubically, non-distended,
bowel sounds present, no organomegaly, large well healed
surgical incision
GU: foley, cloudy urine
Ext: cool extremities, thin skin, 1+ pulses, no clubbing,
cyanosis or edema
Neuro: moving all extremities, otherwise not cooperating
Discharge Exam:
Vitals: 98.6 130/68 85 16 96% RA
General: A&Ox3, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Unlabored breathing, clear to ausculatation 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,
Ext: Warm, well perfused, trace edema
Skin: no rash
Neuro: Alert and Oriented x3. CN II-XII intact. ___ stenght
thoughout. Sensation intact to light touch. Unstable gait.
Pertinent Results:
Admission/Pertinent Labs:
___ 11:35AM BLOOD WBC-29.5*# RBC-4.89 Hgb-14.8 Hct-45.6
MCV-93 MCH-30.3 MCHC-32.6 RDW-16.4* Plt ___
___ 08:00PM BLOOD WBC-27.9* RBC-3.61* Hgb-10.7* Hct-34.0*
MCV-94 MCH-29.8 MCHC-31.6 RDW-16.0* Plt ___
___ 03:50AM BLOOD WBC-10.8 RBC-3.30* Hgb-9.7* Hct-31.0*
MCV-94 MCH-29.4 MCHC-31.3 RDW-16.2* Plt ___
___ 11:35AM BLOOD Neuts-89* Bands-1 Lymphs-2* Monos-8 Eos-0
Baso-0 ___ Myelos-0 NRBC-1*
___ 12:25PM BLOOD ___ PTT-35.6 ___
___ 12:25PM BLOOD Glucose-107* UreaN-28* Creat-1.4* Na-130*
K-5.5* Cl-95* HCO3-25 AnGap-16
___ 08:00PM BLOOD Glucose-170* UreaN-21* Creat-0.8 Na-136
K-4.3 Cl-109* HCO3-19* AnGap-12
___ 07:09AM BLOOD Glucose-74 UreaN-7 Creat-0.4 Na-139 K-3.6
Cl-110* HCO3-22 AnGap-11
___ 12:25PM BLOOD ALT-21 AST-41* AlkPhos-94 TotBili-1.1
___ 08:00PM BLOOD Albumin-2.9* Calcium-6.8* Phos-2.3*
Mg-1.5*
___ 03:50AM BLOOD Calcium-7.0* Phos-1.7* Mg-2.0
___ 05:41AM BLOOD Calcium-8.0* Phos-1.1* Mg-1.4*
___ 12:24PM BLOOD Type-CENTRAL VE pO2-37* pCO2-41 pH-7.37
calTCO2-25 Base XS--1
___ 05:55PM BLOOD ___ pO2-40* pCO2-44 pH-7.26*
calTCO2-21 Base XS--6
___ 11:39AM BLOOD Glucose-100 Lactate-4.6* Na-127* K-8.2*
Cl-98 calHCO3-21
___ 11:14AM BLOOD Lactate-1.0
.
EKG: ___
Sinus rhythm with first degree A-V delay. Cannot exclude old
inferior
myocardial infarction. No significant delay compared to previous
tracing
of ___ other than slower sinus rate.
.
CXR: ___
IMPRESSION: Low lung volumes and large hiatal hernia. New
retrocardiac
opacity, potentially atelectasis, infection is also possible.
Repeat with PA and lateral views may help further characterize
if patient is amenable.
.
___ PICC LIne: ___
IMPRESSION: Uncomplicated ultrasound and fluoroscopically guided
single-lumen PICC line placement via the right brachial venous
approach. Final internal length is 37 cm, with the tip
positioned in the distal SVC. The line is ready to use.
.
Renal Ultraound: ___
IMPRESSION:
1. Stable simple cyst in the upper pole of the right kidney.
2. Stable calyceal diverticulum in the left kidney.
3. Small non-obstructing calculi as described.
.
Stool C-diff ___ Negative
Urine Culture: ___: Consistent with mixed fecal
contamination
Blood Cultures: ___: Negative
.
Discharge Labs:
___ 12:24PM BLOOD WBC-6.7 RBC-4.03* Hgb-11.8* Hct-36.8
MCV-91 MCH-29.3 MCHC-32.1 RDW-15.9* Plt ___
___ 12:24PM BLOOD Glucose-113* UreaN-6 Creat-0.4 Na-137
K-3.8 Cl-100 HCO3-29 AnGap-12
___ 12:24PM BLOOD Calcium-8.5 Phos-1.9* Mg-1.4*
Brief Hospital Course:
___ F with h/o CAD s/p CABG and stents, HTN, HL,
hypothyroidism, dementia, and frequent MDR (MRSA, VRE, ESBL)
UTIs who is admitted with lethargy, minimal responsiveness,
fevers and hypotension consistent with urosepsis.
.
# Urosepsis: Prior to admission, patient had a urine culture
drawn and was being treated for a UTI with macrobid in her
nursing facility. Urine culture returned growing ESBL e.coli for
which she'd been started on ertapenem one day prior to
admission. On the day of transfer to ___, urine culture grew
VRE. Patient was brought to ED because she was only responsive
to sternal rub in her nursing facility. Her systolic blood
pressures were in ___. She was volume resuscitated with 4.5L
IVF and transferred to MICU. A central line was placed in the ED
given poor access and in the MICU she continued to receive IVFs
with improvement in systolic blood pressure to the ___. Patient
was started on Linezolid immediately and continued on meropenem.
She did not require vasopressors. Urine culture was
contaminated, c.diff was negative, and blood cultures did not
grow any organism. Once patient was transferred to the floor
she remained hemodynamically stable with no fevers. Infectious
disease was consulted who did not recommend any chronic
suppressive antibiotics given that continued oral antibiotic
exposure as suppressive regimen would likely increase selective
pressure for ongoing resistant bacterial pathogens or yeast
superinfection. Patient also had renal ultrasound which did not
show any significant structural changes that would predispose
patient to recurrent UTIs. She will continue treatment with
Ertapenem and Linezolid for total of two weeks for treatment of
complicated UTI. She will follow up with urogyn to further
evaluate why she may been having recurrent UTIs.
.
# Altered Mental Status: Patient was found lethargic and
responsive only to painful stimuli on admission. This was
attributed to sepsis and patient's mental status initially
improved with IVFs and treatment of her UTI as above. Through
her hospital course she did have waxing and waning delirium
which would improve after having son at bedside.
.
# CAD/CHF: s/p 3-vessel CABG in ___ (SVG to LAD, SVG to
Diagonal, SVG to RCA) and bare metal stents in ___ (SVG to LAD
in ___ and SVG to RCA in ___. She remained euvolemic during
this hospitalization with no concern for ACS or CHF
exacerbations. She was continued on aspirin, Plavix,
atorvastatin, metoprolol and enalapril.
.
# Hypertension: Home anti-hypertensive were held initially given
septic shock but restarted as patient became hypertensive on the
medical floors. Her blood pressure then were consistently in
the 160s range therefore her dose of amlodipine and enalapril
were increased.
.
# Hyperlipidemia: Continued atorvastatin
.
# Hiatal hernia/GERD: Continued omeprazole
.
# Behcet disease: Patient takes methotrexate 10mg weekly. Her
methotrexate was held during this admission given her episode of
urosepsis. After discussion with PCP her methotrexate ___ be
held indefinitely for now unless she develops any flare of her
Behcet's disease. Patient should follow up with PCP (also a
rheumatologist) who will consider restarting methotrexate if
patient every symptomatic again.
.
# Dementia: Held Remeron given its interaction with Linezolid
with risk of serotonin syndrome. Remeron should be restarted by
PCP when antibiotics regimen completed. Continued Donepezil.
.
# Communication: ___ (HCP) Home: ___, Cell:
___
CODE STATUS: Full Code during this admission
.
Transitions of Care:
- Remeron has been stopped given its interaction with Linezolid
with risk of serotonin syndrome. Patient can be restarted on
Remeron once Linezolid treatment has been completed.
- Patient will follow up with Uro-gyn for evaluation of
recurrent UTIs.
- Patient will need CBC, chem 10 including phos checked on ___
to evaluate for any signs of toxicity from her antibiotic
treatment as well as to monitor for resolution of her
hypophosphatemia.
- Methotrexate was discontinued after speaking with PCP.
Patient may be restarted with methotrexate in the future if she
has any flare up of her Behcet disease.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Ondansetron 4 mg PO Q8H:PRN nausea
2. Mirtazapine 7.5 mg PO HS
3. Enalapril Maleate 10 mg PO DAILY
Hold for BP<100
4. Metoprolol Succinate XL 100 mg PO DAILY
Hold for BP<100
5. INVanz *NF* (ertapenem) 1 gram Injection daily
___
6. Heparin 5000 UNIT SC BID
7. Clopidogrel 75 mg PO DAILY
8. Acetaminophen 650 mg PO Q6H:PRN pain, fever
9. TraMADOL (Ultram) 100 mg PO BID:PRN mod-severe pain
10. Acidophilus *NF* (L.acidoph &
___ acidophilus) 175 mg Oral
daily Duration: 10 Days
D1= ___. Antacid *NF* (alum-mag hydroxide-simeth;<br>calcium
carbonate;<br>calcium carbonate-mag hydroxid) unknown Oral Q4h
prn GI upset
12. Aspirin 325 mg PO DAILY
13. Atorvastatin 80 mg PO DAILY
14. Calcium Carbonate 500 mg PO DAILY
15. Vitamin D 200 UNIT PO DAILY
16. Docusate Sodium 100 mg PO BID:PRN constipation
17. Donepezil 5 mg PO HS
18. Bisacodyl 10 mg PR HS:PRN constipation
19. FoLIC Acid 1 mg PO DAILY
20. CefTAZidime Dose is Unknown IV Frequency is Unknown
21. Magnesium Oxide 400 mg PO BID
22. Lidocaine 5% Patch 1 PTCH TD DAILY right shoulder
23. Methotrexate 10 mg PO 1X/WEEK (FR)
24. Milk of Magnesia 30 mL PO PRN constipation
25. Multivitamins 1 TAB PO DAILY
26. Gabapentin 600 mg PO BID
27. Amlodipine 2.5 mg PO DAILY
Hold for BP<100
28. Omeprazole 20 mg PO BID
29. Acetaminophen 1000 mg PO BID
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain, fever
2. Aspirin 325 mg PO DAILY
3. Atorvastatin 80 mg PO DAILY
4. Bisacodyl 10 mg PR HS:PRN constipation
5. Clopidogrel 75 mg PO DAILY
6. Docusate Sodium 100 mg PO BID:PRN constipation
7. Donepezil 5 mg PO HS
8. FoLIC Acid 1 mg PO DAILY
9. Gabapentin 600 mg PO BID
10. Heparin 5000 UNIT SC BID
11. Lidocaine 5% Patch 1 PTCH TD DAILY right shoulder
12. Multivitamins 1 TAB PO DAILY
13. Omeprazole 20 mg PO BID
14. Calcium Carbonate 500 mg PO DAILY
15. Linezolid ___ mg PO Q12H
16. TraMADOL (Ultram) 100 mg PO BID:PRN mod-severe pain
17. Ondansetron 4 mg PO Q8H:PRN nausea
18. INVanz *NF* (ertapenem) 1 gram Injection daily
___ Last Day os ___.
19. Magnesium Oxide 400 mg PO BID
20. Amlodipine 5 mg PO DAILY
21. Enalapril Maleate 15 mg PO DAILY
22. Vitamin D 400 UNIT PO DAILY
23. Metoprolol Succinate XL 100 mg PO DAILY
Hold for BP<100
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
1. Urinary Tract Infection
2. Urosepsis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear ___ was a pleasure taking care of you during your hospitalization
at ___. You were found to have urinary tract infection in your
nursing facility and started on antibitoics. However your
urinary tract infection worsened leading to very low blood
pressures and changes in your mental status. You were treated
with intravenous fluids and stronger antibiotics with sigificant
improvement in your symptoms. You will continue to be on
antibiotics until ___. You should follow up with
uro-gynecologist (see below) to determine why you may be having
recurrent urinary tract infection.
Following Changes were made to your medications:
STARTED Linezolid and Ertapenem with last day being ___
STOPPED Methotrexate per your PCP ___. Your PCP may
restart this medication in the future.
STOPPED Mirtazapine beucase of its interaction with one of your
antibtiocs. Your PCP may restart you on this medication at the
end of your antibiotic treatment.
STOPPED Ceftaxizide as it is no longer needed
STOPPED Milk of Magnesia because of your low phosphorus
STOPPED Acidophilus as it is no longer needed.
INCREASED the dose of your blood pressure medication Amlodopine
and Enalapril.
Followup Instructions:
___
|
19670384-DS-32
| 19,670,384 | 24,963,863 |
DS
| 32 |
2191-05-20 00:00:00
|
2191-05-23 16:21:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Chocolate Flavor / Simvastatin / Morphine Sulfate / Allopurinol
/ Augmentin / ciprofloxacin
Attending: ___
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
The patient is a ___ year-old female with h/o FSGS s/p
living-unrelated renal transplant in ___, osteonecrosis of
several joints ___ to steroids, DVT/PE on coumadin p/w RLQ pain
x 1.5d. Per patient she began to experiences sharp abdominal
pain at the site of her graft on ___. Pain was initially
intermittent in nature but now is more constant. She
additionally reports watery non-bloody diarrhea that has become
more solid over the same time period. She denies nausea or
vomiting and states she has been able to maintain good oral
intake of fluids. She denies associated fevers or chills. Urine
output has remained constant. She further denies dysuria,
urinary frequency, urgency or sick contacts.
.
In the ED, initial vitals were 97.1 71 161/90 16 100% RA. Labs
were significant for Cr 2.5 (baseline 1.5). UA was negative.
Renal ultrasound demonstrated normal appearance of RLQ
transplant kidney; no hydronephrosis or perinephric fluid;
patent main renal artery and main renal vein; normal resistive
indices. She was given 2L of fluid in addition to morphine for
pain control. The patient was admitted to transplant nephrology
for acute kidney injury. At the time of transfer, VS: 97.9 65 16
131/81 96%RA.
.
Of note the patient also with recent gout flare that was treated
with a 1 week steriod taper.
.
On the floor, the patient reports continued pain in RLQ but is
otherwise well appearing.
.
ROS: (+)per HPI, also notes dry non productive cough
denies fever, chills, night sweats, headache, vision changes,
rhinorrhea, congestion, sore throat, cough, shortness of breath,
chest pain, nausea, vomiting, BRBPR, melena, hematochezia,
dysuria, hematuria.
Past Medical History:
1. Focal sclerosing glomerulonephritis status post kidney
transplant in ___.
2. A history of CMV infection.
3. Acute transplant rejection that had been treated with OKT3 in
___.
4. DVT and pulmonary embolism on Coumadin.
5. AVN.
6. TIA.
7. Hypertension.
8. Hyperlipidemia.
9. Metabolic syndrome
10. Gout.
11. Nephrolithiasis with ureteral stent placements.
12. Osteonecrosis of bilateral hips, shoulders, knees, status
post surgical interventions.
13. Left cataract surgery in ___.
14. Right cataract surgery in ___.
15. Skin cancer status post surgery in ___.
16. Basal cell carcinoma in ___.
17. A left adnexal mass s/p salpingo-oophorectomy.
18. Cervical dysplasia.
19. Hyperparathyroidism secondary to renal failure.
20. Appendicectomy.
21. Endometrial ablation for menorrhagia in ___.
22. ___ laparoscopy
Social History:
___
Family History:
Dad MI at age ___. Brother MI at age ___. Sister with FSGS s/p
renal transplant.
.
Physical Exam:
ADMISSION EXAM
VS: 97.6 130/76 82 16 100% RA
GENERAL: Well appearing F who appears stated age. Comfortable,
in no acute distress
HEENT: Sclera anicteric. PERRL, EOMI.
NECK: Supple with low JVP
CARDIAC: PMI located in ___ intercostal space, midclavicular
line. RRR, S1 S2 clear and of good quality without murmurs, rubs
or gallops. No S3 or S4 appreciated.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use, moving air well and
symmetrically. CTAB, no crackles, wheezes or rhonchi.
ABDOMEN: Non-distended, soft, tender to palpation in RLQ, no
rebound or guarding.
EXTREMITIES: Warm and well perfused, no clubbing, cyanosis or
edema.
NEURO: CN II-XII intact grossly, strength ___ throughout,
sensation intact to light touch.
.
DISCHARGE EXAM
VS: 97.6 133/81 (120/72-133/81) 70 (65-70) 18 98% RA
GENERAL: Well appearing F who appears stated age. Comfortable,
in no acute distress
HEENT: Sclera anicteric. PERRL, EOMI.
NECK: Supple with low JVP
CARDIAC: PMI located in ___ intercostal space, midclavicular
line. RRR, no murmurs, rubs or gallops. No S3 or S4 appreciated.
LUNGS: CTAB
ABDOMEN: Non-distended, soft,mildy tender to palpation in RLQ,
no rebound or guarding.
EXTREMITIES: Warm and well perfused, no clubbing, cyanosis or
edema.
Pertinent Results:
ADMISSION LABS
___ 04:50AM BLOOD WBC-6.5 RBC-4.34# Hgb-12.3 Hct-36.2
MCV-83 MCH-28.4 MCHC-34.0 RDW-13.9 Plt ___
___ 04:50AM BLOOD Neuts-55.4 ___ Monos-5.2 Eos-2.9
Baso-0.7
___ 04:50AM BLOOD ___ PTT-52.9* ___
___ 04:50AM BLOOD Glucose-106* UreaN-41* Creat-2.5* Na-138
K-3.5 Cl-100 HCO3-26 AnGap-16
___ 05:04AM BLOOD Lactate-1.5
.
DISCHARGE LABS
___ 06:30AM BLOOD WBC-5.0 RBC-3.85* Hgb-10.7* Hct-32.0*
MCV-83 MCH-27.7 MCHC-33.3 RDW-13.9 Plt ___
___ 10:45AM BLOOD ___ PTT-59.0* ___
___ 06:30AM BLOOD Glucose-120* UreaN-32* Creat-1.7* Na-138
K-3.7 Cl-106 HCO3-22 AnGap-14
.
DRUG MONITORING
___ 06:05AM BLOOD tacroFK-7.4
___ 06:30AM BLOOD tacroFK-7.8
.
URINE STUDIES
___ 04:50AM URINE Color-Straw Appear-Clear Sp ___
___ 04:50AM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-TR
___ 04:50AM URINE RBC-1 WBC-2 Bacteri-NONE Yeast-NONE Epi-6
___ 05:19PM URINE Color-Straw Appear-Clear Sp ___
___ 05:19PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
___ 07:23AM URINE Hours-RANDOM UreaN-816 Creat-106 Na-88
K-26 Cl-37
___ 07:23AM URINE Osmolal-534
.
MICROBIOLOGY
URINE CULTURE (Final ___:
LACTOBACILLUS SPECIES. >100,000 ORGANISMS/ML..
___ ___ (___) REQUESTED SENSITIVITIES
___.
Sensitivity testing performed by Sensititre.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
LACTOBACILLUS SPECIES
|
AMPICILLIN------------<=0.12 S
GENTAMICIN------------ <=2 S
PENICILLIN G----------<=0.06 S
.
URINE CULTURE (Final ___:
LACTOBACILLUS SPECIES. 10,000-100,000 ORGANISMS/ML.
.
OVA + PARASITES (Final ___:
NO OVA AND PARASITES SEEN.
This test does not reliably detect Cryptosporidium,
Cyclospora or
Microsporidium. While most cases of Giardia are detected
by routine
O+P, the Giardia antigen test may enhance detection when
organisms
are rare.
.
CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final ___:
Feces negative for C.difficile toxin A & B by EIA.
(Reference Range-Negative).
FECAL CULTURE (Final ___: NO SALMONELLA OR SHIGELLA
FOUND.
CAMPYLOBACTER CULTURE (Final ___: NO CAMPYLOBACTER
FOUND.
.
STUDIES
Renal ultrasound
FINDINGS: The transplanted kidney located in the right lower
quadrant and measures 10.9 cm in its long axis. Vascularity is
grossly normal. Resistive indices in the upper, mid and lower
portions of the kidney are 0.7-0.68, 069-0.67, and 0.67-0.63,
respectively. The main renal vein is patent with directionally
appropriate flow. The main renal artery shows a normal arterial
waveform with brisk upstrokes and a peak systolic velocity of
104 106 cm/sec. There is no hydronephrosis or perinephric fluid
collection.
IMPRESSION: Normal renal transplant ultrasound.
.
STUDIES
Renal ultrasound
FINDINGS: The transplanted kidney located in the right lower
quadrant and measures 10.9 cm in its long axis. Vascularity is
grossly normal. Resistive indices in the upper, mid and lower
portions of the kidney are 0.7-0.68, 069-0.67, and 0.67-0.63,
respectively. The main renal vein is patent with directionally
appropriate flow. The main renal artery shows a normal arterial
waveform with brisk upstrokes and a peak systolic velocity of
104 106 cm/sec. There is no hydronephrosis or perinephric fluid
collection.
IMPRESSION: Normal renal transplant ultrasound.
.
CT ABDOMEN PELVIS
IMPRESSION:
1. No cause identified for the patient's pain.
2. Normal-appearing renal transplant within the right iliac
fossa.
Brief Hospital Course:
PRIMARY REASON FOR ADMISSION
The patient is a ___ year-old female with h/o FSGS s/p kidney txp
___, osteonecrosis of several joints ___ to steroids, DVT/PE on
coumadin p/w RLQ pain, noted to have ___.
.
ACTIVE ISSUES
.
# ___: This was ultimately felt to be reflective of volume
depletion. FeUREA of 47% was not consistent pre-renal etiology
however the patient was having diarrhea and therefore is likely
volume depleted. The patient was given IVF with improvement in
her creatinine from 2.5 on admission to 1.7 at the time of
discharge. Both a US and CT of her transplant graft were normal.
UA was unremarkable and urine culture showed only vaginal flora.
There was concern for possible tacrolimus toxicity given
diarrhea however her level was appropriate. The patient's home
diuretics and lisinopril were held throughout admission.
Lisinopril was restarted on discharge. She will follow-up with
her nephrologist regarding restarting her lasix.
.
# Diarrhea/Abdominal pain- Viral gastroenteritis was felt to be
the most likely etiology of her symptoms. Patient is at risk
for bacterial infection given immunosuppression. However stool
studies (including C. diff toxin) were negative and CT of her
abdomen and pelvis were normal. Given location of pain there was
concern for dysfunction of her renal graft. However both
ultrasound and CT showed a normal graft with normal vasculature.
Diarrhea improved prior to discharge.
.
STABLE ISSUES
# FSGS s/p transplant: Patient was continued on her home does of
tacrolimus and sirolimus. Levels were appropriate. As above US
and CT of the graft were normal.
.
# DVT/PE on coumadin: INR was monitored throughout admission.
Coumadin was held on ___ and ___ given a supratherpeutic
INR. Patient was instructed to restart coumadin the day
following discharge and follow-up with her PCP for INR
monitoring and coumadin dose adjustment.
.
# Hypertension: Patient was continued on her home amlodipine and
metoprolol. Lisinopril was held throughout admission but
restarted at the time of discharge.
.
# Depression: Patient was continued on her home citalopram
.
TRANSITIONAL ISSUES
- Patient will follow-up with her PCP for INR monitoring and
coumadin dose adjustment
- Patient was full code throughout this admission
Medications on Admission:
- sirolimus 2 mg PO daily
- tacrolimus 2 mg PO Q12H
- oxycodone 5 mg PO Q4H prn
- citalopram 40 mg PO daily
- calcitriol 0.5 mcg PO daily
- lisinopril 5 mg PO once a day.
- zolpidem 5 mg PO HS as needed for insomnia.
- amlodipine 5 mg PO once a day.
- metoprolol succinate 100 mg PO once a day.
- leucovorin calcium 10 mg PO daily
- furosemide 80 mg PO once a day.
- colchicine 0.6 mg PO once a day.
- senna 8.6 mg Tablet PO BID
- docusate sodium 100 mg PO BID as needed for constipation.
- coumadin
Discharge Medications:
1. sirolimus 1 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
2. tacrolimus 1 mg Capsule Sig: Two (2) Capsule PO Q12H (every
12 hours).
3. citalopram 40 mg Tablet Sig: One (1) Tablet PO once a day.
4. calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
5. zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed for insomnia.
6. amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. metoprolol succinate 100 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
8. colchicine 0.6 mg Tablet Sig: One (1) Tablet PO once a day.
9. Vicodin ___ mg Tablet Sig: ___ Tablets PO every ___ hours
as needed for pain.
10. warfarin 6 mg Tablet Sig: One (1) Tablet PO once a day.
11. lisinopril 5 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
Acute Kidney Injury
Viral Gastroenteritis
Secondary Diagnosis
Focal sclerosing glomerulonephritis status post kidney
transplant
Hypertension.
Hyperlipidemia
Gout
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Ms ___,
It was a pleasure participating in your care while you were
admitted to ___. As you know
you were admitted because your creatinine was high. We believe
this is most likely because you were dehydrated from diarrhea.
Given your abdominal pain and diarrhea you had a CT scan of your
abdomen that did not show any acute signs of infection.
We made the following changes to your medications
1. STOP lasix (this will be continued at a later date in time)
.
Please begin taking your coumadin again tomorrow at your usual
time. You should continue to take all medications as instructed.
Followup Instructions:
___
|
19670384-DS-33
| 19,670,384 | 20,392,717 |
DS
| 33 |
2191-05-31 00:00:00
|
2191-06-01 16:20:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Chocolate Flavor / Simvastatin / Morphine Sulfate / Allopurinol
/ Augmentin / ciprofloxacin
Attending: ___
Chief Complaint:
cough, shortness of breath, syncope.
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ y.o. woman with a history of FSGS s/p
kidney transplant, DVT on coumadin, previous NSTEMI, and
extensive PMH who presents with an episode of anaphylactic shock
after ingesting chocolate. The night prior to presentation, Ms.
___ was celebrating ___ Day with friends at a bar.
After several drinks of alcohol, she had a ___ day
shot" which had chocolate. After taking the shot, Ms. ___
developed perioral tingling and cough. The cough worsened in
severity until she could not breath. At this time, a bar patron
sourced 75 mg of benadryl. She took the benadryl, but
experienced no improvement in symptoms. She continued to cough
until she had emesis x2. Subsequently, she lost conciousness.
Per report of her friends and of EMS, she stopped breathing and
was pulseless. A fireman arrived on scene and began CPR. She
began breathing after the CPR. When EMS arrived they
administered an epi pen and she fully regained consciousness.
Upon coming to, Ms. ___ remembers being loaded onto a
stretcher. She was able to follow EMS commands. She was taken to
the ___ ED. During the ride she reports having "full body
shivers" that resolved by the time she arrived in the hospital.
She reports that she was not inebriated prior to the onset of
this episode. She had no history
.
At the ED her vitals were: 98.0, 93, 158/85, 18, 100% 2L. Her
exam was benign. Labs were notable for a creatinine of 2.1
(baseline 1.5-1.9), K 3.0, HCO3 16, and lactate of 3.8. In the
ED she received K 40 meq and fmotidine 20 mg IV.
.
When transferred to the floor she was complaining of residual
throat irritiation ("throat is scratching") and
tingling/swelling in her hands bilaterally. Her exam was
otherwise unremarkable. She had no difficulty breathing. The
swelling and tingling in her hands resolved after an hour.
.
Ms. ___ was not allergic to chocolate until her kidney
transplant (donor was allergic to chocolate). Prior reactions to
chocolate have included hives, cough, and perioral tingling, but
nothing as severe as occured the night prior to presentation.
She has no history of seizure.
.
Of note, she was admitted ___ to ___ for ___ after a 4 day
history of watery diarrhea causing dehydration and increase in
creatinine to 2.5. She had pain over her graft site. She was
treated with IV hydration and discharged.
.
ROS: endorses pain in her left lateral tongue. currently denies
HA, fever, myalgias/althragias, neck pain, runny nose, shortness
of breath, chest pain/pressure, N/V, change in bowel habits,
change in stool color, change in bladder habits, change in urine
color.
Past Medical History:
1. Focal sclerosing glomerulonephritis status post kidney
transplant in ___.
2. A history of CMV infection.
3. Acute transplant rejection that had been treated with OKT3 in
___.
4. DVT and pulmonary embolism on Coumadin.
5. AVN.
6. TIA.
7. Hypertension.
8. Hyperlipidemia.
9. Metabolic syndrome
10. Gout.
11. Nephrolithiasis with ureteral stent placements.
12. Osteonecrosis of bilateral hips, shoulders, knees, status
post surgical interventions.
13. Left cataract surgery in ___.
14. Right cataract surgery in ___.
15. Skin cancer status post surgery in ___.
16. Basal cell carcinoma in ___.
17. A left adnexal mass s/p salpingo-oophorectomy.
18. Cervical dysplasia.
19. Hyperparathyroidism secondary to renal failure.
20. Appendicectomy.
21. Endometrial ablation for menorrhagia in ___.
22. ___ laparoscopy
Social History:
___
Family History:
Dad MI at age ___. Brother MI at age ___. Sister with FSGS s/p
renal transplant.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS - 97.7 120/80 84 18 98%RA
GENERAL - Alert, interactive, well-appearing in NAD
HEENT - PERRL, EOMI, sclerae anicteric, MMM, OP clear, no
pharyngeal/uvular edema. No periorbital/lip edema.
NECK - Supple, no thyromegaly, no JVD, no carotid bruits
HEART - PMI non-displaced, RRR, nl S1-S2, no MRG
LUNGS - wheezing bilaterally with forced expiration. good air
movement throughout
ABDOMEN - NABS, soft/NT/ND, no masses or HSM
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses, surgical
scars over both shoulders, c/d/i.
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
___ throughout although movement limited by pain, sensation
grossly intact throughout, cerebellar exam intact, steady gait .
.
Discharge Physical Exam:
Vitals: T 97.7 BP 124-138/78-84 HR 65 RR 18 O2 Sat 99% RA
General: Patient lying in bed in NAD, completing full sentences.
HEENT: No periorbital or lip edema
CV: RRR. ___ systolic murmur best appreciated at the LUSB
LUNGS: Clear to auscultation bilaterally. No crackles or
wheezes. No accessory muscle use. Nml work of breathing.
ABD: NABS+. Soft. ND/NT
EXT: WWP. 2+ DPs bilaterally. No clubbing, cyanosis, or edema.
NEURO: ___ strength plantar and dorsiflexion of ankles
bilaterally. Senesation to light touch grossly intact.
Pertinent Results:
Admission labs:
___ 04:18AM BLOOD Lactate-3.8*
___ 02:43AM BLOOD Calcium-9.4 Phos-2.7 Mg-1.8
___ 02:43AM BLOOD cTropnT-<0.01
___ 02:43AM BLOOD Glucose-189* UreaN-36* Creat-2.1* Na-140
K-3.0* Cl-103 HCO3-16* AnGap-24*
___ 02:43AM BLOOD ___ PTT-43.4* ___
___ 02:43AM BLOOD Neuts-66.3 ___ Monos-3.8 Eos-2.0
Baso-0.5
___ 02:43AM BLOOD WBC-9.1# RBC-4.34 Hgb-11.9* Hct-36.5
MCV-84 MCH-27.4 MCHC-32.6 RDW-14.3 Plt ___
.
ECG (___): Sinus rhythm. Diffuse non-specific ST-T wave
flattening. Compared to the previous tracing of ___ the rate
has increased. There is diffuse non-specific ST-T wave
flattening. Otherwise, the P-R interval is normal. Otherwise, no
diagnostic interim change.
.
Imaging:
CXR IMPRESSION (___): No evidence of acute cardiopulmonary
process.
.
Discharge labs:
___ 05:05AM BLOOD WBC-5.8 RBC-3.84* Hgb-10.8* Hct-32.2*
MCV-84 MCH-28.0 MCHC-33.5 RDW-14.4 Plt ___
___ 05:05AM BLOOD ___
___ 05:05AM BLOOD Glucose-87 UreaN-16 Creat-1.7* Na-142
K-4.0 Cl-114* HCO3-20* AnGap-12
.
Microbiology:
___ 9:56 am STOOL CONSISTENCY: NOT APPLICABLE
Source: Stool.
**FINAL REPORT ___
CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final ___:
Feces negative for C.difficile toxin A & B by EIA.
(Reference Range-Negative).
Brief Hospital Course:
# Viral gastroenteritis: The patient acutely developed nausea,
vomiting, and profuse diarrhea on hospital day 3 attributable to
viral gastroenteritis. Supportive therapy with anti-emetics and
IV fluids were given to the patient. The patient's symptoms
improved, so that on day of discharge she was tolerating an oral
diet without nausea and decreased diarrhea.
.
# Anaphylaxis - Patient has known allergy to chocolate to which
she was exposed leading to anaphylaxis given hypotonia and loss
of conciousness/arrest. Epinephrine was given at the seen. She
remained hemodynamically stable during her stay at ___.
Patient was given methylprenisolone as she developed tongue
swelling on the left side, not associated with scratching throat
or swelling of the throat. Patient was seen by allergy team, who
recommended that the patient receive prednisone 60mg daily for 2
more days as well as famotidine 20mg twice daily for 2 more
days. The patient also had beandryl ___ as needed for
allergy symptoms available to her. The patient had an EpiPen
available to her during the admission, but it was not used
during the admission. The patient was discharged from this
hospitalization with a prescription for an EpiPen with
instructions to carry this with her at all times. The allergist
recommended that the patient either ___ with her previous
allergist at ___ or with the allergist she saw during this
admission.
OUTPATIENT ISSUES: Patient is to strictly avoid chocolate.
Patient should carry an EpiPen with her at all times.
.
# Acute Kidney Injury - Upon admission, the patient's serum
creatinine was elevated at 2.1 attributable to anaphylactic
shock leading to pulseless arrest. The patient received IV
fluids and her serum creatinine trended to baseline of 1.6-1.7,
and acute kidney injury resolved. On day of discharge, patient's
serum creatinine was 1.7. Tacrolimus and sirolimus were
continued through the admission and levels were monitored and
found to be at appropriate levels.
.
# FSGS status post renal tramsplant: Levels of tacrolimus and
sirolimus were monitored through the admission. The patient was
continued on home doses of tacrolimus and sirolimus.
.
# History of deep vein thrombosis and pulmonary embolism on
coumadin: The patient's INR was trended through the admission.
Her home dose of coumadin was continued through a majority of
the admission. Her INR on day of discharge was 3.1, and the
patient was instructed to take 4mg of coumadin until her
___ appointment with her primary care physician for
___ of the patient's INR.
OUTPATIENT ISSUES: Repeat INR at hospital ___
appointment with patient's primary care physician.
.
# Hypertension: Intially, patient was not conitnued on any of
her home anti-hypertensives given her anaphylactic shock. The
patient was restarted initially on her home amlodipine. With
stabilization of the patient's blood pressure, she was restarted
on her home dose of lisinopril and metoprolol. When the
development of diarrhea, the patient's lisinopril was
discontinued. On day of discharge, the patient's lisinopril was
restarted so that she was taking her original anti-hypertensive
regimen.
.
# Depression: Home citalopram was continued through the
admission.
Medications on Admission:
1. sirolimus 1 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
2. tacrolimus 1 mg Capsule Sig: Two (2) Capsule PO Q12H (every
12 hours).
3. citalopram 40 mg Tablet Sig: One (1) Tablet PO once a day.
4. calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
5. zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed for insomnia.
6. amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. metoprolol succinate 100 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
8. colchicine 0.6 mg Tablet Sig: One (1) Tablet PO once a day.
9. Vicodin ___ mg Tablet Sig: ___ Tablets PO every ___ hours
as needed for pain.
10. warfarin 6 mg Tablet Sig: One (1) Tablet PO once a day.
11. lisinopril 5 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Medications:
1. epinephrine 0.3 mg/0.3 mL Pen Injector Sig: One (1) Pen
Injector Intramuscular ONCE MR1 (Once and may repeat 1 time) for
1 doses.
Disp:*2 Pen Injector(s)* Refills:*0*
2. citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
3. sirolimus 1 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
4. tacrolimus 1 mg Capsule Sig: Two (2) Capsule PO Q12H (every
12 hours).
5. calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
6. metoprolol succinate 100 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
7. warfarin 2 mg Tablet Sig: Two (2) Tablet PO once a day.
8. colchicine 0.6 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. zolpidem 5 mg Tablet Sig: One (1) Tablet PO at bedtime as
needed for insomnia.
11. Vicodin ___ mg Tablet Sig: ___ Tablets PO every six (6)
hours as needed for pain.
12. diphenhydramine HCl 25 mg Capsule Sig: ___ Capsules PO every
six (6) hours as needed for itching/allergic rx: Maximum dose of
12 tabs in 24 hours.
Disp:*30 Capsule(s)* Refills:*0*
13. ___ 200-25-400-40 mg/30 mL
Mouthwash Sig: Thirty (30) mL Mucous membrane PRN as needed for
Tongue Pain: Swish and spit.
Disp:*250 mL* Refills:*0*
14. colchicine 0.6 mg Tablet Sig: One (1) Tablet PO once a day.
15. lisinopril 5 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
Anaphylatic Shock, resolved
SECONDARY DIAGNOSIS:
Hypertension
status post renal transplant
History of DVT/PE
Viral gastroenteritis
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 during your hospitalization
at ___.
You were hospitalized after anaphylactic shock after drinking a
beverage that contained chocolate. You were treated with
anti-allergy medications- including diphenhydramine, famotidine,
and steroids. The allergist at ___
___ saw you as well during this admission. You can ___
with him as needed or ___ with the allergist that you had
seen at ___.
During this hospital admission, you acutely developed diarrhea
and nausea attributed to a viral gastroenteritis. You were
started on IV fluids, and your symptoms were improved on day of
discharge.
Please take all medications as instructed. Please note the
following medication changes:
1. *ADDED* EpiPen 0.3mg injection into the muscle as needed for
symptoms of anaphylaxis (throat swelling). Carry the EpiPen on
you at all times.
2. *ADDED* Diphenhydramine ___ every 6 hours as needed for
allergy symptoms/itchiness
3.*DECREASE* Warfarin dose to 4mg daily as your INR was high at
3.1 during this admission. Have your primary care physician
___ your INR during your appointment on ___
to determine whether your dosing needs to be changed.
4.*ADDED* Magic mouth wash as needed for tongue pain. Swish and
spit this medication out.
**AVOID** chocolate as this seemed to be the trigger that led to
this hospitalization.
Please keep all ___ appointments; your up-coming ___
appointments are listed below. You have a ___ appointment
scheduled with your primary care physician for ___.
Followup Instructions:
___
|
19670384-DS-35
| 19,670,384 | 27,155,359 |
DS
| 35 |
2191-11-25 00:00:00
|
2191-11-25 20:38:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Chocolate Flavor / Simvastatin / Allopurinol / Augmentin /
ciprofloxacin
Attending: ___
Chief Complaint:
Pain with swallowing
Major Surgical or Invasive Procedure:
Fiberoptic scope with ENT on ___ and ___
History of Present Illness:
HPI: ___ year old s/p renal transplant ___ years ago on
immunosuppressive medications (tacrolimus, sirolimus) presents
with left sided odynophagia and abnormal laboratory values from
___. Patient has experienced cold symptoms for past
three weeks including cough with phlegm, sore throat, sinusitis
localized to the left side and headaches. She notes a fever of
101 early on that is uncharacteristic given her
immunosuppression regimen. She was initially treated with ceftin
by her PCP ___ 8 days which resulted in diarrhea and was
subsequently swiched to biaxin 4 days prior to admission with
resolution of her diarrhea.
Her cold symptoms are resolving as she denies further sputum
production, improving sinus symptoms but she still has a dry
cough. She now notes worsening left-sided odynophagia to both
solids and liquids starting 2 days prior to admission. She
states that the pain feels like "swallowing glass" and is
localized to the side of her left tongue. She does not
appreciate any masses in her oral cavity or neck. Her throat
pain has continued to worsen until about 1:30am on the day of
admission when she had so much pain that she was unable to
swallow her medications.
ED course:
At the ED in ___, she had abnormal laboratory values
with an increase in her creatinine from 1.8 to 2.9, and elevated
INR. She received 2 liters of fluid at ___ and was
subsequently transferred.
ROS:
She admits that her urine has been more concentrated recently.
She denies nausea/vomiting, fevers/chills, ear
ache/vertigo/dizziness, diarrhea/constipation, chest pain,
abdominal pain, back pain, headaches. She does not a change in
voice. Denies unintentional weight loss.
Past Medical History:
1. Focal sclerosing glomerulonephritis status post kidney
transplant in ___.
2. A history of CMV infection.
3. Acute transplant rejection that had been treated with OKT3 in
___.
4. DVT and pulmonary embolism on Coumadin.
5. AVN.
6. TIA.
7. Hypertension.
8. Hyperlipidemia.
9. Metabolic syndrome
10. Gout.
11. Nephrolithiasis with ureteral stent placements.
12. Osteonecrosis of bilateral hips, shoulders, knees, status
post surgical interventions.
13. Left cataract surgery in ___.
14. Right cataract surgery in ___.
15. Skin cancer status post surgery in ___.
16. Basal cell carcinoma in ___.
17. A left adnexal mass s/p salpingo-oophorectomy.
18. Cervical dysplasia.
19. Hyperparathyroidism secondary to renal failure.
20. Appendicectomy.
21. Endometrial ablation for menorrhagia in ___.
22. ___ laparoscopy
Social History:
___
Family History:
Dad MI at age ___. Brother MI at age ___. Sister with FSGS s/p
renal transplant.
Physical Exam:
On admission:
Vitals: T98 BP 128/82 HR 78 RR 18 97%/RA
Gen: NAD, fatigued, hoarse voice, speaking in full sentences, no
stridor
HEENT: Uvula midline, no exudates, no erythema from tonsils.
Clear tympanic membranes bilaterally. Good dentition. No focal
signs of erythema, lesions or masses on the tongue or buccal
mucosa.
Neck: Tenderness to palpation of lateral left neck, full ROM. No
LAD.
Cardiac: Regular rate and rhythm, no m/r/g
Pulm: CTA bilaterally. No CVA tenderness.
Abd: + bowel sounds, soft, nontender, nondistended. Nontender
over transplant site. Numerous well-healed surgical incision
marks.
Ext: Warm, well perfused. No edema
Neuro: Oriented X3. Bilateral nystagmus noted on both sides. CN
V, VII intact. Grip strength equal bilaterally.
On discharge:
VS afebrile, normotensive, non-tachycardic, non-tachypneic and
saturating high ___ on RA
GA: NAD, well-appearing, no hoarseness of voice
HEENT: PERRL, EOMI, oropharynx clear without exudates
Neck: soft, no tenderness to L lateral neck, no LAD, full ROM.
Pulm: CTAB, no w/r/rh
CV: RRR, no m/r/g
Abd: soft, NT/ND, normoactive BS, no HSM
Ext: warm, 2+ peripheral pulses, no calf tenderness
Back: mild tenderness to lower back
Neuro: A&Ox3, CNII-XII grossly intact, normal gait
Pertinent Results:
On admission:
___ 08:00AM BLOOD WBC-8.6# RBC-4.14* Hgb-11.5* Hct-35.1*
MCV-85 MCH-27.8 MCHC-32.8 RDW-15.0 Plt ___
___ 08:00AM BLOOD Neuts-57.9 ___ Monos-5.0 Eos-2.2
Baso-0.9
___ 09:40AM BLOOD ___ PTT-54.9* ___
___ 08:00AM BLOOD Glucose-117* UreaN-43* Creat-2.2* Na-141
K-4.2 Cl-108 HCO3-24 AnGap-13
___ 08:00AM BLOOD Calcium-8.5 Phos-3.2
___ 08:00AM BLOOD tacroFK-13.5 rapmycn-13.6
___ 09:20PM BLOOD tacroFK-10.6 rapmycn-11.5
On discharge:
___ 06:45AM BLOOD WBC-4.7 RBC-3.48* Hgb-9.5* Hct-29.6*
MCV-85 MCH-27.2 MCHC-31.9 RDW-15.3 Plt ___
___ 06:45AM BLOOD ___ PTT-48.1* ___
___ 06:45AM BLOOD Calcium-8.7 Phos-3.1 Mg-1.6
___ 06:45AM BLOOD tacroFK-2.5*
___ 06:45AM BLOOD tacroFK-7.1 rapmycn-6.1
Micro:
**FINAL REPORT ___
R/O Beta Strep Group A (Final ___:
NO BETA STREPTOCOCCUS GROUP A FOUND.
**FINAL REPORT ___
Respiratory Viral Culture (Final ___:
No respiratory viruses isolated.
Culture screened for Adenovirus, Influenza A & B,
Parainfluenza type
1,2 & 3, and Respiratory Syncytial Virus..
___ CMV Viral Load: none detected
___ Monospot: neg
___ ASO neg
EBV PCR, QUANTITATIVE, WHOLE BLOOD
Test Result Reference
Range/Units
SOURCE Whole Blood
EBV DNA, QN PCR 1193 H <200 copies/mL
This test was developed and its performance
characteristics have been determined by ___, ___.
Performance characteristics refer to the
analytical performance of the test.
This test is performed pursuant to a license
agreement with ___ Molecular Systems, ___.
For more information on this test, go to
___
REPORT COMMENT:
EDTA WHOLE BLOOD
Radiology:
CT Neck ___
FINDINGS: There is bilateral tonsillar swelling and thickening
of the
aryepiglottic folds. There is also swelling of the epiglottis.
In these
areas, there is loss of fat plane consistent with inflammation.
No focal
fluid collection or subcutaneous air is identified.
Evaluation of the cervical lymph chain demonstrates no
pathologic
lymphadenopathy by imaging criteria. The thyroid gland is
normal. The
salivary glands are unremarkable in appearance. The neck
vessels enhance
bilaterally without significant stenosis. There is mild
degenerative disease
of the cervical spine with small osteophytes at C4-C5, C5-C6 and
C6-C7 with no
significant canal narrowing.
IMPRESSION: Swelling of the bilateral tonsils as well as
thickening of the
aryepiglottic folds and swelling of the epiglottis with loss of
fat planes,
consistent with inflammation. No peritonsillar abscess.
Brief Hospital Course:
___ year old s/p renal transplant ___ years ago on
immunosuppressive medications (tacrolimus, sirolimus) presents
with severe left sided odynophagia and acute kidney injury most
likely prerenal secondary to poor PO intake for three to four
days prior to admission; later on developed C. difficile colitis
and lower back pain s/p mechanical fall.
#Severe Left-sided odynophagia: On admission, patient describes
pain as ___ when swallowing and ___ at rest localized to the
left side of the throat. Initial physical examination did not
reveal exudates, mild erythema in posterior oropharynx, and no
lymphadenopathy in neck. Neck was supple with no loss of ROM.
Given pt's immunosuppression and severity of odynophagia and
"hot potato voice" this presentation was concerning for
epiglottitis/peritonsillar abscess and airway compromise.
Further imaging (U/S and CT) did not reveal drainable abscess.
Chest xray and CT chest showed no focal lesions in the lungs. CT
of neck made epiglottitis concerning and ID was consulted and
recommended a brief course of vancomycin and ceftriaxone before
re-assessment of airway with ENT. Pain improved with PO
morphine solution and possibly with antibiotics. ___ ENT
reassessed with scope and was not convinced that epiglottis was
infected and visually more consistent with pharyngitis vs
supraglottitis. ID team then recommended 7 day course of
levofloxacin PO which was continued until ___. By ___, pt's
odynophagia had resolved completely and was tolerating regular
diet. Of note, EBV PCR showed elevated titer and ID was informed
in order to look into possible intervention. ID concluded that
this was most likely reactivated EBV in setting of acute
infection and since pt is now asymptomatic, would not recommend
intervention. ID did recommend rechecking EBV PCR, and if titer
trends upward, it was recommended for transplant nephrology to
investigate potential post-transplant lymphoproliferative
disorder.
#Acute on chronic kidney disease: Presented initially with ___
with Cr 2.2 and most likely prerenal due to poor PO intake and
renal transplant team collaborated closely with medical team as
pt has a history of renal transplant. Creatinine normalized
with increasing fluid by Hospital Day 3. Before admission, pt
missed 2 days of sirolimus and tacrolimus due to odynophagia and
there was concern for rejection. Trough levels for both
medications taken per renal transplant recommendations, and
troughs for both supratherapeutic initially (>13 for each) as
pt's biaxin most likely inhibited proper metabolism of
tacrolimus and rapamycin. Tacrolimus restarted as oral solution
on ___ with sirolimus held until ___ when trough returned at
4.8. New onset C.diff prompted repeat trough levels for tacro.
Pt continued to produce adequate urine output with no other
electrolyte abnormalities. Creatinine back at baseline of 1.5
upon discharge.
#C.diff colitis: Patient notes frequent bouts of loose/watery
stools on night of ___, within 24 hours after starting
levofloxacin. Given past history of C.diff, history of
immunosuppression, and recent abx treatment, this was concerning
for recurrent C.diff colitis. ___ stool specimen positive for C.
diff and 500 mg Flagyl PO was started; this was switched to PO
vancomycin on ___. ID team recommended to keep pt on
levofloxacin despite new onset of C. diff colitis and pt
completed 7 day course of levofloxacin succusfully. IV fluids
were given as pt was having at least 10 BMs per day from
___. Pt's frequency of BMs and volume of diarrhea
decreased immensely with vancomycin and pt was discharged once
team was comfortable with her adequate PO intake to keep her
hydrated while having mild diarrhea.
#Sacral back pain, s/p Fall: On ___, patient tripped over a
blanket on the way out of bed, landed on buttocks and hit the
back of her on the wall. No loss of consciousness. A CT of the
head showed no evidence of itnracranial hemorrhage or skull
fracture, notable for paranasal sinuses demonstrate
near-complete opacification of the left sphenoid sinuses as well
as significant mucosal thickening of the left maxillary sinus.
Bilateral hip xrays showed no evidence of fracture. Patient
noted pain on urination/defecation in the back along with pain
in the buttocks region, specifically in sacrum and not coccyx.
Neurological exam normal. Orthopedics consulted and recommended
opiates for pain management as well as 3 days of diazepam for
muscle spasm contributing to pain; no need for CT or MRI of back
to fully rule out coccyx fracture as this would not change
management. Pt's sacral pain improved with opiates and
benzodiazepine and was fully ambulatory upon discharge. Physical
therapy saw the pt and cleared her for discharge.
#Elevated ___, PTT and INR: Initially supratherapeutic >4, and
thus coumadin held. Biaxin most likely interacted with coumadin
and thus affecting its metabolism. Levels fell to 1.8 on ___,
heparin bridge started while pt was able to start taking PO
warfarin. Patient re-started on 5 mg coumadin ___. INR
returned to 2.0 on ___ and heparin drip was stopped. Coumadin
dose was titrated as we checked daily INRs and took into
consideration interactions between warfarin and antibiotics
(Flagyl, levofloxacin). As pt's INR was 3 on day prior to
admission, coumadin was further titrated down to 2.5mg. She is
to have her INR checked and reviewed by PCP at her ___ appointment.
#Hypertension: BP medications intially held given Hct. Blood
pressure increased on ___ with a spike of SBP to 198. Pt was
given hydralazine, which reduced blood presure to 172/100 and
she was re-started on metoprolol tartrate 50 mg BID the
following day (patient normally on extended release metoprolol
100 mg). Following this blood pressure normalized to baseline
thereafter (120-130s/60s-70s). Lasix and amlodipine were held
upon discharge as pt was still having bouts of diarrhea and was
instructed to discuss restarting it at her PCP appointment on
___.
#Oral thrush: ___, patient's PE exam revealed white plaques
bilateral in posterior oropharynx, and tonsils. Non-exudative
most suggestive of oral thrush. The following day, oral thrush
progressively evolving. Treatment for nystatin spit and spit
was provided x4 per day on ___. Oral thrush improved and
eventually resolved in two days. Pt was discharged without
residual signs of thrush.
Transitional issues:
-Pt is to followup with PCP to recheck INR and to discuss
restarting Lasix and amlodipine
-Pt is to followup with nephrologist Dr ___ is to followup with transplant nephrologist regarding
monitoring tacrolimus and sirolimus, and follow-up on repeat EBV
PCR.
-Pt is to finish 14 day course of PO metronidazole after
completion of levofloxacin (day 1 = ___, end date ___
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from PatientwebOMR.
1. Colchicine 0.6 mg PO ONCE Duration: 1 Doses
2. Zolpidem Tartrate 10 mg PO HS:PRN insomnia
3. Lopressor 100 mg PO DAILY
4. Hydrocodone-Acetaminophen (5mg-500mg 1 TAB PO Frequency is
Unknown
5. Warfarin 5 mg PO DAILY16
6. Amlodipine 5 mg PO DAILY
7. Citalopram 40 mg PO DAILY
8. HydrOXYzine 25 mg PO Q4H:PRN pruritus
9. Calcitriol 0.5 mcg PO DAILY
10. Furosemide 80 mg PO DAILY
11. Tacrolimus 1 mg PO Q12H
12. Sirolimus 1 mg PO DAILY
Daily dose to be administered at 6am
Discharge Medications:
1. Calcitriol 0.5 mcg PO DAILY
2. Citalopram 40 mg PO DAILY
3. Lopressor 100 mg PO DAILY
4. Sirolimus 1 mg PO DAILY
Daily dose to be administered at 6am
5. Tacrolimus 1 mg PO Q12H
6. Colchicine 0.6 mg PO ONCE Duration: 1 Doses
7. Zolpidem Tartrate 10 mg PO HS:PRN insomnia
8. HydrOXYzine 25 mg PO Q4H:PRN pruritus
9. Outpatient Lab Work
Pulmonary embolism, DVT V12.51
Please draw labs on ___
PTT, ___ for ___ appointment
Please fax results to Dr. ___ ___
10. Vancomycin Oral Liquid ___ mg PO Q6H
RX *Vancocin 125 mg 1 capsule(s) by mouth every six (6) hours
Disp #*52 Capsule Refills:*0
11. Diazepam 2 mg PO Q6H:PRN back pain
RX *diazepam 2 mg 1 Tablet(s) by mouth every six (6) hours Disp
#*8 Tablet Refills:*0
12. Hydrocodone-Acetaminophen (5mg-500mg ___ TAB PO Q6H:PRN pain
13. Warfarin 2 mg PO DAILY16
Discharge Disposition:
Home
Discharge Diagnosis:
Pharyngitis, supraglottitis
Acute Kidney Injury
Clostridium difficile colitis
Sacral back pain, status post mechanical fall
Secondary:
History of Deep Vein Thrombosis
History of focal segmental glomerulosclerosis, status post
kidney transplant
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was our pleasure caring for you at the ___.
You were admitted to the hospital for severe pain with
swallowing and we were concerned for an abscess in your throat
and worried about your kidney function especially since you were
unable to take your immunosuppressive medications. Your kidney
function improved with IV fluids. The ENT and Infectious Disease
specialists were consulted to interpret the lab results and CT
scan and concluded that you had an infection of your throat
which we thought would be best treated with antibiotics. You
made improvement with your swallowing and were able to tolerate
PO medications towards the end of your hospital course. You
completed a 7 day course of levofloxacin (ending on ___.
Please continue your immunosuppression medications (tacrolimus,
sirolimus) as previously prescribed. Your warfarin was decreased
to a lower dose and you will need to have your INR checked and
reviewed with your PCP on ___. Please have your
transplant and INR (please bring your prescription) labs drawn
on ___.
We are rechecking your EBV virus level since it was elevated
during your hospital course. Your transplant doctor ___
follow-up on this level.
Followup Instructions:
___
|
19670384-DS-36
| 19,670,384 | 22,662,120 |
DS
| 36 |
2191-12-25 00:00:00
|
2191-12-25 21:47:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Chocolate Flavor / Simvastatin / Allopurinol / Augmentin /
ciprofloxacin
Attending: ___
Chief Complaint:
Right knee calf pain and swelling
Major Surgical or Invasive Procedure:
Right knee arthrocentesis x 2
History of Present Illness:
___ pmHx s/p kidney transplant in ___, osteoarthritis due to
chronic steroid use with b/l knee, hip, and shoulder
replacements, NSTEMI, TIA, recent admission(Supraglottitis,
Cdiff) and multiple DVTs/PE on chronic coumadin presenting with
4 days progressive R calf swelling, pain. Patient reports
gradual onset pain and swelling starting ___.
Presented to PCP ___, reports negative US. Patient reports
progressive pain and swelling, inability to ambulate starting
night PTA. Patient describes pain as ___ when walking,
worsened with foot dorsiflexion. Patient denies fevers, chills,
chest pain, SOB, headache, numbness/tingling aside from
longstanding post op denervation. Patient reports that she has
had very volatile INR's over the past ___ years, and recently had
an INR of 4 when she was admitted. Also, she had a fall while
she was an inpatient ___. She has not fallen since.
In the ED, patient had an ultrasound negative for DVT but
suspicious for knee hematoma. After xray of the knee, ortho
tapped it and withdrew sanguinous fluid. Labs were significant
for supratherapeutic ___, mild anemia, no leukocytosis, and
CKD with Cr 1.8 (baseline ~1.5).
Past Medical History:
1. Focal sclerosing glomerulonephritis status post kidney
transplant in ___.
2. A history of CMV infection.
3. Acute transplant rejection that had been treated with OKT3 in
___.
4. DVT and pulmonary embolism on Coumadin.
5. AVN.
6. TIA.
7. Hypertension.
8. Hyperlipidemia.
9. Metabolic syndrome
10. Gout.
11. Nephrolithiasis with ureteral stent placements.
12. Osteonecrosis of bilateral hips, shoulders, knees, status
post surgical interventions.
13. Left cataract surgery in ___.
14. Right cataract surgery in ___.
15. Skin cancer status post surgery in ___.
16. Basal cell carcinoma in ___.
17. A left adnexal mass s/p salpingo-oophorectomy.
18. Cervical dysplasia.
19. Hyperparathyroidism secondary to renal failure.
20. Appendicectomy.
21. Endometrial ablation for menorrhagia in ___.
22. ___ laparoscopy
Social History:
___
Family History:
Dad MI at age ___. Brother MI at age ___. Sister with FSGS s/p
renal transplant.
Physical Exam:
Admission Physical Exam:
Vitals: T97.5 BP 141/91 HR 66 RR 18 100%/RA
Gen: NAD, lying in bed, reports pain
HEENT: Dry Mucous Membranes. EOMI. No sclear icterus.
Neck: No LAD, No JVD.
Cardiac: Regular rate and rhythm, no m/r/g
Pulm: CTA bilaterally.
Abd: + bowel sounds, soft, nontender, nondistended. Nontender
over transplant site. Numerous well-healed surgical incision
marks.
Ext: Tenderness on posterior aspect of anterior third of R calf.
Tenderness on R knee. Swollen knee. Left leg without
edema/tenderness. 2+ pulses b/l. Pain on dorsi/plantar flexion
of R foot, > with dorsiflexion
Neuro: Oriented X3.
Discharge Physical Exam:
VS: Tm/c 99.5 130/87 86 18 100% RA
Gen: well appearing
CV: nls1s2 RRR no mrg
Lungs: CTAB
Abd: soft, NT ND +BS
Ext: R knee more swollen then L, slightly warmer, TTP on medial
aspect of right knee
Pertinent Results:
ADMISSION:
___ 09:50AM BLOOD WBC-5.2 RBC-3.73* Hgb-10.9* Hct-31.9*
MCV-85 MCH-29.2 MCHC-34.2 RDW-15.0 Plt ___
___ 09:50AM BLOOD Neuts-44* Bands-0 Lymphs-45* Monos-6
Eos-5* Baso-0 ___ Myelos-0
___ 09:50AM BLOOD Hypochr-NORMAL Anisocy-NORMAL
Poiklo-OCCASIONAL Macrocy-NORMAL Microcy-OCCASIONAL
Polychr-OCCASIONAL Ovalocy-OCCASIONAL
___ 09:50AM BLOOD ___ PTT-54.9* ___
___ 09:50AM BLOOD Glucose-120* UreaN-38* Creat-1.8* Na-142
K-3.5 Cl-103 HCO3-27 AnGap-16
___ 05:30AM BLOOD Albumin-4.2 Calcium-9.2 Phos-2.9 Mg-1.9
___ 05:30AM BLOOD 25VitD-28*
___ 09:50AM BLOOD CRP-24.6*
___ 05:30AM BLOOD tacroFK-4.0* rapmycn-8.0
___ 10:21AM BLOOD Lactate-2.1*
___ 07:07AM BLOOD freeCa-1.20
___ 04:10PM URINE Color-Straw Appear-Clear Sp ___
___ 04:10PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-TR
___ 04:10PM URINE RBC-1 WBC-1 Bacteri-FEW Yeast-NONE Epi-1
___ 04:10PM URINE UCG-NEGATIVE
DISCHARGE:
___ 06:05AM BLOOD WBC-5.1 RBC-3.69* Hgb-10.6* Hct-32.0*
MCV-87 MCH-28.9 MCHC-33.2 RDW-14.6 Plt ___
___ 06:05AM BLOOD ___ PTT-32.8 ___
___ 06:05AM BLOOD ESR-115*
___ 06:05AM BLOOD Glucose-105* UreaN-24* Creat-1.5* Na-136
K-4.7 Cl-99 HCO3-27 AnGap-15
___ 06:05AM BLOOD Calcium-9.8 Phos-4.6* Mg-2.3 UricAcd-7.7*
___ 06:05AM BLOOD tacroFK-5.1
___ 06:08AM URINE Color-Yellow Appear-Hazy Sp ___
___ 06:08AM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-SM
___ 06:08AM URINE RBC-<1 WBC-5 Bacteri-FEW Yeast-NONE Epi-7
JOINT FLUID:
___ 02:55PM JOINT FLUID WBC-711* HCT,Fl-25* Polys-66*
___ Monos-0 Eos-1*
___ 02:00PM JOINT FLUID WBC-333* HCT,Fl-2.5* Polys-47*
___ Monos-4 Eos-1*
___ 02:55PM JOINT FLUID Crystal-NONE
___ 02:00PM JOINT FLUID Crystal-NONE
MICROBIOLOGY:
___ Joint fluid Gm stain: Negative
___ Joint fluid culture: Negative
IMAGING:
___ ___ U/S: IMPRESSION:
1. No DVT in right lower extremity.
2. 6.8 x 3.1 x 5.9 cm complex fluid collection along the right
anteromedial knee may be consistent with a hematoma.
___ R Knee Xray: IMPRESSION:
Moderate right knee joint effusion. No evidence of hardware
failure.
Brief Hospital Course:
___ with history of kidney transplant, hypertension, b/l TKRs,
and hypercoagulability previously on coumadin here with
hemarthosis c/b intractable pain.
ACTIVE ISSUES:
# Spontaneous Hemarthosis: Previously anticoagulated however we
reversed her INR and her effusion improved as did her pain which
was initially intractable. Arthrocentesis was performed on two
different occasions and their was no evidence of a crystal
arthopathy or septic arthritis. Her pain was controlled with
standing Tylenol, narcotic medication, and Gabapentin.
# Hypercoagulability: ___ homocysteinemia. She is followed by
outpatient hematology. We discontinued her Warfarin and will
hold it upon discharge. Her hypercoagulability and need for
ongoing anticoagulation is questioned giving no clots over the
past ___ years and the possible trigger of her operations. She
will be followed as an outpatient.
# Hypertension: Her blood pressures were poorly controlled in
setting of pain. We continued her home losartan and amlodipine
and this should be followed as an outpatient to ensure that her
pressures come back down as pain improves.
- Uptitrate as needed
CHRONIC ISSUES:
# S/p Renal Transplant: Patient with renal transplant in ___.
Tacrolimus and Rapamycin levels checked while inpatient and at
therapeutic levels.
- Sirolimus 1mg daily
- Tacrolimus 1.5mg BID
- Check Tacro and ___ level daily
# ___ on CKD: Creatinine initially elevated from baseline
(1.4-1.5) on admission but resolved.
# Severe osteoarthritis: continued pain medication.
# Normocytic Anemia: Hct at baseline (~31). Likely due to her
chronic kidney disease. It remained stable during the admission.
TRANSITIONAL ISSUES:
- Hemarthrosis follow up to ensure continued resolution
- F/u with hematologist about whether she will need ongoing
anticoagulation
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from ___ Notes.
1. Calcitriol 0.5 mcg PO DAILY
2. Citalopram 40 mg PO DAILY
3. Sirolimus 1 mg PO DAILY
Daily dose to be administered at 6am
4. Tacrolimus 1.5 mg PO Q12H
5. Zolpidem Tartrate 10 mg PO HS:PRN insomnia
6. Warfarin 2 mg PO DAILY16
7. Metoprolol Succinate XL 50 mg PO DAILY
8. Amlodipine 5 mg PO DAILY
hold for sbp<90
9. Hydrocodone-Acetaminophen (5mg-500mg 1 TAB PO Q8H:PRN pain
10. Colchicine 0.6 mg PO DAILY
11. Furosemide 80 mg PO DAILY
Discharge Medications:
1. Amlodipine 5 mg PO DAILY
hold for sbp<90
2. Calcitriol 0.5 mcg PO DAILY
3. Citalopram 40 mg PO DAILY
4. Sirolimus 1 mg PO DAILY
Daily dose to be administered at 6am
5. Tacrolimus 1.5 mg PO Q12H
6. Zolpidem Tartrate 10 mg PO HS:PRN insomnia
7. Acetaminophen 1000 mg PO Q 8H pain or fever
do not exceed 3 g per day. alert H.O. if giving for fever
8. Docusate Sodium 100 mg PO BID
9. Losartan Potassium 25 mg PO DAILY
hold for sbp < 100
RX *losartan 25 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
10. Senna 1 TAB PO BID:PRN constipation
11. Furosemide 80 mg PO DAILY
12. Metoprolol Succinate XL 50 mg PO DAILY
13. Morphine SR (MS ___ 15 mg PO Q12H
hold for sedation or rr < 10
RX *morphine 15 mg 1 tablet(s) by mouth twice a day Disp #*21
Tablet Refills:*0
14. Colchicine 0.6 mg PO DAILY
15. HYDROmorphone (Dilaudid) 4 mg PO Q4H:PRN pain
hold for sedation or rr<10
RX *hydromorphone 4 mg 1 tablet(s) by mouth every four (4) hours
Disp #*20 Tablet Refills:*0
16. Gabapentin 300 mg PO HS
hold for sedation
RX *gabapentin 300 mg 1 capsule(s) by mouth hs Disp #*15 Capsule
Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnosis:
Hemarthrosis
Secondary Diagnosis:
Coagulopathy
Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking care of you while you were at the ___
___. You came in to the hospital
with a painful leg and were found to have a hemarthrosis
(bleeding in to your knee) that we thought was due to your
elevated INR. We held your Coumadin and your INR came down and
the bleeding stopped. We are sending you home with pain
medication and we expect it to get better as the blood in your
joint is reabsorbed. For your increased risk of bleeding, we
held your Coumadin while you were an inpatient and spoke with
our Hematology doctors as ___ as Dr. ___ previous
___. They thought that you no longer need to be on
Coumadin currently, but should follow up with Dr. ___. You
should take 2mg of Folic Acid as an outpatient due to your high
homocysteine levels. You also had high blood pressure while you
were here, even after we restarted your medications. We believe
this is due to the severe amount of pain you have been having
and you can follow up with your PCP about this.
Followup Instructions:
___
|
19670384-DS-39
| 19,670,384 | 25,275,790 |
DS
| 39 |
2193-05-30 00:00:00
|
2193-06-08 16:11:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Chocolate Flavor / Simvastatin / Allopurinol / Augmentin /
ciprofloxacin
Attending: ___.
Chief Complaint:
nausea, vomiting, diarrhea
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
___ PMH HTN, s/p LURT ___ ___ FSGS on tacrolimus & sirolumus
p/w N/V/D, fever, cough, abd pain. She reports 3d of cough, sore
throat, watery diarrhea, and fever to 101-102 with nausea and
dry heaves that started today. She also has a dry non-productive
cough, sore throat, and fatigue. Denies CP, dyspnea, abd pain,
pain over transplanted kidney, dysuria. Recently around nephew,
denies other sick contacts. No history of transplant rejection.
In the ED, initial vitals were 14:44 3 99.9 93 123/81 20 97%
- Labs: ___: cre to 2.3, HCO3 to 19
- Lactate 1.2
- LFTs: WNL
- Urine: Pnd, no urine yet
- CXR: No acute cardiopulmonary process
- Flu swab
- Flagyl for possible c. diff
- Zofran x2
- 3L IVF
On the floor, patient is comfortable, but has some coughing.
ROS: per HPI, denies headache, vision changes, shortness of
breath, chest pain, abdominal pain, constipation, BRBPR, melena,
hematochezia, dysuria, hematuria.
Past Medical History:
- Focal sclerosing glomerulonephritis status post kidney
transplant in ___
- Acute transplant rejection that had been treated with OKT3 in
___
- History of EBV viremia ___
- H/o c. diff (___)
- DVT and pulmonary embolism on Coumadin until ___ (stopped ___
hemarthrosis)
- TIA
- Hypertension
- Hyperlipidemia
- Gout
- Nephrolithiasis with ureteral stent placements
- Osteonecrosis of bilateral hips, shoulders, knees, status post
surgical interventions
- Left cataract surgery in ___
- Right cataract surgery in ___
- Skin cancer status post surgery in ___
- Basal cell carcinoma in ___
- Left adnexal mass s/p salpingo-oophorectomy.
- Cervical dysplasia
- Hyperparathyroidism secondary to renal failure
- Appendicectomy
- Endometrial ablation for menorrhagia in ___
- ___ laparoscopy
Social History:
___
Family History:
Dad MI at age ___. Brother MI at age ___. Sister with FSGS s/p
renal transplant.
Physical Exam:
PHYSICAL EXAM ON ADMISSION:
===========================
VS: 99.2, 100/60, 72, 98%
General: somewhat ill appearing, but comfortable
HEENT: shotty LAD in neck, no sinus tenderness, PERRL
Neck: JVP flat
CV: soft ___ systolic flow murmur with no radiation
Lungs: CTAB
Abdomen: bowel sounds present, well healed scar, soft,
non-tender, non-distended
GU: No foley
Ext: No edema
Neuro: appropriate, AAOx3
Skin: no breakdown
PHYSICAL EXAM ON DISCHARGE:
=========================
VS: 98.1 161/91 66 18 100% on RA
___ yeasterday, x1 since MN
I/O: 2160/2425
GEN: resting comfortably in bed, NAD, AAOx3, pleasant,
conversational
HEENT: NCAT, MMM
NECK: No JVD
CV: RR, S1+S2, NMRG
RESP: CTABL, no w/r/r
ABD: LLQ tenderness, normoactive BS
GU: Deferred
EXT: WWP, no edema
NEURO: CN II-XII grossly intact, MAE
Pertinent Results:
LABS ON ADMISSION:
===================
___ 03:49PM LACTATE-1.2
___ 03:30PM GLUCOSE-108* UREA N-29* CREAT-2.3* SODIUM-135
POTASSIUM-3.4 CHLORIDE-99 TOTAL CO2-19* ANION GAP-20
___ 03:30PM ALT(SGPT)-19 AST(SGOT)-26 ALK PHOS-64 TOT
BILI-0.4
___ 03:30PM LIPASE-40
___ 03:30PM ALBUMIN-4.2
___ 03:30PM WBC-8.2 RBC-4.14* HGB-12.0 HCT-35.1* MCV-85#
MCH-29.0 MCHC-34.2 RDW-14.1
___ 03:30PM NEUTS-64 BANDS-4 ___ MONOS-9 EOS-0
BASOS-0 ATYPS-1* ___ MYELOS-0
___ 03:30PM HYPOCHROM-NORMAL ANISOCYT-NORMAL
POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL
POLYCHROM-NORMAL
___ 03:30PM PLT COUNT-224
LABS ON DISCHARGE:
==================
___ 05:00AM BLOOD WBC-5.6 RBC-3.87* Hgb-11.0* Hct-33.8*
MCV-87 MCH-28.5 MCHC-32.7 RDW-14.0 Plt ___
___ 05:00AM BLOOD Plt ___
___ 05:00AM BLOOD Glucose-86 UreaN-20 Creat-1.6* Na-143
K-4.1 Cl-109* HCO3-23 AnGap-15
___ 05:00AM BLOOD Calcium-9.1 Phos-3.3 Mg-1.9
PERTINENT LABS:
==============
___ 03:30PM BLOOD ALT-19 AST-26 AlkPhos-64 TotBili-0.4
___ 03:30PM BLOOD Lipase-40
___ 05:50AM BLOOD tacroFK-5.3
___ 06:20AM BLOOD tacroFK-5.8
___ 05:30AM BLOOD tacroFK-5.6
___ 05:00AM BLOOD tacroFK-7.0
___ 03:49PM BLOOD Lactate-1.2
MICROBIOLOGY:
===========
___ 3:30 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
__________________________________________________________
___ 3:25 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
OVA AND PARASITE: NEGATIVE
C. DIFF: NEGATIVE
CMV VIRAL LOAD: NONE DETECTED
BLOOD CULTURE ___: NO GROWTH
IMAGING:
CXR ___:
The cardiac, mediastinal and hilar contours are normal. Lungs
are clear. The pulmonary vasculature is normal. No pleural
effusion or pneumothorax is seen. There are no acute osseous
abnormalities. Bilateral total shoulder arthroplasties are
incompletely imaged.
IMPRESSION:
No acute cardiopulmonary process.
Brief Hospital Course:
Ms. ___ is a pleasant ___ year old lady with ESRD ___ FSG, s/p
LURT ___ (now on tacrolimus & sirolumus), who presented with
N/V/D, fever, cough, currently being treated for c. difficile
colitis and influenza.
# Fevers with URI type symptoms: Most likely due to a viral
process. Negative for influenza. Negative for C. diff. CMV viral
load none detected. Stool ova/parasite negative. No
leukocytosis. Exposure to sick contacts makes her more likely to
have a viral illness causing diarrhea. The patient was hydrated
with IVF to keep net even. She was initially started on tamiflu
for possible flu but it was discontinued when DFA was negative.
- Ondansetron 4 mg IV Q8H:PRN nausea
# Diarrhea: Watery, non-bloody, ___ BMx/day, about ___. Most
likely viral gastroenteritis but other possible causes include
medication induced (colchicine) vs. other infectious causes
since pt on immunosuppressants. She was initially treated with
vancomycin po but it was discontinued when C. diff was negative.
Ova/parasite negative. CMV viral load not detected. Symptoms
improved with loperamide. Pt was hydrated with IVF to keep net
even. Pt has been on colchicine for many years and thus,
unlikely to be the cause of diarrhea given presence of fever. We
continued this medication on discharge and we will leave further
management in the discretion of PCP.
# ___: s/p LURT in ___ for FSGS. Creatinine on admission 2.3.
Baseline creatinine 1.6. Most likely prerenal in the setting of
GI losses and dehydration. It improved with IVF hydration.
# s/p LURT: in ___ for FSGS on immunosuppression, Sirolimus and
tacrolimus. No adjustments given diarrhea, which can increase
levels by damage to the mucosa. Not on Bactrim or Valcyte.
- Sirolimus 1 mg PO DAILY
- Tacrolimus 1 mg PO Q12H
# HTN: Home regimen include metoprolol XL, amlodipine, losartan,
and lasix. These medications were held in the setting of ___,
soft BP, and diarrhea. Once symptoms improved, they were resumed
on discharge.
TRANSITIONAL ISSUES
===================
- Code status: Full code.
- Emergency contact: ___, sister: ___.
- Studies pending on discharge: ___: blood cultures x2.
- Transition to uloric from colchicine as an outpatient (often
colchicine is continued during the transition).
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Calcitriol 0.5 mcg PO DAILY
2. Citalopram 40 mg PO DAILY
3. Colchicine 0.6 mg PO DAILY
4. Famotidine 20 mg PO Q24H
5. FoLIC Acid 1 mg PO DAILY
6. Hydrocodone-Acetaminophen (5mg-500mg) ___ TAB PO Q4H:PRN pain
7. Metoprolol Succinate XL 50 mg PO DAILY
8. Sirolimus 1 mg PO DAILY
9. Tacrolimus 1 mg PO Q12H
10. Zolpidem Tartrate 10 mg PO HS:PRN insomnia
11. Amlodipine 5 mg PO DAILY
12. Furosemide 80 mg PO DAILY
13. Losartan Potassium 25 mg PO DAILY
Discharge Medications:
1. Calcitriol 0.5 mcg PO DAILY
2. Citalopram 40 mg PO DAILY
3. Famotidine 20 mg PO Q24H
4. FoLIC Acid 1 mg PO DAILY
5. Hydrocodone-Acetaminophen (5mg-500mg) ___ TAB PO Q4H:PRN pain
6. Sirolimus 1 mg PO DAILY
7. Tacrolimus 1 mg PO Q12H
8. Zolpidem Tartrate 5 mg PO HS:PRN insomnia
9. Amlodipine 5 mg PO DAILY
10. Furosemide 80 mg PO DAILY
11. Losartan Potassium 25 mg PO DAILY
12. Metoprolol Succinate XL 50 mg PO DAILY
13. LOPERamide 2 mg PO QID:PRN diarrhea
14. Colchicine 0.6 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: Viral gastroenteritis
Viral upper respiratory infection
Acute kidney injury
Secondary: Hypertension
ESRD s/p transplant
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! You were admitted to
___ because of diarrhea,
fevers, and upper respiratory symptoms. We think you likely had
a viral infection with gastroenteritis. You did not have an
infection called c. difficile or influenza, though initially, we
started treatment for these (they were eventually stopped). We
started an anti-diarrheal medication called loperamide, which
improved your symptoms. You also had mild kidney injury which
improved with fluids.
Your colchicine was continued until you transition to Uloric.
You should follow up with your nephrologist and PCP.
Followup Instructions:
___
|
19670384-DS-42
| 19,670,384 | 23,570,900 |
DS
| 42 |
2194-05-18 00:00:00
|
2194-05-21 13:48:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Chocolate Flavor / Simvastatin / Allopurinol / Augmentin /
ciprofloxacin
Attending: ___.
Chief Complaint:
dehydration
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ yo female h/o FSGS s/p renal transplant and recent breast
surgery who presented with confusion and dehydration. She had
elective breast reduction surgery on ___, and was doing well
post-op with minimal pain. The patient's sister noticed that she
was not acting like herself on ___ and called the surgeon,
who recommended they go to the hospital and have labs checked
for renal function. The went to ___ on ___ and found Cr
2.1 (baseline 1.5), and the patient was transferred to ___.
The patient does not recall feeling confused, but believes her
sister's assessment because she is a nurse. She states that she
has taken all medications and not missed any doses. She reports
normal PO intake, but her sister told her she thought that she
was dehydrated. She sas treated for UTI last week (symptoms of
dysuria) but this resolved with antibiotics.
In the ED, initial VS 99.3, 87, 131/87, 15, 94% 2L. Exam was
significant for Guaiac neg stool.Labs notable for: Cr 1.6, AST
198, trop 3.08->3.09, Utox + opiates, neg UA. Renal transplant,
Neurology, Plastic Surgery and Cardiology were consulted and
recommended admission to medicine. Patient given: azithromycin,
ondansetron, ASA, Prograf, 2L NS. Vitals prior to transfer: 99,
103, 123/77, 18, 96% Nasal Cannula.
On the floor, pt reports that she is feeling thirsty and tired
but denies CP, SOB, cough, palpitations, dysuria. She does not
believe that she is confused.
Review of Systems:
(+) per HPI
(-) fever, chills, night sweats, headache, vision changes,
rhinorrhea, congestion, sore throat, cough, shortness of breath,
chest pain, abdominal pain, nausea, vomiting, diarrhea,
constipation, BRBPR, melena, hematochezia,
Past Medical History:
- FSGN status post kidney transplant in ___
- Acute transplant rejection that had been treated with OKT3 in
___
- History of EBV viremia ___
- h/o C. diff (___)
- DVT/PE on Coumadin until ___ (stopped ___ hemarthrosis)
- TIA
- Hypertension
- Hyperlipidemia
- Gout
- Nephrolithiasis with ureteral stent placements
- Osteonecrosis of bilateral hips, shoulders, knees, status post
surgical interventions
- Left cataract surgery in ___
- Right cataract surgery in ___
- Skin cancer status post surgery in ___
- Basal cell carcinoma in ___
- Left adnexal mass s/p salpingo-oophorectomy.
- Cervical dysplasia
- HyperPTH secondary to renal failure
- Appendectomy
- Endometrial ablation for menorrhagia in ___
- ___ laparoscopy
Social History:
___
Family History:
Sister with FSGS s/p transplant and avascular necrosis.
Uncle with RA.
Physical Exam:
ADMISSION:
==========
Vitals - AF 120/78, 88, 18 (O2 sat not yet recorded)
GENERAL: NAD, NC off
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, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: no cyanosis, clubbing or edema, moving all 4
extremities with purpose
PULSES: 2+ DP pulses bilaterally
NEURO: AAOx3. CN II-XII intact
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
.
DISCHARGE:
==========
Vitals: 98.5, 117/73, 84, 18, 95RA
Exam:
GENERAL - Well-appearing, seated at side of bed.
HEART - RRR, nl S1-S2, no MRG
LUNGS - CTAB
EXTREMITIES - 1+ edema to ankles
NEURO - awake, A&Ox3
Pertinent Results:
ADMISSION:
==========
___ 04:50PM CK(CPK)-1211*
___ 04:50PM CK-MB-31* MB INDX-2.6 cTropnT-2.77*
___ 09:00AM GLUCOSE-165* UREA N-17 CREAT-1.3* SODIUM-139
POTASSIUM-3.2* CHLORIDE-101 TOTAL CO2-26 ANION GAP-15
___ 09:00AM ALT(SGPT)-40 AST(SGOT)-170* CK(CPK)-1617* ALK
PHOS-102 TOT BILI-0.4
___ 09:00AM CK-MB-55* MB INDX-3.4 cTropnT-3.00*
___ 09:00AM CALCIUM-8.2* PHOSPHATE-1.7* MAGNESIUM-1.4*
CHOLEST-159
___ 09:00AM TRIGLYCER-130 HDL CHOL-34 CHOL/HDL-4.7
LDL(CALC)-99
___ 09:00AM TSH-0.89
___ 09:00AM tacroFK-7.8
___ 09:00AM WBC-11.7* RBC-3.13* HGB-8.3* HCT-25.2*
MCV-81* MCH-26.4* MCHC-32.8 RDW-15.2
___ 09:00AM PLT COUNT-367#
___ 09:00AM PLT COUNT-367#
___ 09:00AM ___ PTT-22.7* ___
___ 03:25AM cTropnT-3.09*
___ 02:20AM URINE HOURS-RANDOM
___ 02:20AM URINE HOURS-RANDOM UREA N-547 CREAT-79
SODIUM-39 POTASSIUM-15 CHLORIDE-46 PHOSPHATE-40.7 MAGNESIUM-2.3
___ 02:20AM URINE OSMOLAL-362
___ 02:20AM URINE bnzodzpn-NEG barbitrt-NEG opiates-POS
cocaine-NEG amphetmn-NEG mthdone-NEG
___ 02:20AM URINE COLOR-Straw APPEAR-Clear SP ___
___ 02:20AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
___ 02:20AM URINE RBC-0 WBC-<1 BACTERIA-FEW YEAST-NONE
EPI-3
___ 02:20AM URINE HYALINE-3*
___ 01:54AM LACTATE-1.0
___ 01:35AM ___ TO PTT-UNABLE TO ___
TO
___ 01:30AM GLUCOSE-153* UREA N-24* CREAT-1.6* SODIUM-138
POTASSIUM-3.6 CHLORIDE-100 TOTAL CO2-26 ANION GAP-16
___ 01:30AM estGFR-Using this
___ 01:30AM ALT(SGPT)-40 AST(SGOT)-198* CK(CPK)-1862* ALK
PHOS-97 TOT BILI-0.4
___ 01:30AM LIPASE-20
___ 01:30AM cTropnT-3.08*
___ 01:30AM CK-MB-82* MB INDX-4.4
___ 01:30AM ALBUMIN-3.2* CALCIUM-8.7 PHOSPHATE-1.9*
MAGNESIUM-1.6
___ 01:30AM OSMOLAL-287
___ 01:30AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
___ 01:30AM WBC-8.3 RBC-2.92* HGB-7.6*# HCT-24.3* MCV-83
MCH-26.2* MCHC-31.4# RDW-14.9
___ 01:30AM NEUTS-72.3* ___ MONOS-8.1 EOS-0.9
BASOS-0.2
___ 01:30AM PLT COUNT-217
.
IMAGING:
========
___/ ECG:
Sinus rhythm. Baseline artifact. Non-specific ST-T wave
flattening in the precordial leads. Compared to the previous
tracing of ___ the heart rate is faster.
___ Echocardiogram:
The left atrium is normal in size. No atrial septal defect is
seen by 2D or color Doppler. The estimated right atrial pressure
is ___ mmHg. Left ventricular wall thickness, cavity size and
regional/global systolic function are normal (LVEF >55%). Right
ventricular chamber size and free wall motion are normal. The
aortic valve leaflets (3) appear structurally normal with good
leaflet excursion and no aortic stenosis or aortic
regurgitation. The mitral valve appears structurally normal with
trivial mitral regurgitation. The estimated pulmonary artery
systolic pressure is normal. There is no pericardial effusion.
Compared with the prior study (images reviewed) of ___,
the findings are similar.
___nd brain
1. Circle of ___ patent. Left fetal origin posterior cerebral
artery.
2. Bilateral vertebral arteries, common carotid arteries, and
carotid bifurcations patent. No evidence of carotid stenosis by
NASCET criteria. Please note that the origins of vertebral
arteries and common carotid arteries were not included on this
examination.
___ CXR:
There has been worsening of the bibasilar opacities. This may
represent pneumonia or aspiration. There is likely overlying
subsegmental atelectasis at the bases. Heart size is within
normal limits. There is no overt pulmonary edema or
pneumothoraces. Bilateral shoulder arthroplasties are present.
.
MICROBIOLOGY:
=============
C diff ___: NEGATIVE
___ Respiratory viral panel screen and culture: NEGATIVE
___ CMV VL: not detected.
___ Blood Culture: No Growth (FINAL)
___ Influenza PCR: NEGATIVE
.
DISCHARGE LABS:
===============
___ 08:09AM BLOOD WBC-10.7 RBC-2.82* Hgb-7.4* Hct-23.1*
MCV-82 MCH-26.3* MCHC-32.1 RDW-15.4 Plt ___
___ 08:09AM BLOOD Glucose-109* UreaN-15 Creat-1.9* Na-139
K-4.4 Cl-106 HCO3-23 AnGap-14
___ 08:09AM BLOOD ALT-111* AST-99* AlkPhos-108* TotBili-0.3
___ 08:09AM BLOOD Calcium-9.1 Phos-2.8 Mg-1.5*
Brief Hospital Course:
___ yo woman s/p renal transplant ___, recent breast surgery and
UTI treated with ___ transferred from ___ for
evaluation of confusion, malaise and ___, found to have HCAP and
an NSTEMI.
.
>> Active issues:
# HCAP: Infiltrate on CXR, new O2 requirement and mild
leukocytosis (and recent admission in ___ to meet HCAP
criteria). Pt recieved CTX prior to transfer, azithromycin in
___ ED. CXR read showed consistent with pneumonia, and patient
was treated with vancomycin/cefepime, weaned from supplemental
O2, and transitioned to PO levofloxacin on ___. Plan for 8d
course of ABX.
.
# NSTEMI: Troponin peaked at 3, chest pain free, nononspecific
ST changes on EKG. Possibly had event during recent surgery. Pt
evaluated by cardiology in ED, they do not plan LHC at this
point. Treated with ASA 81mg PO, home metoprolol 50mg PO daily,
and initially with a trial of 40mg atorvastatin which was
eventually changed to pravastatin given transaminitis and CK
elevation. Repeat EKG without changes, and patient remained
chest pain free for rest of stay. Consider outpatient stress
test.
.
# ___: Cr variable throughout admission, 1.2 to 2.1 with is
within range of variable baseline Cr. Pt given IVF initially in
course. Adjusted tacrolimus and sirolimus dosing based on
levels. ___ held as Cr slightly uptrending prior to discharge.
Home Lasix held during admission and restarted on discharge. Pt
to have repeat labs within 1wk of discharge and ___ to be
restarted per outpatient Renal recs.
.
# Acute on chronic anemia: Hb stable in ___ range during
admission, which was decrease from ___ range earlier in
___. Iron studies c/w anemia of inflammation. No signs of
bleeding. No transfusion given during admission but close ___
labs set up for after discharge.
.
# Transaminitis: Initial AST elevation from muscular etiology.
ALT later uptrended slightly likely from med effect but
stabilized at approx 100. Recommend repeat LFT measure at PCP
___. Viral hepatitis (HBV, HCV) serologies negative.
.
# Antibiotic-associated Diarrhea: Developed watery diarrhea on
day 5 of admission. C diff negative.
.
# Encephalopathy: No neurological symptoms on exam. Likely from
PNA. Remained oriented and free of neuro sx throughout
admission. MRA was reassuring.
.
# S/p reduction mammoplasty: Plastic surgery evaluated pt in ED,
had no concern for hematoma, infection, or other postoperative
complication. Plastics and outpt surgeon provided wound care
recs.
.
>> Chronic issues:
# FSGS s/p living, unrelated transplant in ___ as
above.
Managed throughout admission in consultation with renal
transplant team. Continued immunosuppression with tacrolimus and
sirolimus, adjusting for daily levels per above.
.
# HTN: Continued home Amlodipine, and Metoprolol. D/c losartan
given ___.
.
>> Transitional issues:
# Full code
# Pt to have repeat CBC and chemistries within 1wk of discharge
per standing renal transplant lab order to check on Cr and H/H.
Sirolimus and tacro levels also at this time given pt discharged
on lower dose of both immunosuppressive meds. Dr. ___
___ prior to discharge to expect lab results.
# Please check LFTs at PCP ___.
# Pt discharged on ASA 81, pravastatin given NSTEMI and will ___
with cardiology. Consider outpatient stress test.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Calcitriol 0.5 mcg PO DAILY
2. Citalopram 40 mg PO DAILY
3. Febuxostat 120 mg PO DAILY
4. FoLIC Acid 1 mg PO DAILY
5. Gabapentin 600 mg PO QHS
6. Hydrocodone-Acetaminophen (5mg-325mg) 1 TAB PO Q6H:PRN pain
7. Sirolimus 1 mg PO DAILY
8. Tacrolimus 1 mg PO Q12H
9. Zolpidem Tartrate 10 mg PO HS:PRN insomnia
10. Metoprolol Succinate XL 50 mg PO DAILY
11. Amlodipine 5 mg PO DAILY
12. Furosemide 80 mg PO DAILY
13. Losartan Potassium 25 mg PO DAILY
14. Pantoprazole 40 mg PO Q12H
15. Ondansetron 4 mg PO Q8H:PRN nausea
Discharge Medications:
1. Amlodipine 5 mg PO DAILY
2. Calcitriol 0.5 mcg PO DAILY
3. Citalopram 40 mg PO DAILY
4. FoLIC Acid 1 mg PO DAILY
5. Gabapentin 600 mg PO QHS
6. Metoprolol Succinate XL 50 mg PO DAILY
7. Pantoprazole 40 mg PO Q12H
8. Aspirin 81 mg PO DAILY
RX *aspirin 81 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
9. Pravastatin 20 mg PO QPM
RX *pravastatin 20 mg 1 tablet(s) by mouth daily in the evening
Disp #*30 Tablet Refills:*0
10. Febuxostat 120 mg PO DAILY
11. Hydrocodone-Acetaminophen (5mg-325mg) 1 TAB PO Q6H:PRN pain
12. Ondansetron 4 mg PO Q8H:PRN nausea
13. Zolpidem Tartrate 10 mg PO HS:PRN insomnia
14. Levofloxacin 750 mg PO Q48H
Last day ___
RX *levofloxacin 750 mg 1 tablet(s) by mouth every other day
Disp #*4 Tablet Refills:*0
15. Furosemide 80 mg PO DAILY
16. Sirolimus 0.5 mg PO DAILY
RX *sirolimus [Rapamune] 0.5 mg 1 tablet by mouth daily Disp
#*30 Tablet Refills:*0
17. Tacrolimus 1 mg PO QAM
RX *tacrolimus [Prograf] 0.5 mg 2 capsule(s) by mouth in the
morning and 1 capsule in the evening Disp #*90 Capsule
Refills:*0
18. Tacrolimus 0.5 mg PO QPM
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: Health-care associated pneumonia, NSTEMI, acute kidney
injury
Secondary: s/p renal transplant
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 during your
hospitalization. You were admitted with confusion and
dehydration. You were found to have had a heart attack and a
pneumonia. IV fluids improved your dehydration and your
pneumonia symptoms improved with IV antibiotics so you were
transitioned to oral antibiotics.
Cardiology was consulted and did not feel that you needed a
procedure on your heart. Your heart enzymes began to trend down
and you did not experience any chest pain. Given concern for a
TIA (mini stroke) and your heart attack you are on aspirin and
cholesterol lowering medication. You should follow up in the
cardiology clinic and stroke clinic as an outpatient.
You will continue oral antibiotics at home for your pneumonia.
Please follow-up at the appointments listed below. Please note
the following changes to your home medications:
- START Levofloxacin 750mg every other day - LAST DAY ___
- START Aspirin 81mg daily
- START Pravastatin 20mg daily
- STOP Losartan until instructed to restart by your kidney
doctor
- CHANGE your Sirolimus TO 0.5mg daily (per new prescription)
- CHANGE your Tacrolimus TO 1mg in the morning and 0.5mg in the
evening (per new prescription)
***Please get your bloodwork done next ___ according
to your usual renal transplant standing lab order from Dr.
___.
Here are some instructions from Dr. ___ surgeon about
your postoperative wound care: You can shower at anytime. After
you shower, please simply place dayliners, light days or similar
in bra to absorb drainage. Bra ___ except during shower for 2
weeks and then for comfort.
Followup Instructions:
___
|
19670384-DS-47
| 19,670,384 | 29,678,917 |
DS
| 47 |
2194-12-18 00:00:00
|
2194-12-18 22:17:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Chocolate Flavor / Simvastatin / Allopurinol / Augmentin /
ciprofloxacin
Attending: ___.
Chief Complaint:
fever and diarrhea
Major Surgical or Invasive Procedure:
NONE
History of Present Illness:
Ms. ___ is a ___ year old woman with history of ESRD from FSGS
s/p LURT in ___, baseline Cr 1.7, CAD, hypertension, previous
C. diff infection in ___ s/p augmentin who presents with fever
and diarrhea. She reports that about a month ago she was bitten
by a child she babysits. For that bite, she was treated with
augmentin for 2 weeks. She developed diarrhea while on augmentin
and she was tested for c.diff which was negative. Her BMs then
initially returned to normal after discontinuation of the
antibiotic. However, on ___, she had the onset of abdominal
pain and cramping with profuse watery diarrhea associated with
fevers of up to 102. She describes the abdominal pain as a
"volcano" at baseline a ___ but increases intermittently to an
intense crampy pain. She has taken her medications, but has not
eaten much over the past 2 days. She has been trying to keep up
with PO fluids. She denies NV, but she states that food simply
"runs through her." She denies dysuria, hematuria, pain over her
allograft or suprapubic pain. She denies blood in her stool. She
denies sick contacts. The finger would from when the child bit
her has healed completely. She denies any new, exotic or raw
food recently, denies sick contacts.
In the ED, initial vitals were: T98.1, HR 89, BP 114/81, O2 99%
on RA, pt found to have abdominal pain in the periumbilical
region, evaluated with ECG and CE, BCx, UCx, C diff toxin, stool
cx, serum CMV PCR
treated with metronidazole 500mg IV and ceftriaxone 1g IV x 1
On the floor,vital signs: 98.1 89 114/81 18 99% RA
Pt reports baseline ___ abdominal pain around the umbilicus.
Has had no additional diarrha. Denies current fevers/chills,
chest pain, SOB, ___ edema. Denies decreased UOP
Past Medical History:
- CAD with h/o NSTEMI
- FSGN status post kidney transplant in ___
- Acute transplant rejection that had been treated with OKT3 in
___
- History of EBV viremia ___
- h/o C. diff (___)
- DVT/PE on Coumadin until ___ (stopped ___ hemarthrosis)
- TIA
- Hypertension
- Hyperlipidemia
- Gout
- Nephrolithiasis with ureteral stent placements
- Osteonecrosis of bilateral hips, shoulders, knees, status post
surgical interventions
- Left cataract surgery in ___
- Right cataract surgery in ___
- Skin cancer status post surgery in ___
- Basal cell carcinoma in ___
- Left adnexal mass s/p salpingo-oophorectomy.
- Cervical dysplasia
- HyperPTH secondary to renal failure
- Appendectomy
- Endometrial ablation for menorrhagia in ___
- ___ laparoscopy
Social History:
___
Family History:
Brother ___ had MI, Dad was ___ and had MI.
Sister with FSGS s/p transplant and avascular necrosis.
Uncle with RA.
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vital Signs:98.1 89 114/81 18 99% RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, no JVD,
conjunctiva pale
CV: Regular rate and rhythm, normal S1 + S2, systolic murmur
LUSB, no rubs/gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, non-distended, mild tenderness to palpation
around umbilicus, hypoactive bowel sounds, no organomegaly, no
rebound or guarding, no tenderness over transplant site
GU: No foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, moving all extremities spontaneously,
gait deferred.
DISCHARGE PHYSICAL EXAM
Vitals: 98.2 65 122/80 16 96RA 70.3kg
General: Alert, oriented, no acute distress
HEENT: conjunctiva pale
CV: RRR, nl S1, S2, systolic murmur LUSB, no rubs/gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, non-distended, mild tenderness to palpation
around umbilicus, hypoactive bowel sounds, no organomegaly, no
rebound or guarding, no tenderness over transplant site
GU: No foley
Ext: Warm, well perfused, 2+ pulses, no edema
Neuro: CNII-XII intact, moving all extremities spontaneously
Pertinent Results:
ADMISSION LABS
___ 09:23AM BLOOD WBC-9.4 RBC-3.93 Hgb-10.8* Hct-33.9*
MCV-86 MCH-27.5 MCHC-31.9* RDW-16.8* RDWSD-53.1* Plt ___
___ 09:23AM BLOOD Neuts-60.5 ___ Monos-13.0
Eos-0.2* Baso-0.3 Im ___ AbsNeut-5.67 AbsLymp-2.41
AbsMono-1.22* AbsEos-0.02* AbsBaso-0.03
___ 09:23AM BLOOD Glucose-121* UreaN-24* Creat-1.6* Na-138
K-3.6 Cl-102 HCO3-23 AnGap-17
___ 09:23AM BLOOD ALT-16 AST-20 AlkPhos-84 TotBili-0.5
___ 09:23AM BLOOD Albumin-3.8
___ 07:15AM BLOOD Calcium-9.2 Phos-2.8 Mg-1.8
___ 07:15AM BLOOD rapmycn-7.1
___ 07:15AM BLOOD tacroFK-3.1*
___ 09:23AM BLOOD Lactate-1.0
DISCHARGE LABS
___ 07:36AM BLOOD WBC-5.9 RBC-3.56* Hgb-10.0* Hct-31.4*
MCV-88 MCH-28.1 MCHC-31.8* RDW-16.5* RDWSD-53.5* Plt ___
___ 07:36AM BLOOD Glucose-107* UreaN-21* Creat-1.3* Na-141
K-3.7 Cl-108 HCO3-21* AnGap-16
___ 09:42AM BLOOD tacroFK-5.6
IMAGING:
___ CXR
The heart is top-normal in size. There is no focal
consolidation. There is
no pneumothorax or pleural effusion. Bilateral shoulder
prostheses are
present.
IMPRESSION:
No evidence of pneumonia.
___ RENAL TRANSPLANT US
The right lower quadrant transplant renal morphology is normal.
Specifically,
the cortex is of normal thickness and echogenicity, pyramids are
normal, there
is no urothelial thickening, and renal sinus fat is normal.
There is no
hydronephrosis and no perinephric fluid collection.
The resistive index of intrarenal arteries 0.68, 0.71, and 0.69
upper, mid,
and lower intrarenal arteries, within the normal range. The
main renal artery
shows a normal waveform, with prompt systolic upstroke and
continuous
antegrade diastolic flow, with peak systolic velocity of 97.8.
Vascularity is
symmetric throughout transplant. The transplant renal vein is
patent and shows
normal waveform.
IMPRESSION:
Normal renal transplant ultrasound.
MICROBIOLOGY:
___ 11:25 am Immunology (CMV) CMV Viral Load (Pending):
URINE CULTURE (Final ___:
ESCHERICHIA COLI. 10,000-100,000 ORGANISMS/ML..
PRESUMPTIVE IDENTIFICATION.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
AMPICILLIN------------ <=2 S
AMPICILLIN/SULBACTAM-- <=2 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
OVA + PARASITES (Final ___: NO OVA AND PARASITES SEEN.
C. difficile DNA amplification assay (Final ___: Negative
for toxigenic C. difficile by the Illumigene DNA amplification
assay.
FECAL CULTURE (Final ___: NO SALMONELLA OR SHIGELLA
FOUND.
CAMPYLOBACTER CULTURE (Final ___: NO CAMPYLOBACTER
FOUND.
FECAL CULTURE - R/O VIBRIO (Final ___: NO VIBRIO FOUND.
FECAL CULTURE - R/O YERSINIA (Final ___: NO YERSINIA
FOUND.
FECAL CULTURE - R/O E.COLI 0157:H7 (Final ___: NO E.COLI
0157:H7 FOUND.
Cryptosporidium/Giardia (DFA) (Final ___: NO
CRYPTOSPORIDIUM OR GIARDIA SEEN.
Brief Hospital Course:
Ms. ___ is a ___ year old woman with history of ESRD from FSGS
s/p LURT in ___, baseline Cr 1.7, CAD s/p NSTEMI, hypertension,
previous C. diff infection in ___ s/p augmentin presents with
fever and diarrhea found to have complicated cystitis.
# Complicated cystitis: The patient presented with fevers and
diarrhea. Though her history was initially concerning for C.
diff infection given her recent history of antibiotic use, the
patient was found to have pyuria with urine culture growing E
coli sensitive to cephalosporins and ciprofloxacin and negative
C diff stool antigen. The patient was evaluated with stool
studies which were normal and CXR which was normal. The patient
was evaluated with CMV viral load which was negative. Ova and
parasites were negative. The patient was started on ceftriaxone
transitioned to cefpodoxime to complete a 14 day course though
___. The patient was evaluated with a renal transplant
ultrasound which was normal.
# ESRD s/p LURT ___ on immunosuppression: The patient's
creatinine was found to be at baseline. The patient's tacrolimus
and sirolimus levels were monitored throughout her admission and
she was discharged on her home regimen. The patient's furosemide
was held initially given her infection. This medication was
restarted on discharge.
# HTN: The patient was continued on her home metoprolol
succinate 75mg PO qday.
# Hyperparathyroidism: continued calcitriol
# CAD s/p NSTEMI: The patient was continued on her home aspirin
81mg PO qday, clopidogrel 75 mg PO daily, atoravastatin 80mg PO
qPM, and nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain. The
patient had a recent admission for chest pain which was thought
to be GI in origin. She was continued on her home famotidine 20
mg PO DAILY:PRN nausea, abdominal pain, and pantoprazole 40 mg
PO Q24H
# Depression/anxiety: continued citalopram 40 mg PO DAILY
# Insomnia: continued zolpidem 10mg PO qHS PRN
# Pain management: continued hydrocodone-Acetaminophen
(5mg-325mg) 1 TAB PO Q6H:PRN pain
# Vitamin deficiency: continued folic acid 1mg PO qday
# Gout: continued febuxostat 120mg PO qday
Transitional Issues:
- Continue cefpodoxime 400mg PO q12hours through ___ for
complicated cystitis
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amlodipine 5 mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 80 mg PO QPM
4. Citalopram 40 mg PO DAILY
5. Calcitriol 0.5 mcg PO DAILY
6. Clopidogrel 75 mg PO DAILY
7. Hydrocodone-Acetaminophen (5mg-325mg) 1 TAB PO Q6H:PRN pain
8. Zolpidem Tartrate 10 mg PO QHS:PRN insomnia
9. Tacrolimus 1 mg PO Q12H
10. Sirolimus 1 mg PO DAILY
11. Pantoprazole 40 mg PO Q24H
12. Febuxostat 120 mg PO DAILY
13. FoLIC Acid 1 mg PO DAILY
14. Furosemide 80 mg PO DAILY
15. Metoprolol Succinate XL 75 mg PO DAILY
16. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
17. Famotidine 20 mg PO DAILY:PRN nausea, abdominal pain
18. Aluminum-Magnesium Hydrox.-Simethicone ___ mL PO QID:PRN
nausea
Discharge Medications:
1. Amlodipine 5 mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 80 mg PO QPM
4. Calcitriol 0.5 mcg PO DAILY
5. Citalopram 40 mg PO DAILY
6. Clopidogrel 75 mg PO DAILY
7. Famotidine 20 mg PO DAILY:PRN nausea, abdominal pain
8. Febuxostat 120 mg PO DAILY
9. FoLIC Acid 1 mg PO DAILY
10. Furosemide 80 mg PO DAILY
11. Metoprolol Succinate XL 75 mg PO DAILY
12. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
13. Pantoprazole 40 mg PO Q24H
14. Sirolimus 1 mg PO DAILY
15. Tacrolimus 1 mg PO Q12H
16. Zolpidem Tartrate 10 mg PO QHS:PRN insomnia
17. Aluminum-Magnesium Hydrox.-Simethicone ___ mL PO QID:PRN
nausea
18. Hydrocodone-Acetaminophen (5mg-325mg) 1 TAB PO Q6H:PRN pain
19. Cefpodoxime Proxetil 400 mg PO Q12H Duration: 21 Doses
RX *cefpodoxime 200 mg 2 tablet(s) by mouth every 12 hours Disp
#*21 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
primary: complicated urinary tract infection in the setting of
kidney transplant, diarrhea
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
Thank you for allowing us to participate in your care at ___!
You were admitted to the hospital with abdominal pain and
diarrhea. You were found to have infection of your bladder. We
evaluated your transplanted kidney with an ultrasound and it was
found to be normal. You were also evaluated with stool studies
which showed that you do not have C. diff. We started you on an
antibiotics, cefpodoxime. You should continue this antibiotic
through ___.
We wish you the best!
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
19670384-DS-49
| 19,670,384 | 29,106,564 |
DS
| 49 |
2195-03-25 00:00:00
|
2195-03-25 16:38:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Chocolate Flavor / Simvastatin / Allopurinol / Augmentin /
ciprofloxacin
Attending: ___.
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
HISTORY OF PRESENTING ILLNESS:
Ms. ___ is a ___ y/o female with a history of FSGN s/p renal
transplant in ___, DVT/PE previously on coumadin but stopped
due to hemarthrosis, and CAD s/p multiple NSTEMIs without
interventions who presented with acute substernal chest pain.
She graduated from cardiac rehab in ___ at which time she
was able to walk 45 min w/o any chest discomfort or SOB. On the
evening prior to admission she was driving back from ___
when she developed ___ dull, squeezing retrosternal chest pain
radiating to L neck and L arm. This came in the context of a
couple of days of general malaise. Her pain was not positional
or pleuritic (unlike her prior PE which was pleuritic in
nature). There was no associated upper resp symptoms, no nausea,
abd pain, no black stools. No SOB, palpitations, PND, orthopnea,
or decrease in exercise tolerance. She finished driving back
from ___ and went straight to the ED.
To recap her recent cardiac hx: In ___, she went to
___ with chest pain, found to have trop 0.05, <1mm STE in
III but no true ST elevations. Managed medically w/ metoprolol
and atorvastatin. Patient had a PMIBI which showed fixed defect
in area of LCx and EF 45%. An echo hypokinesis consistent with
the stress test and an EF of 50%. She was started on plavix on
discharge.
She was admitted in ___ and ___ for NSTEMIs. During her
___ admission she had chest pain, underwent cardiac cath on ___
which
showed LAD 30%, LCx 50% mid stenosis, OM1 occluded, OM2
occluded, RCA ___ 40% and mid 50% stenosis. No interventions
performed. She was started on imdur and metoprolol increased.
Exercise stress test was negative.
In ___ she presented with 3 episodes of isolated substernal
chest pain 2 days ago associated with SOB. These episodes were
relieved by SL nitro and lasted for less than 15 minutes. EKG
was without
changes, troponin negative. Ranolazine was started. Other
concerns were recurrent PE, gastritis or musculoskeletal origin.
PE was ruled
out with VQ scan (obtained to prevent renal injury), gastritis
was unlikely as no improvement noted with GI cocktail. Given
lack of response to nitroglycerin and improvement with
anti-inflammatories and narcotics, concern was increased for
musculoskeletal origin of
chest pain.
Of note troponins were negative during her ___ and ___
admissions for CP. She did have mildly positive trop in ___.
Her only other pos troponin in our system was ___: she had a
trop >3.0 and nonspecific EKG changes. She was seen by cards;
this was thought to be demand ischemia in setting of admission
for HCAP and ___.
In the ED initial vitals were: 97.2 69 148/80 16 100% RA.
Past Medical History:
- CAD with h/o NSTEMI
- FSGN status post kidney transplant in ___
- Acute transplant rejection that had been treated with OKT3 in
___
- History of EBV viremia ___
- h/o C. diff (___)
- DVT/PE on Coumadin until ___ (stopped ___ hemarthrosis)
- TIA
- Hypertension
- Hyperlipidemia
- Gout
- Nephrolithiasis with ureteral stent placements
- Osteonecrosis of bilateral hips, shoulders, knees, status post
surgical interventions
- Left cataract surgery in ___
- Right cataract surgery in ___
- Skin cancer status post surgery in ___
- Basal cell carcinoma in ___
- Left adnexal mass s/p salpingo-oophorectomy.
- Cervical dysplasia
- HyperPTH secondary to renal failure
- Appendectomy
- Endometrial ablation for menorrhagia in ___
- ___ laparoscopy
Social History:
___
Family History:
Brother ___ had MI, Dad was ___ and had MI.
Sister with FSGS s/p transplant and avascular necrosis.
Uncle with RA.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: 97.7 114/72 57 18 97 RA
GENERAL: WDWN woman in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthelasma.
NECK: Supple with JVP of 6 cm.
CARDIAC: PMI located in ___ intercostal space, midclavicular
line. RR, normal S1, S2. No murmurs/rubs/gallops. No thrills,
lifts.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. No crackles, wheezes or
rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: trace edema. 2+ ___ and DP pulses
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES: Distal pulses palpable and symmetric
DISCHARGE PHYSICAL EXAM:
VS: 98.3 100s-110s/60s ___ 99 RA
GENERAL: WDWN woman in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthelasma.
NECK: Supple with JVP of 6 cm.
CARDIAC: PMI located in ___ intercostal space, midclavicular
line. RR, normal S1, S2. No murmurs/rubs/gallops. No thrills,
lifts.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. No crackles, wheezes or
rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: trace edema. 2+ ___ and DP pulses
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES: Distal pulses palpable and symmetric
Pertinent Results:
ADMISSION LABS:
___ 04:45AM PLT COUNT-299
___ 04:45AM NEUTS-51.9 ___ MONOS-10.0 EOS-2.2
BASOS-0.4 IM ___ AbsNeut-4.83 AbsLymp-3.28 AbsMono-0.93*
AbsEos-0.20 AbsBaso-0.04
___ 04:45AM WBC-9.3# RBC-3.89* HGB-11.1* HCT-33.3* MCV-86
MCH-28.5 MCHC-33.3 RDW-13.9 RDWSD-43.3
___ 04:45AM calTIBC-277 FERRITIN-247* TRF-213
___ 04:45AM ALBUMIN-4.3 CALCIUM-10.3 PHOSPHATE-4.0
MAGNESIUM-1.8 IRON-44
___ 04:45AM LIPASE-52
___ 04:45AM ALT(SGPT)-18 AST(SGOT)-22 ALK PHOS-91 TOT
BILI-0.3
___ 04:45AM estGFR-Using this
___ 04:45AM GLUCOSE-131* UREA N-52* CREAT-2.7* SODIUM-140
POTASSIUM-3.0* CHLORIDE-96 TOTAL CO2-26 ANION GAP-21*
___ 05:24AM ___ PTT-31.9 ___
___ 10:40AM PTT-150*
___ 10:33PM URINE MUCOUS-RARE
___ 10:33PM URINE RBC-3* WBC-1 BACTERIA-FEW YEAST-NONE
EPI-2
___ 10:33PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-SM
___ 10:33PM URINE COLOR-Straw APPEAR-Clear SP ___
___ 10:33PM URINE HOURS-RANDOM CREAT-65 SODIUM-17
POTASSIUM-14 CHLORIDE-LESS THAN TOT PROT-<6 PROT/CREA-<0.1
TROPONIN TREND:
___ 04:45AM BLOOD cTropnT-<0.01
___ 10:40AM BLOOD cTropnT-<0.01
DRUG LEVELS:
___ 09:30AM BLOOD tacroFK-3.9* rapmycn-7.3
DISCHARGE LABS:
___ 06:50AM BLOOD Glucose-95 UreaN-40* Creat-2.1* Na-141
K-4.0 Cl-106 HCO3-24 AnGap-15
___ 06:50AM BLOOD tacroFK-6.1
___ 06:50AM BLOOD Calcium-9.2 Phos-2.8 Mg-2.0
**STUDIES**
___ RENAL US
IMPRESSION:
1. Mild ectasia of the upper renal pole of the right lower
quadrant
transplant kidney is unchanged from the prior exam. No mass or
stone.
2. Patent renal vasculature with segmental arterial resistive
indices ranging
from 0.67-0.71.
___ CXR
No acute cardiopulmonary process.
Brief Hospital Course:
Ms. ___ is a ___ y/o female with a history of FSGN s/p renal
transplant in ___, DVT/PE previously on coumadin but stopped
due to hemarthrosis, and CAD s/p multiple NSTEMIs without
interventions who presented with acute substernal chest pain.
Ruled out for ACS with 2 neg trops and no EKG changes.
ACTIVE ISSUES:
#CHEST PAIN: This was Ms. ___ ___ presentation this year
with substernal chest pain. She was initially on heparin drip
and nitro drip but these were stopped after she was ruled out
for ACS in the ED with two negative trops and no EKG changes.
Prior studies were reviewed: she has known occlusion of both
obtuse marginal arteries on cath ___ PMIBI ___ showed
fixed, severe perfusion defect involving the LCx territory. It
was felt likely that her chest pain did represent angina, as she
has the aforementioned known CAD and has chest pain ___ times
per month relieved by sublingual nitro. Unfortunately, she's had
severe headache in the past with imdur and had severe diarrhea
with ranolozine. She continued on metoprolol. We uptitrated her
amlodipine from 5 to 10. She continued on her statin.
#ACUTE ON CHRONIC KIDNEY INJURY: She had a Cr elevated above
baseline on admission (Cr 2.7 from 2.3 in ___ and was
followed by transplant nephrology while inpatient. Her tacro and
sirolimus levels were followed and were within goal on current
regimen (tacro level on ___ was 6.1). Her ___ improved with
gentle IVF and was most likely prerenal in etiology.
CHRONIC ISSUES
# Normocytic Anemia: Her hgb was at baseline. Iron studies were
consistent with anemia of chronic disease and anemia of CKD (low
TIBC, elevated ferritin).
# Gout: continued home febuxostat. Asymptomatic while inpatient.
# Depression: continued home citalopram.
#Gerd: continued home famotidine, PPI.
TRANSITIONAL ISSUES:
-She needs to follow up w/her cardiologist regarding mamangement
of her chest pain. For now, she's been having chest pain only
___ / month so medical management may be reasonable. Could also
consider a repeat stress. Discharged on higher dose of
amlodipine (increased from 5 to 10 daily); please f/u BPs on
this regimen.
-Tacro and Sirolimus doses on discharge: tacrolimus 2mg qAM/1mg
qPM, sirolimus 2mg PO daily. Of note the dose, she was taking on
admission was different than what was documented in her last
nephrology note. Troughs were checked and within therapeutic
window.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amlodipine 5 mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 80 mg PO QPM
4. Calcitriol 0.5 mcg PO DAILY
5. Citalopram 40 mg PO DAILY
6. Clopidogrel 75 mg PO DAILY
7. Febuxostat 120 mg PO DAILY
8. Metoprolol Succinate XL 75 mg PO DAILY
9. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
10. Sirolimus 2 mg PO DAILY
11. Tacrolimus 2 mg PO QAM
12. Zolpidem Tartrate 10 mg PO QHS:PRN insomnia
13. Docusate Sodium 100 mg PO BID
14. Famotidine 20 mg PO DAILY
15. Hydrocodone-Acetaminophen (5mg-325mg) 1 TAB PO Q6H:PRN pain
16. Pantoprazole 40 mg PO Q12H
17. Furosemide 40 mg PO DAILY
18. Tacrolimus 1 mg PO QPM
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 80 mg PO QPM
3. Calcitriol 0.5 mcg PO DAILY
4. Citalopram 40 mg PO DAILY
5. Clopidogrel 75 mg PO DAILY
6. Docusate Sodium 100 mg PO BID
7. Famotidine 20 mg PO DAILY
8. Febuxostat 120 mg PO DAILY
9. Hydrocodone-Acetaminophen (5mg-325mg) 1 TAB PO Q6H:PRN pain
10. Metoprolol Succinate XL 75 mg PO DAILY
11. Pantoprazole 40 mg PO Q12H
12. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
13. Zolpidem Tartrate 10 mg PO QHS:PRN insomnia
14. Amlodipine 10 mg PO DAILY
15. Sirolimus 2 mg PO DAILY
16. Tacrolimus 2 mg PO QAM
17. Tacrolimus 1 mg PO QPM
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSES:
coronary artery disease
end stage renal disease s/p LURT
acute allograft renal dysfunction
SECONDARY DIAGNOSES:
depression
gout
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___:
You were admitted to ___ with chest pain. This was most likely
due to the blockages in your arteries that supply your heart.
These blockages are in small arteries, so we continued your home
medicines for heart disease and could not do any intervention on
the blockages.
We also tracked your levels of your transplant medications, and
the doses were adjusted.
If you have chest pain, it's OK to take up to 3 nitroglycerins,
five minutes apart. If your pain doesn't resolve with 3 nitros,
please call your doctor.
It was a pleasure to care for you!
Your ___ Team
Followup Instructions:
___
|
19670384-DS-51
| 19,670,384 | 27,945,109 |
DS
| 51 |
2195-05-31 00:00:00
|
2195-06-01 17:17:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Chocolate Flavor / Simvastatin / Allopurinol / Augmentin /
ciprofloxacin
Attending: ___
Chief Complaint:
Diarrhea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is a ___ woman with a history of FSGN s/p renal
transplant in ___, DVT/PE (previously on Coumadin but stopped
due to hemarthrosis), CAD, anemia, s/p prior breast reduction
surgery and now s/p breast fat necrosis removal on ___,
history of C.diff infection and Klebsiella Pneumonia UTI who
presents with diarrhea 10 times per day.
The patient was recently hospitalized on ___ for confusion
felt to be from Dilaudid and pre-renal ___ in which her Cr went
back to baseline of 2.0 prior to discharge. Renal transplant US
at that time was normal.
The patient notes 10 watery BM's since ___. She denies
associated nausea, vomiting, fever, chills, cough, dysuria, back
pain, or sick contacts. She does endorse generalized weakness
and shortness of breath when walking up a flight of stairs.
In the ED, initial vital signs were:
Temp 99.5, HR 71, BP 118/78, RR 16, 100% RA
- Labs were notable for: Na 137, K 4.7, Cl 101, Bicarb 32, Cr
3.1, CBC not obtained.
- Imaging: CXR without acute intrathoracic abnormality.
- The patient was given:
IVF 1000 mL NS 1000 mL
PO/NG Aspirin 81 mg
PO/NG Atorvastatin 80 mg
PO/NG Clopidogrel 75 mg
PO/NG Amlodipine 5 mg
PO Metoprolol Succinate XL 75 mg
- Consults:
Renal transplant fellow consulted who recommended obtaining
stool for c. diff, stool culture, crypto, giardia, viral
culture, ova and parasite. Recommended CMV PCR, urine culture,
blood culture, and holding Lasix. Recommended IVF. Recommended
continuing tacro 1 mg BID and sirolimus 2 mg daily with
tacrolimus and sirolimus trough tomorrow morning
Vitals prior to transfer were:
Temp 99.5, HR 71, RR 118/78, RR 16, 100% RA
Upon arrival to the floor, the patient notes she has had
diarrhea since ___ that is yellow/green and non-bloody in
appearance. She denies associated fever, chills, nausea,
vomiting, or abdominal pain. She notes that she has had c.
difficile 5 times in the past last in ___ for which she was
on PO vanco for about 1 month. She notes that her c. difficile
episodes usually consist of just diarrhea without associated
abdominal pain.
She also endorses SOB with ambulation up the stairs but denies
associated chest pain. She notes she has been taking all of her
medications as prescribed but stopped taking her lasix on ___
because she felt dehydrated from the diarrhea.
REVIEW OF SYSTEMS:
[+] per HPI
[-] Denies headache, visual changes, pharyngitis, rhinorrhea,
nasal congestion, cough, fevers, chills, sweats, weight loss,
dyspnea, chest pain, abdominal pain, nausea, vomiting,
constipation, hematochezia, dysuria, rash, paresthesias,
weakness
Past Medical History:
- CAD with h/o NSTEMI
- FSGN status post kidney transplant in ___
- Acute transplant rejection that had been treated with OKT3 in
___
- History of EBV viremia ___
- h/o C. diff (___)
- DVT/PE on Coumadin until ___ (stopped ___ hemarthrosis)
- TIA
- Hypertension
- Hyperlipidemia
- Gout
- Nephrolithiasis with ureteral stent placements
- Osteonecrosis of bilateral hips, shoulders, knees, status post
surgical interventions
- Left cataract surgery in ___
- Right cataract surgery in ___
- Skin cancer status post surgery in ___
- Basal cell carcinoma in ___
- Left adnexal mass s/p salpingo-oophorectomy.
- Cervical dysplasia
- HyperPTH secondary to renal failure
- Appendectomy
- Endometrial ablation for menorrhagia in ___
- ___ laparoscopy
Social History:
___
Family History:
Brother ___ had MI, Dad was ___ and had MI.
Sister with FSGS s/p transplant and avascular necrosis.
Uncle with RA.
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
VITALS - 98.0, BP 103/77, HR 67, RR 18, 95% RA
GENERAL - pleasant, well-appearing, in no apparent distress
HEENT - normocephalic, atraumatic, no conjunctival pallor or
scleral icterus, PERRLA, EOMI, OP clear
NECK - supple,
CARDIAC - regular rate & rhythm, normal S1/S2, no murmurs rubs
or gallops
PULMONARY - clear to auscultation bilaterally, without wheezes
or rhonchi
ABDOMEN - hyperactive bowel sounds, soft, non-tender,
non-distended, no organomegaly
EXTREMITIES - warm, well-perfused, no cyanosis, clubbing or
edema
SKIN - without rash
NEUROLOGIC - A&Ox3, CN II-XII grossly normal, normal sensation,
with strength ___ throughout. Gait assessment deferred
PSYCHIATRIC - listen & responds to questions appropriately,
pleasant
DISCHARGE PHYSICAL EXAM:
=========================
VS: 98.3F BP 116-130/63-67 HR 55-57 RR18 100% RA
GENERAL - pleasant, well-appearing, in no apparent distress
HEENT - no conjunctival pallor or scleral icterus, OP clear
NECK - supple, no LAD
CARDIAC - regular rate & rhythm, normal S1/S2, no murmurs
PULMONARY - clear to auscultation bilaterally
ABDOMEN -bowel sounds present, soft, non-tender, non-distended,
no organomegaly
EXTREMITIES - warm, well-perfused, no or edema
NEUROLOGIC - A&Ox3, CN II-XII grossly normal
Pertinent Results:
ADMISSION LABS:
==================
___ 12:14AM BLOOD WBC-7.6 RBC-3.56* Hgb-9.7* Hct-30.8*
MCV-87 MCH-27.2 MCHC-31.5* RDW-13.2 RDWSD-41.5 Plt ___
___ 06:45PM BLOOD Glucose-108* UreaN-32* Creat-3.1*# Na-137
K-4.7 Cl-101 HCO3-22 AnGap-19
___ 06:45PM BLOOD Calcium-10.5* Phos-4.7*# Mg-1.7
___ 05:45AM BLOOD tacroFK-5.9 rapmycn-12.2
PERTINENT RESULTS/MICRO:
========================
C. difficile DNA amplification assay (Final ___:
FECAL CULTURE (Final ___:
NO ENTERIC GRAM NEGATIVE RODS FOUND.
NO SALMONELLA OR SHIGELLA FOUND.
CAMPYLOBACTER CULTURE (Final ___: NO CAMPYLOBACTER
FOUND.
OVA + PARASITES (Final ___:
NO OVA AND PARASITES SEEN.
NO VIBRIO FOUND.
NO YERSINIA FOUND.
NO E.COLI 0157:H7 FOUND
NO CRYPTOSPORIDIUM OR GIARDIA SEEN.
CMV Viral Load (Final ___:
CMV DNA not detected.
Blood culture pending
Urine culture no growth
DISCHARGE LABS:
==============
___ 06:05AM BLOOD WBC-5.7 RBC-3.62* Hgb-9.8* Hct-31.8*
MCV-88 MCH-27.1 MCHC-30.8* RDW-13.1 RDWSD-41.5 Plt ___
___ 06:05AM BLOOD Glucose-99 UreaN-18 Creat-1.5* Na-138
K-3.9 Cl-107 HCO3-20* AnGap-15
___ 06:05AM BLOOD Calcium-10.0 Phos-3.2 Mg-1.8
___ 06:05AM BLOOD tacroFK-3.2*
IMAGING:
========
___ CXR:
PA and lateral chest radiograph demonstrates clear lungs
bilaterally. There is no pleural effusion. Cardiomediastinal
and hilar contours are within normal limits. There is no
pneumothorax. Patient is status post bilateral shoulder
arthroplasties.
Brief Hospital Course:
Ms. ___ is a ___ woman with a history of FSGN s/p
renal transplant in ___, DVT/PE (previously on Coumadin but
stopped due to hemarthrosis), CAD, anemia, s/p prior breast
reduction surgery and now s/p breast fat necrosis removal on
___ with recent hospitalization and discharge on ___ for
acute kidney injury now presenting with diarrhea found to have
acute kidney injury.
# Diarrhea: Patient reported subacute worsening of diarrhea
since last discharge. Differential included infectious etiology
given recent hospitalization as well as c. difficile given that
this episode is consistent with patient's prior episodes that
have been without associated abdominal pain. Her c.diff assay
was negative as well as other infectious studies. Overall this
would be patient's at least ___ recurrence given her noting she
has had c. difficile 4 times prior. Other etiologies for
diarrhea may include sirolimus toxicity though this was less
likely as patient was taking 1mg BID instead of 2 mg daily. This
was also unlikely tacrolimus induced diarrhea, given levels
being low to normal. Other etiologies include viral etiologies,
her norovirus assay was negative. Patient was given IV fluids
and loperamide for diarrhea. No antibiotics were initiated given
patient was overall well appearing, with good PO intake, no
leukocytosis and no fevers. However, given patient's history of
multiple diarrheal episodes, she was scheduled for outpatient GI
followup.
#Acute on chronic renal disease (baseline Cr 2.0): Patient with
___ on CKD with BUN/Cr ratio consistent with intrinsic etiology.
Patient recently underwent renal transplant US on ___ that was
within normal limits. Patient's renal function improved with IV
fluids and PO intake.
# History of FSGN s/p renal transplant: Continued Sirolimus 2
mg PO DAILY (target trough ___, Tacrolimus increased to 2mg
BID from 1 mg BID.
# Acute on chronic anemia: Ptient had a baseline anemia with
most recent baseline Hg around ___. Iron studies last month
consistent with anemia of chronic disease/CKD.
# Hypertension: once patient's volume status stabilized, home
amlodipine 5 mg daily was resumed
CHRONIC ISSUES:
================
# CAD: Patient has history of multiple NSTEMis. Prior studies
show known occlusion of both obtuse marginal arteries on cath
___ PMIBI ___ showed fixed, severe perfusion defect
involving the LCx territory. Continued home medications of
aspirin, Plavix, metoprolol succinate and atorvastatin.
#Hyperparathyroidism: continued calcitriol
# DVT/PE: Not on warfarin due to hemarthrosis.
# Depression: Continued citalopram 40 mg daily
# Gout: Continued Febuxostat 120 mg PO DAILY
TRANSITIONAL ISSUES:
======================
-increased tacrolimus to 2mg twice a day from 1mg twice a day,
rapamycin unchanged
-please repeat transplant labs on ___
-please follow up with gastroenterology for diarrhea
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 80 mg PO QPM
3. Calcitriol 0.5 mcg PO DAILY
4. Citalopram 40 mg PO DAILY
5. Clopidogrel 75 mg PO DAILY
6. Docusate Sodium 100 mg PO BID
7. Famotidine 20 mg PO DAILY
8. Febuxostat 120 mg PO DAILY
9. Metoprolol Succinate XL 75 mg PO DAILY
10. Sirolimus 2 mg PO DAILY
11. Hydrocodone-Acetaminophen (5mg-325mg) 1 TAB PO Q6H:PRN pain
12. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
13. Amlodipine 5 mg PO DAILY
14. Furosemide 40 mg PO DAILY
15. Zolpidem Tartrate 5 mg PO QHS:PRN insomnia
16. Tacrolimus 1 mg PO Q12H
Discharge Medications:
1. Amlodipine 5 mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 80 mg PO QPM
4. Calcitriol 0.5 mcg PO DAILY
5. Citalopram 40 mg PO DAILY
6. Clopidogrel 75 mg PO DAILY
7. Famotidine 20 mg PO DAILY
8. Febuxostat 120 mg PO DAILY
9. Hydrocodone-Acetaminophen (5mg-325mg) 1 TAB PO Q6H:PRN pain
10. Metoprolol Succinate XL 75 mg PO DAILY
11. Sirolimus 2 mg PO DAILY
12. Docusate Sodium 100 mg PO BID
13. Furosemide 40 mg PO DAILY
14. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
15. LOPERamide 2 mg PO QID:PRN diarrhea
RX *loperamide 2 mg 1 pill by mouth every 6 hours Disp #*40
Capsule Refills:*0
16. Multivitamins W/minerals 1 TAB PO DAILY
RX *multivitamin,tx-minerals 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*0
17. Tacrolimus 2 mg PO Q12H
RX *tacrolimus 1 mg 2 capsule(s) by mouth twice a day Disp #*60
Capsule Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
-Non-infectious diarrhea
-FSGN s/p renal transplant on Tacrolimus and Sirolimus
Secondary Diagnosis:
-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 ___ on ___ after you had repeated
episodes of diarrhea and found to have some renal injury. Your
kidney function improved with IV fluids. Your cultures did not
show any clear infection in your stool. Your diarrhea improved
with anti-diarrheals. Given that we do not know exactly why you
had diarrhea, we would like you to follow up with outpatient GI
doctors for further ___.
We want to assure you are taking the right dose of your
immunosuppressant medications. The doses are: increasing
tacrolimus to 2mg twice a day, keep rapamycin 2mg once a day
We wish you the best,
Your ___ care team
Followup Instructions:
___
|
19670384-DS-52
| 19,670,384 | 29,411,955 |
DS
| 52 |
2195-07-31 00:00:00
|
2195-08-01 22:55:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Chocolate Flavor / Simvastatin / Allopurinol / Augmentin /
ciprofloxacin / morphine
Attending: ___.
Chief Complaint:
Diarrhea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with ESRD from ___ s/p LURT in ___ and recurrent C. diff
colitis who presents with several episodes of watery diarrhea
over the past three days.
Of note, she was hospitalized in ___ with diarrhea for
which a broad work-up was negative. Post-discharge she was seen
in GI clinic and underwent ___ on ___ that did not show
evidence of any further pathology except mild inflammation in
her stomach. Her diarrhea had actually completely resolved by
the beginning of ___, however, three days prior to
presentation it recurred. She describes the diarrhea as
non-bloody and almost clear watery. Associated with the diarrhea
has been decreased appetite, dizziness with standing, and
abdominal pain near her allograft. No change in her urine output
or quality, no associated fever, chills, chest pain, dysuria,
lower extremity edema, or rash. She denies consumption of raw
food or sick contacts; she has had some fast food and ___
restaurant food in the last week.
In the ED, initial vital signs were: 5 98.2 65 114/84 18 100% RA
- Labs were notable for: H/H 10.7/33.7, BUN/Cr 52/2.5, lactate
1.3, U/A with blood, few bacteria, hyaline casts with negative
UCG
- Imaging: renal transplant ultrasound with slightly elevated
main renal artery resistive index
- The patient was given: 500 cc NS
- Consults: renal transplant
Vitals prior to transfer were: 2 98.5 60 107/65 16 99% RA
Upon arrival to the floor, she endorses the above story. She is
thirsty.
Past Medical History:
- CAD with h/o NSTEMI
- FSGN status post kidney transplant in ___
- Acute transplant rejection that had been treated with OKT3 in
___
- History of EBV viremia ___
- h/o C. diff (___)
- DVT/PE on Coumadin until ___ (stopped ___ hemarthrosis)
- TIA
- Hypertension
- Hyperlipidemia
- Gout
- Nephrolithiasis with ureteral stent placements
- Osteonecrosis of bilateral hips, shoulders, knees, status post
surgical interventions
- Left cataract surgery in ___
- Right cataract surgery in ___
- Skin cancer status post surgery in ___
- Basal cell carcinoma in ___
- Left adnexal mass s/p salpingo-oophorectomy.
- Cervical dysplasia
- HyperPTH secondary to renal failure
- Appendectomy
- Endometrial ablation for menorrhagia in ___
- ___ laparoscopy
Social History:
___
Family History:
Brother ___ had MI, Dad was ___ and had MI.
Sister with FSGS s/p transplant and avascular necrosis.
Uncle with RA.
Physical Exam:
ON ADMISSION:
VITALS: 98 125/77 60 20 100% RA
GENERAL: Pleasant, well-appearing, in no apparent distress.
HEENT - MM dry, anicteric sclera, no conjunctival pallor
NECK: Supple, no LAD, JVP flat
CARDIAC: brady, regular, normal S1/S2, no murmurs rubs or
gallops.
PULMONARY: Clear to auscultation bilaterally, without wheezes
or rhonchi.
ABDOMEN: mild tenderness in RLQ though not over allograft, no
rebound or guarding, no tenderness in rest of abdomen
EXTREMITIES: Warm, well-perfused, no edema.
SKIN: Without rash.
NEUROLOGIC: gait is normal, moving all extremities without
focal deficit
ON DISCHARGE:
VITALS: 98.3 100s-120s/50s-70s ___ 99-100% RA
GENERAL: Pleasant, well-appearing, in no apparent distress.
HEENT - MM dry, anicteric sclera, no conjunctival pallor
NECK: Supple, no LAD, JVP flat
CARDIAC: brady, regular, normal S1/S2, no murmurs rubs or
gallops.
PULMONARY: Clear to auscultation bilaterally, without wheezes
or rhonchi.
ABDOMEN: mild tenderness in RLQ, no rebound or guarding, no
tenderness in rest of abdomen
EXTREMITIES: Warm, well-perfused, no edema.
SKIN: Without rash.
NEUROLOGIC: gait is normal, moving all extremities without
focal deficit
Pertinent Results:
ON ADMISSION:
___ 12:40PM BLOOD WBC-8.3 RBC-3.87* Hgb-10.7* Hct-33.7*
MCV-87 MCH-27.6 MCHC-31.8* RDW-15.2 RDWSD-48.0* Plt ___
___ 12:40PM BLOOD Neuts-62.5 ___ Monos-10.1 Eos-1.9
Baso-0.5 Im ___ AbsNeut-5.21 AbsLymp-2.07 AbsMono-0.84*
AbsEos-0.16 AbsBaso-0.04
___ 12:40PM BLOOD Glucose-107* UreaN-52* Creat-2.5* Na-137
K-3.4 Cl-100 HCO3-23 AnGap-17
___ 12:40PM BLOOD ALT-16 AST-22 AlkPhos-86 TotBili-0.4
___ 12:40PM BLOOD Lipase-46
___ 12:40PM BLOOD Albumin-4.4
___ 07:30AM BLOOD tacroFK-6.1
___ 01:00PM BLOOD Lactate-1.3
ON DISCHARGE:
___ 07:35AM BLOOD WBC-6.7 RBC-3.48* Hgb-9.6* Hct-30.4*
MCV-87 MCH-27.6 MCHC-31.6* RDW-14.9 RDWSD-46.9* Plt ___
___ 07:35AM BLOOD Glucose-94 UreaN-29* Creat-1.7* Na-145
K-4.1 Cl-112* HCO3-23 AnGap-14
___ 07:35AM BLOOD Calcium-9.6 Phos-2.4* Mg-1.8
___ 07:30AM BLOOD tacroFK-5.0 rapmycn-7.4
___ 07:35AM BLOOD tacroFK-6.2
MICROBIOLOGY:
___ STOOL OVA + PARASITES-FINAL INPATIENT
___ STOOL C. difficile DNA amplification
assay-FINAL; FECAL CULTURE-FINAL; CAMPYLOBACTER CULTURE-FINAL;
OVA + PARASITES-FINAL; FECAL CULTURE - R/O VIBRIO-FINAL; FECAL
CULTURE - R/O YERSINIA-FINAL; FECAL CULTURE - R/O E.COLI
0157:H7-FINAL; Cryptosporidium/Giardia (DFA)-FINAL EMERGENCY
WARD
___ URINE URINE CULTURE-FINAL EMERGENCY WARD
___ BLOOD CULTURE Blood Culture, Routine-PENDING
EMERGENCY WARD
___ Immunology (CMV) CMV Viral Load-FINAL
EMERGENCY WARD
___ BLOOD CULTURE Blood Culture, Routine-PENDING
IMAGING:
___ RENAL TRANSPLANT US: No hydronephrosis or a perinephric
fluid collection noted. Normal corticomedullary differentiation
is maintained. Transplant renal parenchymal echogenicity
appears normal.
Slightly elevated main renal artery resistive index may reflect
hypovolemia and secondary elevation of velocities in setting of
diarrhea. The intrarenal arterial resistive indices however are
within the normal range.
Brief Hospital Course:
___ yoF with h/o FSGS s/p LURT in ___ on chronic
immunosuppression, DVT/PE (previously on Coumadin but stopped
due to hemarthrosis), CAD, and anemia who was admitted with
recurrent diarrhea and acute on chronic renal failure. She was
treated supportively with IV fluids. Stool studies, including
culture and ova + parasites, were all negative. CMV, EBV, and
crypto were sent given immunosuppression but were negative.
Patient's diarrhea was self-limited and resolved after four
days. Loperamide had been started but she only received one dose
prior to resolution of symptoms. Patient's diarrhea was thought
to be secondary to a viral gastroenteritis.
Given ___, patient had renal ultrasound which was notable only
for slightly elevated main renal artery resistive index, which
was thought to reflect hypovolemia. Her creatinine improved from
2.5 to her baseline of 1.7 by time of discharge. ___ was
therefore thought to be prerenal from diarrhea.
OTHER ISSUES:
# Chronic renal insufficiency: Creatinine initially was
increased compared to baseline but downtrended to baseline with
IVF. Renal ultrasound with slightly higher resistive indices
that was thought to reflect hypovolemia.
# H/O FSGS s/p LURT ___: Patient was continued on home
sirolimus and tacrolimus and levels were routinely monitored.
Tacrolimus was increased as patient's diarrhea was resolving.
CHRONIC ISSUES:
# Hypertension: Continued home amlodipine
# CAD: Patient has history of multiple NSTEMIs. Prior studies
show known occlusion of both obtuse marginal arteries on cath
___ PMIBI ___ showed fixed, severe perfusion defect
involving the LCx territory. She was continued on aspirin,
Plavix, atorvastatin, and metoprolol.
# Hyperparathyroidism: Continued calcitriol
# Depression: Continue citalopram 40 mg daily
# Gout: Continued Febuxostat 120 mg PO DAILY
TRANSITIONAL ISSUES:
- Patient discharged home with loperamide for diarrhea
- Patient's home tacrolimus dose was increased to 1.5mg q12h
given resolution of diarrhea.
- Patient's home Lasix was held during admission given prerenal
___. Please resume as tolerated
- Patient to have BNP, tacrolimus and sirolimus trough checked
on ___
- Code status: Full
- Name of health care proxy: ___
Relationship: sister
___ on ___:
The Preadmission Medication list is accurate and complete.
1. Amlodipine 5 mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 80 mg PO QPM
4. Calcitriol 0.5 mcg PO DAILY
5. Citalopram 40 mg PO DAILY
6. Clopidogrel 75 mg PO DAILY
7. Famotidine 20 mg PO DAILY
8. Febuxostat 120 mg PO DAILY
9. Hydrocodone-Acetaminophen (5mg-325mg) 1 TAB PO Q6H:PRN pain
10. Metoprolol Succinate XL 75 mg PO DAILY
11. Sirolimus 1 mg PO DAILY
12. Furosemide 40 mg PO DAILY
13. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
14. Multivitamins W/minerals 1 TAB PO DAILY
15. Tacrolimus 1 mg PO Q12H
16. Zolpidem Tartrate 10 mg PO QHS
Discharge Medications:
1. Amlodipine 5 mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Metoprolol Succinate XL 75 mg PO DAILY
4. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
5. LOPERamide 2 mg PO QID:PRN diarrhea
RX *loperamide 2 mg 1 by mouth four times a day Disp #*30 Tablet
Refills:*0
6. Zolpidem Tartrate 10 mg PO QHS
7. Tacrolimus 1.5 mg PO Q12H
RX *tacrolimus 1 mg 1 capsule(s) by mouth every twelve (12)
hours Disp #*60 Capsule Refills:*0
RX *tacrolimus 0.5 mg 1 capsule(s) by mouth every twelve (12)
hours Disp #*60 Capsule Refills:*0
8. Atorvastatin 80 mg PO QPM
9. Calcitriol 0.5 mcg PO DAILY
10. Citalopram 40 mg PO DAILY
11. Clopidogrel 75 mg PO DAILY
12. Famotidine 20 mg PO DAILY
13. Febuxostat 120 mg PO DAILY
14. HYDROcodone-Acetaminophen (5mg-325mg) 1 TAB PO Q6H:PRN pain
15. Sirolimus 1 mg PO DAILY
Daily dose to be administered at 6am
16. Multivitamins W/minerals 1 TAB PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY:
Viral gastroenteritis
Acute on chronic renal insufficiency
SECONDARY:
- Focal segmental glomerulosclerosis s/p living unrelated kidney
transplant in ___ on chronic immunosuppression
- Chronic kidney disease stage IV
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were admitted to ___ because you were experiencing watery
diarrhea, thought to be from viral gastroenteritis. We gave you
IV fluids for hydration until you were able to eat. All of your
stool and viral studies were negative. You were started on
loperamide but were only given one dose before your diarrhea
improved.
You may use loperamide if you experience loose stools. However,
please seek medical attention should you experience watery
diarrhea, fevers/chills, or nausea/vomiting.
You will also have repeat labs on ___. Please hold off on
taking your Lasix until then. At discharge, you weighed 136 lbs.
It is very important that you weigh yourself every morning
before getting dressed and after going to the bathroom. Call
your doctors if your ___ goes up by more than 3 lbs in 1 day
or more than 5 lbs in 3 days.
Please see below for your pending and scheduled appointments
with your PCP and transplant nephrologist.
We wish you the best,
Your ___ Care Team
Followup Instructions:
___
|
19670384-DS-53
| 19,670,384 | 28,259,697 |
DS
| 53 |
2195-11-01 00:00:00
|
2195-11-02 19:45:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Chocolate Flavor / Simvastatin / Allopurinol / Augmentin /
ciprofloxacin / morphine
Attending: ___
Chief Complaint:
Leg pain, volume overload
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ year-old lady with a history of FSG s/p LURT
in ___, CAD s/p CABG presenting with right leg pain and weight
gain.
Over the past week she has noted a increase of 14lbs in her
weight along with increasing lower extremity edema. She also hit
her right leg against a piece of bar furniture resulting in a
visible hematoma which has been very painful for her.
In the ED:
-Initial vitals were: 98.6 72 167/90 18 100% RA
-Exam notable for: Soft tissue hematoma lateral to the right
tibia, very tender to palpation in the region, tender with
ranging of the ankle
-Labs notable for:
*Hb 10.8 (baseline)
*Cr 1.6 (baseline_
*BNP ___
-Imaging notable for:
*Renal Tx US: Normal renal transplant ultrasound
*CXR: No acute cardiopulmonary process.
*R tib/fib XR: No acute fracture.
Patient was given: Furosemide 40mg IV x1, Hydromorphone total
2mg IV, Tacrolimus 1.5mg x2, Sirolimus 1mg x1
-Nephrology consulted and recommended:
*Diurese 40mg IV Lasix
*Continue home immunosuppressants
*Please check immunosuppressant levels
*Admit to ET
-Orthopedics was consulted and recommended:
*Contusion and hematoma, no fracture, no surgical management
indicated
Vitals prior to transfer: 97.8 | 71 | 126/66 | 18 | 100% RA
On the floor, patient complains of ongoing right leg pain.
ROS:
(+) Per HPI
(-) Denies fever, chills, night sweats.
Denies headache, sinus tenderness, rhinorrhea or congestion.
Denies cough, shortness of breath. Denies chest pain or
tightness, palpitations. Denies nausea, vomiting, diarrhea,
constipation or abdominal pain. No recent change in bowel or
bladder habits. No dysuria. Denies arthralgias or myalgias.
Past Medical History:
- CAD with h/o NSTEMI
- FSGN status post kidney transplant in ___
- Acute transplant rejection that had been treated with OKT3 in
___
- EBV viremia
- History of recurrent C. diff colitis
- DVT/PE on Coumadin until ___ (stopped ___ hemarthrosis)
- TIA
- Hypertension
- Hyperlipidemia
- Gout
- Nephrolithiasis with ureteral stent placements
- Osteonecrosis of bilateral hips, shoulders, knees, status post
surgical interventions
- Left cataract surgery in ___
- Right cataract surgery in ___
- Skin cancer status post surgery in ___
- Basal cell carcinoma in ___
- Left adnexal mass s/p salpingo-oophorectomy.
- Cervical dysplasia
- HyperPTH secondary to renal failure
- Appendectomy
- Endometrial ablation for menorrhagia in ___
Social History:
___
Family History:
Brother ___ had MI, Dad was ___ and had MI.
Sister with FSGS s/p transplant and avascular necrosis.
Uncle with RA.
Physical Exam:
PHYSICAL EXAM ON ADMISSION:
===========================
Vital Signs: 98.3 | 148/93 | 84 | 18 | 99% RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL,
neck supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
GU: No foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
___ edema to shins. Tender erythematous violaceous indurated
area of about 4cm in lower third of right leg.
Neuro: Grossly non-focal
PHYSICAL EXAM ON DISCHARGE:
===========================
Vital Signs: 98.6 120/77 71 16 99% RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL,
neck supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
GU: No foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis.
Trace ___ edema, 2+ DP pulses. Tender erythematous violaceous
indurated area of about 4cm in lower third of right leg.
Neuro: CN II-XII grossly intact. AO x 4.
Pertinent Results:
LABORATORY RESULTS ON ADMISSION:
================================
___ 01:35PM BLOOD WBC-6.9 RBC-3.90 Hgb-10.8* Hct-34.9
MCV-90 MCH-27.7 MCHC-30.9* RDW-14.3 RDWSD-46.5* Plt ___
___ 12:30AM BLOOD Neuts-50.7 ___ Monos-8.4 Eos-2.0
Baso-0.3 Im ___ AbsNeut-3.63 AbsLymp-2.74 AbsMono-0.60
AbsEos-0.14 AbsBaso-0.02
___ 01:35PM BLOOD UreaN-42* Creat-1.6* Na-141 K-3.9 Cl-103
HCO3-23 AnGap-19
___ 12:30AM BLOOD cTropnT-<0.01 proBNP-___*
___ 01:35PM BLOOD Albumin-4.1 Calcium-9.6 Phos-3.3
___ 12:33AM BLOOD Lactate-0.9
PERTINENT INTERVAL LABS:
========================
___ 01:35PM BLOOD rapmycn-4.0*
___ 01:35PM BLOOD tacroFK-3.6*
___ 07:00AM BLOOD tacroFK-5.6
___ 07:00AM BLOOD rapmycn-3.6*
___ 06:00AM BLOOD tacroFK-5.5 rapmycn-3.7*
LABORATORY RESULTS ON DISCHARGE:
================================
___ 06:00AM BLOOD WBC-5.2 RBC-3.83* Hgb-10.5* Hct-34.0
MCV-89 MCH-27.4 MCHC-30.9* RDW-14.3 RDWSD-46.0 Plt ___
___ 06:00AM BLOOD ___ PTT-31.4 ___
___ 12:59PM BLOOD Glucose-113* UreaN-35* Creat-1.8* Na-141
K-4.2 Cl-103 HCO3-27 AnGap-15
___ 06:00AM BLOOD ALT-12 AST-17 AlkPhos-86 TotBili-0.4
___ 12:59PM BLOOD Calcium-9.4 Phos-3.5 Mg-1.9
IMAGING:
========
___ TTE:
---------------
The left atrium is normal in size. Left ventricular wall
thicknesses and cavity size are normal. There is mild regional
left ventricular systolic dysfunction with hypokinesis of the
mid inferolateral and distal inferior walls. The remaining
segments contract normally. Overall left ventricular systolic
function is low normal (LVEF 50-55%). Quantitative (biplane)
LVEF = 51 %. The estimated cardiac index is normal
(>=2.5L/min/m2). Diastolic function could not be assessed. Right
ventricular chamber size and free wall motion are normal. The
aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. The mitral valve leaflets are
structurally normal. There is no mitral valve prolapse. Mild
(1+) mitral regurgitation is seen. There is no pericardial
effusion.
Compared with the prior study (images reviewed) of ___,
the findings are similar.
___ TTE:
--------------
The left atrium is elongated. No atrial septal defect is seen by
2D or color Doppler. Left ventricular wall thicknesses and
cavity size are normal. There is hypokinesis of the distal
inferior and distal septal segments, as well as the true apex.
Right ventricular chamber size and free wall motion are normal.
The diameters of aorta at the sinus, ascending and arch levels
are normal. The aortic valve leaflets (3) appear structurally
normal with good leaflet excursion and no aortic stenosis or
aortic regurgitation. The mitral valve leaflets are structurally
normal. Mild (1+) mitral regurgitation is seen. The estimated
pulmonary artery systolic pressure is normal. There is a very
small pericardial effusion.
IMPRESSION: Normal left ventricular cavity size with regional
wall motion abnormalities, as described above consistent with
single vessel coronary artery disease. Mild mitral
regurgitation. Normal pulmonary artery systolic pressure.
Compared with the prior study (images reviewed) of ___,
the regional wall motion abnormalities and mildly depressed left
ventricular systolic function are new. Of note, the wall motion
abnormalities are best appreciated in the apical views; there
were no apical images performed on the prior study.
___ RENAL TRANSPLANT ULTRASOUND:
Normal renal transplant ultrasound.
___ CHEST X RAY:
No acute cardiopulmonary process.
Brief Hospital Course:
Ms. ___ is a ___ year-old lady with a history of FSG s/p LURT
in ___, CAD presenting with right leg pain and weight gain of
14 lbs over 6 days.
# Edema/ weight gain: BNP was elevated on admission at ___,
however TTE with LVEF 51%, essentially unchanged from ___.
She does have regional wall motion abnormalities with
hypokinesis of the mid inferolateral and distal inferior walls.
Again, these are unchanged from ___ and troponins were negative
x 2. She has knoen CAD (see below). LFTs were within normal
limits. Cr on admission was 1.5, which is her baseline. Renal
transplant ultrasound was without abnormalities. Labs otherwise
only notable for increased protein : creatinine ratio of 0.4
from 0.2. She received diuresis with IV furosemide, with net
negative 2.1 L over stay. She developed ___ with aggressive
diuresis, with Cr peak 1.9. Cr decreased to 1.8 after holding a
dose of furosemide prior to discharge. She was instructed to
hold her home diuretics for 2 days, and restart with 40 mg PO
Lasix BID on ___. She will need her labs checked on ___ as
well.
# S/p LURT: She was continued on home immunosuppression with
tacrolimus 1.5 q12H and sirolimus 1mg q24H. On day of discharge,
tacro trough 5.5 and sirolimus trough 3.7.
# R leg hematoma: Patient developed hematoma after bumping her R
leg on a piece of bar furniture. She is on clopidogrel 75 mg
daily. She failed outpatient vicodin and had been taking PO
dilaudid left over from her breast surgery in ___. She was
provided with 2 mg PO hydromorphone q4H PRN pain, and has been
taking a 2 mg pill every 5 hours. We will provide her with a
script for 2 mg PO hydromorphone q6H PRN pain x 3 days, with
further pain control per PCP. We expect pain from her hematoma
to decrease as he edema resolves.
# CAD: Patient has history of multiple NSTEMIs. Prior studies
show known occlusion of both obtuse marginal arteries on cath
___ PMIBI ___ showed fixed, severe perfusion defect
involving the LCx territory. No active ACS. She was continued on
home metoprolol XL 75mg daily, ASA 81, atorvastatin 80mg qPM,
and clopidogrel 75mg daily. Per outpatient cardiology note
___, there is consideration to stopping her clopidogrel.
# Hyperparathyroidism: continued calcitriol
# DVT/PE: Not on warfarin due to hemarthrosis.
# Depression: Continued citalopram 40 mg daily
# Gout: Continued Febuxostat 120 mg PO DAILY
Transitional issues:
====================
[ ]She should hold home diuretics x 2 days ___
[ ]She should get electrolytes and Creatinine checked on ___
[ ]Plan is to start PO furosemide 40 mg BID on ___
[ ]She should follow up with Dr. ___ on ___
[ ]Can consider ACE-I as outpatient given newly elevated
protein/creatinine ratio
[ ]Script provided for 2 mg PO hydromorphone q6H PRN pain x 3
days for R leg hematoma
[ ]Further pain management per PCP
# CODE: Full
# CONTACT: ___ (SISTER) ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. amLODIPine 5 mg PO DAILY
2. Atorvastatin 80 mg PO QPM
3. Calcitriol 0.5 mcg PO DAILY
4. Citalopram 40 mg PO DAILY
5. Clopidogrel 75 mg PO DAILY
6. Famotidine 20 mg PO DAILY
7. Furosemide 80 mg PO DAILY
8. Febuxostat 120 mg PO DAILY
9. HYDROcodone-Acetaminophen (5mg-325mg) 1 TAB PO Q6H:PRN Pain -
Moderate
10. Metoprolol Succinate XL 75 mg PO DAILY
11. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN cp
12. Sirolimus 1 mg PO DAILY
13. Tacrolimus 1.5 mg PO Q12H
14. Zolpidem Tartrate 10 mg PO QHS:PRN insomnia
15. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Bisacodyl 10 mg PO EVERY OTHER DAY
2. HYDROmorphone (Dilaudid) 2 mg PO Q6H:PRN Pain - Severe
Duration: 3 Days
RX *hydromorphone 2 mg 1 tablet(s) by mouth every 6 hours as
needed for pain Disp #*12 Tablet Refills:*0
3. Polyethylene Glycol 17 g PO DAILY
4. Furosemide 40 mg PO BID
To be started on ___. amLODIPine 5 mg PO DAILY
6. Aspirin 81 mg PO DAILY
7. Atorvastatin 80 mg PO QPM
8. Calcitriol 0.5 mcg PO DAILY
9. Citalopram 40 mg PO DAILY
10. Clopidogrel 75 mg PO DAILY
11. Famotidine 20 mg PO DAILY
12. Febuxostat 120 mg PO DAILY
13. Metoprolol Succinate XL 75 mg PO DAILY
14. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN cp
15. Sirolimus 1 mg PO DAILY
16. Tacrolimus 1.5 mg PO Q12H
17. Zolpidem Tartrate 10 mg PO QHS:PRN insomnia
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnoses
Edema
s/p LURT
R leg hematoma
Secondary Diagnosis:
CAD
Discharge Condition:
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Level of Consciousness: Alert and interactive.
Mental Status: Clear and coherent.
Discharge Instructions:
Dear Ms. ___,
You were admitted to the ___
because you noticed that your weight had increased by 14 lbs
over 6 days.
While you were here, we gave you IV Lasix to try to get rid of
the excess volume. However, your kidney function declined with
the high doses of water pills that we gave you, with increase of
Creatinine from 1.5 to 1.8. We would like you to not take your
home Lasix until ___, and start with 40 mg twice a day on
___. We would also like you to have your labs drawn on ___
___.
We investigated the reason for your weight gain. The ultrasound
of your heart showed that your heart is still pumping as well as
it did in ___, with LVEF of 51% which is in the normal
range. Your liver function tests were normal. Your creatinine on
admission was the same as your baseline.
You also had leg pain after hitting your leg on furniture at a
bar. We gave you some dilaudid while you were with us to help
you with the pain. We provided you a prescription for this
medication for a few more days. Please do not drive while taking
narcotics. Narcotics also cause constipation. If you are not
having regular bowel movements, take stool softeners and/or
laxitives as needed.
It was a pleasure taking care of you.
Sincerely,
Your ___ care team
Followup Instructions:
___
|
19670384-DS-56
| 19,670,384 | 22,898,422 |
DS
| 56 |
2196-03-26 00:00:00
|
2196-03-29 19:49:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Chocolate Flavor / Simvastatin / Allopurinol / Augmentin /
ciprofloxacin / morphine
Attending: ___
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
History of Presenting Illness:
___ yo F with PMH CAD/NSTEMI, FSGN s/p renal txp in ___ (acute
rejection ___, CAD with non-ST elevation myocardial infarction
status post CABG, DVT/PE on Coumadin until ___ (stopped ___
hemarthrosis), TIA and 2 lacunar strokes, HTN, HL presents with
chest pain.
The patient reports that on 6pm on ___ she experienced
sudden onset of inspiratory chest pain and dyspnea. Pain only
with inspiration in right flank/back. Could not lie flat due to
dyspnea, and new dyspnea on exertion. Patient says felt very
similar to prior PE ___ years ago. Does not feel similar to
prior MIs, where she had squeezing sub-sternal chest pain
radiating to arm and jaw.
The patient is not on any estrogens, does not smoke, did take
plane trip to ___ last week. Has not noted any pain or
swelling in extremities.
She originally presented to ___. CXR was obtained
and was unremarkable per report. Due to a mechanical fall last
week with headstrike, the patient had a CT head which was
reportedly negative. Due to high concern for PE, the patient was
started on heparin empirically and subsequently transferred to
___. CTA was not obtained due to concern about renal
transplant.
In our ___, VS were 97.5 70 134/92 16 96% RA
Patient was transferred to the floor, where she reported story
as above. Reported same pleuritic chest pain and difficult
catching breath, with no other symptoms.
Past Medical History:
NEPHROLOGY
- FSGS status post kidney transplant in ___
- Acute transplant rejection that had been treated with OKT3 in
___
- Nephrolithiasis with ureteral stent placements
- HyperPTH secondary to renal failure
CARDIOLOGY
- CAD with h/o NSTEMI
- Hypertension
- Hyperlipidemia
INFECTIOUS DISEASE
- EBV viremia
- History of recurrent C. diff colitis
- Osteonecrosis of bilateral hips, shoulders, knees, status post
surgical interventions
HEMATOLOGY
- DVT/PE on Coumadin until ___ (stopped ___ hemarthrosis)
- TIA and 2 lacunar strokes
SURGERY
- Left cataract surgery in ___
- Right cataract surgery in ___
- Left adnexal mass s/p salpingo-oophorectomy.
- Skin cancer status post surgery in ___
- Basal cell carcinoma in ___
- Appendectomy
RHEUMATOLOGY
- Gout
GYNECOLOGY
- Cervical dysplasia
- Endometrial ablation for menorrhagia in ___
Social History:
___
Family History:
Brother ___ had MI, Dad was ___ and had MI.
Twin sister with FSGS s/p transplant and avascular necrosis and
MIs.
Uncle with RA.
Physical Exam:
ADMISSION EXAM
==============
Vitals: 97.4 PO 152 / 92 89 20 97 ra
GENERAL: Pleasant, well-appearing, in no apparent distress.
HEENT - normocephalic, atraumatic, no conjunctival pallor or
scleral icterus
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: Warm, well-perfused, no cyanosis, clubbing or
edema.
SKIN: Without rash.
NEUROLOGIC: A&Ox3, CN II-XII grossly normal, normal sensation,
with strength ___ throughout.
DISCHARGE EXAM
==============
Vitals: Tmax 98.3 BP 90-120/60-80s HR 60-80s RR ___ O2 95-96%
GENERAL: Pleasant, well-appearing, in no apparent distress.
HEENT - normocephalic, atraumatic, no conjunctival pallor or
scleral icterus
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: Warm, well-perfused, no cyanosis, clubbing or
edema.
SKIN: Without rash.
NEUROLOGIC: A&Ox3, CN II-XII grossly normal, normal sensation,
with strength ___ throughout.
Pertinent Results:
ADMISSION LABS
==============
___ 12:40PM BLOOD WBC-8.0 RBC-4.00 Hgb-11.0* Hct-34.9
MCV-87 MCH-27.5 MCHC-31.5* RDW-14.9 RDWSD-47.8* Plt ___
___ 12:40PM BLOOD ___ PTT-150* ___
___ 12:40PM BLOOD Plt ___
___ 12:40PM BLOOD Glucose-101* UreaN-39* Creat-1.8* Na-139
K-3.4 Cl-99 HCO3-27 AnGap-16
___ 12:40PM BLOOD ALT-9 AST-17 CK(CPK)-57 AlkPhos-94
TotBili-0.4
___ 12:40PM BLOOD Calcium-8.9 Phos-3.7 Mg-1.4*
___ 12:40PM BLOOD tacroFK-11.6 rapmycn-5.9
MICROBIOLOGY
============
___ CULTUREBlood Culture,
Routine-PENDINGINPATIENT
___ CULTUREBlood Culture,
Routine-PENDINGINPATIENT
___ CULTURE-FINALINPATIENT
IMAGING
=======
___ V/Q scan
IMPRESSION: Very low likelihood ratio ratio for new pulmonary
embolism.
___ CXR
IMPRESSION:
No evidence of pneumonia. No pulmonary edema.
___ CTA Chest
IMPRESSION:
1. No evidence of pulmonary embolism or acute aortic
abnormality.
2. Lobulated predominantly fatty appearing tissue seen in
bilateral breasts, can be correlated with prior breast imaging
and/or history of surgery.
DISCHARGE LABS
==============
___ 05:13AM BLOOD WBC-6.4 RBC-3.68* Hgb-10.5* Hct-32.5*
MCV-88 MCH-28.5 MCHC-32.3 RDW-14.8 RDWSD-47.7* Plt ___
___ 05:13AM BLOOD Plt ___
___ 05:13AM BLOOD ___
___ 05:13AM BLOOD Glucose-110* UreaN-35* Creat-2.3* Na-137
K-4.3 Cl-98 HCO3-24 AnGap-19
___ 05:13AM BLOOD Calcium-9.1 Phos-3.9 Mg-1.9
___ 05:13AM BLOOD tacroFK-11.3
Brief Hospital Course:
HOSPITAL COURSE
===============
___ yo F with PMH CAD/NSTEMI, FSGN s/p renal txp in ___ (acute
rejection ___, DVT/PE on Coumadin until ___ (stopped ___
hemarthrosis), TIA and 2 lacunar strokes, HTN, HL presented as
OSH transfer from OSH with chest pain and dyspnea on exertion.
Was empirically started on heparin, but V/Q scan and CTA
negative for PE or dissection. Troponin negative x3 with no EKG
changes. Pain decreased but still present at time of discharge,
patient advised to follow up outpatient with cardiologist for
possible echo or stress test. Creatinine bumped from 1.8 to 2.3
on discharge in setting of CTA; patient to have labs checked
___ or ___ with results followed up by transplant
nephrology.
ACTIVE ISSUES
=============
# Chest pain
Patient presenting with chest pain consistent with previous PE.
Low clinical suspicion for dissection. Patient with history of
MIs but pain not consistent, trops negative x 2, and no EKG
changes. Both V/Q scan and CTA negative for PE, so stopped
empiric heparin gtt on ___. Will f/u with cardiology
outpatient for possible stress test.
# Acute kidney injury
Creatinine 2.3 on ___ from 1.8 day prior, likely in response
to contrast on ___ CTA. 1L NS on ___ to hydrate; patient to
have labs checked ___ or ___ with results followed up by
transplant nephrology.
# ESRD s/p renal transplant: Admission Cr of 1.8 from a baseline
of 1.8-2.0. Patient took double dose of immunosuppression on
___, so pending levels readjusted doses as below.
- Prograf was decreased from 2mg twice a day to 1.5 mg twice a
day based on levels.
- Continued sirolimus 1 mg PO daily
CHRONIC ISSUES
==============
# CHF: Patient w/new CHF last admission (TTE with ejection
fraction 51% and wall motion abnormalities). Continued
furosemide 40 mg daily.
# HTN: Continued home amlodipine.
# CAD with h/o NSTEMI: Continued home metoprolol, ASA,
clopidogrel, atorvastatin.
# GERD: Continued PPI.
# GOUT: Continued febuxostat
TRANSITIONAL ISSUES
===================
[] Prograf was decreased from 2mg twice a day to 1.5 mg twice a
day based on levels.
[] Patient to call cardiologist ___ and make an
appointment in the next few weeks for an echocardiogram or
stress test.
[] Patient to get usual kidney labs checked on ___ or ___
due to Cr 2.3 on discharge, to be followed up by transplant
nephrologist
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Pantoprazole 40 mg PO Q24H
2. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild
3. amLODIPine 5 mg PO DAILY
4. Aspirin 81 mg PO DAILY
5. Atorvastatin 80 mg PO QPM
6. Calcitriol 0.5 mcg PO DAILY
7. Citalopram 40 mg PO DAILY
8. Clopidogrel 75 mg PO DAILY
9. Febuxostat 120 mg PO DAILY
10. Furosemide 40 mg PO DAILY
11. HYDROcodone-Acetaminophen (5mg-325mg) 1 TAB PO Q4H:PRN Pain
- Moderate
12. Metoprolol Succinate XL 75 mg PO DAILY
13. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
14. Ondansetron 4 mg PO Q8H:PRN nausea
15. Sirolimus 1 mg PO DAILY
16. Tacrolimus 2 mg PO Q12H
17. Zolpidem Tartrate 10 mg PO QHS
Discharge Medications:
1. Tacrolimus 1.5 mg PO Q12H
RX *tacrolimus 0.5 mg 1 capsule(s) by mouth Twice a day Disp
#*30 Capsule Refills:*0
2. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild
3. amLODIPine 5 mg PO DAILY
4. Aspirin 81 mg PO DAILY
5. Atorvastatin 80 mg PO QPM
6. Calcitriol 0.5 mcg PO DAILY
7. Citalopram 40 mg PO DAILY
8. Clopidogrel 75 mg PO DAILY
9. Febuxostat 120 mg PO DAILY
10. Furosemide 40 mg PO DAILY
11. HYDROcodone-Acetaminophen (5mg-325mg) 1 TAB PO Q4H:PRN Pain
- Moderate
12. Metoprolol Succinate XL 75 mg PO DAILY
13. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
14. Ondansetron 4 mg PO Q8H:PRN nausea
15. Pantoprazole 40 mg PO Q24H
16. Sirolimus 1 mg PO DAILY
17. Zolpidem Tartrate 10 mg PO QHS
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis
-Atypical chest pain
Secondary diagnosis
- Acute kidney injury
- End stage renal disease status point kidney transplant
- Coronary artery 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 you were having chest
pain and shortness of breath. Our tests for blood clots and
heart attacks were all normal. Your pain improved, and we felt
it was safe to be discharged and follow up with your
cardiologists for a possible echocardiogram or stress test.
Please call your cardiologist and make an appointment in the
next few weeks for an echocardiogram or stress test. Please also
get your standing kidney labs checked on ___ or ___ at
your usual site; they will be forwarded to your kidney doctor.
Your dose of Prograf was decreased from 2mg twice a day to 1.5
mg twice a day based on your blood levels.
It was a privilege to care for you in the hospital, and we wish
you all the best.
Sincerely,
Your ___ Health Team
Followup Instructions:
___
|
19670384-DS-57
| 19,670,384 | 21,564,920 |
DS
| 57 |
2196-04-03 00:00:00
|
2196-04-05 15:07:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Chocolate Flavor / Simvastatin / Allopurinol / Augmentin /
ciprofloxacin / morphine
Attending: ___.
Chief Complaint:
fever
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
___ year old female with history of CAD/NSTEMI, FSGN s/p renal
transplant in ___ (acute rejection in ___, DVT/PE on Coumadin
until ___ stopped secondary to hemarthrosis, TIA with 2 lacunar
strokes, hypertension, hyperlipidemia presenting with nausea,
vomiting, and fever after recent hospitalization at ___ from
___.
Patient notes that since last discharge, her chest pain has
improved, she developed nausea/vomiting since three days prior
to admission with 4 episodes of vomiting on day of presentation
with fever to 102.5F at home. There is no blood within the
vomit. She has developed a mild dry cough. Denies any chest
pain, chest pressure, chest palpitations, shortness of breath,
diarrhea. She denies sore throat, neck stiffness, photophobia,
rash, or new joint pains. Denies any sick contacts at home.
During prior hospitalization, patient had chest discomfort and
was empirically started on heparin gtt but a V/Q scan and CTA
was negative for PE or dissection, with troponin negative x 3,
no EKG changes. During hospitalization, creatinine uptrended to
2.3 in the setting of CTA. Plan was for follow up with
cardiology for possible stress test.
In the ED, initial vitals were: 100.0, 92, 154/88, 18, 98% on
RA.
Labs were notable for CBC with H/H of 10.6/32.8. LFT's notable
for AST 43. Chemistry showed Na 132, magnesium 1.5, phosphorous
2.6, potassium (hemolyzed) was 5.5 but on repeat was 3.9,
creatinine 1.9 (baseline 1.5-2.0). Lactate 2.1. UA performed
which showed negative nitrite, negative leuks, few bactermia.
FluPCR negative.
Renal ultrasound performed which showed "resistive indices of
the intrarenal arteries within normal limits. Main renal artery
shows normal waveform with weak systolic velocity of 97.2
cm/sec. Mild hydronephrosis demonstrated in the upper lobe of
the renal transplant kidney. No perineprhic fluid collection."
Renal transplant consulted who recommended urine culture, blood
culture, CXR, c. difficile, EKG, cycling cardiac markers and IVF
rehydration if was volume depleted.
In the ED: patient ondansetron 4 mg IV x 1, 1L normal saline.
On the floor, she notes a mild frontal headache. She also
acknowledges the dry cough she has experienced.
Of note, she was supposed to be discharged on tacrolimus 1.5 mg
PO Q12H but has continued to take 2 mg PO Q12H.
Review of systems: Please HPI.
Past Medical History:
NEPHROLOGY
- FSGS status post kidney transplant in ___
- Acute transplant rejection that had been treated with OKT3 in
___
- Nephrolithiasis with ureteral stent placements
- HyperPTH secondary to renal failure
CARDIOLOGY
- CAD with h/o NSTEMI
- Hypertension
- Hyperlipidemia
INFECTIOUS DISEASE
- EBV viremia
- History of recurrent C. diff colitis
- Osteonecrosis of bilateral hips, shoulders, knees, status post
surgical interventions
HEMATOLOGY
- DVT/PE on Coumadin until ___ (stopped ___ hemarthrosis)
- TIA and 2 lacunar strokes
SURGERY
- Left cataract surgery in ___
- Right cataract surgery in ___
- Left adnexal mass s/p salpingo-oophorectomy.
- Skin cancer status post surgery in ___
- Basal cell carcinoma in ___
- Appendectomy
RHEUMATOLOGY
- Gout
GYNECOLOGY
- Cervical dysplasia
- Endometrial ablation for menorrhagia in ___
Social History:
___
Family History:
Lives in a 2 family house. Her mother lives upstairs. She has
no
children. She is retired, previoulsy worked as ___ at
___. She uses occasional alcohol. No tobacco or drugs. Has a
twin sister with similar health issues.
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vital Signs: 100.3, 122/78, 92, 16, 94% on RA.
General: Alert, oriented, pleasant affect, laying comfortably
in bed.
HEENT: Sclerae anicteric, dry mucous membranes, oropharynx
clear, EOMI, PERRL, no nuchal rigidity, no elevated JVD.
CV: Regular rate and rhythm, normal S1 + S2, no murmurs.
Lungs: Clear to auscultation bilaterally, no wheezes, rales or
rhonchi.
Abdomen: soft, non-tender, non-distended, no rebound or
guarding, normoactive bowel sounds, transplanted kidney in right
lower quadrant is non-tender to palpation.
Ext: Warm, well perfused, no lower extremity edema.
Neuro: CNII-XII intact, ___ strength upper/lower extremities.
SKIN: warm but no rashes appreciated.
DISCHARGE PHYSICAL EXAM:
Vital Signs: 98.0 117 / 75 61 18 95 RA
General: Alert, oriented, lying comfortably in bed.
HEENT: Sclerae anicteric, oropharynx clear, EOMI, PERRL
CV: Regular rate and rhythm, normal S1 + S2, no murmurs.
Lungs: Clear to auscultation bilaterally, no wheezes, rales or
rhonchi.
Abdomen: soft, non-tender, non-distended, no rebound or
guarding, normoactive bowel sounds, transplanted kidney in right
lower quadrant is non-tender to palpation.
Ext: Warm, well perfused, no lower extremity edema.
Neuro: CNII-XII grossly intact, ___ strength upper/lower
extremities.
Pertinent Results:
ADMISSION LABS:
___ 10:30PM WBC-7.4 RBC-3.84* HGB-10.6* HCT-32.8* MCV-85
MCH-27.6 MCHC-32.3 RDW-15.0 RDWSD-46.3
___ 10:30PM NEUTS-68.3 LYMPHS-17.8* MONOS-12.9 EOS-0.3*
BASOS-0.3 IM ___ AbsNeut-5.03 AbsLymp-1.31 AbsMono-0.95*
AbsEos-0.02* AbsBaso-0.02
___ 10:30PM ___ PTT-30.5 ___
___ 10:30PM PLT COUNT-304
___ 10:30PM ALBUMIN-3.7 CALCIUM-9.0 PHOSPHATE-2.6*
MAGNESIUM-1.5*
___ 10:30PM cTropnT-<0.01
___ 10:30PM LIPASE-31
___ 10:30PM ALT(SGPT)-13 AST(SGOT)-43* ALK PHOS-79 TOT
BILI-0.5
___ 10:30PM GLUCOSE-149* UREA N-20 CREAT-1.9* SODIUM-132*
POTASSIUM-5.5* CHLORIDE-95* TOTAL CO2-21* ANION GAP-22*
___ 10:47PM LACTATE-2.1* K+-3.9
___: Renal Transplant Ultrasound:
IMPRESSION:
1. Resistive indices of the intrarenal arteries are within
normal range.
2. Main renal artery shows normal waveform with peak systolic
velocity of 97.2 cm/sec.
3. Mild hydronephrosis demonstrated in the upper pole of the
renal transplant kidney.
4. No perinephric fluid collection.
CXR ___: CXR
Compared to chest radiographs since ___, most
recently ___ and ___.
Progressive peribronchial opacification at the right lung base
compared to
___ is new from ___, probably pneumonia. Heart
size
top-normal. Left lung clear. No pulmonary edema or pleural
effusion.
DISCHARGE LABS:
___ 05:14AM BLOOD WBC-5.5 RBC-3.14* Hgb-8.5* Hct-27.0*
MCV-86 MCH-27.1 MCHC-31.5* RDW-14.6 RDWSD-45.9 Plt ___
___ 05:14AM BLOOD Plt ___
___ 04:50AM BLOOD Glucose-98 UreaN-18 Creat-1.6* Na-140
K-4.0 Cl-103 HCO3-23 AnGap-18
___ 05:36AM BLOOD ALT-12 AST-18 LD(LDH)-173 AlkPhos-77
TotBili-0.2
___ 04:50AM BLOOD Calcium-8.9 Phos-3.6 Mg-1.8
Brief Hospital Course:
Patient is a ___ year old female with history of CAD/NSTEMI, FSGN
s/p renal transplant in ___ (acute rejection in ___, DVT/PE
on Coumadin until ___ stopped secondary to hemarthrosis, TIA
with 2 lacunar strokes, hypertension, hyperlipidemia presenting
with nausea, vomiting, and fever after recent hospitalization at
___ from ___. Her respiratory viral panel
returned positive for + parainfluenza. CXR was significant for a
right sided pneumonia. She was initiated on CAP treatment with
ceftriaxone and azithromycin.
# Community acquired pneumonia
# Parainfluenza
# Fever in immunosuppressed individual: T to 102.5 at home.
Patient with cough. Also experiencing nausea and vomiting, and
diarrhea in hospital. CXR with subtle RLL opacity that evolved
to more obvious consolidation on ___ CXR. Positive for
parainfluenza 2 with likely bacterial superinfection. She was
treated cefpodoxime/azithromycin for a total of five days.
# Headache: Patient reported headaches in the setting of acute
illness as able. Neck was supple and without meningismus. She
was treated with oxycodone 5 mg q 6 hr and provided with a short
course upon discharge.
CHRONIC ISSUES
==============
# ESRD s/p renal transplant: s/p transplant in ___, acute
rejection in ___. Creatinine 1.9 on admission. Baseline
1.5-2.0. Patient was supposed to be on tacrolimus 1.5 mg PO BID
since most recent discharge but she states she has been taking
2.0 mg PO BID. She was again downtitrated to 1.5 mg BID and
continued on sirolimus 1 mg daily. She was continued on
calcitriol 0.5 mg PO daily.
# HFpEF: Patient with CHF on prior admission (TTE ___ with EF
of 50% and hypokinesis of the mid inferolateral and distal
inferior segments). Her home furosemide was held in the setting
of acute illness and restarted upon discharge.
# CAD with history of NSTEMI: No current chest pain. trop x 1
negative. She was continued on metoprolol succinate, aspirin,
clopidogrel, atorvastatin.
# Hypertension: Home amlodipine was subsequently and
subsequently restarted on ___
# GERD:
- continue pantoprazole 40 mg PO Q24H.
# Gout:
- continue febuxostat 120 mg PO daily.
TRANSITIONAL Issues:
- Continue cefpodoxime/azithromycin for a total of a five day
course (D1 ___- D5 ___
- QTc 480 on day of discharge. Please do f/u EKG after
antibiotic course finished.
- Patient noted to have elevated EBV to 1206 during this
admission; thought to be secondary to acute illness; please
recheck EBV viral load and monitor in conjunction with her renal
transplant doctors
- Prograf was decreased from 2mg twice a day to 1.5 mg twice a
day based on levels
- Patient with persistent headaches in the setting of acute
illness, nonresponsive to tramadol, responsive to oxycodone;
will provide a short script of oxycodone post-discharge
- Please consider outpatient stress test once pneumonia has
resolved given patient's initial complaint of chest pain
- Blood cultures pending at the time of discharge
- CTA from ___ showed "lobulated predominantly fatty appearing
tissue seen in bilateral breasts can be correlated with prior
breast imaging and/or history of surgery," further workup
deferred to the outpatient setting
# CONTACT INFORMATION: ___ (sister): ___.
# CODE STATUS: Full Code (confirmed)
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild
2. amLODIPine 5 mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. Atorvastatin 80 mg PO QPM
5. Calcitriol 0.5 mcg PO DAILY
6. Citalopram 40 mg PO DAILY
7. Clopidogrel 75 mg PO DAILY
8. Febuxostat 120 mg PO DAILY
9. Metoprolol Succinate XL 75 mg PO DAILY
10. Pantoprazole 40 mg PO Q24H
11. Sirolimus 1 mg PO DAILY
12. Tacrolimus 2 mg PO Q12H
13. Zolpidem Tartrate 10 mg PO QHS
14. Furosemide 40 mg PO DAILY
15. HYDROcodone-Acetaminophen (5mg-325mg) 1 TAB PO Q4H:PRN Pain
- Moderate
16. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
17. Ondansetron 4 mg PO Q8H:PRN nausea
Discharge Medications:
1. Azithromycin 250 mg PO Q24H
RX *azithromycin 250 mg 1 tablet(s) by mouth q24hr Disp #*1
Tablet Refills:*0
2. Cefpodoxime Proxetil 400 mg PO Q12H
RX *cefpodoxime 200 mg 2 tablets by mouth q12 hr Disp #*6 Tablet
Refills:*0
3. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain - Severe
RX *oxycodone 5 mg 1 capsule(s) by mouth q8hr Disp #*30 Capsule
Refills:*0
4. Tacrolimus 1.5 mg PO Q12H
RX *tacrolimus [Prograf] 0.5 mg 1 capsule(s) by mouth q12 hours
Disp #*60 Capsule Refills:*1
RX *tacrolimus [Prograf] 1 mg 1 capsule(s) by mouth q12 hr Disp
#*60 Capsule Refills:*1
5. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild
Do not take additional Tylenol once ___ resume your home
acetaminophen-hydromorphone.
6. amLODIPine 5 mg PO DAILY
7. Aspirin 81 mg PO DAILY
8. Atorvastatin 80 mg PO QPM
9. Calcitriol 0.5 mcg PO DAILY
10. Citalopram 40 mg PO DAILY
11. Clopidogrel 75 mg PO DAILY
12. Febuxostat 120 mg PO DAILY
13. Furosemide 40 mg PO DAILY
14. Metoprolol Succinate XL 75 mg PO DAILY
15. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
16. Ondansetron 4 mg PO Q8H:PRN nausea
17. Pantoprazole 40 mg PO Q24H
18. Sirolimus 1 mg PO DAILY
19. Zolpidem Tartrate 10 mg PO QHS
20. HELD- HYDROcodone-Acetaminophen (5mg-325mg) 1 TAB PO Q4H:PRN
Pain - Moderate This medication was held. Do not restart
HYDROcodone-Acetaminophen (5mg-325mg) until ___ STOP taking
oxycodone and ___ speak with your other providers
___:
Home
Discharge Diagnosis:
Primary:
Parainfluenza
Community Acquired Pneumonia
Secondary:
Gastroenteritis
FSGN s/p renal transplant
History of DVT/PE
History of TIA
Hypertension
Hyperlipidemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking care of ___ at ___.
___ came back to the hospital because ___ were experiencing
fevers, nausea, vomiting, and diarrhea. We tested ___ for
norovirus and influenza (flu) which came back negative. ___ did
test positive for parainfluenza, which is a respiratory virus.
Your chest xray showed a right sided pnuemonia, so we treated
___ with antibiotics. We gave ___ some IV fluids to help prevent
dehydration. Overall, your symptoms improved and we feel it is
safe for ___ to go home at this time.
During this hospitalization, ___ had severe headaches which
required treatment with a narcotic medication called oxycodone.
We are discharging ___ with a very short supply of medications
to treat your headaches. We expect your headaches to improve
after treatment of your infection. Do not take ANY other
narcotic medications including tramadol, hydromorphone, or
codeine at this time. ___ do not have to fill the entire script
if ___ feel that ___ do not require these medications to manage
your pain. Please speak to your primary care doctors about your
___ control moving forward.
We also changed your tacrolimus dose and have provided ___ with
a new prescription. ___ should take 1.5 mg of tacrolimus twice a
day. Please talk to your renal transplant doctors about when ___
should have your tacrolimus level checked.
Sincerely,
Your ___ Team
Followup Instructions:
___
|
19670384-DS-58
| 19,670,384 | 23,212,563 |
DS
| 58 |
2196-05-05 00:00:00
|
2196-05-13 16:08:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Chocolate Flavor / Simvastatin / Allopurinol / Augmentin /
ciprofloxacin / morphine
Attending: ___.
Chief Complaint:
Chest pressure
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old woman with history of CAD/NSTEMI, FSGN s/p renal
transplant in ___ (acute rejection in ___, DVT/PE on Coumadin
until ___ stopped secondary to hemarthrosis, TIA with 2 lacunar
strokes, hypertension, hyperlipidemia presenting with substernal
chest pressure identical to prior NSTEMI.
She reports that she awoke from sleep with sudden onset chest
pressure. Took 2 SL NG with no relief. Got another 1 SL NG and
aspirin on the way in ambulance with no relief. During this time
she reports being unable to catch a full breath, but denies
shortness of breath per se. No cough, fevers/chills,
nausea/vomiting. Patient received 324 aspirin PO and x3 nitro
prior to arrival.
Recently admitted for chest pain which turned out to be
pneumonia, no cardiac issues at that time. Since this
hospitalization and prior to the current episode the patient had
no chest discomfort or respiratory symptoms, and felt in her
normal state of health.
In the ED initial vitals were: 8 98.7 77 122/79 16 98% RA
EKG: NSR at 68 bpm, LAD, NI, no ST/TW changes
Exam: Discomfort from pain. RRR no m/r/g, CTAB
Labs/studies notable for: Trop-T <0.01; 140/3.2/100/___/2.0
- CXR (___): No radiographic evidence of an acute
cardiopulmonary abnormality.
Patient was given:
___ 04:18 SL Nitroglycerin SL .3 mg
___ 04:25 SL Nitroglycerin SL .3 mg
___ 04:37 IV Fentanyl Citrate 50 mcg
___ 05:42 IV Fentanyl Citrate 50 mcg
___ 05:42 PO Potassium Chloride 40 mEq
___ 06:33 IV Heparin 4000 UNIT
___ 06:33 IV Heparin
___ 06:37 IV DRIP Nitroglycerin (0.35-3.5 mcg/kg/min
ordered)
___ 07:02 IV DRIP Nitroglycerin
Vitals on transfer: 6 62 98/55 18 97% RA
On the floor she continues to have pain, mostly unchanged from
when the episode began. It is worse with
REVIEW OF SYSTEMS: 10-point ROS otherwise negative.
Past Medical History:
NEPHROLOGY
- FSGS status post kidney transplant in ___
- Acute transplant rejection that had been treated with OKT3 in
___
- Nephrolithiasis with ureteral stent placements
- HyperPTH secondary to renal failure
CARDIOLOGY
- CAD with h/o NSTEMI
- Hypertension
- Hyperlipidemia
INFECTIOUS DISEASE
- EBV viremia
- History of recurrent C. diff colitis
- Osteonecrosis of bilateral hips, shoulders, knees, status post
surgical interventions
HEMATOLOGY
- DVT/PE on Coumadin until ___ (stopped ___ hemarthrosis)
- TIA and 2 lacunar strokes
SURGERY
- Left cataract surgery in ___
- Right cataract surgery in ___
- Left adnexal mass s/p salpingo-oophorectomy.
- Skin cancer status post surgery in ___
- Basal cell carcinoma in ___
- Appendectomy
RHEUMATOLOGY
- Gout
GYNECOLOGY
- Cervical dysplasia
- Endometrial ablation for menorrhagia in ___
Social History:
___
Family History:
Lives in a 2 family house. Her mother lives upstairs. She has
no
children. She is retired, previoulsy worked as ___ at
___. She uses occasional alcohol. No tobacco or drugs. Has a
twin sister with similar health issues.
Physical Exam:
====================
ADMISSION EXAM
====================
VS: Afebrile, BP 117/71, HR 60, RR 16, O2sat 96% RA
GENERAL: Lying comfortably in bed, mildly anxious, NAD, speaking
in full sentences
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva pink.
NECK: Supple without elevated JVP
CARDIAC: RRR, no m/r/g, no murmurs, gallops or rubs
LUNGS: No chest wall deformities, scoliosis or kyphosis. CTAB
without increased work of breathing, no wheezes or crackles.
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: No ___ edema
PULSES: Distal pulses palpable and symmetric
====================
DISCHARGE EXAM
====================
VS: 97.8-98.5F, bp 135/80 (116-149/76-85), HR56-66, RR18-20,
O2sat 96-98% on RA
Weight: 65.8kg standing weight (66.5kg on ___
I/O: ___ (8h), 1200/1700 (24h)
GENERAL: Awake, alert, in no acute distress, resting comfortably
in bed
HEENT: NC/AT, PERRLA, clear conjunctiva b/l, MMM
Mouth - Hard palate with 4 punctated lesions, vesicular in
appearance? with dry crusted erythema, no active bleeding,
non-tender
NECK: Supple without elevated JVP
CARDIAC: RRR, S1, S2, no murmurs, rubs, or gallops
LUNGS: CTAB, good aeration throughout, no wheezes or crackles
ABDOMEN: Soft, non-distended, +BS, non-tender to palpation in
all four quadrant
EXTREMITIES: 2+ pulses, warm, no edema
PULSES: Distal pulses palpable and symmetric
Pertinent Results:
================
ADMISSION LABS
================
___ 04:14AM BLOOD WBC-8.8 RBC-4.04 Hgb-10.7* Hct-34.3
MCV-85 MCH-26.5 MCHC-31.2* RDW-14.6 RDWSD-44.5 Plt ___
___ 04:14AM BLOOD Neuts-48.9 ___ Monos-8.6 Eos-3.2
Baso-0.6 Im ___ AbsNeut-4.28 AbsLymp-3.37 AbsMono-0.75
AbsEos-0.28 AbsBaso-0.05
___ 04:14AM BLOOD Plt ___
___ 09:59AM BLOOD ___ PTT-28.0 ___
___ 04:14AM BLOOD Glucose-124* UreaN-32* Creat-2.0* Na-140
K-3.2* Cl-100 HCO3-22 AnGap-21*
___ 04:14AM BLOOD cTropnT-<0.01
___ 08:00AM BLOOD cTropnT-<0.01
___ 04:14AM BLOOD CRP-14.6*
========
LABS
========
___ 08:00AM BLOOD cTropnT-<0.01
___ 04:14AM BLOOD cTropnT-<0.01
==============
MICROBIOLOGY
==============
None
==============
IMAGING
==============
CXR (___):
No radiographic evidence of an acute cardiopulmonary
abnormality.
Bilateral ___ U/S (___):
No evidence of deep venous thrombosis in the right or left lower
extremity
veins.
V/Q scan (___):
IMPRESSION: Normal ventilation and perfusion without
significant defect. No evidence of pulmonary embolus.
TTE (___):
The left atrial volume index is normal. Mild symmetric left
ventricular wall thicknesses with normal cavity sizel. There is
mild regional left ventricular systolic dysfunction with
hypokinesis of the inferolateral wall. The remaining segments
contract normally (biplane LVEF = 43 %). There is no ventricular
septal defect. Right ventricular chamber size and free wall
motion are normal. The diameters of aorta at the sinus,
ascending and arch levels are normal. The aortic valve leaflets
(3) are mildly thickened but aortic stenosis is not present. No
aortic regurgitation is seen. The mitral valve appears
structurally normal with trivial mitral regurgitation. The
pulmonary artery systolic pressure could not be quantified.
There is no pericardial effusion.
IMPRESSION: Normal left ventricular cavity size with regional
systolic dysfunction most c/w CAD.No valvular pathology or
pathologic flow identified.
Compared with the prior study (images reviewed) of ___,
the findings are similar.
ECG (___):
Sinus rhythm. Compared to the previous tracing of ___ no
change.
Intervals Axes
Rate PR QRS QT QTc (___)
59 ___ 476/474
=================
DISCHARGE LABS
=================
___ 06:45AM BLOOD WBC-10.1* RBC-3.75* Hgb-10.1* Hct-32.0*
MCV-85 MCH-26.9 MCHC-31.6* RDW-14.7 RDWSD-45.5 Plt ___
___ 06:45AM BLOOD Plt ___
___ 06:45AM BLOOD ___ PTT-25.0 ___
___ 06:45AM BLOOD Glucose-157* UreaN-52* Creat-2.5* Na-145
K-3.6 Cl-102 HCO3-19* AnGap-28*
___ 06:45AM BLOOD Calcium-9.8 Phos-3.3 Mg-1.8
___ 06:45AM BLOOD tacroFK-5.6 rapmycn-4.9*
Brief Hospital Course:
Ms. ___ is a ___ y/o woman with history of CAD/NSTEMI, FSGN s/p
renal transplant in ___ (acute rejection in ___, DVT/PE on
Coumadin until ___ stopped secondary to hemarthrosis, TIA with
2 lacunar strokes, hypertension, hyperlipidemia, recent hospital
admission for pneumonia who presented with substernal chest
pressure that worsened with deep inspiration. Troponins were
negative, and she had no ischemic changes on ECG. V/Q scan was
negative for PE and LENIs were negative for DVTs, and TTE was
without evidence of right heart strain, so her heparin gtt was
discontinued. Her chest pain was attributed to post-viral
pericarditis with recent hospitalization in ___ for
parainfluenza, however no evidence on ECG of pericarditis. Given
the patient's renal disease, she was started on prednisone for
treatment of her pericarditis with a slow taper and resolution
of her pain.
TRANSITIONAL ISSUES:
- Discharge weight= 65.8 kg
- Discharge Cr= 2.5
NEW MEDICATIONS
- Started on prednisone 20 mg for post-viral pericarditis (___) with taper as follows:
-- ___ - ___ Prednisone 20 mg daily
-- ___ Prednisone 15 mg daily
-- ___ - ___ Prednisone 10 mg daily
-- ___ - ___ Prednisone 5 mg daily
-- ___ - ___ Prednisone 2.5 mg daily
-- ___ Prednisone 2.5 mg ever other day
- Held: Amlodipine due to ___ and ___ BP control (SBP 130-140s)
- Discontinued Zolpidem and started on Trazodone for insomnia
- Repeat chem 7 on ___ given ___
- Patient will need a new cardiologist (prior cardiologist Dr.
___ has left current practice), she is set up to see NP on
___.
CODE STATUS: Full Code
CONTACT: ___ (sister): ___.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 80 mg PO QPM
4. Calcitriol 0.5 mcg PO DAILY
5. Citalopram 40 mg PO DAILY
6. Clopidogrel 75 mg PO DAILY
7. Febuxostat 120 mg PO DAILY
8. Pantoprazole 40 mg PO Q24H
9. Sirolimus 1 mg PO DAILY
10. Furosemide 40 mg PO DAILY
11. Metoprolol Succinate XL 75 mg PO DAILY
12. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
13. Ondansetron 4 mg PO Q8H:PRN nausea
14. Zolpidem Tartrate 10 mg PO QHS
15. amLODIPine 5 mg PO DAILY
16. HYDROcodone-Acetaminophen (5mg-325mg) 1 TAB PO Q4H:PRN Pain
- Moderate
17. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain - Severe
18. Tacrolimus 1 mg PO Q12H
Discharge Medications:
1. PredniSONE 15 mg PO DAILY Duration: 5 Doses
This is dose # 2 of 5 tapered doses
RX *prednisone 5 mg ___ tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
2. PredniSONE 10 mg PO DAILY Duration: 5 Doses
This is dose # 3 of 5 tapered doses
3. PredniSONE 5 mg PO DAILY Duration: 5 Doses
This is dose # 4 of 5 tapered doses
4. PredniSONE 2.5 mg PO DAILY Duration: 5 Doses
This is dose # 5 of 5 tapered doses
RX *prednisone 2.5 mg 1 tablet(s) by mouth daily Disp #*10
Tablet Refills:*0
5. TraZODone 25 mg PO QHS:PRN Insomnia
RX *trazodone 50 mg 0.5 (One half) tablet(s) by mouth qhs PRN
Disp #*15 Tablet Refills:*0
6. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild
7. Aspirin 81 mg PO DAILY
8. Atorvastatin 80 mg PO QPM
9. Calcitriol 0.5 mcg PO DAILY
10. Citalopram 40 mg PO DAILY
11. Clopidogrel 75 mg PO DAILY
12. Febuxostat 120 mg PO DAILY
13. Furosemide 40 mg PO DAILY
14. Metoprolol Succinate XL 75 mg PO DAILY
15. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
16. Ondansetron 4 mg PO Q8H:PRN nausea
17. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain - Severe
18. Pantoprazole 40 mg PO Q24H
19. Sirolimus 1 mg PO DAILY
20. Tacrolimus 1 mg PO Q12H
21. HELD- amLODIPine 5 mg PO DAILY This medication was held. Do
not restart amLODIPine until patient sees PCP (primary care
doctor).
22. HELD- HYDROcodone-Acetaminophen (5mg-325mg) 1 TAB PO Q4H:PRN
Pain - Moderate This medication was held. Do not restart
HYDROcodone-Acetaminophen (5mg-325mg) until speaking with your
primary care physician
23. HELD- Zolpidem Tartrate 10 mg PO QHS This medication was
held. Do not restart Zolpidem Tartrate until speaking with your
primary care physician
24.Outpatient Lab Work
Chem 7 on ___
ICD 10 N17.9
Please fax results to Name: ___ MD
Fax: ___
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY:
- Pericarditis
SECONDARY:
- End stage renal disease s/p renal transplant
- Diastolic heart failure
- Hypertension
- Depression
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking care of you. You came to the hospital
because you were having chest pain. Fortunately, we found that
you did not have a heart attack. We think that your chest pain
was caused by inflammation of the sac surrounding the heart
(pericarditis). We gave you steroids and your pain improved.
Please continue your steroids (prednisone) as below:
-- ___ - ___ Prednisone 20 mg daily
-- ___ Prednisone 15 mg daily
-- ___ - ___ Prednisone 10 mg daily
-- ___ - ___ Prednisone 5 mg daily
-- ___ - ___ Prednisone 2.5 mg daily
-- ___ Prednisone 2.5 mg ever other day
We wish you the best of health.
Sincerely,
Your ___ Team
Followup Instructions:
___
|
19670770-DS-15
| 19,670,770 | 25,599,811 |
DS
| 15 |
2160-10-07 00:00:00
|
2160-10-07 15:25:00
|
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: CARDIOTHORACIC
Allergies:
Penicillins / codeine / Demerol / morphine
Attending: ___.
Chief Complaint:
chest tube pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ s/p left lower lobe superior segmentectomy and MLND for
nodule that was concerning for malignancy(pathology pending).
She
had a persistent air leak after surgery and so was discharged
home with pneumostat in place on ___. She was doing ok at home
but on ___, she started having increased SOB despite using her
albuterol inhaler so she called Thoracic Surgery and was
instructed to fill a prescription for albuterol nebulizer. This
helped with her shortness of breath significantly but yesterday
evening, while her daughter was draining her pneumostat, she
developed worsening SOB and chest pain with improvement after
draining was stopped. This morning she developed worsening chest
pain and SOB after her daughter again attempted to drain it so
she decided to come to the ED. She denies any fevers, chills,
nausea or vomiting. No abdominal pain.
In the ED, sats were 91% on RA and improved to 95% on 2L nasal
cannula.
Past Medical History:
asthma
COPD
HLD
HTN
h/o pulmonary abcess LUL ___, resolved
s/p open CCY and lap hysterectomy
Social History:
___
Family History:
Mother CAD, multiple myeloma
Father CVA
___ sister with breast cancer
Offspring healthy
Other
Physical Exam:
Temp: 98.8 HR: 90 BP: 118/74 RR: 22 O2 Sat: 96% NC
GENERAL
[x] WN/WD [x] NAD [x] AAO [ ] abnormal findings:
HEENT
[x] NC/AT [x] EOMI [x] PERRL/A [x] Anicteric
[x] OP/NP mucosa normal [x] Tongue midline
[x] Palate symmetric [x] Neck supple/NT/without mass
[x] Trachea midline [x] Thyroid nl size/contour
[ ] Abnormal findings:
RESPIRATORY
[x] CTA/P [x] Excursion normal [x] No fremitus
[x] No egophony [x] No spine/CVAT
[ ] Abnormal findings:
CARDIOVASCULAR
[x] RRR [x] No m/r/g [x] No JVD [x] PMI nl [x] No edema
[x] Peripheral pulses nl [x] No abd/carotid bruit
[ ] Abnormal findings:
GI
[x] Soft [x] NT [x] ND [x] No mass/HSM [x] No hernia
[ ] Abnormal findings:
GU [x] Deferred
[ ] Nl genitalia [ ] Nl pelvic/testicular exam [ ] Nl DRE
[ ] Abnormal findings:
NEURO
[x] Strength intact/symmetric [x] Sensation intact/ symmetric
[x] Reflexes nl [x] No facial asymmetry [x] Cognition intact
[x] Cranial nerves intact [ ] Abnormal findings:
MS
[x] No clubbing [x] No cyanosis [x] No edema [x] Gait nl
[x] No tenderness [x] Tone/align/ROM nl [x] Palpation nl
[x] Nails nl [ ] Abnormal findings:
LYMPH NODES
[x] Cervical nl [x] Supraclavicular nl [x] Axillary nl
[x] Inguinal nl [ ] Abnormal findings:
SKIN
[x] No rashes/lesions/ulcers
[x] No induration/nodules/tightening [ ] Abnormal findings:
PSYCHIATRIC
[x] Nl judgment/insight [x] Nl memory [x] Nl mood/affect
[ ] Abnormal findings:
Pertinent Results:
___ 12:40PM WBC-7.9 RBC-4.28 HGB-12.4 HCT-37.5 MCV-88
MCH-29.0 MCHC-33.1 RDW-13.1 RDWSD-41.7
___ 12:40PM NEUTS-68.7 ___ MONOS-9.1 EOS-1.6
BASOS-0.5 IM ___ AbsNeut-5.41# AbsLymp-1.55 AbsMono-0.72
AbsEos-0.13 AbsBaso-0.04
___ 12:40PM PLT COUNT-249
___ 12:40PM GLUCOSE-119* UREA N-13 CREAT-0.5 SODIUM-133
POTASSIUM-4.5 CHLORIDE-96 TOTAL CO2-25 ANION GAP-17
___ CXR :
Left lower lobe atelectasis and small left pleural effusion. No
pneumothorax
___ CXR :
Tiny left apical pneumothorax status post left chest tube
removal
___ CXR :
In comparison to ___ chest radiograph, a tiny left
apical
pneumothorax has decreased in size, and additional small
loculated
pneumothoraces in the retrosternal and left basilar regions are
not
appreciably changed. Persistent left retrocardiac atelectasis
with otherwise clear lungs. Small left pleural effusion is
unchanged.
Brief Hospital Course:
Mrs. ___ in the Emergency Room by the Thoracic
Surgery service and admitted to the hospital for further
management. As her initial chest xray showed a fully expanded
left lung and there was no air leak from her pneumostat, the
tube was removed. Her post pull chest xray revealed a very tiny
left apical space. Her room air saturations were 94% and her
pain was much less post tube removal.
She remained hospitalized overnight and a repeat chest xray was
done on ___ which showed a stable left apical space. She
was up and walking and was much more comfortable. Her port sites
were healing well. As her chest xray was stable, she was
discharged to home on ___ and will follow up with Dr. ___
in 2 weeks.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Valsartan 160 mg PO DAILY
2. Tiotropium Bromide 1 CAP IH DAILY
3. Amlodipine 2.5 mg PO DAILY
4. Simvastatin 20 mg PO QPM
5. Fluticasone Propionate 110mcg 1 PUFF IH BID
6. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600
mg(1,500mg) -400 unit oral BID
7. Potassium Chloride 10 mEq PO Q48H
8. albuterol sulfate 2.5 mg /3 mL (0.083 %) inhalation Q4H:PRN
SOB
9. albuterol sulfate 90 mcg/actuation inhalation Q6H:PRN
wheezing
10. Chlorthalidone 25 mg PO EVERY OTHER DAY
11. Vitamin D 3000 UNIT PO DAILY
Discharge Medications:
1. Amlodipine 2.5 mg PO DAILY
2. Chlorthalidone 25 mg PO EVERY OTHER DAY
3. Fluticasone Propionate 110mcg 1 PUFF IH BID
4. Simvastatin 20 mg PO QPM
5. Tiotropium Bromide 1 CAP IH DAILY
6. Valsartan 160 mg PO DAILY
7. Acetaminophen 1000 mg PO Q8H:PRN pain
8. Docusate Sodium 100 mg PO BID
9. Milk of Magnesia 30 mL PO Q6H:PRN constipation
10. Senna 8.6 mg PO BID:PRN constipation
11. TraMADOL (Ultram) 50 mg PO Q4H:PRN pain
12. albuterol sulfate 2.5 mg /3 mL (0.083 %) inhalation Q4H:PRN
SOB
13. albuterol sulfate 90 mcg/actuation INHALATION Q6H:PRN
wheezing
14. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600
mg(1,500mg) -400 unit oral BID
15. Potassium Chloride 10 mEq PO Q48H
Hold for K >
16. Vitamin D 3000 UNIT PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Left pneumothorax resolved
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 pain and shortness of
breath related to draining the pneumostat. Your chest xray
showed full expansion and the leak resolved therefore the tube
was removed and serial chest xrays are stable. You are now ready
for discharge home.
* Continue to use your incentive spirometer 10 times an hour
while awake.
* Check your incisions daily and report any increased redness or
drainage. Cover the area with a gauze pad if it is draining.
* Your chest tube dressing may be removed in 48 hours. If it
starts to drain, cover it with a clean dry dressing and change
it as needed to keep site clean and dry.
* 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 ___ mg every 8 hours 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
* No tub bathing, swimming or hot tubs until incision healed
* No lotions or creams to incision site
* Walk ___ times a day and gradually increase your activity as
you can tolerate.
Call Dr. ___ ___ if you experience:
-Fevers > 101 or chills
-Increased shortness of breath, chest pain or any other
symptoms that concern you.
Followup Instructions:
___
|
19671034-DS-8
| 19,671,034 | 22,655,398 |
DS
| 8 |
2187-01-30 00:00:00
|
2187-01-30 16:33:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: PLASTIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
right breast cellulitis
Major Surgical or Invasive Procedure:
___
US-guided aspiration of the right breast fluid
History of Present Illness:
___ h/o breast cancer s/p SM with expander to implant recon ___
___ c/b capsular contracture so now three weeks s/p bilateral
implant exchange, capsulotomies and fat grafting of the breasts
to improve contour ___ ___. Post-op period uneventful
until 3 days ago (___) she noticed redness on the lateral
and inferior right breast accompanied by moderate localized
tenderness prompting presentation to Dr. ___. An U/S was done
at that time revealing no underlying collection ___ the right
breast; as such she was started on Augmentin as an outpatient
with instruction to observe it closely. However, she began
spiking fevers over the next ___ (Tmax 103.9 per patient)
accompanied by chills. Her breast erythema remained stable but
she had no other systemic signs of infection. She called Dr.
___ ___ who told her to immediately report to the ED.
Past Medical History:
Breast cancer
Social History:
___
Family History:
Noncontributory
Physical Exam:
Focused Physical Exam:
Vitals: 99.2, 101, 99/58, 18 (99% on RA)
Breasts: Incisions healing well bilaterally. Patchy Erythema
seen on right breast extending along the inferolateral ___ of
the right breast as well as all along the lateral right breast
and down the right flank (area outlined with a marker). Of note,
no induration, drainage or underlying fluctuance detected. Exam
otherwise benign.
Pertinent Results:
___ 09:59PM LACTATE-1.3
___ 09:53PM GLUCOSE-142* UREA N-6 CREAT-0.6 SODIUM-136
POTASSIUM-3.5 CHLORIDE-98 TOTAL CO2-25 ANION GAP-17
___ 09:53PM estGFR-Using this
___ 09:53PM WBC-18.9* RBC-3.15* HGB-9.5* HCT-29.4* MCV-93
MCH-30.2 MCHC-32.3 RDW-13.4 RDWSD-45.6
___ 09:53PM NEUTS-83.8* LYMPHS-10.7* MONOS-3.5* EOS-0.7*
BASOS-0.2 IM ___ AbsNeut-15.83* AbsLymp-2.02 AbsMono-0.67
AbsEos-0.13 AbsBaso-0.04
___ 09:53PM PLT COUNT-217
___ 07:49AM BLOOD WBC-8.3# RBC-2.86* Hgb-8.5* Hct-26.4*
MCV-92 MCH-29.7 MCHC-32.2 RDW-13.2 RDWSD-43.9 Plt ___
.
IMAGING:
Radiology Report UNILAT BREAST US LIMITED Study Date of
___ 10:37 AM
IMPRESSION:
Cellulitis ___ the upper-outer right breast/lower right axilla.
Small amount of ___ effusion with no separate fluid
collection ___ the upper-outer right breast/right axilla.
.
Radiology Report UNILAT BREAST US LIMITED RIGHT Study Date of
___ 2:23 ___
IMPRESSION:
Fluid surrounding the right breast implant. There is some
debris noted at the 9 o'clock location.
RECOMMENDATION(S): Right breast aspiration requested and
recommended with
specimens sent to micro bacteriology.
.
Radiology Report BREAST CYST ASPIRATION W/ US GUIDANCE RIGHT
Study Date of ___ 2:23 ___
IMPRESSION:
Technically successful US-guided aspiration of the right breast
fluid
collection at 9 o'clock.
.
MICROBIOLOGY:
___ 3:45 pm ABSCESS Site: BREAST
RIGHT BREAST FLUID. ON ANTIBIOTICS AUGMENTIN, KEFLEX,
VANCOMYCIN.
GRAM STAIN (Final ___:
2+ ___ per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS AND SINGLY.
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.
This isolate is presumed to be resistant to clindamycin
based on
the detection of inducible resistance .
SENSITIVITIES: MIC expressed ___
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN----------- R
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- 0.25 S
OXACILLIN------------- 0.5 S
TETRACYCLINE---------- <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
ANAEROBIC CULTURE (Preliminary): NO ANAEROBES ISOLATED.
Brief Hospital Course:
The patient was admitted to the plastic surgery service on
___ for observation and treatment of a right breast
reconstruction cellulitis. An ultrasound on ___ revealed some
fluid noted around the breast implant. An ultrasound guided
aspiration of this fluid was performed and was sent for culture.
.
Neuro: The patient's pain was well controlled with PO pain
medication.
.
CV: The patient was stable from a cardiovascular standpoint;
vital signs were routinely monitored.
.
Pulmonary: The patient was stable from a pulmonary standpoint;
vital signs were routinely monitored.
.
GI/GU: The patient was given IV fluids when maintained NPO ___
case of need for OR and then tolerated a regular diet when diet
advanced. Intake and output were closely monitored.
.
ID: The patient was given one dose of zosyn IV and then started
on IV vancomycin, cefepime and flagyl on admission. She
responded well to this regimen. On hospital day #3, the culture
showed staph aureus so flagyl was discontinued. The patient
continued to improve on vancomycin and cefepime. On hospital
day#4, sensitivity data revealed MSSA and vancomycin and
cefepime were discontinued. The patient was discharged home on
dicloxacillin for 30 days.
.
Prophylaxis: The patient received subcutaneous heparin during
this stay, and was encouraged to get up and ambulate as early as
possible.
.
At the time of discharge on hospital day#4, the patient was
doing well, afebrile with stable vital signs, tolerating a
regular diet, ambulating, voiding without assistance, and pain
was well controlled. Right breast/flank cellulitis was largely
resolved with minimal evidence of erythema and good improvement
___ tenderness to palpation.
Medications on Admission:
MVI
Calcium Carbonate-VitD3
Augmentin
Zyrtec
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN fever or pain
2. DiCLOXacillin 500 mg PO Q6H Duration: 30 Days
RX *dicloxacillin 500 mg 1 capsule(s) by mouth every six (6)
hours Disp #*120 Capsule Refills:*0
3. Fluconazole 150 mg PO Q72H PRN yeast infection
RX *fluconazole 150 mg 1 tablet(s) by mouth Every 72 hours Disp
#*3 Tablet Refills:*1
4. Ibuprofen 600 mg PO Q6H:PRN pain
Discharge Disposition:
Home
Discharge Diagnosis:
Right breast cellulitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted on ___ for observation/treatment of a right
chest/breast cellulitis. Please follow these discharge
instructions:
.
-Continue to monitor your right breast and flank area for
continued improvement. If the redness and swelling increase,
please call Dr. ___ to report this.
-Should you have fevers and chills, please call Dr. ___
immediately to report.
-Continue your antibiotics until they are finished (30 days!).
-Antibiotics may sometimes cause certain bacteria and/or fungus
to flourish ___ your gut/vagina. Try to replace good bacteria
daily (see the next bullet point). Should you experience
symptoms of a vaginal yeast infection (burning, itching,
thick/yellowish discharge), you should fill the prescription for
'Fluconazole'. You have been given 3 pills ___ your prescription
which is three treatments. Take one tablet to treat the yeast
infection. If ___ three days, you are still symptomatic, take
another tablet. If still symptomatic ___ three more days, take
the last tablet.
-You may consider eating a probiotic yogurt daily to replace
the 'good' bacteria ___ your intestinal tract. If you cannot
tolerate yogurt then you may buy 'acidophilus' over the counter
as a supplement choice. Acidophilus is a 'friendly' bacteria
for your gut.
-If you start to experience excessive diarrhea, please call Dr.
___ to report this.
-Do not overexert yourself and no strenuous exercise for now.
-You may take either tylenol or advil (ibuprofen) for your
discomfort. Take as directed.
Followup Instructions:
___
|
19671034-DS-9
| 19,671,034 | 28,776,735 |
DS
| 9 |
2189-05-02 00:00:00
|
2189-05-02 09:41:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: PLASTIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Right implant infection
Major Surgical or Invasive Procedure:
1. Removal of right breast implant and washout
History of Present Illness:
CC: Right breast pain
HPI:
___ year old female with breast cancer s/p bilateral
mastectomy and complicated reconstruction history including
bilateral TE to implants in ___ complicated by contracture s/p
capsulotomies and exchange in ___ c/b infection of the right
prosthesis s/p ultrasound guided drainage in ___ who presented
with right breast erythema, fevers, and fluid collection to Dr.
___ 2 weeks ago and was started on PO amoxicillin. A
culture of drained fluid reportedly grew MSSA. Her prior
cultures from ___ also grew MSSA. She reports that today she
felt increased swelling and pain of the right breast as well as
chills and headaches so was told to present to the ED.
Past Medical History:
Breast cancer
Social History:
___
Family History:
Noncontributory
Physical Exam:
Right breast dressing/incision intact with prolene. Tegaderm. JP
drain x 1 with serosanguineous drainage.
Pertinent Results:
n/a
Brief Hospital Course:
The patient presented to the emergency department and admitted
to the PRS service for operative intervention. The patient was
taken to the operating room on ___ for right implant removal and
washout over JP drain which the patient tolerated well. For full
details of the procedure please see the separately dictated
operative report. The patient was taken from the OR to the PACU
in stable condition and after satisfactory recovery from
anesthesia was transferred to the floor.
The ___ hospital course was otherwise unremarkable.
Cultures at the time of discharge are pending, but show no PMNs
or microorganisms.
She will be discharged on a course of Duricef.
At the time of discharge the patient's pain was well controlled
with oral medications, incisions were clean/dry/intact, and the
patient was voiding/moving bowels spontaneously. She will go
home with one JP drain in the right chest.
The patient will follow up with Dr. ___ routine. A
thorough discussion was had with the patient regarding the
diagnosis and expected post-discharge course including reasons
to call the office or return to the hospital, and all questions
were answered. The patient was also given written instructions
concerning precautionary instructions and the appropriate
follow-up care. The patient expressed readiness for discharge.
Medications on Admission:
Meds:
--------------- --------------- ---------------
---------------
Active Medication list as of ___:
Medications - Prescription
AZELASTINE - azelastine 0.15 % (205.5 mcg) nasal spray. 1 spray
each nostril twice a day as needed for allergy symptoms -
(Prescribed by Other Provider; Dose adjustment - no new Rx)
AMOXICILLIN
Medications - OTC
BIOTIN - biotin 1 mg tablet. 1 tablet(s) by mouth twice a day -
(OTC)
CHOLECALCIFEROL (VITAMIN D3) - cholecalciferol (vitamin D3)
1,000 unit tablet. 1 tablet(s) by mouth once a day -
(Prescribed by Other Provider; ___)
FEXOFENADINE-PSEUDOEPHEDRINE [ALLEGRA-D 24 HOUR] - Allegra-D 24
Hour 180 mg-240 mg tablet,extended release. 1 tablet(s) by mouth
once a day as needed for allergy symptoms - (Prescribed by
Other Provider; ___)
LACTOBACILLUS COMBINATION NO.4 [PROBIOTIC] - Probiotic 3
billion cell capsule. 1 (One) capsule(s) by mouth once a day -
(Prescribed by Other Provider; Dose adjustment - no new Rx)
MULTIVITAMIN [DAILY MULTI-VITAMIN] - Daily Multi-Vitamin
tablet. 1 tablet(s) by mouth once a day - (Prescribed by Other
Provider)
VEGAN D3 - vegan D3 . 1 spray orally daily - (___)
Discharge Medications:
1. Acetaminophen 650 mg PO 5X/DAY
2. cefaDROXil 500 mg oral Q12H Duration: 13 Days
RX *cefadroxil 500 mg 1 capsule(s) by mouth Twice daily Disp
#*26 Capsule Refills:*0
3. Ibuprofen 600 mg PO Q6H:PRN Pain - Moderate
Reason for PRN duplicate override: Alternating agents for
similar severity
4. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain -
Moderate
RX *oxycodone 5 mg 1 capsule(s) by mouth every four hours Disp
#*15 Capsule Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Right breast implant infection
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Post Surgery Instructions
Timeline:
Arrange for someone to stay with you in the immediate days after
discharge.
Wound care:
Empty and record drain output 3 times daily
Only sponge bathing is allowed until all the drains have been
removed
Do not soak in tub after surgery and pat the skin dry
afterwards
Do not apply ANY hot or cold compresses
Medication:
Take the antibiotic prescribed until completely gone
Your prescribed pain medicine should be used on an as needed
basis. As soon as you are comfortable doing so switch to
extra-strength Tylenol or Ibuprofen, as narcotics may be causing
nauseating and/or constipation
We recommend taking over the counter aids such as senekot-S or
Colace while recovering from surgery to maintain bowel
regularity
DO NOT drive until you have stopped all pain medications. For
most driving is OK 2 weeks after surgery
Diet:
Avoid alcohol while taking prescription pain medication but it
is acceptable in moderation once use of these medications are
stopped
Activity:
No SMOKING
No lifting of objects >5 lbs. until seen in clinic
Daily walks are recommended
Followup Instructions:
___
|
19671045-DS-13
| 19,671,045 | 27,433,268 |
DS
| 13 |
2190-05-16 00:00:00
|
2190-05-16 16:24:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
L breast pain and drainage
Major Surgical or Invasive Procedure:
L breast abscess I&D
History of Present Illness:
Left breast swelling, pain and drainage for about 1 week. Had an
incision and drainage at ___ 4 days ago with a ring placed to
keep incision open. Scheduled to return to ___ on ___ but
started draining increasing amount and pain was unbearable so
she came in to ___ on ___. Now draining mostly clear,
foul-smelling fluid. Had 2 past abscesses in left armpit and 1
in right armpit with I&D. No history of diabetes. She is not
breastfeeding. Recent use of crack cocaine, but denies IV drug
use. No fevers. WBC is 22.
Past Medical History:
PMH:
Manic depression
Inpatient psych (recent discharge)
Substance abuse (crack cocaine, denies IV)
PSH:
Appendectomy
Multiple abortions with d&c (most recent 5 months ago)
Social History:
___
Family History:
FH:
NC
Physical Exam:
Admission Physical Exam:
VS: 98.5 99 112/68 18 99% RA
General: uncomfortable, falls asleep every few minutes.
Breast/axilla: incision site from I&D actively draining
clear-white thin, foul-smelling fluid, severe pain with
palpation of site.
Neuro: slurring speech, somewhat confused.
Discharge Physical Exam:
VS: 98.___.8 85 125/75 14 99RA
Gen: NAD
Card: RRR
Lungs: CTA bil
Abd: soft, nt, nd
Wound: no purulent drainage from incision, less but some
residual firmness inferior to I&D incision but no
warmth/fluctuance/signs of cellulitis
Ext: no CCE
Pertinent Results:
___ 05:14AM BLOOD Glucose-93 UreaN-7 Creat-0.9 Na-140 K-3.5
Cl-104 HCO3-26 AnGap-14
___ 05:14AM BLOOD WBC-22.0*# RBC-3.98* Hgb-11.9* Hct-35.9*
MCV-90 MCH-29.9 MCHC-33.2 RDW-13.5 Plt ___
___ 05:14AM BLOOD Neuts-80.9* Lymphs-9.3* Monos-9.2 Eos-0.4
Baso-0.2
Brief Hospital Course:
The patient is status post left breast abscess I&D. The patient
tolerated the procedure well; reader is referred to operative
report for full details of surgery. The patient was transferred
to the recovery room and admitted to the floor for further
monitoring. The patient hospital course was stable.
Neuro: Post-operatively, the patient had good pain control and
was transition to oral pain medications.
Cardiac: The patient was stable from a cardiovascular
standpoint; vital signs were routinely monitored.
Pulmonary: The patient was stable from a pulmonary standpoint.
GI/GU: Post-operatively, the patient was given IV fluids until
tolerating oral intake. Her diet was advanced the same evening,
which was tolerated well. Intake and output were closely
monitored. The patient voided without difficulty.
ID: The patient's wound was left open in the OR and packed with
sterile Kerlex. Packing changes were done every 8 hours
beginning POD#1. The patient was placed on IV Vanc and Flagyl
initially, before transitioning to IV Vanc and Unasyn for
broader coverage on POD#1. OR cultures grew out mixed flora and
she was transitioned to PO Augmentin on POD#2, with she
tolerated well and remained afebrile.
DVT Prophylaxis: The patient wore pneumatic compression boots,
and was encouraged to ambulate as early as possible.
At the time of discharge on POD#3, the patient was doing well,
afebrile with stable vital signs, tolerating a regular diet,
ambulating, voiding without assistance, and pain was well
controlled. The patient will follow-up with Dr. ___ her
postoperative appointment.
Discharge Medications:
1. Aripiprazole 5 mg PO DAILY
2. DiphenhydrAMINE 25 mg PO HS
3. Divalproex (DELayed Release) 500 mg PO BID
4. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
RX *oxycodone 5 mg 1 tablet(s) by mouth every 4 hours Disp #*20
Tablet Refills:*0
5. Amoxicillin-Clavulanic Acid ___ mg PO Q12H
RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tablet(s) by
mouth every 12 hours Disp #*14 Tablet Refills:*0
6. Docusate Sodium 100 mg PO BID
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice
daily Disp #*14 Capsule Refills:*1
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
L breast abscess
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Incision Care:
*Please call your doctor 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. Gently pat the area dry. Replace the packing
with dry sterile Kerlex. Replace the dressing with dry, sterile
gauze as needed.
.
General Discharge Instructions:
1. Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids.
2. Avoid lifting that requires you to strain until you follow-up
with your surgeon, who will instruct you further regarding
activity restrictions.
3. Resume your regular medications unless instructed otherwise
and take any new meds as ordered .
4. You may take your prescribed pain medication for moderate to
severe pain. You may switch to Tylenol or Extra Strength
Tylenol for mild pain as directed on the packaging. Please note
that Percocet and Vicodin have Tylenol as an active ingredient
so do not take these meds with additional Tylenol.
5. Take prescription pain medications for pain not relieved by
tylenol.
6. Take Colace, 100 mg by mouth 2 times per day, while taking
the prescription pain medication if you are experiencing
constipation. You may use a different over-the-counter stool
softener if you wish.
7. 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.
8. Please follow-up with your surgeon and Primary Care Provider
(PCP) as advised.
.
Please call your doctor or nurse practitioner or return to the
nearest ER if you experience
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 experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain is 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.
Followup Instructions:
___
|
19671332-DS-4
| 19,671,332 | 27,535,620 |
DS
| 4 |
2131-09-29 00:00:00
|
2131-09-29 22:07:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Dyspnea on exertion
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old female with CKD stage V secondary to type 2 DM and
hypertension presenting with weight gain, malaise and worsening
dyspnea on exertion. Pt reports that on ___ she was
extremely short of breath going up two flight of stairs to get
to her apartment. The shortness of breath prompted a call to
EMS, and pt was ultimately brought ___
___. At ___, pt's H/H were noted to be 7.8/24.3 and she
was found to be volume overloaded in the setting of a worsening
BUN/Cr to 103/6.4. She was seen by Nephrology at ___ who
recommended stopping lisinopril, amlodipine, and NaHCO3 tabs. In
addition, they recommended transfer to ___ for initiation of
HD. Pt was subsequently discharged and presented to the ___
ED.
In the ED, initial vitals were: 98.7 87 114/55 16 94%
- Labs were significant for Na 137, K 5.5, CO2 19 from ___,
BUN/Cr 112/6.7 from baseline Cr 5.2-5.8, H/H 8.7/25.7 from
10.5/31.4 ___.
- CXR demonstrated bilateral pleural effusions with overlying
atelectasis, pulmonary edema and enlarged cardiac silhouette.
- The patient was given a dose of ceftriaxone due to concern for
possible pneumonia.
- Renal was consulted in the ED, and plan for initiation of HD
in the AM.
Upon arrival to the floor, pt reports that she feels well with
no acute complaints.
Past Medical History:
HYPERTENSION - ESSENTIAL 401.9
ANEMIA 285.9
Headache 784.0
Benign neoplasm of bone and articular cartilage, site
unspecified 213.9
Leukopenia 288.50
Neoplasm of bone, soft tissue, and skin 239.2
DIABETIC RETINOPATHY
Hypercholesterolemia 272.0
Aortic valve stenosis 424.1
Renal Cyst 753.10
Diabetes Mellitus with Ophthalmic Manifestation 250.50
Diabetic Macular Edema 362.07
Moderate nonproliferative diabetic retinopathy 362.05
Macular Scar 363.32
Cataract ___
Chronic kidney disease, stage V 585.5
Third degree uterine prolapse 618.1
Screening for colon cancer V76.51
Diabetes mellitus with renal complications 250.40, 583.81
Uterovaginal prolapse 618.4
Grief reaction 309.0
Advanced directives, counseling/discussion V65.49
Hyperparathyroidism due to renal insufficiency 588.81
Anemia in chronic kidney disease(285.21) 285.21
Social History:
___
Family History:
Denies FH of kidney disease, DM, HTN, CAD
Physical Exam:
ADMISSION EXAM:
================
Vitals: 98.0 133/71 90 24 99% on 2L
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: Supple, JVP elevated
CV: Regular rate and rhythm, S1 + S2, SEM
Lungs: Crackles at the bases bilaterally
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
GU: No foley
Ext: Warm, well perfused, 2+ edema to knees bilaterally; AV
fistula in LUE with palpable thrill
Neuro: Intact, no asterixis
DISCHARGE EXAM:
================
Vitals: T 98.3, HR 79, BP 112/50, RR 16, SaO2 98% RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
CV: Regular rate and rhythm, S1 + S2, HARSH ___ SEM loudest over
aortic area
Lungs: Non-labored breathing, clear anteriorly
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
Ext: Warm, well perfused, 2+ edema to knees bilaterally; AV
fistula in LUE with palpable thrill and bruit
Neuro: Intact, no asterixis
Pertinent Results:
ADMISSION LABS:
================
___ 07:00PM BLOOD WBC-4.3 RBC-3.08* Hgb-8.7* Hct-25.7*#
MCV-83# MCH-28.3 MCHC-34.0# RDW-15.7* Plt ___
___ 07:00PM BLOOD Glucose-133* UreaN-112* Creat-6.7*#
Na-137 K-5.5* Cl-103 HCO3-19* AnGap-21*
___ 05:06AM BLOOD ALT-17 AST-16 AlkPhos-38 TotBili-0.3
___ 04:38AM BLOOD Calcium-9.1 Phos-7.2* Mg-2.1 Iron-44
___ 04:38AM BLOOD calTIBC-221* Ferritn-217* TRF-170*
___ 04:38AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE
HBcAb-NEGATIVE
___ 04:38AM BLOOD HCV Ab-NEGATIVE
DISCHARGE LABS:
================
___ 05:05AM BLOOD WBC-6.2 RBC-2.69* Hgb-7.6* Hct-22.8*
MCV-85 MCH-28.2 MCHC-33.4 RDW-15.9* Plt ___
___ 05:05AM BLOOD ___ PTT-25.8 ___
___ 05:05AM BLOOD Glucose-84 UreaN-31* Creat-3.1* Na-140
K-3.9 Cl-101 HCO3-29 AnGap-14
___ 05:05AM BLOOD ALT-17 AST-16 AlkPhos-38 TotBili-0.4
___ 05:05AM BLOOD Calcium-8.7 Phos-3.0 Mg-1.9
IMDAGING/STUDIES:
==================
TTE (___):
The left atrium is moderately dilated. There is mild symmetric
left ventricular hypertrophy with normal cavity size. There is
moderate to severe regional left ventricular systolic
dysfunction with septal, anterior and apical severe hypokinesis.
There is no ventricular septal defect. Right ventricular chamber
size and free wall motion are normal. The right ventricular free
wall is hypertrophied. The aortic valve leaflets are moderately
thickened. There is severe aortic valve stenosis (valve area
<1.0cm2). The mitral valve leaflets are mildly thickened.
Moderate (2+) mitral regurgitation is seen. [Due to acoustic
shadowing, the severity of mitral regurgitation may be
significantly UNDERestimated.] The tricuspid valve leaflets are
mildly thickened. There is moderate pulmonary artery systolic
hypertension. There is no pericardial effusion.
IMPRESSION: regional left ventricular systolic dysfunction as
described above, consistent with LAD ischemia/infarction. Severe
calcific aortic stenosis. At least moderate mitral
regurgitation. Moderate pulmonary hypertension.
CXR (___):
IMPRESSION:
Bilateral pleural effusions with overlying atelectasis,
pulmonary edema and enlarged cardiac silhouette.
ECG: SR 88, LBBB, QRS 170
Brief Hospital Course:
Ms. ___ is a ___ year old female with CKD stage V who presented
with volume overload secondary to worsening renal function and
TTE showing new systolic dysfunction.
# CKD stage V: Patient presented with volume overload secondary
to progression of CKD. She was also found to have new systolic
heart failure (see below). Patient underwent three HD sessions.
One session was complicated by infiltration of her fistula, but
subsequent sessions were uncomplicated. Patient was started on
torsemide to augment HD (as she continues to have good urine
output). Patient's dyspnea resolved and she was weaned off
oxygen. She will continue outpatient HD at ___ ___
schedule).
# Systolic heart failure: TTE revealed systolic dysfunction (EF
___ and septal, anterior, and apical hypokinesis, new since
last TTE in ___. She also has severe AS (last TTE with
moderate AS). Cardiology was consulted and recommended a
nuclear stress test, but radiology did not feel comfortable
using persantine given her severe aortic stenosis. Patient will
need a cardiac catheterization as an outpatient. Patient's
labetalol was switched to metoprolol. Her lisinopril was
restarted. She was continued on ASA and statin. Patient has
follow-up scheduled with cardiology in one week.
# Anemia: Likely progression of anemia of CKD, stable. She was
continued on iron supplements and received EPO at HD.
# Hypertension: Patient's blood pressure was well-controlled.
Her labetalol was switched to metoprolol (given new systolic
heart failure) and lisinopril was restarted. Amlodipine was
discontinued as it was not needed.
TRANSITIONAL ISSUES:
=====================
[ ] Patient was found to have new systolic dysfunction on TTE.
She will need outpatient cardiac catheterization (unable to
perform persantine perfusion test due to severe AS). She should
also be evaluated for TAVR given severe aortic stenosis.
[ ] Labetalol was switched to metoprolol. Torsemide was started.
[ ] Amlodipine was discontinued (not needed).
[ ] Patient received first hepatitis B vaccine.
[ ] Evaluated by ___ who recommended home ___
[ ] Patient's hgb fluctuated while in hospital. Should have
repeat CBC along with lytes at next dialysis session
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Calcitriol 0.25 mcg PO DAILY
2. Amlodipine 10 mg PO HS
3. Atorvastatin 80 mg PO QPM
4. Lisinopril 2.5 mg PO DAILY
5. Epoetin Alfa 10,000 Units SC Q4WEEKS
6. Sodium Bicarbonate 650 mg PO BID
7. Labetalol 150 mg PO DAILY
8. Ferrous Sulfate 325 mg PO DAILY
9. Torsemide 2.5 mg PO DAILY
10. Desonide 0.05% Cream 1 Appl TP BID:PRN Rash
11. Ketoconazole Shampoo 1 Appl TP ASDIR
12. Calcium Carbonate 500 mg PO TID W/MEALS
13. Aspirin 81 mg PO DAILY
14. Vitamin D ___ UNIT PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 80 mg PO QPM
3. Calcitriol 0.25 mcg PO DAILY
4. Ferrous Sulfate 325 mg PO DAILY
5. Lisinopril 2.5 mg PO DAILY
6. Torsemide 40 mg PO DAILY
RX *torsemide [Demadex] 20 mg 2 tablet(s) by mouth daily Disp
#*60 Tablet Refills:*0
7. sevelamer CARBONATE 800 mg PO TID W/MEALS
RX *sevelamer carbonate [Renvela] 800 mg 1 tablet(s) by mouth
three times a day Disp #*90 Tablet Refills:*0
8. Desonide 0.05% Cream 1 Appl TP BID:PRN Rash
9. Epoetin Alfa 10,000 Units SC Q4WEEKS
10. Ketoconazole Shampoo 1 Appl TP ASDIR
11. 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
12. Metoprolol Succinate XL 25 mg PO DAILY
RX *metoprolol succinate 25 mg 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
___:
PRIMARY DIAGNOSES:
===================
End stage kidney disease
Systolic heart failure
SECONDARY DIAGNOSES:
=====================
Hypertension
Severe aortic stenosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent with a cane.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure caring for you during your hospitalization at
___. You were admitted for shortness of breath thought to be
due to progression of your kidney disease as well as new heart
disease. You were started on dialysis and underwent three
successful dialysis sessions. Your breathing improved. An
echocardiogram (heart ultrasound) showed that your heart is not
pumping as well as it should be. You will have further tests to
evaluate your heart as an outpatient.
Please continue to take your medications as prescribed and keep
your follow-up appointments.
Sincerely,
Your ___ Team
Followup Instructions:
___
|
19671332-DS-6
| 19,671,332 | 25,818,846 |
DS
| 6 |
2132-11-28 00:00:00
|
2132-12-02 16:03:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
skin changes over site of LUE pseudo aneurysm
Major Surgical or Invasive Procedure:
___: Ligation with partial excision of left upper arm AV
graft.
___: Successful placement of a 19 cm tip-to-cuff length
tunneled dialysis line. The tip of the catheter terminates in
the right atrium.
History of Present Illness:
___ with PMH of DM, ESRD on HD (MWF), severe aortic
stenosis, mitral regurg, CAD, and sCHF (LVEF=35%) who was
recently admitted ___ for septic shock and MSSA bacteremia.
Was noted today at ___ to have concerning appearance of known
pseudoaneurysmal disease prompting patient to be directed to our
ED.
Of note, on her recent admission, ___ demonstrated a patent
graft with no evidence of fluid collection in the vicinity and
CTA of the region ___ demonstrated skin thickening and
subcutaneous edema surrounding the venous anastomosis consistent
with cellulitis, but also no fluid collection. A TTE ___ found
no evidence of valvular vegetations.
Currently the patient is asymptomatic. There is notable
expansion of the proximal aneurysmal region with new skin
thinning and a small ulceration. She does not recall when these
changes occurred but they are new to this examiner since her
discharge ___. She denies increased pain at the site and
there were no difficulties with her HD today or problems with
bleeding. She denies nausea, vomiting, chills, diaphoresis,
chest pain shortness of breath, paresthesias, weakness or
numbness of her hand. Her last day of HD dosed IV Cefazolin
last day is ___.
Past Medical History:
HYPERTENSION - ESSENTIAL 401.9
ANEMIA 285.9
Headache 784.0
Benign neoplasm of bone and articular cartilage, site
unspecified 213.9
Leukopenia 288.50
Neoplasm of bone, soft tissue, and skin 239.2
DIABETIC RETINOPATHY
Hypercholesterolemia 272.0
Aortic valve stenosis 424.1
Renal Cyst 753.10
Diabetes Mellitus with Ophthalmic Manifestation 250.50
Diabetic Macular Edema 362.07
Moderate nonproliferative diabetic retinopathy 362.05
Macular Scar 363.32
Cataract ___
Chronic kidney disease, stage V 585.5
Third degree uterine prolapse 618.1
Screening for colon cancer V76.51
Diabetes mellitus with renal complications 250.40, 583.81
Uterovaginal prolapse 618.4
Grief reaction 309.0
Advanced directives, counseling/discussion V65.49
Hyperparathyroidism due to renal insufficiency 588.81
Anemia in chronic kidney disease(285.21) 285.21
Social History:
___
Family History:
Denies FH of kidney disease, DM, HTN, CAD
Physical Exam:
Exam on Admission
=======================
GEN: NAD, A&O, non-toxic appearing
CV: RRR, ___ SEM
PULM: CTAB, no W/R/C, no respiratory distress
ABDOMEN: Soft. Nondistended, nontender, no rebound or
guarding.
EXTREMITIES: ___ ___ edema to ankles. LUE AVG with strong
thrill & bruit proximally at the arterial side. Multiple
aneurysms along graft which are mildly pulsatile. Thrill is
palpated distally in the upper arm but is weaker than that at
the arterial side. A portion of the proximal pseudoaneuryms is
protuberant with overlying skin changes, small ulceration, and
thinning. This portion is new from her last exam and overall
the region has expanded. Her UE have brisk capillary refill,
there is a palpable radial pulse b/l, and her extremities are
warm. There is no active bleeding. There is surrounding
hyperkeratosis but no surrounding or overlying induration,
erythema, calor, fluctuance, or drainage.
Exam on Discharge
=======================
GEN: elderly woman in no acute distress, sitting in chair
comfortably
CV: RRR, ___ SEM
PULM: Clear to auscultation b/l, no crackles or rhonci
Ext: vertical incision on Left upper extremity is clean, dry,
well approximated and intact. Left hand is slightly swollen due
to ace wrap and is currently elevated. Radial and ulnar pulses
2+ bilaterally. cap refill <3 secs. Extremities are warm and
well perfused. Sensation is intact in the Left upper extremity
and strength ___.
Pertinent Results:
Labs
===============
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW
RDWSD Plt
___ 06:11AM 5.1 2.67* 8.5* 26.5* 99* 31.8 32.1 13.5
47.8 212
___ 05:40AM 5.0 2.67* 8.7* 26.5* 99* 32.6* 32.8 13.5
47.4* 220
___ 04:00AM 4.9 2.67* 8.7* 26.9* 101* 32.6* 32.3 13.7
49.6* 249
BASIC COAGULATION ___ PTT ___
___ 05:40AM 11.9 28.4 1.1
___ 04:00AM 11.9 28.9 1.1
___ 07:40PM 11.2 27.4 1.0
Chemistry
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
___ 06:11AM 80 36* 7.0*# 136 4.0 93* 30 17
___ 05:40AM 74 36* 7.0*# 137 4.5 95* 31 16
___ 04:00AM 75 19 5.0* 139 4.1 96 32 15
CHEMISTRY Calcium Phos Mg
___ 06:11AM 8.6 4.5
___ 05:40AM 8.6 4.5 2.3
___ 04:00AM 4.1 2.1
Imaging
===============
HD Tunneled Line
FINDINGS:
Patent right internal jugular vein. Final fluoroscopic image
showing
double-lumen hemodialysis catheter with tip terminating in the
right atrium.
IMPRESSION:
Successful placement of a 19 cm tip-to-cuff length tunneled
dialysis line.
The tip of the catheter terminates in the right atrium. The
catheter is ready
for use.
Microbiology
===============
___ 10:34 pm TISSUE LEFT ARM AV GRAFT.
GRAM STAIN (Final ___:
2+ ___ per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES.
NO MICROORGANISMS SEEN.
TISSUE (Preliminary): NO GROWTH.
Brief Hospital Course:
Ms. ___ was admitted to the Transplant Surgery service
under Dr. ___ on ___. She underwent an emergent
partial excision of her left upper extremity arteriovenous
graft. Post operatively she was continued on HD dosed cefazolin.
On ___, Ms. ___ underwent a procedure for placement of
tunneled dialysis line in the Right internal jugular vein. The
procedure was successful and on ___ she underwent hemodialysis,
keeping with her current HD schedule of MWF. She was re-started
on her home medications. Of note, her left hand became swollen
after placement of an ace bandage for post operative wound
dressing. She was directed to keep her arm elevated to
facilitate decreasing the swelling.
On ___ she was evaluated by ___ and was cleared to be
discharged home. She was discharged home the afternoon of ___.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 80 mg PO QPM
3. Docusate Sodium 100 mg PO 3X/WEEK (___)
4. CeFAZolin 2 g IV POST HD (MO,WE)
5. CeFAZolin 3 gram IV POST HD (FR)
6. Triamcinolone Acetonide 0.1% Cream 1 Appl TP BID
7. Calcium Acetate 667 mg PO TID W/MEALS
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 80 mg PO QPM
3. Calcium Acetate 667 mg PO TID W/MEALS
4. CeFAZolin 2 g IV POST HD (MO,WE)
At dialysis
5. CeFAZolin 3 gram IV POST HD (FR)
___
6. Docusate Sodium 100 mg PO 3X/WEEK (___)
At Dialysis
7. Acetaminophen 650 mg PO TID
8. Triamcinolone Acetonide 0.1% Cream 1 Appl TP BID
Discharge Disposition:
Home
Discharge Diagnosis:
Mechanical complication of left arm AV graft.
ESRD
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Please call Dr. ___ office at ___ if you develop
fever or chills, left hand pain, cold/blue or numbness in the
left hand, incisional redness, drainage or bleeding, arm or hand
swelling or any other concerning symptoms.
Continue home medications as previously ordered
Continue dialysis per your outpatient schedule. You will be
receiving IV antibiotics following dialysis at least through
___ for previous MSSA infection.
Elevate left arm on two pillows when sitting and lying down.
Followup Instructions:
___
|
19671332-DS-7
| 19,671,332 | 25,644,091 |
DS
| 7 |
2133-03-10 00:00:00
|
2133-03-10 18:28:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
cefazolin
Attending: ___.
Chief Complaint:
Fever, nausea/vomiting
Major Surgical or Invasive Procedure:
Note Date: ___
Signed by ___, MD on ___ at 11:31 am
Affiliation: ___
NEEDS COSIGN
___ was called to remove right IJ tunneled HD catheter as
catheter
was no longer needed and there was concern for pus being
expressed from right IJ site.
Using 1% lidocaine to provide local anesthesia, the HD catheter
was removed in the patient's room. Patient tolerated the
procedure well. No acute complications.
History of Present Illness:
___ with PMH of DM, ESRD on HD (MWF), severe aortic
stenosis, mitral regurg, DM2, CAD, and sCHF (LVEF=35%), hx MSSA
bacteremia, now presenting with fever. Family called EMS as
patient was getting ready for her routine dialysis treatment.
Family felt patient to be more lethargic than usual and also
vomited her breakfast. An oral temp was taken to be ___. Pt
recounts feeling weak and vomiting in the AM. She missed her
scheduled dialysis.
She denies any CP, SOB, chills, headache. No hematuria, dysuria,
or constipation or diarrhea. Pt feeling improved at this time.
In the ED, initial vitals were:
97.0 102 114/48 18 98% RA
Labs notable for:
WBC 21.0 (94%N), Hgb 13.4, Plt 192
K 4.8, lactate 2.0
CXR showed mild to moderate pulmonary vascular congestion. No
discrete focal consolidation seen.
Patient was given:
___ 16:55 IV Piperacillin-Tazobactam 4.5 g
___ 17:31 IV Vancomycin 1000 mg
Decision was made to admit for infectious workup and dialysis
Vitals prior to transfer:
On the floor, patient is somewhat somnolent but responsive. She
does not recall the events bringing her to the hospital, until
prompted. Does not complain of fever.
ROS:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain.
Denies headache, sinus tenderness, rhinorrhea or congestion.
Denies cough, shortness of breath. Denies chest pain or
tightness, palpitations. Denies nausea, vomiting, diarrhea,
constipation or abdominal pain. No recent change in bowel or
bladder habits. No dysuria. Denies arthralgias or myalgias.
Past Medical History:
HYPERTENSION - ESSENTIAL 401.9
ANEMIA 285.9
Headache 784.0
Benign neoplasm of bone and articular cartilage, site
unspecified 213.9
Leukopenia 288.50
Neoplasm of bone, soft tissue, and skin 239.2
DIABETIC RETINOPATHY
Hypercholesterolemia 272.0
Aortic valve stenosis 424.1
Renal Cyst 753.10
Diabetes Mellitus with Ophthalmic Manifestation 250.50
Diabetic Macular Edema 362.07
Moderate nonproliferative diabetic retinopathy 362.05
Macular Scar 363.32
Cataract ___
Chronic kidney disease, stage V 585.5
Third degree uterine prolapse 618.1
Screening for colon cancer V76.51
Diabetes mellitus with renal complications 250.40, 583.81
Uterovaginal prolapse 618.4
Grief reaction 309.0
Advanced directives, counseling/discussion V65.49
Hyperparathyroidism due to renal insufficiency 588.81
Anemia in chronic kidney disease(285.21) 285.21
Social History:
___
Family History:
Denies FH of kidney disease, DM, HTN, CAD
Physical Exam:
ADMISSION PHYSICAL EXAM:
=========================
Vital Signs: 101.5 PO 103 / 60 L Lying ___ RA
General: Fatigued, oriented to hospital (not ___, person,
city, but not year. 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, ___ SEM
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
GU: No foley
Ext: Warm, well perfused, 2+ pulses, palpable thrill LUE with
area of surrounding discoloration/induration but no overt
infection
Neuro: CNII-XII intact, moving all extremities, +/- mild
asterixis vs mild tremor
DISCHARGE PHYSICAL EXAM:
==========================
VS: Tm 98.3 103/63 75 (75-79) 18 94 ra
General: NAD
HEENT: Sclera anicteric, MMM, oropharynx clear
CV: Regular rate and rhythm, normal S1 + S2, ___ systolic
ejection murmur best heard at LSB and radiates through
precordium.
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
GU: No foley
Ext: Warm, well perfused, 2+ pulses, LUE AVF with palpable
thrill. Lines: s/p R chest tunneled line removal, dressing is
c/d/I, wound is with superficial skin desquamation and
discoloration but not warm, nontender with no e/o infection
Pertinent Results:
ADMISSION LABS:
================
___ 03:10PM BLOOD WBC-21.0*# RBC-4.38# Hgb-13.4# Hct-43.1#
MCV-98 MCH-30.6 MCHC-31.1* RDW-15.7* RDWSD-54.7* Plt ___
___ 03:10PM BLOOD Neuts-94.2* Lymphs-1.5* Monos-3.4*
Eos-0.0* Baso-0.2 Im ___ AbsNeut-19.75*# AbsLymp-0.31*
AbsMono-0.71 AbsEos-0.00* AbsBaso-0.04
___ 03:10PM BLOOD Glucose-82 UreaN-45* Creat-6.8* Na-140
K-5.6* Cl-94* HCO3-26 AnGap-26*
___ 03:10PM BLOOD ALT-19 AST-46* LD(LDH)-510* AlkPhos-70
TotBili-0.3
___ 03:10PM BLOOD Albumin-4.2 Calcium-9.9 Phos-4.1 Mg-2.0
___ 06:24AM BLOOD %HbA1c-4.7 eAG-88
___ 03:33PM BLOOD Lactate-2.0 K-4.8
___ 09:53AM BLOOD Lactate-1.3 K-4.9
DISCHAGE LABS:
================
___ 05:38AM BLOOD WBC-4.2 RBC-3.55* Hgb-10.6* Hct-34.0
MCV-96 MCH-29.9 MCHC-31.2* RDW-14.9 RDWSD-52.7* Plt ___
___ 05:38AM BLOOD Glucose-83 UreaN-29* Creat-4.9*# Na-134
K-3.9 Cl-94* HCO3-27 AnGap-17
___ 05:38AM BLOOD Calcium-8.7 Phos-4.1 Mg-2.0
MICROBIOLOGY:
=============
___ 3:20 pm BLOOD CULTURE
Blood Culture, Routine (Preliminary):
STAPH AUREUS COAG +. FINAL SENSITIVITIES.
Consultations with ID are recommended for all blood
cultures
positive for Staphylococcus aureus, yeast or other
fungi.
Staphylococcus species may develop resistance during
prolonged
therapy with quinolones. Therefore, isolates that are
initially
susceptible may become resistant within three to four
days after
initiation of therapy. Testing of repeat isolates may
be
warranted.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN----------<=0.25 S
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- 0.5 S
OXACILLIN------------- 0.5 S
TRIMETHOPRIM/SULFA---- <=0.5 S
Aerobic Bottle Gram Stain (Final ___:
GRAM POSITIVE COCCI IN CLUSTERS.
Reported to and read back by ___ ON ___ AT
13:54.
___ 3:10 pm BLOOD CULTURE
Blood Culture, Routine (Preliminary):
STAPH AUREUS COAG +.
Consultations with ID are recommended for all blood
cultures
positive for Staphylococcus aureus, yeast or other
fungi.
SENSITIVITIES PERFORMED ON CULTURE # ___-___
___.
Aerobic Bottle Gram Stain (Final ___:
GRAM POSITIVE COCCI IN PAIRS AND CLUSTERS.
Reported to and read back by ___ (___) ___.
___ 2:08 am URINE Source: ___.
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
___ 7:24 am BLOOD CULTURE X2 #1.
Blood Culture, Routine (Pending):
___ 9:24 am STOOL CONSISTENCY: NOT APPLICABLE
Source: Stool.
**FINAL REPORT ___
C. difficile DNA amplification assay (Final ___:
Negative for toxigenic C. difficile by the Illumigene DNA
amplification assay.
(Reference Range-Negative).
___ 1:50 pm BLOOD CULTURE X2 Source: Line-dialysis.
Blood Culture, Routine (Pending):
___ 10:40 am BLOOD CULTURE X2
Blood Culture, Routine (Pending):
___ 7:30 am BLOOD CULTURE X1
Blood Culture, Routine (Pending):
ECG:
=====
ECG Study Date of ___ 1:08:40 ___
Clinical indication for EKG: R53.1 - Weakness
Sinus tachycardia. Left bundle-branch block. Probable left
atrial
abnormality. Left axis deviation. Compared to the previous
tracing of ___ no change.
IMAGING:
=========
CHEST (PA & LAT) Study Date of ___ 1:48 ___
IMPRESSION:
Mild to moderate pulmonary vascular congestion. No discrete
focal
consolidation seen.
TTE (Complete) Done ___ at 2:31:50 ___
The left atrium is mildly dilated. No atrial septal defect is
seen by 2D or color Doppler. Left ventricular wall thicknesses
are normal. The left ventricular cavity size is normal. Overall
left ventricular systolic function is moderately depressed
(LVEF= 35 %). No masses or thrombi are seen in the left
ventricle. There is no ventricular septal defect. Right
ventricular chamber size is normal with mild global free wall
hypokinesis. The aortic valve leaflets are moderately thickened.
There is moderate aortic valve stenosis (valve area 1.0-1.2cm2).
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 severe mitral annular calcification.
There is mild functional mitral stenosis (mean gradient 7 mmHg)
due to mitral annular calcification. Mild to moderate (___)
mitral regurgitation is seen. [Due to acoustic shadowing, the
severity of mitral regurgitation may be significantly
UNDERestimated.] The tricuspid valve leaflets are mildly
thickened. Moderate to severe [3+] tricuspid regurgitation is
seen. There is moderate pulmonary artery systolic hypertension.
Compared with the prior study (images reviewed) of ___,
the heart rate is slower. LV systolic function appears less
vigorous.
Brief Hospital Course:
___ with NIDDM, CAD, severe aortic stenosis (Area <1.0), HFrEF
(EF35%), ESRD on HD (MWF), hx MSSA bacteremia ___ AVF infection
s/p AVF revision ___ getting HD thru temporary tunneled line,
now presenting with fevers, purulent drainage from tunneled
line, and MSSA bacteremia.
#MSSA Bacteremia: History of MSSA bacteremia from LUE AVF
infection requiring AVF revision last month. Now with purulent
drainage expressed from temporary tunneled line site and blood
culture x2 with pan-sensitive MSSA. Likely central line
infection, now s/p line removal ___. Per outpatient HD, pt was
able to complete cefazolin course for prior history of MSSA
bacteremia. However, pt's son reports the pt developed a severe
allergy to cefazolin near end of the prior course, with a
superficial desquamating rash that covered the pt's back, chest,
arms, and face. This allergy was reportedly confirmed by a
dermatologist. TTE with no evidence of valvular vegetation;
however, despite adequate windows, sensitivity for detecting
vegetation is questionable in light of the pt's pan-valvular
disease (evidence of mitral annular calcification, MR/MS, AR/AS,
TR). These same limitations would also make it difficult to rule
out vegetation on TEE as well.
# CKD stage V: Initiated ___, secondary to long standing
diabetes, on HD MWF. Has LUE fistula, revised in ___.
Presented with infected tunneled line s/p line removal ___. HD
was continued while inpatient via LUE AVF. Nephrocaps started.
#Diarrhea: ___ be due to meds such as zosyn, less likely
infectious. Cdiff negative.
CHRONIC ISSUES
===============
# Anemia. Hemoglobin was stable. Likely ACD given ESRD. She is
on Aranesp q 2 weeks.
# Systolic heart failure: Diagnosed ___ with LVEF ___
consistent with LAD ischemia. Cath showed 3 vessel CAD.
Continued aspirin, atorvastatin. Was previously on lisinopril
and metoprolol but was held after admission for sepsis in
___.
# Non-insulin dependent Diabetes Mellitus: Complicated by
retinopathy and CKD. It does not appear that she is on any
medications for glycemic control. Pt's son reports DM is diet
controlled. A1c 4.7%
# Severe AS: Patient with severe AS on TTE with valve area <1.0.
Per OMR notes she is undergoing evaluation for CABG/AVR.
# Skin sensitivity: Prefers paper tape.
TRANSITIONAL ISSUES:
====================
#MSSA Bacteremia: pt will require Vancomycin dosed with HD (MWF)
for 6 week course (D1 ___ End: ___. Confirmed plan
with HD at ___.
#Cefazolin allergy: pt's son reports the pt developed a
superficial desquamating whole-body rash that was reportedly
confirmed by a dermatologist to be an allergy to cefazolin.
There is, however, no documentation of this allergy at the pt's
HD center. We would recommend confirming this allergy via
dermatology records or official allergy testing, as this will
guide future antibiotic regimens.
#sCHF: Lisinopril 2.5 QD restarted for cardiac benefit,
shouldn't have BP effect at this low dose. Can consider
metoprolol as well for OMT of CHF.
#New medications: Vancomycin as above. Lisinopril as above.
#Discharge Cr: 4.9
CORE MEASURES:
=======================
# CONTACT: Name of health care proxy: ___ AND ___
___
___: son and daughter
Phone number: ___ AND ___
# DISPO: SIRS pending clinical improvement
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 80 mg PO QPM
3. Calcium Acetate 667 mg PO TID W/MEALS
4. Docusate Sodium 100 mg PO 3X/WEEK (___)
5. Acetaminophen 650 mg PO TID
6. Clobetasol Propionate 0.05% Cream 1 Appl TP BID
7. Nephrocaps 1 CAP PO QAM
Discharge Medications:
1. Lisinopril 2.5 mg PO DAILY
RX *lisinopril 2.5 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
2. Vancomycin 1000 mg IV HD PROTOCOL
RX *vancomycin 1 gram 1 gram IV with HD Disp #*1 Vial Refills:*0
3. Acetaminophen 650 mg PO TID
4. Aspirin 81 mg PO DAILY
5. Atorvastatin 80 mg PO QPM
6. Calcium Acetate 667 mg PO TID W/MEALS
7. Clobetasol Propionate 0.05% Cream 1 Appl TP BID
8. Docusate Sodium 100 mg PO 3X/WEEK (___)
9. Nephrocaps 1 CAP PO QAM
10.Outpatient Lab Work
ALL LAB RESULTS SHOULD BE SENT TO:
ATTN: ___ CLINIC - FAX: ___
WEEKLY: CBC with differential, BUN, Cr, Vancomycin trough AST,
ALT
11.Rolling Walker
Diagnosis: Impaired functional Mobility
Prognosis: Good
Length of Need: 13 months
Discharge Disposition:
Home With Service
Facility:
___
___:
PRIMARY DIAGNOSIS:
------------------
Methicillin-sensitive staphylococcus aureus bacteremia
Chronic kidney disease stage 5
SECONDARY DIAGNOSIS:
Anemia
Severe aortic stenosis
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 hospitalized because of fevers. We believe this
occurred because of an infection in your blood that started in
the temporary line you were using for dialysis. The line was
removed and you were treated with antibiotics. Your fevers then
improved.
You were also evaluated by our physical therapists, who
recommended that you were safe to be discharged home with
physical therapy as an outpatient.
We are glad that you are feeling better.
All the best,
Your ___ team
Followup Instructions:
___
|
19671332-DS-8
| 19,671,332 | 28,172,677 |
DS
| 8 |
2133-05-18 00:00:00
|
2133-05-18 14:39:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
cefazolin
Attending: ___.
Chief Complaint:
Thrombosed AV graft fistula
Major Surgical or Invasive Procedure:
Left AV fistulogram with thrombectomy (___)
History of Present Illness:
Ms ___ is a ___ yoF with PMHx of DM, ESRD on HD (MWF), severe
aortic stenosis, mitral regurgitation, CAD, and HFrEF
(LVEF=35%), hx of MSSA bacteremia, now presenting with clotted
fistula. According to patient, she was supposed to get dialysis
today but tech could not access fistula. Last HD session was
___. Otherwise, patient feels in usual state of
health. Transplant surgery and ___ consulted in ED. Concluded pt
had thrombosed L AVG. ___ will schedule patient for fistulogram +
thrombectomy +/- balloon angioplasty +/- stenting +/- placement
of temp vs tunneled hemodialysis line. THey are requesting
patient remains NPO currently in case of procedure tomorrow but
___ resident said the case may be pushed until ___. To note,
patient has a history of MSSA bacteremia from LUE AVF infection
requiring AVF revision in ___. Most recent MSSA bacteremia
was from tunneled line in ___. Patient finished course of
antibiotics ___. At last admission allergy to cefazolin was
confirmed. patient had reported superficial desquamating rash on
pt's back,chest, arms, and face. Allergy was confirmed by
dermatologist.
In the ED, initial vitals were:
98.1 96 113/64 16 99% RA
Exam notable for L antecubital AV graft w/o thrill
Labs showed 6.0>10.___.2<185
Ca: 10.4 Mg: 2.6 P: 2.6
141/4.___/39/6.5<114
Repeat K at 1814: 4.6
No imaging done.
No medications given.
___ and Xplant surgery were consulted as above
Decision was made to admit to medicine for further management
in preparation for ___ intervention hopefully in AM.
On arrival to the floor, patient reports that the fistula is
clogged but has no pain associated with it. She is complaining
of some constipation.
Past Medical History:
Essential hypertension
Anemia of CKD
Headache
Benign neoplasm of bone and articular cartilage, site
unspecified
Leukopenia
Neoplasm of bone, soft tissue, and skin
Hypercholesterolemia
Aortic valve stenosis
Renal Cyst
Macular Scar
Cataract
Chronic kidney disease, stage V
Uterovaginal prolapse
Hyperparathyroidism due to renal insufficiency
Anemia in chronic kidney disease
DMII with renal and ophthalmic complications
Mitral regurgitation
CAD with triple vessel disease
MSSA Bacteremia
Developed dermatitis due to plastic tape or cefazolin over AVG
in
___.
___ : development of pseudo aneurysm resulting in a partial
excision
___: AVG revision and thrombectomy.
___ Angiojet thrombectomy of completely thrombosed left
AVG. Plasty with 6 and 7mm balloons and ___ of the arterial
anastomosis
Social History:
___
Family History:
Denies FH of kidney disease, DM, HTN, CAD
Physical Exam:
ADMISSION EXAM:
================
Vital Signs: 97.9PO 106/62 92 18 93 RA
General: NAD
HEENT: Sclera anicteric, MMM, oropharynx clear
CV: Regular rate and rhythm, normal S1 + S2, ___ systolic
ejection murmur best heard at LSB and radiates through
precordium but not axillae or carotids.
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, non-tender, non-distended, bowel sounds
decreased, no organomegaly, no rebound or guarding
GU: No foley
Ext: Warm, well perfused, 1+ pulses in upper and LEs, LUE AVF
with no thrill. 2+ edema of left foot to below the knee, 1+
edema on right.
SKIN: Xerosis of the left upper extremity surrounding the AVF
with some scaling. Bandage over the fistula with no active
oozing or bleeding. Some hyperpigmentation around right lower
neck/upper chest/over clavicle where tunneled line was
previously located.
DISCHARGE EXAM:
================
Vitals: 98.6 PO, 90-99/54-63, 77-91, 18, ___ ra
General: Pleasant elderly female in NAD
HEENT: Sclera anicteric, MMM, oropharynx clear
CV: Regular rate and rhythm, normal S1 + S2, ___ systolic
ejection murmur best heard at RUSB.
Lungs: Faint crackles in the right lower base. Otherwise no
significant wheezing or rhonchi.
Abdomen: Soft, non-tender, non-distended, bowel sounds
decreased,
no organomegaly, no rebound or guarding.
Ext: Warm, well perfused, 1+ pulses in upper and LEs, LUE AVF
with palpable thrill. Trace edema bilaterally.
SKIN: Chronic venous stasis changes, xerosis of the left upper
extremity surrounding the AVF with some scaling. Some
hyperpigmentation around right lower neck/upper chest/over
clavicle where tunneled line was previously located.
Pertinent Results:
ADMISSION LABS:
================
___ 06:05PM BLOOD WBC-6.0 RBC-3.47* Hgb-10.7* Hct-33.2*
MCV-96 MCH-30.8 MCHC-32.2 RDW-16.3* RDWSD-55.8* Plt ___
___ 06:05PM BLOOD Neuts-75.5* Lymphs-13.5* Monos-7.5
Eos-2.7 Baso-0.5 Im ___ AbsNeut-4.54# AbsLymp-0.81*
AbsMono-0.45 AbsEos-0.16 AbsBaso-0.03
___ 06:05PM BLOOD Glucose-114* UreaN-39* Creat-6.5*# Na-141
K-4.7 Cl-96 HCO3-31 AnGap-19
___ 06:05PM BLOOD Calcium-10.4* Phos-2.6* Mg-2.6
___ 06:14PM BLOOD K-4.6
DISCHARGE LABS:
===============
___ 07:50AM BLOOD WBC-6.7 RBC-3.10* Hgb-9.3* Hct-28.5*
MCV-92 MCH-30.0 MCHC-32.6 RDW-16.2* RDWSD-53.2* Plt ___
___ 07:50AM BLOOD Plt ___
___ 07:50AM BLOOD Glucose-96 UreaN-71* Creat-9.7*# Na-142
K-6.0* Cl-95* HCO3-19* AnGap-34*
___ 07:50AM BLOOD Calcium-9.9 Phos-3.9 Mg-2.9*
___ 01:38PM BLOOD K-3.9
MICROBIOLOGY:
===============
___ 8:55 am BLOOD CULTURE
Blood Culture, Routine (Pending): No growth to date
___ 7:07 am BLOOD CULTURE
Blood Culture, Routine (Pending): No growth to date
IMAGING/STUDIES:
=================
AV Fistulogram (___):
FINDINGS:
1. Complete thrombosis of the left upper extremity AV graft to
the level of the outflow vein.
2. Outflow vein stenosis with improvement following angioplasty
to 6 then 7 mm.
3. Satisfactory appearance of the arterial anastomosis. No
in-graft or central venous stenosis.
IMPRESSION:
Satisfactory restoration of flow following chemical and
mechanical thrombolysis with a good angiographic and clinical
result.
Brief Hospital Course:
Patient is a ___ with history of DM, ESRD on HD (MWF), severe
aortic stenosis, mitral regurgitation, CAD, and HFrEF
(LVEF=35%), hx of MSSA bacteremia, now presenting with clotted
fistula s/p thrombectomy and fistulogram on ___.
ACTIVE ISSUES:
===============
# Clotted L AVF: Patient presented to regularly scheduled
dialysis on ___, and graft was unable to be accessed. She was
referred to the ED, where she was noted not to have a palpable
thrill. ___ was consulted and she underwent AV graft fistulogram
with thrombectomy on ___ with improved flow. Dialysis was
attempted on ___ although graft was unable to be accessed.
Dialysis was attempted again on ___ successfully and the
patient was discharged home.
# ESRD on HD (___): Initiated ___, secondary to long standing
diabetes. Has L antecubital fistula, revised in ___ in
setting of MSSA bacteremia. She was continued on nephrocaps and
calcitriol during hospitalization.
# Hypotension: Noted to have softer blood pressures during
hospitalization with SBP in the ___. Appears to be at baseline.
Patient asymptomatic. At home written for lisinopril 2.5mg po
daily, although on discussion with the patient and her family
she does not take this regularly at home. Please discuss further
as an outpatient about need for lisinopril.
CHRONIC ISSUES
===============
# Anemia: Likely anemia secondary to ESRD. On Aranesp q 2 weeks.
Stable during admission with discharge H/H of 9.___.5.
# Systolic heart failure: Diagnosed ___ with LVEF ___
consistent with LAD ischemia. Her last cath showed 3 vessel CAD.
By report was prescribed lisinopril, although family reports
that she does not take this at home. Not restarted while
inpatient due to soft blood pressures. Should consider
restarting as outpatient. Metoprolol was held during ___
hospitalization and not restarted. Should also discuss
restarting this as an outpatient. Fluid was managed with HD, and
patient appeared euvolemic during hospitalization.
# Coronary Artery Disease: Continued on aspirin and atorvastatin
during admission.
# Non-insulin dependent Diabetes Mellitus: Complicated by
retinopathy and CKD. It does not appear that she is on any
medications for glycemic control. Pt's son reports DM is diet
controlled. A1c 4.7%.
# Severe AS: Patient with severe AS on TTE with valve area <1.0.
She will follow-up for ongoing evaluation for CABG/AVR.
# Skin sensitivity with scaling rash: Recommend outpatient
dermatology follow-up.
# Hx of MSSA bacteremia: Last bacteremia in ___ and patient
finished course of vancomycin ___. No fevers/chills this
admission. Blood cultures pending on discharge.
***TRANSITIONAL ISSUES***
- Patient has several stitches in AVF s/p procedure with ___,
these can be removed at appointment with Dr. ___
- ___ discontinued during last hospitalization; can
consider as an outpatient if this should be restarted in the
setting of her known heart failure
- Lisinopril not given during hospitalization; by report she
does not take at home anyways. Please follow-up as outpatient
- Noted to have some scaling over AV graft site as well as
scaling on her face; may benefit from dermatology follow-up
- Continue work-up for AVR as scheduled
- Blood cultures pending on discharge
- Discharge weight: 64.1 kg
- Code: Full
- Contact: Name of health care proxy: ___ AND ___
___
___: son and daughter Phone number: ___ AND
___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 80 mg PO QPM
3. Calcium Acetate 667 mg PO TID W/MEALS
4. Docusate Sodium 100 mg PO 3X/WEEK (___)
5. Acetaminophen 650 mg PO TID
6. Clobetasol Propionate 0.05% Cream 1 Appl TP BID
7. Nephrocaps 1 CAP PO QAM
8. Lisinopril 2.5 mg PO DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO TID
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 80 mg PO QPM
4. Calcium Acetate 667 mg PO TID W/MEALS
5. Clobetasol Propionate 0.05% Cream 1 Appl TP BID
6. Docusate Sodium 100 mg PO 3X/WEEK (___)
7. Nephrocaps 1 CAP PO QAM
8. HELD- Lisinopril 2.5 mg PO DAILY This medication was held.
Do not restart Lisinopril until instructed by Dr. ___
___ Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
Left AV Graft Fistula Thrombosis (___)
Secondary Diagnosis:
End Stage Renal Disease on Hemodialysis
Hyperkalemia
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 ___ after
your graft was unable to be accessed at dialysis. In the
Emergency Department you were noted to have a clot in your graft
blocking any flow. On ___ you underwent a fistulagram with
Interventional Radiology and the clot was removed. On ___ we
attempted dialysis, although were unable to access your graft.
On ___ you underwent your regularly scheduled dialysis without
any difficulty.
Please weigh yourself every morning, call MD if weight goes up
more than 3 lbs. You should resume your regular dialysis as
scheduled.
It was a pleasure taking care of you,
Your ___ Team
Followup Instructions:
___
|
19671670-DS-6
| 19,671,670 | 23,097,776 |
DS
| 6 |
2169-01-11 00:00:00
|
2169-01-12 11:53:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Shortness of Breath
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
Ms. ___ is an ___ year-old lady with a PMH of COPD, with
recent treatment for COPD exacerbation by our ED ___, now
re-presenting with shortness of breath and cough.
Cough began last week; it is intermittently productive of beige
sputum, with no blood in it. She denies any fevers or chills; in
the ED, she had reported feeling feverish around noon today. As
noted, she was seen in our ED on ___, and prescribed 5 days
of azithromycin, prednisone 60 mg and albuterol inhaler. She
followed up with her PCP, and noted that she didn't like taking
the prednisone, but continued treatment anyway. She also reports
discomfort with deep breathing but no chest pain. In the ED, she
reported that SOB worsened today at around noon when she was
taking a walk. She felt improved after getting nebulizers from
the EMS.
In the ED, initial vs were: 99.3 89 171/72 22 98% neb. Peak flow
pre-nebs was 120. Labs were remarkable for WBC 12.7 with 80%N
(no bands); lactate 1.1; troponin < 0.01. Blood culture was
sent. CXR PA/lat showed hyperinflated lungs, and ED staff
thought possibly a LLL consolidation. Patient was given
albuterol/ipratropium nebulizers and levofloxacin. Peak flow
after nebs was 110, but patient reports feeling much better
after nebulizers. EKG (not uploaded on the Dash) reportedly
showed non-specfic ST-T changes, consistent with prior. Vitals
on transfer were: 98.4 87 136/64 24 97% RA.
On the floor, patient was breathing comfortably. She wonders why
this could not be treated as an outpatient. She was having left
buttock pain, but feels better lying on her right side.
Review of sytems:
(+) Per HPI. Low back pain that she attributes to being very
bony, decreased PO intake recently.
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies chest pain or tightness, palpitations.
Denies nausea, vomiting, diarrhea, constipation or abdominal
pain. No dysuria. Denies arthralgias or myalgias. Ten point
review of systems is otherwise negative.
Past Medical History:
osteoporosis
h/o right partial lobectomy for lung nodule- reportedly benign
arthritis
COPD
Social History:
___
Family History:
non-contributory
Physical Exam:
Admission Physical Exam:
Vitals- 98.6 167/73 102 20 93%RA 36kg 5'1"
General- Elderly and frail. Alert, oriented, no acute distress
HEENT- Sclera anicteric, MMM, oropharynx clear.
Neck- supple, JVP not elevated, no LAD
Lungs- Diffuse wheezes, worse with forced exhalation. Good air
movement throughout.
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
GU- no foley
Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro- Alert, awake and oriented x3. Speech fluent. CNs2-12
grossly intact and symmetric, motor function grossly normal
.
Discharge Physical Exam:
Vitals- 98.0 147/61 71 16 99%RA 36kg 5'1"
General- Elderly and frail. Alert, oriented, no acute distress
HEENT- Sclera anicteric, MMM, oropharynx clear.
Neck- supple, JVP not elevated, no LAD
Lungs- Diffuse wheezes, worse with forced exhalation. Good air
movement throughout.
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
GU- no foley
Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro- Alert, awake and oriented x3. Speech fluent. CNs2-12
grossly intact and symmetric, motor function grossly normal
Pertinent Results:
Admission Labs:
___ 11:35PM PLT COUNT-255
___ 11:35PM NEUTS-80.4* LYMPHS-10.3* MONOS-7.8 EOS-1.0
BASOS-0.5
___ 11:35PM WBC-12.7* RBC-4.12* HGB-13.3 HCT-39.6 MCV-96
MCH-32.2* MCHC-33.5 RDW-12.7
___ 11:35PM cTropnT-<0.01
___ 11:35PM GLUCOSE-109* UREA N-20 CREAT-0.7 SODIUM-137
POTASSIUM-4.2 CHLORIDE-100 TOTAL CO2-26 ANION GAP-15
___ 11:40PM LACTATE-1.1
___ 11:40PM ___ COMMENTS-GREEN TOP
.
Discharge Labs:
___ 07:40AM BLOOD WBC-11.1* RBC-3.91* Hgb-12.6 Hct-37.1
MCV-95 MCH-32.3* MCHC-34.0 RDW-12.4 Plt ___
___ 07:40AM BLOOD Glucose-79 UreaN-19 Creat-0.8 Na-136
K-4.4 Cl-98 HCO3-27 AnGap-15
___ 07:40AM BLOOD CK(CPK)-29
___ 07:40AM BLOOD CK-MB-1 cTropnT-<0.01
.
Microbiolgy:
Blood Cultures x2 (___): Pending.
.
Pathology: None.
.
Imaging/Studies:
# CXR (___): IMPRESSION: New left lower lobe pneumonia.
Brief Hospital Course:
Ms. ___ is an ___ year-old lady with a PMH of COPD, with
recent treatment for COPD exacerbation by our ED ___, now
re-presenting with shortness of breath and cough.
.
Active Diagnoses:
.
# LLL Pneumonia vs. COPD exacerbation: She was recently treated
for a COPD exacerbation but she claims that she was still
coughing and short of breath. She has been afebrile. Chest X-ray
in the ER showed new LLL consolidation consistent with
pneumonia. Leukocytosis with neutrophilic predominance was also
present. She was started on levofloxacin, prednisone, and
albuterol/ipratroprium neubulizer treatments. Blood and sputum
culutres were obtained. Her O2 saturation on the floor was 93%
on RA. She began to feel better after receiving the nebulizer
treatments. She was able to maintain her O2 saturations after
ambulation. She was taught how to use Advair, Spiriva, and her
albuterol inhaler. She was then discharged home. She will follow
up with her PCP in one week.
.
Chronic Diagnoses:
.
# Back/hip pain: Likely secondary to osteoarthritis and very
thin body habitus. She was given Tylenol as needed for pain.
# Hypertension: She was mildly hypertensive on arrival to the
floor, with some contribution of pain from hip. No chest pain,
HA or blurry vision. Her home enalapril was continued.
# Osteoporosis: Continued home calcium and vitamin D.
# History of cancers: Stable. No findings to suggest recurrence
of malignancy.
.
Transitional Issues:
# She will have home nursing care to insure that she is taught
how to take Advair, Spiriva, and use her albuterol inhaler.
# She will follow up with her PCP ___ 1 week.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Pravastatin 20 mg PO DAILY
2. Enalapril Maleate 10 mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. Multivitamins 1 TAB PO DAILY
5. Calcium 500 + D (calcium carbonate-vitamin D3) 500
mg(1,250mg) -200 unit Oral daily
Discharge Medications:
1. Enalapril Maleate 10 mg PO DAILY
2. Multivitamins 1 TAB PO DAILY
3. Pravastatin 20 mg PO DAILY
4. PredniSONE 40 mg PO DAILY Duration: 5 Days
RX *prednisone 20 mg 2 tablet(s) by mouth daily Disp #*8 Tablet
Refills:*0
5. Calcium 500 + D (calcium carbonate-vitamin D3) 500
mg(1,250mg) -200 unit Oral daily
6. Albuterol Inhaler 2 PUFF IH Q4H:PRN shortness of breath
Please teach patient how to use with spacer
RX *albuterol sulfate 90 mcg 2 puffs inh every four (4) hours
Disp #*2 Unit Refills:*0
7. Aerochamber MV (inhalational spacing device) 1 aerochamber
Miscellaneous With inhaler
RX *inhalational spacing device [Aerochamber MV] use with
inhaler Disp #*1 Unit Refills:*0
8. Tiotropium Bromide 1 CAP IH DAILY
RX *tiotropium bromide [Spiriva with HandiHaler] 18 mcg 1 inh
daily Disp #*30 Capsule Refills:*0
9. Aspirin 81 mg PO DAILY
10. Levofloxacin 500 mg PO Q24H
RX *levofloxacin [Levaquin] 500 mg 1 tablet(s) by mouth daily
Disp #*6 Tablet Refills:*0
11. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
RX *fluticasone-salmeterol [Advair Diskus] 250 mcg-50 mcg/Dose 1
puff inh twice a day Disp #*1 Unit Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary: Left Lower Lobe Pneumonia, COPD exacerbation
Secondary: Dyslipidemia, Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were seen in the hospital after having a cough productive of
beige sputum for the past week. You felt a little feverish
yesterday. In the ER, your chest X-ray showed that you had
developed a pneumonia. You were given breathing treatments and
you were started on antibiotics and steroids. You started to
feel better and were discharged. You will be discharged with
medicines that will help to treat your COPD. Please continue the
steroids for four more days and the levofloxacin for 6 more
days.
It was a pleasure to be a part of your care.
Followup Instructions:
___
|
19672507-DS-7
| 19,672,507 | 23,439,700 |
DS
| 7 |
2181-11-18 00:00:00
|
2181-11-18 19:00:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
abd pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ w h/o etoh and recurrent pancreatitis p/w abdominal pain.
Pt was in USOH until morning of ___ when he had sudden onset of
sharp epigastric pain similar to his previous pancreatitis pain.
It is constant, non-radiating, associated with some episodes of
bilious non-bloody emesis. Alleviated only with pain meds, worse
with any PO. Severe. No diarrhea or abdominal distention. No
sick contacts. Denies jaundice, icterus, dark urine, ___
stools, history of gallstones. Denies abdominal trauma, new
meds. Reports he only drinks 4 drinks at a time once or twice a
week. Last drink was on ___ when he reports having had 4 beers.
No sick contacts, viral URIs, FHx of GI issues.
Endorses a brief (minutes) long episode of sharp sub-sternal
pain/pressure only after vomiting which resolved spontaneously.
No SOB. No personal or family history of heart disease. No
cholesterol, HTN.
Pt denies current or previous history of etoh withdrawal. Denies
HA, anxiety, tremor, AH/VH.
Reports chills without fevers. No HA, confusion, weakness (other
than globally weak because he hasn't eaten), paresthesias, URI
sxs, dysuria, hematuria, urinary frequency (actually less since
not taking great PO today), joint pain (beyond baseline LBP),
myalgias, sick contacts, recent travel. 10 pt ROS otherwise
negative.
In ED, 97.2 66 161/81 16 100%RA. Severe epigastric tenderness.
Labs showed elevated lipase and leukocytosis. Recevied morphine
4mg IV x1, then hydromorphone 1mg IV, magic mouthwash and Zofran
4mg IV x2, 1L NS, admitted to medicine.
Past Medical History:
pancreatitis, pt reports 8 previous episodes
heavy etoh use per chart, pt denies any withdrawal symptoms
low back pain
Social History:
___
Family History:
no GI disorders, no cardiac disease
Physical Exam:
ADMISSION
98.5 PO 132 / 62 51 14 100
pleasant, uncomfortable, in pain
NCAT, anicteric
slightly bradycardic, I/VI SEM
CTAB, speaking comfortably in full sentences
soft, ttp epigastrum, negative ___ (but limited by
patient's pain), non-distended, NABS
wwp, neg edema
A&Ox3, EOMI, PERRL, face symmetric with activation, tongue
midline, ___ BUE/BLE, SILT BUE/BLE, no tremor, no tongue
fasciculation
no rash, no diaphoresis
no foley
Discharge PE:
VS: 98.2 120 / 74 77 16 98 RA
Gen: supine in bed, comfortable appearing
Eyes - EOMI
ENT - OP clear, MMM
Heart - RRR no mrg
Lungs - CTA bilaterally
Abd - soft, NT, ND +BS
Ext - no edema
Skin - no rashes
Vasc - 2+ DP/radial pulses
Neuro - AOx3, moving all extremities
Psych - appropriate
Pertinent Results:
___ 04:46PM GLUCOSE-118* UREA N-12 CREAT-0.7 SODIUM-139
POTASSIUM-4.1 CHLORIDE-99 TOTAL CO2-26 ANION GAP-18
___ 04:46PM ALT(SGPT)-19 AST(SGOT)-24 ALK PHOS-97 TOT
BILI-0.6
___ 04:46PM LIPASE-829*
___ 04:46PM ALBUMIN-5.0
___ 04:46PM WBC-17.0* RBC-5.25 HGB-15.9 HCT-47.4 MCV-90
MCH-30.3 MCHC-33.5 RDW-12.1 RDWSD-39.8
___ 04:46PM NEUTS-88.8* LYMPHS-7.1* MONOS-3.3* EOS-0.1*
BASOS-0.2 IM ___ AbsNeut-15.10* AbsLymp-1.20 AbsMono-0.56
AbsEos-0.01* AbsBaso-0.03
EKG: SB at 50, NANI, JPE V1-V3, biphasic T in V1 and TWI in III
(no olds for comparison)
CXR: Final Report
EXAMINATION:
Chest: Frontal and lateral views
INDICATION: History: ___ with epigastric pain // ?free air
TECHNIQUE: Chest: Frontal and Lateral
COMPARISON: None.
FINDINGS:
The lungs are clear without focal consolidation. No pleural
effusion or
pneumothorax is seen. The cardiac and mediastinal silhouettes
are
unremarkable. No evidence of free air is seen beneath the
diaphragms.
IMPRESSION:
No acute cardiopulmonary process. No evidence of free air
beneath the
diaphragms.
Brief Hospital Course:
This is a ___ year old male with past medical history of alcohol
abuse complicated by prior alcoholic pancreatitis admitted
___ with alcoholic pancreatitis, treated with conservative
management.
# Acute pancreatitis: Patient presented with abdominal pain,
nausea and vomiting in the setting of reported recent alcohol
and fatty food consumption. Calcium and triglycerides wnl.
Ultrasound without signs of gallstones or biliary obstruction.
Patient treated conservatively with NPO, IV fluids, symptom
control with IV dilauidid and Zofran. His symptoms improved and
his pain was ___ on day of discharge. His diet was advanced to
regular low fat which he tolerated well without pain.
-Continue low fat diet
-Counseled on importance of alcohol cessation.
# Leukocytosis - Peaked at 17k at admission without signs of
infection. Trended to normal without intervention. Suspect
stress and inflammatory response to pancreatitis.
# Alcohol Abuse - no issues with withdrawal. Treated with
thiamine and folate repletion. Social work consulted and
provided patient with outpatient resources.
# Lower back pain - continued home gabapentin
# Tobacco abuse - continued nicotine patch
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Gabapentin 1200 mg PO TID
Discharge Medications:
1. Gabapentin 1200 mg PO TID
Discharge Disposition:
Home
Discharge Diagnosis:
# Acute pancreatitis
# Leukocytosis
# Alcohol Abuse
# Lower back pain
# Tobacco abuse
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr. ___:
It was a pleasure caring for you at ___. You were admitted
with abdominal pain from pancreatitis. This was due to alcohol.
You were treated with fluids and pain medications and you
improved. You are now ready for discharge home. It is very
important that you avoid drinking alcohol to prevent this from
happening again.
Followup Instructions:
___
|
19672845-DS-22
| 19,672,845 | 27,439,137 |
DS
| 22 |
2191-11-28 00:00:00
|
2191-11-28 14:13:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Fall
Major Surgical or Invasive Procedure:
Intubation ___
History of Present Illness:
___ (MRN ___ is a ___ woman, past medical
history of invasive pleural carcinoma and colonic mass,
dementia, B12 and iron deficiency, who presents from her nursing
home after a fall. Patient is unable to provide a history.
History is obtained from outside hospital records.
She "presents to the emergency room after a fall with a head
strike at the nursing facility. There is no loss of
consciousness, and the patient was initially awake and talking.
She is brought to the emergency room for further evaluation.
Shortly after arrival to the emergency room, patient became less
responsive, with eyes deviated to the right, no longer answering
questions, making some purposeful movements with arms with
painful stimuli, but unable to provide any history." Given the
deterioration in mental status, she was intubated for airway
protection. Her blood pressures range from 100s-130s, and "were
not elevated enough to start a nicardipine drip." Her legal
guardian is ___ who Dr. ___ attending) spoke with
on the phone. "The patient has no living family members or next
of kin and [Ms. ___ is a professional guardian taking care
of her. There is no MOLST and she is full code for now and would
want emergency interventions, but (Ms. ___ may readdress
that situation if her situation becomes more dire." She was
transferred for further care to ___.
Of note,: The patient has a baseline of dementia and walks with
a walker. She was previously followed for a porocarcinoma, and
per her last Heme-onc notes, she was found to have a colonic
mass on an OSH colonoscopy, which was being worked up at ___.
Unable to reach legal ___. A message was left
on her voicemail (phone ___.
On neuro ROS, unable to assess ___ mental status On general
review of systems, unable to assess ___ mental status
Past Medical History:
Skin lesions, generalized
Porocarcinoma of RUE
?Colonic Mass, per notes on ___, undergoing workup at ___.
Squamous cell carcinoma
B12 deficiency
Anxiety
Psychosis
Pseudophakia
Vitamin D deficiency
Hematuria
History of fracture of the left hip, ___ ORIF at ___
History of fracture right hip
Dementia
Insomnia
Cholecystectomy
Tonsillectomy
Pseudoexfoliation, lens capsule
Severe stage glaucoma
Social History:
___
Family History:
Unknown
Physical Exam:
ON ADMISSION
============
Vitals: No temperature recorded.
73 128/74 19 100% Intubation
General: Intubated, sedated, cachetic with temporal wasting
HEENT: NC/AT,
Pulmonary: Intubated
Cardiac: RRR, warm, well-perfused
Abdomen: soft, non-distended
Extremities: No ___ edema.
Skin: no rashes or lesions noted.
Neurologic: Propofol 40 held for ___ minutes.
-Mental Status: Minimal spontaneous eye opening. Occasionally
turns eyes to name, but inconsistent. Does not track or regard.
Inconsistently follows appendicular commands with Right hand -
able to squeeze and release; cannot show two fingers; does not
follow with left hand. Unable to follow midline commands.
-Cranial Nerves:
II, III, IV, VI: R pupil 3 to 2mm and brisk; L pupil 4 mm NR.
+BTT bilaterally. gaze midline, unable to test EOMI
V: intact corneal bilaterally
VII: unable to assess facial symmetry.
VIII: Hearing intact to voice bilaterally.
IX, X: Unable to test cough/gag, as patient bites on ETT.
-Sensory - Motor: Decreased bulk, normal tone throughout. No
adventitious movements, such as tremor, noted. Spontaneous
purposeful movements of RUE and RLE antigravity. Minimal
withdrawal of LUE to noxious, LLE TF to noxious (pinch).
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 2 0
R 2 2 2 2 0
Plantar response was extensor bilaterally.
-Coordination: unable to assess
-Gait: unable to assess
DISCHARGE EXAM:
================
Pt looks comfortable, NAD, non-labored breathing.
Pertinent Results:
___ 03:48AM BLOOD %HbA1c-5.0 eAG-97
___ 03:48AM BLOOD Triglyc-191* HDL-26* CHOL/HD-4.4
LDLcalc-50
___ 03:48AM BLOOD TSH-2.7
___ 05:00AM BLOOD WBC-15.8* RBC-3.06* Hgb-8.4* Hct-28.0*
MCV-92 MCH-27.5 MCHC-30.0* RDW-16.5* RDWSD-52.5* Plt ___
___ 05:00AM BLOOD Glucose-93 UreaN-27* Creat-0.6 Na-142
K-5.2* Cl-104 HCO3-29 AnGap-9*
___ 05:00AM BLOOD Calcium-8.9 Phos-3.7 Mg-2.3
CT HEAD ___
Acute intraparenchymal hemorrhage centered in the region of the
right basal ganglia and internal capsule spanning up to 3.0 cm
with surrounding edema. No midline shift.
TTE ___
The left atrium is normal in size. Left ventricular wall
thicknesses and cavity size are normal. There is moderate
regional left ventricular systolic dysfunction with hypokinesis
of the distal ___ of the ventricle, most c/w takotsubo
cardiomyopathy. The remaining segments contract normally (LVEF =
___. Right ventricular chamber size and free wall motion are
normal. The aortic valve leaflets (3) are mildly thickened but
aortic stenosis is not present. No aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. There is no
mitral valve prolapse. There is no systolic anterior motion of
the mitral valve leaflets. Trivial mitral regurgitation is seen.
Moderate [2+] tricuspid regurgitation is seen. There is mild
pulmonary artery systolic hypertension. There is a
trivial/physiologic pericardial effusion.
IMPRESSION: Regional left ventricular systolic dysfunction,
most c/w takotsubo cardiomyopathy. Moderate tricuspid
regurgitation. Mild pulmonary hypertension.
MRI HEAD / MRA HEAD W/O CONTRAST ___
1. Moderately motion degraded examination.
2. Stable known acute right basal ganglia - centered parenchymal
hematoma.
3. No mass.
4. Brain parenchymal atrophy. Mild chronic small vessel
ischemic changes.
5. Severely motion degraded nondiagnostic MRA brain. No
definite vascularity at the level of the hematoma.
6. Left lens dislocation, stable.
Brief Hospital Course:
Ms ___ is a ___ year old woman with a history of dementia
who presented to an outside hospital on ___t her
nursing home. Although she was noted to initially be awake and
following commands, she subsequently became minimally responsive
with R gaze deviation and was intubated for airway protection.
CT head revealed a right basal ganglia intraparenchymal
hemorrhage. Clinically, her course continues to be complicated
by a baseline of poor cognitive status in setting of malignancy
(porocarcinoma, colonic mass suspicious for colon cancer).
Prognosis for meaningful recovery remains dismal and escalation
of care is medically futile. Disposition was initially
complicated by the fact that her legal guardian did not have
authority to change her goals of care to comfort measures only
(CMO). Following a court case on ___, her legal guardian was
given authority to make the decision about whether to change her
code status to CMO. Then she was transferred to CMO from DNR/DNI
per her legal guardian.
#Intraparenchymal hemorrhage: She was intubated at the outside
hospital and subsequently transferred to ___ and admitted to
the Neuro ICU. MRI shows no underlying mass, and MRA did not
reveal any vascular malformation. Given the location of the
bleed as well as her cardiomyopathy (see below), it was felt
that a transient adrenergic surge led to an acute rise in blood
pressure, causing her hemorrhage. Blood pressure was maintained
<150, although she did not require any anti-hypertensives to
adhere to this. Given the report of unresponsiveness with right
eye deviation at the outside hospital, there was concern for
seizure. EEG monitoring was performed for 24 hours but did not
reveal any seizures or epileptiform discharges.
#Takotsubo cardiomyopathy
#Cardiogenic shock: On arrival to the ICU, she was noted to be
hypotensive to the 80-90s systolic, without response to IV fluid
boluses. Lactate was elevated to 2 on admission. She maintained
a urine output of at 0.5cc/kg/hr, although her mental status was
difficult to follow given her hemorrhage and intubation. A
bedside as well as formal echocardiogram were consistent with
Takotsubo cardiomyopathy. She was initially started on
Epinephrine, which was subsequently changed to Vasopressin.
#Pulmonary hypoxia
#Pneumonia: Completed full course of Vancomycin 500mg q12h
(___) and Cefepime 1g q24h
(___). Active diuresis with Lasix was conducted
to improve oxygenation.
#Goals of care/Code status: Ms ___ health care decisions are
made by her legal ___, as she has no living
relatives. Given her acute intracranial hemorrhage and
cardiogenic shock, as well as poor baseline function, it was
felt that in the event she were to acutely worsen, CPR and
intubation would be medically futile and harmful to the patient.
According to hospital policy CP-26 regarding care that is futile
or harmful, her code status was changed to DNAR/DNI. Patient was
later transitioned to ___ focused care only per her legal
guardian.
Transitional Issues:
==============
- All home medications were stopped.
1. Dysphagia screening before any PO intake? (x) Yes - () No
2. DVT Prophylaxis administered? (x) Yes - () No
3. Smoking cessation counseling given? () Yes - (x) 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)? () Yes - (x) 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 1000 mg PO BID:PRN Pain - Mild
2. brimonidine 0.2 % left eye BID
3. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600
mg(1,500mg) -400 unit oral BID
4. Ferrous Sulfate 325 mg PO BID
5. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
6. Senna 8.6 mg PO DAILY
7. Sertraline 50 mg PO DAILY
8. TraZODone 50 mg PO QHS
Discharge Medications:
1. Glycopyrrolate 0.1 mg IV Q6H:PRN excess secretions
2. Haloperidol 0.25 mg IV Q6H:PRN anxiety
3. LORazepam 0.5-2 mg IV Q4H:PRN anxiety or agitation
4. Morphine Sulfate ___ mg IV Q1H:PRN pain or respiratory
distress
5. OLANZapine (Disintegrating Tablet) 5 mg PO Q4H:PRN
delirium/restlessness
6. Ondansetron ___ mg IV Q6H:PRN nausea/vomiting
7. Acetaminophen 1000 mg PO BID:PRN Pain - Mild
8. TraZODone 50 mg PO QHS
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Right basal ganglia intraparenchymal hemorrhage
Pneumonia
Takotsubo cardiomyopathy
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Lethargic but arousable.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Ms. ___,
You were hospitalized following a fall in which you struck your
head resulting from an ACUTE HEMORRHAGIC STROKE, a condition
where a blood vessel providing oxygen and nutrients to the brain
has diminished flow due to hemorrhage. The brain is the part of
your body that controls and directs all the other parts of your
body, so damage to the brain from being deprived of its blood
supply can result in a variety of symptoms.
Stroke can have many different causes, so we assessed you for
medical conditions that might raise your risk of having stroke.
In order to prevent future strokes, we plan to modify those risk
factors. Your risk factors are:
- High blood pressure
We are changing your medications as follows:
- Stopped all home meds
- Started comfort medications (see list)
Sincerely,
Your ___ Neurology Team
Followup Instructions:
___
|
19672860-DS-17
| 19,672,860 | 28,853,265 |
DS
| 17 |
2135-06-03 00:00:00
|
2135-07-02 13:55:00
|
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:
___: Open exploratory laparotomy, lysis of adhesions, wound
closure in layers and negative pressure VAC placement.
___: ___ line placement
History of Present Illness:
Mr. ___ is a ___ who underwent an open R hemicolectomy
on ___ for cecal volvulus, who presents to the ED with 24
hours of nausea/emesis, distension and inability to tolerate
PO's.
With regards to his recent surgical history, he presented to the
ED on ___ with 1 day of acute RLQ pain and nausea, and was
found to have evidence of a cecal volvulus on CT scan. His
symptoms had largely subsided by the time of our evaluation,
suggesting a transient/resolved process, however given the risk
of recurrence he underwent an open R hemicolectomy with primary
ileocolic anastomosis. The case was uncomplicated, as was his
postoperative course, and he was discharged 2 days ago on
___, tolerating a diet, passing flatus and having liquid
stools. However, yesterday morning he woke up with nausea and
had
several bouts of bilious emesis over the course of the day, in
addition to increasing abdominal distension and inability to
tolerate POs. Last BM was yesterday afternoon around 1pm, hasn't
passed flatus since yesterday morning. He denies fevers/chills,
chest pain, dyspnea, BRBPR, melena, dysuria.
Past Medical History:
Past Medical History: none
Past Surgical History: open R hemicolectomy ___ (___),
excision cyst neck left
Social History:
___
Family History:
Family History: No known GI history
Physical Exam:
Admission Physical Exam:
Vitals: T 98.8, HR 80, 111/64, 16, 100% RA
GEN: A&O, NAD
HEENT: No scleral icterus, mucus membranes moist
CV: regular rate and rhythm
PULM: breathing comfortably on room air, no respiratory distress
ABD: Soft, mildly distended/RLQ tender to palpation, well-healed
midline incision w staples c/d/i.
Ext: No ___ edema, ___ warm and well perfused
Discharge Physical Exam on ___:
Vitals: T 97.9 oral BP 115/72 HR 80 RR 18 O2 Sat: 98% RA
Gen: A+Ox3. NAD.
Chest: Regular rate and rhythm, no m/g/r
Lungs: Lung sounds clear bilaterally
ABD: Soft, non-tender, +BS. Midline incision well-approximated,
OTA, no erythema, hematoma, or drainage noted.
Ext: No edema or calf pain.
Pertinent Results:
___ 06:08AM BLOOD WBC-5.4 RBC-4.17* Hgb-12.6* Hct-38.8*
MCV-93 MCH-30.2 MCHC-32.5 RDW-12.8 RDWSD-43.6 Plt ___
___ 10:45AM BLOOD Neuts-71.2* Lymphs-15.1* Monos-12.5
Eos-0.3* Baso-0.3 Im ___ AbsNeut-4.43 AbsLymp-0.94*
AbsMono-0.78 AbsEos-0.02* AbsBaso-0.02
___ 06:08AM BLOOD Glucose-89 UreaN-19 Creat-0.6 Na-141
K-4.6 Cl-103 HCO3-23 AnGap-15
___ 07:00AM BLOOD ALT-59* AST-27 LD(LDH)-223 AlkPhos-88
TotBili-0.5
___ 06:08AM BLOOD Calcium-9.4 Phos-4.5 Mg-2.1
___ 04:49AM BLOOD Triglyc-85
___ 02:05AM BLOOD Lactate-1.3
___ 02:30AM URINE Color-Yellow Appear-Clear Sp ___
___ 02:30AM URINE Blood-NEG Nitrite-NEG Protein-30*
Glucose-NEG Ketone-80* Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
___ 02:30AM URINE RBC-1 WBC-2 Bacteri-FEW* Yeast-NONE Epi-0
___ 02:30AM URINE Mucous-RARE*
**FINAL REPORT ___
URINE CULTURE (Final ___: < 10,000 CFU/mL.
CT ABD & PELVIS WITH CONTRAST ___:
IMPRESSION:
1. Distended and stool-filled cecum with a dilated distal ileum.
There is
decompression of the ascending colon which then reconstitutes
more distally near the transverse colon. Additionally, there is
prominence of the fluid-filled appendix. Findings are
concerning for a bowel obstruction secondary to a cecal
volvulus. Additionally, because of the pattern of the small
bowel displacing the ascending colon, an internal hernia
component should also be considered. The bowel wall enhances
normally. There is small volume free fluid in the pelvis.
2. Mild delayed nephrogram on the right compared to the left
with fullness of the right renal collecting system and mild
hydroureter. No stone is
demonstrated. Findings may be secondary to adjacent bowel
dilatation/distension. As the ureter is distended to the level
of the bowel abnormality in right lower quadrant and is normal
inferiorly
3. Small amount of ascites
ABDOMEN (SUPINE & ERECT) ___:
IMPRESSION:
1. Numerous dilated loops of small bowel with air-fluid levels,
findings
concerning for obstruction. Recommend further evaluation with
CT
abdomen/pelvis.
2. Small amount of pneumoperitoneum noted below the right
hemidiaphragm, not unexpected in the setting of recent surgery.
CT ABD & PELVIS WITH CONTRAST ___:
IMPRESSION:
1. Multiple dilated loops of small bowel containing air-fluid
levels, with
transition point located in the right lower quadrant and
collapsed loops of distal bowel, consistent with high-grade
obstruction.
2. Redemonstration of mild fullness of the right renal
collecting system and mild hydroureter extending to the
midportion of the right ureter, similar in appearance to prior
CT abdomen/pelvis from ___. Again no stone is
demonstrated. Findings may be secondary to adjacent bowel
distension.
3. Few locules of air within the urinary bladder, likely
secondary to recent instrumentation. However correlation with
urinalysis should also be considered to exclude infection.
4. Small volume free fluid in the pelvis.
5. Trace right pleural effusion.
ABDOMEN (SUPINE ONLY) ___:
IMPRESSION:
Persistent moderate-to-severe small bowel dilatation. Enteric
contrast in the proximal:, Unchanged suggesting slow motility.
No evidence of free air. Advancing the nasogastric tube by at
least 5 cm may be appropriate for better seating in the stomach.
CT ABD & PELVIS WITH CONTRAST ___:
IMPRESSION:
1. Small bowel dilated up to 6.9 cm up to the ileocolic
anastomosis, with
probable transition point within the right hemiabdomen, which
could represent persistent high-grade obstruction. Recommend
repeat imaging without oral and IV contrast to reassess
progression of the oral contrast.
2. Mild to moderate free fluid in the pelvis as before, with
worsening
enhancement of the peritoneum, suggestive of peritonitis.
3. Tiny bilateral pleural effusions are seen, slightly worse
compared to
previously.
CHEST (PORTABLE AP) ___:
IMPRESSION:
Heart size and mediastinum are stable. NG tube tip is in the
stomach. Right PICC line tip is at the cavoatrial junction.
Epidural pain control devise is in place. Small pneumoperitoneum
is related to recent laparoscopic surgery. No focal
consolidations or other findings that can explain patient's
symptoms demonstrated.
Brief Hospital Course:
Mr. ___ is a ___ who underwent an open right hemicolectomy
on ___ for cecal volvulus, who presented to the ED this
admission with 24 hours of nausea/emesis, distension and
inability to tolerate PO's. He underwent a CT abdomen/pelvis
which demonstrated a high grade SBO w/ transition point in the
RLQ. He was admitted to ___ for a trial of non-operative
management. An NGT was placed and he later underwent
gastrografin study which indicated a partial small bowel
obstruction with contrast seen in the ascending colon
(presumably new contrast) and rectum (presumably old contrast).
On ___, the patient was passing flatus. On ___, the patient
had bowel movements and the NGT was removed and he was advanced
to clears. A KUB was later obtained due to abdominal distension
and it showed moderate to severe small bowl diliation w/
contrast in the proximal colon. Diet was backed down to NPO and
a NGT was replaced. Given the patient's slow return of bowel
function and persistent bowel obstruction, surgery was
indicated.
On ___, the patient was taken to the operating room and
underwent open exploratory laparotomy, lysis of adhesions, wound
closure in layers and negative pressure VAC
placement. This procedure went well (reader, please refer to
operative note for details). The Acute Pain Service placed an
epidural for pain control. A foley catheter was left in place
and he was kept NPO with IVF. A PICC line was placed and TPN was
initiated. NGT was clamped and then later placed to gravity.
The pravena vac was removed on POD #4. The patient passed
flatus. On POD #5, the NGT was removed, he was started on sips,
epidural and foley were removed and he had a bowel movement. He
was written for acetaminophen and oxycodone PRN for pain
control. On POD #6, the patient was started on a regular diet
which he tolerated. His TPN was cycled and eventually
discontinued on ___ before discharge home.
At the time of discharge, the patient was doing well, afebrile
and hemodynamically stable. The patient was tolerating a diet,
ambulating, voiding without issue, having regular bowel
movements, and pain was well controlled. His PICC line was
removed prior to discharge. The patient received discharge
teaching and follow-up instructions with understanding
verbalized and agreement with the discharge plan. He will follow
up with Dr. ___ in ___ clinic in two weeks.
Medications on Admission:
None
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild/Fever
Discharge Disposition:
Home
Discharge Diagnosis:
Persistent high grade 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 ___ with a small bowel obstruction. You
were initially treated non-operatively with bowel rest,
nasogastric tube decompression, intravenous fluids, monitoring
of your abdominal exam and abdominal x-rays. You were started on
TPN (nutrition through the IV) due to prolonged bowel rest.
Despite many days of this approach, your obstruction never
resolved and ultimately you required an operation to fix the
problem. You underwent a open exploratory laparotomy with lysis
of adhesions, which went well. Post-operatively, you progressed
and had return of bowel function. You are now tolerating a
regular diet, moving your bowels, voiding, and your pain is well
controlled. You are ready to be discharged home to continue your
recovery.
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within ___ hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications, unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than ___ lbs until you follow-up with your
surgeon.
Avoid driving or operating heavy machinery while taking pain
medications.
Incision Care:
*Please call your doctor or nurse practitioner if you have
increased pain, swelling, redness, or drainage from the incision
site.
*Avoid swimming and baths until your follow-up appointment.
*You may shower, and wash surgical incisions with a mild soap
and warm water. Gently pat the area dry.
*If you have staples, they will be removed at your follow-up
appointment.
Followup Instructions:
___
|
19673077-DS-7
| 19,673,077 | 28,141,597 |
DS
| 7 |
2145-01-13 00:00:00
|
2145-01-14 11:22:00
|
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:
Right heart catheterization ___
Therapeutic Phlebotomy ___ and ___
History of Present Illness:
Mr. ___ is a ___ w/ a hx of HTN (non compliant w/
antihypertensives) and DMII, who presents from the ED with
hypoxia in setting of hypertensive urgency and concern for acute
pulmonary edema.
For about several weeks prior to admission the pt began to have
increasing lower extremity swelling and shortness of breath. He
presented to his PCP's office on ___. At his PCP apt, he was
found to be significantly elevated BP in the setting of non
compliance w/ medications. At home he is prescribed amlodipine
2.5mg, HCTZ 25mg, and lisinopril 40mg for hypertension, however
he had not taken any of his medications for at least 2 weeks
because he could not afford them. He was also noted to be
hypoxic w/ crackles on exam so was referred to ___ ED.
In the ED he continued to be hypertensive w/ SBPs up to 190s and
also required increasing O2 per NC until he was finally started
on BiPAP.
His vitals were: T 97.9, HR 88, BP 169/99, RR 18, O2 91% on
BiPAP.
EKG demonstrated NSR w/ ___, left atrial abnormality, LVH, no ST
elevations/depressions.
Labs/studies notable for:
pH 7.28, pCO2 72, pO2 76, HCO3 35
Trop-T: 0.10
proBNP: 1398
Na 145, K 4.4, Cl 102, CO2 33, BUN 23, Cr 1.3, glucose 112
WBC 5.8, H/H 18.1/58.6, Plts 159
Patient was given: Lasix 80mg IV x1 and started on nitro gtt.
Vitals on transfer: BP 149/75, 94% on BiPAP.
On arrival to the CCU, the pt was hemodynamically stable,
however still with elevated blood pressures. He denied CP or
SOB, stating that he felt that his breathing had already
improved and that his legs were less swollen than when he
arrived in the ED.
Past Medical History:
PAST MEDICAL HISTORY:
1. CARDIAC RISK FACTORS
- DMII, not on insulin
- Hypertension
- Dyslipidemia
2. CARDIAC HISTORY
- None
3. OTHER PAST MEDICAL HISTORY
- None
Social History:
___
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death.
Physical Exam:
ADMISSION EXAM
===============
VS: T 99.5, HR 89, BP 148/78, RR 28, O2 SAT 91% on BiPAP
GENERAL: Well developed, well nourished in NAD. Oriented x3.
Mood, affect appropriate.
HEENT: Normocephalic atraumatic. Sclera anicteric. PERRL. EOMI.
Conjunctiva were pink. No pallor or cyanosis of the oral mucosa.
No xanthelasma.
NECK: Supple. JVP elevated.
CARDIAC:Regular rate and rhythm. Normal S1, S2. No murmurs,
rubs, or gallops.
LUNGS: Mild bibasilar crackles
ABDOMEN: Soft, non-tender, obese. No hepatomegaly. No
splenomegaly.
EXTREMITIES: Warm, well perfused. 2+ edema lower extremities
SKIN: No significant skin lesions or rashes.
PULSES: Distal pulses palpable and symmetric.
DISCHARGE EXAM
===============
PHYSICAL EXAMINATION:
VS: HR 51 BP 109/70 90% SA02 on CPAP
I/O: Reviewed in ___.
GENERAL: Patient is seated at the bedside in no pain or distress
HEENT: EOM grossly intact
NECK: supple, JVP not appreciated on exam
CARDIAC: RRR, S1/S2, no murmurs gallops or rubs
PULM: unlabored, clear to auscultation posteriorly, no wheezes
or
crackles
ABDOMEN: soft, obese, NT, ND, no organomegaly
EXTREMITIES: warm, well perfused, 1+ non-pitting edema
NEURO: non-focal
Pertinent Results:
ADMISSION LABS
===============
___ 05:11PM BLOOD WBC-5.8 RBC-6.65* Hgb-18.1* Hct-58.6*#
MCV-88 MCH-27.2 MCHC-30.9* RDW-17.1* RDWSD-48.4* Plt ___
___ 05:11PM BLOOD Glucose-112* UreaN-23* Creat-1.3* Na-145
K-4.4 Cl-102 HCO3-33* AnGap-10
___ 05:11PM BLOOD CK-MB-7 proBNP-1398*
___ 02:58AM BLOOD Albumin-3.3* Calcium-8.7 Phos-5.3* Mg-1.8
___ 03:40AM BLOOD %HbA1c-7.9* eAG-180*
___ 05:19PM BLOOD ___ pO2-76* pCO2-72* pH-7.28*
calTCO2-35* Base XS-3
___ 03:20AM BLOOD ___ pO2-67* pCO2-96* pH-7.26*
calTCO2-45* Base XS-11
___ 05:26AM BLOOD Type-ART pO2-111* pCO2-82* pH-7.30*
calTCO2-42* Base XS-10
DISCHARGE LABS
===============
___ 09:23AM BLOOD WBC-3.8* RBC-6.40* Hgb-17.5 Hct-54.0*
MCV-84 MCH-27.3 MCHC-32.4 RDW-15.1 RDWSD-43.5 Plt ___
___ 09:23AM BLOOD Calcium-9.4 Phos-4.0 Mg-1.9
JAK2 mutation was negative
IMAGING
========
CXR ___
Moderate cardiomegaly and moderate interstitial pulmonary edema.
No focal
consolidations.
ECHO ___
The left atrium is mildly dilated. There is moderate symmetric
left ventricular hypertrophy. The left ventricular cavity size
is normal. Regional left ventricular wall motion is normal. Left
ventricular systolic function is hyperdynamic (EF>75%). The
estimated cardiac index is high (>4.0L/min/m2). There is a
moderate resting left ventricular outflow tract gradient in the
context of a high cardiac index. There was no change in the left
ventricular outflow tract gradient with Valsalva maneuver. The
right ventricular free wall is hypertrophied. The right
ventricular cavity is mildly dilated with normal free wall
contractility. 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. Mild (1+) aortic regurgitation is seen. The mitral
valve leaflets are structurally normal. There is no mitral valve
prolapse. There is systolic anterior motion of the mitral valve
leaflets. Mild (1+) mitral regurgitation is seen. There is a
trivial/physiologic pericardial effusion.
IMPRESSION: Moderate symmetric left ventricular hypertrophy with
hyperdynamic systolic function. ___ with mild posterior mitral
regurgitation. Right ventricular hypertrophy with mildly dilated
cavity and normal systolic function. Trivial pericardial
effusion. In the absence of a history of systemic hypertension,
findings could be c/w hypertrophic cardiomyopathy (or
infiltrative disease) .
CMR: Pending final read
MICRO
======
None.
Brief Hospital Course:
___ w/ a hx of HTN and DMII who presents with hypoxia in setting
of hypertensive urgency and CXR suggestive of acute pulmonary
edema. The patient was admitted and treated for his hypertension
with multiple medications listed below until his BP was
consistently <140/90. He was also diuresed for fluid overload
and CHF, as well as worked up for underlying lung disorders.
#Hypertensive urgency: Patient admitted with BP 200s systolic,
thought to be caused by longstanding untreated essential
hypertension. He was worked up for other causes with a renal
artery Doppler which was normal, a TSH, and cortisol which were
both normal as well. Renin/aldosterone negative. The other
leading contributor to his HTN was thought to be untreated OSA.
He was treated with a nitro gtt in the acute setting and then
transitioned to PO meds with Torsemide 20mg PO QD, Lisinopril
40mg PO QD, Amlodipine 5mg PO QD, Carvedilol 50mg PO BID, and
Spironolactone 25mg.
#) Acute on chronic diastolic HF
#) Pulmonary HTN, mild (type II)
#) Acute on chronic hypercarbic respiratory failure:
Patient presented in severe respiratory distress requiring
emergent BiPAP. He was found to be in flash pulmonary edema on
background of pulmonary hypertension due to diastolic heart
failure as well as likely contribution of OSA and obesity
hypoventilation syndrome. Labs were consistent with acute on
chronic disease course given large degree of renal compensation
for hypercarbia. Cardiac imaging was suggestive of LVH with
diastolic dysfunction and RHC demonstrated mild pHTN. The
patient was eventually weaned to supplemental O2 per NC. He was
discharged with home O2 with plans for a formal sleep study as
well as pulmonary function tests per pulmonology.
#) Acute on chronic diastolic HF
#) Pulmonary HTN, mild (type II)
#) Acute on chronic hypercarbic respiratory failure: flash
pulmonary edema on background pulmonary HTN ___ diastolic HF.
Probable components of OSA/OHS/COPD too. Marked CO2 retention
and
renal compensation, suggesting chronicity. CT chest with
pulmonary edema. RHC with mild pHTN. Outpatient PSG and PFTs in
order to further characterize lung disease. The patient also
used CPAP at night and will continue to use this after his
discharge. The patient will also need outpatient PFTs to confirm
his underlying lung disease. A JAK2 mutation was negative.
#) LVH w/ ___: symmetric LVH w/ hyperdynamic systolic function
(LVEF = >75%) on TTE ___. ___ w/ mild posterior mitral
regurgitation. Suspect chronic, uncontrolled hypertension versus
hypertrophic cardiomyopathy or infiltrative process. The patient
was treated as above and was diuresed with Lasix and a Lasix
gtt. The patient had a CMR performed while in the CCU and the
final read on this is still pending.
#) Erythrocytosis, secondary: presume compensatory in setting of
OSA/obesity hypoventilation, albeit worsening d/t
hemoconcetration. HCT near 65%. No new neurologic sx. EPO low,
suggesting polycythemia ___ versus improved pulmonary function
(i.e., remove stimulus). A JAK2 mutation was sent and was
negative. Heme saw the patient and phlebotomized him and treated
him as a presumred Polycythemia ___ patient since his EPO
levels were low. He was phlebotomized on ___ and ___. Goal Hct
to be 45%, pheresis attending notified with plan tophlebotomize
as an outpatient every other day.
#Sleep apnea: Patient used BiPAP at night and would desat at
night. Plan for formal sleep study per pulm. The patient was set
up with rides from home in order to make it to all of his follow
up appointments.
Transitional Issues:
======================
[ ] Check 24h urinary cortisol
[ ] Outpatient hematuria workup - recommend referral for
cystoscopy and CTU
[ ] Ensure malignancy screening is up to date
[ ] Assist patient with resources so he can make it to his
appointments
[ ] A1c was 7.9%. On metformin. Please recheck chem-10 in 1 week
to ensure no evidence of acidosis or worsening creatinine while
on metformin. Consider additional titration of diabetes
medications.
[ ] Recheck chem 10 in 1 week.
[ ] Please titrate diuretics
- Scheduled with Infusion on ___ @ 3p and ___ @ 1p for
Therapeutic Phlebotomy
- Outpatient sleep study (already ordered; scheduled for ___.
Email ___ of the Sleep Unit if questions) to
coordinate home CPAP/NIPPV.
- Outpatient PFTs prior to Pulmonology follow-up (already
scheduled)
- Outpatient pulmonology follow-up. Appointment already
scheduled.
New Medications:
Lisinopril 40mg once daily
Carvedilol 50mg BID
Amlodipine 5mg once daily
Spironolactone 25mg once daily
Torsemide 20mg once daily
Medications Stopped:
Hydrochlorothiazide 25mg Daily
Discharge weight: 117.8kg
Discharge creatinine: 1.4
# CODE: Full
# CONTACT/HCP: Daughters ___ ___ and ___
___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lisinopril 40 mg PO DAILY
2. Hydrochlorothiazide 25 mg PO DAILY
3. MetFORMIN (Glucophage) 1000 mg PO BID
4. Escitalopram Oxalate 20 mg PO DAILY
5. Atorvastatin 40 mg PO DAILY
6. Aspirin 81 mg PO DAILY
7. amLODIPine 2.5 mg PO DAILY
Discharge Medications:
1. Carvedilol 50 mg PO BID
RX *carvedilol 25 mg 2 tablet(s) by mouth twice a day Disp #*60
Tablet Refills:*0
2. Spironolactone 25 mg PO DAILY
RX *spironolactone 25 mg 1 tablet(s) by mouth Daily Disp #*30
Tablet Refills:*0
3. Torsemide 20 mg PO DAILY
RX *torsemide 20 mg 1 tablet(s) by mouth Daily Disp #*30 Tablet
Refills:*0
4. amLODIPine 5 mg PO DAILY
RX *amlodipine 5 mg 1 tablet(s) by mouth Daily Disp #*30 Tablet
Refills:*0
5. Aspirin 81 mg PO DAILY
RX *aspirin 81 mg 1 tablet(s) by mouth Daily Disp #*30 Tablet
Refills:*0
6. Atorvastatin 40 mg PO DAILY
RX *atorvastatin 40 mg 1 tablet(s) by mouth at bedtime Disp #*30
Tablet Refills:*0
7. Escitalopram Oxalate 20 mg PO DAILY
RX *escitalopram oxalate 20 mg 1 tablet(s) by mouth Daily Disp
#*30 Tablet Refills:*0
8. Lisinopril 40 mg PO DAILY
RX *lisinopril 40 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
9. MetFORMIN (Glucophage) 1000 mg PO BID
RX *metformin 1,000 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*0
10.Oxygen
Oxygen therapy with ambulation and noctural
4 Liters by nasal cannula
R09.02, G47.33, E66.2, I50.9
11.BIPAP
BIPAP
Ins P 7cm/H20, Exp P min 8
max IPAP 15, 4LNC O2
R09.02, G47.33, E66.2, I50.9
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY:
========
Hypertension
Hypertensive Urgency
Congestive Heart Failure
Erythrocytosis
SECONDARY:
==========
Obstructive Sleep Apnea
Pulmonary Hypertension (mild)
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were hospitalized because you were having trouble breathing
and your blood pressure was very high.
While you were admitted you were given oxygen to help you
breath. You were also given medications to take fluid off your
body and also to lower your blood pressure. Several tests were
done to evaluate your heart and lungs. Your hemoglobin levels
(measure of blood count) were found to be higher than normal so
you had some blood removed while you were here.
When you go home it is very important that you continue taking
all your medications as instructed. You should get a scale and
weigh yourself every day. If you gain more than 2 pounds in one
day you should call your doctor right away. He/she may need to
tell you to take extra medications if your weight goes up too
much. We are also sending you home with oxygen and you should
wear it while you are walking around during the day and while
you sleep at night.
It is also important that you go to all the follow up
appointments listed below.
Wishing you the best!
Your ___ Care Team
Followup Instructions:
___
|
19673092-DS-11
| 19,673,092 | 22,505,025 |
DS
| 11 |
2141-08-07 00:00:00
|
2141-08-27 12:34:00
|
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 motorcycle crash
Major Surgical or Invasive Procedure:
___: Open reduction internal fixation of right proximal
humerus fracture.
___: Washout of right shoulder.
History of Present Illness:
Mr. ___ is s/p MVC who presented to outside hospital was
discovered to have Right proximal humerus fracture, pulmonary
contusions and was subsequently transferred to ___ for further
evaluation and management.
___ was wearing a helmet while driving his motorcycle during
the accident and denies loss of consciousness. He states he
landed on his Right shoulder. He was able to ambulate
unassisted after the accident and did not report any significant
pain nor issues in doing so.
Patient arrived to ED at ___ hemodynamically stable on NC O2.
He reports pain to his Right shoulder with XR and CT imaging
illustrating a proximal humerus fracture and dislocation. He
endorses paresthesia to Right shoulder in axillary nerve
distribution, but is otherwise neurovascarly intact and is
minimally able to move wrist/fingers but is limited due to his
pain in Right shoulder. He also reports pain to his Right knee
and tib/fib, pain to Right hand over his "blisters" and minor
pain over Left superficial forearm abrasions.
He denies SOB, chest pain, pain to other extremities,
nausea/vomiting and pain relatively well controlled.
Right hand dominant. No issues with prior anesthesia. No chronic
medications/no anticoag medications
Past Medical History:
Significant EtOH consumption, pancreatitis (approx. ___ years
ago), s/p hernia repair
Social History:
___
Family History:
Non-contributory
Physical Exam:
Admission Physical Exam:
No acute distress, in some pain, A&Ox3
___: tachy but regular rhythm on peripheral assessment
Pulm: non labored breathing on room air
Discharge Physical Exam on ___:
VS: T 98.6 BP 135/83 HR 92 RR 18 O2 Sat: 98% RA
GEN: NAD. A+Ox3
CV: RRR
Pulm: Lung sounds clear bilaterally
Abd: Soft, non-tender, non-distended. +BS
Ext: Right shoulder with dressing C/D/I w/ minimal swelling
noted. Abrasion on right forearm with xeroform. Right knee
swollen with abrasion, DSD.
Pertinent Results:
IMAGING:
CXR ___:
Displaced fracture of the right proximal humerus. No acute
intrathoracic process, no pneumothorax.
CT C-spine ___:
No evidence of acute abnormality in the cervical spine.
Left Forearm x-ray ___:
AP and lateral view of the left forearm show no fracture or
dislocation. No other bone or joint abnormality.
CT Head ___:
No acute intracranial abnormality.
CT Chest ___:
No fracture seen within the chest. Probably extensive pulmonary
contusion in the right lung.
CT Abdomen/Pelvis ___:
No evidence of acute injury in the abdomen/pelvis.
Right knee/Tib/fib x-ray ___:
No acute fracture or dislocation
Right Hand x-ray ___:
No acute fracture or dislocation.
Right Shoulder CT ___:
Acute displaced comminuted fracture of the proximal humerus.
Right Humerus x-ray ___:
Acute comminuted fracture of the right proximal humerus.
CXR OSH ___:
Right lung infiltrates which may represent pneumonia or
contusion.
___ DUP EXT LOW UNILAT (DVT) RIGHT ___:
No evidence of deep venous thrombosis in the right lower
extremity veins.
CHEST (PORTABLE AP) ___:
In comparison with the study of ___, there again are low
lung volumes that accentuate the prominence of the transverse
diameter of the heart. Atelectatic changes are seen at the bases
without definite vascular congestion, acute focal pneumonia, or
pneumothorax.
LABS:
___ 09:30PM HBsAg-NEG
___ 09:30PM HIV Ab-NEG
___ 09:30PM HCV Ab-NEG
___ 06:54AM GLUCOSE-136* LACTATE-2.8* CREAT-1.0 NA+-141
K+-3.9 CL--108 TCO2-19*
___ 06:30AM UREA N-17
___ 06:30AM LIPASE-1113*
___ 06:30AM CALCIUM-8.8
___ 06:30AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
tricyclic-NEG
___ 06:30AM WBC-19.0* RBC-5.02 HGB-14.1 HCT-42.9 MCV-86
MCH-28.1 MCHC-32.9 RDW-12.8 RDWSD-39.8
___ 06:30AM NEUTS-84.6* LYMPHS-5.0* MONOS-9.3 EOS-0.1*
BASOS-0.3 IM ___ AbsNeut-16.07* AbsLymp-0.95*
AbsMono-1.76* AbsEos-0.01* AbsBaso-0.05
___ 06:30AM PLT COUNT-190
___ 06:30AM ___ PTT-25.1 ___
___ 06:51AM BLOOD Glucose-90 UreaN-13 Creat-0.8 Na-140
K-4.6 Cl-104 HCO3-25 AnGap-11
___ 06:51AM BLOOD Calcium-8.7 Phos-4.0 Mg-2.1
Brief Hospital Course:
Mr. ___ is a ___ y/o M who presented to OSH s/p MCC where he
was discovered to have a right proximal humerus fracture and
pulmonary contusions and was subsequently transferred to ___
for further evaluation and management on ___. He arrived at
___ hemodynamically stable. He was admitted to the Acute Care
Surgery service for treatment. Orthopedic Surgery was consulted
for the right proximal humerus fracture and he was taken to the
operating room on HD1 and underwent ORIF of the right humerus
fracture. The patient was then transferred to the surgical floor
after a brief stay in the PACU.
On POD1, the patient complained of anterior right knee pain and
RLE edema. He also reported right shoulder pain. A RLE
ultrasound was obtained which showed no evidence of DVT. He had
sinus tachycardia to the 110s and his CBC was trended and showed
that Hct decreased from 42.9 -> 31.7 -> 25.2. Thus, he received
1 unit PRBCs. Orthopedic Surgery checked compartment pressures
on POD1 and POD2 in the RUE and RLE and there was no s/s of
compartment syndrome. The patient was noted to have a tense
right shoulder and thus on POD2, it was decided that he would
need surgery for his right shoulder hematoma. He was taken back
to the OR with Orthopedic Surgery and underwent washout of the
right shoulder. This procedure went well with an EBL of 100mL.
He did require blood transfusions post-operatively for a
downtrending Hct. Post-operative hematocrit was 23.1. He
received 1 unit PRBCs during which his temperature increased to
Tmax of 102 with mild tachycardia to 110s. The transfusion was
stopped and he was given IV Benadryl and Tylenol with
appropriate response. This was followed by transfusion of 1
additional unit of PRBCs overnight on ___. Because the
patient's Hct did not respond appropriately to the transfusions,
hemolysis labs were checked which were within normal limits. By
HD5, the patient's Hct had stabilized and he was medically
cleared for discharge. In terms of his pulmonary contusions, his
respiratory status was monitored and remained stable. He was
encouraged to use the incentive spirometer and he was weaned
from nasal cannula to room air on HD1.
Physical and occupational therapy worked with the patient
throughout his hospital course and he was cleared for discharge
to home. The patient also was seen by social work due to some
PTSD symptoms from the crash. At the time of discharge on
___, the patient was doing well, afebrile and
hemodynamically stable. The patient was tolerating a diet,
ambulating, voiding without assistance, and pain was well
controlled on oral pain medications. The patient received
discharge teaching and follow-up instructions with understanding
verbalized and agreement with the discharge plan. Per the
Orthopedic team, he will be discharged on 28 days of full-dose
aspirin for VTE prophylaxis following surgery and will follow up
in their clinic.
Of note, the patient had some hypertension this admission with
SBP into the 160-170s, but asymptomatic. Patient was told to
follow up with his primary care provider after discharge for
further evaluation.
Medications on Admission:
None
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild
Please do not exceed 3gm in a 24 hour period.
RX *acetaminophen 500 mg 2 tablet(s) by mouth every eight (8)
hours Disp #*42 Tablet Refills:*1
2. Aspirin 325 mg PO DAILY Duration: 28 Days
RX *aspirin 325 mg 1 tablet(s) by mouth once a day Disp #*28
Tablet Refills:*0
3. Bacitracin Ointment 1 Appl TP BID RLE road rash
RX *bacitracin zinc 500 unit/gram Please apply to right lower
extremity abrasion. twice a day Refills:*0
4. Ibuprofen 600 mg PO DAILY:PRN Pain - Mild
Please take with food.
RX *ibuprofen 600 mg 1 tablet(s) by mouth once a day Disp #*7
Tablet Refills:*0
5. Lidocaine 5% Patch 1 PTCH TD QAM Back pain
Please apply to affected area. On for 12 hours. Off for 12
hours.
RX *lidocaine [Aspercreme (lidocaine)] 4 % Please apply to
affected area. once a day Disp #*7 Patch Refills:*0
6. Polyethylene Glycol 17 g PO DAILY
Hold for loose stool.
7. TraMADol 50 mg PO Q6H:PRN Pain - Moderate
Reason for PRN duplicate override: d/cing oxycodone
Please take lowest effective dose and wean as tolerated.
RX *tramadol 50 mg 1 tablet(s) by mouth every six (6) hours Disp
#*20 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Right humerus fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were admitted to ___ after
a motorcycle crash and were found to have right humerus
fracture. You were taken to the operating room for repair of the
fracture on ___ and then taken back to the OR on ___ for washout
of a hematoma (blood collection) that you developed in the right
shoulder. You received 3 blood transfusions while in the
hospital and your blood levels are now stable. You also worked
with physical and occupational therapy, who have cleared you to
go home. 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.
Activity: non-weight bearing right arm in sling, passive range
of motion ok; no active range of motion.
Ok to remove sling for changing, etc.
For pain, can alternate Tylenol and Motrin as needed.
Please take Aspirin 325 mg once daily for 28 days
Dressings may be removed when saturated or bothersome and left
open to air if no drainage.
Followup Instructions:
___
|
19673247-DS-17
| 19,673,247 | 22,919,925 |
DS
| 17 |
2180-06-04 00:00:00
|
2180-06-07 19:53:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Aspirin
Attending: ___.
Chief Complaint:
hyperglycemia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ y/o male with PMHx of peripheral neuropathy, BPH, low back
pain, who was seen by his PCP ___ ___ for left foot pain of ___s generalized fatigue, anorexia, and 20lb wt loss
over the past 2 months. He had previously been seen on ___ with
complaints of fever, bloating, flatulence, abdominal cramps,
nausea, vomiting and diarrhea though these episodes were
fleeting and resolved soon after their onset. Of note, he did
have >1000 glucose in his UA on ___. Prior to these labs his
most recent glucose was 80 early in ___. At this time, he just
endorses anorexia. He has no abdominal pain with eating or
dysphagia. Labs on ___ revealed metabolic acidosis and blood
glucose of 600, he was referred to the ___ ED. Of note the
patient does not have a prior diagnosis of diabetes. Besides his
foot pain, he otherwise feels quite well.
In the ED initial VS were 98.6 99 182/70 18 100% 2LNC. Initial
labs significant for glucose 597, HCO3 21, AG 24, +urine
ketones. He was placed on insulin drip with IVF. AG closed and
insulin gtt was stopped around noon on ___, at which time he
was transitioned to SC insulin. Urinalysis significant for trace
blood but no bacteria. Blood culture preliminary growing gram
positive cocci in clusters and pairs (1 out of 4 bottles),
second set of cultures sent. He was given a dose of CTX in the
ED. He was admitted for further evaluation and treatment.
Past Medical History:
- Low back pain
- Peripheral neuropathy
- BPH
- Glaucoma
- Gout
- HTN
Social History:
___
Family History:
no hx of cancer or DM
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS 98.6 99 182/70 18 100% 2LNC
GENERAL: NAD
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
patent nares, MMM, good dentition, nontender supple neck, no
LAD, no JVD
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs
LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: 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: 99.0 ___ 110 18 97% RA
General: Well-appearing elderly gentleman lying comfortably in
bed
HEENT: MMM, good dentition. Lower lip appears dry and cracked.
Anicteric sclera, PERRL
Neck: supple, no lymphadenopathy, no JVD
Lungs: breathing comfortably without accessory muscles, CTAB
CV: RRR, S1/S2, no murmurs, gallops, or rubs
Abdomen: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
Ext: warm and well perfused. left foot slightly swollen, and TTP
on the plantar surface and the lateral dorsal surface. Gait not
assessed due to pain. ~4cm circular rea of tissue breakdown and
scabbing at R antecub with surrounding erythema
Neuro: ___ grossly intact
SKIN: raised pigmented papules diffusely over patient's back
Pertinent Results:
ADMISSION LABS
___ 08:30PM GLUCOSE-679* UREA N-24* CREAT-1.2 SODIUM-137
POTASSIUM-5.3* CHLORIDE-99 TOTAL CO2-22 ANION GAP-21
___ 08:30PM WBC-5.1 RBC-4.72 HGB-13.3* HCT-42.6 MCV-90
MCH-28.3 MCHC-31.3 RDW-11.9
___ 08:30PM NEUTS-66.8 ___ MONOS-6.3 EOS-0.5
BASOS-0.6
___ 08:30PM PLT COUNT-138*
___ 08:30PM ___ PTT-26.1 ___
___ 08:30PM ALT(SGPT)-32 AST(SGOT)-21 ALK PHOS-80 TOT
BILI-0.3
___ 08:30PM LIPASE-89*
___ 08:30PM ALBUMIN-4.3 CALCIUM-9.6 PHOSPHATE-3.7
MAGNESIUM-2.3
___ 11:15PM URINE BLOOD-SM NITRITE-NEG PROTEIN-NEG
GLUCOSE-1000 KETONE-40 BILIRUBIN-NEG UROBILNGN-NEG PH-5.5
LEUK-NEG
___ 11:15PM URINE RBC-5* WBC-<1 BACTERIA-NONE YEAST-NONE
EPI-<1
___ 11:15PM URINE COLOR-Straw APPEAR-Clear SP ___
DISCHARGE LABS
___ 07:40AM BLOOD WBC-4.4 RBC-4.24* Hgb-12.1* Hct-37.3*
MCV-88 MCH-28.5 MCHC-32.4 RDW-11.9 Plt ___
___ 07:40AM BLOOD Glucose-154* UreaN-11 Creat-0.8 Na-141
K-3.6 Cl-107 HCO3-23 AnGap-15
___ 07:40AM BLOOD Calcium-8.4 Phos-2.7 Mg-1.5*
MICROBIOLOGY
___ 8:30 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___:
STAPHYLOCOCCUS, COAGULASE NEGATIVE.
SENSITIVITIES PERFORMED ON REQUEST..
Isolated from only one set in the previous five days.
Aerobic Bottle Gram Stain (Final ___:
Reported to and read back by ___. ___ @ 1702 ON ___ -
___.
GRAM POSITIVE COCCI.
IN PAIRS AND CLUSTERS AND IN SHORT CHAINS.
___ 9:00 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
___ 11:15 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___: <10,000 organisms/ml.
___ 5:50 pm BLOOD CULTURE
Blood Culture, Routine (Pending):
___ 5:50 pm BLOOD CULTURE
Blood Culture, Routine (Pending):
___ 1:00 pm BLOOD CULTURE
Blood Culture, Routine (Pending):
___ 7:40 am BLOOD CULTURE
Blood Culture, Routine (Pending):
___ 7:40 am BLOOD CULTURE
Blood Culture, Routine (Pending):
___ 3:14 pm STOOL CONSISTENCY: NOT APPLICABLE
Source: Stool.
**FINAL REPORT ___
C. difficile DNA amplification assay (Final ___:
Negative for toxigenic C. difficile by the Illumigene DNA
amplification assay.
(Reference Range-Negative).
STUDIES
___ CXR
IMPRESSION:
The lung volumes are normal. Normal size of the cardiac
silhouette. Normal
hilar and mediastinal structures. Minimal bilateral apical
thickening. No pleural effusions. No pneumonia, no pulmonary
edema.
___ L FOOT PLAIN FILMS
IMPRESSION:
No findings specific for gout or osteomyelitis.
Relatively mature appearing periosteal new bone formation along
the medial proximal diaphysis of the second metatarsal,
associated with a thin oblique linear lucency through the medial
cortex. This may represent chronic change related to altered
weight-bearing, but the possibility of an incomplete stress
fracture cannot be entirely excluded. Otherwise, no evidence for
fracture detected about the left foot.
Brief Hospital Course:
___ y/o male with PMHx of peripheral neuropathy, BPH, low back
pain referred from his PCP's office with hyperglycemia of 600s
and DKA.
___ y/o male with PMHx of peripheral neuropathy, BPH, low back
pain referred from his PCP's office with hyperglycemia of 600s
and DKA.
# Diabetic ketoacidosis: Patient without prior known history of
DM, presented with glucose 600s, AG 24, +urine ketones. Unclear
how long the patient had been hyperglycemic, but given his HbA1c
of 11.7, his presentation certainly represented a chronic
process. Unclear precipitant as positive blood cultures (only
___ bottles with coag negative Staph) were consistent with
contaminant and the patient waws without any localizing source
of infection per history and on exam. Given the late
presentation for new-onset diabetes, autoimmune pancreatitis was
considered; patient will have further work-up as an outpatient
with ___. Per ___ recommendations, the patient was
initially placed in 15 units qhs Lantus, HISS, and metformin 500
mg BID. Because the patient continued to have elevated
fingerstick blood glucoses, ___ further uptitrated the
patient's regimen to 20 units qam, HISS, and metformin 1000 mg
BID with close outpatient ___ after discharge.
# Coagulase negative Staph aureus bacteremia. Likely to be a
contaminant per above. The patient has no new areas of tissue
breakdown except for at his R elbow from tape in the ED.
# Right elbow cellulitis. Patient acquired skin tear while in
the ED with subsequent mild cellulitis. Will complete short
course of Keflex with PCP ___.
# Weight loss: Patient with 20-pound weight loss over the past 2
months, with associated anorexia and fatigue, most likely due to
new diabetes. The primary team discussed the patient's weight
loss with the patient's PCP who will plan to pursue malignancy
work-up if his weight loss does not stabilize with his new
insulin regimen.
# Foot Pain: Plain films showed bone spur along plantar surface
of foot correlating with site of foot pain. Patient received
tylenol PRN.
# BPH: stable. Continued doxazosin and finasteride.
***TRANSITIONAL ISSUES***
- Will f/u with ___ on ___ to further titrate
insulin/metformin regimen.
- Will f/u with PCP to assess improvement of cellulitis.
Discharged on short course of PO Keflex.
- PCP ___ pursue CT imaging for malignancy work-up if weight
loss continues
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Doxazosin 8 mg PO QHS:PRN pt only takes when he's peeing too
much
2. Finasteride 5 mg PO HS
3. Gabapentin 600 mg PO BID
4. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES HS
5. TraMADOL (Ultram) 50-100 mg PO DAILY
6. Multivitamins 1 TAB PO DAILY
7. Combigan (brimonidine-timolol) 0.2-0.5 % ophthalmic 1 drop in
both eyes twice daily
Discharge Medications:
1. Doxazosin 8 mg PO QHS:PRN pt only takes when he's peeing too
much
2. Finasteride 5 mg PO HS
3. Gabapentin 600 mg PO Q8H
4. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES HS
5. Multivitamins 1 TAB PO DAILY
6. TraMADOL (Ultram) 50-100 mg PO DAILY
7. Combigan (brimonidine-timolol) 0.2-0.5 % ophthalmic 1 drop in
both eyes twice daily
8. Acetaminophen 1000 mg PO Q6H:PRN pain
RX *acetaminophen 500 mg 2 tablet(s) by mouth q6 Disp #*240
Tablet Refills:*0
9. Cephalexin 500 mg PO Q6H
RX *cephalexin 500 mg 1 capsule(s) by mouth q6 Disp #*26 Capsule
Refills:*0
10. MetFORMIN (Glucophage) 1000 mg PO BID
RX *metformin [Glucophage] 1,000 mg 1 tablet(s) by mouth twice a
day Disp #*60 Tablet Refills:*0
11. Glargine 20 Units Breakfast
Glargine 0 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
RX *blood sugar diagnostic [Freestyle InsuLinx] with testing
Disp #*300 Strip Refills:*2
RX *insulin glargine [Lantus] 100 unit/mL ASDIR 20 Units before
BKFT; 0 Units before BED; Disp #*1 Vial Refills:*2
RX *blood-glucose meter [FreeStyle Lite Meter] Use to check
blood sugars after meals Disp #*1 Kit Refills:*0
RX *insulin lispro [Humalog] 100 unit/mL ASDIR Up to 7 Units QID
per sliding scale Disp #*5 Cartridge Refills:*0
RX *lancets Disp #*200 Each Refills:*2
RX *insulin syringe-needle U-100 [FreeStyle Precision] 31 gauge
x ___ use with insulin Disp #*100 Syringe Refills:*2
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Type II Diabetes
Diabetic Ketoacidosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear ___,
___ you for choosing us for your care. You were admitted with
very high blood sugars that were responsible for causing your
blood to become too acidic. We treated this with insulin. Based
on your laboratory studies, you have diabetes. We started you on
a regimen of Metformin and Insulin. Please follow up with a
provider at the ___ to adjust your insulin as well as
to figure out why you have new-onset diabetes.
You also complained of foot pain--we did Xrays which did not
suggest an infection, large fracture or gout. It did show a bone
spur, which may be the cause of your pain. You can continue to
treat the pain with Tylenol.
Thank you for allowing us to participate in your care. All best
wishes for your recovery.
Sincerely,
Your ___ medical team
Followup Instructions:
___
|
19673689-DS-14
| 19,673,689 | 24,720,232 |
DS
| 14 |
2189-08-23 00:00:00
|
2189-08-24 07:50:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
___ cardiac catheterization without need for intervention
History of Present Illness:
___ with HTN, HLD, diet controlled DM2, asthma presenting with
___ weeks of exertional substernal chest discomfort relieved
with ___ of rest.
She reports midline burning chest discomfort x ___ weeks which
occurs reliably after walking for ___ and resolves
immediately with rest. Dyspneic with ambulation. No associated
diaphoresis, nausea, vomiting, palpitations, or dizziness. No
recent surgery, immobilization, travel, leg pain/swelling or
history of blood clots.
She has not taken additional meds for her symptoms. Currently
pain free, last episode occurred on initial presentation to ED
while walking to work. She has a history of uncontrolled HTN and
ran out of labetalol several weeks ago. She states she has been
taking all other meds. She has been using albuterol once daily
as needed, no cough or fever. Nuclear persantine stress test in
___ was normal.
Initial vitals in the ED were T98.2, HR64, BP215/119, RR16,
99RA. EKG with sinus bradycardia at 52 bpm, TWI in V6. She was
given her home BP meds and aspirin 325mg. CXR without acute
findings. She was in the ED observation unit overnight. She had
two sets of negative troponins. Exercise stress test this
morning showed 0.5-1.0mm upsloping in inferolateral leads and
produced anginal type symptoms. Low functional capacity - HR
only got to 96 on the ETT.
Cardiology was consulted in the ED. She was loaded with Plavix
600mg and admitted to ___ for cardiac cath. On the floor,
patient denied any chest pain or other symptoms.
Past Medical History:
Obesity, BMI 32.6 on ___
Hypertension
Hyperlipidemia
Diabetes type 2, last A1c 6.7% on ___
Asthma
Social History:
___
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death. Mother with DM and HTN.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: T98.2, BP140/87, HR57, RR14, 96RA
GENERAL: middle aged female, no acute distress, awake and alert,
sitting up in chair
HEENT: EOMI, MMM, good dentition
NECK: nontender and supple, enlarged 1.5cm tonsillar nontender
lymph nodes, JVP not elevated
CARDIAC: RRR, normal S1 S2, ___ systolic murmur loudest at ___
LUNG: clear, no rales, wheezes, or rhonchi, no accessory muscle
use
ABDOMEN: +BS, soft, nontender, nondistended, no rebound or
guarding
EXT: warm well-perfused, no cyanosis, clubbing or edema
PULSES: 2+ DP and ___ pulses bilaterally
NEURO: CN ___ tested and intact, strength ___ UE and ___,
sensation grossly normal, normal speech
SKIN: no rashes or lesions
DISCHARGE PHYSICAL EXAM:
VS: T98.4, BP138/80 (119-163), HR70 (49-70), RR18, 97% RA
GENERAL: middle aged female, no acute distress, awake and alert
HEENT: moist mucous membranes
NECK: JVP not elevated
CARDIAC: RRR, normal S1 S2, ___ systolic murmur loudest at ___
LUNG: clear, no rales, wheezes, or rhonchi, no accessory muscle
use
ABDOMEN: +BS, soft, nontender, nondistended, no rebound or
guarding
EXT: warm well-perfused, no cyanosis, clubbing or edema. Right
wrist bandage c/d/i, site is nontender.
PULSES: 2+ DP and ___ pulses bilaterally
NEURO: sensation grossly normal, normal speech
SKIN: no rashes or lesions
Pertinent Results:
ADMISSION LABS:
___ 11:05AM BLOOD WBC-6.0 RBC-4.69# Hgb-11.6* Hct-39.2#
MCV-84 MCH-24.8* MCHC-29.7* RDW-14.7 Plt ___
___ 11:05AM BLOOD ___ PTT-32.8 ___
___ 11:05AM BLOOD Glucose-132* UreaN-27* Creat-0.8 Na-143
K-4.1 Cl-100 HCO3-32 AnGap-15
___ 07:35AM BLOOD Calcium-9.2 Phos-4.0 Mg-2.1
CARDIAC ENZYMES:
___ 11:05AM BLOOD cTropnT-<0.01
___ 05:00PM BLOOD cTropnT-<0.01
___ CXR
There is minor mid lung atelectasis. No focal consolidation is
seen. There is no pleural effusion or pneumothorax. The aorta
is tortuous. The cardiac silhouette is mildly enlarged. No
overt pulmonary edema is seen.
___ ETT
This was an inactive overweight ___ year old DM2 woman with HTN
and HLD, who was referred to the lab from the ED after negative
serial cardiac markers for an evaluation of exertional chest
discomfort. She exercised for 6 minutes of a Modified ___
protocol ___ METs) and stopped due to fatigue. This represents
a fair functional capacity for her age. SHe complained of
mid-sternal burning of "medium" intensity starting at 4 minutes
of exercise and resolving by 1 minute of recovery. There was
0.5-1mm ST segment flattening in the inferolateral leads noted
near peak exercise, which returned back to baseline by 3 minutes
of recovery. The rhythm was sinus with two isolated APB's seen
during exercise. The heart rate response to exercise was blunted
in the setting of beta blockade. The blood pressure response to
exercise was appropriate.
IMPRESSION: Borderline ischemic ECG changes noted in the
presence of
anginal type symptoms. Blunted HR response. Fair functional
capacity
demonstrated.
___ TTE
The left atrial volume is normal. No atrial septal defect is
seen by 2D or color Doppler. The estimated right atrial pressure
is ___ mmHg. Left ventricular wall thickness, cavity size and
regional/global systolic function are normal (LVEF >55%).
Quantitative (biplane) LVEF = 69 %. The estimated cardiac index
is normal (>=2.5L/min/m2). Tissue Doppler imaging suggests an
increased left ventricular filling pressure (PCWP>18mmHg).
Doppler parameters are most consistent with Grade II (moderate)
left ventricular diastolic dysfunction. Right ventricular
chamber size and free wall motion are normal. The aortic arch is
mildly dilated. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion and no aortic
stenosis or aortic regurgitation. The mitral valve appears
structurally normal with trivial mitral regurgitation. There is
no mitral valve prolapse. The estimated pulmonary artery
systolic pressure is normal. There is no pericardial effusion.
IMPRESSION: Normal biventricular regional/global systolic
function. Grade II diastolic dysfunction with elevated left
ventricular enddiastolic pressure and normal pulmonary artery
systolic pressure. Mildly dilated aortic arch.
Compared with the prior study (images reviewed) of ___,
findings are similar.
___ CARDIAC CATH
Final read pending. Prelim read is clean coronaries. No
obstructions. Some slow flow suggestive of microvascular
disease.
Brief Hospital Course:
___ with HTN, HLD, diet controlled DM2, asthma presenting with
___ weeks of substernal chest pain brought on by exertion and
relieved with rest, with negative troponins x2 but positive
exercise stress test, suggestive of unstable angina.
# Unstable angina. Chest pain without troponin elevation or EKG
changes, but positive on exercise stress test. Symptoms are
typical for classic angina, with substernal chest pain brought
on by exertion, relieved after 15 minutes of rest. She was
initially observed overnight in the ED with two troponins
negative. In the morning, patient exercised for 6 minutes on
Modified ___ protocol ___ METS) and stopped due to fatigue.
0.5-1.0mm ST segment flattening seen in inferolateral leads in
setting of anginal type symptoms, and she was admitted to
inpatient cardiology. She was loaded with Plavix 600mg ___ in
ED and started on aspirin 325, atorvastatin 80, and home
lisinopril 40, labetalol 900 BID. She had no further chest pain
after admission. TTE showed grade II diastolic dysfunction,
EF>55%. She underwent cardiac cath which showed no obstructive
lesions, but slow flow suggestive of some microvascular disease.
Her atorvastatin was increased to 80mg for full CAD protection.
Started Imdur 30mg daily for microvascular disease and angina.
Otherwise, she is already on aspirin, lisinopril, and beta
blocker.
# Hypertension. Elevated blood pressures on presentation, in
setting of chest pain and labetalol non-compliance in last month
(ran out of prescription). Continued home meds: chlorthalidone
25, diltaizem ER 360 ER, labetalol 900 BID, lisinopril 40.
Irbesartan was held in-house as it is non-formulary, but will be
restarted on discharge.
# Hyperlipidemia. Switched atorvastatin to atorvastatin 80 for
full anginal and CAD protection.
# Diabetes type 2, diet controlled. Last A1c 6.7% on ___.
Stable.
# Asthma. Stable. No wheezing or dyspnea. Continued home Advair
and albuterol.
# Communication: daughter ___ ___
# Code: FULL confirmed with patient ___
### TRANSITIONAL ISSUES ###
1) Atorvastatin increased to 80mg daily.
2) Started Imdur 30mg daily for microvascular disease and
angina.
3) Follow up with PCP.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 325 mg PO DAILY
2. Chlorthalidone 25 mg PO DAILY
3. Diltiazem Extended-Release 360 mg PO DAILY
4. irbesartan 300 mg oral DAILY
5. Labetalol 900 mg PO BID
6. Lisinopril 40 mg PO DAILY
7. Atorvastatin 20 mg PO DAILY
8. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
9. albuterol sulfate 90 mcg/actuation inhalation QID PRN
wheezing
Discharge Medications:
1. Aspirin 325 mg PO DAILY
2. Atorvastatin 80 mg PO DAILY
RX *atorvastatin 80 mg 1 tablet(s) by mouth once a day Disp #*60
Tablet Refills:*0
3. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
4. Labetalol 900 mg PO BID
5. albuterol sulfate 90 mcg/actuation inhalation QID PRN
wheezing
6. Chlorthalidone 25 mg PO DAILY
7. Diltiazem Extended-Release 360 mg PO DAILY
8. irbesartan 300 mg oral DAILY
9. Lisinopril 40 mg PO DAILY
10. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
RX *isosorbide mononitrate 60 mg 1 tablet extended release 24
hr(s) by mouth once a day Disp #*60 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY:
1) Unstable angina
SECONDARY:
1) Hypertension
2) Hyperlipidemia
3) Diabetes mellitus, type 2
4) Obesity
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure caring for you at ___
___. You were admitted to the hospital because of
chest pain. You were found to have an abnormal exercise stress
test, likely due to unstable angina. You had a cardiac
catheterization which did not have any obstructions, but some
slow flow suggestive of microvascular disease.
Your atorvastatin was increased to 80mg. You were started on
Imdur 30mg daily, which is a medication to prevent angina and
chest pain. You will have follow up with your PCP ___.
Followup Instructions:
___
|
19673689-DS-16
| 19,673,689 | 21,499,808 |
DS
| 16 |
2193-11-27 00:00:00
|
2193-11-27 13:56:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Influenza
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ female with history of
hypertension, hyperlipidemia, diabetes, reactive airway disease,
presenting with 6 days of productive cough, fevers, chills, and
myalgias.
Episode initially started on ___ with shortness of breath,
sore throat, myalgias, weakness, decreased p.o. intake, and
lightheadedness. All the symptoms worsened as the week went on,
and this morning she felt significantly weak and lightheaded on
standing which prompted ED visit. She is uptodate on flu shot,
denies smoking or exposure to second hand smoke. She does not
use
home inhalers as her insurance requires a co-pay which she can't
afford. She has had minimal po intake since ___ but denies
any nausea or vomiting. No abdominal pain. Does note ___
episodes
of loose stool, nonbloody. Patient states that grandchild and 2
children have similar symptoms.
In the ED:
VS: AF, P ___ BP 150-160's/80's, 95-98% on RA
Exam:
Gen: awake, alert, comfortable
H&N: NCAT
EENT: Dry mucous membranes
Cardiac: regular rate and rhythm, no murmur
Pulm: no increased work of breathing, diffuse expiratory
rhonchus/wheezing
Abdomen: soft, nontender
Ext: no ___ edema
Skin: no rash
Psych: normal mood
Neuro: Speech Fluent, moving all extremities
Labs: Cr 2.0 (b/l 1.2), FluA positive
Imaging: CXR without acute cardiopulm process
Impression: Flu + ___
Interventions: Duonebs x3 + 1L NS bolus
Course: Admit for risky elder with flu and ___
On arrival to the floor patient was initially without acute
complaint but after ambulating to the bathroom and having an
episode of loose stool she had a witnessed pre-syncopal event
and
severe weakness requiring assist back to bed. VSS except for
mild
sinus bradycardia at the time, but she was given another 1L NS
and 12-lead ECG obtained and found to be unchanged from prior
(NSR, stable q waves in V1-V3, no acute ST-T changes).
ROS: Pertinent positives and negatives as noted in the HPI. All
other systems were reviewed and are negative.
Past Medical History:
T2DM
HTN
HL
Asthma
CAD
Social History:
___
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death. Mother with DM and HTN.
Physical Exam:
Admission Exam:
ITALS: Temp: 98.6 (Tm 98.6), BP: 135/87, HR: 80, RR: 18, O2 sat:
96%, O2 delivery: Ra
GENERAL: Alert tired-appearing
EYES: Anicteric, pupils equally round
ENT: Ears and nose without visible erythema. Oropharynx without
visible lesion, erythema or exudate
CV: Heart regular, no murmur, no S3, no S4. No JVD.
RESP: bibasilar crackles that clear with cough, upper airway
ronchi throughout with good air movement bilaterally. Breathing
is non-labored
GI: Abdomen soft, non-distended, non-tender to palpation. Bowel
sounds present. No HSM
GU: No suprapubic fullness or tenderness to palpation
MSK: Neck supple, moves all extremities, strength grossly
symmetric
SKIN: No obvious rashes or ulcerations noted on cursory skin
exam
NEURO: Alert, oriented, face symmetric, speech fluent, moves all
limbs
PSYCH: pleasant, appropriate affect
Discharge Exam:
Pertinent Results:
Admission labs:
___ 11:45AM BLOOD WBC-5.3 RBC-4.92 Hgb-12.3 Hct-39.2
MCV-80* MCH-25.0* MCHC-31.4* RDW-14.2 RDWSD-41.2 Plt ___
___ 11:45AM BLOOD Neuts-56.1 ___ Monos-13.6*
Eos-0.2* Baso-0.4 Im ___ AbsNeut-2.97 AbsLymp-1.55
AbsMono-0.72 AbsEos-0.01* AbsBaso-0.02
___ 06:15AM BLOOD ___ PTT-25.4 ___
___ 11:45AM BLOOD Glucose-184* UreaN-83* Creat-2.0* Na-140
K-3.9 Cl-96 HCO3-28 AnGap-16
___ 06:15AM BLOOD ALT-17 AST-17 AlkPhos-95 TotBili-0.2
___ 06:15AM BLOOD Albumin-3.9 Calcium-9.0 Phos-3.0 Mg-2.6
___ 12:50PM BLOOD %HbA1c-7.7* eAG-174*
Discharge Labs:
Reports:
CXR PA/LAT: In comparison with the study of ___,
there is little change and no evidence of acute cardiopulmonary
disease. Specifically, no evidence of pneumonia. Round
opacification in the azygos region suggests calcified lymph node
related to old granulomatous disease.
Brief Hospital Course:
___ is a ___ woman with a history of diabetes mellitus type 2,
hypertension and coronary artery disease who presented a with
productive cough, fevers, chills and found to have influenza A
as well as acute renal failure.
#Acute influenza A, pneumonia:
The patient presented with fevers, cough and shortness of breath
without a focal consolidation on chest x-ray. She was found to
have influenza A and given high risk given age and comorbidities
she was admitted to medicine. She was treated with Tamiflu
renally dosed to complete a ___cute renal failure:
#Orthostatic hypotension:
Acute Renal failure and orthostatic hypotension on admission
both though likely related to hypovolemia in the setting of
acute viral illness. She was treated with 1 L of IV fluids and
her creatinine improved dramatically. The day following
admission she remained slightly orthostatic when attempting to
walk to bathroom for which she received another bolus of IV
fluids. Her home anti-hypertensives were held until she
demonstrated clinical improvement. On discharge chlorthalidone
and labetalol were both held due to well controlled BPs in house
and orthostatic hypotension on ___.
Transitional Issues:
- Consider restarting Chlorthalidone and Labetalol at next
office visit
- Tamiflu to complete ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. irbesartan 300 mg oral DAILY
2. Labetalol 600 mg PO BID
3. MetFORMIN (Glucophage) 500 mg PO DAILY
4. Chlorthalidone 25 mg PO QAM
5. Atorvastatin 20 mg PO QPM
6. Diltiazem Extended-Release 360 mg PO DAILY
7. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY
8. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN angina
9. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
10. albuterol sulfate 90 mcg/actuation inhalation ___ puffs po
q4 hr as needed for prn wheezing
Discharge Medications:
1. OSELTAMivir 30 mg PO BID
RX *oseltamivir 30 mg 1 capsule(s) by mouth twice a day Disp #*8
Capsule Refills:*0
2. albuterol sulfate 90 mcg/actuation inhalation ___ puffs po
q4 hr as needed for prn wheezing
3. Atorvastatin 20 mg PO QPM
4. Diltiazem Extended-Release 360 mg PO DAILY
5. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
6. irbesartan 300 mg oral DAILY
7. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY
8. MetFORMIN (Glucophage) 500 mg PO DAILY
9. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN angina
10. HELD- Chlorthalidone 25 mg PO QAM This medication was held.
Do not restart Chlorthalidone until You speak to your primary
care physician
11. HELD- Labetalol 600 mg PO BID This medication was held. Do
not restart Labetalol until You speak to your primary care
physician
___:
Home
Discharge Diagnosis:
Influenza A
Acute renal failure
Orthostatic hypotension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Ms ___,
It was a pleasure caring for you during this hospitalization.
You were admitted to ___ with
cough, shortness of breath and fevers at home. It was found
that you had Influenza A infection and acute renal failure. You
were treated with IV fluids which improved your kidney function.
We also treated with medication called Tamiflu to treat the
influenza. You continued to improve and were discharged home.
We are holding a couple of your blood pressure medications
because your blood pressures were well controlled in the
hospital without them and you had low blood pressure when
standing to go to the bathroom. Please discuss this with your
primary care physician who can decide to restart them or not.
It was a pleasure caring for you during this hospitalization.
Your ___ inpatient team
Followup Instructions:
___
|
19674020-DS-17
| 19,674,020 | 26,686,732 |
DS
| 17 |
2183-02-02 00:00:00
|
2183-02-03 16:51:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Fall and Syncopy
Major Surgical or Invasive Procedure:
Endoscopic ultrasound with biopsy
History of Present Illness:
___ with HTN, HLD, T2DM, RA and NASH who presents after fall at
home. Patient reports that she had what was described as a
mechanical fall at home during which her foot got caught and she
fell backwards, striking her head. No LOC.
She initially presented to the ___ where she had a
negative head and C-spine CT and a scalp laceration which was
repaired. Patient was on the commode and reportedly had an event
where her arms stiffened, she was unresponsive and eyes deviated
to the left. Daughter witnessed the event and per notes, no
tonic-clonic movements. Repeat head CT was obtained and was
unchanged from the initial. She was transferred to the ___ ___
for neurological evaluation.
In the ___ ___, initial VS were 97.9 84 106/69 16 99% r. Labs
were notable for a WBC of 14, Na of 125, K of 2.9 and INR of
1.4. Initial trop was negative. Neuro was consulted who felt
this was a vagal event after moving her bowels and had little
concern for a seizure.
Currently, patient is alert and feels comfortable.
Past Medical History:
HISTORY OF BASAL CELL CARCINOMA V10.83G
ARTHRITIS - RHEUMATOID ___
HYPERTENSION - ESSENTIAL, UNSPEC 401.9CS
FOOT DROP 736.79AK
ADVANCE DIRECTIVES V65.49N
GAIT ABNMLTY 781.2N
THYROID NODULE 241.0U
Toxic Multinodul Goiter 242.20L
Type 2 Diabetes Mellitus, Uncontrolled 250.02B
Fatty Liver/NASH 571.8AN
Urinary Tract Anomaly 753.9X
Osteopenia 733.90B
Hypercholesterolemia 272.0BE
Colonic adenoma ___
Constipation, chronic 564.00A
Social History:
___
Family History:
NC
Physical Exam:
ADMISSION PE:
VITALS: 97 122/63 80 16 99% RA
GENERAL: Alert, comfortable, NAD
HEENT: PERRL, EOMI
NECK: no carotid bruits, JVD
LUNGS: CTAB
HEART: RRR, normal S1 S2, no MRG
ABDOMEN: Soft, NT, NABS, no organomegaly
EXTREMITIES: No c/c/e
NEUROLOGIC: A+OX3
DISCHARGE PE:
VITALS: 98.1 123/66 77 20 99% RA
GENERAL: Alert, comfortable, NAD
HEENT: Stitches on head intact, small amount of oozing this AM
NECK: no carotid bruits, JVD
LUNGS: CTAB
HEART: RRR, normal S1 S2, no MRG
ABDOMEN: Soft, NT, NABS, no organomegaly
EXTREMITIES: No c/c/e
NEUROLOGIC: A+OX3
Pertinent Results:
ADMISSION LABS:
___ 03:55AM BLOOD WBC-14.6* RBC-3.71* Hgb-12.2 Hct-33.4*
MCV-90 MCH-32.8* MCHC-36.5* RDW-12.7 Plt ___
___ 03:55AM BLOOD ___ PTT-20.6* ___
___ 03:55AM BLOOD Glucose-173* UreaN-13 Creat-0.7 Na-125*
K-2.9* Cl-90* HCO3-22 AnGap-16
___ 03:55AM BLOOD ALT-189* AST-117* LD(LDH)-312*
CK(CPK)-175 AlkPhos-70 TotBili-0.8
___ 05:30PM BLOOD Calcium-8.5 Phos-2.3* Mg-1.6
___ 03:55AM BLOOD Osmolal-261*
___ 08:55AM BLOOD TSH-2.3
___ 06:59AM BLOOD AFP-4.2
___ 05:30PM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE
HBcAb-NEGATIVE IgM HBc-NEGATIVE
___ 05:30PM BLOOD HCV Ab-NEGATIVE
RUQ Ultrasound:
FINDINGS: Within the liver, there are multiple hypoechoic
masses, the largest in the left lobe measuring 3.0 x 2.6 x 3.0
cm. The pancreatic duct is significantly dilated to 8 mm and
there is a hypoechoic pancreatic head mass measuring 3.7 x 3.2 x
3.7 cm. The patient is status post apparent cholecystectomy
with no dilation of the common bile duct which measures 3 mm.
Main portal vein is patent with appropriate directional flow.
Limited views of the aorta and IVC are unremarkable. Spleen
measures 9 cm and is unremarkable. The right kidney measures
10.4 cm. The left kidney measures 10.9 cm. There is a 1.7 x
1.6 cm left parapelvic cyst.
IMPRESSION:
1. Pancreatic head mass causing pancreatic ductal dilatation.
2. Multiple liver metastasis.
CT TORSO:
1. Large pancreatic head/uncinate hypodense lesion, likely
representing
adenocarcinoma with extensive metastatic disease to the liver
and mediastinal lymph nodes. The mass completely encases the
superior mesenteric artery and vein. There is no biliary ductal
dilatation.
2. Bilateral hypodense nodules within the thyroid are
incompletely evaluated.
3. Trace amount of ascites.
Brief Hospital Course:
___ with T2DM, HTN, HLD, RA who presents after mechanical fall
and apparent syncopal episode in ___, now with
transaminitis and hyponatremia, found to have a new pancreatic
mass and multiple liver lesions.
# Pancreatic head mass/liver lesions/Transaminitis: Patient's
transaminases had been trendeing up as an outpatient, and were
elevated on admission. A RUQ ultrasound showed a pancreatic
head mass, biliary dictal dilation, and multiple liver lesions.
She underwent an EUS and biopsies were obtained of the
pancreatic mass and liver lesions. Staging CT scan confirmed
likely metastatic disease with mediastinal lymph node
involvement. Biopsy results pending at the time of discharge.
Patient will follow up with Dr. ___ week to go over the
biopsy results.
#Syncope/Fall: Patient initially presented after mechanical
fall, head laceration. This was stapled in the ___. The
patient then had a vasovagal event while straining to have a
bowel movement at the ___. She had no further syncope
during her admission. She was orthostatic, which resolved with
IVFs. Her chlorthalidone was also discontinued.
# Hyponatremia: Na 125/124 on admission, 131 on discharge. Per
urine electrolytes, was likely hypovolemic hyponatremia as it
corrected with IVFs. Her chlorthalidone was held as above.
#HTN: Held chlorthalidone as above, continued atenolol and
losartan.
#RA: Continued home prednisone
# Transitional Issues:
- Follow - up Pathology results from pancreas and liver biopsy
Medications on Admission:
Preadmissions medications listed are incomplete and require
futher investigation. Information was obtained from
PatientAtrius.
1. Ciprofloxacin HCl 500 mg PO Q24H
2. GlipiZIDE 5 mg PO QPM
3. GlipiZIDE 7.5 mg PO QAM
4. Omeprazole 20 mg PO DAILY
5. Atenolol 50 mg PO DAILY
Hold for HR<55 or SBP <100
6. Chlorthalidone 25 mg PO DAILY
Hold for SBP <100
7. Losartan Potassium 50 mg PO DAILY
Hold for SBP <100
8. FoLIC Acid 1 mg PO DAILY
9. PredniSONE 5 mg PO DAILY
10. Simvastatin 20 mg PO DAILY
11. Loratadine *NF* 10 mg Oral daily
12. Aspirin 81 mg PO DAILY
13. Calcium Carbonate 500 mg PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Atenolol 50 mg PO DAILY
Hold for HR<55 or SBP <100
3. Calcium Carbonate 500 mg PO DAILY
4. FoLIC Acid 1 mg PO DAILY
5. Losartan Potassium 50 mg PO DAILY
Hold for SBP <100
6. Omeprazole 20 mg PO DAILY
7. PredniSONE 5 mg PO DAILY
8. GlipiZIDE 5 mg PO QPM
9. GlipiZIDE 7.5 mg PO QAM
10. Loratadine *NF* 10 mg Oral daily
11. Lorazepam 1 mg PO Q6H:PRN anxiety
hold for sedation rr < 12
RX *Ativan 1 mg 1 pill by mouth every 6 hours as needed for
anxiety Disp #*28 Capsule Refills:*0
12. Senna 1 TAB PO BID:PRN constipation
RX ___ 8.6 mg 1 tablet by mouth twice a day Disp #*14
Capsule Refills:*0
13. Ondansetron 4 mg PO Q8H:PRN nausea
RX *ondansetron HCl 4 mg 1 Tablet(s) by mouth every 8 hours Disp
#*21 Capsule Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Syncope
Pancreatic mass
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were seen in the hospital after a fall. You had several
electrolyte abnormalities that were likely secondary to
dehydration that corrected with IV fluids. You also had an
ultrasound of your liver and pancreas which showed a mass in
your pancreases and multiple masses in your liver. Dr. ___
___ go over the biopsy results with you next week.
It was a pleasure taking care of you during your hospital stay.
Followup Instructions:
___
|
19674244-DS-24
| 19,674,244 | 25,395,676 |
DS
| 24 |
2193-06-26 00:00:00
|
2193-07-01 09:00:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Morphine / Iron Complex / Penicillins
Attending: ___
Chief Complaint:
bradycardia & CP s/p US-guided renal biopsy
Major Surgical or Invasive Procedure:
s/p renal bx as outpatient, no procedures while inpatient
History of Present Illness:
Mr. ___ is a ___ year-old male with history of FSGS/ESRD s/p
cadaveric renal transplant in ___, ___, DMII, and hypertension
who underwent an elective renal transplant biopsy this morning
and was referred to the ED from the RDU due to an episode of
bradycardia and chest pain. The biopsy was planned due to
increasing proteinuria. He underwent the biopsy without
complication and then returned to the radiology day care unit.
Shortly after arrival to the RDU he developed bradycardia to the
mid 30___ with associated lightheadedness. He was normotensive at
this time. He was given a 250 cc NS bolus and within 5 minutes
his bradycardia resolved, but he began experiecing dyspnea. Then
about 5 minutes later he develops a short episode of chest
discomfort. An EKG was completed and was without changes from
his baseline. He was transferred to the ED for further
evaluation.
In the ED EKG was again without change. Trop was mildly elevated
at 0.02. He was given 325 mg po ASA and transferred to Epistein
___.
On arrival to the floor, patient's VSS. He denies further
episodes of chest pain, dyspnea, or lightheadedness since
leaving the RDU. Currently he feels back to his baseline. He is
very hungry and hasn't taken any of his am medications. He has
voided twice since the biopsy and denies hematuria. He has only
very mild pain at the biopsy site.
Review of systems:
(+) Per HPI; he admits to slight weight loss with increased
lasix and improvement in lower extremity edema. He has mild DOE
which has been stable.
(-) Denies fever, chills, night sweats. Denied cough. Denied
nausea, vomiting, diarrhea, constipation or abdominal pain. No
recent change in bowel or bladder habits. No dysuria. Denied
arthralgias or myalgias. All other review of systems are
negative.
Past Medical History:
- ESRD ___ FSGS s/p cadveric Tx ___
- Depression
- Hyperlipidemia
- sCHF
- Hypertension
- tertiary hyperparathyroidism with chondrocalcinosis
- Diabetes Type II
- Gout
- Squamous cell carcinomas of the left hand and right cheek s/p
Mohs micrographic surgery and repair by full thickness skin
graft
- nasal polypectomy (___)
- L forearm loop goretex AV graft (___)
- s/p open CCY (___)
- s/p AV graft thrombectomy (___)
- L brachial artery-to-axillary vein AV Graft (___)
- repair of quads (___)
- removal of AV graft (___)
- s/p left hemithyroidectomy (___)
- R ___ MT head resection
Social History:
___
Family History:
noncontributory
Physical Exam:
Admission PEx:
Vitals: 98.2 121/72 92 18 100%RA
General: Middle-aged male sitting in bed in NAD. Alert &
appropriate.
HEENT: Sclera anicteric, MMM, oropharynx clear
Lungs: Breathing comfortably, slight crackles at the bases.
CV: RRR, no MRG
Abdomen: soft, non-tender, non-distended. no tenderness over the
RLQ transplanted kidney. Dressing in place over biopsy site,
c/d/i.
Ext: warm, trace edema bilaterally
Discharge PEx:
General: Middle-aged male sitting in bed in NAD. Alert &
appropriate.
HEENT: Sclera anicteric, MMM, oropharynx clear
Lungs: Breathing comfortably, slight crackles at the bases.
CV: RRR, no MRG
Abdomen: soft, non-tender, non-distended. no tenderness over the
RLQ transplanted kidney. Dressing in place over biopsy site,
c/d/i.
Ext: warm, trace edema bilaterally
Pertinent Results:
Labs on admission:
___ 07:40AM BLOOD WBC-9.8 RBC-4.54* Hgb-13.9* Hct-44.2
MCV-97 MCH-30.6 MCHC-31.4 RDW-15.0 Plt ___
___ 09:55AM BLOOD Neuts-76.3* Lymphs-14.7* Monos-6.8
Eos-1.5 Baso-0.8
___ 07:40AM BLOOD ___
___ 07:40AM BLOOD Glucose-107* UreaN-52* Creat-1.3* Na-138
K-5.3* Cl-101 HCO3-26 AnGap-16
___ 07:40AM BLOOD ALT-17 AST-30 TotBili-0.2
___ 09:55AM BLOOD CK-MB-3
___ 09:55AM BLOOD cTropnT-0.02*
___ 05:15PM BLOOD CK-MB-2 cTropnT-0.02*
___ 05:45AM BLOOD CK-MB-2 cTropnT-0.02*
___ 07:40AM BLOOD Calcium-8.8 Phos-3.5
BK Virus DNA, Quantitative Real-Time PCR
BK Virus, QN PCR No DNA Detected
<500 copies/mL
___ 07:50AM URINE Color-Straw Appear-Clear Sp ___
___ 07:50AM URINE Blood-NEG Nitrite-NEG Protein-100
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG
___ 07:50AM URINE RBC-1 WBC-<1 Bacteri-NONE Yeast-NONE
Epi-0
___ 07:50AM URINE Hours-RANDOM Creat-58 TotProt-123
Prot/Cr-2.1*
Labs on Discharge:
___ 05:45AM BLOOD WBC-8.0 RBC-4.43* Hgb-13.6* Hct-43.2
MCV-98 MCH-30.7 MCHC-31.4 RDW-14.9 Plt ___
___ 05:45AM BLOOD ___ PTT-26.7 ___
___ 05:45AM BLOOD Glucose-88 UreaN-31* Creat-1.0 Na-139
K-4.6 Cl-104 HCO3-25 AnGap-15
___ 05:45AM BLOOD CK(CPK)-49
___ 05:45AM BLOOD Calcium-8.7 Phos-3.2 Mg-1.8
Imaging:
ECHO ___ (outpatient): The left atrium is mildly dilated. Left
ventricular wall thicknesses are normal. The left ventricular
cavity size is normal. There is moderate global left ventricular
hypokinesis (LVEF = 35 %). Right ventricular chamber size and
free wall motion are normal. The aortic valve is not well seen.
There is mild aortic valve stenosis (valve area 1.2-1.7 cm2).
The mitral valve leaflets are mildly thickened. There is no
mitral valve prolapse. Trivial mitral regurgitation is seen.
There is borderline pulmonary artery systolic hypertension.
There is no pericardial effusion.
Compared with the findings of the prior study (images reviewed)
of ___, the left ventricular ejection fraction is
reduced; mild aortic stenosis is now present
___ EKG: Sinus rhythm with frequent ventricular premature
beats. Left ventricular hypertrophy with lateral ST-T wave
abnormalities. Compared to the previous tracing of ___
voltage is more prominent.
Brief Hospital Course:
___ year-old male with FSGS/ESRD s/p cadaveric renal transplant
in ___, ___, DMII, and hypertension s/p an elective renal
transplant biopsy this morning complicated by a post-procedure
episode of bradycardia and chest pain, likely secondary to
vasovagal pre syncope given patient's history and workup.
# Bradycardia/Chest pain: The patient developed bradycardia and
then a short episode of chest pain in the RDU after his renal
biopsy. EKG was without ischemic changes. Trop was only very
mildly elevated at 0.02, MB flat x3. He was only bradycardic for
about 5 minutes and he did not become hypotensive during the
episode although he felt lightheaded and dyspneic. Patient also
describes being scared by the procedure and has been stressed
about getting biopsy results. Patient was monitored on telemetry
for further bradycardia and did not show any abnormalities on
telemetry during stay. Patient was given 325 mg of aspirin in
the ED and Hct was followed closely, which remained stable.
Biopsy site was also clean, dry, intact, nontender. Patient was
told to restart baby ASA once home for CAD
prevention/progression.
# FSGS s/p cadaveric renal transplant in ___: Patient has had
increasing proteinuria and underwent renal biopsy this am. No
pain at the biopsy site or hematuria. Patient was continued on
MMF & prednisone. No post procedural bleeding noted on exam and
labs.
#CHF: EF 35% as of ECHO on ___, patient should be on
spirinolactone and beta blocker. Patient to meet with
cardiologist within a few days, an appointment that was just set
up for patient by PCP, who will address this issue. Unlikely
that this played a role in patient's admission.
.
.
Transitional Issues:
Patient to follow up with PCP and cardiology as outpatient.
Medications on Admission:
albuterol sulfate [ProAir HFA] 90 mcg HFA Aerosol Inhaler 1 puff
inhaled every four hourse as needed for wheezing
allopurinol ___ mg by mouth once a day
atorvastatin [Lipitor] 20 mg Tablet 1 Tablet(s) by mouth once a
day
cinacalcet [Sensipar] 60 mg Tablet 1 Tablet(s) by mouth once a
day
diltiazem HCl 300 mg Ext Release 24hr 1 Cap by mouth once a day
furosemide 20 mg by mouth once a day
lisinopril 40 mg by mouth once a day
metformin 500 mg by mouth once a day
mycophenolate sodium 360 mg Delayed Release(E.C.) 2 Tablets po
bid
omeprazole 20 mg Capsule, Delayed Release(E.C.) 1 tab once a day
prednisone 5 mg Tablet by mouth once a day
aspirin 81 mg by mouth once a day (on hold for biopsy)
calcium citrate-vitamin D3 315 mg-200 unit by mouth daily
Discharge Medications:
1. nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
2. albuterol sulfate 90 mcg/actuation HFA Aerosol Inhaler Sig:
One (1) Puff Inhalation Q4H (every 4 hours) as needed for
wheezing.
3. allopurinol ___ mg Tablet Sig: One (1) Tablet PO once a day.
4. atorvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
5. cinacalcet 60 mg Tablet Sig: One (1) Tablet PO once a day.
6. diltiazem HCl 300 mg Capsule, Extended Release Sig: One (1)
Capsule, Extended Release PO DAILY (Daily).
7. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day.
9. metformin 500 mg Tablet Extended Release 24 hr Sig: One (1)
Tablet Extended Release 24 hr PO DAILY (Daily).
10. mycophenolate sodium 360 mg Tablet, Delayed Release (E.C.)
Sig: Two (2) Tablet, Delayed Release (E.C.) PO twice a day.
11. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
12. prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
13. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO once a day.
14. Calcium Citrate + D 315-200 mg-unit Tablet Sig: One (1)
Tablet PO once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
vasovagal bradycardia
.
ESRD ___ FSGS s/p cadveric Tx ___
- Depression
- Hyperlipidemia
- sCHF
- Hypertension
- tertiary hyperparathyroidism with chondrocalcinosis
- Diabetes Type II
- Gout
- Squamous cell carcinomas of the left hand and right cheek s/p
Mohs micrographic surgery and repair by full thickness skin
graft
- nasal polypectomy (___)
- L forearm loop goretex AV graft (___)
- s/p open CCY (___)
- s/p AV graft thrombectomy (___)
- L brachial artery-to-axillary vein AV Graft (___)
- repair of quads (___)
- removal of AV graft (___)
- s/p left hemithyroidectomy (___)
- R ___ MT head resection
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 after an episode of
low heart rate and chest pain following your kidney biopsy. We
performed various tests, and given your quick recovery, it is
likely that you experienced what we call a vasovagal event,
which is benign. Please continue to take all of your home
medications as prescribed.
You recently had an echocardiography done, which indicated that
perhaps you would benefit from beta blocker or aldosterone
receptor blocker therapy--please discuss this with your PCP and
cardiologist at your scheduled appointments.
Your outpatient appointments are detailed below.
Followup Instructions:
___
|
19674244-DS-25
| 19,674,244 | 20,023,731 |
DS
| 25 |
2193-11-01 00:00:00
|
2193-11-02 21:15:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Morphine / Iron Complex / Penicillins
Attending: ___
Chief Complaint:
SOB, cough, fever
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with hx FSGS/ESRD s/p
cadaveric renal transplant in ___ on pred/tacro/mmf, with
biopsy
proven chronic allograft nephropathy, marked transplant
glomerulopathy with widespread peritubular capillary C4d
positivity, suggesting acute and chronic humoral rejection. In
addition, he has known donor-specific antibodies against DR15,
DQ5, and DR51.
He also has a hx of ?sCHF (appears one Echo underestimated EF
and following echo reporterd 55%), COPD, DMII, and hypertension
who presents with cough, SOB and fever x8 days. ___ (5 days
PTA) he saw his renal doctor (___) for a scheduled
appointment and mentioned 3 days of cough and runny nose (not
thought to be a pneumonia at that time). Two days later, cough
became productive of green sputum and he developed increasing
dyspnea on exertion. Dr. ___ started him on
azithromycin on ___. He currently feels like his cough
improved and is no longer productive, but continues to have
signficant DOE at just a few feet. Additionally notes left sided
back and b/l chest "pins" lateral to both nipples, headache, and
mild nausea with coughing. He also reports chest pressure, and
inability for his "lungs to fill." Otherwise, patient denies
abdominal pain, emesis or diarrhea or any fevers/chills at home.
No weight loss. No dysuria or new rashes. Denies recent abx and
has not been recently in the hospital. No recent travel and no
sick contacts.
In the ED, initial vs were 100.1 87 147/75 18 92%RA. CXR wet
read showed a retrocardiac opacity concerning for pneumonia.
Received levofloxacin 750mg PO and duonebs. ECG showed old
q-waves in the lateral leads, LVH, no acute changes.
On arrival to the floor, patient reports still having some SOB
with deep breaths, and chest pressure. VS: T98.4, BP131/50, p84,
RR20, 97%3L
Past Medical History:
- ESRD ___ FSGS s/p cadveric Tx ___
- Depression
- Hyperlipidemia
- sCHF
- Hypertension
- tertiary hyperparathyroidism with chondrocalcinosis
- Diabetes Type II
- Gout
- Squamous cell carcinomas of the left hand and right cheek s/p
Mohs micrographic surgery and repair by full thickness skin
graft
- nasal polypectomy (___)
- L forearm loop goretex AV graft (___)
- s/p open CCY (___)
- s/p AV graft thrombectomy (___)
- L brachial artery-to-axillary vein AV Graft (___)
- repair of quads (___)
- removal of AV graft (___)
- s/p left hemithyroidectomy (___)
- R ___ MT head resection
Social History:
___
Family History:
noncontributory
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: T98.4, BP131/50, p84, RR20, 97%3L
GEN Alert, oriented, no acute distress
HEENT NCAT MMM EOMI sclera anicteric, OP clear
NECK supple, no JVD, no LAD
PULM Good aeration, coughing. Diffuse weazing.
CV RRR normal S1/S2, no mrg
ABD soft NT ND normoactive bowel sounds, no organomegaly
EXT WWP 2+ pulses palpable bilaterally, R foot somewhat
edematous. Has had surgeries on that foot for congitsal
clubbing.
NEURO CNs2-12 intact, motor function grossly normal
SKIN no ulcers or lesions
DISCHARGE PHYSICAL EXAM:
VS: T98.9, BP112-130/50-71, p68-87, RR18, 100%2L
GEN Alert, oriented, no acute distress
HEENT NCAT MMM EOMI sclera anicteric, OP clear
NECK supple, no JVD, no LAD
PULM Good aeration, coughing. Diffuse weazing.
CV RRR normal S1/S2, no mrg
ABD soft NT ND + bs, no hepatosplenomegaly
Pertinent Results:
___ 01:30AM BLOOD WBC-15.3* RBC-4.40* Hgb-13.5* Hct-42.1
MCV-96 MCH-30.8 MCHC-32.2 RDW-14.0 Plt ___
___ 06:15AM BLOOD WBC-12.8* RBC-4.19* Hgb-12.9* Hct-40.6
MCV-97 MCH-30.7 MCHC-31.6 RDW-14.0 Plt ___
___ 10:30AM BLOOD WBC-10.3 RBC-3.95* Hgb-12.3* Hct-37.7*
MCV-96 MCH-31.2 MCHC-32.6 RDW-13.6 Plt ___
___ 01:30AM BLOOD Neuts-86.4* Lymphs-8.3* Monos-4.5 Eos-0.6
Baso-0.2
___ 01:30AM BLOOD Glucose-150* UreaN-45* Creat-1.6* Na-142
K-4.4 Cl-104 HCO3-25 AnGap-17
___ 06:15AM BLOOD Glucose-121* UreaN-39* Creat-1.4* Na-142
K-4.6 Cl-105 HCO3-28 AnGap-14
___ 10:30AM BLOOD Glucose-218* UreaN-46* Creat-1.6* Na-139
K-4.7 Cl-101 HCO3-28 AnGap-15
___ 01:30AM BLOOD ALT-24 AST-18 CK(CPK)-68 AlkPhos-64
TotBili-0.4
___ 01:30AM BLOOD cTropnT-0.02*
___ 01:53PM BLOOD CK-MB-2 cTropnT-0.03*
___ 06:15AM BLOOD CK-MB-2 cTropnT-0.03*
___ 06:15AM BLOOD Calcium-9.0 Phos-3.5 Mg-1.6
___ 10:30AM BLOOD Calcium-8.8 Phos-3.4 Mg-1.5*
___ 01:30AM BLOOD Albumin-4.2
___ 06:15AM BLOOD tacroFK-5.2
___ 10:30AM BLOOD tacroFK-7.8
___ 04:42PM BLOOD tacroFK-6.0
___ 02:06AM BLOOD Lactate-1.9
___ 10:19AM URINE Color-Yellow Appear-Clear Sp ___
___ 10:19AM URINE Blood-TR Nitrite-NEG Protein-100
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
___ 10:19AM URINE RBC-<1 WBC-1 Bacteri-FEW Yeast-NONE
Epi-<1
Respiratory Viral Antigen Screen (Final ___:
Negative for Respiratory Viral Antigen.
Specimen screened for: Adeno, Parainfluenza 1, 2, 3,
Influenza A, B,
and RSV by immunofluorescence.
Refer to respiratory viral culture for further
information.
___: NEGATIVE for Pneumocystis jirovecii (carinii).
URINE CULTURE (Final ___: NO GROWTH.
CMV Viral Load (Final ___:
CMV DNA not detected.
___ ECG: Sinus rhythm and occasional ventricular ectopy. Left
ventricular hypertrophy
with minor ST-T wave changes as recorded on ___ without
diagnostic interim
change.
___ CXR: IMPRESSION: No acute process.
___ CT Chest w/o contrast: IMPRESSION:
1. Multifocal ___ opacities in both lungs,
predominantly the right
lung, concerning for infectious bronchiolitis. Bronchial wall
thickening,
with few areas of impaction, suggestive of small airways
inflammation.
2. Extensive coronary arterial calcification and thoracic
aortic
calcification.
3. Pulmonary arterial hypertension.
4. Stenosis at the origin of the SMA, correlate clinically for
signs of
mesenteric ischemia.
Brief Hospital Course:
___ hx renal transplant in ___ on pred/tacro/myfortic, sCHF,
DMII, and hypertension who presents with cough, SOB and fever x8
days
#SOB/DOE: Pt with leukocytosis (WBC 15: 86N L8), productive
cough, dyspnea, low-grade fever. CXR final read showed no
findings. Old CT showed emphysema, thought to be infectious
exacerbation of COPD. Patient improved on Levofloxacin and
scheduled Ipratropium/albuterol nebs. Viral swab, legionella
antigen, sputum cultures all negative. On discharge, did not
require any supplemental oxygen, leukocytosis resolved, and he
was not febrile. Cough also improved.
# Chest Pressure: Patient with DOE and "chest pressure" no chest
pain on admission. ECG with q-waves shown on previous ECG, no
acute process. Trop .02 and stable. Resolved shortly after
admission.
# Cadaveric Renal Transplant: on myfortic, tacrolimus, and
prednisone at home. He has an element of chronic rejection. Per
a recent renal note: "He has deteriorating graft function due
to acute and chronic humoral rejection as suggested by his C4d
positivity and transplant glomerulopathy respectively. We
previously increased his immunosuppression to full dose CellCept
and continued him on steroids and Prograf. I would like to
treat him with Rituxan and IVIG once Dr. ___ there is
no invasive skin cancer that needs to be addressed first." In
house, he was continued on his anti-rejection medications and
his Creatinine remained at baseline (~1.5). Tacrolimus levels
were all normal.
Chronic Issues:
#Hypertension. Patient continued on Lisinopril, Diltiazem, and
Metoprolol at home doses.
#sCHF: Patient with ?CHF hx. EF 35% as of ECHO on ___
___, increased to 55% in ___, note says possible
underestimate of ___ read. On Lisinopril and Metoprolol.
#T2DM: On Insulin sliding scale
#Bone mineral disease. He is on Sensipar for
hyperparathyroidism with reasonable PTH and vitamin D (27). His
last bone density was in ___, which showed osteopenia.
Transition Issues:
# Patient should have follow up to ensure resolution of his
acute infectious process
# Patient should be treated for COPD as he has a previous
diagnosis by CT but has never been treated for it
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from Patient.
1. Nicotine Patch 14 mg TD DAILY
2. Albuterol Inhaler 2 PUFF IH Q6H:PRN shortness of breath
hold for HR>110
3. Allopurinol ___ mg PO DAILY
4. Atorvastatin 20 mg PO DAILY
5. Cinacalcet 30 mg PO DAILY
6. Diltiazem Extended-Release 300 mg PO DAILY
hold for SBP<90
7. Furosemide 20 mg PO DAILY
hold for SBP<90
8. Lisinopril 40 mg PO DAILY
hold for SBP<90, K>5.5
9. Omeprazole 20 mg PO DAILY
10. PredniSONE 5 mg PO DAILY
11. Aspirin 81 mg PO DAILY
12. Cal-Citrate *NF* (calcium citrate-vitamin D2) 315-200 Oral
daily
13. Myfortic *NF* (mycophenolate sodium) 720 mg Oral BID
14. Metoprolol Tartrate 12.5 mg PO BID
15. Tacrolimus 1 mg PO Q12H
Discharge Medications:
1. Allopurinol ___ mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. PredniSONE 5 mg PO DAILY
4. Atorvastatin 20 mg PO DAILY
5. Furosemide 20 mg PO DAILY
hold for SBP<90
6. Lisinopril 40 mg PO DAILY
hold for SBP<90, K>5.5
7. Omeprazole 20 mg PO DAILY
8. Myfortic *NF* (mycophenolate sodium) 720 mg Oral BID
9. Albuterol Inhaler 2 PUFF IH Q6H:PRN shortness of breath
hold for HR>110
10. Cal-Citrate *NF* (calcium citrate-vitamin D2) 315-200 Oral
daily
11. Tacrolimus 1 mg PO Q12H
12. Nicotine Patch 14 mg TD DAILY
13. Diltiazem Extended-Release 300 mg PO DAILY
hold for SBP<90
14. Cinacalcet 30 mg PO DAILY
15. Levofloxacin 750 mg PO DAILY Duration: 4 Days
RX *levofloxacin 750 mg 1 tablet(s) by mouth daily Disp #*4
Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis:
Community-acquired 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 taking care of you while you were at the ___
___. You came to the hospital for
increasing shortness of breath, productive cough, and fever. You
also had chest pressure. We started you on antibiotics and your
shortness of breath improved. You are now being discharged
home. Please remember to take all of your prescribed
medications and follow up with the appointments listed below.
The following changes have been made to your medications:
We ADDED levofloxacin, an antibiotic, to treat your pneumonia
Followup Instructions:
___
|
19674244-DS-26
| 19,674,244 | 20,098,645 |
DS
| 26 |
2194-10-11 00:00:00
|
2194-10-12 23:49:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Morphine / Iron Complex / Penicillins
Attending: ___.
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
cardiac catheterization with no intervention
History of Present Illness:
Mr. ___ is a ___ year old man with a history of DM, COPD,
resolved cardiomyopathy (LVEF 35% in ___, 55% in ___, FSGS
with subsequent ESRD s/p cadaveric renal transplant in ___
(second kidney transplant) with chronic allograft nephropathy
who intially presented with admitted to transplant surgery
service on ___ for SBO, then transferred to the CCU for
NSTEMI management.
The patient initially came to the ___ ED with severe
mid-abdominal pain associated with n/v. He was found to have a
SBO on CT and then admitted to transplant surgery for further
management. He reported exertional angina over this past year
and noted substernal chest pressure radiating down his left arm
a/w mild dyspnea, worse with brisk walk and climbing stairs.
Over the past 3 weeks, these symptoms have come on more
frequently and these episodes have become more prolonged (2
minutes max) with no change in severity. In the ___ days prior
to presentation, he began experiencing this chest pressure at
rest; each episode resolved spontaneously. First set of cardiac
enzymes checked on ___ during an episode of CP showed CK-MB 24
and Troponin 1.35. Troponin peaked at 2.07, CK-MB at 28 and are
now downtrending. EKG showed sinus tachycardia 100 bpm,
leftward axis, multifocal PVCs, lateral downsloping biphasic T
waves (present on prior EKG).
Pt was evaluated by Cardiology, and given crescendo angina and
NSTEMI, the patient underwent cath on ___. Cardiac cath on ___
___ significant 3VD (90% proximal LAD, 90%
LCx before large OM, 80% proximal RCA and 80% RPL). Cath also
showed moderately elevated L-sided filling pressures. During
cath, pt developed acute dyspnea with initial elevated PASP of
60; symptoms improved and PASP reduced to ___ after IV NTG
initiated. Of note, the pt has very limited access--cath
performed via R brachial (unable to access R femoral, R radial;
pt has L AV fistula) and is not a candidate for IABP.
On arrival to the floor, VS T 98.3 HR 96 BP 126/76 RR 19 O2sat
94% on RA. Patient was chest pain-free; reports his last
episode of chest discomfort was earlier this morning. He denies
any dyspnea, palpitations, orthopnea, PND, or syncope. He also
reports improvement of his abdominal pain, denies any n/v, and
began passing gas yesterday though he has not had any bowel
movements yet.
Pt endorses worsening anxiety and requests sleep aid in
hospital.
REVIEW OF SYSTEMS
On review of systems, s/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. 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.
Cardiac review of systems is notable for absence of chest pain,
paroxysmal nocturnal dyspnea, orthopnea, ankle edema,
palpitations, syncope or presyncope.
Past Medical History:
- ESRD ___ FSGS s/p cadveric Tx ___
- Depression
- Hyperlipidemia
- sCHF
- Hypertension
- tertiary hyperparathyroidism with chondrocalcinosis
- Diabetes Type II
- Gout
- Squamous cell carcinomas of the left hand and right cheek s/p
Mohs micrographic surgery and repair by full thickness skin
graft
- nasal polypectomy (___)
- L forearm loop goretex AV graft (___)
- s/p open CCY (___)
- s/p AV graft thrombectomy (___)
- L brachial artery-to-axillary vein AV Graft (___)
- repair of quads (___)
- removal of AV graft (___)
- s/p left hemithyroidectomy (___)
- R ___ MT head resection
Social History:
___
Family History:
noncontributory
Physical Exam:
Admission:
VS: T 98.3 HR 96 BP 126/76 RR 19 O2sat 94% on RA
General: elderly male lying on side in bed, in mild discomfort
HEENT: MMdry, EOMI, anicteric sclero
Neck: supple, no JVD
CV: tachycardic, regular rhythm. nml S1 and S2. no m/r/g
Lungs: bibasilar crackles
Abdomen: soft, distended, nontender to palpation
GU: no Foley in place, deferred
Ext: WWP, 1+ pitting edema to mid-tibia of BLE, good radial
pulses bilaterally, good 2+ distal pulses of BLE
Neuro: AOx3, nonfocal
Discharge:
VS: T 99.4 HR 98 HR 86, BP 143/84, RR 15, O2sat 96%
General: Elderly male sitting in chair, NAD
HEENT: MMM, EOMI, anicteric sclera
Neck: Supple, JVP 8 cm
CV: Tachycardic, regular rhythm. nml S1 and S2. no m/r/g.
Lungs: Bibasilar rales
Abdomen: Soft, nondistended, nontender to palpation, NABS
Ext: WWP, 2+ pulses of BLE, significant ecchymosis of RUE with
improved swelling, RUE is as warm as LUE; sensation intact
bilaterally with pain only @ site of ecchymosis
Neuro: AOx3, nonfocal
Pertinent Results:
___ 01:53PM LACTATE-1.3
___ 01:48PM tacroFK-6.9
___ 05:50AM URINE HOURS-RANDOM
___ 05:50AM URINE GR HOLD-HOLD
___ 05:50AM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 05:50AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-100
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5
LEUK-NEG
___ 05:50AM URINE RBC-1 WBC-0 BACTERIA-NONE YEAST-NONE
EPI-0
___ 05:50AM URINE HYALINE-11*
___ 04:57AM COMMENTS-GREEN TOP
___ 04:57AM LACTATE-1.3
___ 04:30AM GLUCOSE-176* UREA N-41* CREAT-1.9* SODIUM-142
POTASSIUM-5.1 CHLORIDE-100 TOTAL CO2-28 ANION GAP-19
___ 04:30AM estGFR-Using this
___ 04:30AM WBC-16.3* RBC-5.06 HGB-15.2 HCT-46.3 MCV-92
MCH-30.0 MCHC-32.8 RDW-13.9
___ 04:30AM NEUTS-83.2* LYMPHS-10.3* MONOS-5.4 EOS-0.8
BASOS-0.4
___ 04:30AM PLT COUNT-233
___ 04:30AM ___ PTT-27.9 ___
___ CARDIAC CATH
Cardiac Output Results
PhaseFick
C.O.(l/min)Fick
C.I. (l/min /m2)TD
CO (l/min)TD
CI (l/min/m2)
Baseline4.432.42
Hemodynamic Measurements (mmHg)
Baseline
SiteSysDiasEndMeanA WaveV WaveHR
AO ___
RA ___
PCW ___
PA 4320 29 96
RV ___
Contrast Summary
ContrastTotal (ml)
Optiray (ioversol 320 mg/ml)40
Radiation Dosage
Effective Equivalent Dose Index (mGy)495.105
Radiology Summary
Total Runs
Total Fluoro Time (minutes)7.0
Findings
ESTIMATED blood loss: 150 cc
Hemodynamics (see above):
Coronary angiography: right dominant
LMCA: No significant stenosis
LAD: Heavily calcified 90% proximal; Small distal vessel but
probably mid vessel target
LCX: Heavily calcified; Diffuse 90% before large OM - good
target
RCA: Ectatic, calcified. 80% proximal; diffuse mid disease; RPL
80%
Note: Patient developed acute dyspnea after LCA injections. IV
nitro started. Initial PA systolic pressure 60 and reduced to
___
on nitroglycerin. Dyspnea resolved.
Potential for Radiation Injury
This patient underwent a procedure performed under fluoroscopic
(X-ray) guidance. Procedures involving lengthy exposures to
X-rays may cause damage to the skin and/or hair. These adverse
effects may be increased if one has had previous (especially
recent) radiation exposure to the same skin area. Radiation
injury to the skin can take many forms, including an area of
redness, blistering, hair loss, or ulceration. These effects may
appear after a few weeks or even after several months. If an of
these occur on the side and back of the torso (or elsewhere),
please contact the Interventional Cardiology Section at
___ to arrange further evaluation.
Assessment & Recommendations
1. Severe 3 vessel CAD
2. Moderately elevated left sided filling pressures
3. Transfer to CCU; Not a candidate for IABP. CSURG consult.
___ ECHO
The left atrium is elongated. Left ventricular wall thicknesses
are normal. The left ventricular cavity size is normal. LV
systolic function appears depressed (ejection fraction 30
percent) secondary to extensive severe apical
hypokinesis/akinesis with focal apical dyskinesis (no definite
apical thrombus seen). The inferior free wall and lateral wall
also appear hypokinetic. Tissue Doppler imaging suggests an
increased left ventricular filling pressure (PCWP>18mmHg). The
right ventricular free wall thickness is normal. Right
ventricular chamber size is normal. with focal hypokinesis of
the apical free wall. The number of aortic valve leaflets cannot
be determined. The aortic valve leaflets are moderately
thickened. The aortic valve is not well seen. There is mild
aortic valve stenosis. Trace aortic regurgitation is seen. The
mitral valve leaflets are structurally normal. There is no
mitral valve prolapse. Mild (1+) mitral regurgitation is seen.
There is moderate pulmonary artery systolic hypertension. There
is no pericardial effusion.
Compared with the prior study (images reviewed) of ___,
left ventricular contractile function is significantly reduced,
with focal wall motion abnormalities suggestive of intercurrent
myocardial infarction. Dr ___ by telephone at 11:00
am.
___ EKG
Sinus rhythm. Premature ventricular complex. Leftward axis.
Possible prior
lateral myocardial infarction. Extensive T wave inversions in
the precordial leads consistent with possible ischemia. Clinical
correlation is suggested. Compared to the previous tracing of
___ the ventricular rate is slower and the frequency of
ectopy is less pronounced. The precordial T wave inversions are
deeper and more extensive.
Brief Hospital Course:
Pt is a ___ with PMHx ESRD, DM, COPD, admitted to Transplant
Surgery for SBO, found to have NSTEMI, then transferred to CCU
s/p cath showing significant 3VD.
ACTIVE ISSUES:
# NSTEMI: Pt has had crescendo anginal symptoms with NSTEMI.
Cath showed significant 3VD. Given poor access, pt is not a
candidate for IABP. Will require surgical management if pt has
recurrence of chest pain. Pt was started on a heparin gtt.
Plavix was held for pending CABG. He was started on
atorvastatin 80 mg and ASA 81 and continued on metoprolol
(increased to 200 mg qd) and imdur 30 mg qd. The pt's home
diltiazem was d/c'ed as was his ACEi given his kidney function.
The pt was counselled on the benefits of CABG and the risks of
prolonging this procedure given his severe CAD and symptoms, but
did not want to pursue a CABG during this hospitalization.
Follow-up with his cardiologist, Dr. ___, was scheduled.
# SBO: The pt's n/v improved with NGT placement and bowel rest.
Transplant surgery treated him with famotidine 20 mg IV qd. His
NGT was clamped and then pulled short after transfer to the CCU
and at discharge, he had already begun passing gas and having
BMs and was able to tolerate a regualr diet.
CHRONIC ISSUES:
# ESRD: Pt has ESRD ___ FSGS, s/p cadaveric renal transplant in
___, now on tacrolimus and MMF with chronic allograft
nephropathy and transplant nephropathy. Nephrology Transplant
evaluated the pt and transitioned him to his home Tacrolimus,
MMF, and prednisone following resolution of his SBO. His Cr at
admission was 1.9. Cr was stable 1.4 upon transfer; baseline
per OMR is 1.4-1.6.
# HTN: Pt's SBPs in 120s in unit. His home ACEi was d/c'ed given
his kidney function.
# Hyperlipidemia: Stable. Atorvastatin increased to 80 mg.
# DMII: Last HbA1c 5.4 in ___. At home on metformin 500 mg
qd. Pt was placed on ISS for BGs > 200.
# COPD: Stable. Pt did not endorse any dyspnea or wheezing.
Continued tiotropium bromide 1 cap IH qd.
TRANSITIONAL ISSUES:
CODE: Full (discussed with pt)
EMERGENCY CONTACT: wife ___ ___
- Pt understands that he has severe CAD and will require CABG in
the future. He has follow-up with his outpatient cardiologist
and Cardiac surgery to schedule CABG.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN wheezing
2. Atorvastatin 20 mg PO DAILY
3. Cinacalcet 30 mg PO DAILY
4. Diltiazem Extended-Release 300 mg PO DAILY
5. Furosemide 20 mg PO DAILY
6. Lisinopril 40 mg PO DAILY
7. MetFORMIN (Glucophage) 500 mg PO DAILY
8. Allopurinol ___ mg PO DAILY
9. Metoprolol Succinate XL 25 mg PO DAILY
10. Mycophenolate Mofetil 720 mg PO BID
11. Omeprazole 20 mg PO DAILY
12. PredniSONE 5 mg PO DAILY
13. Tacrolimus 1 mg PO Q12H
14. Tiotropium Bromide 1 CAP IH DAILY
15. Aspirin 81 mg PO DAILY
16. Calcium 500 + D (D3) *NF* (calcium carbonate-vitamin D3)
500-125 mg-unit Oral twice daily
Discharge Medications:
1. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN wheezing
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 80 mg PO DAILY
RX *atorvastatin 80 mg one tablet(s) by mouth daily Disp #*30
Tablet Refills:*2
4. Furosemide 20 mg PO DAILY
5. Omeprazole 20 mg PO DAILY
6. PredniSONE 5 mg PO DAILY
7. Tacrolimus 1 mg PO Q12H
8. Tiotropium Bromide 1 CAP IH DAILY
9. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
RX *isosorbide mononitrate [Imdur] 30 mg one tablet extended
release 24 hr(s) by mouth daily Disp #*30 Tablet Refills:*2
10. Calcium 500 + D (D3) *NF* (calcium carbonate-vitamin D3)
500-125 mg-unit Oral twice daily
11. Mycophenolate Mofetil 720 mg PO BID
12. Metoprolol Succinate XL 200 mg PO DAILY
RX *metoprolol succinate 200 mg one tablet extended release 24
hr(s) by mouth daily Disp #*30 Tablet Refills:*2
13. Allopurinol ___ mg PO DAILY
14. Cinacalcet 30 mg PO DAILY
15. MetFORMIN (Glucophage) 500 mg PO DAILY
16. Nitroglycerin SL 0.4 mg SL PRN chest pain
RX *nitroglycerin [Nitrostat] 0.4 mg one tab sublingually as
needed Disp #*25 Tablet Refills:*2
Discharge Disposition:
Home
Discharge Diagnosis:
Small Bowel obstruction
Non ST elevation myocardial infarction
Hypertension
Diabetes
Dyslipidemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
It was a pleasure taking care of ___ at ___.
___ had trouble breathing and was found to have a heart attack.
A cardiac catheterization showed that ___ had severe blockages
in three of your heart arteries and will need to have bypass
surgery to prevent a larger heart attack. ___ were seen by Dr.
___ surgery and will see him again as an outpatient to
discuss the surgery. Weigh yourself every morning, call Dr.
___ weight goes up more than 3 lbs in 1 day or 5
pounds in 3 days.
___ also had a small bowel obstruction and needed a tube in your
nose to remove liquid in your stomach until the obstruction
cleared. ___ now seem to have recovered from this.
It is extremely important that ___ do not start smoking again
when ___ get home. Smoking can cause heart attack and will make
recovering from surgery much harder.
Followup Instructions:
___
|
19674244-DS-28
| 19,674,244 | 29,883,591 |
DS
| 28 |
2194-12-03 00:00:00
|
2194-12-03 13:35:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: CARDIOTHORACIC
Allergies:
Morphine / Iron Complex / Penicillins
Attending: ___.
Chief Complaint:
diarrhea
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. ___ is a ___ year old gentleman with a history of a renal
transplant s/p CABG ___
re-admit with elevated WBC and diarrhea. Given the patient's
immunosuppression and worsening constitutional symptoms, the
biggest concern is C. diff.
Past Medical History:
- ESRD ___ FSGS s/p cadveric Tx ___, first transplant ___
- Depression
- Hyperlipidemia
- Suspected cardiomyopathy with LVEF 35% in ___, improved to
55% one month later. Etiology unclear.
- Hypertension
- tertiary hyperparathyroidism with chondrocalcinosis
- Diabetes Type II
- Gout
- Squamous cell carcinomas of the left hand and right cheek s/p
Mohs micrographic surgery and repair by full thickness skin
graft
- R ___ MT head resection
- COPD
Past Surgical History
- Nasal polypectomy (___)
- L forearm loop goretex AV graft (___)
- s/p open CCY (___)
- s/p AV graft thrombectomy (___)
- L brachial artery-to-axillary vein AV Graft (___)
- repair of quads (___)
- removal of AV graft (___)
- s/p left hemithyroidectomy (___)
- Squamous cell carcinomas of the left hand and right cheek s/p
___ micrographic surgery and repair by full thickness skin
graft
- Left lower extremity dialysis loop
- B/L. Total Knee Replacements
Social History:
___
Family History:
diabetes mellitus and CAD in parents
Physical Exam:
97.7 75 98/59 20 95% RA
General:
Skin: intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x] sternotomy site with some
eccymosis, no drainage or cellulitis. there is some fullness at
the upper portion of the wound but no clear collection or
drainage. chest tube sites are clean and healing, no drainage.
Heart: RRR [x] Irregular [] Murmur [] grade ______
Abdomen: Soft [x] non-distended [x] non-tender [x]
Extremities: Warm [x], well-perfused [x] Edema [] trace edema
bilat ___. R knee minimally swollen and tender to palpation.
There is ecchymosis over medial thigh (from saphenous vein
harvest site) and lower leg but wounds are otherwise healing
without drainage or overlying fluctuance
Neuro: Grossly intact [x]
Pertinent Results:
___ 06:00AM BLOOD WBC-10.8 RBC-3.18* Hgb-9.6* Hct-30.0*
MCV-94 MCH-30.3 MCHC-32.1 RDW-16.5* Plt ___
___ 06:00AM BLOOD Glucose-104* UreaN-44* Creat-1.5* Na-131*
K-4.7 Cl-95* HCO3-24 AnGap-17
___ 08:35AM BLOOD ALT-13 AST-14 AlkPhos-57 Amylase-30
TotBili-0.5
___ ___ M ___ ___
Radiology Report CHEST (PA & LAT) Study Date of ___ 6:25 ___
___ ___ 6:25 ___
CHEST (PA & LAT) Clip # ___
Reason: ?pneumonia
Final Report
CHEST RADIOGRAPH PERFORMED ON ___
COMPARISON: Prior exam from ___.
CLINICAL HISTORY: Nausea, vomiting, question pneumonia.
FINDINGS: AP portable upright as well as a lateral view of the
chest was
provided. Midline sternotomy wires are again seen. The
previously noted left IJ central venous catheter has been
removed. Clips are noted in the right upper quadrant. The
kyphotic angulation of the T-spine causes distortion of the
chest on the frontal projection. However, allowing for this,
there is no definite consolidation or pneumothorax. Blunting of
the left CP angle is stable and could represent a small
effusion. There is likely bibasilar atelectasis. No signs of
pulmonary edema. Heart size is difficult to assess.
Mediastinal contour is stable. Bony structures appear intact.
No free air below the right hemidiaphragm.
IMPRESSION: Stable, limited exam with small left effusion and
probable
bibasilar atelectasis.
___. ___
___: WED ___ 7:27 ___
Brief Hospital Course:
This ___ year old male is s/p CABGx4 ___ and was discharged to
rehab. He had a decreased appetite, nausea, and diarrhea at
rehab and was sent to ___ for evaluation. He had an elevated WBC
of 23,000 and was hyponatremic. He had an ileus and c. diff
infection was suspected. ID was consulted and he was pan
cultured. His c. diff culture was negative but his WBC rapidly
decreased to 11,000 and his symptoms resolved. ID recommended a
7 day course of Flagyl. He was closely followed by renal
transplant team who managed his calcium, sodium, and fluid
status. He needs daily sodium, creatinine, and calcium testing
and the transplant clinic at ___ will call the rehab for the
results. His cinecalecet was held because of low calcium and was
restarted before he left.
He was advanced to a normal diet with a 1000 cc fluid
restriction and tolerated it. He needs encouragement to eat and
needs supplemental frappes. He was discharged to rehab in stable
condition with appropriate follow up.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Allopurinol ___ mg PO DAILY
2. Aspirin EC 81 mg PO DAILY
3. Atorvastatin 20 mg PO DAILY
4. PredniSONE 5 mg PO DAILY
5. Omeprazole 20 mg PO DAILY
6. Tacrolimus 1 mg PO Q12H
7. Cinacalcet 30 mg PO DAILY
8. Acetaminophen 650 mg PO Q4H:PRN fever, pain
9. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheezing
10. Amlodipine 5 mg PO DAILY
11. Bisacodyl ___AILY:PRN constipation
12. TraMADOL (Ultram) 50 mg PO Q4H:PRN pain
13. Tucks Hemorrhoidal Oint 1% ___ID PRN hemorrhoids
14. Metoprolol Tartrate 25 mg PO BID
15. Myfortic (mycophenolate sodium) 720 Oral bid
16. Ipratropium Bromide Neb 1 NEB IH Q4H
17. Lorazepam 0.25 mg PO Q12H:PRN anxiety
18. Insulin SC
Sliding Scale
Fingerstick QACHS
Insulin SC Sliding Scale using REG Insulin
19. Furosemide 40 mg PO DAILY
20. Hemorrhoidal Suppository ___ID PRN hemorrhoids
21. Docusate Sodium 100 mg PO BID
22. Diltiazem 60 mg PO QID
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN pain fever
2. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheezing
3. Aspirin 81 mg PO DAILY
4. Diltiazem 60 mg PO QID
5. Furosemide 40 mg PO DAILY
6. Ipratropium Bromide Neb 1 NEB IH Q4H
7. Metoprolol Tartrate 25 mg PO BID
8. Myfortic (mycophenolate sodium) 720 Oral bid
9. Citalopram 10 mg PO DAILY
10. Omeprazole 20 mg PO DAILY
11. PredniSONE 5 mg PO DAILY
12. Tacrolimus 1 mg PO Q12H
13. TraMADOL (Ultram) 50 mg PO Q4H:PRN pain
RX *tramadol 50 mg 1 tablet(s) by mouth every six (6) hours Disp
#*40 Tablet Refills:*0
14. Tucks Hemorrhoidal Oint 1% ___ID PRN hemorrhoids
15. Heparin 5000 UNIT SC TID
16. MetRONIDAZOLE (FLagyl) 500 mg IV Q8H
17. Allopurinol ___ mg PO DAILY
18. Amlodipine 5 mg PO DAILY
19. Atorvastatin 20 mg PO DAILY
20. Bisacodyl ___AILY:PRN constipation
21. Cinacalcet 30 mg PO DAILY
22. Docusate Sodium 100 mg PO BID
23. Hemorrhoidal Suppository ___ID PRN hemorrhoids
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
ESRD ___ FSGS s/p cadveric Tx ___ transplant ___,
Depression, Hyperlipidemia, Suspected cardiomyopathy w/LVEF
___ ^55%, Hypertension, tertiary hyperparathyroidism
w/chondrocalcinosis, Diabetes Type II, Gout, Squamous cell
carcinomas-left hand/right cheek s/p Mohs micrographic surgery
and repair by full thickness skin graft, R ___ MT head
resection, COPD, Nasal ___, L forearm goretex AV
___, open CCY (___), AV graft
___, L brachial artery-axillary vein AV
___, repair of ___, removal of AV ___,
left ___, Squamous cell carcinomas left hand
& right cheek s/p Mohs micrographic surgery & repair full
thickness skin graft, Left lower extremity dialysis loop, b/l
TKR,
presumed c. diff infection, ileus
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating, gait steady
Sternal pain managed with oral analgesics
Sternal Incision - healing well, no erythema or drainage
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming, and look at your incisions
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns ___
**Please call cardiac surgery office with any questions or
concerns ___. Answering service will contact on call
person during off hours**
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
Followup Instructions:
___
|
19674244-DS-31
| 19,674,244 | 28,478,629 |
DS
| 31 |
2196-11-07 00:00:00
|
2196-11-07 14:38:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
Morphine / Iron Complex / Penicillins / Iodinated Contrast Media
- IV Dye
Attending: ___.
Chief Complaint:
Lower extremity swelling and decreased urine output
Major Surgical or Invasive Procedure:
___: exploratory laparotomy, small-bowel resection, abdomen
left open with small bowel in discontinuity
___: exploratory laparotomy with re-anastomosis of jejunum
to D4 portion of duodenum
___: diagnostic paracentesis
___: (1) exploratory laparotomy washout and ___
gastrostomy. VAC placement.
(2) tracheostomy
History of Present Illness:
___ yo M w/ DM, HTN, CAD s/p CABGx4, ESRD secondary to FSGS s/p
renal transplant x 2 p/w DOE, +anasarca p/w 1 week ___
swelling and decreased UOP found to have ___ on CKD with
creatinine 3.3 (baseline ___. Also increased dyspnea over
past few days and wife reports using more pillows at night to
sleep. No fevers/chills, cough is at baseline, no abdominal
pain, N/V/D, CP, additional complaints.
In the ED, vitals: 98.1 ___ 110-130s/60-70s 18 94-100% 2L NC
(home ___ NC). Labs significant for creatinine 3.3 and nt-pro
BNP 37996. Trop 0.13 -> 0.12. Received 80 mg IV lasix at 7 am
and urinated 120 cc, then ordered an extra 40 mg IV but still
only urinated 200 ccs. Seen by Renal, recommended 150 mg IV
chlorothiazide followed by 100 mg IV lasix. Also recommended 80
mg IV lasix BID and keep foley for monitoring. Put out 250 cc in
foley in ED, approx another 200 cc on arrival to floor.
TTE showed LVEF = 30% (down from 50-55% in ___, but had
previously been 35% ___ with moderate AS, trace AR. CXR
showed mild pulmonary edema. EKG showed lateral T-wave
inversions and the patient's troponins are trending. Renal
ultrasound limited but normal. Lower extremity dopplers limited
but normal
Given home medications, though renally dosed allopurinol to 100
qd and held bactrim given ___.
Past Medical History:
PMH:
- Perforated gastric ulcer s/p partial gastrectomy ___
- Disseminated adenovirus s/p cidofovir with eradication ___
- MRSA and stenotrophomonas VAP ___
- CAD s/p CABG x 4 (LIMA-LAD,SVG-OM,SVG-PLV1,SVG-PLV2) in ___
- ESRD ___ FSGS s/p cadveric Tx ___, first transplant ___
- Depression
- Hyperlipidemia
- Suspected cardiomyopathy with LVEF 35% in ___, improved to
55% one month later; etiology unclear.
- Hypertension
- Tertiary hyperparathyroidism with chondrocalcinosis
- Diabetes Type II
- Gout
- Squamous cell carcinomas of the left hand and right cheek s/p
Mohs micrographic surgery and repair by full thickness skin
graft
- R ___ MT head resection
- COPD
PAST SURGICAL HISTORY:
- Nasal polypectomy (___)
- L forearm loop goretex AV graft (___)
- s/p open CCY (___)
- s/p AV graft thrombectomy (___)
- L brachial artery-to-axillary vein AV Graft (___)
- repair of quads (___)
- removal of AV graft (___)
- s/p left hemithyroidectomy (___)
- Squamous cell carcinomas of the left hand and right cheek s/p
Mohs micrographic surgery and repair by full thickness skin
graft
- Left lower extremity dialysis loop
- B/L. Total Knee Replacements
- Partial gastrectomy & gastrostomy tube (___) for perforated
gastric ulcer
Social History:
___
Family History:
Significant for diabetes and coronary artery disease.
Physical Exam:
ADMISSION:
Wt 64 kg (standing)
VS: 97.7, 136/72, 73, 20, 91% 4L
General: Tired appearing man, lying in bed, breathing without
accessory muscle use on NC
HEENT: MMM
Neck: difficult to assess JVD given engorged external jugular
but appears elevated
CV: RRR, no murmurs
Lungs: crackles at bases, coarse wheezes throughout
Abdomen: soft, non-tender, +BS
GU: foley, reddish urine in bag
Ext: warm, well-perfused, pulses intact in upper and lower
extremities bilaterally, 2+ dependent pitting edema to thighs
Neuro: A&Ox3, CNII-XII grossly intact
Skin: warm, dry
DISCHARGE:
General: NAD
CV: RRR, no M/R/G
Pulm: no respiratory distress, slighlty diminished breath sounds
at bases b/l
Abdomen: soft, NT, ND. Wound vac in place
Ext: WWP, no CCE
Pertinent Results:
___ 01:05AM BLOOD WBC-7.9 RBC-3.61* Hgb-10.4* Hct-33.0*
MCV-91 MCH-28.8 MCHC-31.5* RDW-16.3* RDWSD-54.3* Plt ___
___ 01:05AM BLOOD Neuts-71.9* ___ Monos-7.4
Eos-0.4* Baso-0.4 Im ___ AbsNeut-5.67 AbsLymp-1.52
AbsMono-0.58 AbsEos-0.03* AbsBaso-0.03
___ 01:05AM BLOOD Glucose-206* UreaN-72* Creat-3.2*# Na-134
K-5.0 Cl-98 HCO3-25 AnGap-16
___ 01:05AM BLOOD ALT-14 AST-15 AlkPhos-92 TotBili-0.2
___ 01:05AM BLOOD Lipase-22
___ 01:05AM BLOOD ___
___ 01:05AM BLOOD cTropnT-0.12*
___ 03:40PM BLOOD cTropnT-0.13*
___ 01:05AM BLOOD Albumin-3.1* Calcium-7.9* Phos-4.9*
Mg-2.0
___ 01:05AM BLOOD D-Dimer-2278*
___ 05:25AM BLOOD CRP-284.7*
___ 01:05AM BLOOD tacroFK-12.3
___ 10:37AM BLOOD ___ pO2-193* pCO2-68* pH-7.35
calTCO2-39* Base XS-9
___ 12:03AM BLOOD Lactate-1.1
ECHO ___
The left atrium is mildly dilated. Left ventricular wall
thicknesses are normal. The left ventricular cavity size is
normal. There is moderate to severe global left ventricular
hypokinesis (LVEF = 30 %) with regional variation: inferior and
posterior walls severely hypokinetic. Tissue Doppler imaging
suggests an increased left ventricular filling pressure
(PCWP>18mmHg). The right ventricular free wall thickness is
normal. Right ventricular chamber size is normal. with mild
global free wall hypokinesis. There are three aortic valve
leaflets. The aortic valve leaflets are moderately thickened.
There is moderate aortic valve stenosis (valve area 1.1cm2).
Trace aortic regurgitation is seen. The mitral valve leaflets
are mildly thickened. Trivial mitral regurgitation is seen. [Due
to acoustic shadowing, the severity of mitral regurgitation may
be significantly UNDERestimated.] There is moderate pulmonary
artery systolic hypertension. There is no pericardial effusion.
ECHO ___
The left atrial volume index is moderately increased. Left
ventricular wall thicknesses are normal. The left ventricular
cavity size is normal. There is moderate to severe global left
ventricular hypokinesis with regional variation (LVEF = 30 %).
The inferior wall is akinetic. The posterior wall is severely
hypokinetic. Tissue Doppler imaging suggests an increased left
ventricular filling pressure (PCWP>18mmHg). Right ventricular
chamber size and free wall motion are normal. The number of
aortic valve leaflets cannot be determined. The aortic valve
leaflets are moderately thickened. There is mild aortic valve
stenosis (valve area 1.2-1.9cm2). No aortic regurgitation is
seen. The mitral valve leaflets are mildly thickened. Mild (1+)
mitral regurgitation is seen. [Due to acoustic shadowing, the
severity of mitral regurgitation may be significantly
UNDERestimated.] The estimated pulmonary artery systolic
pressure is normal. There is no pericardial effusion.
Compared with the prior study (images reviewed) of ___,
right ventricular function appears impproved.
ECHO ___
The left atrium and right atrium are normal in cavity size. Left
ventricular wall thicknesses and cavity size are normal. There
is severe global left ventricular hypokinesis (LVEF = 20 %).
Systolic function of apical segments is relatively preserved.
Right ventricular chamber size is normal with moderate global
free wall hypokinesis. There is no pericardial effusion.
IMPRESSION: Suboptimal image quality. Normal left ventricular
cavity size with severe global dysfunction c/w diffuse process.
Right ventricular free wall hypokinesis.
Compared with the prior study (images reviewed) of ___,
global biventricular systolic function is now more depressed.
ECHO ___
The left atrium is mildly dilated. No atrial septal defect is
seen by 2D or color Doppler. Left ventricular wall thicknesses
and cavity size are normal. Overall left ventricular systolic
function is severely depressed (LVEF= 20 %). 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 is normal. with
moderate global free wall hypokinesis. 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. Moderate (2+) mitral
regurgitation is seen. [Due to acoustic shadowing, the severity
of mitral regurgitation may be significantly UNDERestimated.]
Moderate to severe [3+] tricuspid regurgitation is seen. There
is moderate pulmonary artery systolic hypertension. There is no
pericardial effusion.
IMPRESSION: Severely depressed left ventricular systolic
function. Increased left ventricular filling pressure.
Moderately depressed right ventricular function. Moderate mitral
regurgitation. Moderate to severe tricuspid regurgitation.
Moderate pulmonary artery systolic hypertension.
Compared with the prior study (images reviewed) of ___, a
comprehensive study was performed today (previously focused)
allowing for the assessment of valvular disease. The
biventricular systolic function is similar.
ECHO ___
Overall left ventricular systolic function is severely depressed
(LVEF= 20 %). No masses or thrombi are seen in the left
ventricle. Right ventricular chamber size is normal. with
moderate global free wall hypokinesis. The aortic valve leaflets
(3) are mildly thickened. The aortic valve VTI = 31.5 cm. There
is mild aortic valve stenosis (valve area 1.2-1.9cm2). Mild (1+)
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. Mild to moderate (___) mitral regurgitation
is seen. [Due to acoustic shadowing, the severity of mitral
regurgitation may be significantly UNDERestimated.] There is a
trivial/physiologic pericardial effusion.
IMPRESSION: Severely depressed global left ventricular systolic
function. Moderately depressed right ventricular systolic
function. Mild aortic stenosis by continuity equation in the
setting of depressed ventricular systolic function; leaflets
appear more pliable than is suggested. Mild aortic
regurgitation. Mild to moderate mitral regurgitation. Tricuspid
regurgitation is seen, but cannot be quantified.
Compared with the prior study (images reviewed) of ___,
the pulmonary artery systolic pressure has decreased from 45
mmHg. It is unclear if there has been a change in the severity
of tricuspid regurgitation; it is likely similar and the
previously reported 3+ may have been an overestimate.
BILATERAL LOWER EXTREMITY VENOUS DUPLEX ___
Somewhat limited evaluation of the calves due to patient's
inability to lie down and right calf soft tissue edema. Within
these limitations, no evidence of deep venous thrombosis in the
bilateral lower extremity veins.
RENAL TRANSPLANT ULTRASOUND ___
1. There appears to be diastolic flow in the intrarenal
arteries, but the exam was limited by technical difficulties and
this may not be true diastolic flow. If the apparent diastolic
flow is accurately measured on this exam, it is within the
normal range. However, if clinical concern persists, repeat
renal D
oppler ultrasound could be performed.
2. Otherwise normal appearance of renal transplant.
CT CHEST ___
1. Lobar atelectasis and pneumonia of both lung bases.
2. Right greater than left moderate pleural effusions.
3. Persistent mediastinal adenopathy and increased axillary
adenopathy.
4. 12 mm right thyroid nodule.
CT HEAD ___
1. No evidence of hemorrhage, infarct, or fractures.
2. Nasal tube is present on the right.
3. Ventricles appear prominent for given age of patient.
4. Atherosclerotic calcifications are visualized in the
bilateral ICA.
CT ABD/PELV ___
1. No evidence of anastomotic leak.
2. Worsening ascites, now moderate, with diffuse anasarca.
3. Nodular contour of the liver suggestive of cirrhosis. No
splenomegaly.
CT CHEST ___
Unchanged mild mediastinal adenopathy. Status post CABG with
severe coronary and aortic valve calcifications. The partly
loculated bilateral pleural effusions with subsequent areas of
parenchymal consolidation are constant. The pre-existing
parenchymal opacity in the apical segment of the left lower lobe
is better defined and smaller than on the previous examination.
The pre-existing upper lobe ground-glass opacities are less
extensive than on the previous examination and show a more
nodular appearance.
PARACENTESIS ___
Technically successful ultrasound-guided diagnostic paracentesis
yielding 20cc of cloudy right ascitic fluid
___ 5:22 am MRSA SCREEN Source: Nasal swab.
**FINAL REPORT ___
MRSA SCREEN (Final ___: No MRSA isolated.
___ 8:20 am SPUTUM Source: Expectorated.
**FINAL REPORT ___
GRAM STAIN (Final ___:
___ PMNs and <10 epithelial cells/100X field.
4+ (>10 per 1000X FIELD): GRAM NEGATIVE ROD(S).
RESPIRATORY CULTURE (Final ___:
MODERATE GROWTH Commensal Respiratory Flora.
ALCALIGENES (ACHROMOBACTER) SPECIES. MODERATE GROWTH.
sensitivity testing performed by Microscan.
Ertapenem Susceptibility testing requested by ___ ___
___
(___). Ertapenem = 2 MCG/ML.
Ertapenem sensitivity testing performed by Microscan.
Susceptibility results were obtained by a procedure
that has not
been standardized for this organism Results may not be
reliable
and must be interpreted with caution.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ALCALIGENES (ACHROMOBACTER) SPECIES
|
AMIKACIN-------------- =>64 R
CEFEPIME-------------- 16 I
CEFTAZIDIME----------- =>32 R
CEFTRIAXONE----------- =>64 R
CIPROFLOXACIN--------- 2 I
GENTAMICIN------------ =>16 R
IMIPENEM-------------- 2 S
LEVOFLOXACIN---------- 2 S
MEROPENEM------------- 2 S
PIPERACILLIN/TAZO----- <=8 S
TOBRAMYCIN------------ =>16 R
TRIMETHOPRIM/SULFA---- <=2 S
___ 2:50 pm STOOL CONSISTENCY: NOT APPLICABLE
Source: Stool.
**FINAL REPORT ___
C. difficile DNA amplification assay (Final ___:
Reported to and read back by ___ ___ @10:05 AM.
CLOSTRIDIUM DIFFICILE.
Positive for toxigenic C. difficile by the Illumigene
DNA
amplification. (Reference Range-Negative).
___ 4:23 pm PERITONEAL FLUID PERITONEAL FLUID.
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final ___:
Reported to and read back by ___ ___ (___)
2:29PM
___.
ENTEROCOCCUS SP.. RARE GROWTH.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROCOCCUS SP.
|
AMPICILLIN------------ =>32 R
LINEZOLID------------- 2 S
PENICILLIN G---------- =>___ R
VANCOMYCIN------------ =>32 R
ANAEROBIC CULTURE (Final ___: NO ANAEROBES ISOLATED.
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
Brief Hospital Course:
___ yo M w/ DM, HTN, CAD s/p CABGx4, ESRD secondary to FSGS s/p
renal transplant x 2 p/w DOE, +anasarca p/w ___ swelling and
decreased UOP found to have acute on chronic systolic CHF
exacerbation (in setting of newly depressed EF) diuresed but
course c/b NSTEMI, HCAP, worsening pleural effusion and SBO
requiring exploratory laparotomy. ***
NEURO: Patient's pain was well-controlled on PRN Tylenol and
narcotics. During periods of intubation, patient was sedated on
propofol and fentanyl drips. On ___, patient was noticed to
have a left-sided neglect while working with Physical Therapy.
CT head was negative for stroke or acute intracranial process.
CARDIOVASCULAR: Patient had multiple cardiac issues during this
admission.
# Acute on chronic systolic CHF exacerbation: Newly depressed EF
(30% from 50-55%, though had previously been 35% ___ w/ hx
CAD s/p 4 CABGs. Initially on lasix drip with twice daily
dosing of chlorothiazide 500 mg plus lasix 160 mg, then
transitioned to torsemide 20 mg daily once at dry weight ___
kg.) Continued home aspirin, atorvastatin, hydralazine,
metoprolol, nitroglycerin prn, isosorbide mononitrate.
# NSTEMI: Trop elevation up to 0.17 on ___ w/ dynamic STD in
V5-V6 during episodes of chest pain. Likely lost a vein graft in
the last month or so given regional wall motion abnormalitites
on TTE. Received heparin gtt x 48 hours from ___ to ___.
Continued imdur, hydralazine, ASA, atorvastatin. Cardiology
consulted, recommended mycoardial viability study, which was
completed ___ and showed moderate inferior and inferoseptal wall
defects at 20 minutes that improved at 4 hours and 24 hours,
suggesting viable myocardium. No fixed focal perfusion
abnormalities. Cardiac catheterization was put on hold due to
SBO.
#PEA arrest: Patient was extubated on ___ but required
re-intubation several hours later due to hypoxia. Shortly after
re-intubation, he became hemodynamically unstable without
immediate improvement in oxygenation. He became extremely
tachycardic and hypotension and went into PEA arrest requiring a
___ min of chest compressions and epinephrine with ROSC. After
chest tube placement for suspected pneumothorax, the patient had
a second PEA arrest with ROSC after ___ of chest compressions.
An informal bedside Echo done during this time showed severe LV
hypokinesis with EF 15%. He subsequently required quadruple
pressors to maintain his MAP but was able to wean off all
pressors in less than 24 hours.
#Supraventricular arrhythmia: After pressors were weaned,
patient was resumed on IV metoprolol - the dosing was increased
per Cardiology to control tachycardia with a supraventricular
arrhythmia.
#History of CAD & CABG: Patient was continued was home aspirin,
Plavix. Metoprolol was resumed when appropriate.
PULMONARY: Patient had multiple pulmonary issues during this
admission.
# Bilateral pleural effusions: In setting of CHF exacerbation
and HCAP (see below), noted to be worsening on CXR and CT with
higher oxygen requirement than at home (between ___ L O2 during
admission in comparison to 2L intermittently at home.)
#HCAP: See "Infectious Disease"
#COPD: Patient was continued on home albuterol and ipratropium
inhalers.
#Respiratory failure: The patient was intubated for his bowel
resection and remained intubated until POD1 after re-anastomosis
and abdominal closure was completed. He failed extubation on
___ due to hypoxia. His oxygenation did not immediately improve
with upon re-intubation, and CXR showed complete white out of
his left lung. Shortly after the film was shot, he became
extremely hemodynamically unstable and went into PEA arrest x2
(as described under "Cardiovascular"). A left chest tube was
placed due to suspicion for a pneumothorax without much
improvement. A bronchoscopy was done showing copious thick
yellow secretions in the left bronchial tree. After these
secretions were suctioned, oxygenation improved significantly.
Though the patient was able to wean to minimal ventilatory
support, there was great concern that he would not be able to
tolerate extubation and a tracheostomy was placed. He was unable
to wean to trach mask due to significant anxiety.
GASTROINTESTINAL:
#SBO: During his hospital course, patient developed worsening
abdominal pain with associated leukocytosis; KUB and CT showed
closed loop obstruction. On ___, he underwent an exploratory
laparotomy with small bowel resection in left in discontinuity
with open abdomen. He returned to the OR two days lover for
re-anastomosis of the jejunum to the D4 portion of the duodenum.
A CT abd/pelv was done on ___ in the setting of worsening
leukocytosis, which showed no anastomotic leak. Regardless, the
patient complained of worsening abdominal pain and taken back to
the OR on ___ for exploration - the anastomosis was intact. One
liter of ascitic fluid was drained, and the abdomen was washed
out. A
#Wound infection: Noted on OR take back on ___. Fascia was
closed and the wound was left open with a wound VAC that was
changed q3 days with good wound healing.
#SBP: Given finding of ascites on his ___ CT, a diagnostic
paracentesis was performed on. Only a small amount of fluid was
drained ___ but it eventually grew VRE, and the patient was
started on linezolid.
#Malnutrition: Given the patient's ventilator-dependence and
severity of illness, the patient received nutrition via enteral
feeds (Nepro). He received a gastronomy tube with the
tracheostomy.
#C diff infection: see "Infectious Disease"
RENAL:
# ___ on CKD: Admitted with creatinine of 3.2 on previous
baseline of ~2.5. Concern for inevitable need for dialysis but
was able to diurese to 1.7 on ___. Creatinine increased again to
2.0 on ___ in setting of SBO. His creatinine began to decrease
post-op but his kidney function suffered another insult with his
PEA arrest. He briefly became anuric with Cr peaking at 2.4. He
was given Lasix 100 BID with significant improvement in urinary
output as well as Cr, and dialysis was able to be avoided.
# Kidney transplant: Patient was followed by Transplant
Nephrology and tacrolimus was dosed by level. Home prednisone
was resumed post-op.
HEMATOLOGY: Patient received multiple blood transfusions for low
hematocrit. Subcutaneous heparin was also given for DVT
prophylaxis.
ENDOCRINE: Patient's blood sugars were well-controlled on
insulin sliding scale.
INFECTIOUS DISEASE: Patient suffered from multiple infectious
processes during this admission.
#HCAP: New leukocytosis on ___, chest CT showed bilateral HCAP,
and sputum culture growing alcaligenes. No PNA clinically
(fevers, cough). UA and urine cultures neg. ID consulted.
Initially started on vanc and cefepime (day 1 = ___, then
d/c-ed vanc ___ because MRSA swab negative. Changed to meropenem
on ___ when sensitivities came back. ___ changed to
levofloxacin on ___ given concern that carbapenem was causing
nausea, but changed back to meropenem on ___ this was
discontinued on ___ for a 10day course.
#SBP: Patient was started on linezolid for VRE that grew in his
ascitic fluid.
#C diff: The patient was discovered to have C diff on ___ and
started on PO vancomycin and IV flagyl.
CHRONIC:
# COPD - continued home albuterol prn and symbicort. Initially
started on duonebs, then changed to home spiriva.
# CKD - continue cinacalcet, started calcium acetate ___ given
high phos
# Anxiety - ativan prn
# Gout - continued allopurinol
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 325 mg PO Q8H:PRN fever, pain
2. Albuterol Inhaler 4 PUFF IH Q4H:PRN wheezing
3. Allopurinol ___ mg PO DAILY
4. Aspirin 81 mg PO DAILY
5. Atorvastatin 40 mg PO QPM
6. Cinacalcet 30 mg PO DAILY
7. ClonazePAM 0.5 mg PO QPM
8. Docusate Sodium 100 mg PO BID:PRN constipation
9. HydrALAzine 50 mg PO Q8H
10. PredniSONE 5 mg PO DAILY
11. Tiotropium Bromide 1 CAP IH DAILY
12. Magnesium Oxide 400 mg PO BID
13. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation
inhalation BID
14. Metoprolol Succinate XL 150 mg PO DAILY
15. Tacrolimus 1 mg PO Q12H
16. Clopidogrel 75 mg PO DAILY
17. Isosorbide Mononitrate (Extended Release) 120 mg PO DAILY
18. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN CP
19. Furosemide 40 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Acute on chronic ___ pneumonia
Small bowel obstruction
PEA arrest
Secondary bacterial peritonitis (VRE)
Wound infection
C. diff infection
Acute kidney injury
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 excess fluid due to an
exacerbation of your chronic congestive heart failure. We gave
you medications to help remove the extra fluid. You also had
hospital-acquired pnuemonia and we gave you antibiotics. You had
chest pain that was concerning for cardiac pain and we treated
you with medical therapy. You had abdominal pain and you were
found to have a bowel obstruction that required surgery to
removed dead bowel. You were also unable to come off of the
ventilator and therefore required a tracheostomy and feeding
tube. You are now ready for discharge to a long-term care
facility to continue your recovery. You will need to follow up
in the Acute Care Surgery clinic as well as your other
healthcare providers.
Please read the following instructions for discharge:
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.
Followup Instructions:
___
|
19674244-DS-33
| 19,674,244 | 29,619,168 |
DS
| 33 |
2197-01-03 00:00:00
|
2197-01-04 09:20:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Morphine / Iron Complex / Penicillins / Iodinated Contrast Media
- IV Dye
Attending: ___
___ Complaint:
respiratory distress
Major Surgical or Invasive Procedure:
Placement of tunneled Left subclavian CVC by Interventional
Radiology on ___.
Removal of chest tubes by radiology.
History of Present Illness:
___ year-old male with complex past medical history including CAD
s/p CABG x4 , CHF with EF of 20%, ESRD secondary to FSGS s/p
transplant x2, gastrostomy, COPD, with recently complicated
medical course c/b respiratory failure now s/p trach with
hypotension, new multifocal pneumonia and concern for chest tube
migration.
The patient had a prolonged hospitalization from ___ to
___ ___ which he presented with an an acute on chronic CHF
exacerbation, whose course was compilcated by NSTEMI, closed
loop bowel obstruction s/p small bowel resection, staged
anastamosis, respiratory failure requiring intubation, PEA
arrest x2 with ROSC x2, HCAP, VRE SBP, C dif, ___ on CKD without
need for dialysis, and ultimately tracheostomy and gastrostomy.
He was recently admiteed from his skilled nursing facility with
another prolonged hospital course from ___ when he
initially prsented with worsening mental status. He was found
to have bilateral pleural effusions and had bilateral chest
tubes placed. Additionally hemodialysis was iniatied on ___
given declinining UOP. Given multiple prior AV fistulas a
tunneled L IJ had to be placed. He was also found to have MDR
PNA with BALS growing psuedomonas, alcaligenes, and a non
fermenter. On discharge he was on Amkiacin, Ceftazidime, and
inhaled tobramycin for coverage.
He had been doing well up to the ___ prior to admission and
able to communicate with family by writing. However he was given
seroquel and reportedly had altered mental status and was not
acting like himself. There was also concern that his right sided
chest tube was bumped out of place two days prior to admission
per family reports, and was again adjusted on the day prior to
admission. He presented due to concerns for right sided chest
tube displacement and altered mental status. He was briefly seen
at an OSH then transfered to ___ for further management.
On arrival his initial vitals were T 97.8 HR 84 BP 84/49 RR 24
RA Given concern for unreliable blood pressures he had a femoral
A line placed, as well as a right femoral line placed for
access. He was initially on a levophed gtt but with the a line
his pressures improved and the levophed gtt was able to be
stopped. He had been weaned to a trach mask at ___ but on
admission was placed on mechanical ventilation.
Labs were notable for
-wbc ct 14.9, h/h 9.3/31.4, platelets 201, trop 0.23, Cr 2.4,
lactate 1.5, VBG (intubated) ___
Imaging was notable for
-CT Torso with multifocal PNA, moderate R pleural effusion,
moderate L hydropneumothroax, and diffuse anasarca
- Bedside Echo with concern for possible vegetation
Patient was given 1L NS, IV flagyl, IV Vanc, cefepime, 0.5 mg
dilaudid, and started on levophed gtt, whichw as subsequently
discontinued as above.
Renal was consulted who did not think the patient needed urgent
HD, but will likely need HD on ___. Surgery was consulted who
agreed with admission to FICU.
On arrival to the FICU, the patient is mechanically ventilated.
He is alert and responsive to quetions. He denies being ___ any
pain. He is unable to answer any further questions. Per family
at bedside his mental status is almost back to baseline
currently.
Past Medical History:
PMH:
- Perforated gastric ulcer s/p partial gastrectomy ___
- Disseminated adenovirus s/p cidofovir with eradication ___
- MRSA and stenotrophomonas VAP ___
- CAD s/p CABG x 4 (LIMA-LAD,SVG-OM,SVG-PLV1,SVG-PLV2) ___ ___
- ESRD ___ FSGS s/p cadveric Tx ___, first transplant ___
- Depression
- Hyperlipidemia
- Suspected cardiomyopathy with LVEF 35% ___ ___, improved to
55% one month later; etiology unclear.
- Hypertension
- Tertiary hyperparathyroidism with chondrocalcinosis
- Diabetes Type II
- Gout
- Squamous cell carcinomas of the left hand and right cheek s/p
Mohs micrographic surgery and repair by full thickness skin
graft
- R ___ MT head resection
- COPD
- Closed loop bowel obstruction
PAST SURGICAL HISTORY:
- Nasal polypectomy (___)
- L forearm loop goretex AV graft (___)
- s/p open CCY (___)
- s/p AV graft thrombectomy (___)
- L brachial artery-to-axillary vein AV Graft (___)
- repair of quads (___)
- removal of AV graft (___)
- s/p left hemithyroidectomy (___)
- Squamous cell carcinomas of the left hand and right cheek s/p
Mohs micrographic surgery and repair by full thickness skin
graft
- Left lower extremity dialysis loop
- B/L. Total Knee Replacements
- Partial gastrectomy & gastrostomy tube (___) for perforated
gastric ulcer
- Ex-lap, small bowel resection (___), and reanastomosis
(jejunum and D4) (___)
- tracheostomy and ___ gastrostomy (___)
___: admitted for MRSA pneumonia.
Social History:
___
Family History:
Significant for diabetes and coronary artery disease.
Physical Exam:
ADMISSION
Vitals: T: 98.5 HR ___ BP 103/60 AC FiO2 50% F 20 Vt 450 PEEP 5
GENERAL: No acute distress, cachechtic, chronically ill
HEENT: NCAT, trach ___ place,
LUNGS: Coarse lungs sounds throughout, bilateral chest tubes ___
place, r sided tunnel catether appears c/d/i
CV: regular rate and rhythm
ABD: somwhat firm, midline surgical scar, G tube ___ place, c/d/i
EXT: atrophic muscles, warm well perfused, diffuse pitting edema
of upper and lower extremities, ulcer ___ right distal forearm,
femoral A line and CV line
NEURO: alert, following commands, pupils equal and reactive,
moving all extremeties
DISCHARGE:
VS: 98.8 127/84 95 18 100% PSV 50% ___
GEN NAD, trach w/ vent
RESP diffuse ronchi and end exp crackles
COR RRR no MRG
ABD soft NT ND
EXT dependent 2+ pitting edema
SACRUM: sacral ulcer to bone.
Pertinent Results:
ADMISSION LABS
___ 12:15PM BLOOD WBC-14.9* RBC-2.79* Hgb-9.3* Hct-31.4*
MCV-113* MCH-33.3* MCHC-29.6* RDW-22.6* RDWSD-94.2* Plt ___
___ 12:15PM BLOOD Neuts-87.4* Lymphs-4.0* Monos-6.9
Eos-0.3* Baso-0.1 NRBC-0.1* Im ___ AbsNeut-13.00*#
AbsLymp-0.59* AbsMono-1.02* AbsEos-0.04 AbsBaso-0.02
___ 12:15PM BLOOD Plt ___
___ 12:43PM BLOOD ___ PTT-25.4 ___
___ 06:20PM BLOOD ___ 12:15PM BLOOD Glucose-205* UreaN-79* Creat-2.4* Na-132*
K-4.9 Cl-98 HCO3-25 AnGap-14
___ 12:15PM BLOOD ALT-19 AST-65* AlkPhos-225* TotBili-0.4
___ 12:15PM BLOOD CK-MB-2
___ 12:15PM BLOOD cTropnT-0.23*
___ 12:09AM BLOOD CK-MB-3 cTropnT-0.27*
___ 03:45AM BLOOD CK-MB-3 cTropnT-0.27*
___ 12:15PM BLOOD Albumin-2.7* Calcium-9.7 Phos-2.5*
Mg-2.7*
___ 03:45AM BLOOD Hapto-152
___ 12:15PM BLOOD Amkacin-16.7*
___ 01:02PM BLOOD Amkacin-5.5*
IMAGING AND STUDIES
CT torso ___. Progressive, now severe bilateral airspace opacities,
worrisome for multifocal pneumonia.
2. Unchanged, moderate right pleural effusion and moderate left
hydropneumothorax. A left sided pigtail catheter has been
partially withdrawn,with the coiled tip still residing within
the pleural space.
3. Diffuse anasarca, mesenteric fluid, and bilateral hydroceles
are compatible with fluid overload and third spacing ___ the
setting of renal failure.
4. Chronic bilateral native renal atrophy with an unremarkable
appearing left pelvic renal transplant.
5. Moderate cardiomegaly and extensive atherosclerosis.
6. Enlarged main and right pulmonary arteries, compatible with
underlying pulmonary arterial hypertension.
CXR ___
Lines and tubes ___ place. Retrocardiac opacity may represent
persistent pneumonia and small pleural effusion.
EKG: Sinus rhythm, RBB, T wave inversion ___ V1-V3, ST
depressions ___ lateral leads, concern for worsening depressions
___ V2
TTE ___
The left atrium is mildly dilated. Left ventricular wall
thicknesses are normal. The left ventricular cavity size is
normal. There is severe global left ventricular hypokinesis
(LVEF = 20 %) with inferior akinesis. Tissue Doppler imaging
suggests an increased left ventricular filling pressure
(PCWP>18mmHg). The right ventricular free wall is hypertrophied.
The right ventricular cavity is moderately dilated with mild
global free wall hypokinesis and focal akinesis of the apical
free wall. The number of aortic valve leaflets cannot be
determined. The aortic valve leaflets are moderately thickened.
There is mild aortic valve stenosis. Trace aortic regurgitation
is seen. The mitral valve leaflets are mildly thickened. An
eccentric, posteriorly directed jet of Mild (1+) mitral
regurgitation is seen. [Due to acoustic shadowing, the severity
of mitral regurgitation may be significantly UNDERestimated.]
Due to the eccentric nature of the regurgitant jet, its severity
may be significantly underestimated (Coanda effect). The
tricuspid valve leaflets are mildly thickened. There is moderate
pulmonary artery systolic hypertension. Significant pulmonic
regurgitation is seen. There is no pericardial effusion.
IMPRESSION: no vegetations seen
UNILAT UP EXT VEINS US RIGHT ___
There is normal flow with respiratory variation ___ the bilateral
subclavian vein. The right internal jugular and axillary veins
are patent, show normal color flow and compressibility. The
right brachial, basilic, and cephalic veins are patent,
compressible and show normal color flow and augmentation.
No evidence of deep vein thrombosis ___ the right upper
extremity.
PORTABLE CXR ___
IMPRESSION: Minimal improvement ___ diffuse parenchymal
opacities, which now appear more consistent with moderate
pulmonary edema rather than multifocal pneumonia. Persistent
left basilar pneumothorax.
MICROBIOLOGY
___: BLOOD CULTURE: PENDING.
___: BLOOD CULTURE: PENDING.
___: BLOOD CULTURE: PENDING.
___ 2:10 am SPUTUM Source: Endotracheal.
GRAM STAIN (Final ___:
>25 PMNs and <10 epithelial cells/100X field.
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS AND CLUSTERS.
RESPIRATORY CULTURE (Preliminary):
Commensal Respiratory Flora Absent.
Due to mixed bacterial types ( >= 3 colony types) an
abbreviated
workup will be performed appropriate to the isolates
recovered from
this site.
STAPH AUREUS COAG +. SPARSE GROWTH.
YEAST. SPARSE GROWTH.
GRAM NEGATIVE ROD(S). SPARSE GROWTH.
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------------ <=0.5 S
LEGIONELLA CULTURE (Preliminary): NO LEGIONELLA ISOLATED.
Immunoflourescent test for Pneumocystis jirovecii (carinii)
(Final
___: NEGATIVE for Pneumocystis jirovecii
(carinii).
FUNGAL CULTURE (Preliminary):
YEAST.
DISCHARGE LABS
___ 03:08AM BLOOD WBC-12.1* RBC-2.74* Hgb-8.9* Hct-30.3*
MCV-111* MCH-32.5* MCHC-29.4* RDW-22.6* RDWSD-91.4* Plt ___
___ 03:08AM BLOOD Neuts-82* Bands-1 Lymphs-7* Monos-8 Eos-1
Baso-0 ___ Metas-1* Myelos-0 AbsNeut-10.04* AbsLymp-0.85*
AbsMono-0.97* AbsEos-0.12 AbsBaso-0.00*
___ 03:08AM BLOOD Hypochr-NORMAL Anisocy-1+ Poiklo-1+
Macrocy-3+ Microcy-NORMAL Polychr-1+ Ovalocy-1+
Schisto-OCCASIONAL
___ 03:08AM BLOOD ___ PTT-28.9 ___
___ 03:08AM BLOOD Glucose-71 UreaN-34* Creat-1.6* Na-138
K-4.2 Cl-102 HCO3-29 AnGap-11
___ 03:08AM BLOOD Calcium-9.6 Phos-3.1 Mg-2.3
___ 03:08AM BLOOD Vanco-20.1*
Brief Hospital Course:
___ year-old male with complex past medical history including CAD
s/p CABG x4 , CHF with EF of 20%, ESRD secondary to FSGS s/p
transplant x2, gastrostomy, COPD, with recently complicated
medical course c/b respiratory failure now s/p trach with
hypotension, presented to ___ with new multifocal pneumonia.
# Hypotension
Patient initially presented to the ED with hypotension requiring
levophed gtt. However when femoral a line subsequently placed
patients pressures were noted to be normal and levophed gtt able
to be discontinued, questioning veracity of pressure readings on
cuff. Patient pan-cultured w/ NGTD, TTE w/o vegetations, CXR
remarkable for pneumonia as below. Pressures stable ___ the FICU
requiring no further intervention.
#DIFFERENCES ___ BLOOD PRESSURE ___ RIGHT ARM BLOOD PRESSURE CUFF
AND FEMORAL A-LINE: OF NOTE, PATIENT'S A-LINE READINGS WERE
ROUTINELY 20 mm HG higher than the right arm blood pressure
cuff. During the hospitalization, the patient's blood pressure
used was the femoral A-line that was placed during the
hospitalization. This patient's A-line was removed prior to
discharge from the hospital.
# Multifocal Pneumonia
CT Torso with concern for bilateral opacities concerning for new
multifocal pneumonia. Pt with leukocytosis to 14.9 though
appears to have chronic leukocytosis. S/p Vanc/Flagyl/Cefepime
___ the ED for coverage. There was concern for septic emboli ___
setting of concern for cardiac vegetation seen on bedside echo
___ the ED but TTE revealed no such vegetations. Patient with
history of MDR VAP for which he was recently discharged on
amikacin, ceftazidime, inhaled tobramycin so there was initial
concern for MDR gram negative organism and ID was consulted.
Sputum culture gram stain notable for gram positive cocci ___
pairs and chains so there was no recommended change ___
antibiotics w/ the exception of discontinuation of inhaled
tobramycin. Patient on vancomycin while awaiting culture data.
Eventually, BAL grew MRSA, as well as gram negative rods
(although the gram negative rods were considered a likely
colonizer). Ceftazidime and amikacin were discontinued with the
approval of infectious disease. He was continued on vancomycin
for MRSA multifocal pneumonia. Plan for IV vancomycin until
___ for total 14 day course. Vancomycin PO until ___ for
history of Cdiff.
# Respiratory failure
Patient on chronic ventilatory at ___. Pt had HD for volume
overload. TTE obtained and showed severe LV global hypokinesis,
EF 20% which was similar to prior echocardiograms (___).
PNA managed as above.
# Volume Overload
Patient with evidence of volume overload on physical exam and
with diffuse anasarca and evidence of fluid overload likely ___
setting of renal failure. Patient received 1 L NS ___ ED ___ the
setting of an EF of 20% on most recent TTE. Patient anuric.
Renal consulted and underwent HD while ___ house.
# Bilateral pleural effusions
Patient s/p bilateral pigtail placement for pleural effusions.
Concern for right sided chest tube malpositioned. Surgery
consulted- no change ___ chest tubes was needed. Patient
continued to have significant output from tubes. ___ consulted
and recommended removing tubes only when less than 10 cc/d for 2
days. These chest tubes were removed by Interventional Radiology
during this hospitalization as chest tube removal was not
significant.
# CHF with reduced EF
Recent TTE with reduced to 20%. Patient with evidence of volume
overload, but warm and well perfused on exam, and no elevation
of lactate. Metoprolol initially held with concern for
decompensated CHF, on discharge restarted. TTE repeated showing
stable reduced EF. Pt underwent HD for volume overload as above.
# Concern for worsening ST depressions ___ V2
ECG with concern for possible worsening depressions ___ V2.
Initial troponins .23 though ___ setting of ERSD. Concern for
demand ischemia given poor substrate and increased stress likely
___ setting of worsening multifocal PNA. PE also on differential
as above.
# ESRD s/p transplant on HD
Patient with evidence of volume overload on exam. Renal
consulted and patient underwent HD while ___ house ___,
___, continued on prednisone s/p transplant.
# Anemia
Pt given 1 u PRBC during HD on ___ w appropriate rise ___ Hb.
# SVT
Patient with reported history of supraventricular arrhythmia for
which he is on IV metoprolol. Metoprolol held ___ setting of
possible decompensated HF. Metoprolol restarted on ___.
# CAD s/p CABG x4
Patient continued aspirin, Plavix. Metoprolol as above.
# Hx of Cdiff
Patient w/ Cdiff during ___ admission, continued on PO
Vancomycin. Course clarified with Infectious Disease and will
continue for two weeks after discontinuation of vancomycin
(until ___.
TRANSITIONAL ISSUES:
-Patient admitted w/ home medication of midodrine. Patient did
not require midodrine while ___ the ICU. If blood pressures are
consistently low (SBP<90), this could be considered added back
- Please re-assess pre-admission medication of heparin 25,000
units IV push inj 3/wk, Mo, We, Fr. This was on pre-admission
medication form.
- Abx course: continue IV vancomycin until ___.
- continue PO Vancomycin for chronic C.diff with end date
___ (when PNA course is complete)
- new tunnled left IJ line requires ETOH locks for MDR
bacteremia history - instill 2mL 70% ETOH into central catheter
port for local dwell 2 hours then aspirate, followed by saline
and heparin PRN (2mL 10 unit)
- patient on HD MWF.
- patient on chronic ventilator w/ tracheostomy.
- very important: patient's right blood pressure cuff was
measured and was noted to be 20 points less than the femoral
A-line that was placed. During hospitalization, his femoral
A-line was used as the correct blood pressure measurement.
- patient on chronic ventilator w/ tracheostomy. Vent settings
on discharge: CPAP FiO2 50% PEEP 5 PSV 20
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Acetaminophen 650 mg PO Q6H:PRN pain/fever
2. Albuterol 0.083% Neb Soln 1 NEB IH Q1H:PRN wheeze
3. Albuterol Inhaler ___ PUFF IH Q4H:PRN Wheeze
4. Amikacin 450 mg IV POST HD (___)
5. Aspirin 325 mg PO DAILY
6. Calcium Carbonate 500 mg PO Q6H
7. CefTAZidime 2 g IV POST HD (___)
8. Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL BID
9. Clopidogrel 75 mg PO DAILY
10. Collagenase Ointment 1 Appl TP BID
11. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol
12. Docusate Sodium (Liquid) 100 mg PO BID
13. Famotidine 20 mg PO DAILY
14. Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol
15. Glucose Gel 15 g PO PRN hypoglycemia protocol
16. Haloperidol ___ mg IV Q6H:PRN agitation
17. Heparin 5000 UNIT SC BID
18. Heparin Flush (10 units/ml) 2 mL IV DAILY and PRN, line
flush
19. HYDROmorphone (Dilaudid) 0.25 mg IV Q4H:PRN breakthrough
20. Metoprolol Tartrate 12.5 mg PO BID
21. Midodrine 10 mg PO TID
22. Ondansetron 4 mg IV Q8H:PRN nausea
23. OxycoDONE Liquid ___ mg PO Q4H:PRN pain
24. PredniSONE 5 mg PO DAILY
25. Senna 8.6 mg PO BID:PRN constipation
26. Simethicone 40-80 mg PO QID:PRN bloating
27. Sodium Chloride 0.9% Flush 10 mL IV DAILY and PRN, line
flush
28. Tobramycin Inhalation Soln 300 mg IH BID PER ACS
29. Vancomycin Oral Liquid ___ mg PO Q6H
30. Detemir 8 Units Q24H
Insulin SC Sliding Scale using REG Insulin
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain/fever
2. Albuterol 0.083% Neb Soln 1 NEB IH Q1H:PRN wheeze
3. Aspirin 325 mg PO DAILY
4. Calcium Carbonate 500 mg PO Q6H
5. Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL BID
6. Clopidogrel 75 mg PO DAILY
7. Collagenase Ointment 1 Appl TP BID
8. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol
9. Docusate Sodium (Liquid) 100 mg PO BID
10. Famotidine 20 mg PO DAILY
11. Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol
12. Glucose Gel 15 g PO PRN hypoglycemia protocol
13. Heparin Flush (10 units/ml) 2 mL IV DAILY and PRN, line
flush
14. HYDROmorphone (Dilaudid) 0.25 mg IV Q4H:PRN breakthrough
15. Detemir 8 Units Q24H
Insulin SC Sliding Scale using REG Insulin
16. Heparin 5000 UNIT SC BID
17. Ondansetron 4 mg IV Q8H:PRN nausea
18. OxycoDONE Liquid ___ mg PO Q4H:PRN pain
19. PredniSONE 5 mg PO DAILY
20. Senna 8.6 mg PO BID:PRN constipation
21. Simethicone 40-80 mg PO QID:PRN bloating
22. Sodium Chloride 0.9% Flush 10 mL IV DAILY and PRN, line
flush
23. Vancomycin Oral Liquid ___ mg PO Q6H
24. Vancomycin 1000 mg IV HD PROTOCOL
25. Metoprolol Tartrate 12.5 mg PO BID
26. Ethanol 70% Catheter DWELL (Tunneled Access Line) 2 mL DWELL
DAILY
27. Albuterol Inhaler 6 PUFF IH Q4H:PRN Wheeze
28. darbepoetin alfa ___ polysorbat 25 mcg/mL injection Q7D
29. Haloperidol 0.5 mg PO Q3H:PRN anxiety
30. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary:
Hypotension
Multifocal pneumonia
Secondary:
Coronary artery disease
End stage renal disease
Chronic heart failure with reduced ejection fraction
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Lethargic but arousable.
Activity Status: Bedbound.
Discharge Instructions:
Dear Mr. ___,
You were admitted to the ICU with problems breathing and low
blood pressure. You were found to have a lung infection called
pneumonia and put on antibiotics to treat it. You have dialysis
while ___ the hospital. You will be going home on supplemental
oxygen which will be decreased at your facility.
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs.
It was a pleasure to care for you!
-Your ___ Team
Followup Instructions:
___
|
19674342-DS-22
| 19,674,342 | 29,902,944 |
DS
| 22 |
2142-02-11 00:00:00
|
2142-02-11 20:34:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
positive blood cultures
Major Surgical or Invasive Procedure:
PICC Insertion ___
History of Present Illness:
___ with history of ___ ___ LLL lobectomy and XRT in ___,
bladder CA, sCHF ___ BiV-ICD, AR and MR repair on ___ who
presents from home after being found to have positive blood
cultures.
The patient endorses a history of progressive malaise for about
8 months. He is unable to state any specific symptoms but notes
heavy night sweats a few times per week that will drench his
shirt.
During his recent MV repair, he was exposed to mycobacterium
chimaera in the ___ 3T Heater-Cooler System used for
cardiothoracic surgery. He was evaluated by Dr. ___ of
infectious disease on ___ and obtained blood cultures which
resulted positive for GPCs in chains. He was called and told to
present to the ED. He went to ___ and then was
transferred to ___.
The patient has also endorsed myalgias and b/l hip arthralgia.
he was a history of Lyme and Babesiosis and has received
treatment for these conditions. He has no chest pain or dyspnea.
He endorses chronic back pain related to his XRT for which he
has a spinal stimulator. He is without n/v/d, abdominal pain or
dysuria.
Upon arrival to the ED he was noted to be hemodynamically stable
and a set of blood cultures were obtained. Upon discussion with
Dr. ___ was started on vancomycin.
In the ED, initial vitals were:
T 98.4 HR 80 BP 118/68 R 20 SpO2 99% RA
- Labs notable for:
Hgb 11.8, WBC 134
Chem7, LFTs wnl INR 1.2
- Imaging was notable for:
___ Chest (Pa & Lat)
IMPRESSION:
No acute cardiopulmonary process.
- Patient was given:
___ 21:37 PO OxyCODONE (Immediate Release) 5 mg
___ 22:02 PO OxyCODONE (Immediate Release) 10 mg
Upon arrival to the floor, patient reports no symptoms except
for his stable malaise
REVIEW OF SYSTEMS: per HPI
Past Medical History:
-___
--___ chemotherapy and XRT
--___ LLL lobectomy ___
--residual chronic left chest wall pain ___ spinal cord
stimulator placement for pain
-Bladder Cancer
--___ TURBT
--___ Mitomycin C
-Basal Cell Ca
--___ Mohs procedure
-___
--___ BiV-ICD ___
--last interrogation ___ wnl
-Mitral Regurgitation
--___ MV repair with annuloplasty band ___
-Tricuspid valve regurgitation
-Pulmonary hypertension
-LBBB
-Depression
-Diaphragmatic hernia ___
--___ Gortex repair
-GERD
-Lyme Disease
-Babesiosis
FOREIGN BODIES: per prior ID notes
-BiV-ICD
-Annuloplasty band
-Spinal cord stimulator
-Gortex hernia repair
Social History:
___
Family History:
Maternal aunts and uncles with history of myocardial infarction.
Denies history of autoimmune disorders.
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vital Signs: T 97.8 BP 132/71 HR 85 R 19 SpO2 98 Ra
GEN: NAD
HEENT: good dentition, sclerae anicteric
___: Regular, I/VI SEM, well healed surgical scar left chest.
ICD L anterior chest without erythema, pain or fluctuation
RESP: CTAB
ABD: NTND no HSM. Spinal stimulator located over left buttock
without erythema, pain or fluctuation
EXT: warm without edema
NEURO: CN II-XII grossly intact, strength ___ UE and ___ b/l
DISCHARGE PHYSICAL EXAM:
Vitals: 97.5 PO 109/70 80 18 96 RA
GEN: NAD
HEENT: missing front left incisor, sclerae anicteric
Neck: mobile soft tissue mass over mid-cervical spine, nontender
___: Regular, I/VI SEM heard best at upper sternal borders, well
healed surgical scar left chest. ICD L anterior chest without
erythema, pain, or fluctuance
RESP: CTAB, no W/R/C
ABD: non-distended. Soft, non-tender, BS present.
EXT: WWP, no edema
BACK: incision from spinal stimulator battery L buttocks,
battery
palpable, no overlying erythema/warmth, back nontender
NEURO: moving all 4 extremities with purpose
Pertinent Results:
ADMISSION LABS:
----------------
___ 12:20PM BLOOD WBC-6.8 RBC-4.21* Hgb-12.4* Hct-37.6*
MCV-89 MCH-29.5 MCHC-33.0 RDW-14.0 RDWSD-45.5 Plt ___
___ 12:20PM BLOOD Neuts-64.3 ___ Monos-8.1 Eos-4.0
Baso-0.6 Im ___ AbsNeut-4.39 AbsLymp-1.55 AbsMono-0.55
AbsEos-0.27 AbsBaso-0.04
___ 12:20PM BLOOD Plt ___
___ 12:20PM BLOOD UreaN-18 Creat-0.9
___ 12:20PM BLOOD ALT-21 AST-21 CK(CPK)-43* AlkPhos-118
TotBili-0.2
INTERIM LABS:
--------------
___ 06:00AM BLOOD Vanco-26.8*
___ 12:20PM BLOOD CRP-3.2
___ 06:00AM BLOOD TSH-2.3
DISCHARGE LABS:
----------------
___ 05:33AM BLOOD WBC-5.1 RBC-4.08* Hgb-12.0* Hct-35.3*
MCV-87 MCH-29.4 MCHC-34.0 RDW-13.7 RDWSD-42.8 Plt ___
___ 05:33AM BLOOD Plt ___
MICROBIOLOGY:
--------------
___ Blood Culture, Routine-PENDING INPATIENT
___ Blood Culture, Routine-PENDING INPATIENT
___ Blood Culture, Routine-PENDING INPATIENT
___ Blood Culture, Routine-PENDING INPATIENT
___ Blood Culture, Routine-no growth
___ Blood Culture, Routine-no growth
___ URINE CULTURE-no growth
___ Blood Culture, Routine-no growth
___ 12:20 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___:
VIRIDANS STREPTOCOCCI.
Isolated from only one set in the previous five days.
SENSITIVITY REQUESTED PER ___ ___.
Sensitivity testing performed by Sensititre.
CLINDAMYCIN <= 0.12 MCG/ML.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
VIRIDANS STREPTOCOCCI
|
CLINDAMYCIN----------- S
ERYTHROMYCIN---------- =>8 R
PENICILLIN G----------<=0.06 S
VANCOMYCIN------------ <=1 S
Aerobic Bottle Gram Stain (Final ___:
GRAM POSITIVE COCCI IN CHAINS.
Reported to and read back by ___. ___ ___
08:53AM.
___ BLOOD CULTURE ( MYCO/F LYTIC BOTTLE) BLOOD/FUNGAL
CULTURE-PRELIMINARY; BLOOD/AFB CULTURE-PRELIMINARY no growth
___ BLOOD CULTURE Blood Culture, Routine-FINAL negative
___ BLOOD CULTURE ( MYCO/F LYTIC BOTTLE) BLOOD/FUNGAL
CULTURE-PRELIMINARY; BLOOD/AFB CULTURE-PRELIMINARY no growth
IMAGING:
----------
___ CXR
Chronic post treatment changes without superimposed acute
cardiopulmonary
process.
___ CT CERVICAL W&W/O CONSTRAST
A lipoma is identified in the subcutaneous fat in the posterior
neck C3-4
level. No evidence of infection is identified.
___ TTE
The left atrium is normal in size. No atrial septal defect is
seen by 2D or color Doppler. Left ventricular wall thicknesses
are normal. The left ventricular cavity size is normal. There is
mild regional left ventricular systolic dysfunction with
posterior hypokinesis suggested.. No masses or thrombi are seen
in the left ventricle. There is no ventricular septal defect.
Right ventricular chamber size and free wall motion are normal.
The diameters of aorta at the sinus, ascending and arch levels
are normal. The aortic valve leaflets (3) are mildly thickened
but aortic stenosis is not present. No masses or vegetations are
seen on the aortic valve. Trace aortic regurgitation is seen. A
mitral valve annuloplasty ring is present. The mitral annular
ring appears well seated with normal gradient. No mass or
vegetation is seen on the mitral valve. No mitral regurgitation
is seen. The tricuspid valve leaflets are mildly thickened.
Moderate [2+] tricuspid regurgitation is seen. There is mild
pulmonary artery systolic hypertension. There is no pericardial
effusion.
Compared with the prior study (images reviewed) of ___, no
clear change.
___ TEE
No atrial septal defect is seen by 2D or color Doppler. Overall
left ventricular systolic function is moderately depressed.
There are simple atheroma in the descending thoracic aorta. The
aortic valve leaflets (3) appear structurally normal with good
leaflet excursion and no aortic stenosis. No masses or
vegetations are seen on the aortic valve. Mild (1+) aortic
regurgitation is seen. A mitral valve annuloplasty ring is
present. The transmitral gradient is normal for this prosthesis.
No mass or vegetation is seen on the mitral valve. Mild (1+)
mitral regurgitation is seen. Mild tricuspid regurgitation is
present. [Due to acoustic shadowing, the severity of tricuspid
regurgitation may be significantly UNDERestimated.] No
vegetation/mass is seen on the pulmonic valve.
IMPRESSION: No mass or vegetations concerning for endocarditis.
Well-seated mitral annuloplasty ring with normal function. Mild
aortic regurgitation. Mild mitral regurgitation.
___ TEETH (PANOREX)
#18- gross caries, #20, #21 both with recurrent decay. #32-
gross caries.
___ CXR
In Comparison with the study of ___, there is an placement
of right subclavian PICC line. The tip is difficult to see,
though it appears to be in the mid SVC, covered over by multiple
other tubes and wires. Little change in the appearance of the
heart and lungs.
Brief Hospital Course:
___ y/o male with a PMH of NSCLC ___ LLL lobectomy and XRT
(___), bladder CA ___ TURBT, CHF ___ BiV-ICD (___), aortic
regurgitation, and MR ___ MV repair annuloplasty band (___)
presenting to outpatient infectious disease clinic after
exposure to M. chimaera found in ___ 3T Heater-Cooler
System used for cardiothoracic surgery. He presented with months
of fatigue, dyspnea, and night sweats, had blood cultures drawn,
and was found to have viridans step bacteremia, was admitted for
expedited workup.
# Strep Viridans Bacteremia
# concern for subacaute endocarditis
# Poor dentition
Patient has multiple foreign bodies including spinal stimulator,
Gortex hernia repair, annuloplast band and ICD in addition to
MVR. He met 3 minor Duke criteria (splinter hemorrhage, positive
blood culture, and
predisposing heart condition) and given the patient's duration
of
symptoms and prosthetic endovascular material, there was concern
for subacute bacterial endocarditis. Patient initially was on
vancomycin/ceftriaxone (___) while speciation/sensitivities
were pending, ultimately narrowed to ceftriaxone. All
surveillance cultures were NGTD. TTE/TEE showed no evidence of
valvular vegetations. MRI could not be done due to hardware.
Patient remained afebrile and without other objective signs of
infection.
Dental consult was called given patient's poor dentition and
showed no acute infection. Patient was concerned that his spinal
stimulator was a potential nidus of infection and wanted to have
the battery exchanged while in the hospital, however the
suspicion was low for this to be a source of infection given his
lack of localizing symptoms. Outpatient pain provider was
contacted, deferred assessment of risk of device involvement to
the infectious disease team and recommended patient follow up
with him after his treatment was completed.
Decision ultimately made to treat for prosthetic valve
endocarditis given clinical symptoms and positive blood culture
despite negative ECHO with 6 weeks of IV ceftriaxone. PICC was
placed, f/u with OPAT, ___ services arranged.
# Neck Lipoma: Patient had firm posterior neck mass, initially
concerning for infection, which showed a lipoma on CT scan.
#Chronic Systolic Heart failure: EF 40% severe MR and
moderate-severe TR, ___ ICD placement ___. Remained euvolemic.
Continued home carvedilol, lisinopril and furosemide.
___ MVR: Operation on ___ annuloplasty band via open heart
procedure. Exposure to M. chimaera found in ___ 3T
Heater-Cooler System used for cardiothoracic surgery. Not on
anticoagulation. No signs of heart failure on exam. Management
as above.
#Chronic Pain: ___ XRT ___ for ___. Spinal stimulator in
place. Home fentanyl patch and oxycodone continued.
#Depression: continued home lorazepam. High risk combination
with pain regimen above noted, though patient seemed well
stabilized on home regimen.
#GERD: continued home PPI
TRANSITOINAL ISSUES:
- Patient needs weekly labs drawn while on CTX, arranged through
OPAT
- IV Ceftriaxone ___, last day ___
- Patient discharged with ___
- Per Dental Consultation: Teeth #18, #32 are non-restorable and
need to be extracted as they present a risk for acute infection.
Teeth #20,#21 need to be restored.
# CODE: full (confirmed)
# CONTACT:
Name of health care proxy: ___
Relationship: sister
Phone number: ___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. carvedilol phosphate 10 mg oral QHS
2. Furosemide 40 mg PO EVERY OTHER DAY
3. Lisinopril 2.5 mg PO QHS
4. LORazepam 1 mg PO Q3H
5. Omeprazole 20 mg PO BID
6. Fentanyl Patch 50 mcg/h TD Q48H
7. OxyCODONE (Immediate Release) 15 mg PO Q3H:PRN Pain -
Moderate
8. Aspirin 81 mg PO QHS
9. Multivitamins 1 TAB PO QHS
10. Polyethylene Glycol 17 g PO DAILY
11. HydrOXYzine 50 mg PO QHS
Discharge Medications:
1. CefTRIAXone 2 gm IV Q 24H
RX *ceftriaxone in dextrose,iso-os 2 gram/50 mL 2 g IV once a
day Disp #*36 Intravenous Bag Refills:*0
2. Aspirin 81 mg PO QHS
3. carvedilol phosphate 10 mg oral QHS
4. Fentanyl Patch 50 mcg/h TD Q48H
5. Furosemide 40 mg PO EVERY OTHER DAY
6. HydrOXYzine 50 mg PO QHS
7. Lisinopril 2.5 mg PO QHS
8. LORazepam 1 mg PO Q3H
9. Multivitamins 1 TAB PO QHS
10. Omeprazole 20 mg PO BID
11. OxyCODONE (Immediate Release) 15 mg PO Q3H:PRN Pain -
Moderate
12. Polyethylene Glycol 17 g PO DAILY
13.Outpatient Lab Work
CBC with differential, Chem 7, AST, ALT, Alk Phos, ESR, CRP
Fax results to ___ at ___
ICD-10: R78.81 Bacteremia
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Strep Viridans bacteremia
___ mitral valve annuloplasty
Neck Lipoma
Dental caries
Chronic pain
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You came to the hospital because you had cultures of your blood
taken that were found to be growing bacteria called
Streptococcus Viridans.
It is possible that this infection in your blood is causing your
fatigue.
You had some additional testing done including pictures of your
heart and consultation with the dental team that did not show
any source of infection. It was determined by our infection
experts that the safest thing to do is treat you for a possible
infection in your heart called endocarditis.
The infectious disease team was not concerned that your spinal
stimulator was the cause of your infection. Dr. ___
___ that you follow up with him in the office regarding
battery exchange, but noted that he will not be able to do the
procedure until you are fully treated for this infection.
You will have 6 weeks of an antibiotic called ceftriaxone. A
visiting nurse ___ come to your house to administer this
medicine and teach you how to give it to yourself. They will
also send blood tests to the infectious disease team every week
while you are taking ceftriaxone.
Please take all of your medications as prescribed and attend
your followup appointments as below.
You should call your primary care doctor's office on ___ to
schedule a follow-up appointment.
You should call your dentist to discuss having some teeth
extracted as they present a risk for acute infection, and you
have some other cavities that can be restored.
We wish you the best,
Your ___ Team
Followup Instructions:
___
|
19674514-DS-11
| 19,674,514 | 23,108,851 |
DS
| 11 |
2163-10-22 00:00:00
|
2163-10-22 13:33:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Stridor/Neck mass
Major Surgical or Invasive Procedure:
___ Cardiac cath
___ Urgent coronary artery bypass graft x2. Left internal
mammary artery to left anterior descending artery and saphenous
vein graft to obtuse marginal artery
___ Laryngectomy, Thyroidectomy with re-implantation of
parathyroids, tracheostomy and PEG
History of Present Illness:
___ year old male with ___ transferred from ___ with
hoarseness and stridor for advanced airway management. He has
had several months of exertional dyspnea, cough productive of
white sputum, "noisy breathing", and dysphagia requiring soft
foods. He presented a week ago to ___ and was
treated for presumed COPD exacerbation with a prednisone taper
and azithromycin. He presented again with persistent symptoms
yesterday AM. A CTA was performed which was negative for PE but
did show a thyroid goiter narrowing the trachea to 9mm and
debris extending from the trachea into the left mainstem
bronchus and down into the LLL bronchus/branches. He was given a
dose of pip/tazo and transferred here, admitted to the MICU.
Here, he continued to have stridor and was very anxious even
after given a dose of benzos. He was intubated for airway
protection. An ECG was checked about an hour prior to intubation
and noted to have poor R-wave progression so cardiology was
consulted. He was referred for a cardiac catheterization and
found to have left main and is now being referred for
revascularization.
Past Medical History:
None
COPD by CXR
Social History:
___
Family History:
No family h/o thyroid disease. Son with DM.
Physical Exam:
On admission:
Vitals: 98.0 75 153/50 26 94% on 4L
General: Alert, oriented, no acute distress, very hoarse voice
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL, L
eye with lower lid exposed ___ remote trauma, edentulous
Neck: supple, thyroid is visibly enlarged L > R; no discrete
palpable nodules
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Poor air movement throughout, audible upper airway
inspiratory and expiratory stridor
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
Pertinent Results:
Images:
___ CT-A:
debris extending from the trachea into the left mainstem
bronchus and down into the LLL bronchus and its branches.
Partial obliteration of these airways. No underlying mass in LLL
or definite mass along course of the airway - ? aspiration vs.
hemorrhage vs. mucus plugging. Minimal subtle groundglass
nodular opacity at both lung bases - ? atelectasis. A thyroid
goiter narrows the trachea to a diameter of 9 mm at the superior
margin of this exam.
.
___ CXR:
No acute cardiopulmonary process; bilateral pleural
calcifications w/o mass, ? ankylosing spondylitis w/ smooth
ossification of anterior longitudinal ligaments
.
EKG on admission: SR 76, U waves, notched R waves in II,III,aVF
EKG ___: SR with significant T wave inversions in II/III/avF,
V2-V6. No q waves. Persistently flat T waves in I/avL
.
MRI ___:
1. 7.2 x 5.1 x 3.9 cm laryngeal mass, extending superiorly to
the level of the pre epiglottic space, and inferiorly abutting
the thyroid gland. The lesion does not definitively arise from
the thyroid gland, though this can not be excluded.
Considerations favour a squamous cell malignancy of the larynx
or anaplastic thyroid malignancy. Correlation to direct
visualization/tissue sampling is recommended. There are
scattered prominent cervical lymph nodes, without definite
lymphadenopathy.
2. Multilevel cervical spinal degenerative change, including
moderately severe spinal canal stenosis at C3-C4, with
associated spinal cord deformity.
3. Round structure at the foramen of ___, likely a colloid
cyst.
.
FNA Neck Mass ___:
FNA, left neck mass, cell block: Positive for malignant cells
consistent with squamous cell carcinoma; see note.
Note: This likely represents a squamous cell carcinoma arising
in the head and neck region, however, a squamous component of
anaplastic thyroid carcinoma cannot be excluded. Clinical
correlation is recommended.
Clinical:
Gross: The cytology specimen (___-___) is received labeled
with the patient's name and medical record number. A cell block
is made using plasma-thrombin method and submitted in cassettes
"A".
.
Cardiac catheterization ___:
Coronary angiography: right dominant
LMCA: No significant stenosis
LAD: Origin 90% - diseased to left main
LCX: 60%, hazy OM.
RCA: TO proximal; L.R and R>R collaterals. Poor distal targets
.
Echo ___: PRE-BYPASS:
The left atrium is dilated. The right atrium is dilated. No
atrial septal defect is seen by 2D or color Doppler. Left
ventricular wall thicknesses are normal. There is severe
regional left ventricular systolic dysfunction with akinesis mid
to apical segments. Overall left ventricular systolic function
is severely depressed (LVEF= ___. There are simple atheroma
in the aortic arch. There are simple atheroma in the descending
thoracic aorta. There are three aortic valve leaflets. No aortic
regurgitation is seen. The mitral valve leaflets are moderately
thickened. Mild (1+) mitral regurgitation is seen. There is a
very small pericardial effusion. Dr. ___ was notified
in person of the results in the operating room.
POST-BYPASS: The patient is AV paced on titrated norepinephrine
infusion. The valves remain unchanged. RV function is unchanged.
LV EF slightly improved, now 30%, although the apex remains
significantly more hypokinetic than the hypokinetic basal &
mid-papillary segments. The aorta remains intact post bypass.
Dr. ___ is aware.
.
___ ESOPHAGUS
FINDINGS:
Barium passes freely through the pharynx into the esophagus with
no
extraluminal contrast to suggest a leak or fistula. Limited
views of the
lower esophagus are unremarkable. A surgical drain is seen in
the right neck.
The patient has an NG tube in place in the esophagus which is
partially
visualized. Multilevel degenerative changes of the cervical
spine are
unchanged from prior MRI.
IMPRESSION:
No evidence of leak or fistula
.
___ CT abdomen and pelvis
IMPRESSION:
1. Active bleeding from the ___ portion of the duodenum.
2. Moderate pericardial effusion and a moderate to large
bilateral pleural
effusions.
3. Probable small splenic infarct.
4. Mild intra-abdominal ascites.
Notification: The above findings were discussed with Dr. ___
at ___s with the interventional radiology service (Dr
___
immediately upon discovery at 18:30 by Dr ___
telephone.
.
___ 04:05AM BLOOD WBC-9.8 RBC-3.14* Hgb-9.5* Hct-28.9*
MCV-92 MCH-30.2 MCHC-32.9 RDW-14.4 Plt ___
___ 05:15AM BLOOD WBC-10.9 RBC-3.14* Hgb-9.3* Hct-28.6*
MCV-91 MCH-29.7 MCHC-32.7 RDW-14.4 Plt ___
___ 02:38AM BLOOD ___ PTT-30.5 ___
___ 04:05AM BLOOD Glucose-76 UreaN-15 Creat-0.8 Na-137
K-4.1 Cl-99 HCO3-28 AnGap-14
___ 05:15AM BLOOD Glucose-80 UreaN-18 Creat-0.8 Na-134
K-4.0 Cl-95* HCO3-31 AnGap-12
___ 04:59AM BLOOD Glucose-112* UreaN-19 Creat-0.8 Na-137
K-4.1 Cl-96 HCO3-34* AnGap-11
___ 05:42AM BLOOD Glucose-129* UreaN-20 Creat-0.7 Na-135
K-3.7 Cl-95* HCO3-35* AnGap-9
___ 05:20AM BLOOD ALT-47* AST-45* AlkPhos-122 Amylase-103*
TotBili-0.8
___ 02:33AM BLOOD ALT-57* AST-82* AlkPhos-139* TotBili-2.1*
___ 05:20AM BLOOD Lipase-128*
___ 01:17AM BLOOD Lipase-115*
___ 04:05AM BLOOD Calcium-8.8 Mg-2.1
___ 05:15AM BLOOD Albumin-2.8* Calcium-8.7 Mg-2.1
___ 04:59AM BLOOD Albumin-2.9* Calcium-8.0* Mg-2.2
___ 02:38AM BLOOD Albumin-2.7* Calcium-7.5* Phos-2.6*
Mg-2.2
___ 05:18AM BLOOD Albumin-2.7* Calcium-7.3* Mg-2.0
___ 01:17AM BLOOD Calcium-7.8* Phos-4.1 Mg-2.2
___ 01:50AM BLOOD Calcium-8.2* Phos-2.1* Mg-2.3
___ 02:38AM BLOOD PTH-110*
___ 10:13PM BLOOD PTH-18
___ 02:38AM BLOOD 25VitD-18*
Brief Hospital Course:
___ year old male with ?history of COPD presents with SOB, hoarse
voice and stridor. There was significant narrowing of the
trachea by external compression to 9mm as seen on CTA at ___
___. He was transferred to ___ for further management on
___. On arrival, patient developed worsening stridor and
desaturated to 80%, and was subsequently intubated on ___ with
fiberoptic approach. During intubation, epiglottis reportedly
enlarged and upper airway markedly narrowed with copious
secretions, but without appreciable intra-tracheal lesion. ENT,
interventional pulmonary, as well as endocrine surgery were
consulted. Initial labs showed normal TSH and fT4. MRI was
obtained which showed 7.2 x 5.1 x 3.9 cm laryngeal mass,
extending superiorly to the level of the pre-epiglottic space
and inferiorly abutting the thyroid gland, ? SCC or anaplastic
thyroid malignancy. Cytopathologist performed FNA at the bedside
on ___, which was consistent with squamous cell carcinoma
of laryngeal origin. ENT was involved early in hospital course.
Medical oncology and radiation oncology were consulted for
assistance in management.
EKG changes were noted on day of transfer, with poor R wave
progression, incomplete LBBB, and diffuse sub-mm STE. There was
an increase in troponin, and transthoracic echocardiogram
suggested depressed EF of ___, with marked regional/apical
aneurysm/dysfunction of both ventricles c/w mid-LAD CAD or
Takotsubo cardiomyopathy. On hospital day three he underwent
cardiac catheterization which showed three vessel coronary
artery disease. He underwent surgical work-up and he was brought
to the operating room on ___ for a coronary artery bypass graft
x 2. Please see operative note for surgical details. Following
surgery he was transferred to the CVICU for invasive monitoring
in stable condition.
The patient remained intubated due to narrowing of the airway
from the laryngeal tumor. Norepinephrine was required for blood
pressure support. This was weaned in the following days. Tube
feeds were initiated. He developed ventricular ectopy and AFib
in the immediate post-op period which was treated with
Amiodarone. This was discontinued when the rhythm turned to
junctional. EP was consulted.
Chest tubes were discontinued without complication.
ORL continued to follow and performed laryngectomy/thyroidectomy
trach/PEG on ___. Tube feeds were reintroduced as
tolerated. Post-op delerium was managed with Precedex. Haldol
was avoided due to long QTc.
He was found to have a duodenal bleed and embolized with ___.
Heparin was held and he was transfused 4 units of PRBC.
Hematocrit stabilized. The patient was transferred to the
telemetry floor for further recovery. Foley was discontinued-
then re-placed for urinary retention. Barium study was
performed with no evidence of leak or fistula. Diet was
initiated and advanced as tolerated. He will remain on cycled
tube feeds until he is taking adequate POs (~75% of meals). He
is using Ensure Plus supplements. Endocrine was consulted for
assistance with Calcium management. Detailed recommendations
regarding Calcium management are ordered. The patient will
___ with ENT next week. He should schedule an EGD with
Gastroenterology when cleared by ENT.
The patient made slow, steady progress and was discharged to ___
___ in ___ on POD 26 with explicit ___
instructions.
Medications on Admission:
Aspirin 325 mg Daily
Discharge Medications:
1. Acetaminophen 650 mg NG Q4H:PRN pain/fever
2. Bacitracin Ointment 1 Appl TP QID
3. Bisacodyl ___AILY:PRN constipation
4. Levothyroxine Sodium 50 mcg NG DAILY
5. Metoprolol Tartrate 6.25 mg NG BID
6. Sucralfate 1 gm PO QID
7. Ciprofloxacin HCl 500 mg PO Q12H UTI Duration: 2 Doses
8. Aspirin 81 mg PO DAILY
9. Calcium Carbonate 2500 mg PO BID Duration: 6 Days
may decrease to daily if corrected Ca is >9 on ___, and
discontinue if corrected Ca is >8 on ___. Furosemide 40 mg IV DAILY Duration: 10 Days
Please re-evalaute need for ongoing diuresis after 10 days of
Lasix
11. Pantoprazole 40 mg IV Q12H
12. Potassium Chloride 40 mEq PO DAILY Duration: 10 Days
13. Sodium Chloride 0.9% Flush 3 ml IV DAILY:PRN flush
14. Vitamin D 50,000 UNIT PO 1X/WEEK (MO) Duration: 8 Weeks
after 8 weeks, dose will change to ___ Units daily
15. Outpatient Lab Work
Calcium and Albumin on ___
*If Corrected Calcium is >9- reduce Calcium Carbonate to daily*
16. Outpatient Lab Work
Calcium and Albumin on ___
*If Corrected Calcium is >8, discontinue Calcium Carbonate*
17. Atorvastatin 10 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Coronary artery disease s/p Coronary artery bypass graft x 2
Laryngeal Cancer
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating, deconditioned
Incisional pain managed with oral analgesics
Incisions:
Sternal - healing well, no erythema or drainage
Leg, Right- healing well, no erythema or drainage
Edema 2+
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns ___
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
**Please call cardiac surgery office with any questions or
concerns ___. Answering service will contact on call
person during off hours**
Followup Instructions:
___
|
19674707-DS-10
| 19,674,707 | 23,960,671 |
DS
| 10 |
2131-11-07 00:00:00
|
2131-11-07 12:47:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: CARDIOTHORACIC
Allergies:
Hydrocodone / Oxycodone / Vicodin / Hydromorphone
Attending: ___.
Chief Complaint:
esophageal tear
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. ___ is a ___ year old male with history of 4 vessel CABG
(___), carotid endarterectomy (___), and Roux-en-Y
hepaticojejunostomy (___) who is transferred from ___
___ after esophageal tear s/p endoscopic removal of large
impacted food bolus. He was eating steak ___ night and
reported swallowing a large bite that caught in his esophagus.
He has previous experienced this before and has always been able
to cough up the food bolus. This time, he reports coughing up
one piece but could feel more stuck in the esophagus but thought
it would pass in time. Overnight, he experienced dry heaves and
spit up of mucous. He could not tolerate sips of water without
spitting up. He presented to ___ around 3:30 ___ on
___ and was taken to the endoscopy suite around 9 ___ for
retrieval of the food bolus. Per reports, during the procedure,
the gastroscope entered into the muscular layer of the
mid-esophagus. The food bolus was ultimately removed with
several passes, but EGD did further note ulcerated distal
esophagus, multiple nonbleeding duodenal ulcerations, in
addition to the esophageal tear made. He received 1 dose of
Vancomycin and Zosyn prior to transfer, to which he had a
reaction to vancomycin. Thoracic Surgery at ___ (Dr. ___
was consulted and recommended transfer to ___, so he was
subsequently transferred directly from the endoscopy suite.
Upon arrival, his vitals were stable. He endorsed vague
abdominal pain, worsened by persistent coughing, and back pain,
but had no nausea, vomiting, fever, chills, chest pain,
shortness of breath. Chest XR showed pneumomediastinum with air
tracking along the descending aorta. Thoracic Surgery has been
consulted to evaluate for possible esophageal perforation.
Past Medical History:
PAST MEDICAL HISTORY:
Diabetes Mellitus Type II
Diabetic Neuropathy
Gastritis
Gastroesophageal Reflux Disease
Hyperlipidemia
Hypertension
Right Bundle Branch Block
PAST SURGICAL HISTORY:
- ___ - Roux-en-Y hepaticojejunostomy, open CCY (no
malignancy)
- ___ - 4 vessel CABG
- ___ - L carotid endarterectomy
- Laser eye surgery for diabetic retinopathy
- Cataract surgery
- Achilles tendon repair
- Total hip replacement
Social History:
___
Family History:
Mother - DM, MI, deceased age ___
Father - MI, deceased age ___
Physical Exam:
On admission:
Temp: 99.0, HR: 93 BP: 155/77 RR: 18 O2 Sat: 100% RA
GENERAL: uncomfortable appearing
HEENT: NCAT, EOMI, MMM, no crepitus
CV: regular rate and rhythm
PULM: Easy work of breathing, clear to auscultation bilaterally.
Well-healed midline sternotomy scar. No crepitus
ABD: Soft, nondistended, nontender to palpation. Well-healed R
subcostal scar without hernias or masses. No rebound or guarding
EXT: Warm, well perfused
On discharge:
VS: Tmax 100.3, Tc 98.3, HR 93, BP 131/64, RR 18, SpO2 100%RA
GENERAL: No acute distress
HEENT: NCAT, EOMI, MMM, no crepitus
CV: regular rate and rhythm
PULM: Easy work of breathing, clear to auscultation bilaterally.
Well-healed midline sternotomy scar. No crepitus
ABD: Soft, nondistended, nontender to palpation. Well-healed R
subcostal scar without hernias or masses. No rebound or guarding
EXT: Warm, well perfused
Pertinent Results:
On admission:
___ 01:20AM BLOOD WBC-10.8# RBC-3.45* Hgb-11.8* Hct-32.0*
MCV-93 MCH-34.2* MCHC-36.8* RDW-12.5 Plt ___
___ 01:20AM BLOOD Neuts-83.5* Lymphs-12.2* Monos-3.7
Eos-0.5 Baso-0.2
___ 01:20AM BLOOD ___ PTT-29.3 ___
___ 01:20AM BLOOD Glucose-152* UreaN-17 Creat-0.7 Na-137
K-3.1* Cl-105 HCO3-20* AnGap-15
On discharge:
___ 06:17AM BLOOD WBC-6.6 RBC-3.39* Hgb-11.9* Hct-32.0*
MCV-94 MCH-34.9* MCHC-37.0* RDW-12.6 Plt ___
___ 06:17AM BLOOD Glucose-151* UreaN-10 Creat-0.7 Na-130*
K-3.9 Cl-96 HCO3-25 AnGap-13
___ 06:17AM BLOOD Calcium-8.8 Phos-1.9* Mg-2.0
===============
IMAGING
===============
___ CXR
Mediastinal air tracking along the descending thoracic aorta.
___ BARIUM SWALLOW
No leak detected.
___ CHEST PA/LAT
Pneumomediastinum collected along the thoracic aorta from the
arch to the
diaphragm is unchanged since ___. There is no pneumothorax or
pleural
effusion. Heart size is normal.
___ CT CHEST
Substantial amount of pneumomediastinum predominantly in the
lower mediastinum surrounding the gastroesophageal junction
continuing to warrant the retroperitoneum with extensive
involvement of the retroperitoneum tracking around the stomach
the duodenum and the hepatic vasculature. Most likely the
location of the tear is in the distal esophagus around the
gastroesophageal junction.
Small amount of left pleural effusion with minimal amount of
contrast, potentially related to the esophagram.
Unremarkable appearance of sternotomy and sternotomy wires.
Compression fractures of the mid thoracic vertebral bodies.
Brief Hospital Course:
Mr. ___ is a ___ year old gentleman who was transferred from
___ after experiencing an esophageal tear during
endoscopic removal of a impact food bolus in the distal
esophagus. Chest x-ray at ___ demonstrated
pneumomediastinum. At ___, he underwent barium swallow
that demonstrated no frank tear in the esophagus or
extravasation of contrast. He was subsequently admitted for
observation. He spiked a low-grade fever to 100.3, and WBC rose
to 16. CT chest was obtained and demonstrated a substantial
amount of pneumomediastinum predominantly in the lower
mediastinum surrounding the gastroesophageal junction,
continuing to warrant the retroperitoneum with extensive
involvement of the retroperitoneum tracking around the stomach
the duodenum and the hepatic vasculature. Based on this, the
likely location of a tear was noted to be at the distal
gastroesophageal junction. The patient's leukocytosis
downtrended to WBC of 6, and fevers resolved without
antibiotics.
He was able to tolerate a clear liquid diet and subsequently a
mechanical soft diet, which he should continue at home for the
next ___ weeks. He can follow-up with Dr. ___ for his
hepatology issues as well as for the new issue of
pneumomediastinum.
Medications on Admission:
1. Lisinopril 20 mg PO DAILY
2. Desonide 0.05% Cream 1 Appl TP DAILY
3. Triamcinolone Acetonide 0.025% Cream 1 Appl TP BID PRN
pruritis
4. Ketoconazole 2% 1 Appl TP BID
5. Metoprolol Succinate XL 25 mg PO DAILY
6. MetFORMIN (Glucophage) 1000 mg PO BID
7. Fluticasone Propionate NASAL 2 SPRY NU DAILY
8. ipratropium bromide 0.03 % nasal Q12H:PRN congestion
9. Pravastatin 40 mg PO QPM
10. Ferrous Sulfate 325 mg PO DAILY
11. Multivitamins 1 TAB PO DAILY
12. Isosorbide Dinitrate 30 mg PO DAILY
13. Magnesium Oxide 250 mg PO BID
14. Aspirin 325 mg PO DAILY
15. FoLIC Acid 0.4 mg PO DAILY
Discharge Medications:
1. Aspirin 325 mg PO DAILY
2. Fluticasone Propionate NASAL 2 SPRY NU DAILY
3. Lisinopril 20 mg PO DAILY
4. MetFORMIN (Glucophage) 1000 mg PO BID
5. Metoprolol Succinate XL 25 mg PO DAILY
6. Pravastatin 40 mg PO QPM
7. Desonide 0.05% Cream 1 Appl TP DAILY
8. Ferrous Sulfate 325 mg PO DAILY
9. FoLIC Acid 0.4 mg PO DAILY
10. ipratropium bromide 0.03 % nasal Q12H:PRN congestion
11. Isosorbide Dinitrate 30 mg PO DAILY
12. Ketoconazole 2% 1 Appl TP BID
13. Magnesium Oxide 250 mg PO BID
14. Multivitamins 1 TAB PO DAILY
15. Triamcinolone Acetonide 0.025% Cream 1 Appl TP BID PRN
pruritis
16. Omeprazole 20 mg PO DAILY
RX *omeprazole 20 mg 1 capsule(s) by mouth once a day Disp #*30
Capsule Refills:*1
Discharge Disposition:
Home
Discharge Diagnosis:
Esophageal tear
Pneumomediastinum
Leukocytosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were admitted to the hospital for observation following your
esophageal tear. The barium swallow was negative for a leak but
you did have a low grade temperature and an elevated white blood
cell count. A chest CT was done for further evaluation which
showed no source of infection, but air in your chest that was
tracking down to your belly. This was expected from our initial
findings. However, you continued to feel better, and you were
able to tolerate a clear liquid diet and then subsequently soft
foods. Your white blood cell count and fevers improved without
antibiotics.
We feel that it is safe to discharge you home at this time.
Please continued on a soft diet for the next ___ weeks. Please
follow-up with Dr. ___ has previously seen you for your
GI issues. It was a pleasure being a part of your care, and we
wish you all the best.
Sincerely,
Your ___ Surgical Team
Followup Instructions:
___
|
19674970-DS-18
| 19,674,970 | 25,735,487 |
DS
| 18 |
2192-03-16 00:00:00
|
2192-03-15 14:20:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Augmentin / Percodan
Attending: ___
Chief Complaint:
increased frequency of falls
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Pt is a ___ y/o M with PMHx significant for DMII, colon cancer
(resection in ___ peripheral neuropathy, HTN, HLD, obesity,
stage IV CKD, anemia, who presented to the ED with recent
episodes of weakness/pre-syncope. Of note, patient is a poor
historian. Pt describes 6 weeks of unsteadiness on his feet,
with worsening over the past 10 days. Describes feeling that his
legs are "giving out" on him (particularly the left leg) while
walking. Also describes a sensation of "dizziness" but is unable
to give further details. Pt describes chronic neuropathy in his
feet, which exacerbates the above symptoms. The above symptoms
have caused him to stumble and fall many times recently. No LOC,
no head strike. He also reports some numbness in his left fifth
finger, which is new.
In addition to the above symptoms, he also has been experiencing
frequent vomitting for the past few months (approx 3x/week). Not
clearly related to eating. Not related to the above presyncopal
episodes. He has chronic diarrhea since his colonic resection
which has not changed. No blood in his emesis or stools. He was
recently being treated for what sounds like h.pylori, with some
loss of appetite while he was on the abx therapy. He also
endorses dyspnea on exertion.
Has ___ appt today and had to stop several times for
dizziness and leg weakness, prompting ED eval. In the ED,
initial VS were 98.6 63 171/82 18 99%. Exam showed mild
intentional tremor with bilateral hands, bilateral ___ numbness
L>R, downgoing toes. Labs were significant for Hct 29.6
(baseline ___ in ___ labs), creat 3.7 (baseline ~3.2). Head
CT showed foci is suggestive of old lacunar infarctions.
Neurology was consulted, who felt that s/s were likely
disautonomia related to DM. VS prior to transfer were Temp: 98.1
°F (36.7 °C), Pulse: 62, RR: 16, BP: 183/77, O2Sat: 100, O2Flow:
REVIEW OF SYSTEMS:
Denies fever, chills, night sweats, headache, rhinorrhea,
congestion, sore throat, cough, chest pain, abdominal pain,
constipation, BRBPR, melena, hematochezia, dysuria, hematuria.
Past Medical History:
- type 2 diabetes
- hypertension
- hyperlipidemia
- obesity
- stage IV kidney disease
- hyperparathyroidism
- ? sleep apnea, pt denies
- anemia
- GERD
- glaucoma
- hypertensive retinopathy
- colon ca (s/p resection in ___
- h.pylori s/p triple abx therapy ___
Social History:
___
Family History:
Mother died of liver cancer. Father died of stroke at ___.
Brother died of MI at ___. Grandmother with DM, died of related
complications. Other cancers in family members.
Physical Exam:
ADMISSION EXAM
VS - Temp 98.2 F, BP 175/79, HR 62, RR 16, O2-sat 100% RA
GENERAL - Alert, interactive, well-appearing in NAD
HEENT - EOMI, sclerae anicteric, MMM, OP clear
NECK - Supple, JVP non-elevated
HEART - RRR, nl S1-S2, no MRG
LUNGS - CTAB, no wheezes/rales/ronchi, good air movement, resp
unlabored, no accessory muscle use
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, multiple healed
surgical scars
EXTREMITIES - WWP, no c/c/e
SKIN - healing abrasions on right shin, small amount of drainage
from lower abrasion
NEURO - awake, CNs II-XII grossly intact, muscle strength ___
throughout, endorses loss of sensation to halfway up to the knee
bilaterally as well as in the ___ finger on the L hand. FInger
to nose intact. Gait short distance is intact.
RECTAL: decreased rectal tone. Intact sensation, Prostate not
appreciated.
DISCHARGE EXAM
Pertinent Results:
ADMISSION LABS
___ 04:34PM BLOOD WBC-6.0 RBC-3.17* Hgb-9.7* Hct-29.5*
MCV-93 MCH-30.5# MCHC-32.7 RDW-12.9 Plt ___
___ 04:34PM BLOOD Neuts-68.4 ___ Monos-4.5 Eos-2.3
Baso-0.4
___ 04:34PM BLOOD ___ PTT-30.3 ___
___ 04:34PM BLOOD Glucose-73 UreaN-34* Creat-3.7*# Na-146*
K-4.0 Cl-116* HCO3-19* AnGap-15
___ 04:34PM BLOOD ALT-12 AST-14 AlkPhos-111 TotBili-0.3
___ 04:34PM BLOOD Lipase-42
___ 04:34PM BLOOD Albumin-3.6 Calcium-8.5 Phos-2.7 Mg-2.1
PERTINENT LABS AND STUDIES
___ 05:30AM BLOOD VitB12-584 Folate-13.1
___ 05:30AM BLOOD %HbA1c-7.9* eAG-180*
___ 05:30AM BLOOD TSH-2.8
___ 04:34PM BLOOD cTropnT-0.03*
___ 12:38AM BLOOD CK-MB-3 cTropnT-0.03*
___ 05:30AM BLOOD CK-MB-2 cTropnT-0.03*
___ 10:00PM URINE Blood-SM Nitrite-NEG Protein-600
Glucose-150 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
___ 10:00PM URINE RBC-2 WBC-7* Bacteri-FEW Yeast-NONE Epi-4
___ 10:00PM URINE CastGr-18* CastHy-23* CastWBC-1*
___ CT HEAD WITHOUT CONTRAST No acute intracranial
hemorrhage or mass effect. Three subcentimeter hypodensities in
the right cerebrum, likely the sequela of chronic microvascular
ischemia. A dedicated MRI may be obtained for further
characterization if clinical suspicion for an acute infarction
is high.
___ MRI LUMBAR SPINE in discussion with radiologist, no
spine involvement. Degenerative disease. Final read pending.
DISCHARGE LABS
___ 06:20AM BLOOD WBC-5.4 RBC-2.99* Hgb-9.5* Hct-29.1*
MCV-97 MCH-31.6 MCHC-32.5 RDW-13.2 Plt ___
___ 06:20AM BLOOD Glucose-127* UreaN-41* Creat-3.8* Na-144
K-4.4 Cl-115* HCO3-20* AnGap-13
___ 06:20AM BLOOD Calcium-8.2* Phos-4.3 Mg-2.1
Brief Hospital Course:
Pt is a ___ y/o M with PMHx significant for DMII, colon cancer
(resection in ___ peripheral neuropathy, HTN, HLD, obesity,
stage IV CKD, anemia, who presented to the ED with recent
episodes of weakness/pre-syncope.
.
ACUTE CARE
# Pre-Syncope: Although patient's complaints are vague,
components of his story sound orthostastic. Given his recent
increase in nausea, vomiting and diarrhea, he may be more dry
than usual. Further indications of dehydration: he patient also
has muddy brown casts and hyaline casts on his UA, his
creatinine is up to 3.8 from 3.2 (___), possibly secondary
to pre-renal causes. His orthostatics are borderline positive on
presentation and throughout hospitalization despite adequate PO
intake and no vomiting. Lasix was held during hospitalization.
Cardiac etiology is possibility, although patient's story is not
consistent with cardiac etiology of pre-syncope, given he is a
diabetic, he may be less likely to experience chest pain. Pt
with new RBBB (since ___ on ECG but no e/o active ischemia.
Tn's flat (0.03 x 3), no arrhythmias on telemetry x 24hours. No
e/o valvular pathology on stress echo in ___. Regarding
neurological etiologies, CT head showing hypodensities c/w old
lacunar infarcts but no acute process per prelim read, MRI would
be indicated to assess chronicity. Neuro consulted in the ED and
suggested possiblity of autonomic dysfunction ___ DM, patient
declines compression stockings. B12, Folate and TSH within
normal limits. Outpatient autonomic evaluation was organized for
the patient. We recommended to the patient to check his BP and
BG when he has this feeling of pre-syncope. He was also advised
to use a cane to ambulate, but refused.
.
CHRONIC CARE
# Nausea/Vomiting: LFTs and abdominal exam WNLs. Could
potentially be related to gastroparesis; however, history not
totally classic for this. Patient reports that he does not want
to take Reglan.
.
# DM: HgA1C 7.9%. Continued on lantus 80 units qAM (home dose
is confirmed 100 units qAM at home), HISS (on a very aggressive
novolog sliding scale at home), and ASA 81mg.
.
# CKD: Cr slightly up from baseline 3.2 to 3.8. Patient has
been evaluated for fistula and is discussing renal transplant.
He was continued on his Calcitriol. Due to CKD, his gabapentin
dose should be tapered down.
.
# HTN: continue metoprolol, losartan. Held lasix during
hospitalization.
.
# HLD: continue lipitor
.
# Recent H.Pylori: patient has completed triple abx therapy.
Continue pantoprazole
.
# Glaucoma: continue home Cosopt and Xalatan.
.
TRANSITIONS IN CARE:
CODE:
CONTACT:
PENDING STUDIES:
- MRI Lumbar Spine
ISSUES TO DISCUSS AT FOLLOW UP:
- autonomic testing
Medications on Admission:
- Zoloft 100 Mg 3 tab am
- Xalatan 0.005 % instill 1 drop by ophthalmic route every day
into affected eye(s) in the evening
- Vitamin D2 50,000 Unit take 1 capsule (50000UNITS) by ORAL
route every week other week
- Toprol Xl 100 Mg take 1 tablet (100MG) by ORAL route every day
- Protonix 40 Mg take 1 tablet (40MG) by ORAL route every day
- Novolog 100 Unit/ml inject up to 180 units per day
- Multivitamin 1 time per day
- Lipitor 40mg tab take 1 tablet by oral route every day
- Lantus 100 Unit/ml inject by Subcutaneous route per insulin
protocol
- Gabapentin 300 Mg take ___ times every day
- Furosemide 40 Mg take 1 tablet (40MG) by oral route every day
- Folic Acid 1 Mg 1 time per day
- Cyanocobalamin 1,000 Mcg take by Oral route every day
- Cozaar 25 Mg take 1 tablet (25MG) by oral route every day
- Cosopt 2 %-0.5 % 1 drop bid both eyes
- Calcitriol 0.25 Mcg take 1 capsule (0.25MCG) by oral route
every 2 days
- Anti-diarrheal 2 Mg
- Amoxicillin 500 Mg take 1 capsule (500MG) by oral route every
TID for 14 days, filled on ___
- Flagyl 375mg 2 capsules qday for 14 days, filled on ___
-Zifaxin 200mg 4 tabs qday for 14 days, filled on ___
Discharge Medications:
1. sertraline 100 mg Tablet Sig: Three (3) Tablet PO once a day.
2. latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at
bedtime).
3. Vitamin D2 50,000 unit Capsule Sig: One (1) Capsule PO every
other week.
4. metoprolol succinate 100 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO once a day.
5. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
6. Novolog 100 unit/mL Solution Sig: One Hundred Eighty (180) U
Subcutaneous once a day: Up to 180U per day.
7. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. Lantus 100 unit/mL Solution Sig: One Hundred (100) U
Subcutaneous qam.
11. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day.
12. cyanocobalamin (vitamin B-12) 500 mcg Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
13. losartan 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
14. dorzolamide-timolol ___ % Drops Sig: One (1) Drop
Ophthalmic BID (2 times a day).
15. calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO EVERY
OTHER DAY (Every Other Day).
16. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
17. bacitracin-polymyxin B Ointment Sig: One (1) Appl
Topical BID (2 times a day).
18. gabapentin 600 mg Tablet Sig: One (1) Tablet PO BID to qday
for 5 days: Take twice a day for 5 days. Then take daily.
Disp:*40 Tablet(s)* Refills:*0*
19. Blood Pressure Cuff Misc Sig: One (1) Miscellaneous
once.
Disp:*1 * Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
primary diagnosis
type II diabetes mellitus with complications of neuropathy,
nephropathy
diabetic gastroparesis
stage IV chronic kidney disease
lacunar strokes
secondary diagnoses:
hypertension
hyperlipidemia
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 ___ for increased frequency of falls.
The cause of your falls is likely due to multiple factors: your
decreased sensation in your feet, you may have been dehydrated
from vomiting and having diarrhea. You did have a CT scan of
your head, this did not show new changes. You also had an MRI of
your back.
Please note the following changes to your medications:
- STOP your Lasix (Furosemide) for ___. Restart on ___.
- DECREASE your gabapentin
Please be sure to see your physicians.
Followup Instructions:
___
|
19674970-DS-19
| 19,674,970 | 26,339,285 |
DS
| 19 |
2193-06-24 00:00:00
|
2193-06-24 20:19:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Augmentin / Percodan
Attending: ___.
Chief Complaint:
Needs Dialysis
Major Surgical or Invasive Procedure:
Dialysis (___)
History of Present Illness:
Mr. ___ is a ___ yo M whose past medical history is
significant for Stage V CKD, HTN, and diabetes who presents from
the ___ clinic for dialysis with a Cr. of 8.8 on ___.
Had a left A-V fistula placed one year ago. He has never had
dialysis before and is still making urine. He is complaining of
nausea, vomitting, shortness of breath, leg swelling, and
peripheral neuropathy for the past several weeks. He was seen in
the ___ clinic on ___ and it was noted he had worsening
dyspnea on exertion, worsening lower extremity edema, persistent
nausea with occasional vomiting, and ongoing diarrhea (hx of
gastroparesis). His creatinine on ___ was 9.4 and his Lasix
dose was increased to 40mg daily. Currently, he is afebrile,
denies pleuritic chest pain, changes to his mental status, and
abdominal pain.
In the ED, initial vital signs were T 98.8, P 81, BP 190/66, R
16 O2 sat 98%. His EKG showed T-wave inversion and RBBB that was
similar to previous on ___. Nephrology was consulted and
recommended that he receive dialysis tomorrow. He was found to
be anemic in the ER. A rectal exam was performed and he was
guaic negative.
On the floor, T 98, BP 190/75, P 79, RR 18, O2 96% RA
Review of Systems:
(+) per HPI
(-) fever, chills, night sweats, headache, vision changes,
rhinorrhea, congestion, sore throat, cough, shortness of breath,
chest pain, abdominal pain, nausea, vomiting, diarrhea,
constipation, BRBPR, melena, hematochezia, dysuria, hematuria.
Past Medical History:
- type 2 diabetes
- hypertension
- hyperlipidemia
- obesity
- stage IV kidney disease
- hyperparathyroidism
- ? sleep apnea, pt denies
- anemia
- GERD
- glaucoma
- hypertensive retinopathy
- colon ca (s/p resection in ___
- h.pylori s/p triple abx therapy ___
Social History:
___
Family History:
Mother died of liver cancer. Father died of stroke at ___.
Brother died of MI at ___. Grandmother with DM, died of related
complications. Other cancers in family members.
Physical Exam:
Admission Physical Exam:
Vitals- ___, 190/75, 79, 18, 96% RA
General: A&Ox3, No acute distress, sitting up in bed
HEENT: PERRL, EOMI, MMM, anicteric sclera
Neck: supple
CV: regular rate, soft systolic murmur
Lungs: decreased breath sounds bilaterally, crackles ___ of the
way up his lungs bilaterally
Abdomen: soft, non-tender, non-distended
GU: no CVA tenderness
Ext: 3+ pedal edema bilaterally, L AVF with thrill and bruit
present
Neuro: CNII-XII grossly intact and symmetric, motor grossly
intact and symmetric.
Skin: warm, dry, no rashes
Discharge Physical Exam:
Vitals: 98.0 168/80 70 16 96% RA
General: A&Ox3, No acute distress, sitting up in bed
HEENT: PERRL, EOMI, MMM, anicteric sclera
Neck: supple, JVP at angle of mandible
CV: regular rate, soft systolic murmur
Lungs: clear to ascultation with slight crackles at the lung
bases
Abdomen: soft, non-tender, non-distended
GU: no CVA tenderness
Ext: 2+ pedal edema bilaterally improving, L AVF with thrill and
bruit present
Neuro: CNII-XII grossly intact and symmetric, motor grossly
intact and symmetric.
Skin: warm, dry, no rashes
Pertinent Results:
Admission Labs:
___ 02:35PM ___ PTT-33.2 ___
___ 02:35PM PLT COUNT-190
___ 02:35PM NEUTS-78.7* LYMPHS-12.5* MONOS-6.7 EOS-1.8
BASOS-0.4
___ 02:35PM WBC-5.1 RBC-2.20* HGB-7.0* HCT-21.6* MCV-98
MCH-31.8 MCHC-32.4 RDW-14.8
___ 02:35PM HCV Ab-NEGATIVE
___ 02:35PM HBsAg-NEGATIVE HBs Ab-NEGATIVE HBc
Ab-NEGATIVE
___ 02:35PM PTH-374*
___ 02:35PM calTIBC-172* FERRITIN-254 TRF-132*
___ 02:35PM IRON-21*
___ 02:35PM CK-MB-6
___ 02:35PM cTropnT-0.16*
___ 02:35PM CK(CPK)-109
___ 02:35PM estGFR-Using this
___ 02:35PM GLUCOSE-172* UREA N-91* CREAT-8.8* SODIUM-139
POTASSIUM-4.2 CHLORIDE-113* TOTAL CO2-14* ANION GAP-16
___ 02:51PM K+-4.2
Interval Labs:
___ 07:55AM BLOOD WBC-5.4 RBC-2.13* Hgb-6.9* Hct-20.9*
MCV-98 MCH-32.3* MCHC-33.0 RDW-15.0 Plt ___
___ 07:55AM BLOOD Glucose-98 UreaN-92* Creat-9.2* Na-142
K-4.7 Cl-114* HCO3-15* AnGap-18
___ 07:55AM BLOOD Calcium-6.7* Phos-7.0* Mg-1.8
___ 09:08AM BLOOD WBC-5.3 RBC-2.60* Hgb-8.2* Hct-25.0*
MCV-96 MCH-31.5 MCHC-32.8 RDW-15.5 Plt ___
___ 09:08AM BLOOD Glucose-209* UreaN-72* Creat-7.3*# Na-143
K-4.6 Cl-110* HCO3-21* AnGap-17
___ 09:08AM BLOOD Albumin-2.6* Iron-49
___ 09:08AM BLOOD calTIBC-166* Ferritn-301 TRF-128*
___ 07:30AM BLOOD WBC-5.8 RBC-2.60* Hgb-8.3* Hct-24.8*
MCV-95 MCH-31.7 MCHC-33.3 RDW-15.5 Plt ___
___ 07:30AM BLOOD Glucose-121* UreaN-85* Creat-8.0* Na-143
K-4.2 Cl-110* HCO3-21* AnGap-16
___ 07:20AM BLOOD Calcium-7.3* Phos-4.6*# Mg-1.8
___ 06:55AM BLOOD WBC-5.1 RBC-2.53* Hgb-8.1* Hct-23.9*
MCV-95 MCH-32.2* MCHC-34.0 RDW-15.2 Plt ___
___ 06:55AM BLOOD Glucose-162* UreaN-67* Creat-6.2*# Na-143
K-4.2 Cl-108 HCO3-28 AnGap-11
Discharge Labs:
___ 06:45AM BLOOD WBC-4.8 RBC-2.38* Hgb-7.4* Hct-22.2*
MCV-93 MCH-31.1 MCHC-33.4 RDW-14.8 Plt ___
___ 06:45AM BLOOD Glucose-105* UreaN-44* Creat-4.7*# Na-141
K-3.9 Cl-103 HCO3-29 AnGap-13
___ 06:45AM BLOOD CK(CPK)-PND
___ 06:45AM BLOOD CK-MB-PND cTropnT-PND
Microbiology: None
Pathology: None
Imaging/Studies:
ECG (___): Sinus rhythm. Right bundle-branch block with left
anterior fascicular block.Non-specific ST segment changes in the
lateral and high lateral leads. Compared to the previous tracing
of ___ the ventricular rate is faster.
CXR (___): IMPRESSION: AP chest compared to ___:
Mild pulmonary edema is new, mild-to-moderate cardiomegaly
increased slightly, pulmonary vasculature more engorged, and
small-to-moderate right pleural effusion persist, findings all
pointing to worsening cardiac decompensation. No pneumothorax.
CXR (___):
IMPRESSION: AP chest compared to ___ and ___, 5:06
p.m.:
Lung volumes have improved since ___. The mild pulmonary
edema has
decreased. Residual opacification at the lung base could be
persistent edema and atelectasis, but should be followed to
exclude developing pneumonia. The heart is mildly enlarged. The
central veins are not dilated, and therefore volume overload is
probably not present. No pneumothorax.
Brief Hospital Course:
Mr. ___ is a ___ yo M whose past medical history is
significant for Stage V CKD, HTN, and diabetes who presents from
the ___ clinic for dialysis with a Cr. of 8.8 and
worsening uremic symptoms on ___.
Active Diagnoses:
# AOCKD: Patient presented with worsening peripheral neuropathy,
worsening dyspnea, and lower extremity edema for the past 3
weeks. He has had a patent AVF in his L arm for the past year.
He was started on hemo-dialysis on ___. His hepatitis
serologies were negative as was his PPD. He got 2 more session
of dialysis on ___ and ___. He stated that he was breathing
better and his leg edema has decreased. He was discharged to a
rehab facility on ___ because of his history of falls and ___
reccommendations. He will continue hemo-dialysis as an
outpatient and follow up in the ___ clinic in 2 weeks
time.
# HTN: SPB in the 190s on admission and his home BP medications
(metoprolol, lasix, and amlodipine) were continued. His SPB was
between 170s-180s on ___ following dialysis. SBP returned back
to the 190s on the evening of ___ requiring 2 one time doses of
10mg Hydralizine overnight. His amlodipine dose was increased to
7.5 mg on ___ and his SBP has been less than 190 since. BP
meds will be further titrated at HD.
# Anemia: Improved. Patient's Hct was 21.6 on admission. 25.0 on
___ after transfusion of 1 unit of PRBCs. Iron studies
revealed: Iron 49, TIBC: 166, Ferritin 301, and TRF: 128. His
hematocrit remained stable at discharge. He may be placed on EPO
as an outpatient per nephrology.
# Chest pain: Pain started at 3am on ___ and was atypical in
character. It had more plueritic features than cardiac features.
The pain was sharp and worse with breathing deeply. The pain
resolved after 10 minutes. EKG on ___ showed no changes from
the previous on ___. His Troponin was mildly elevated (in
the setting of ESRD) but was stable on repeat.
Chronic Diagnoses:
# DM: Stable. His home regimen was continued.
# HLD: continued home dose of atorvastatin.
# Hx of Colon Cancer: stable, no abd pain and having bowel
movements.
Transitional Issues:
# Will be discharged to rehab facility per physical therapy's
recommendations and patient's recent fall history.
# Continue dialysis three times a week as an outpatient set up
by nephrology starting on ___
# He will follow up with the nephrologist at the ___
clinic.
# He will follow up with his PCP upon leaving rehab.
Medications on Admission:
1. Atorvastatin 40 mg PO DAILY
2. Calcitriol 0.25 mcg PO EVERY OTHER DAY
3. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP BOTH EYES BID
4. FoLIC Acid 1 mg PO DAILY
5. Furosemide 40 mg PO BID
Hold for SBP <100
6. Glargine 50 Units Breakfast
Insulin SC Sliding Scale using HUM Insulin
7. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES HS
8. Metoprolol Succinate XL 50 mg PO DAILY
Please Hold SBP <100, HR <59
9. Sertraline 100 mg PO DAILY
10. Aspirin 81 mg PO EVERY OTHER DAY
11. Gabapentin 100 mg PO HS
12. Amlodipine 5 mg PO DAILY
Hold for SBP <100
Discharge Medications:
1. Amlodipine 7.5 mg PO DAILY
2. Aspirin 81 mg PO EVERY OTHER DAY
3. Atorvastatin 40 mg PO DAILY
4. Calcitriol 0.5 mcg PO DAILY
5. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP BOTH EYES BID
6. FoLIC Acid 1 mg PO DAILY
7. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES HS
8. Sertraline 100 mg PO DAILY
9. Metoprolol Succinate XL 50 mg PO DAILY
10. Furosemide 160 mg PO DAILY
11. Gabapentin 100 mg PO QHD
12. Insulin SC
Sliding Scale
Fingerstick QACHS
Insulin SC Sliding Scale using HUM Insulin
13. Ondansetron 4 mg PO Q8H:PRN nausea
14. Calcium Acetate 1334 mg PO TID W/MEALS
15. Nephrocaps 1 CAP PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Stage V Renal Failure requiring hemo-dialysis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. ___,
You came to the hospital because you had worsening shortenss of
breath, leg swelling, and you needed dialysis. You were seen by
the nephrologist and you had three sessions of dialysis. Your
leg swelling and shortness of breath have improved. You are
going to go to a rehab facility to help you with walking around.
You will start dialysis as an outpatient this ___.
Please follow-up with your primary doctor after discharge from
rehab.
Followup Instructions:
___
|
19675321-DS-13
| 19,675,321 | 26,597,629 |
DS
| 13 |
2174-02-02 00:00:00
|
2174-02-03 17:03:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
___
Attending: ___.
Chief Complaint:
headache
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ RHW with multiple medical conditions including psoriatic
arthritis on methotrexate, h/o PE on warfarin, h/o breast cancer
with right mastectomy ___ months of chemo, and daily
migraines since her ___ (bifrontal throbbing ___, HNT, HLD,
DM, fibromyalgia presented to ___ after waking up at her
normal time (___) with ___ right sided constant headache. She
says the pain was precisely on the right side of her head from
the midline of the face to the occiput. There were no associated
vision changes including no eye pain, loss of vision or double
vision. There was no jaw claudication. There was no photophobia,
phonophobia, N/V. She called her PCP and went to ___ for
evaluation. INR =1.8, CTH and CTA head/neck showed no evidence
of IPH. Her headache was treated with Tylenol and single doses
of Benadryl and Compazine. She was transferred to ___ for
neurological evaluation.
Past Medical History:
- psoriatic arthritis on methotrexate
- h/o PE on warfarin (reason for lifetime treatment unknown to
patient)
- h/o breast cancer with DCIS of right breast (___) DCIS of
left breast (___) and recurrence of DCIS of right breast with
mastectomy ___ only able to tolerate ___ months of chemo
(stopped secondary to unbearable diarrhea)
- daily migraines since her ___ (bifrontal throbbing ___
- HNT
- HLD
- DM
- fibromyalgia
- right leg infection treated with abx + home wound care
(___)
- infection under pannus treated with multiple topical creams
- glaucoma
- multiple finger surgeries
- no history of miscarriages
Social History:
___
Family History:
- mom with DM and a stroke, does not know her father's medical
history
- two sisters, ___, ___, DM, stroke, dementia
- two children, ___, ___, healthy
- two healthy grandchildren
Physical Exam:
- Vitals: pain ___ 88 121/52 18 77%RA
- General: Awake, cooperative, NAD. Talkative. Morbidly obese.
- HEENT: NC/AT, no temporal tenderness, mild point tenderness
over the right occiput
- Neck: Supple. Able to touch chin to chest. No nuchal rigidity
- Pulmonary: CTABL
- Cardiac: RRR, no murmurs
- Abdomen: soft, nontender, distended secondary to obesity
- Extremities: bilateral lower extremity edema with thickened
skin (evidence of chronic vascular changes), all fingers with
swan neck deformities and multiple well healed scars from
previous surgeries.
- Skin: no rashes or lesions noted.
Pertinent Results:
___ 10:31PM BLOOD WBC-6.0 RBC-3.93* Hgb-11.3* Hct-34.1*
MCV-87 MCH-28.7 MCHC-33.0 RDW-18.0* Plt ___
___ 10:31PM BLOOD Glucose-146* UreaN-21* Creat-1.3* Na-142
K-4.9 Cl-105 HCO3-27 AnGap-15
___ 10:31PM BLOOD Calcium-8.1* Phos-3.1 Mg-1.9
___ 10:31PM BLOOD CRP-32.9*
___ 10:39PM BLOOD Lactate-2.0
REPORTS
MRV ___
IMPRESSION:
No dural venous sinus thrombosis.
Brief Hospital Course:
This is a ___ year old woman with a history of psoriatic
arthritis on methotrexate, history of DCIS s/p radiation and
partial chemo, fibromyalgia, and chronic migraine presenting
with acute onset right sided ___ headache. She improved at
___ with conservative management. CT head was negative,
and she was transferred to ___ for consideration of LP. Neuro
evaluation in the ___ remarked potential for giant cell arteritis
and initially recommended ophtho evaluation. However, consult
service in house noted this was not needed as the patient had no
visual complaints and was able to read. No temporal pain, no jaw
claudication. She was discharged home without any changes to her
medical regimen.
TRANSITIONAL ISSUE:
- consider workup for temporal arteritis if recurrent symptoms
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amitriptyline 125 mg PO QHS
2. Furosemide 20 mg PO DAILY
3. Glargine 42 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
4. Ferrous Sulfate 325 mg PO DAILY
5. Lisinopril 2.5 mg PO DAILY
6. Lovastatin 20 mg oral DAILY
7. MetFORMIN XR (Glucophage XR) 750 mg PO DAILY
8. Methotrexate 22.5 mg PO 1X/WEEK (MO)
9. Omeprazole 20 mg PO DAILY
10. Oxycodone-Acetaminophen (5mg-325mg) 1 TAB PO DAILY:PRN pain
11. Timolol Maleate 0.5% 1 DROP BOTH EYES BID
12. Aspirin 81 mg PO DAILY
13. Warfarin 2.5 mg PO 2X/WEEK (___)
14. FoLIC Acid 1 mg PO DAILY
15. Warfarin 5 mg PO 5X/WEEK (___)
Discharge Medications:
1. Amitriptyline 125 mg PO QHS
2. Aspirin 81 mg PO DAILY
3. FoLIC Acid 1 mg PO DAILY
4. Furosemide 20 mg PO DAILY
5. Glargine 42 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
6. Lisinopril 2.5 mg PO DAILY
7. Lovastatin 20 mg oral DAILY
8. Omeprazole 20 mg PO DAILY
9. Timolol Maleate 0.5% 1 DROP BOTH EYES BID
10. Warfarin 2.5 mg PO 2X/WEEK (___)
11. Ferrous Sulfate 325 mg PO DAILY
12. MetFORMIN XR (Glucophage XR) 750 mg PO DAILY
13. Methotrexate 22.5 mg PO 1X/WEEK (MO)
14. Oxycodone-Acetaminophen (5mg-325mg) 1 TAB PO DAILY:PRN pain
15. Warfarin 5 mg PO 5X/WEEK (___)
Discharge Disposition:
Home
Discharge Diagnosis:
Headache, possibly from cervicalgia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure participating in your care at ___
___ ___.
You were admitted to determine whether or not your headache is
particularly dangerous. It does not appear to be caused by a
bleed inside your head, and you were observed for a period to
ensure that the headache had resolved.
Followup Instructions:
___
|
19675441-DS-14
| 19,675,441 | 25,175,590 |
DS
| 14 |
2116-09-11 00:00:00
|
2116-09-13 22:32:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / Bactrim
Attending: ___.
Chief Complaint:
Altered mental status
___
Major Surgical or Invasive Procedure:
Lumbar puncture on ___
History of Present Illness:
___ F with unknown medical history presenting with AMS from
___. She is alert and awake but not
oriented. Pt is non-communicative and unable to provide history.
Per daughter #1, pt was last seen normal one month ago and
seemed normal 4 days PTA while talking on the phone with
daughter #2. Found to be acting strange by her boyfriend 3 days
PTA (walking out in the street in her underwear, trying to smoke
the wrong end of a cigarette). Per family, pt has h/o
prescription drug abuse. Admitted to ___ ___ night
from the ___ for confusion.
Irregular behavior continued at ___ where she complained
of dysuria. She then developed urinary and stool incontinence.
Found to have UTI and given Cipro (presumed to have been started
2 days PTA but unclear). Pt was ambulatory at ___. Staff
at ___ noticed new cuts on elbows/ bruises on head on the
day of ___ and called EMS to bring her to ___.
There are reports of additional recent falls. Was at ___ 2
weeks ago after falling in the shower and had MRI head showing
no acute intracranial process. Per boyfriend, he thinks that
she's gotten progessively worse since then, especially her
memory. Pt has poor hygiene while at ___. She has not
received any antipsychotics at ___.
In the ___, initial VS were 98.0, BP 116/79, HR 94, RR 20, 96%RA.
Pt triggered in the ___ for AMS and received head CT w/o
contrast. Head CT showed 4mm right frontal cortex hyperdensity
concerning for possible subdural hematoma vs motion artifact.
There was no mass effect. Neurosurgery consulted and does not
think there is a bleed.
On arrival to the floor, patient reports that she has no
complaints but questioning limited secondary to altered mental
status and poor attention.
REVIEW OF SYSTEMS: Pt poor historian
+ pain at laceration
Denies fever, chills, night sweats, headache, vision changes,
rhinorrhea, congestion, sore throat, cough, shortness of breath,
chest pain, abdominal pain, nausea, vomiting, diarrhea,
constipation, BRBPR, melena, hematochezia, dysuria, hematuria.
All other 10-system review negative in detail.
Past Medical History:
Polysubstance abuse
CKD
asthma
nephrolithiasis
multiple cystoscopies
left ureteral stent
multiple ESWLs
Social History:
___
Family History:
Heart disease, DM, CKD, nephrolithiasis
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS - 98.0, BP 123/72, HR 81, RR 18, 98%RA
General: NAD, alert and awake, not oriented
HEENT: 2x2mm laceration in left parietal region, no purulent
drainage. R pupil > L pupil but both reactive to light. Appears
sensitive to light on exam. OP clear. Edentulous.
Neck: Supple, no nuchal rigidity, no JVD, no carotid bruits.
CV: RRR, normal S1/S2, no murmurs, rubs ___
Lungs: CTAB but poor effort secondary to mental status
Abdomen: Obese, NT, ND, NABS, no rebound or guarding, no masses,
no organomegaly
Ext: Bilateral lower extremity pain on palpation. Legs equally
warm, well perfused, pulses 2+, no clubbing/cyanosis/edema.
Neuro: Not oriented. CN ___ grossly intact. Poor attention. UE
reflexes +1 bilaterally could not test ___ secondary to poor
cooperation. Marked ankle clonus bilaterally. +clonic jerks on
exam. Gait not tested.
DISCHARGE PHYSICAL EXAM:
VS: 97.7, BP 124/76, HR 71 RR 16, 99% RA
General: NAD, conversant today. Still oriented only to person,
but answers simple questions appropriately
HEENT: Slight anisocoria R>L (chronic), EOMI, MMM, OP clear,
poor dentition
Neck: Supple, no JVD, no carotid bruits
Lungs: CTAB, no wheeze, rales, rhonchi
CV: RRR, normal S1/S2, no murmurs, rubs or gallops
Abdomen: Soft, NT, ND, no rebound tenderness, NABS, no
organomegaly
Ext: Warm, well perfused, pulses 2+, no clubbing, cyanosis or
edema
Neuro: CN ___ grossly intact, sensation not tested
Pertinent Results:
ADMISSION LABS:
___ 04:30PM BLOOD WBC-10.0 RBC-5.26 Hgb-15.5 Hct-47.1
MCV-90 MCH-29.5 MCHC-32.9 RDW-13.9 Plt ___
___ 04:30PM BLOOD Neuts-70.9* ___ Monos-4.8 Eos-0.8
Baso-1.2
___ 06:28PM BLOOD ___ PTT-35.3 ___
___ 04:30PM BLOOD Glucose-116* UreaN-19 Creat-1.7* Na-140
K-4.2 Cl-100 HCO3-26 AnGap-18
___ 04:30PM BLOOD ALT-13 AST-18 AlkPhos-76 TotBili-0.5
___ 04:30PM BLOOD Lipase-29
___ 04:30PM BLOOD Albumin-4.7 Calcium-10.3 Phos-2.8 Mg-1.8
___ 04:30PM BLOOD VitB12-783
___ 04:30PM BLOOD TSH-0.89
___ 04:30PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 04:38PM BLOOD Lactate-1.4
PERTINENT LABS:
___ 07:15AM BLOOD Glucose-87 UreaN-19 Creat-1.2* Na-144
K-3.9 Cl-108 HCO3-24 AnGap-16
___ 06:50AM BLOOD CK(CPK)-41
___ 07:05AM BLOOD ALT-12 AST-13 AlkPhos-66 TotBili-0.4
___ 06:50AM BLOOD HCG-<5
___ 06:50AM BLOOD HIV Ab-NEGATIVE
___ 06:50AM BLOOD Lithium-<0.2
___ 04:30PM BLOOD VitB12-783
___ 04:30PM BLOOD TSH-0.89
___ 04:38PM BLOOD Lactate-1.4
DISCHARGE LABS: STOPPED DRAWING LAB WORK ON ___ 07:00AM BLOOD WBC-8.8 RBC-5.21 Hgb-15.8 Hct-46.9 MCV-90
MCH-30.3 MCHC-33.7 RDW-14.2 Plt ___
___ 07:00AM BLOOD Glucose-89 UreaN-18 Creat-1.2* Na-143
K-4.1 Cl-108 HCO3-23 AnGap-16
___ 07:00AM BLOOD Calcium-9.2 Phos-4.0 Mg-2.0
MICROBIOLOGY:
___ 4:30 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
___ 5:35 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
___ 9:22 pm SEROLOGY/BLOOD
**FINAL REPORT ___
RAPID PLASMA REAGIN TEST (Final ___:
NONREACTIVE.
___ 2:26 pm CSF;SPINAL FLUID Source: LP #3.
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final ___: NO GROWTH.
VIRAL CULTURE (Preliminary): NO VIRUS ISOLATED.
PERTINENT IMAGING:
MRI Brain (___):
FINDINGS: Images are degraded by patient motion as noted above.
Within that substantial constraint, ventricles and sulci are
noted to be normal in size and configuration. There is no
definite intracranial hemorrhage. Note is made of bilateral,
symmetric, anterior and posterior diffuse cerebral white matter
FLAIR and T2 weighted signal hyperintensity. Similarly, note is
made of abnormal hyperintensity involving the globus pallidus
bilaterally, or strikingly on the left than right. There is no
focal mass effect. Primary intracranial flow voids are normal.
There is no abnormally slow focus of diffusion.
IMPRESSION: Image degraded examination, with diffuse bilateral
symmetric
cerebral white matter and globus pallidus signal abnormality
overall, this appearance is concordant with toxic/metabolic
leukoencephalopathy.
EEG (___):
MPRESSION: This telemetry captured no pushbutton activations. It
showed a
normal waking background with possible muscle artifact. There
are no clear epileptiform features, and there were no
electrographic seizures. No clear changes in EEG were evident as
some of the jerking episodes were reviewed.
CXR (___):
FINDINGS: Frontal and lateral views of the chest were obtained.
Patchy right basal opacity is seen, which could be due to
aspiration or infection. The left lung is clear. There is no
pleural effusion or pneumothorax. The cardiac and mediastinal
silhouettes are unremarkable. No displaced fracture is seen.
IMPRESSION:
Subtle patchy right base opacity could be due to aspiration,
infection or
atelectasis.
Head CT (___):
FINDINGS: There is a focal hyperdensity along the right frontal
convexity which measures approximately 4 mm in width. Given
the patient motion and surrounding artifact, this area is
difficult to evaluate. Though it is likely artifact, a small
focal subdural hematoma is difficult to exclude. There is no
adjacent mass effect. No other hemorrhage is identified. There
is no large vascular territory infarction. The ventricles and
sulci are normal in size and configuration. The basal cisterns
are patent. No fracture is identified. There are some
aerosolized secretions in the left maxillary
sinus. The remainder of the visualized paranasal sinuses,
mastoid air cells, and middle ear cavities are clear. The soft
tissues are unremarkable.
IMPRESSION: Very limited by motion; however, a 4 mm
hyperdensity along the right frontal convexity is likely
artifact rather than a small subdural hematoma. Recommend close
short-term follow-up.
Brief Hospital Course:
PRIMARY REASON FOR HOSPITALIZATION:
Ms. ___ is a ___ w/ unknown ___ but with a long standing
h/o of polysubstance abuse who was admitted on ___ from
___ facility after found to have an altered
mental status at home on ___.
ACTIVE DIAGNOSES:
# Altered mental status
Pt was originally taken to ___ who transferred her to
___ who then transferred her to
___. Pt was essentially nonverbal on arrival to ___ and
gradually improved communication over the course of her
hospitalization. Pt's orientation waxed and waned daily while in
the hospital.
Ms. ___ had an extensive workup as an inpatient. CT head
w/o contrast on ___ had a 4mm hyperdensity in the R frontal
convexity (study poor quality due to pt movement). Seen by
neurosurgery in ___ who felt that hyperdensity was motion
artifact and did not intervene. CXR on ___ showed subtle patchy
right base opacity read as possible atelectasis. Urine tox in
___ ___ was negative but was + for benzos at ___ on
___. Pt had an EEG on ___ which showed diffused slowing
consistent with delirium. All blood work was negative for
infection or metabolic disturbance. TSH, B12, RPR and CSF HSV
PCR were normal/negative. Neurology was consulted and felt pt
had an encephalopathy secondary to an unknown toxic ingestion.
Pt had MRI head w/o contrast which showed diffuse bilateral
symmetric cerebral white matter and globus pallidus signal
abnormalities consistent with toxic encephalopathy. ___ guided LP
done on ___ was normal. Toxicology was consulted and
recommended a lithium level which was normal. Psychiatry saw the
pt and suggested an acute delirium possibly due to benzo
withdrawal. Pt started on trial low dose benzo schedule with no
clinical improvement ___ after 3 days due to drowsiness). Pt
also empirically treated with IV thiamine for Wernicke's
encephalopathy with no clinical improvement after 3 days.
Pt showed gradual improvement in communication and was
sporadically verbal beginning HD #2/#3. However, she still
continued to be inattentive, have waxing/waning orientation and
inappropriate laughter throughout her hospitalization.
# ___
She was also found to be in ___ on admission. Baseline
creatinine was 0.97 per outside records. Creatinine on admission
was 1.7 and likely secondary to poor PO intake. Urine
eosinophils were negative, urine lytes were WNL. Creatinine
trended down to 1.2 with gentle hydration.
# Disposition
Inpatient team initiated guardianship proceedings with pt's
daughter ___ being the guardian. The court hearing took place
on ___ and guaradianship was granted. The patient was
discharged from the hospital to an extended care facility on
___.
CHRONIC DIAGNOSES:
Due to incomplete history on admission, the pre-admission
medication list is the only available guide to this patient's
chronic stable health issues and is provided below:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Pregabalin 50 mg PO BID
2. Citalopram 20 mg PO DAILY
3. Omeprazole 20 mg PO DAILY
4. Hydrochlorothiazide 25 mg PO DAILY
5. Tamsulosin 0.4 mg PO HS
6. Simvastatin 20 mg PO DAILY
7. Cyanocobalamin ___ mcg PO Frequency is Unknown
8. Vitamin D 50,000 UNIT PO 1X/WEEK (___)
9. Ciprofloxacin HCl 250 mg PO Q12H
10. OxycoDONE (Immediate Release) 5 mg PO Frequency is Unknown
11. Naproxen 375 mg PO Q12H
12. ProAir HFA *NF* (albuterol sulfate) 90 mcg/actuation
Inhalation 2 puffs every 6 hours
13. Phenazopyridine 100 mg PO TID
14. Baclofen 10 mg PO TID
TRANSITIONAL ISSUES:
- Patient should follow up with a PCP, ___ for ongoing
monitoring for improvement in her mental status.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Pregabalin 50 mg PO BID
2. Citalopram 20 mg PO DAILY
3. Omeprazole 20 mg PO DAILY
4. Hydrochlorothiazide 25 mg PO DAILY
5. Tamsulosin 0.4 mg PO HS
6. Simvastatin 20 mg PO DAILY
7. Cyanocobalamin ___ mcg PO Frequency is Unknown
8. Vitamin D 50,000 UNIT PO 1X/WEEK (___)
9. Ciprofloxacin HCl 250 mg PO Q12H
10. OxycoDONE (Immediate Release) 5 mg PO Frequency is Unknown
11. Naproxen 375 mg PO Q12H
12. ProAir HFA *NF* (albuterol sulfate) 90 mcg/actuation
Inhalation 2 puffs every 6 hours
13. Phenazopyridine 100 mg PO TID
14. Baclofen 10 mg PO TID
Discharge Medications:
1. Cyanocobalamin ___ mcg PO DAILY
2. Simvastatin 20 mg PO DAILY
3. Acetaminophen 650 mg PO Q6H:PRN for pain
4. Docusate Sodium 100 mg PO BID
5. FoLIC Acid 1 mg PO DAILY
6. Multivitamins 1 TAB PO DAILY
7. Nicotine Patch 21 mg TD DAILY
8. Senna 1 TAB PO BID:PRN constipation
9. Thiamine 100 mg PO DAILY
10. Citalopram 20 mg PO DAILY
11. Vitamin D 50,000 UNIT PO 1X/WEEK (___)
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary Diagnosis:
Toxic/metabolic encephalopathy
Secondary Diagnosis:
Acute kidney injury
Discharge Condition:
Mental Status: Confused - always.
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. You were admitted to ___
from ___ for altered mental status.
During your admission, you had an extensive work up for your
changed mental status. All diagnostic tests performed were
normal. A lumbar puncture was done (needle into the back to
collect spinal fluid for testing) and was normal with no signs
of infection and without complication following the procedure.
A chest xray was done and had no evidence of heart or lung
problems. You had an electroencephalogram (sticker probes that
measure brain electrical patterns) which showed no evidence of
seizure activity. You also had a CT of the head without contrast
which did not show any masses or bleeds. You also had an MRI of
the head without, which showed tissue changes consistent with a
toxic ingestion. You were also seen by the following specialties
while at ___: Neurosurgery, Neurology, Toxicology and
Psychiatry. Physical therapy and occupational therapy saw you in
the hospital and recommended that you be discharged to a long
term care facility to improve your overall functioning and
ensure your safety outside the hospital. Nutrition experts also
were involved in your care.
We also found that your kidneys were not working as well as they
should. This was most likely due to dehydration and low blood
pressure. You were given fluids and your kidney function
improved but did not return to its previous level.
During your hospitalization, your care team was concerned that
you could not make your own medical decisions. We asked our case
management team and social worker to review your case. They
recommended that we have the court appoint a guardian to assist
you in making decisions. Your daughter ___ was appointed your
guardian. You remained in the hospital until the guardianship
process was complete. You are now ready to leave the hospital.
Please take all your medications as directed.
Thank you for allowing us to participate in your care.
Followup Instructions:
___
|
19675441-DS-15
| 19,675,441 | 20,295,628 |
DS
| 15 |
2120-02-09 00:00:00
|
2120-02-09 16:19:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / Bactrim / Toradol
Attending: ___.
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
ERCP on ___ and ___
History of Present Illness:
Ms. ___ is a ___ year old woman with a history of CCY,
biliary stent placement in ___, who presents from ___
___ with abdominal pain for repeat ERCP.
Patient reports she has had pain now on and off for over a
month. She recalls that she was unable to eat much during
___ due to abdominal pain. In the past two weeks,
however, she has noted that her pain is much worse. The pain is
located in her epigastric region, radiating around her abdomen
and around her back. The pain is worse in the epigastric and RUQ
areas. On ___, she reports a temperature to 101 at home. She
then started Tylenol and didn't have any more fevers. She
endorses some diarrhea, nausea and vomiting as well. She hasn't
been able to eat anything given these symptoms. She has also had
increasing itchiness as well.
Of note, patient was admitted in ___ to ___ for
abdominal pain and found to have acute cholecystitis and had CCY
that was converted to open and c/b bile leak. She had an ERCP on
___ with sphinecterotomy and a plastic stent was placed. Per
ERCP report, repeat ERCP was recommended in 3 months for
evaluation and stent removal, but it is unclear if this ever
occurred.
Given the above symptoms, she presented to ___.
There, CT A/P showed, "new 2 cm CBD dilation with enhancing
wall, stent in place, intrahepatic biliary dilation, 4.7x1.4cm
ovoid cystic structure with wall enhancement and septation in
gallbladder fossa." She received zosyn and was then transferred
to ___ for further management.
In the ED, initial vitals were: 96.5 65 132/67 18 97% RA Labs
notable for CBC WNL. Chemistry with Cr 1.4 (baseline 1.2-1.4),
LFTs ALT 190 AST 131 AP 611 T.bili 3.7 (direct 3.0), UA bland.
RUQ u/s showed prominence of the common bile duct measuring 9 mm
with proximal portion of CBD stent noted and collection in the
gallbladder fossa measuring 1.9 x 1.9 x 1.3 cm without evidence
of surrounding inflammation. Surgery was consulted who advised
admission to medicine for repeat ERCP. ERCP advised: NPO, coags,
and admission for ERCP tomorrow AM. She received: Zosyn,
morphine 4mg and admitted for further care.
On the floor, patient reports continued abdominal pain, rated
___. It is improved from prior. She is hungry but knows she
cannot eat. She denies any nausea or vomiting at present. She
denies any fevers but does endorse chills.
ROS: positive per above, otherwise negative
Past Medical History:
Polysubstance abuse
CKD
asthma
nephrolithiasis
multiple cystoscopies
left ureteral stent
multiple ESWLs
Social History:
___
Family History:
Heart disease, DM, CKD, nephrolithiasis
Physical Exam:
Admission exam:
VS: 97.5 PO 124/74 74 16 95% RA
General: well appearing woman, no acute distress
HEENT: PERRL, EOMI, oropharynx clear, neck is supple
CV: r/r/r, no murmurs
Resp: CTA bilaterally
Abd: soft, tenderness to palpation in the epigastric and RUQ
regions, no rebound tenderness
Ext: wwp, no peripheral edema, there are multiple excoriations
noted on the arms and legs from scratches
Neuro: alert and oriented, CN II-XII intact, moving all
extremities
Discharge PE:
97.4 141 / 83 62 18 97 RA
Gen: NAD, sitting in chair eating lunch comfortably
Eyes: EOMI, anicteric sclera
ENT: MMM, OP clear, poor dentition
Cardiovasc: RRR, no MRG, full pulses, no edema
Resp: normal effort, no accessory muscle use, lungs CTA ___.
GI: soft, mild distention, large RUQ scar. mild RUQ tenderness,
No rebound or guarding.
MSK: No significant kyphosis. No palpable synovitis.
Skin: No visible rash. No jaundice.
Neuro: AAOx3. No facial droop.
Psych: Full range of affect
Pertinent Results:
Labs at ___:
___
6 > ___ < 196
143 | 105 | 11
---------------< 119
4.1 | 22 | 1.4
AST/ALT 171/233
Tbili/ALP 3.___/644
Admission labs:
___ 09:05AM BLOOD Neuts-53.4 ___ Monos-6.9 Eos-3.5
Baso-0.6 Im ___ AbsNeut-2.63 AbsLymp-1.74 AbsMono-0.34
AbsEos-0.17 AbsBaso-0.03
___ 09:05AM BLOOD Glucose-95 UreaN-10 Creat-1.4* Na-140
K-4.1 Cl-105 HCO3-20* AnGap-19
___ 09:05AM BLOOD ALT-190* AST-131* AlkPhos-611*
TotBili-3.7* DirBili-3.0* IndBili-0.7
___ 09:05AM BLOOD Albumin-3.5
___ 09:43AM BLOOD Lactate-1.6
Imaging:
___ RUQ u/s
IMPRESSION:
1. Prominence of the common bile duct measuring 9 mm with
proximal portion of CBD stent noted.
2. Known collection in the gallbladder fossa measuring 1.9 x 1.9
x 1.3 cm
without evidence of surrounding inflammation.
3. Atrophic kidneys bilaterally with no evidence of obstructing
renal stone.
4. Echogenic liver consistent with steatosis. Other forms of
liver disease
and more advanced liver disease including steatohepatitis or
significant
hepatic fibrosis/cirrhosis cannot be excluded on this study.
5. Borderline splenomegaly.
___ CT torso
Findings:
The CBD is dilated and measures 2cm with enhancing wall, new
since the prior examination. A stent is again noted in the CBD
with its proximal end in the mid common bile duct and distal end
in the duodenum. No CBD calculus is noted. There is mild
dilatation of the intrahepatic biliary ducts with wall
enhancement, new since the prior examination. There is a 4.7 x
1.4cm ovoid cystic structure with wall enhancement and septation
in the gallbladder fossa, contiguous with the CBD. Surgical
clips are noted in the gallbladder fossa. The pancreatic duct is
nondilated. The kidneys are atrophic with extensive vascular
calcification and ephrocalcinosis. There are also nonobstructing
renal calculi bilaterally. The spleen and adrenals are
unremarkable.
Impression
Ovoid cystic structure with wall enhancement and septation in
the gallbladder fossa, contiguous with the common bile duct,
which may represent dilated cystic duct or a loculated fluid
collection. Dilated common bile duct and intrahepatic biliary
ducts with wall enhancement, new since the prior examination, of
concern for stent malfunction with interval development of
cholangitis. Recommend clinical correlation.
ERCP ___:
Impression: A previously placed plastic stent was found in the
major papilla and was removed with a snare.
Cannulation of the biliary duct was successful and deep with an
extraction balloon using a free-hand technique.
Contrast medium was injected resulting in complete
opacification. The procedure was not difficult.
The common bile duct, common hepatic duct, right and left
hepatic ducts, and biliary radicles were partially filled with
contrast and well visualized.
The CBD and common hepatic duct were dilated to 1.4 cm and there
was evidence of multiple filling defects in the CBD and common
hepatic duct consistent with sludge and stones.
The extraction balloon was exchanged for a CRE balloon and a
sphincteroplasty was performed from 10 to 12 mm.
The CRE balloon catheter was exchanged for an extraction
balloon.
Balloon sweeps were performed for over 1.5 hours and yielded
copious sludge, pus, stones and stone fragments.
To minimize anesthesia time given the already lengthy procedure
and given previous non-compliance with removal of her previously
placed biliary stent a decision was made to place a ___ plastic
nasal-biliary tube.
This was secured in place using a nasal bridle.
A cholangiogram though the nasal-biliary tube did not reveal
clear filling defects.
Recommendations: NPO overnight with aggressive IV hydration
with LR at 200 cc/hr
Keep patient NPO
No aspirin, Plavix, NSAIDS, Coumadin for 5 days.
Continue antibiotics to complete a course for cholangitis.
Keep nasal-biliary tube to straight drainage
Cholangiogram through the nasal-biliary tube tomorrow and if
filling defects are seen a repeat ERCP with balloon sweeps
tomorrow.
Otherwise, if no filling defects are seen we will pull the
nasal -biliary ___ tomorrow.
CT A/P ___:
IMPRESSION:
1. A nasobiliary tube is present, extending into the left main
biliary duct.
2. There is been interval improvement in intrahepatic bile duct
dilatation.
Extrahepatic bile duct dilatation has slightly decreased.
3. There is no evidence of fluid collection in the gallbladder
fossa.
4. There is mild nephrocalcinosis and scarring of the kidneys
bilaterally,
possibly due to previous tubular necrosis.
ERCP ___:
Impression: The scout film revealed the previously placed
nasobiliary tube in place.
Contrast was injected via the nasobiliary drain - there was
evidence of a multiple filling defects in the CBD.
___ to the CBD filling defects the decision was made to
proceed with the ERCP.
After nasobiliary drain removal, the bile duct was deeply
cannulated with the balloon.
Contrast was injected and there was brisk flow through the
ducts. Contrast extended to the entire biliary tree.
The CHD/CBD were 10mm in diameter. There were multiple filling
defects.
The left and right hepatic ducts and all intrahepatic branches
were normal.
The biliary tree was swept with a 9-12mm balloon starting at
the bifurcation. Multiple stones, stone fragments and sludge
were removed.
The CBD and CHD were swept repeatedly.
The final occlusion cholangiogram showed no evidence of filling
defects in the CBD. Excellent bile and contrast drainage was
seen endoscopically and fluoroscopically.
Due to her history of non-compliance (no show for a repeat ERCP
as recommended in ___, the decision was made not to place
a stent given risk of stent occlusion/cholangitis.
Otherwise normal ercp to third part of the duodenum
Recommendations: Return to ward under ongoing care.
Clear fluids when awake then advance diet as tolerated.
Further recommendations as per ERCP from ___
Follow for response and complications. If any abdominal pain,
fever, jaundice, gastrointestinal bleeding please call ERCP
fellow on call ___
Discharge labs:
___ 06:35AM BLOOD WBC-4.6 RBC-3.40* Hgb-10.1* Hct-33.1*
MCV-97 MCH-29.7 MCHC-30.5* RDW-14.8 RDWSD-52.8* Plt ___
___ 06:35AM BLOOD Glucose-99 UreaN-12 Creat-1.4* Na-142
K-3.8 Cl-105 HCO3-28 AnGap-13
___ 06:35AM BLOOD ALT-175* AST-126* AlkPhos-403*
TotBili-1.4
Brief Hospital Course:
Ms. ___ is a ___ year old woman with a history of CCY and
biliary stent placement in ___, who presents from ___
___ with abdominal pain for repeat ERCP.
# Abdominal pain
# cholangitis
Patient's pain in conjunction with her fever and obstructive
pattern of LFTs suggests cholangitis. This is likely due to
complication from her stent as it has been in place for > ___ year
as she was noncompliant with follow-up. She was started on IV
Unasyn for cholangitis. S/p ERCP with removal of stent,
multiple stones and pus with placement of nasobiliary tube on
___. There was concern for a fluid collection around the
gallbladder area on prior CT but this was not seen on repeat CT.
CT showing improved biliary dilation, LFTs downtrending and
lipase normal. She underwent repeat ERCP with removal of stones
and the nasobiliary tube. She tolerated the procedure well, her
pain resolved and she was tolerating a regular diet.
-Continue PO Augmentin for 5 more days for total 10 day course
for cholangitis
-Counseled patient and daughter to monitor for worsening
abdominal pain, fevers or jaundice and call her doctor or return
to the emergency room if they develop.
# CKD
Creatinine appears at baseline at 1.4, remained at baseline.
# History of TBI
# Chronic cognitive deficits
# ? seizure d/o
# h/o depression
# Prior poly-substance abuse
She has poor memory and is very impulsive which per daughter is
her baseline. Previously required temporary guardianship but
currently appears able to make decisions. Her daughter ___ is
her HCP.
- cont home citalopram
- cont Topamax
# GERD
- cont home omeprazole
# HLD
- held home simvastatin in setting of LFT abnormalities,
restarted on discharge
# core measures
FEN: Regular
Ppx: heparin sq
code status: full code
contact: daughter ___ ___
dispo: home without services
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. TraZODone 25 mg PO BID
2. Simvastatin 20 mg PO QPM
3. Topiramate (Topamax) 50 mg PO BID
4. Omeprazole 20 mg PO BID
5. Citalopram 10 mg PO DAILY
6. Multivitamins 1 TAB PO DAILY
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild/Fever
2. Amoxicillin-Clavulanic Acid ___ mg PO Q12H Duration: 5 Days
RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tablet by mouth
twice a day Disp #*10 Tablet Refills:*0
3. Citalopram 10 mg PO DAILY
4. Multivitamins 1 TAB PO DAILY
5. Omeprazole 20 mg PO BID
6. Simvastatin 20 mg PO QPM
7. Topiramate (Topamax) 50 mg PO BID
8. TraZODone 25 mg PO BID
Discharge Disposition:
Home
Discharge Diagnosis:
Cholangitis due to choledocholithiasis with obstruction
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were admitted with abdominal pain, nausea, vomiting and
jaundice (yellowing of the skin and eyes). You underwent two
ERCP procedures with removal of your old bile duct stent and
multiple stones and sludge. Your symptoms improved and you were
able to eat a regular diet. Please follow-up with your primary
care physician as scheduled. If you develop any worsening
abdominal pain, fevers or chills, yellowing of the skin or eyes
or darkening of the urine please call your doctor or return to
the emergency department.
Followup Instructions:
___
|
19676494-DS-14
| 19,676,494 | 26,518,131 |
DS
| 14 |
2151-02-24 00:00:00
|
2151-02-24 12:09:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Headache
Major Surgical or Invasive Procedure:
___ L craniotomy for resection of L frontal lesion
History of Present Illness:
Patient is a ___ year old female who has a ___ year history of
occipital headaches for which she was seeing a neurologist. Her
neurologist ordered a MRI scan of the brain which incidentally
found a left frontal meningioma measuring 4.7cm at it's thickest
point and causing cerebral edema and subfalcine herniation. She
was sent to ___ by her neurologist after the findings were
discovered. She denies nausea, vomiting, dizziness, difficulty
ambulating, changes in vision, hearing, or speech, change in
bowel or bladder function.
Past Medical History:
Migraines
Social History:
Works for ___
Married
Physical Exam:
On admission:
PHYSICAL EXAM:
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: PERRL EOMs intact without nystagmus
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 4mm 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: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power ___ throughout. No pronator drift
Sensation: Intact to light touch, and proprioception bilaterally
Toes downgoing bilaterally
Coordination: normal on finger-nose-finger bilaterally
Upon discharge:
AOx3, MAE full motor, incision C/D/I with staples
Pertinent Results:
___ Brain MRI with and without:
Left frontal brain mass consistent with a meningioma measuring
4x5cm with associated mass effect and 3mm midline shift.
CT HEAD W/O CONTRAST ___
1. the large left frontal extra-axial mass with expected
post-operative change, including loculated left frontal
pneumocephalus and small amount of blood products layering at
the margin of the resection cavity.
2. Otherwise, unchanged left frontal vasogenic edema and
associated
mass-effect on the ipsilateral lateral ventricle with similar
degree of
rightward subfalcine herniation.
MRI head ___:
IMPRESSION:
1. Status post resection of left frontal meningioma, with
residual relatively thin but focal ___ enhancement in
the left frontal surgical bed. Given the appropriately early
post-operative timing of this study, and the relative lack of
___ enhancement elsewhere, this finding must be
regarded with suspicion for residual dural-based tumor.
2. New cortical and subcortical infarct in the left frontal
lobar surgical bed, that likely relates to the recent surgery.
3. Extensive left frontal vasogenic edema with 9 mm rightward
shift of the midline structures, similar in appearance to the
pre-operative CT.
Brief Hospital Course:
Ms. ___ was admitted after an MRI showed a left frontal
meningioma to Neurosurgery. Discussion with Dr ___ was had
and the plan was to proceed with surgery. On ___, patient was
pre-oped and consent for a L craniotomy for resection of tumor.
She was neuro intact on examination. On ___, patient was taken
to the OR. Some tumor was seen eroding through the bone and the
bone was removed and a titanium mesh was placed. She was
extubated and transferred to the ICU for further monitoring.
Post op head CT was performed which showed no acute hemorrhage
and pneumocephalus. On exam, she was intact. On ___, she
remained intact. MRI head was performed and showed no residual
tumor. She was trasnferred to the floor. Her decadron was taper
over 2 weeks per plan. ___ ___ evaluated her and cleared her for
home with outpatient ___.
She was discharged home ___
Medications on Admission:
BCP, Imitrex, Zyrtec
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN pain/fever
2. Famotidine 20 mg PO BID
RX *famotidine 20 mg 1 tablet(s) by mouth twice a day Disp #*30
Tablet Refills:*0
3. LeVETiracetam 500 mg PO BID
RX *levetiracetam 500 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*3
4. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*60 Tablet Refills:*0
5. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*60 Capsule Refills:*0
6. Lorazepam 0.5 mg PO HS:PRN anxiety
RX *lorazepam 0.5 mg 1 tablet(s) by mouth at bedtime Disp #*14
Tablet Refills:*0
7. Dexamethasone 4 mg PO Q8H Duration: 3 Days
Taper as directed
Tapered dose - DOWN
RX *dexamethasone 2 mg 2 tablet(s) by mouth every eight (8)
hours Disp #*47 Tablet Refills:*0
8. Outpatient Physical Therapy
ICD-9 code: 192.1
Outpatient ___
Restrictions: ___ lb weight restriction x 4 weeks
Discharge Disposition:
Home
Discharge Diagnosis:
Left frontal Meningioma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Craniotomy for Tumor Excision
Dr. ___
Have a friend/family member check your incision daily for
signs of infection.
Take your pain medicine as prescribed.
Exercise should be limited to walking; no lifting, straining,
or excessive bending.
Your wound was closed with staples then you must wait until
after they are removed to wash your hair. You may shower before
this time using a shower cap to cover your head.
Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace) &
Senna while taking narcotic pain medication.
Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, and
Ibuprofen etc.
You have been discharged on Keppra (Levetiracetam), you will
not require blood work monitoring.
If you are being sent home on steroid medication, make sure
you are taking a medication to protect your stomach (Prilosec,
Protonix, or Pepcid), as these medications can cause stomach
irritation. Make sure to take your steroid medication with
meals, or a glass of milk.
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.
YOU ARE BEING SENT HOME WITH A DEXAMETHASONE TAPER. PLEASE TAKE
PEPCID WHILE ON DEXAMETHASONE FOR STOMACH PROTECTION AND TAKE
WITH FOOD. PLEASE FOLLOW THE TAPER AS DIRECTED:
4 MG (2 TABS) BY MOUTH EVERY 8 HOURS FOR 3 DAYS (9 TOTAL DOSES)
THEN
3 MG (1.5 TABS) BY MOUTH EVERY 8 HOURS FOR 3 DAYS (9 TOTAL
DOSES)
THEN
2 MG (1 TAB) BY MOUTH EVERY 8 HOURS FOR 3 DAYS (9 TOTAL DOSES)
THEN
2 MG (1 TAB) BY MOUTH EVERY 12 HOURS FOR 3 DAYS (9 TOTAL DOSES)
THEN DISCONTINUE.
Followup Instructions:
___
|
19676519-DS-13
| 19,676,519 | 20,172,122 |
DS
| 13 |
2116-02-10 00:00:00
|
2116-02-10 12:30:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
aspiration pneumonia/ respiratory failure
Major Surgical or Invasive Procedure:
s/p percutaneous endoscopic gastrostomy tube placement ___
History of Present Illness:
Mr. ___ is well known to the ___ team as he is s/p
___ ligation on ___ with ___. Please refer to ___
summary on ___ for further hospital course details.
He presents from rehab tonight after his DHT was "dislodged" and
his resp status concerning for aspiration pneumonia. On
assessment in the ED, episodes of apnea were noted. Pt was
intubated secondary to resp failure. He was fully cultured and
empiric ABX were initiated. He was admitted to ___ intubated,
sedated.
Of note, prior to his discharge on ___, he was followed by
the speech pathology team and due to deconditioning he failed a
video swallow exam on ___. The patient was made NPO with all
meds and nutrition via DHT.
Past Medical History:
Abdominal Aortic Aneurysm s/p repair
Atrial Fibrillation
Bladder Lesions
Carotid Artery Stenosis
Coronary Artery Disease
Gastroesophageal Reflux Disease
Hyperlipidemia
Hypertension
Hypothyroidism
Iliac Aneurysm, bilateral
AAA repair
Chest Wall Cyst, benign, ___
Knee Replacement, left ___
Prostatectomy
CABG/pulmonary vein isolation/L atrial appendage ligation ___
Social History:
___
Family History:
Brother - passed from ___ at ___
Father - passed from MI at ___
Mother - passed from cerebral aneurysm at ___
Physical Exam:
Admit PE
HR: 122 AF BP Right: 156/85 RR: 16 O2 sat: 94% being ambued
with 100% FIO2
2L
Height: 73 in Weight: 102.6 kgs
General:intubated & sedated
___ irregular->AF on tele
Neuro: pt sedated at this time
PE not performed as Pt was being intubated upon my evaluation
Discharge PE:
24 HR Data (last updated ___ @ 1107)
Temp: 97.4 (Tm 97.8), BP: 139/65 (119-139/65-76), HR: 92
(85-99), RR: 18 (___), O2 sat: 93% (93-100), O2 delivery: RA,
Wt: 212.96 lb/96.6 kg
Fluid Balance (last updated ___ @ 600)
Last 8 hours Total cumulative 165ml
IN: Total 290ml, TF/Flush Amt 290ml
OUT: Total 125ml, Urine Amt 125ml
Last 24 hours Total cumulative 513ml
IN: Total 1338ml, TF/Flush Amt 1338ml
OUT: Total 825ml, Urine Amt 825ml
General/Neuro: NAD A/O x3 non-focal
Cardiac: Irregular
Lungs: (L)basilar crackles, few (R)basilar crackles, No resp
distress
Abd: NBS Soft ND NT peg site clean and dry
Extremities: trace edema
Wounds: Sternal: CDI no erythema or drainage Sternum stable
Pertinent Results:
LABS:
___ 02:06AM BLOOD WBC-5.5 RBC-2.75* Hgb-7.4* Hct-24.7*
MCV-90 MCH-26.9 MCHC-30.0* RDW-17.2* RDWSD-55.4* Plt ___
___ 02:06AM BLOOD Plt ___
___ 02:06AM BLOOD ___ PTT-33.0 ___
___ 02:06AM BLOOD Glucose-104* UreaN-40* Creat-1.3* Na-147
K-4.1 Cl-109* HCO3-25 AnGap-13
___ 01:55PM BLOOD Glucose-135* UreaN-41* Creat-1.2 Na-145
K-4.4 Cl-110* HCO3-24 AnGap-11
___ 03:22AM BLOOD Glucose-101* UreaN-43* Creat-1.2 Na-151*
K-4.6 Cl-115* HCO3-24 AnGap-12
___ 02:06AM BLOOD Calcium-7.7* Phos-3.7 Mg-2.2
___ 06:16AM BLOOD WBC-5.5 RBC-3.06* Hgb-8.1* Hct-26.8*
MCV-88 MCH-26.5 MCHC-30.2* RDW-17.7* RDWSD-56.0* Plt ___
___ 06:16AM BLOOD Glucose-127* UreaN-31* Creat-1.1 Na-147
K-4.5 Cl-107 HCO3-21* AnGap-19*
___ 06:16AM BLOOD Calcium-8.4 Phos-3.8 Mg-2.3
___ 1:02 pm SPUTUM Source: Endotracheal.
**FINAL REPORT ___
GRAM STAIN (Final ___:
>25 PMNs and <10 epithelial cells/100X field.
2+ ___ per 1000X FIELD): BUDDING YEAST WITH
PSEUDOHYPHAE.
2+ ___ per 1000X FIELD): MULTIPLE ORGANISMS
CONSISTENT WITH
OROPHARYNGEAL FLORA.
RESPIRATORY CULTURE (Final ___:
SPARSE GROWTH Commensal Respiratory Flora.
YEAST. SPARSE GROWTH.
PA/LAT CXR ___
No significant change in small left pleural effusion and
associated basilar atelectasis. Similar right basilar opacities
also possibly reflecting atelectasis, though worsened compared
to radiograph from ___.
___ ECHOCARDIOGRAPHY REPORT
___ at 2:34:32 ___
Normal Range
Left Atrium - Long Axis Dimension: *6.4 cm <= 4.0 cm
Left Atrium - Four Chamber Length: *6.4 cm <= 5.2 cm
Left Atrium - Volume: *96 ml < 40 ml
Left Atrium - LA Volume/BSA: *44 ml/m2 <= 34 ml/m2
Right Atrium - Four Chamber Length: *6.5 cm <= 5.0 cm
Left Ventricle - Septal Wall Thickness: 1.1 cm 0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness: 1.0 cm 0.6 - 1.1
cm
Left Ventricle - Diastolic Dimension: 5.3 cm <= 5.6 cm
Left Ventricle - Systolic Dimension: 4.6 cm
Left Ventricle - Fractional Shortening: *0.13 >= 0.29
Left Ventricle - Ejection Fraction: 35% >= 55%
Left Ventricle - Stroke Volume: 69 ml/beat
Left Ventricle - Cardiac Output: 6.11 L/min
Left Ventricle - Cardiac Index: 2.79 >= 2.0 L/min/M2
Left Ventricle - Septal Peak E': *0.07 m/s > 0.08 m/s
Left Ventricle - Ratio E/E': 13 < 13
Right Ventricle - Diastolic Diameter: *4.8 cm <= 4.0 cm
Aorta - Sinus Level: *4.8 cm <= 3.6 cm
Aorta - Arch: *3.7 cm <= 3.0 cm
Aortic Valve - Peak Velocity: 1.3 m/sec <= 2.0 m/sec
Aortic Valve - LVOT VTI: 12
Aortic Valve - LVOT diam: 2.7 cm
Mitral Valve - E Wave: 0.9 m/sec
Mitral Valve - E Wave deceleration time: 183 ms 140-250 ms
TR Gradient (+ RA = PASP): 18 mm Hg <= 25 mm Hg
Findings
This study was compared to the prior study of ___.
LEFT ATRIUM: Moderately increased LA volume index.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Moderately dilated RA.
LEFT VENTRICLE: Normal LV wall thickness. Normal LV cavity size.
Moderately depressed LVEF. TDI E/e' >13, suggesting PCWP>18mmHg.
No resting LVOT gradient.
RIGHT VENTRICLE: Normal RV free wall thickness. Mildly dilated
RV cavity. Moderate global RV free wall hypokinesis.
AORTA: Moderately dilated aorta at sinus level. Focal
calcifications in aortic root. Mildly dilated aortic arch. Focal
calcifications in aortic arch.
AORTIC VALVE: ?# aortic valve leaflets. Mildly thickened aortic
valve leaflets (3). No AS. No AS. Moderate (2+) AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild
mitral annular calcification. Mild thickening of mitral valve
chordae. Calcified tips of papillary muscles. No MS. ___ MR.
___ VALVE: Normal tricuspid valve leaflets with trivial
TR. Normal tricuspid valve supporting structures. No TS. Normal
PA systolic pressure.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet.
No PS. Physiologic PR. Normal main PA. No Doppler evidence for
PDA
PERICARDIUM: No pericardial effusion.
Conclusions
The left atrial volume index is moderately increased. The right
atrium is moderately dilated. Left ventricular wall thicknesses
are normal. The left ventricular cavity size is normal. Overall
left ventricular systolic function is moderately depressed (LVEF
= 35 %) secondary to inferior hypokinesis and posterior
akinesis. Tissue Doppler imaging suggests an increased left
ventricular filling pressure (PCWP>18mmHg). The right
ventricular free wall thickness is normal. The right ventricular
cavity is mildly dilated with at least moderate global free wall
hypokinesis. The aortic root is moderately dilated at the sinus
level. The aortic arch is mildly dilated. There are focal
calcifications in the aortic arch. The number of aortic valve
leaflets cannot be determined. The aortic valve leaflets (3) are
mildly thickened but aortic stenosis is not present. There is no
aortic valve stenosis. Moderate (2+) aortic regurgitation is
seen. The mitral valve leaflets are mildly thickened. Trivial
mitral regurgitation is seen. The estimated pulmonary artery
systolic pressure is normal. There is no pericardial effusion.
CT HEAD W/O CONTRAST
There is no evidence of infarction, hemorrhage, edema, or mass.
There is
prominence of the ventricles and sulci suggestive of
involutional changes. There are patchy periventricular and
subcortical hypodensities. This is a nonspecific finding and
most likely represents small vessel ischemic gliotic change in a
patient of this age.
There is no evidence of fracture. There is partial
opacification of the
anterior ethmoidal air cells and left frontal sinus, likely
related to
intubation in the presence of an nasoenteric tube. Vascular
calcification is evident. The visualized portion of the
paranasal sinuses, mastoid air cells, and middle ear cavitiesare
otherwise clear. The visualized portion of the orbits are
unremarkable.
IMPRESSION:
1. No evidence of acute intracranial process.
2. Age related involutional changes. Patchy periventricular and
subcortical hypodensities, likely small vessel ischemic gliotic
change.
Brief Hospital Course:
Mr. ___ was transferred to ___ ___ from rehab after his
feeding tube had become dislodged at rehab and he developed
respiratory distress with concern for aspiration. He had
multiple witnessed periods of apnea in the emergency department
and was electively intubated. He was started on empiric broad
spectrum antibiotics for health care associated pneumonia. His
sputum culture was negative and he was weaned off all
antibiotics by ___. He had a PEG placed on ___ without
difficulty. He had a CT scan of his head on ___ that was
negative for any acute infarct. He weaned from mechanical
ventilation and was extubated on ___. He had hypernatremia up to
a sodium of 151 and was given free water boluses with
normalization of his sodium. He remained extubated and was
transferred to the step down floor on ___. He had persistent
night time encephalopathy, gerontology service was consulted for
management. He was taken off Seroquel and started on trazodone
which improved his sleeping and delirium. He was ready for
discharge to rehab ___ at ___.
Medications on Admission:
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
2. Amiodarone 200 mg PO BID Duration: 4 Weeks
take 200mg BID for 2 weeks, then take 200mg daily for 2 weeks,
then stop
3. Bisacodyl 10 mg PR QHS:PRN constipation
4. Docusate Sodium 100 mg PO BID:PRN constipation
5. GuaiFENesin 10 mL PO Q6H:PRN cough/congestion
6. Heparin 5000 UNIT SC BID
evaluate after 5 days
7. Insulin SC
Sliding Scale
Fingerstick QACHS
Insulin SC Sliding Scale using REG Insulin
8. Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY
Duration: 30 Days
9. Metoprolol Tartrate 100 mg PO TID
10. QUEtiapine Fumarate 12.5 mg PO QHS:PRN agitation
11. Senna 8.6 mg PO BID:PRN Constipation - First Line
12. Aspirin 81 mg PO DAILY
13. Levothyroxine Sodium 25 mcg PO WED, THURS, FRI, SAT, SUN
14. Levothyroxine Sodium 50 mcg PO MON, TUES
15. Atorvastatin 20 mg PO QPM
16. HELD- amLODIPine 5 mg PO DAILY This medication was held. Do
not restart amLODIPine until talking with your cardiologist
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q4H:PRN Pain - Mild
2. Albuterol Inhaler 2 PUFF IH Q4H:PRN wheezing
3. Docusate Sodium (Liquid) 100 mg PO BID
4. Heparin 5000 UNIT SC TID
5. Lidocaine 5% Patch 1 PTCH TD QAM
6. Sarna Lotion 1 Appl TP QID:PRN itching
7. TraZODone 100 mg PO QHS
please give at 8 pm
RX *trazodone 100 mg 1 tablet(s) by mouth at bedtime Disp #*5
Tablet Refills:*0
8. Furosemide 20 mg PO DAILY
9. Amiodarone 200 mg PO DAILY s/p PVI
10. Aspirin 81 mg PO DAILY
11. Atorvastatin 20 mg PO QPM
12. Levothyroxine Sodium 25 mcg PO 5X/WEEK (___)
13. Levothyroxine Sodium 50 mcg PO 2X/WEEK (___)
14. Metoprolol Tartrate 75 mg PO TID
15. Polyethylene Glycol 17 g PO DAILY:PRN constipation
16. Tamsulosin 0.4 mg PO QHS
17. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Acute respiratory failure secondary to aspiration pneumonia
severe oropharyngeal dysphagia s/p PEG
aspiration pneumonia-treated
Acute encephalopathy multifactorial
Secondary Diagnosis
Hematuria when previously on anticoagulant
Coronary artery disease s/p coronary vascularization
Atrial fibrillation s/p MAZE ___
Chronic Systolic heart failure
Abdominal aortic aneurysm repair for 6.4 cm aneurysm
Bilateral common iliac aneurysms
Carotid disease
Hypothyroidism
Benign cyst in chest
AAA repair ___ at ___
Chest cyst removed ___ via R thoracotomy
Left knee surgery
Appendectomy, R paramedian
Tonsillectomy
Discharge Condition:
Alert and oriented x3, non-focal
Ambulating with assistance unsteady gait
Sternal pain managed with acetaminophen
Sternal Incision - healing well, no erythema or drainage
Abdomen- soft, NT, ND, normoactive bowel sounds, PEG site
healing well, no erythema or drainage
Edema - trace
Discharge Instructions:
Discharge Instructions:
Please shower daily -wash incisions gently with mild soap, no
baths or swimming, look at your incisions daily
Please - NO lotion, cream, powder or ointment to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics
Clearance to drive will be discussed at follow up appointment
with surgeon
No lifting more than 10 pounds for 10 weeks
Encourage full shoulder range of motion, unless otherwise
specified
**Please call cardiac surgery office with any questions or
concerns ___. Answering service will contact on call
person during off hours**
Followup Instructions:
___
|
19676805-DS-30
| 19,676,805 | 28,888,352 |
DS
| 30 |
2143-09-22 00:00:00
|
2143-09-22 20:59:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Aspirin / Morphine / Ambien
Attending: ___
Chief Complaint:
Diarrhea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is a ___ male with history of hyperlipidemia,
gastric cancer, CKD, CHF, PPM, adrenal insufficiency, DVT on
Eliquis, chronic abdominal pain who presents with 3 or 4 days of
general weakness and dizziness, and labored breathing per his
wife. He had pre-syncope when getting out of the car. He is also
had 2 days of nonbloody diarrhea. His symptoms began when he was
prescribed Valtrex for shingles. He developed light headedness
the next day. The diarrhea began 3 days after he was on it. The
valtrex was held but his diarrhea continued. + dry heaves.
Denies fevers. Denies chest pain, palpitations, headache, neck
pain or stiffness, rashes. He does not take diuretics daily but
did take a dose yesterday due to increased lower extremity
edema. He occasionally has dysuria, denies hematuria. Denies
blood in the stool or dark stools. Patient states his normal
blood pressure is in the ___ systolic. He has lost 6 lbs in 3
weeks.
He was treated for VRE UTI in ___. No sick contacts.
No foreign travel. No strange foods. No uncooked seafoods.
Upon arrival to the ED VS: 98.6, 105, 82/58, 28, 99% on RA
Lactate 4.8 -> 3.4
Cr = 2.7
BNP = 5041 decreased from recent value > 30K ___ years ago
Bicarb = 15
Trop < 0.01
He triggered for hypotension. he was given LR/hydrocortisone 100
mg/cefepime/vancomycin 1500 mg. Cardiology interrogated his ___
which was found to be functioning well.
ROS: Pertinent positives and negatives as noted in the HPI. All
other systems were reviewed and are negative.
Past Medical History:
Hypertension
Hyperlipidemia
Gout
sCHF (EF 35-40%)
moderate AI, mild MR, dilated aortic root to 4.3cm
gastric cancer s/p resection
appendiceal cancer s/p appendectomy, chemotherapy, radiation
ventral hernia s/p repair w/ mesh ___
B12 deficiency
chronic abdominal pain
Pancreatic enzyme deficiency
Chronic kidney disease
S/p hip fracture repair ___ at ___
R DVT on ___- he is currently on eliquis
Social History:
___
Family History:
Father with DM, CHF, MI
Physical Exam:
ADMISSIOH PHYSICAL EXAM
========================
78.1 kg (discharge weight) in ___
77.79 kg (171.49 lb)
VITALS: 98.1 PO 93 / 63 R Lying ___ RA
GENERAL: Alert, well appearing and in no apparent distress
EYES: Anicteric, pupils equally round
ENT: Ears and nose without visible erythema, masses, or trauma.
Moist Oropharynx without visible lesion, erythema or exudate
CV: Distant heart sounds, regular, no murmur, no S3, no S4. No
JVD. No HJR.
RESP: Lungs clear to auscultation with good air movement
bilaterally. Breathing is non-labored
GI: Abdomen soft, non-distended, non-tender to palpation. Bowel
sounds present. No HSM
GU: No suprapubic fullness or tenderness to palpation
MSK: Neck supple, moves all extremities, strength grossly full
and symmetric bilaterally in all limbs
RLE with increased calf diameter which is chronic since DVT.
2+ DPP b/l
SKIN: R upper chest with crusted vesicular lesions in a
dermatomal distribution
NEURO: Alert, oriented, face symmetric, gaze conjugate with
EOMI, speech fluent, moves all limbs, sensation to light touch
grossly intact throughout
PSYCH: pleasant, appropriate affect
DISCHARGE PHYSICAL EXAM:
========================
24 HR Data (last updated ___ @ 758)
Temp: 98.0 (Tm 98.4), BP: 100/67 (91-100/61-67), HR: 83 (66-84),
RR: 18, O2 sat: 97% (97-98), O2 delivery: Ra, Wt: 179.5 lb/81.42
kg
Wt: 77.8 -> 78.2 -> 79.8 -> 80.9 -> 81.1 kg -> 81.2 -> 81.4 kg
today
GEN: Sitting comfortably in bed in NAD
EYES: Anicteric, non-injected sclerae
ENT: MMM, grossly nl OP.
CV: RRR nl S1/S2 no g/r/m, ICD L chest wall, no clear JVD
CHEST: CTAB
GI: + BS, soft, NT, ND, no HSM
GU: No suprapubic fullness or tenderness to palpation
EXT: WWP, 2+ edema in RLE (chronic from DVT) and trace in LLE.
SKIN: Left chest wall with crusted lesions along T4 dermatome
wrapping around to the back, does not cross midline, no other
dermatomes with rashes noted
NEURO: AOx3, CN II-XII intact, ___ strength all extremities,
sensation grossly intact throughout, gait nl
PSYCH: pleasant, appropriate affect.
Pertinent Results:
ADMISSION:
==========
___ 01:15PM BLOOD WBC-16.3* RBC-3.70* Hgb-11.5* Hct-38.0*
MCV-103* MCH-31.1 MCHC-30.3* RDW-13.5 RDWSD-50.2* Plt ___
___ 01:15PM BLOOD Neuts-81.0* Lymphs-12.8* Monos-5.3
Eos-0.1* Baso-0.2 Im ___ AbsNeut-13.21* AbsLymp-2.09
AbsMono-0.87* AbsEos-0.01* AbsBaso-0.04
___ 01:15PM BLOOD ___ PTT-37.3* ___
___ 07:16AM BLOOD Fibrino-88*
___ 08:25AM BLOOD Fibrino-97*
___ 06:18AM BLOOD Fibrino-91*
___ 01:15PM BLOOD Glucose-121* UreaN-25* Creat-2.7* Na-143
K-3.9 Cl-111* HCO3-15* AnGap-17
___ 07:16AM BLOOD ALT-20 AST-23 LD(LDH)-225 CK(CPK)-45*
AlkPhos-121 TotBili-0.4
___ 01:15PM BLOOD cTropnT-<0.01 proBNP-5041*
___ 07:00PM BLOOD cTropnT-<0.01
___ 07:16AM BLOOD CK-MB-3 cTropnT-<0.01
___ 01:15PM BLOOD Calcium-8.4 Phos-3.9 Mg-1.6
___ 01:36PM BLOOD Lactate-4.8*
___ 07:10PM BLOOD Lactate-3.4*
___ 01:19PM BLOOD Lactate-4.5*
___ 07:16AM BLOOD Lactate-3.2*
___ 01:23PM BLOOD Lactate-3.0*
___ 09:58PM BLOOD Lactate-2.5*
___ 07:56AM BLOOD Lactate-2.3*
DISCHARGE:
==========
WBC 6.6, Hgb 9.5 (from 9.9), Plt 106
INR 1.7 (from 1.7)
Fibrinogen 96
Na 143, K 4.3, Cl 111, BUN 16, Cr 1.4 (from 1.4), HCO3 23, AG 9
Ca 7.6 (alb 1.9), Mg 1.8, Phos 2.4
LFTs WNL
Trop <0.01, CK-MB 3
Cortisol 7.8
Lact 4.8 -> 3 -> 2.5 -> 2.3
MICRO:
- CDI: negative
- Stool cultures: negative
- Noro: negative
- Flu: negative
- UCx: ___ CFUs (Enterococcus)
_________________________________________________________
ENTEROCOCCUS SP.
|
AMPICILLIN------------ <=2 S
LINEZOLID------------- 2 S
NITROFURANTOIN-------- <=16 S
TETRACYCLINE---------- =>16 R
VANCOMYCIN------------ =>32 R
- BCx: negative x 2
Tele (___): NSVT 8 beats on ___ at 11:24, NSVT 17 beats
with capture beat on ___ at 06:11, ~3 runs of regular SVT at
~130s last a few minutes each on ___ AM
IMAGING:
========
EKG (___):
ST at 108 bpm, LAD, PR 156, QRS 108, QTC 471, TWI V2 with TW
flattening V5-V6 (largely unchanged from ___
EKG (___):
NSR at 87 bpm, LAD with likely LAFB, PR 132, QRS 122, QTC 483,
no
ischemic changes (QTC dec from 495 on ___
TTE (___):
Severe regional LV systolic dysfunction most c/w multivessel CAD
(EF 20%). Mild to mod eccentric AI. Mild MR. ___ to prior.
EKG (___):
NSR at 80 bpm, LAD, PR 154, QRS 106, QTC 482, PVCs, TWI AVR,
V2-V3 (compared to ___, QTC longer and TWI V4 new)
CTAP (non-con) (___):
No evidence of acute process involving the abdomen or pelvis.
Brief Hospital Course:
___ hx chronic systolic CHF (EF 25% w/ mod AI, ICD for ppx), CKD
stage III, gastric cancer status post total gastrectomy
w/esophagojejunostomy ___, appendiceal carcinoma s/p chemoXRT
and R hemicolectomy ___ c/b radiation enteritis/colitis,
perforation, and enterocutaneous fistula requiring ileostomy and
subsequent reversal, pancreatic insufficiency, chronic abdominal
pain (on opiates), s/p CCY, adrenal insufficiency,
hypothyroidism, RLE DVT (on apixaban) admitted with diarrhea and
___, with course complicated by VT for which he received an
appropriate shock on ___ and SVT.
# Diarrhea:
# Chronic abdominal pain and nausea:
# Pancreatic insufficiency:
# Severe protein calorie malnutrition:
P/w ___ episodes of watery diarrhea per day with hypovolemia.
Unclear etiology, but suspect viral gastroenteritis given
spontaneous improvement (norovirus was negative). DDx includes
drug-induced (although new recent meds - valacylovir for
shingles
and apixaban - are not common culprits) and known pancreatic
insufficiency, for which he is on Creon. C.diff negative. Low
suspicion for radiation-induced enteritis this far out from
chemoXRT (in ___. Lactate was elevated as below, likely from
hypovolemia and improved with IVFs, with lower suspicion for
ischemic colitis or mesenteric ischemia in absence of worsening
abdominal pain (chronic abdominal pain for years of unclear
etiology was unchanged and abd exam was benign). CTAP this
admission showed no acute process, though limited by lack of
contrast in setting of ___. His diarrhea resolved
spontaneously, and he was having ___ formed BMs at the time of
discharge with his baseline minimal nausea and chronic abdominal
pain. Of note, patient was admitted in ___ with profound
diarrhea and hypovolemic shock, concerning for protein-losing
enteropathy for which he briefly required TPN. W/u that
admission
was unrevealing. He is currently followed by GI as outpatient
(Drs. ___ for ongoing w/u of chronic abdominal pain,
possible malabsorption, and malnutrition. Labs this admission
were concerning for ongoing malnutrition from likely GI source,
with albumin of 1.9. He will be discharged to ___ with Drs.
___ for further w/u; may need to consider supplemental
nutrition going forward. Home Creon was continued on discharge,
as was his home dilaudid (for which no additional prescriptions
were given; would attempt to taper dilaudid as outpatient if
possible). Would also avoid addition of QTC-prolonging
medications, including anti-emetics, going forward giving
QTC-prolonging effects of anti-arrhythmics (see below).
# Elevated lactate:
Lactate 4.8 on admission, likely secondary to hypovolemia from
diarrhea. Ultimately resolved with IVFs (~4L this admission) and
resolution of diarrhea. Low suspicion for bowel ischemia as
above
as abdominal pain was mild and chronic. CTAP without acute
pathology, though limited by lack of contrast in setting of CKD.
Asymptomatic bacteriuria, but low suspicion for sepsis and BCx
negative. No e/o cardiogenic shock, with TTE unchanged from
prior.
# Ventricular tachycardia:
# ICD shock:
# SVT:
Developed 1 min of MMVT on ___, for which ATP was unsuccessful
and he received a 41J shock. Rhythm converted to PMVT and then
self-converted prior to second shock. Unclear trigger, likely
electrolyte derangements from diarrhea, with low suspicion for
cardiac ischemia given negative biomarkers and non-ischemic EKG.
TTE was performed and was unchanged from prior, with severe
regional LV systolic dysfunction most c/w multivessel CAD (EF
20%). Seen by EP, who adjusted ICD ATP threshold and recommended
initiation of sotalol (started ___, dosed at 80mg daily given
CrCl ~52. Home metoprolol was initially held in the setting of
sotalol initiation. He continued to have short runs of
asymptomatic NSVT (including 17 beat run on the day of
discharge), as well as intermittent regular SVT. He was
evaluated
by EP on the day of discharge, who felt that he was safe for
discharge on sotalol 80mg daily with reinitiation of metoprolol
at half his home dose (Toprol 25mg daily in place of home
metoprolol tartrate 25mg BID). He will ___ with his PCP ___ ___
and with his cardiologist (Dr. ___ in ___ on ___
___ see NP ___. QTC should be rechecked at that appointment
and consideration should be given to increasing sotalolol to BID
dosing if CrCl>60. QTC 471 on ___. Magnesium supplementation
was prescribed on discharge.
# Macrocytic anemia:
# Thrombocytopenia:
# Low fibrinogen:
Appears to have chronic macrocytic anemia, thrombocytopenia, and
low fibrinogen levels going back to ___ be secondary to
chronic malabsorption vs marrow process. Hgb was 11.5 on
admission with plt 150, likely hemoconcentration. Hgb remained
stable in the ___ range with platelets in the low 100s during
his hospitalization, not far from his prior baseline. Fibrinogen
was in the ___ with no e/o DIC/hemolysis in the absence of
schistocytes on RBC smear and nl LDH. There was no e/o bleeding.
Hgb 9.5 and plt 106 on discharge. He will ___ with Drs. ___ for further w/u of possible GI causes for malabsorption.
In
addition, would recommend that he be referred for outpatient
hematology evaluation.
# Acute Renal Failure:
# Chronic Kidney Disease stage III:
Cr 2.7 on admission, likely pre-renal in setting of diarrhea.
Improved to 1.4 at discharge (b/l 1.2-1.7) with IVFs and
resolution of diarrhea.
# Chronic Systolic CHF:
EF ___ with moderate AI, unchanged on repeat TTE this
admission. Initially dehydrated in setting of diarrhea, for
which
PRN Lasix was held and fluids were given. Sotalol was initiated
and metoprolol adjusted as above. He appeared euvolemic at
discharge, with discharge weight of 179.5 lbs. Home lasix 40mg
daily PRN for weight gain was resumed on discharge. He will ___
with his outpatient cardiologist on ___ for CHF and VT. Would
consider initiation of ACE-in and spironolactone going forward
if
able to tolerate.
# Coagulopathy:
INR initially elevated to 2.8, out of proportion to apixaban
use.
Likely component of malnutrition and improved to 1.7 at
discharge
with vit K administration (residual elevation likely
attributable
to apixaban).
# Asymptomatic Bacteriuria:
# Urinary retention:
UCx on admission with VRE. Pt without urinary symptoms and low
suspicion for sepsis. Not treated. Home finasteride and
Tamsulosin continued without e/o urinary retention.
# Chronic Adrenal Insufficiency:
He is not on chronic maintenance steroids, but took low-dose
prednisone in the week prior to admission for shingles as
instructed by his outpatient endocrinologist. Rec'd 100 mg
hydrocortisone in ED in setting of diarrhea. AM cortisol WNL.
SBPs were at baseline in ___, with no evidence for adrenal
insufficiency. In the setting of VT this admission, however, he
received his outpatient protocol of prednisone 3mg x 1d, 2mg x
1d, and 1mg x 1d, completed ___. He will ___ with outpatient
endocrinology on ___.
# Shingles:
Developed shingles of L chest in the days prior to admission,
for
which PCP initiated valacyclovir, discontinued prior to
admission
for diarrhea (not a common side effect). Rash had crusted on
admission, and valacyclovir was not resumed.
# RLE DVT:
Continued home apixaban (no indication for renal dosing) RLE DVT
diagnosed ___. Duration deferred to outpatient providers.
# GERD: continued home PPI
# HLD: continued home statin.
# Hypothyroidism: continued home levothyroxine
** TRANSITIONAL **
[ ] repeat CBC and BMP at PCP ___ on ___
[ ] ___ anemia/thrombocytopenia/low fibrinogen; consider heme
referral
[ ] trend QTC on sotalol; avoid QTC-prolonging medications
[ ] ___ VT and SVT on sotalol and adjusted metoprolol; may
increase sotalol to BID dosing if CrCl >60 if HRs/QTC can
tolerate
[ ] trend weights; d/c weight 179.5 lbs, resumed home Lasix 40mg
daily PRN weight for weight gain
[ ] cardiology ___ for HFrEF; consider ACE-in and spironolactone
if able to tolerate
[ ] ___ with Drs. ___ for chronic abdominal pain/nausea
and malnutrition; may need to consider supplemental nutrition
[ ] taper dilaudid if able
- Code: Full, confirmed by admitting MD
- Dispo: home with services (___) on ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Metoprolol Tartrate 25 mg PO BID
2. Pantoprazole 40 mg PO Q24H
3. Finasteride 5 mg PO DAILY
4. Tamsulosin 0.4 mg PO QHS
5. Apixaban 5 mg PO BID
6. Simvastatin 10 mg PO QPM
7. Levothyroxine Sodium 25 mcg PO DAILY
8. Creon 12 2 CAP PO QIDWMHS
9. Vitamin D ___ UNIT PO DAILY
10. Ascorbic Acid ___ mg PO BID
11. Ferrous Sulfate 325 mg PO BID
12. Probiotic (B.breve-L.acid-L.rham-S.thermo;<br>L.
acidophilus-L. rhamnosus;<br>L.rhamn
A
-
___
-
___
40-Bifido 3-S.thermop;<br>Lactobacillus
acidophilus;<br>lactobacillus comb no.10;<br>lactobacillus
combination no.4;<br>lactobacillus combo no.11) 15 billion cell
oral DAILY
13. HYDROmorphone (Dilaudid) 2 mg PO Q4H:PRN Pain - Moderate
14. PredniSONE 3 mg PO DAILY PRN acute illness
15. Furosemide 40 mg PO DAILY PRN weight gain >2 lbs
Discharge Medications:
1. LOPERamide 2 mg PO TID:PRN Diarrhea
RX *loperamide [Anti-Diarrheal (loperamide)] 2 mg 1 capsule(s)
by mouth every 8 hours as needed Disp #*30 Capsule Refills:*0
2. Magnesium Oxide 400 mg PO DAILY
RX *magnesium oxide 400 mg 1 capsule(s) by mouth once a day Disp
#*30 Capsule Refills:*0
3. Metoprolol Succinate XL 25 mg PO DAILY
RX *metoprolol succinate [Toprol XL] 25 mg 1 tablet(s) by mouth
once a day Disp #*30 Tablet Refills:*0
4. Sotalol 80 mg PO DAILY
RX *sotalol 80 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
5. Apixaban 5 mg PO BID
6. Ascorbic Acid ___ mg PO BID
7. Creon 12 2 CAP PO QIDWMHS
8. Ferrous Sulfate 325 mg PO BID
9. Finasteride 5 mg PO DAILY
10. Furosemide 40 mg PO DAILY PRN weight gain >2 lbs
11. HYDROmorphone (Dilaudid) 2 mg PO Q4H:PRN Pain - Moderate
12. Levothyroxine Sodium 25 mcg PO DAILY
13. Pantoprazole 40 mg PO Q24H
14. PredniSONE 3 mg PO DAILY PRN acute illness
15. Probiotic (B.breve-L.acid-L.rham-S.thermo;<br>L.
acidophilus-L. rhamnosus;<br>L.rhamn
A
-
___
-
___
40-Bifido 3-S.thermop;<br>Lactobacillus
acidophilus;<br>lactobacillus comb no.10;<br>lactobacillus
combination no.4;<br>lactobacillus combo no.11) 15 billion cell
oral DAILY
16. Simvastatin 10 mg PO QPM
17. Tamsulosin 0.4 mg PO QHS
18. Vitamin D ___ UNIT PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Diarrhea
Ventricular tachycardia
Chronic systolic heart failure
Shingles
Anemia/thrombocytopenia
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 diarrhea of unclear cause, which resolved
spontaneously. While here, you were found to have ventricular
tachycardia, resulting in an ICD shock. You were seen by the EP
service and initiated on a new medication (sotalol) along with a
different formulation of your home metoprolol.
It will be important to follow up with your cardiology team for
your heart failure and this arrhythmia. In addition, you will
need to follow up with Drs. ___ for ongoing
investigation of your abdominal pain and likely malnutrition.
Your weight at discharge was 179.5 lbs. Please weigh yourself
daily and take your home Lasix 40mg for weight gain >2 lbs per
day or 5 lbs per week.
With best wishes,
___ Medicine
Followup Instructions:
___
|
19676805-DS-31
| 19,676,805 | 23,628,778 |
DS
| 31 |
2143-10-29 00:00:00
|
2143-10-30 06:06:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Aspirin / Morphine / Ambien
Attending: ___.
Chief Complaint:
Generalized weakness and dizziness
Major Surgical or Invasive Procedure:
___ Femoral line placement
___ Arterial line placement
___ PICC line insertion
History of Present Illness:
___ male with history of hyperlipidemia, gastric cancer
s/p Roux-en Y esophagojejunostomy and appendiceal carcinoma s/p
right hemocolectomy ___, CKD (1.2-1.7), Heart Failure with
Reduced Ejection fraction, concern for adrenal insufficiency,
DVT on Eliquis, chronic abdominal pain who presents with 1 month
of general weakness and dizziness with worsening dizziness over
the past week, unable to stand or walk over the past couple
days.
Mr. ___ notes that he has been feeling increasingly ill over
the past 2 days. He cannot cite a specific change in his health
but does note increasing fatigue over the past 2 days. He has
ongoing nausea, abdominal pain and dizziness. He does not recall
any melenic stools. He states that he is also been checking his
blood pressure at home which is been low, 80s-90s. He denies
sick contacts, recent travels. Has had ongoing rhinorrhea for
the past ___ weeks but no acute changes. His diarrhea has
actually been improved since that time. His abdominal pain is at
its baseline and he denies fevers at home.
Of note, he was admitted ___ in the setting of pre-syncope.
This was predated by diarrhea and hypovolemia with an elevated
lactate. His diarrhea resolved spontaneously. He was noted to be
malnourished, received IV resuscitation, pancreatic enzyme
supplementation and plan for GI follow up. He similarly had an
___ during his previous admission to 2.7 which improved to 1.4
(baseline 1.2-1.7) prior to discharge.
He was last seen by ___ Endocrinology in ___. He was
noted to have undergone several previous cortisol stimulation
tests that were not consistent with AI. He was previously on
steroids but weaned in the past year.
In the ED,
Initial Vitals: T97.9 HR74 BP66/55 100% RA
Exam:
Conversant, alrt, guaiac positive stool
Labs:
CBC: WBC 16.3 Hgb 9.0 Plt 239, Diff: 84% Neutrophils
LFTs: ALT26, AST 28 AP 116
Ca: 7.7
Chemistry: Na: 135, K 6.0 BUN 46, Sr Cr 2.6
Lactate 3.1
troponin <0.01
Imaging:
CXR: No acute cardiopulmonary process.
Consults: None
Interventions:
Hydrocortisone 100mg
LR 500cc
Zosyn
Pantoprazole 40mg
VS Prior to Transfer: HR 70 BP ___ RR 20 97% RA
Past Medical History:
Hypertension
Hyperlipidemia
Gout
sCHF (EF 35-40%)
moderate AI, mild MR, dilated aortic root to 4.3cm
gastric cancer s/p resection
appendiceal cancer s/p appendectomy, chemotherapy, radiation
ventral hernia s/p repair w/ mesh ___
B12 deficiency
chronic abdominal pain
Pancreatic enzyme deficiency
Chronic kidney disease
S/p hip fracture repair ___ at ___ DVT on ___- he is currently on eliquis
Social History:
___
Family History:
Father with DM, CHF, MI
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
VS: HR 70 BP ___ RR 20 97% RA
GEN: Sitting comfortably in bed in NAD
EYES: Anicteric, non-injected sclerae
ENT: MMM, grossly nl OP.
CV: RRR nl S1/S2 no g/r/m, ICD L chest wall, no clear JVD
CHEST: CTAB no w/r/r.
GI: + BS, soft, NT, ND, no HSM
GU: No suprapubic fullness or tenderness to palpation
EXT: WWP, minimal edema in lower extremities.
SKIN: no obvious lesions other than chelitis in corners of mouth
NEURO: AOx3, CN II-XII intact, ___ strength all extremities,
sensation grossly intact throughout, gait not tested
PSYCH: pleasant, appropriate affect.
DISCHARGE PHYSICAL EXAM:
========================
___ 1110 Temp: 98.0 PO BP: 100/64 HR: 87 RR: 18 O2 sat: 96%
O2 delivery: RA FSBG: 139
General: well appearing in no apparent distress
CV: RRR, S1/S2, no murmurs, gallops, or rubs
PULM: no wheezes, crackles or rhonchi, no increased work of
breathing
GI: abdomen soft, nondistended, nontender in all quadrants, no
rebound/guarding
EXTREMITIES: no cyanosis, clubbing. Arms symmetrically
edematous.
Pitting edema in bilateral lower extremities
NEURO: Alert, moving all 4 extremities with purpose
Pertinent Results:
ADMISSION LABS:
========================
___ 12:15PM WBC-16.3* RBC-2.86* HGB-9.0* HCT-29.1*
MCV-102* MCH-31.5 MCHC-30.9* RDW-15.8* RDWSD-54.5*
___ 12:15PM NEUTS-84.7* LYMPHS-10.0* MONOS-4.3* EOS-0.2*
BASOS-0.1 IM ___ AbsNeut-13.80* AbsLymp-1.63 AbsMono-0.70
AbsEos-0.04 AbsBaso-0.01
___ 12:15PM PLT COUNT-239
___ 12:15PM ___ PTT-28.7 ___
___ 12:15PM ALT(SGPT)-26 AST(SGOT)-28 ALK PHOS-116 TOT
BILI-0.5
___ 12:15PM LIPASE-5
___ 12:15PM cTropnT-<0.01
___ 12:15PM GLUCOSE-101* UREA N-46* CREAT-2.6*#
SODIUM-135 POTASSIUM-6.0* CHLORIDE-106 TOTAL CO2-18* ANION
GAP-11
___ 12:34PM LACTATE-3.1* K+-5.3
___ 05:38PM ___ PO2-33* PCO2-32* PH-7.38 TOTAL
CO2-20* BASE XS--5
___ 05:38PM O2 SAT-54
PERTINENT LABS:
===============
___ 11:00PM BLOOD WBC-9.2 RBC-3.01* Hgb-9.3* Hct-29.6*
MCV-98 MCH-30.9 MCHC-31.4* RDW-16.8* RDWSD-53.8* Plt ___
___ 10:45AM BLOOD WBC-8.3 RBC-2.98* Hgb-9.3* Hct-28.8*
MCV-97 MCH-31.2 MCHC-32.3 RDW-17.7* RDWSD-54.6* Plt ___
___ 02:10AM BLOOD WBC-10.1* RBC-2.34* Hgb-7.3* Hct-23.6*
MCV-101* MCH-31.2 MCHC-30.9* RDW-17.5* RDWSD-60.0* Plt ___
___ 03:57AM BLOOD WBC-9.9 RBC-1.92* Hgb-6.0* Hct-19.9*
MCV-104* MCH-31.3 MCHC-30.2* RDW-18.1* RDWSD-65.1* Plt Ct-97*
___ 03:20AM BLOOD WBC-10.6* RBC-2.55* Hgb-8.1* Hct-25.9*
MCV-102* MCH-31.8 MCHC-31.3* RDW-18.6* RDWSD-67.0* Plt Ct-95*
___ 09:57AM BLOOD Heparin-1.26*
___ 03:01PM BLOOD Heparin-0.37
___ 10:00PM BLOOD Heparin-0.35
___ 08:19PM BLOOD Glucose-165* UreaN-41* Creat-2.4* Na-136
K-6.0* Cl-108 HCO3-16* AnGap-12
___ 02:20AM BLOOD Glucose-159* UreaN-34* Creat-2.1* Na-140
K-4.8 Cl-108 HCO3-18* AnGap-14
___ 09:45AM BLOOD Glucose-169* UreaN-33* Creat-1.7* Na-140
K-4.1 Cl-113* HCO3-16* AnGap-11
___ 03:20AM BLOOD Glucose-90 UreaN-26* Creat-1.3* Na-141
K-3.8 Cl-112* HCO3-18* AnGap-11
___ 04:00AM BLOOD proBNP-2201*
___ 09:45AM BLOOD calTIBC-118* ___ Ferritn-483*
TRF-91*
___ 05:17PM BLOOD Prolact-10
___ 04:00AM BLOOD TSH-1.3
___ 08:22PM BLOOD Lactate-3.0* K-5.4
___ 04:04AM BLOOD Lactate-1.8 K-5.1
___ 09:58AM BLOOD Lactate-3.9*
___ 01:47PM BLOOD Lactate-4.5*
___ 11:48PM BLOOD Lactate-2.4*
___ 03:22PM BLOOD Lactate-2.3*
___ 10:55AM BLOOD freeCa-1.14
___ 05:38PM BLOOD O2 Sat-54
___ 12:15PM BLOOD O2 Sat-51
IMAGING/STUDIES:
================
CXR ___
No acute cardiopulmonary process.
CT A/P ___ Without Contrast
1. No retroperitoneal hematoma noted. There is no
intra-abdominal or pelvic free fluid or hemoperitoneum.
2. Numerous incidental findings as before include an elevated
left
hemidiaphragm, post cholecystectomy status, bilateral
nonobstructing renal
calculi and simple cortical renal cysts, extensive sigmoid
diverticulosis.
TTE ___
LVEF ___
Severely depressed left ventricular systolic function. Mild
right ventricular hypokinesis. Moderate aortic insufficiency.
Mild mitral regurgitation. Normal pulmonary pressure.
B/L ___ Ultrasound ___
Deep venous thrombosis of the proximal right superficial femoral
vein
extending to the popliteal vein.
UE Ultrasound ___
Limited evaluation of the area underlying the dressing at the
___ entry site. Otherwise, no evidence of deep vein thrombosis
in the left upper extremity.
UE Ultrasound ___
1. No evidence of deep vein thrombosis in the right upper
extremity.
2. Complex fluid collection in the right antecubital fossa
without definite connection to adjacent vasculature or blood
flow, which could represent a hematoma.
MRI Pituitary ___
1. Normal pituitary MR.
2. Medial deviation of the internal carotid arteries into the
sella turcica bilaterally, a normal variant.
3. Limited imaging of the remainder of the brain demonstrates
atrophy and
periventricular white matter hyperintensity suggesting chronic
small vessel ischemia.
Microbiology:
==============
___ 7:06 am URINE Source: ___.
**FINAL REPORT ___
URINE CULTURE (Final ___:
ENTEROCOCCUS SP.. >100,000 CFU/mL.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROCOCCUS SP.
|
AMPICILLIN------------ <=2 S
LINEZOLID------------- 2 S
NITROFURANTOIN-------- <=16 S
TETRACYCLINE---------- =>16 R
VANCOMYCIN------------ =>32 R
PERTINENT LABS
==============
___ 03:11PM BLOOD Fact II-71* ___ FacVIII-171 Fact
IX-71
___ 04:00AM BLOOD proBNP-2201*
___ 03:20AM BLOOD ___
___ 06:35AM BLOOD Triglyc-108
___ 04:00AM BLOOD TSH-1.3
___ 05:17PM BLOOD Prolact-10
___ 05:18AM BLOOD 25VitD-22*
DISCHARGE LABS
==============
___ 06:35AM BLOOD WBC-5.6 RBC-2.75* Hgb-8.5* Hct-28.4*
MCV-103* MCH-30.9 MCHC-29.9* RDW-17.9* RDWSD-67.9* Plt Ct-79*
___ 06:35AM BLOOD ___
___ 06:35AM BLOOD Glucose-108* UreaN-35* Creat-1.1 Na-144
K-4.1 Cl-111* HCO3-25 AnGap-8*
___ 06:35AM BLOOD Calcium-8.1* Phos-4.1 Mg-2.0
___ 06:35AM BLOOD Triglyc-108
Brief Hospital Course:
Mr. ___ is a ___ male with history of hyperlipidemia,
gastric cancer
s/p Roux-en Y esophagojejunostomy and appendiceal carcinoma s/p
right hemocolectomy ___, CKD (1.2-1.7), Heart Failure with
Reduced Ejection fraction ___, PPM, concern for adrenal
insufficiency (prior equivocal ___ stim tests, previously
managed on prednisone 3mg daily), DVT on Eliquis, and chronic
abdominal pain who
presented with 1 month of general weakness and dizziness with
ongoing shock of unclear etiology, suspected to be secondary to
nutritional deficits.
ACUTE ISSUES
===============
# Shock, undifferentiated:
# Adrenal insufficiency:
Patient presented with shock requiring pressor support although
the etiology was unclear. The etiology is likely multifactorial
and it is possible that he has some underlying autonomic
dysfunction (consider increased vagal tone in the setting of his
prior roux-en-y surgery), so he was started on midodrine and
uptitrated to 15mg TID. There was low suspicion for hemorrhagic
given no overt bleeding and not clinically consistent with
bleeding into an extremity although he had steadily dropping
Hgb. Endocrinology was following as there was suspicion for
adrenal insufficiency. He has had multiple stim test in the past
with inadequate response (none of the stim tests ever reached a
level of 18). He has also had an aldosterone stimulation test
as noted in the labs and it responded well indicating possible
secondary adrenal insufficiency. An MRI of the pituitary was
performed without evidence of adenoma. There was low suspicion
for sepsis (no sources identified). His pressor requirement
norepinephrine was discontinued on ___ with good MAP. Suspect
that his poor nutritional status may have been contributing to
his hypotension and orthostasis, given improvement with TPN
administration.
#Malnutrition:
Patient was quite malnourished with hypoalbuminemia and several
low vitamin/mineral deficiencies including low vitamin D,
vitamin A, zinc, copper, selenium. Niacin was low/normal and
Vitamin E was normal. This was likely secondary to altered GI
anatomy with esophagojejunostomy. A1AT was borderline, but not
felt to be consistent with a protein-losing enteropathy. He was
started on rifaximin for a 2-week course for presumed small
bowel intestinal overgrowth. He was started on TPN via ___ and
began repletion of his nutritional deficiencies.
#Urinary tract infection, catheter-related
Developed UTI following urinary catheter insertion for urinary
retention with symptoms of dysuria and + UA. He was started on
empiric ceftriaxone and then transitioned to augmentin when
urine culture returned as enterococcus (vancomycin resistant).
He should continue for a ___nd date ___.
#Macrocytic anemia
Baseline hemoglobin appears close to 10, stools remaining
reassuring and H/H was trended. B12 was normal. Fibrinogen has
been chronically low. No formal heme onc work up thus far.
Hematology was consulted in the ICU but given Plasmic score 3,
low likelihood of TTP, 4T score of 3, and would also consider
myelodysplasia although also clinically inconsistent with the
acute presentation of his worsening anemia. He is to follow up
with hematology as an outpatient for further evaluation of his
anemia. He received 3 u pRBCs throughout his admission.
Discharge Hgb: 8.5.
___ on CKD: Baseline 1.2-1.7, elevated to 2.6 on presentation,
slowly downtrending back to baseline. Likely pre-renal given
hypotension with some contribution from low blood pressures and
possible ATN. Discharge Cr: 1.1.
#Chronic Systolic CHF:
EF ___ with moderate AI, unchanged on repeat TTE this
admission. ICD in place for ppx. Pt with anasarca which was
thought to be primarily ___ hypoalbuminemia. He was started on
his home dose of diuretic 2 days prior to discharge but was held
on ___ I/s/o dysuria with his UTI. Please weight patient daily
and give furosemide if weight gain > 2 lbs. He was unable to
tolerate daily dosing of furosemide due to urinary irritation
and frequency. Consider restarting daily dosing when UTI
resolves.
#Thrombocytopenia
Platelet count consistently downtrended. DDx included
nutritional (copper/zinc deficiency) v a primary bone marrow
malfunction such as MDS. ___ evaluated pt throughout
hospitalization ruled out TTP/DIC. HIT score was low at 3. Final
assessment was most likely secondary to antibiotic exposure to
pip/tazo on presentation vs less likely nutritional given acute
decline in the hospital. He will follow up with hematology with
consideration of bone marrow biopsy. Discharge platelet count:
79.
# RLE DVT:
# Coagulopathy:
INR 1.7 on presentation likely in the setting of nutritional
deficiency and apixaban use. He was maintained on heparin drip,
and bridged to warfarin per hematology recs due to concern for
malabsorption and inability to determine if therapeutic. He was
continued on warfarin with goal
# History of VT: Noted during ___ admission, started on Sotalol
80mg daily. This was initially continued but then subsequently
held given his ___. As his kidney function improved. He
frequently has bursts of NSVT for which his pacer was required
to appropriately implement ATP. Ectopy improved but was not
eliminated after restarting metop and sotalol daily. Given his
fluctuating renal function, cardiology recommended stopping
sotalol and starting amiodarone 400 BID x 7 days then
transitioning to 200 mg daily. He will follow up with cardiology
as an outpatient.
CHRONIC ISSUES
===============
# Pancreatic Insufficiency:
# Protein Losing Enteropathy, Chronic Pancreatitis
# Chronic Abdominal Pain:
Follows with Dr. ___ ___ GI. Continued on Creon
24,000 units with meals 12,000 lipase with snacks. He was
continued on MVI daily and home hydromorphone. He was initiated
on TPN per above.
# GERD: Continued PPI as above
# HLD: Continued statin
# Hypothyroidism: Continued home levothyroxine
TRANSITIONAL ISSUES:
[] TPN management: Cycled x 24 hours from ___.
Planned to cycle 18 hours overnight on ___ (1800-1400), then if
well tolerated cycle to 12 hours. Recommendations for ___ are
included in the print out. Vitamin supplementation provided
with: 100mg thiamine, 1mg folic acid, 60mcg selenium and 10mg
zinc.
[] Amiodarone 400 mg BID loading dose started on ___ x 7
days (end date ___ will transition to amiodarone 200 mg
daily starting ___.
[] Continue augmentin 875 mg BID to complete 7 day course for
UTI (end date ___.
[] Recommend consolidating metoprolol tartrate 12.5 mg Q6H to
metoprolol succinate 50 mg daily if blood pressure tolerates.
[] Continue close monitoring of INR while on warfarin with goal
INR ___. His primary care office can continue his INR monitoring
once discharged. Please arrange a follow up appointment and
contact them re: warfarin management prior to discharge
(warfarin newly started on this admission). PCP: Dr. ___
___, phone ___, fax ___
[] Consider outpatient autonomics consult for orthostatic
hypotension.
[] Wean Midodrine as able.
[] Please weight patient daily and give furosemide if weight
gain > 2 lbs. He was unable to tolerate daily dosing of
furosemide due to urinary irritation and frequency. Consider
restarting daily dosing when UTI resolves.
[] Further evaluation in ___ clinic for adrenal
insufficiency, many of the desired tests of the pituitary axis
are altered in the acute setting and require follow up as an
outpatient.
[] Follow up needed: hematology (scheduled), endocrinology
(scheduled), GI (scheduled), cardiology (scheduled), primary
care (scheduled).
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Apixaban 5 mg PO BID
2. Ascorbic Acid ___ mg PO BID
3. Ferrous Sulfate 325 mg PO BID
4. Creon 12 2 CAP PO QIDWMHS
5. Finasteride 5 mg PO DAILY
6. HYDROmorphone (Dilaudid) 2 mg PO Q4H:PRN Pain - Moderate
7. Levothyroxine Sodium 25 mcg PO DAILY
8. Pantoprazole 40 mg PO Q24H
9. Simvastatin 10 mg PO QPM
10. Tamsulosin 0.4 mg PO QHS
11. Vitamin D ___ UNIT PO DAILY
12. Furosemide 40 mg PO DAILY PRN weight gain >2 lbs
13. PredniSONE 3 mg PO DAILY PRN acute illness
14. Probiotic (B.breve-L.acid-L.rham-S.thermo;<br>L.
acidophilus-L. rhamnosus;<br>L.rhamn
A
-
___
-
___
40-Bifido 3-S.thermop;<br>Lactobacillus
acidophilus;<br>lactobacillus comb no.10;<br>lactobacillus
combination no.4;<br>lactobacillus combo no.11) 15 billion cell
oral DAILY
15. LOPERamide 2 mg PO TID:PRN Diarrhea
16. Magnesium Oxide 400 mg PO DAILY
17. Metoprolol Succinate XL 25 mg PO DAILY
18. Sotalol 80 mg PO DAILY
Discharge Medications:
1. Amiodarone 400 mg PO BID Duration: 7 Days
End date: ___
2. Amiodarone 200 mg PO DAILY
Start date: ___
3. Amoxicillin-Clavulanic Acid ___ mg PO BID Duration: 11 Doses
End date: ___
4. BD ___ Syringe (syringe (disposable);<br>syringe with
needle) 3 mL 23 x 1 miscellaneous ONCE:PRN injection of
solu-cortef
5. Hydrocortisone 5 mg PO QPM
6. Hydrocortisone 10 mg PO QAM
7. Metoprolol Tartrate 12.5 mg PO Q6H
8. Midodrine 15 mg PO TID
9. rifAXIMin 550 mg PO/NG BID Duration: 13 Days
End date: ___
10. Sodium Chloride 0.9% Flush ___ mL IV DAILY and PRN, line
flush
11. Solu-CORTEF (hydrocorTISone Sod Succinate) 100 mg
intramuscular ONCE:PRN adrenal crisis
Use if feeling extremely ill. Seek emergency medical care after
use.
12. Vitamin A ___ UNIT PO DAILY Duration: 7 Days
13. ___ MD to order daily dose PO DAILY16
14. Pantoprazole 40 mg PO Q12H
15. Ascorbic Acid ___ mg PO BID
16. Creon 12 2 CAP PO QIDWMHS
17. Finasteride 5 mg PO DAILY
18. Furosemide 40 mg PO DAILY PRN weight gain >2 lbs
19. HYDROmorphone (Dilaudid) 2 mg PO Q4H:PRN Pain - Moderate
RX *hydromorphone 2 mg 1 tablet(s) by mouth Q4H:PRN Disp #*42
Tablet Refills:*0
20. Levothyroxine Sodium 25 mcg PO DAILY
21. LOPERamide 2 mg PO TID:PRN Diarrhea
22. Magnesium Oxide 400 mg PO DAILY
23. Probiotic (B.breve-L.acid-L.rham-S.thermo;<br>L.
acidophilus-L. rhamnosus;<br>L.rhamn
A
-
___
-
___
40-Bifido 3-S.thermop;<br>Lactobacillus
acidophilus;<br>lactobacillus comb no.10;<br>lactobacillus
combination no.4;<br>lactobacillus combo no.11) 15 billion cell
oral DAILY
24. Simvastatin 10 mg PO QPM
25. Tamsulosin 0.4 mg PO QHS
26. Vitamin D ___ UNIT PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSES
=================
Malnutrition secondary to Roux-en Y esophagojejunostomy and
appendiceal carcinoma s/p right hemocolectomy ___
Orthostatic hypotension
Anemia
Thrombocytopenia
Discharge Condition:
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Level of Consciousness: Alert and interactive.
Mental Status: Clear and coherent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure being involved in your care while you were
admitted at ___!
What happened while you were at the hospital?
-You were initially admitted to the intensive care unit for low
blood pressure.
-We gave you steroids to help keep your blood pressure in a safe
range.
-We noted that many of your body's vitamins and minerals were
low/deficient. We started TPN, which is nutrition through your
IV, to assist with you nutrition.
-We performed many tests to evaluate your low blood counts. The
most likely cause for your low blood counts was thought to be
nutritional, however we will have you follow up with a
hematologist to further explore this.
What should you do when you leave the hospital?
-Continue taking all of your medications as prescribed
-Keep your appointment with your gastroenterologist Dr. ___.
-Keep your appointment with endocrinology to further evaluate
the cause of your adrenal insufficiency.
-Keep your appointment with hematology to further investigate
your low blood counts.
-Weigh yourself every morning, call MD if weight goes up more
than 3 lbs.
Regarding your adrenal insufficiency, it is important for you to
remember these guidelines:
-Sick Day Rules - patient should take double steroid dose for
two days if they feel sick or have a cold. Furthermore should
triple dose for three days if very ill.
-Use the intramuscular injection of solu-cortef if you feel
extremely ill likely with symptoms of nausea and vomiting.
-Continue wearing your medical bracelet indicating that you have
adrenal insufficiency;
Sincerely,
Your ___ team
Followup Instructions:
___
|
19676837-DS-8
| 19,676,837 | 22,416,136 |
DS
| 8 |
2161-11-14 00:00:00
|
2161-11-14 21:26:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
pedestrian struck by car
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ year old maan who was
struck by a car traveling ___ MPH. The patient reportedly
rolled onto the hood, the car continued to drive for an
additional 20 feet and the patient fell off after the car
stopped. He had loss of consciousness for approximately 15
minutes. On arrival to the ED, he was noted to be confused. Per
SW notes, the patient is cognitively impaired at baseline.
Past Medical History:
Hypertension, hyperlipidemia, brain injury as child with
subsequent cognitive impairment, benign prostatic hypertrophy
Social History:
___
Family History:
Father had MI in his ___ s/p CABG, S/P TAVR, has atrial
fibrillation
Physical Exam:
ICU ADMISSION EXAM:
General: middle aged white man
VS - HR 71, BP 119/81, SaO2 98% on O2 2 Lpm via NC
HEENT: EOMI, no tenderness over face, no blood at nares or ears,
able to open and close jaw without issue, no notable
malocclusion, 8 cm ragged scalp laceration down to bone and a
clear defect
Neck: supple, no signs of injury or trauma
CV: regular rate and rhythm, Left subclavian linein place
Lungs: CTAB
Abdomen: soft, non-tender, not distended, no signs of trauma
GU: no Foley in place, no blood at the meatus
Ext: IO line in place in left leg, warm, dry, no deformities
Neuro: intact, following commands, no clear focal deficits
noted. Slight weakness on RLE relative to ___: multiple superficial abrasions of arms, shins, chest, face
DISCHARGE PHYSICAL EXAM:
GENERAL: well appearing man in NAD
VS: Tm98.5 BP 118-148/67-74 HR ___ RR 16 SaO2 98% on RA
Yesterday I/Os: ___
Tele - no events
NECK: Supple, no evidence of JVD though hard to appreciate due
to neck habitus
CARDIAC: Regular rate and rhythm. Normal S1, S2. No murmurs
LUNGS: Resp unlabored, no accessory muscle use. Breath sounds at
the posterior sides are clear.
ABDOMEN: Soft. Abd appears bloated, soft. No HSM or tenderness.
EXTREMITIES: Trace edema in feet bilaterally L>R, non pitting
Pertinent Results:
___ 07:12AM WBC-8.2 RBC-4.84 HGB-14.1 HCT-41.7 MCV-86
MCH-29.1 MCHC-33.8 RDW-12.2 RDWSD-38.0
___ 03:54PM Neuts-90.9* Lymphs-3.2* Monos-5.1 Eos-0.0*
Baso-0.2 Im ___ AbsNeut-8.49* AbsLymp-0.30* AbsMono-0.48
AbsEos-0.00* AbsBaso-0.02
___ 07:12AM ___ PTT-28.6 ___
___ 08:20AM URINE COLOR-Straw APPEAR-Clear SP ___
___ 08:20AM URINE BLOOD-MOD NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
___ 08:20AM URINE RBC-60* WBC-5 BACTERIA-FEW YEAST-NONE
EPI-<1
___ 03:54PM Glucose-172* UreaN-22* Creat-0.8 Na-139 K-3.1*
Cl-100 HCO3-25 AnGap-17
___ 03:54PM Calcium-9.1 Phos-3.6 Mg-1.5*
___ 07:12AM LIPASE-33
___ 07:12AM ___ 07:12AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 08:20AM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG oxycodn-NEG mthdone-NEG
___ 04:52PM cTropnT-0.10*
___ 08:47PM CK(CPK)-1009* CK-MB-17* cTropnT-0.16* MB
Indx-1.7
___ 02:47AM CK(CPK)-952* CK-MB-22* cTropnT-0.25* MB
Indx-2.3
___ 07:54AM CK(CPK)-861* CK-MB-19* cTropnT-0.28* MB
Indx-2.2
___ 04:15AM proBNP-3246*
___ 05:35AM TSH-1.9
___ 06:40AM WBC-6.2 RBC-3.58* HGB-10.2* HCT-31.5* PLT-226
___ 06:40AM PTT-41.0* INR-1.9*
___ 06:40AM Glucose-114* UreaN-16 Creat-0.6 Na-137 K-4.8
Cl-101 HCO3-24 AnGap-17
___ 06:40AM Calcium-9.4 Phos-3.7 Mg-2.3
ECG ___ 4:27:56 ___
Sinus rhythm with ventricular premature depolarizations. Diffuse
non-specific repolarization abnormalities. No previous tracing
available for comparison.
ECG ___ 4:08:32 ___
Atrial fibrillation with a rapid ventricular response (131 bpm).
Compared to the previous tracing of ___ atrial fibrillation
with a rapid ventricular response has appeared. There are
ischemic appearing T wave abnormalities represented by T wave
inversions in leads I, aVL and V3-V6, more prominent as compared
with the prior changes recorded in the anterolateral leads in
the context of rapid ventricular response. These findings are
consistent with active ischemia and/or infarction. Followup and
clinical correlation are suggested.
ECG ___ 5:03:30 AM
Atrial fibrillation with a rapid ventricular response (101 bpm).
Compared to the previous tracing of ___ the rate has slowed.
The ischemic appearing anterolateral T wave abnormalities
persist, though are less prominent in leads I and aVL and
parallel with slowing of the rate. Rule out myocardial
infarction, Followup and clinical correlation are suggested.
ECG ___ 8:39:36 AM
Sinus rhythm. Lateral limb and precordial T wave inversions.
Consider ischemia. Compared to the previous tracing of ___
then there was atrial fibrillation. Lateral limb and precordial
T wave inversions persist. Clinical correlation is suggested.
CXR ___ 6:57 AM
Lung volumes are low, with exaggeration of bronchovascular
markings. Scattered streaky opacities are consistent with
atelectasis, as seen on the concurrent chest CT. No focal
consolidation. Pleural surfaces are smooth, without effusion or
pneumothorax. Cardiomediastinal silhouette is likely within
normal limits, accounting for supine portable technique. Please
refer to the separate CT dictation for details on osseous
findings.
IMPRESSION: Low lung volumes resulting in patchy atelectasis. No
pneumothorax.
CT HEAD W/O CONTRAST ___ 7:20 AM
There is a 1 cm intraparenchymal hemorrhage in the right
parieto-occipital lobe (02:28), and 0.5 cm right frontal
intraparenchymal hemorrhage (02:29), consistent with contusions.
Hyperdensity in the right sylvian fissure (series 2, image 16)
likely represents a small subarachnoid hemorrhage. Layering
hemorrhage within the occipital horn of the right lateral
ventricle. No shift of midline structures.
No evidence of acute major vascular territory infarction. The
sulci, ventricles cisterns are prominent, but within expected
limits for the degree of patient's senescent related global
cerebral volume loss. Atherosclerotic calcification of the
dominant left vertebral artery and of the bilateral cavernous
internal carotid arteries are identified.
There is no evidence of fracture. Mild mucosal thickening of
the left maxillary, bilateral inferior frontal sinuses and
frontal ethmoidal recess is identified. Otherwise, the remainder
of the visualized paranasal sinuses are clear. The mastoid air
cells and middle ears are well pneumatized and clear. Soft
tissue density in the bilateral external auditory canals are
without erosion, likely representing cerumen.
Large scalp hematoma/laceration with subcutaneous emphysema
measuring approximately 1.7 cm in greatest thickness along the
right parietal vertex.
IMPRESSION:
1. Right-sided hemorrhagic contusions, 0.5 cm in the right
frontal lobe, and 1 cm in the frontoparietal lobe.
2. Small amount hemorrhage in the right lateral ventricle. Trace
subarachnoid hemorrhage in the right sylvian fissure.
3. Large scalp hematoma/laceration along the right vertex,
without evidence of underlying fracture.
CT C-SPINE W/O CONTRAST ___ 7:21 AM
Alignment of the cervical spine is unremarkable. There is no
evidence of acute cervical spine fracture. No prevertebral soft
tissue swelling. Large anterior osteophytes are noted between C4
through C7. No critical spinal canal or neuroforaminal stenosis.
Thyroid gland is not well visualized. Lung apices are clear.
CT ABD & PELVIS WITH CONTRAST ___ 7:21 AM
HEART AND VASCULATURE: The thoracic aorta is normal in caliber
without evidence of acute injury. The heart, pericardium, and
great vessels are within normal limits. Trace pericardial
effusion. Mild coronary artery calcification. There is kinking
of a left subclavian vascular sheath.
AXILLA, HILA, AND MEDIASTINUM: No axillary, mediastinal, or
hilar lymphadenopathy is present. No mediastinal mass or
hematoma. The distal esophagus is distended with fluid.
PLEURAL SPACES: No pleural effusion or pneumothorax.
LUNGS/AIRWAYS: Bibasilar atelectasis is noted. No laceration is
seen. The airways are patent to the level of the segmental
bronchi bilaterally.
BASE OF NECK: Visualized portions of the base of the neck show
no abnormality.
HEPATOBILIARY: The liver demonstrates homogenous attenuation
throughout. There is no evidence of concerning focal lesion or
laceration. Subcentimeter hypodensities in segments 2 and 6 are
too small to characterize, but likely reflect simple cysts.
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 lesion or laceration.
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 concerning focal
renal lesions or hydronephrosis. There are bilateral,
subcentimeter hypodensities in the kidneys, which are too small
to characterize, but likely reflect simple cysts. There is no
perinephric abnormality.
GASTROINTESTINAL: There is a small hiatal hernia. Small bowel
loops demonstrate normal caliber, wall thickness, and
enhancement throughout. Intramural fat in the ascending and
transverse colon could reflect chronic inflammation or be
visualized in the normal population. Otherwise, the colon and
rectum are within normal limits. The appendix is normal. There
is no evidence of mesenteric injury. There is no free fluid or
free air in the abdomen.
PELVIS: There is extraperitoneal fat stranding about the bladder
in the space of Retzius and lateral to the bladder along the
right side without evidence of active extravasation or definite
signs of extraperitoneal bladder rupture. This fat stranding is
likely due to the presence of adjacent pelvic ribs. The distal
ureters are unremarkable. There is no free fluid in the pelvis.
REPRODUCTIVE ORGANS: There is prostatic enlargement with the
superior margin of the prostate indenting the posterior bladder
wall.
LYMPH NODES: There is no retroperitoneal or mesenteric
lymphadenopathy. There is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm or
retroperitoneal hematoma. Mild atherosclerotic disease is noted.
BONES: There are possible, left fifth and bilateral sixth rib
fractures, however this may be due to motion artifact (3:60,
62). Right transverse process fracture at L1, bilateral
transverse process fractures from L2 to L5 vertebral body
levels, bilateral sacral fractures, and bilateral superior and
inferior pubic rami fractures are noted. Cortical irregularity
along the right iliac wing is consistent with a nondisplaced
fracture.
SOFT TISSUES: Incidental note is made of gynecomastia. Hematoma
and soft tissue stranding are seen adjacent to the pelvic
fractures without active extravasation.
IMPRESSION:
1. Fractures involving the right transverse process of L1,
bilateral transverse processes of L2 through L5, bilateral
sacrum, bilateral inferior and superior pubic rami, and right
iliac wing.
2. Possible fractures through the left fifth and bilateral sixth
ribs versus motion artifact. Recommend clinical correlation with
site of tenderness.
3. Extraperitoneal fat stranding about the bladder likely due to
adjacent pelvic fractures without definite signs of bladder
rupture or active contrast extravasation. If there is concern
clinically for extraperitoneal bladder rupture, consider
cystogram for further evaluation.
PELVIS (AP ONLY) PORT ___ 5:56 ___
Multiple fractures are better evaluated on earlier CT.
Vertical lucency at the superior left parasagittal sacrum
compatible with fracture is demonstrated. There is also a
fracture line at the superior aspect of the right sacral ala.
Minimally displaced right superior pubic ramus fracture.
Inferior pubic ramus fractures bilaterally are relatively
difficult to visualize. Minimal contour deformity at the
junction of the left acetabulum and superior pubic ramus
corresponds with known fracture also.
Contrast is present in the bladder air related to earlier CT
exam.
Mild bilateral hip joint degenerative changes are present.
MR ___ SPINE W/O CONTRAST ___ 9:35 ___
CERVICAL: The alignment of the cervical spine is maintained. The
vertebral body heights are maintained at all levels. The marrow
signal appears unremarkable without focal suspicious marrow
lesions. No evidence of ligamentous injury. The visualized
cervical spinal cord appears unremarkable. The posterior fossa
structures appear unremarkable.
The visualized prevertebral, paravertebral and paraspinal soft
tissues appear unremarkable.
At C2-C3, there is a central disc protrusion indenting the
ventral aspect of the cord and ligamentum flavum thickening
encroaching posteriorly resulting moderate spinal canal
stenosis. Bilateral neural foramen are patent.
At C3-C4, there is mild bulging of the disc and ligamentum
flavum thickening indenting the cord and flattening it.
Bilateral uncovertebral and facet arthropathy results in mild
left neural foramen narrowing. Right neural foramen is patent.
At C4-C5, there is bulging of the disc and thickening of the
ligamentum flavum indenting the ventral aspect of cord resulting
in severe spinal canal stenosis. Bilateral uncovertebral and
facet arthropathy results in mild bilateral neural foramen
narrowing.
At C5-C6, a central disc protrusion indents the ventral aspect
of cord resulting in moderate to severe spinal canal stenosis.
Bilateral uncovertebral and facet arthropathy results in
moderate right and mild left neural foramen narrowing.
At C6-C7, a left-sided disc protrusion indents the ventral
thecal sac and contacts the spinal cord. Bilateral neural
foramen and spinal canal are patent.
At C7-T1, there is central disc protrusion indenting the
ventral thecal sac. Bilateral neural foramen and spinal canal
are patent.
THORACIC: The alignment of the thoracic spine is maintained. The
vertebral body heights are maintained at all levels. No abnormal
marrow signal is seen. The visualized thoracic spinal cord
appears unremarkable without focal cord signal abnormality or
cord expansion.
There is loss of intervertebral disc signal at multiple levels
in keeping with disc desiccation.
There is atelectasis in bilateral lower lung zones with small
bilateral pleural effusions. The remaining visualized
prevertebral, paravertebral and paraspinal soft tissues appear
unremarkable.
There is right paracentral disc protrusion at T2-T3. The
neural foramen and spinal canal are patent at all levels.
LUMBAR SPINE: The previously known fractures involving the right
transverse process of L1, bilateral transverse processes of
L2-L5 and sacrum are better evaluated on the prior CT scan.
There is associated marrow edema involving the sacrum.
The vertebral body heights are maintained at all levels. The
alignment of the lumbar spine is maintained. No evidence of
ligamentous disruption. The the visualized lower spinal cord
appears unremarkable with the conus terminating at L2.
The visualized prevertebral, paravertebral and paraspinal soft
tissues appear unremarkable.
At T12-L1 to L3-L4, the neural foramen and spinal canal are
patent.
At L4-L5, there is loss of disc height and signal with diffuse
disc bulge, bilateral facet arthropathy resulting in moderate
left and mild right neural foraminal narrowing. The spinal canal
is patent.
At L5-S1, there is loss of disc height and signal with diffuse
disc bulge resulting in mild bilateral neural foramen narrowing.
The spinal canal is patent.
IMPRESSION:
1. No evidence of cord or ligamentous injury involving the
cervical, thoracic or lumbar spine.
2. Multiple fractures involving the transverse processes of the
lumbar vertebrae and sacrum is better evaluated on prior CT
scan.
3. Multilevel multifactorial degenerative disease of the
cervical spine, most severe at C4-C5 and C5-C6 with severe
spinal canal stenosis and mild-to-moderate neural foramen
narrowing as described above.
4. Unremarkable MRI of the thoracic spine.
5. Multilevel multifactorial degenerative disease of the lower
lumbar spine with moderate left and mild right neural foramen
narrowing at L4-L5 as described above.
CT CYSTOGRAM (PEL) W&W/O CONTRAST ___ 11:53 ___
GASTROINTESTINAL: The visualized colon and small bowel appear
normal. The appendix is normal.
PELVIS: The urinary bladder and distal ureters are unremarkable.
A small amount of the hematoma is noted in the pelvis.
REPRODUCTIVE ORGANS: The visualized reproductive organs 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. Mild
atherosclerotic disease is noted.
BONES: Numerous pelvic fractures are unchanged from prior.
SOFT TISSUES: The abdominal and pelvic wall is within normal
limits.
CT HEAD W/O CONTRAST ___ 9:05 AM
A 5-mm hyperdense intraparenchymal hemorrhage in the right
frontal lobe is unchanged (series 3, image 24). An 1.3 x 0.9-cm
acute intraparenchymal hemorrhage in the right
parietal-occipital lobe appears minimally larger even for
differences in angulation between exams, previously 1 x 0.8 cm
(series 3, image 37). Surrounding small amount of hypodensity
may reflect edema. Serpiginous, hyperdensity in the sylvian
fissure corresponding the subarachnoid hemorrhage is slightly
more prominent and may reflect redistribution of blood products
or interval small amount of hemorrhage (series 3, image 28, 23).
Small amount of intraventricular hemorrhage layering in the
right lateral ventricle occipital horn is overall unchanged
(series 3, image 24). Tiny focus of intraventricular hemorrhage
layering in the left lateral ventricle and occipital horn is
more conspicuous (series 3, image 22). No evidence of new
intraparenchymal focal hemorrhage. No shift of normally midline
structures. Bilateral, symmetric mild prominence of the
ventricles and sulci is nonspecific, and may suggest cortical
volume loss, unchanged. Bilateral vertebral artery and cavernous
internal carotid artery calcifications are moderate.
Right posterior scalp laceration and hematoma has markedly
decreased (Series 3, image 35). No evidence of fracture. The
visualized portion of the paranasal sinuses, mastoid air cells,
and middle ear cavities are essentially clear. The visualized
portion of the orbits are unremarkable.
IMPRESSION:
1. Minimal interval increase in the right parietal occipital
lobe intraparenchymal hemorrhage, now 1.3 x 0.9 cm, previously 1
x 0.8 cm. Redistribution of known right sylvian fissure
subarachnoid hemorrhage.
2. Overall similar 5-mm right frontal lobe intraparenchymal
hemorrhage and small/tiny intraventricular hemorrhage.
3. No new focal intraparenchymal hemorrhage.
4. Evolution of previously noted right posterior scalp hematoma
and laceration.
KNEE (AP, LAT & OBLIQUE) BILAT ___ 4:31 ___
AP and cross-table lateral views of both knees show but no
fracture or joint effusion. On the right, there appears to be
some soft tissue fullness in the infrapatellar region but no fat
fluid level. There is considerable lateral for medial
femorotibial joint space loss on the right with associated
marginal osteophytes at the adjoining lateral tibial plateau and
lateral femoral condyles on that side. Joint spaces are
preserved on the left. Note is made atherosclerotic
calcification in the tibial vessels on the left.
IMPRESSION:
1. Lateral femorotibial joint space narrowing in the right knee
2. Peripheral arterial vascular disease.
CTA HEAD W&W/O C & RECONS ___ 11:11 AM
Approximately 1 cm hemorrhage in the subcortical white matter
of the right precentral gyrus at the vertex and approximately
0.3 cm hemorrhage in the subcortical white matter of the
superior right frontal gyrus, both seen on image 2:29, appear
slightly smaller than on ___. Mild surrounding edema
persists. They are compatible with hemorrhagic contusions or
diffuse axonal injury.
Mild subarachnoid hemorrhage in the right sulci has decreased.
Mild hemorrhage in the occipital horns of the lateral ventricles
is stable in size with decreased density. Mild prominence of the
ventricles is stable and compatible with age-related parenchymal
volume loss.
There is no evidence for a calvarial fracture. There appears
to be a nondisplaced fracture of the anterior process of the
maxilla, image 3:203, similar to ___.
There is mild mucosal thickening in the inferior frontal
sinuses. There is minimal mucosal thickening along the anterior
walls of the sphenoid sinuses and along the floor of the left
maxillary sinus. Mastoid air cells and middle ear cavities are
well aerated. Soft tissue density in bilateral external auditory
canals suggest cerumen. The orbits are unremarkable.
There is common origin of the brachiocephalic and left common
carotid arteries, a normal variant. There is no evidence for
arterial dissection. Bilateral common carotid arteries are
widely patent. Right internal carotid artery is widely patent
without stenosis by NASCET criteria. There is mild calcified
plaque at the origin of the right external carotid artery. There
is mild calcified plaque in the proximal left internal carotid
artery without stenosis by NASCET criteria. Left vertebral
artery is dominant. V1 through V3 segments of bilateral
vertebral arteries are widely patent.
There is no evidence for arterial dissection or intracranial
aneurysm. There is mild calcified plaque in bilateral carotid
siphons and in the V4 segments of bilateral vertebral arteries
without flow-limiting stenosis. There is no evidence for
flow-limiting stenosis elsewhere in the intracranial
circulation. Left ___ is low-lying and extradural, a
normal variant. Nondominant right vertebral artery is
hypoplastic distal to right ___. Major dural venous
sinuses appear patent.
OTHER: Evaluation of the included upper lungs is limited by
respiratory motion artifact. The thyroid gland is grossly
unremarkable. There are degenerative changes in the cervical
spine, as seen on the recent cervical spine MRI.
IMPRESSION:
1. Two right superior frontal subcortical white matter
hemorrhages with mild surrounding edema at have decreased in
size, compatible with hemorrhagic contusions are diffuse axonal
injury. Mild right subarachnoid hemorrhage and minimal bilateral
intraventricular hemorrhage is also decreasing.
2. Nondisplaced fracture of the anterior process of the maxilla,
similar to ___.
3. CTA of the head and neck demonstrates no evidence for
arterial dissection or flow-limiting stenosis.
CHEST (PORTABLE AP) ___ 11:40 AM
Lung volumes are low with increased bibasilar atelectasis.
Moderate to severe cardiomegaly and at least moderate pulmonary
edema are unchanged. Pleural effusions are small, if any.
Interval removal of a left subclavian central venous catheter
introducer.
CHEST (PORTABLE AP) ___ 9:36 ___
In comparison with the the earlier study of this date, there
again is substantial enlargement of the cardiac silhouette with
moderate pulmonary edema and bilateral pleural effusions with
basilar atelectatic changes.
Echocardiogram ___
The left atrium is mildly dilated. The estimated right atrial
pressure is at least 15 mmHg. Left ventricular wall thicknesses
are normal. The left ventricular cavity size is normal. Overall
left ventricular systolic function is moderately depressed (LVEF
= 35%) secondary to extensive apical akinesis with focal apical
dyskinesis. No masses or thrombi are seen in the left ventricle.
Tissue Doppler imaging suggests a normal left ventricular
filling pressure (PCWP<12mmHg). The right ventricular free wall
thickness is normal. Right ventricular chamber size is normal
with focal hypokinesis of the apical free wall. The aortic arch
is mildly dilated. The number of aortic valve leaflets cannot be
determined. The aortic valve leaflets are mildly thickened (?#).
There is no aortic valve stenosis. Trace aortic regurgitation is
seen. The mitral valve leaflets are structurally normal. There
is mild pulmonary artery systolic hypertension. There is no
pericardial effusion.
IMPRESSION: anteroapical myocardial infarct vs Takotsubo
cardiomyopathy
CT HEAD W/O CONTRAST ___ 1:09 ___
Right parieto-occipital intraparenchymal hemorrhage measures
1.2 (AP) x 0.8 (TV) cm , stable from before. Subarachnoid
hemorrhage in the right parietal and left superior parietal
regions also appear similar to before. Small intraventricular
hemorrhage layers along the bilateral lateral ventricle
posterior horns. No new hemorrhage is identified. The ventricles
and sulci are unchanged in size and configuration.
Previously noted maxillary fracture is not included in current
examination. No definite fracture identified The visualized
portion of the paranasal sinuses, mastoid air cells, and middle
ear cavities are clear. The visualized portion of the orbits are
unremarkable.
IMPRESSION:
1. Stable right parietal occipital lobe intraparenchymal
hemorrhage.
2. Stable subarachnoid hemorrhage in the right parietal and left
superior parietal regions.
3. Stable intraventricular hemorrhage as described.
4. No evidence of new intracranial hemorrhage.
CT HEAD W/O CONTRAST ___ 3:37 AM
The known right parieto-occipital intraparenchymal hemorrhage
is unchanged in size, measuring 1.2 x 0.7 cm (2:28).
Subarachnoid hemorrhage in the right parietal and left superior
parietal regions are also similar to before. Again, a small
amount of layering intraventricular hemorrhage in the bilateral
occipital horns of the lateral ventricle is unchanged. No new
intracranial hemorrhage detected. The ventricles and sulci are
stable in size and configuration since the prior study.
No new osseous abnormality. The visualized portion of the
paranasal sinuses, mastoid air cells, and middle ear cavities
are clear. The visualized portion of the orbits are
unremarkable.
IMPRESSION:
1. Stable 1.2 x 0.7 cm right parieto-occipital intraparenchymal
hemorrhage since the prior study.
2. Stable small bilateral subarachnoid hemorrhages.
3. Stable intraventricular hemorrhage.
4. No new intracranial hemorrhage.
CHEST (PORTABLE AP) ___ 4:49 AM
Compared to prior chest radiographs ___ through ___.
New, large area of low relatively uniform opacification in the
right mid and lower hemi thorax is probably increasing large
right pleural effusion. It obscures the right lung. Left lower
lobe has grown progressively more consolidated, either collapsed
or pneumonia. Moderate cardiomegaly and pulmonary vascular
engorgement have increased reflecting volume overload and/or
cardiac decompensation. No pneumothorax.
CT ABDOMEN W/CONTRAST Study Date of ___ 5:36 ___
LOWER CHEST: There are small to moderate bilateral
nonhemorrhagic pleural effusions, which are new from ___. There is adjacent compressive atelectasis of the bilateral
lower lobes. The heart is normal in size. There is no
pericardial effusion. There is mild to moderate calcified
atherosclerosis of the coronary arteries. No diaphragmatic
defects are detected.
HEPATOBILIARY: The liver demonstrates homogenous attenuation
throughout. A 9 mm hypodensity in the right lobe of the liver is
too small to characterize on CT (series 2, image 25). An
additional 6 mm hypodensity in the left lobe is also too small
to characterize (02:23). 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. Subcentimeter hypodensities within the left
kidney are too small to characterize. No suspicious renal
lesions are identified. There is no evidence of hydronephrosis
in either kidney. 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. Note
is made of fat in the wall of the appendix, which is likely due
to prior inflammation. Submucosal fat involving the cecum is
better appreciated on the prior examination.
LYMPH NODES: There is no retroperitoneal or mesenteric
lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. Mild
atherosclerotic disease is noted.
BONES: Fractures involving the transverse process of L1 and
bilateral transverse process ease of L2 through L5 are stable.
SOFT TISSUES: The abdominal and pelvic wall is within normal
limits.
IMPRESSION:
1. Small to moderate bilateral nonhemorrhagic and layering
pleural effusions are new relative to prior study performed ___, associated with compressive atelectasis of the
bilateral lower lobes. Findings likely account for patient
symptomatology of intractable hiccups.
2. Please see CT torso performed ___ for full
description of fractures involving the right transverse process
of L1, bilateral transverse processes of L2 through L5, and
bilateral sacrum.
PELVIS (AP ONLY) ___ 6:17 ___
Right superior inferior pubic rami fractures with mild
displacement are again demonstrated. Nondisplaced left inferior
pubic ramus fracture is demonstrated. Known fracture at the
junction of the right acetabulum and superior pubic ramus is not
well seen. Mild bilateral hip joint degenerative change.
Contrast in the colon and bladder related to recent CT.
UNILAT LOWER EXT VEINS LEFT ___ 3:51 ___
No evidence of deep venous thrombosis in the left lower
extremity veins.
Brief Hospital Course:
Mr ___ is a ___ year old man with developmental delayed who
presented to ED via EMS as a pedestrian struck by car on ___.
He was found to have traumatic brain injury (right parietal and
occipital lobe intraparenchymal hemorrhage [IPH], right frontal
IPH, intraventricular hemorrhage), left 5 and 6 rib fractures,
right 6th rib fracture, right L1 transverse process fracture,
bilateral L2-5 transverse process fractures, bilateral sacral
fracture, bilateral inferior and superior pubic rami fracture
and a large stellate occiput stellate laceration with tissue
loss. On arrival, he was confused but protecting his airway and
cooperative. After his initial assessment and imaging, he was
admitted to the Trauma Surgery service and taken to the trauma
surgical intensive care unit (___) for further monitoring. He
was transferred to floor on hospital day 4 (___). On hospital
day 5, he triggered for atrial fibrillation with rapid
ventricular response. He did not respond to metoprolol pushes on
the floor and was subsequently transferred back to the TSICU
(___) for rate control. He was again transferred to the floor
when his rate was better controlled on ___. On ___, he was
transferred to the cardiology service for further management and
optimization of his new cardiac issues prior to discharge.
# Atrial Fibrillation: Patient developed atrial fibrillation
with rapid ventricular rate ___. He was initially
transferred to the ICU for esmolol gtt. He was successfully
transitioned to diltiazem 60 mg q6h with good rate control. At
some point (unknown when) he converted back to normal sinus
prior to ___ and remained in sinus with last episode of atrial
fibrillation ___. TSH was normal. He was also started on
heparin gtt with neurosurgery approval (given hemorrhagic
contusions). Patient's brain injuries seemed stable after
starting heparin as assessed by repeat CT head. Echocardiogram
showed normal left ventricular wall thickness and cavity size
but LVEF = 35% secondary to extensive apical akinesis with focal
apical dyskinesis consistent with anteroapical myocardial
infarct vs Takotsubo cardiomyopathy. There was no significant
valvular or pericardial disease seen. He was switched from
diltiazem (contraindicated in left ventricular systolic herat
failure) to metoprolol succinate 50 mg given new cardiomyopathy
with reduced EF. He was discharged on heparin gtt as bridge to
warfarin with last INR 1.9.
# New heart failure with Reduced EF: Patient noted to have
radiographic pulmonary edema on CXR of ___ (which may have
also been present on ___. Echocardiogram ___ after onset
of atrial fibrillation with rapid ventricular rate and in
setting of rising troponin-T (0.10 -> 0.28 with normal
creatinine) with elevated CK-MB but low MB index and high CK
revealed LVEF 35% secondary to extensive apical akinesis with
focal apical dyskinesis; estimated PCW <12 mm Hg. Given severe
physiologic and mental stressors recently, cardiac myonecrosis
and acute left ventricular systolic heart failure were felt more
likely due to Takotsubo stress induced cardiomyopathy (and
possible type 2 NSTEMI from rapid ventricular rate) rather than
type 1 infarction with plaque rupture and coronary thrombosis
(especially as LVEF reduction well out of proportion to the
troponin-T and peak MB of 22 with MB index <=2.3%). In any
event, patient was clearly not a candidate at this time for
aggressive systemic anticoagulation (required for CABG) or dual
anti-platelet therapy (required after coronary artery stenting),
so invasive risk stratification was deferred. If the patient has
Takotsubo's Syndrome, his LVEF would be expected to improve in a
few months; if this does not occur, coronary angiography should
be considered if the patient becomes a better candidate for CABG
or dual anti-platelet therapy. Given recent intracranial
bleeding, ASA was deferred while the patient was on heparin
bridging to warfarin, but atorvastatin was begun.
Despite the estimated normal PCW on TTE, patient appeared
volume up with elevated NT-Pro-BNP on transfer ___, as well as
bilateral ___ edema and CT findings of bilateral pleural
effusions. Patient given IV furosemide with good response.
Patient also started on appropriate HFrEF medications:
lisinopril 5 mg daily, metoprolol succinate 50 mg. The patient
appeared clinically euvolemic at time of discharge, so was not
on a diuretic (although a twice weekly oral outpatient regimen
might be reasonable). The family requested follow-up with a
heart failure specialist closer to their home and was referred
to Dr, ___ at ___ (___).
# Hiccups: Patient had severe hiccups that would last ___
hours out of the day since admission. Etiology was unclear, but
given onset after injury, may be due to phrenic nerve injury
from thoracic trauma, less likely from brain trauma. This
improved with decreased frequency with chlorpromazine 25 mg TID.
# left 5 and 6 rib fractures, right 6th rib fracture: Evaluated
by the trauma surgery team and managed non-operatively. He
received oral pain medications and frequent chest physical
therapy to encourage deep inspiration. Incentive spirometry was
also encouraged.
# Multiple transverse process fractures: He had no C-spine
injuries, thus his C-collar was removed. He remained on log-roll
precaution until he was evaluated by spine surgery. Spine
surgery was consulted for the various transverse process
fractures. He was ultimately deemed a non-operative candidate
and his activities were liberalized to activity as tolerated.
# Scalp hematoma and stellate laceration with tissue loss: He
was seen by plastic surgery who washed out and debrided the
scalp laceration. They were able to ultimately close the
laceration at bedside which he tolerated well.
# Right-sided hemorrhagic contusions, 0.5 cm in the right
frontal lobe, and 1 cm in the frontoparietal lobe: Mr. ___
was seen in the ED by neurosurgery for the hemorrhagic
contusions in the brain. He had no shift and evidence of
herniation thus no surgical intervention was indicated. He was
started on Keppra for seizure prevention for 7 days. He
underwent frequent neurological exams while in the TSICU, which
were liberalized on the floor. Repeat CT scan on hospital day
one demonstrated minimal increase in size of contusions. Once he
was started on heparin and became therapeutic, the CT head scans
were repeated which demonstrated no change or increase in
hemorrhagic areas. Plan is for repeat CT head once INR on
warfarin is therapeutic with close outpatient neurosurgery
monitoring.
# Pubic rami fractures and sacral fractures: He was evaluated by
orthopedic surgery for his fractures, which were deemed
manageable by nonoperative methods. They suggested conservative
management at first unless the patient continues to experience
pain. He was evaluated by physical therapy and has mobilized
early as tolerated.
# Altered mental status: He has baseline developmental delay
since childhood. He presented confused, alert and oriented to
person, but he cleared the next day. Since then, he has had
waxing and waning metal status, but has always been able to
protect his airway.
TRANSITIONAL ISSUES:
- Heparin drip should be continued until INR is >2.0 for 2
consecutive days.
- NEW Medications: lisinopril 5 mg daily, metoprolol succinate
50 mg daily, atorvastatin 80 mg daily, warfarin as needed for
INR goal ___
- Patient should continue to wear pneumoboots until ambulating
regularly to prevent blood clots, or until INR consistently
therapeutic.
- Will need cardiology follow up: Recommendation given to
patient for Dr. ___ at ___, ___.
- Will need outpatient repeat TTE in ___ weeks with further risk
stratification for CAD depending on whether or not the left
ventricular systolic function recovers
- ___ need coronary angiography if LVEF does not improve
(arguing against Takotsubo)- Can consider starting furosemide PO
20 mg twice per week if he begins to retain fluid.
- Patient discharged on chlorpromazine 25 mg PO/NG TID for
hiccups. This should be weaned at rehab based on severity of
symptoms.
- Neurosurgery: patient will need Neurosurgery evaluation if at
any time an additional anticoagulation or antithrombotic agent
is prescribed.
- Patient will need repeat head CT once INR is >2.0 for 2
consecutive days. Please fax results to Dr. ___
___: ___.
- Neurosurgery follow up with patient 4 weeks after discharge to
reassess head trauma and bleeding progress.
- Patient will need F/U with Ortho Trauma in ___ weeks from DC
with Dr. ___.
- Code status: FULL
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Finasteride 5 mg PO DAILY
2. Atorvastatin 10 mg PO QPM
Discharge Medications:
1. Atorvastatin 80 mg PO QPM
2. Acetaminophen 1000 mg PO Q8H:PRN pain, fever
3. ChlorproMAZINE 25 mg PO TID
4. Heparin IV Sliding Scale
Indication:
Continue existing infusion at 1350 units/hr
Therapeutic/Target PTT Range: 50-70 seconds
5. Lisinopril 5 mg PO DAILY
6. Metoprolol Succinate XL 50 mg PO DAILY
7. OxyCODONE (Immediate Release) 5 mg PO Q8H:PRN pain
8. Warfarin 7.5 mg PO DAILY16
9. Finasteride 5 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
-Motor vehicle accident
-Hemorrhagic brain contusions
-Transverse process fractures L2-L5
-Pelvic rami fractures
-Rib fractures (left ___ and ___, right ___
-Maxillary fracture
-Scalp laceration
-Atrial fibrillation with rapid ventricular rate
-Acute systolic left ventricular heart failure
-Radiographic pulmonary edema
-Type 2 non-ST segment elevation myocardial infarction
-Presumed ___ stress-induced cardiomyopathy
-Sustained hiccups secondary to diaphragmatic irritation versus
phrenic nerve injury
-Hypertension
-Hyperlipidemia
-Calcific peripheral arterial atherosclerosis
-Benign prostatic hypertrophy
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Mr. ___,
You were admitted to ___ after an accident where you were hit
by a car. You sustained multiple injuries including fractures to
your spine and pelvis. You were also found to have bleeding in
your brain from the accident. This bleeding has been monitored
with repeat head imaging and appears to be stable.
Several days after the accident, you developed an abnormal heart
beat called atrial fibrillation. The pumping function of your
heart was also noted to be decreased. We think that this is
likely due to the stress from the accident. You will need to be
on a new medication to prevent blood clots due to atrial
fibrillation. It is also important that you follow-up with a
cardiologist in ___ weeks to repeat an echo of your heart.
Please do not stop warfarin without speaking first to your
cardiologist, as this could increase your risk of blood clots
and stroke.
Please weigh yourself every day in the morning after you go to
the bathroom and before you get dressed. If your weight goes up
by more than 3 lbs in 1 day or more than 5 lbs in 3 days, please
call your heart doctor or your primary care doctor and alert
them to this change.
We wish you the best of health,
Your ___ Care Team
Followup Instructions:
___
|
19676873-DS-18
| 19,676,873 | 27,969,954 |
DS
| 18 |
2146-10-18 00:00:00
|
2146-10-21 16:47:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
embrel
Attending: ___.
Chief Complaint:
Abdominal pain with nausea and vomiting
Major Surgical or Invasive Procedure:
Hypogastric Artery Ruptured Aneurysm Repair
History of Present Illness:
___ is a ___ w/ hx of RA & Sjogren's on
prednisone, CKD, and ruptured AAA s/p open repair ___ c/b
bleeding requiring takeback and delayed closure who is
presenting
here to the ED w/ <1 day hx of abd pain and n/v/d. She was
hypotensive w/ sBP to ___ on scene. On evaluation here HR ___
and
sBP 110s, and her abd was diffusely ttp. A stat CTA torso was
obtained showing a ruptured R hypogastric aneurysm. Of note, she
recently had DVT and is on Coumadin, INR 3.1, received Kcentra
in
ED.
Past Medical History:
CKD Stage III: thought to be due to HTN
hypercholesterolemia
HTN
cervical spondylosis
Seropositive nonerosive rheumatoid arthritis
Sjogren's syndrome
Osteoarthritis of the hands with chronic pain on first CMCs
left more than right
Right index flexor tendonitis
Peripheral neuropathy
Social History:
___
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.
Physical Exam:
Admission Physical Exam:
VS - 97.8 57 113/64 18 100% RA
Gen - appears in mild to mod distress
CV - RRR
Pulm - non-labored breathing, no resp distress
Abd - soft, mild to mod distension, diffusely ttp w/ no guarding
or rebound
Discharge Physical Exam:
GEN: NAD, A&Ox3
HEENT: NC/AT
CV: RRR, No m/r/g
PULM: CTAB
ABD: Soft, mild pain upon palpation. No signs of surgical site
infection
Pertinent Results:
___ 11:43PM TYPE-ART TEMP-36.9 COMMENTS-GREEN TOP
___ 11:43PM LACTATE-0.7
___ 09:55PM WBC-5.9 RBC-2.21* HGB-6.3* HCT-19.8* MCV-90
MCH-28.5 MCHC-31.8* RDW-16.2* RDWSD-53.0*
___ 09:55PM PLT COUNT-151
___ 04:59PM WBC-6.7 RBC-2.35* HGB-6.8* HCT-21.1* MCV-90
MCH-28.9 MCHC-32.2 RDW-15.8* RDWSD-52.2*
___ 02:17PM WBC-9.1 RBC-2.42* HGB-7.1* HCT-21.9* MCV-91
MCH-29.3 MCHC-32.4 RDW-15.3 RDWSD-50.6*
___ 02:17PM WBC-9.1 RBC-2.42* HGB-7.1* HCT-21.9* MCV-91
MCH-29.3 MCHC-32.4 RDW-15.3 RDWSD-50.6*
___ 02:17PM PLT COUNT-168
___ 06:25AM BLOOD WBC-11.2* RBC-2.76* Hgb-8.0* Hct-25.7*
MCV-93 MCH-29.0 MCHC-31.1* RDW-16.0* RDWSD-54.6* Plt ___
___ 05:50AM BLOOD WBC-10.9* RBC-2.67* Hgb-7.9* Hct-25.0*
MCV-94 MCH-29.6 MCHC-31.6* RDW-16.6* RDWSD-56.3* Plt ___
___ 04:54PM BLOOD WBC-10.2* RBC-2.65* Hgb-7.9* Hct-24.6*
MCV-93 MCH-29.8 MCHC-32.1 RDW-16.2* RDWSD-54.7* Plt ___
___ 06:15AM BLOOD WBC-8.6 RBC-2.27* Hgb-6.7* Hct-21.2*
MCV-93 MCH-29.5 MCHC-31.6* RDW-16.2* RDWSD-54.8* Plt ___
___ 06:25AM BLOOD ___ PTT-35.6 ___
___ 05:50AM BLOOD Plt ___
___ 06:25AM BLOOD Glucose-74 UreaN-47* Creat-2.4* Na-137
K-5.8* Cl-106 HCO3-18* AnGap-13
Brief Hospital Course:
This is a ___ woman with history of RA & Sjogren's on
prednisone, CKD, and ruptured AAA s/p open repair ___ c/b
bleeding requiring takeback and delayed closure who presented to
___
with a ruptured hypogastric artery aneurysm. Patient was
admitted for repair of this aneurysm
For the details of the procedure, please see the surgeon's
operative note. She received ___ antibiotics. He was
admitted to the ___ on
___ post-operatively. The patient tolerated the procedure
well without complications and was brought to the
post-anesthesia care unit in stable condition. After a brief
stay, the patient was transferred to the vascular surgery floor
where she remained through the rest of the
hospitalization.
Post-operatively, she did well. She was able to tolerate a
regular
diet, get out of bed and ambulate without assistance,
void without issues, and pain was controlled on oral medications
alone. She was seen by physical therapy and they determined it
would be best for her to return home as opposed to a rehab
facility. She was deemed ready
for discharge, and was given the appropriate discharge and
follow-up instructions. She will follow up with Dr. ___
staple removal.
Medications on Admission:
B COMPLEX WITH ___ ACID [NEPHROCAPS] - Nephrocaps 1 mg
capsule. 1 capsule(s) by mouth q day - (Prescribed by Other
Provider: during ___ hospitalization)
GABAPENTIN - gabapentin 100 mg capsule. 2 capsule(s) by mouth at
bedtime - (Prescribed by Other Provider: during ___
hospitalization) (Not Taking as Prescribed: taking 200mg bid)
HYDROXYCHLOROQUINE - hydroxychloroquine 200 mg tablet. 1.5
tablet(s) by mouth daily
METOPROLOL SUCCINATE - metoprolol succinate ER 100 mg
tablet,extended release 24 hr. 1 tablet(s) by mouth daily -
(Prescribed by Other Provider: increased during ___
hospitalization)
OMEPRAZOLE - omeprazole 20 mg capsule,delayed release. 1
capsule(s) by mouth q day - (Dose adjustment - no new Rx)
PILOCARPINE HCL - pilocarpine 5 mg tablet. 1 tablet(s) by mouth
twice a day - (Dose adjustment - no new Rx)
PRAVASTATIN - pravastatin 80 mg tablet. 1 (One) tablet(s) by
mouth qpm - (Dose adjustment - no new Rx)
PREDNISONE - prednisone 5 mg tablet. 3 tablet(s) by mouth once a
day for 5 days then 2 tabs x 5 days, then 1 tab x 5 days, then
STOP.
TOCILIZUMAB [ACTEMRA] - Actemra 80 mg/4 mL (20 mg/mL)
intravenous
solution. 320 mg IV monthly - (Dose adjustment - no new Rx)
WARFARIN - warfarin 1 mg tablet. 2 tablet(s) by mouth qpm as
directed by ___ clinic for INR ___ - (Prescribed by Other
Provider: during ___ hospitalization)
Discharge Medications:
1. Docusate Sodium 100 mg PO BID
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice
a day Disp #*20 Capsule Refills:*0
2. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN pain
RX *oxycodone 5 mg ___ tablet(s) by mouth q4-6 hours Disp #*30
Tablet Refills:*0
3. PredniSONE 5 mg PO DAILY Duration: 5 Days
RX *prednisone 5 mg 1 tablet(s) by mouth daily Disp #*5 Tablet
Refills:*0
4. Warfarin 3 mg PO DAILY16 Duration: 1 Dose
Please follow up with primary care physician on ___ regarding
this dose.
RX *warfarin [Coumadin] 1 mg 3 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*0
5. Aspirin 81 mg PO DAILY
6. Gabapentin 200 mg PO TID
7. Hydroxychloroquine Sulfate 300 mg PO DAILY
8. Metoprolol Succinate XL 100 mg PO DAILY
9. Omeprazole 20 mg PO DAILY
10. Pravastatin 80 mg PO QPM
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
S/p repair of hypogastric artery aneurysm repair
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
WHAT TO EXPECT:
1. It is normal to feel weak and tired, this will last for ___
weeks
You should get up out of bed every day and gradually increase
your activity each day
You may walk and you may go up and down stairs
Increase your activities as you can tolerate- do not do too
much right away!
It is normal to have a decreased appetite, your appetite will
return with time
You will probably lose your taste for food and lose some
weight
Eat small frequent meals
It is important to eat nutritious food options (high fiber,
lean meats, vegetables/fruits, low fat, low cholesterol) to
maintain your strength and assist in wound healing
To avoid constipation: eat a high fiber diet and use stool
softener while taking pain medication
Take all the medications you were taking before surgery,
unless otherwise directed
Take one full strength (325mg) enteric coated aspirin daily,
unless otherwise directed
ACTIVITIES:
No driving until post-op visit and you are no longer taking
pain medications
You should get up every day, get dressed and walk, gradually
increasing your activity
You may up and down stairs, go outside and/or ride in a car
Increase your activities as you can tolerate- do not do too
much right away!
No heavy lifting, pushing or pulling (greater than 5 pounds)
until your post op visit
You may shower (let the soapy water run over incision, rinse
and pat dry)
Your incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing
over the area
CALL THE OFFICE FOR : ___
Redness that extends away from your incision
A sudden increase in pain that is not controlled with pain
medication
Temperature greater than 101.5F for 24 hours
Bleeding from incision
New or increased drainage from incision or white, yellow or
green drainage from incisions
Followup Instructions:
___
|
19677105-DS-21
| 19,677,105 | 22,598,237 |
DS
| 21 |
2178-04-29 00:00:00
|
2178-06-13 17:01:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Plavix
Attending: ___.
Chief Complaint:
cc: abdominal pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ year old woman with HTN who presented with abdominal pain.
She has had low level RLQ abdominal pain since ___ which
worsened significantly last night, so she presented to the ED.
She denies any fevers or chills. No nausea or vomiting. She did
have two bowel movements this morning one of which was watery.
No blood in stool. She has been eating and drinking since pain
started, last meal was last night. She currently feels hungry.
In the ED, she was afebrile with leukocytosis to 13k. CT of
abdomen showed divericulitis in the ascending colon. She
received cipro/flagyl and was admitted for further care.
Of note, pt was seen in clinic earlier this year (___) where
she was believed to have had diverticulitis though she refused
to get CT to confirm. She improved without antibiotics. Her last
colonoscopy was in ___ where 2 adenomatous polypse were
removed. She is scheduled for ___ year follow ___ in ___.
ROS: negative except as above
Past Medical History:
htn
osteoporosis
oa
s/p ORIF of L femoral neck fracture
Social History:
___
Family History:
no family history of GI malignancy
Physical Exam:
Vitals: 98.9 134/75 74 16 97%RA
Pain: ___
Gen: comfortable, lying in bed
HEENT: moist mm, clear OP
CV: rrr, no r/m/g, though distant heart sounds
Pulm: clear bilaterally
Abd: soft, tenderness throughout most pronounced in RLQ, no
rebound
Ext: no edema
Neuro: alert and oriented x 3, no deficits
Pertinent Results:
___ 08:50AM WBC-13.1* RBC-4.55 HGB-14.4 HCT-43.7 MCV-96
MCH-31.7 MCHC-33.0 RDW-13.9
___ 08:50AM PLT COUNT-164
___ 08:50AM GLUCOSE-112* UREA N-15 CREAT-0.9 SODIUM-140
POTASSIUM-4.2 CHLORIDE-100 TOTAL CO2-32 ANION GAP-12
___ 08:50AM ALT(SGPT)-20 AST(SGOT)-18 ALK PHOS-57 TOT
BILI-0.5
___ 08:50AM LIPASE-56
___ 08:50AM ALBUMIN-4.1
___ 08:50AM ___ PTT-28.5 ___
Urine Studies:
___ 08:35AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-SM
___ 08:35AM URINE RBC-1 WBC-6* BACTERIA-FEW YEAST-NONE
EPI-4
CT Abdomen/Pelvis:
Extensive inflammatory change and some wall thickening along the
ascending colon with diverticula consistent with severe
diverticulitis. No fluid collection or free air. Follow-up
colonoscopy recommended.
Brief Hospital Course:
Assessment/Plan:
___ year old woman with HTN who presented with acute
uncomplicated diverticulitis.
1. Diverticulitis - she was treated with cipro and flagyl on
presentation. She was initially started on clears. Her abdominal
pain resolved on the second day and she tolerated a regular
diet. She was educated on a low residue high fiber diet to
prevent future episodes. Her antibiotics will continue for a
total of 10 days. She has a colonoscopy already scheduled for 5
weeks following discharge which she should keep.
2. Hypertension - she was kept on her lisinopril at her home
dose
3. Chronic lower extremity edema, her lasix was held initially
and resumed at discharge
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen w/Codeine 1 TAB PO BID:PRN severe pain
2. Estrogens Conjugated 0.625 mg VG WEEKLY
3. Estrace (estradiol) 0.01 % (0.1 mg/gram) vaginal weekly
4. Furosemide 20 mg PO DAILY
5. Hydrochlorothiazide 25 mg PO DAILY
6. Lisinopril 20 mg PO DAILY
7. Aspirin 81 mg PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
___:
diverticulitis
Discharge Condition:
alert and oriented x3
ambulatory
Discharge Instructions:
Dear Ms ___,
It was a pleasure caring for you at ___. You were admitted due
to abdominal pain from diverticulitis. Diverticulitis is
inflammation of part of the colon that happens when small
outpuchings called "diverticula" become occluded and become
inflamed. You have beens started on antiboitics to treat this.
You feel better and are ready for dishcarge. You will need to
complete 10 days total of antibiotics and you will have 8 more
days left to complete at home. Please follow up in clinic as
scheduled to make sure you continue to feel well. We have
started you on a bowel regimen to make sure that you are not
consitpated. This will help prevent these "diverticula" from
forming. In addition, please follow the low residue diet which
we have given you instructions on. Finally, please go to your
scheduled colonoscopy in ___.
If you you have any questions please do not hesitate to reach me
at ___.
Best,
___, MD
Followup Instructions:
___
|
19677105-DS-22
| 19,677,105 | 23,793,213 |
DS
| 22 |
2179-02-15 00:00:00
|
2179-02-16 12:28:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Plavix
Attending: ___
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
Cardiac catheterization ___
History of Present Illness:
Ms. ___ is an ___ year old woman with a history of HTN,
TIA, ?mixed cardiomyopathy, and diverticulitis who presented
with two days of dyspnea, orthopnea and PND.
Of note, she was hospitalized at ___ in ___
with shortness of breath and was found to have myopericarditis
complicated by a pericardial effusion. She apparently had
positive ___ viral titers. She underwent two pericardial
window procedures by Dr. ___, the first on ___
after she was initially admitted and the second on ___ when
she was readmitted with recurrent pleuritic chest pain and
shortness of breath. TTE after the second pericardial window
procedure showed low-normal LV systolic function (LVEF 50%) and
no residual pericardial fluid. ___ was negative.
On ___, she was seen by Dr. ___ in clinic, at which time she
underwent TTE demonstrating improved biventricular systolic
function (LVEF >55%) with minimal AS, trace AR, normal PASP, and
a moderate-sized loculated pericardial effusion adjacent to the
lateral and posterior aspects of the heart. Of note, no
pericardial effusion was noted on the previous TTE here on
___.
Of note, she endorsed left sided chest pain for most of the day
>12 hours ago. She cannot tolerate laying supine. She denies
fever, chills, abdominal pain, nausea, vomiting, diarrhea,
cough, dysuria.
Daughter endorses that prior to her recent illness, ate soup and
bouillon cubes daily, though has stopped now - only eating low
sodium soup.
In the ED, initial vitals were T97.3 P80 BP 161/98 R 28 SaO2
99%/RA
On cardiology fellow's exam in ED, she appeared visibly
tachypneic, sitting upright with crackles bilaterally.
- Labs notable for Cr up to 1.6 from baseline 0.9. BNP 2200.
D-dimer 4700. Mild anemia. Lactate 1.4.
- ECG with ST 125 with low precordial and limb lead voltage,
<1mm STD inferolateral leads.
- Bedside TTE difficult given poor echo windows with habitus and
inability to reposition, but limited views at the mid-papillary
level suggest moderate pericardial effusion primarily
posteriorly and laterally without clear e/o tamponade.
- She was given: Aspirin 324 mg, IV Furosemide 40 mg, PO
Pantoprazole 40 mg, PO Colchicine 0.6 mg, PO Metoprolol
Succinate XL 25 mg
- She underwent a LLE ___: No evidence of deep vein thrombosis
in the left lower extremity veins.
- CXR demonstrated 1. Moderate cardiomegaly, not significantly
changed. 2. Small bilateral pleural effusions. 3. No definite
evidence of pneumonia. No pneumothorax.
On review of systems, s/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. 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.
Cardiac review of systems is notable for absence of chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
ankle edema, palpitations, syncope or presyncope.
Past Medical History:
1. CARDIAC RISK FACTORS:
- Hypertension
- Cardiomyopathy (mixed)
2. CARDIAC HISTORY:
- PUMP FUNCTION: EF >55%
3. OTHER PAST MEDICAL HISTORY: TIA, osteoporosis, obesity,
diverticulitis and left femoral fracture s/p repair
Social History:
___
Family History:
There is no family history of early or sudden cardiac death or
known arrhythmias.
Physical Exam:
ADMISSION PHYSICAL EXAMINATION:
Vitals: 98.9 156/83 94 22 97% RA
Admission Weight: 95 kg
General: sitting at 90 in bed, appears dyspneic, speaking in
broken ___
HEENT: sclerae anicteric, EOMI, NC/AT
Neck: large habitus, prominent JVP at the clavicle while sitting
90 degrees, Kussmaul sign negative
Chest: scars from pericardial windows well healed (below left
breast, and substernal)
CV: soft heart sounds, normal s1/S2, S3 appreciated
Lungs: diffuse end-expiratory wheezing, unable to appreciate
crackles
Abdomen: obese, soft, non-tender, non-distended, normal bowel
sounds
Extr: LLE in compression stocking - difficult to assess for
edema, though estimate 1+, RLE without edema, DP pulses 2+, feet
cool though well perfused
Discharge Physical Exam:
- Vitals: 97.6 106-147/61-64 68-70 18 97%RA
- Weight: 93.6 kg <- 93.3 kg <- 93.9 kg <- 93.4 <- 93.0 <- 92.5
<- 94.4 <- 95
- I/O: ___, ___
- General: sitting in chair at bedside, reclined, breathing
comfortably, speech unlabored
- HEENT: sclerae anicteric, EOMI, NC/AT
- Neck: large habitus
- Abdomen: obese
- Extr: LLE in compression stocking - difficult to assess for
edema, though estimate 1+, RLE without edema, DP pulses 2+, feet
cool though well perfused
Pertinent Results:
ADMISSION LABS:
___ 04:40AM BLOOD WBC-10.0 RBC-3.43* Hgb-10.2* Hct-29.8*
MCV-87 MCH-29.8 MCHC-34.3 RDW-15.0 Plt ___
___ 04:40AM BLOOD ___ PTT-26.7 ___
___ 04:40AM BLOOD Glucose-161* UreaN-27* Creat-1.6* Na-133
K-4.5 Cl-95* HCO3-25 AnGap-18
___ 04:40AM BLOOD proBNP-2203*
___ 04:40AM BLOOD Calcium-8.6 Phos-4.2 Mg-2.1
___ 04:40AM BLOOD D-Dimer-4686*
IMAGING STUDIES:
- ___ TTE: The left atrium is mildly dilated. Left
ventricular wall thickness, cavity size, and global systolic
function are normal (LVEF>55%). Due to suboptimal technical
quality, a focal wall motion abnormality cannot be fully
excluded. The right ventricular cavity is dilated with depressed
free wall contractility. The ascending aorta is mildly dilated.
The aortic valve leaflets are mildly thickened (?#). There is no
aortic valve stenosis. Trace aortic regurgitation is seen. The
mitral valve appears structurally normal with trivial mitral
regurgitation. There is no mitral valve prolapse. The estimated
pulmonary artery systolic pressure is normal. There is an
anterior space which most likely represents a prominent fat pad.
Compared with the report of the prior study (images unavailable
for review) of ___, the right ventricle appears dilated
and the free wall globally hypokinetic.
- ___ V/Q SCAN: Ventilation images could not be obtained due
to claustrophobia. Very low likelihood ratio for recent
pulmonary embolism.
- ___ CARDIAC CATHETERIZATION: final report pending
DISCHARGE LABS:
___ 04:55AM BLOOD WBC-8.0 RBC-3.58* Hgb-10.6* Hct-31.6*
MCV-88 MCH-29.6 MCHC-33.5 RDW-14.9 Plt ___
___ 04:55AM BLOOD Glucose-89 UreaN-31* Creat-1.5* Na-144
K-4.3 Cl-100 HCO3-32 AnGap-16
___ 04:55AM BLOOD Calcium-9.1 Phos-4.1 Mg-2.1
Brief Hospital Course:
Ms. ___ is an ___ year old woman with a history of HTN,
TIA, mixed cardiomyopathy, and diverticulitis who presented with
two days of dyspnea, orthopnea and PND, as well as left sided
chest pain, with elevated pro-BNP and D-dimer, as well as
significant wheeze on exam.
Active Issues
# Dyspnea: her history currently WAs suggestive of acute
decompensated diastolic HF. She recieved diuresis in ED. On
admission to ___ 3, lung exam significant for profound
wheezing. Etiology of dyspnea perhaps multifactorial - though
unknown at this time. CHF exacerbation possible, given some
response with diuresis. Airway hyperreactivity also likely,
given wheezes and improvement with nebs, though could be cardiac
wheezes. PE still possible, given D-dimer and recent
hospitalizations. V/Q scan negative and AC with UFH stopped.
Pericardial effusion also on differential - repeated TTE unable
to further characterize effusion given windows. Orthopnea
improved. Diuresis started though ___ worsened, so stopped.
Underwent cardiac catheterization that showed no restrictive or
constrictive physiology with relatively normal pressures (final
report pending). Received DuoNebs with improvement.
# Acute decompensated diastolic heart failure (EF 50%): patient
presented with ?decompensation of HF and was diuresed. Cr rose
from 1.6 on admission (which is up from ___ baseline) to 1.9
after diuresis. Reported continued orthopnea, though unclear if
patient has tried laying flat - was found sleeping comfortably
in flat position. Cr improved, as below. Catheterization report
attached, though no evidence of tamponade or
restrictive/constrictive physiology.
# ___: baseline Cr appears to be 0.9-1. Given concerns for heart
failure, likely cardiorenal. Urine electrolytes indicate likely
pre-renal. Cr continued to trend up from admission 1.6 to 1.9 on
___, after diuresis. Perhaps patient's Cr was elevated on
admission as was started on diuretic post-hospitalization (when
in Fla.) and overdiuresed there. Received 500 mL NS bolus, and
Cr has been downtrending. ___ Cr 1.5. Patient refused labs this
morning.
- Hold diuresis today
- Will trend Cr as outpatient, consider evaluation for this,
though most likely related to overdiuresis after
hospitalizations in ___
Stable Issues
# Pericardial Effusion: h/o ___ virus causing pericardial
effusion. She is now post pericardial window x2 at hospital. TTE
performed today without clear evidence of effusion, secondary to
poor visualization.
- Colchicine, renally dosed
# Anemia: normocytic. Patient post multiple operations
(pericardial windows x2) and prolonged hospitalizations. Likely
contribution of hospitalizations/phlebotomy and possible anemia
of chronic disease.
- Outpatient management
TRANSITIONAL ISSUES:
-STOPPED furosemide because weight stable off furosemide and
worsening renal function with diuresis.
-Discharge weight: 93.6kg. Monitor closely as outpatient.
-Renally dosed colchicine so dose was reduced by ___ (now 0.3mg
daily).
-Sent home with metoprolol succinate 50mg daily (rather than
25mg BID) for ease of administration
-Decreased PPI to once daily dosing since NSAIDs were stopped in
setting of worsened renal function.
-New Rx for nebulizer machine and DuoNebs
-Consider pulmonary testing
Discharge Medications:
1. Nebulizer
Dispense 1 nebulizer machine. Date: ___
ICD: 493
2. Ipratropium-Albuterol Neb 1 NEB NEB QID:PRN shortness of
breath
RX *ipratropium-albuterol 0.5 mg-3 mg (2.5 mg base)/3 mL 3 mL
inh four times daily Disp #*90 Ampule Refills:*0
3. Multivitamins 1 TAB PO DAILY
4. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation
Q4H: PRN DYSPNEA
5. Colchicine 0.3 mg PO DAILY
RX *colchicine 0.6 mg 0.5 (One half) tablet(s) by mouth daily
Disp #*15 Tablet Refills:*0
6. Metoprolol Succinate XL 50 mg PO DAILY
RX *metoprolol succinate 50 mg 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*0
7. Pantoprazole 40 mg PO Q24H
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY:
-Mild diastolic heart failure exacerbation (acute on chronic)
SECONDARY: TIA, osteoporosis, obesity, diverticulitis and left
femoral fracture s/p repair
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 to care for you at ___. You were admitted
because of difficulty breathing and we initially felt you were
having a heart failure exacerbation. We treated you with
medication to help your body pee out extra fluid (a "diuretic"),
however your kidney function worsened which was a sign that we
were drying you out too much. We stopped the diuretic and your
kidney function improved. A heart catheterization was performed
to directly measure pressures in your heart and assess fluid
levels. Your pressures were normal, so we decided to stop the
treatment to make you pee out extra fluid. You have mild
impairment of the ability of your heart to relax ("diastolic
heart failure"). It is extremely important for you to eat no
more than 2000mg of sodium daily. You also need to limit fluids
to no more than 2 Liters daily. Weigh yourself daily and call
your cardiologist's office if your weight rises more than 1.5kg.
Your weight on discharge: 93.6kg.
The remainder of your workup included a scan to look for blood
clots in the lung which was negative. We also checked an
ultrasound of your heart which showed an enlarged right
ventricle (one of the chambers of your heart). You should follow
up with your cardiologist after hospital discharge.
Please refer to the enclosed medication list regarding
medication changes upon hospital discharge. Please take HALF the
dose of colchicine that you were taking because the higher dose
is not good for your kidneys. Please STOP taking furosemide.
STOP ibuprofen. Decrease your Protonix to once daily dosing. Use
your nebulizer to help your shortness of breath as needed.
We wish you all the best!
Your ___ Team
Followup Instructions:
___
|
19677245-DS-12
| 19,677,245 | 28,230,438 |
DS
| 12 |
2176-08-20 00:00:00
|
2176-08-21 10:06:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
penicillin G / Cipro / prednisone / vancomycin
Attending: ___.
Chief Complaint:
diarrhea, abd pain, and weight loss
Major Surgical or Invasive Procedure:
Endoscopy
History of Present Illness:
___ w/ Hx of gastric bypass, celiac disease, and refractory C
diff colitis who presents w/ 3 months of diarrhea, unintentional
___ lb weight loss, and worsening abd pain of unknown
etiology, w/ negative CDiff, and CT showing biliary ductal
dilitation.
In early ___, the pt underwent a left hip replacement at the
___, after which she was hospitalized for 6 days
due to
uncontrolled hypertension and then discharged to rehab. On
___
she started having ___ diarrhea (___), and
was subsequently found to be positive for C.difficile. She was
started on a 2 week course of PO Vancomycin. On ___ she
completed her course but continued having ___ throughout
___ when she was again found to be positive for C.difficile.
During this time, her Cr had risen from baseline of ___ to
1.8. The pt was restarted on PO Vancomycin for 2 weeks without
much change in her symptoms. She was retested and was positive
again for C.difficile on ___ and started on a 12 week PO
Vancomycin taper. On ___ she
continued having diarrhea and was admitted to ___, where upper
endoscopy and flexible sigmoidoscopy were negative. She was
released on an increased dose of Vanc.
Subsequently, the pt had severe myalgias, arthralgias while on
Vanc. The drug was stopped on ___ by her PCP - labs from ___
showed lipase of 2596, Albumin of 3.3, Cr of 1.2, CRP 36, and
normal LFTs. The pt was switched to flagyl (for 8 days) and
codeine, yet continued to exhibit ___ abd pain,
diarrhea ___ per day, nocturnal incontinence, and chest rash
(thoguht to be drug rxn to Vanc). The pt also noted dysuria for
past few days before coming to hospital.
In the ED, vitals were Temp:97.9 BP:130/83 P:70 RR:18 O2:100%RA.
The pt reports continued diarrhea, nausea, and upper and
suprapubic abdominal pain as well as dysuria. In regards to the
pain, she denied any relation with meals. She denied f/c,
vomiting, flank pain, sob, cough. She has been sober form etoh
for ___ years. Pt's last successful colonscopy was in ___ (poor
visualization ___.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, shortness of breath. Denies chest pain
or tightness, palpitations. Denies nausea, vomiting, diarrhea,
constipation or abdominal pain. No recent change in bowel or
bladder habits. Denies arthralgias or myalgias.
Past Medical History:
Gastric bypass w/ 150lb wt loss in ___
GERD/dysphagia- food ___ retention ___
Anastomotic ulcer (healed, food retention ___
Ampullary stenosis
___ fistula
Celiac disease (diagnosed ___
Grand mal seizure disorder
Stage ___ kidney disease due to NSAIDs
Frequent UTIs (1 every 6 mos)
Bipolar for ___ years - hx of 12 previous suicide attempts
before stabilized on medications; states predominately manic
episodes
Recovering alcoholic - sober x ___ years
Fe deficiency
Asthma
Social History:
___
Family History:
No FHx of celiac. She has four siblings. None have been tested.
Half sister with metastatic breast cancer
Physical Exam:
ON ADMISSION:
=
================================================================
Vitals: T:97.9 BP:107/58 P:72 RR:18 O2:100%RA
GENERAL: NAD
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
patent nares, MMM
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs
LUNG: CTAB, no wheezes, rales, rhonchi
ABDOMEN: nondistended, +BS, diffusely tender to palpations in
all quadrants, no rebound, no guarding, no organomegaly
EXTREMITIES: moving all extremities well, no cyanosis, clubbing
or edema
PULSES: 2+ DP pulses bilaterally
NEURO: CN ___ intact
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
ON DISCHARGE:
=
================================================================
Vitals: T:97.8 BP:97/49 P:77 RR:18 O2:97%RA
GENERAL: NAD
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
patent nares, MMM
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs
LUNG: CTAB, no wheezes, rales, rhonchi
ABDOMEN: nondistended, +BS, diffusely tender to palpations in
all quadrants, no rebound, no guarding, no organomegaly
EXTREMITIES: moving all extremities well, no cyanosis, clubbing
or edema
PULSES: 2+ DP pulses bilaterally
NEURO: CN ___ intact
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
Pertinent Results:
ON ADMISSION:
=
================================================================
___ 01:35PM BLOOD ___
___ Plt ___
___ 01:35PM BLOOD ___
___
___ 01:35PM BLOOD Plt ___
___ 01:35PM BLOOD ___
___
___ 01:35PM BLOOD ___
___ 01:35PM BLOOD ___
___ 09:11AM BLOOD ___
___ Base XS--3 ___ TOP
___ 01:40PM BLOOD ___
___ 01:35PM URINE ___ Sp ___
___ 01:35PM URINE ___
___
___ 01:35PM URINE ___
Epi-<1
IMAGING:
CT ABD & PELVIS W/O CONTRAST (___):
1. Interval increase in the degree of intrahepatic and
extrahepatic biliary dilatation, with the common bile duct now
measuring 1.7 cm. For further evaluation, MRCP could be
performed.
2. No evidence of focal pancreatic duct dilatation or
peripancreatic fat
stranding.
3. Status post ___ gastric bypass with known ___ fistula.
The majority of the oral contrast is seen to travel via the
afferent limb, and the duodenum is moderately dilated with oral
contrast. There is no evidence transition point or focal bowel
obstruction.
ON DISCHARGE:
=
================================================================
___ 07:30AM BLOOD ___ ___
___ 07:30AM BLOOD ___
___ 07:30AM BLOOD ___
___
___ 07:30AM BLOOD ___
___ 07:30AM BLOOD ___
___ 07:30AM BLOOD ___
___ 07:30AM BLOOD ___
MICRO:
C. difficile DNA amplification assay (Final ___: Negative
FECAL CULTURE (Final ___: NO SALMONELLA OR SHIGELLA FOUND.
CAMPYLOBACTER CULTURE: Pending
OVA + PARASITES (Final ___ OVA AND PARASITES SEEN.
FECAL CULTURE - R/O VIBRIO: Pending
FECAL CULTURE - R/O YERSINIA: Pending
FECAL CULTURE - R/O E.COLI 0157:H7 (Final ___: NO E.COLI
FOUND.
Cryptosporidium/Giardia (DFA) (Final ___: NO
CRYPTOSPORIDIUM OR GIARDIA SEEN.
IMAGING:
MRCP (MR ABD ___: PENDING
Brief Hospital Course:
BRIEF HOSPITAL COURSE:
============================================
___ w/ Hx of gastric bypass, celiac disease, and refractory C
diff colitis who presented w/ 3 months of diarrhea,
unintentional weight loss, and worsening abd pain of unknown
etiology
ACTIVE ISSUES:
============================================
#Chronic Diarrhea/Abd Pain
Pt noted that baseline bowel fxn ___ stools per day, worsened
acutely since ___ in setting of PCR+ CDiff colitis, who
completed multiple PO vanc courses, and most recently a 12wk
vancomycin taper which ended abruptly ___ questionable drug rxn
(rash on trunk). Pt recently admitted in mid ___ when she had
___ which were negative for macroscopic or microscopic
findings. Prior to this admission, pt had elevated lipase
suggestive of acute pancreatitis, but it resolved by day of
admission, and pt was without clinical symptoms.
On this admission, CT showed CBD dilitation w/ known ___
fistula, and CDiff was found to be negative. As per GI consult,
pt had MRCP which showed normal CBD diameter, but did identify
intraductal papillary mucinous neoplasm. Bariatric surgery was
consulted who felt that anatomy was intact, and patient may
benefit from rifaximin, but patient had problems gaining
insurance approval for such med in the past despite prior
authorization.
GI consult felt that repeat EGD may be useful but it failed to
identify any potential etiologies of pt's diarrhea. It did
however, make note of superficial ulcerations in the stomach.
Stool Studies were otherwise negative. Interestingly, pt did not
have diarrhea while NPO for procedures, thus secretory process
unlikely. Thus, dietary intolerance (sorbitol or lactose),
overeating, or IBS possible. Pt was discharged on immodium and
lamotil to be taken as needed to control her diarrhea.
Pt was given appt for 3 days after discharge to f/u with her
outpatient GI doctor. Pt was also discharged on Flagyl for GI
ppx while being treated for her UTI.
# Intraductal papillary mucinous neoplasm (IPMN) on MRCP
MRCP (___) finding notes a "3 mm cystic lesion within the
pancreatic tail, which likely represents an intraductal
papillary mucinous neoplasms (IPMN)" which is currently stable.
Due to location in tail (as opposed to duct), relatively small
size, and lack of multiple cysts - immediate f/u is not
requried. Guidelines reccomend that if the cyst is 2 to 3 cm in
size, f/u Endoscopic Ultrasound (EUS) in three to six months. Pt
should follow up this issue w/ GI doctors at ___ next
appointment. If needed, she should be referred to pancreatic
surgery clinic for evaluation.
# UTI
Pt reported several days of dysuria prior to ___ hospital
admission. Pt's UA positive w/ WBC, c/w UTI. Starting on ___,
pt put on ___ course of Bactrim (1 ___ tablet
Q12). In addition, she was given Flagyl for CDiff ppx (as PO
Vancomycin not possible due to pt's previous drug rxn), with
plans to continue it for several days s/p Bactrim completion.
# Celiac disease
Pt compliant with diet, and on ___ medications. Not
likely active disease contributing to diarrhea.
# Seizure disorder
Pt with history of grand mal seizures, previously well
controlled, though recent seizure (4wks ago) concerning that she
may not be absorbing medications appropriately. Was seen by
neurology previously who increased her topiramate without
further seizures. She was continued on home dose AEDs without
any seizure like activity during this hospitalization.
# Bipolar disorder
Pt's mood was stable so she was continued on home dose
duloxetine, buspirone, and quetiapine.
# Hypothyroid
Pt was continued levothyroxine.
TRANSITIONAL ISSUES:
=
=
=
=
=
=
=
=
================================================================
1. Pt can take immodium/lamotil as necessary to control her
diarrhea
2. Pt should follow up with her outpatient GI doctor regarding
her chronic diarrhea and consideration of continue Flagyl
treatment, or resumption on Rifaximin to treat bacterial
overgrowth
3. Pt will need follow up imaging of Intraductal papillary
mucinous neoplasm in ___ months.
4. Pt will need to call PCP and schedule follow up appointment
for general healthcare maintenance.
5. Pt will need to continue Bactrim until ___ to treat her
UTI and continue Flagyl until ___ for CDiff prophylaxis.
6. Pt may benefit from repeat UA in clinic if still having
dysuria.
# CODE: DNR/DNI
# CONTACT: ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. BusPIRone 10 mg PO TID
2. Duloxetine 30 mg PO DAILY
3. FoLIC Acid 1 mg PO DAILY
4. Gabapentin 800 mg PO TID
5. LaMOTrigine 150 mg PO BID
6. Levothyroxine Sodium 88 mcg PO DAILY
7. QUEtiapine Fumarate 25 mg PO BID
8. QUEtiapine Fumarate 100 mg PO QHS
9. Ranitidine 150 mg PO BID
10. Topiramate (Topamax) 250 mg PO BID
11. Vitamin D 1000 UNIT PO DAILY
12. Multivitamins W/minerals 1 TAB PO DAILY
13. Nystatin Cream 1 Appl TP BID
14. esomeprazole magnesium 40 mg oral Daily
15. Ferrous Sulfate 325 mg PO BID
Discharge Medications:
1. BusPIRone 10 mg PO TID
2. Duloxetine 30 mg PO DAILY
3. esomeprazole magnesium 40 mg oral Daily
4. FoLIC Acid 1 mg PO DAILY
5. Gabapentin 800 mg PO TID
6. LaMOTrigine 150 mg PO BID
7. Levothyroxine Sodium 88 mcg PO DAILY
8. Multivitamins W/minerals 1 TAB PO DAILY
9. QUEtiapine Fumarate 25 mg PO BID
10. QUEtiapine Fumarate 100 mg PO QHS
11. Ranitidine 150 mg PO BID
12. Topiramate (Topamax) 250 mg PO BID
13. Vitamin D 1000 UNIT PO DAILY
14. LOPERamide 2 mg PO QID:PRN Diarrhea
RX *loperamide [___] 2 mg 1 tablet by mouth QID:prn
Disp #*120 Tablet Refills:*0
15. MetRONIDAZOLE (FLagyl) 500 mg PO Q8H Duration: 7 Days
RX *metronidazole 500 mg 1 tablet(s) by mouth every eight (8)
hours Disp #*10 Tablet Refills:*0
16. ___ 1 TAB PO Q8H:PRN diarrhea
RX ___ 2.5 ___ mg 1 tablet(s) by mouth
q8h:prn Disp #*90 Tablet Refills:*0
17. Sulfameth/Trimethoprim DS 1 TAB PO BID Duration: 3 Days
RX ___ [Bactrim DS] 800 ___ mg 1
tablet(s) by mouth twice a day Disp #*3 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Chronic Diarrhea of unknown etiology
Urinary Tract Infection
Secondary:
Bipolar
Hypothyroid
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 treating you at the ___
___ during your most recent hospitalization. You
originally presented due to concern regarding your chronic
abdominal pain, diarrhea, and weight loss. Fortunately, you
were found to have had cleared your previous CDiff infection.
However, the cause of your symptoms remains unclear. Your MRCP
did not give us any information regarding your diarrhea, but it
did show that you have a nodule in your pancreas that needs to
be ___ in several months. You will also need to follow up
with your GI doctors regarding this. You had a repeat endoscopy
which showed some irritation of your stomach but nothing
worrysome.
On discharge, you will need to follow up with the GI doctors
regarding your ___. In the meantime, you may take
___ agents such as immodium or lamotil in the
meantime.
You were also found to have a Urinary Tract Infection (UTI),
which was causing your pain on urination. You were put on
Bactrim/Flagyl to treat this UTI - please refer to the
medication sheet for further instructions. We are glad you are
feeling better and we wish you the best.
Followup Instructions:
___
|
19677806-DS-11
| 19,677,806 | 29,655,310 |
DS
| 11 |
2128-04-14 00:00:00
|
2128-04-14 12:49:00
|
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, palpitations
Major Surgical or Invasive Procedure:
___ - TEE Cardioversion
History of Present Illness:
Mr. ___ is an ___
man with DMII, CAD s/p CABG x5 in ___, CHF and AF started on
Coumadin on ___ presenting to the ED with intermittent chest
pain and palpitations.
Pt states that has been having chest pain/pressure + SOB for
several days. Increasing in intensity, keeps him from sleeping.
Improves some with nitro. Denies palpitations. Has chronic b/l
leg swelling that has worsened during this time. States he has
been taking warfarin as prescribed.
Notable recent events:
-___: seen by cardiologist, noted to be tachycardic > 100
bpm. Was then started on atenolol 50mg BID and his lisinopril
was stopped due to concern for lower blood pressures.
-___: seen in urgent care with several weeks of cough and
SOB. This was felt to be related to his tachycardia. CXR showed
no acute abnormality or change.
-Late ___: f/u with holter monitor which captured atrial
flutter with rates between 55 and 120, with frequent unifocal
PVCs (not clearly associated w/sx). Could not r/o atrial tach
b/c rate was 214 (P-P). At this time, he was started on
warfarin.
In the ED initial vitals were: 97.3 | 111 | 101/57 | 16 | 97%
RA
EKG (atrius; read by Dr. ___: difficult to see p waves, rate
105, cpicould be 2:1 atrial tachycardia; rightward axis, less
likely ST with 1st degree AV delay. RBBB, q eaves in III, AVF.
Labs/studies notable for:
___ CXR IMPRESSION: Moderate pulmonary vascular congestion.
No overt pulmonary edema.
Patient was given:
- 20mg IV bolus of diltiazem followed by drip -> became
hypotensive and bradycardic
- furosemide 20mg IV
- furosemide 40mg IV
- metoprolol 25mg PO q6h
Vitals on transfer: 97.7 | 107 | 144/79 | 20 | 98% NC
On the floor, pt denies CP, SOB. Comfortable.
Past Medical History:
CARD:
-CORONARY ARTERY DISEASE S/P CABG X 5 IN ___
-HYPERCHOLESTEROLEMIA
-HYPERTENSION, ESSENTIAL (well controlled)
GI
-DIVERTICULOSIS
-COLONIC ADENOMAS
-FAMILY HISTORY COLON CANCER
HEME:
-ANEMIA
ENDO:
-DIABETES MELLITUS, TYPE 2, UNCONTROLLED
-OBESITY
Social History:
___
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death.
- Sister with benign colonic polyps
- Father with colon cancer
Physical Exam:
ADMISSION VITALS
================
VITALS: 97.7 | 107 | 144/79 | 20 | 98% NC
GENERAL: Well-developed, well-nourished. NAD. Mood, affect
appropriate.
NECK: Supple with JVP at level of mandible
CARDIAC: Irregular, tachycardic. No S1, S2. Clear S3. No
murmurs/rubs No thrills, lifts.
LUNGS: Resp were unlabored. Expiratory wheeze in all fields.
Ronchi in all lung fields.
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: 2+ pitting edema in b/l lower extremities. Pulses
difficult to find given extent of edema, but feet are warm b/l
NEURO: Face grossly symmetric, speech slightly thick, moving all
limbs with purpose against gravity.
DISCHARGE VITALS
=================
Vitals: 98.3 | 115/62 | 70 | 19 | 94%RA
Weight: 101kg
Weight on admission: 106kg
GENERAL: Well-developed, well-nourished. NAD. Sitting
comfortably in chair.
HEENT: Lg tongue (chronic). Thick speech. Tacky mucous
membranes.
NECK: Supple with JVP at level of mandible
CARDIAC: RRR. No S1, S2. No murmurs/rubs No thrills, lifts.
LUNGS: Resp were unlabored. Occasional exp wheeze.
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: 2+ pitting edema in b/l lower extremities. Pulses
difficult to find given extent of edema, but feet are warm b/l
NEURO: Face grossly symmetric, speech slightly thick, moving all
limbs with purpose against gravity.
Pertinent Results:
ADMISSION and PERTINENT INTERVAL LABS
======================================
___ 09:34AM BLOOD WBC-9.5 RBC-4.16* Hgb-10.8* Hct-37.0*
MCV-89 MCH-26.0 MCHC-29.2* RDW-16.5* RDWSD-53.1* Plt ___
___ 09:34AM BLOOD Neuts-75.4* Lymphs-15.5* Monos-6.7
Eos-1.4 Baso-0.5 Im ___ AbsNeut-7.18* AbsLymp-1.48
AbsMono-0.64 AbsEos-0.13 AbsBaso-0.05
___ 09:10AM BLOOD ___ PTT-30.0 ___
___ 09:10AM BLOOD Glucose-239* UreaN-31* Creat-1.1 Na-142
K-4.3 Cl-95* HCO3-34* AnGap-13
___ 09:10AM BLOOD ALT-11 AST-15 LD(LDH)-143 CK(CPK)-27*
AlkPhos-140* TotBili-0.4
___ 09:10AM BLOOD CK-MB-1 proBNP-1660*
___ 09:10AM BLOOD cTropnT-<0.01
___ 10:00AM BLOOD CK-MB-1 cTropnT-<0.01
___ 09:10AM BLOOD Albumin-3.4* Calcium-9.0 Phos-3.6 Mg-2.1
___ 09:10AM BLOOD TSH-1.2
DISCHARGE LABS
==============
___ 05:20AM BLOOD WBC-10.6* RBC-4.71 Hgb-12.0* Hct-40.8
MCV-87 MCH-25.5* MCHC-29.4* RDW-16.5* RDWSD-51.8* Plt ___
___ 05:20AM BLOOD ___ PTT-87.6* ___
___ 05:20AM BLOOD Glucose-143* UreaN-43* Creat-1.2 Na-138
K-4.0 Cl-86* HCO3-39* AnGap-13
STUDIES
=======
___ CXR FINDINGS: PA and lateral views of the chest
provided. There is mild increased interstitial prominence and
moderate pulmonary vascular congestion. There is atelectasis of
the right and left bases. There is no evidence of pleural
effusion or pneumothorax. There is moderate cardiomegaly.
Median sternotomy wires and mediastinal clips are noted.
IMPRESSION: Moderate pulmonary vascular congestion. No overt
pulmonary edema.
___ TEE FINDINGS: Moderate to severe spontaneous echo
contrast but no thrombus is seen in the body of the left atrium
and in the left atrial appendage. The left atrial appendage
emptying velocity is depressed (<0.2m/s). No spontaneous echo
contrast or thrombus is seen in the right atrium or right atrial
appendage. Right atrial appendage ejection velocity is good (>20
cm/s). he aortic valve leaflets are mildly thickened (?#). No
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. A mitral valve annuloplasty ring is present.
No mass or vegetation is seen on the mitral valve. Mild (1+)
mitral regurgitation is seen. There is no pericardial effusion.
IMPRESSION: Moderate-severe spontaneous echo contrast but no
thrombus in the body of the left atrium/left atrial appendage
___ TTE CONCLUSIONS: The left atrium is mildly dilated. No
atrial septal defect is seen by 2D or color Doppler. There is
mild symmetric left ventricular hypertrophy with normal cavity
size and regional/global systolic function (LVEF>55%). 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 valve leaflets are moderately thickened. There is mild
aortic valve stenosis (valve area 1.2-1.9cm2). No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Trivial mitral regurgitation is seen. The tricuspid
valve leaflets are mildly thickened. Moderate [2+] tricuspid
regurgitation is seen. There is moderate pulmonary artery
systolic hypertension. There is no pericardial effusion.
Brief Hospital Course:
Mr. ___ is an ___ man with diabetes, CAD status
post CABG x5 in ___, history of mitral valve repair, atrial
flutter recently diagnosed and started on Coumadin on ___ who
presented to the ED with intermittent chest pain and
palpitations since ___, found to be volume overloaded in the
setting of rapid atrial flutter, who underwent a successfully
TEE cardioversion on ___ and appears to still be in sinus
rhythm, and was aggressively diuresed.
ACUTE MEDICAL ISSUES
=======================
# Atrial flutter with rapid rates - New diagnosis from Holter
monitor as OSH (vs. atrial tachycardia). Was being managed as
outpatient; started on warfarin as of ___ with plan for
outpatient cardioversion. Presented with symptomatic
palpitations, some chest pain, and dyspnea. Was seen by EP in
the ED, though likely to be atrial flutter. Dilt drip was
initially recommended, but given hypotension and bradycardia he
was instead started on metoprolol, which minimally controlled
his rates (110s) at max dosing. He underwent a TEE cardioversion
on ___ and subsequently remained in sinus rhythm with numerous
PACs and PVCs. For anticoagulation, he was bridged with heparin
and given increasing doses of warfarin, becoming therapeutic on
___ with a dose of 7.5mg daily. For rate control he was given
metoprolol 150mg XR PO daily; his atenolol and diltiazem were
held.
# Volume overload: No known heart failure; Pro-BNP in ED 1660
and he was on 60mg torsemide daily due to increasing volume
overload as outpatient. On arrival he had an oxygen requirement
and CXR with signs of vascular congestion, and ongoing pitting
edema that improved with daily dosing of IV furosemide and 2
doses of metolazone. He had no heart failure on ___ TTE (LVEF
>55%, normal RV). Acute decompensation likely due to
tachyarrythmia; per wife, he always has lower extremity edema.
He also received 1 dose acetazolmide on ___ for elevated bicarb.
He was off of oxygen with 1+ calf pitting edema on discharge
(per wife, his baseline) and was sent out on 100mg daily
torsemide with instructions to follow up and dose adjust as
needed.
CHRONIC STABLE ISSUES
=====================
# CAD s/p CABG ___ - Has intermittent angina but none while
inpatient. On isosorbide at home but this was held while
escalating beta blockade, and he was without angina or elevated
blood pressures, so this was held on discharge. Trops negative.
Maintained on ASA and warfarin (bridged with heparin). Continued
home pravastatin given history of myalgias. On metoprolol
succinate 150mg daily post-cardioversion; held home atenolol.
# Microcytic anemia (Hgb ___ with MCV 89). Getting B12
repletion as outpatient. Had Hgb 11 in ___ with recent
ferritin 62. Recent LDH/bili not elevated to suggest lysis.
Retic count high-normal at 2% but might be low relatively since
he is not apparently mounting a response to his anemia. Consider
further workup as outpatient. Last colonoscopy 2 months ago with
11 colorectal polyps (8 tubular adenomas, 3 hyperplastic
polyps), diverticulosis, hemorrhoids.
# Insulin-dependent diabetes: Continued home insulin. Held
metformin, restarted on discharge.
# Depression: Continued home sertraline 100mg daily.
TRANSITIONAL ISSUES
[ ] ___ LABS: Basic metabolic panel, INR
- may need downscale torsemide if bump in Cr or ongoing BUN
elevation
- adjust warfarin or provide bridging given stroke risk
post-cardioversion
[ ] Patient going home with ___ and home ___. Of note, his wife
is highly overwhelmed with his ongoing care needs, but they
declined rehab despite ___ and physician ___. Consider
ongoing home services as needed.
[ ] Consider restarting isosorbide mononitrate if angina recurs
or as otherwise needed
#NEW MEDS:
- Metoprolol succinate 150mg daily
- Nitroglycerin SL
#CHANGED MEDS
- Warfarin 7.5mg daily (3.75mg daily)
- Torsemide 100mg daily (from 60mg daily)
#DICONTINUED MEDS
- Isosorbide Mononitrate 60mg daily
- Atenolol 50mg BID
Discharge weight: 101kg (from 106-107kg)
Discharge creatinine: 1.2
Code status: Full
Contact: ___ (wife/HCP) - ___ |
___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. 70/30 20 Units Breakfast
70/30 20 Units Lunch
70/30 20 Units Dinner
Insulin SC Sliding Scale using novolog Insulin
2. Warfarin 3.75 mg PO DAILY16
3. MetFORMIN XR (Glucophage XR) 1000 mg PO BID
4. Atenolol 50 mg PO DAILY
5. Sertraline 100 mg PO DAILY
6. Pravastatin 20 mg PO QPM
7. ciclopirox 0.77 % topical QAM
8. Torsemide 60 mg PO DAILY
9. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY
10. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Metoprolol Succinate XL 150 mg PO DAILY
RX *metoprolol succinate 50 mg 3 tablet(s) by mouth daily Disp
#*21 Tablet Refills:*0
2. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain/pressure
RX *nitroglycerin 0.3 mg 1 tablet(s) sublingually q5m Disp #*100
Tablet Refills:*0
3. Torsemide 100 mg PO DAILY
RX *torsemide 20 mg 5 tablet(s) by mouth daily Disp #*100 Tablet
Refills:*0
4. Warfarin 7.5 mg PO DAILY16
RX *warfarin [Coumadin] 2.5 mg 3 tablet(s) by mouth daily Disp
#*63 Tablet Refills:*0
5. Aspirin 81 mg PO DAILY
6. ciclopirox 0.77 % topical QAM
7. 70/30 20 Units Breakfast
70/30 20 Units Lunch
70/30 20 Units Dinner
Insulin SC Sliding Scale using novolog Insulin
8. MetFORMIN XR (Glucophage XR) 1000 mg PO BID
9. Pravastatin 20 mg PO QPM
10. Sertraline 100 mg PO DAILY
11. HELD- Isosorbide Mononitrate (Extended Release) 60 mg PO
DAILY This medication was held. Do not restart Isosorbide
Mononitrate (Extended Release) until your cardiologist or PCP
tells you to take it
12.Outpatient Lab Work
___ - INR, Chem-7, Mg I48.92 E87.70
Fax results to ___ ___
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS
=================
#Atrial flutter with uncontrolled rates
#Volume overload
SECONDARY DIAGNOSES
===================
#CAD s/p CABG ___
#MICROCYTIC ANEMIA
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear ___,
It was a pleasure taking care of you at the ___
___!
WHY WAS I IN THE HOSPITAL?
==========================
- You had heart palpitations and trouble breathing, and were
found to have a rapid and irregular heart rate with too much
fluid
WHAT HAPPENED IN THE HOSPITAL?
==============================
- You had a special ultrasound of your heart to make sure you
did not have a clot
- Your underwent a "cardioversion," where you heart was shocked
back into a normal rhythm
- You received medicine to help you pee off some extra fluid
- You were given warfarin and your blood levels were monitored
WHAT SHOULD I DO WHEN I GO HOME?
================================
- Continue to take your medicine as prescribed
- Go to your doctor to have your blood drawn on ___
- Weigh yourself every day and call your doctor if you go up by
>3 lbs
Thank you for allowing us to be involved in your care. We wish
you all the best!
Your ___ Healthcare Team
Followup Instructions:
___
|
19677806-DS-12
| 19,677,806 | 29,677,625 |
DS
| 12 |
2130-04-10 00:00:00
|
2130-04-11 21:38:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Bradycardia, Chest Pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr ___ is an ___ year old man with a history of CAD s/p
CABG (___), mitral valve repair ___, type II DM, CHF (EF?),
atrial flutter s/p CV x2 (most recently ___ on warfarin who
presented to ED with poorly characterized chest pain and feeling
"unwell". He reports that he got up to the bathroom in the
middle
of the night and started to experience symptoms. Endorsing some
chest discomfort, mild dyspnea. His wife checked his vitals with
a home monitor. His oxygen and blood pressure were normal, but
the monitor read a heart rate of 35. He denied any dizziness or
lightheadedness. He took 1 sublingual nitroglycerin with some
resolution of his chest discomfort. His wife was nervous about
the slow heart rate, so she brought him to ED. His symptoms
resolved by the time he had presented to ED.
Of note, patient has history of stable angina and typically
takes
2 SLNTG per month.
On arrival to ED, initial vitals were:
Temp 97.7 | HR 36 | BP 139/46 | RR 16 | SpO2 98% 1L NC
Exam was notable for:
Ill-appearing, bradycardic, distant breath sounds, Bilateral
lower extremity pitting edema
Labs were notable for: (use specific numbers)
Cr 1.3 (baseline Cr 1.1-1.3 per Atrius review)
Trops negative x2
BNP 591
Lactate 1.5
Hgb 9.6 (most recent Hgb 10.4 in ___ in Atrius)
Fingerstick was 47, patient was given dextrose
Studies were notable for:
CXR without pulmonary edema
The patient was given:
Dextrose 50% 25g
ASA 81mg
Insulin 4U SC
Patient was evaluated by At___ cardiology, who did not feel
that
there was real bradycardia, and PVCs made manual pulse difficult
to feel and home monitor did not pick up PVCs. They recommended
discharge home with close follow up with Holter monitoring with
outpatient cardiologist, Dr ___.
ED recommended admission to medicine for close monitoring and
further workup of dizziness.
On arrival to the floor, patient denies fever, chills, chest
pain, dyspnea, palpitations, lightheadedness, dizziness. Has not
had any symptoms since his arrival to ___.
Past Medical History:
CARD:
-CORONARY ARTERY DISEASE S/P CABG X 5 IN ___
-HYPERCHOLESTEROLEMIA
-HYPERTENSION, ESSENTIAL (well controlled)
GI
-DIVERTICULOSIS
-COLONIC ADENOMAS
-FAMILY HISTORY COLON CANCER
HEME:
-ANEMIA
ENDO:
-DIABETES MELLITUS, TYPE 2, UNCONTROLLED
-OBESITY
Social History:
___
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death.
- Sister with benign colonic polyps
- Father with colon cancer
Physical Exam:
ADMISSION PHYSICAL EXAMINATION:
============================
VITALS: ___ 1612 Temp: 98.3 PO BP: 112/50 R Lying HR: 53
RR: 18 O2 sat: 94% O2 delivery: 2L NC
GENERAL: Elderly man sleeping comfortably in bed in no acute
distress
HEENT: Sclera anicteric. Conjunctiva pink.
CARDIAC: Normal rate and rhythm with occasional premature beats.
Grade ___ systolic murmur.
LUNGS: Faint inspiratory crackles bilaterally at the bases. No
wheezes or rhonchi. No increased work of breathing.
ABDOMEN: Soft, NTND.
EXTREMITIES: Warm, well perfused. 1+ pitting edema in bilateral
lower extremities into shin.
NEURO: Sleepy, but easily arousable to voice. Oriented to self
and place. Moving all limbs with purpose.
DISCHARGE PHYSICAL EXAM:
======================
VITALS: 24 HR Data (last updated ___ @ 1213)
Temp: 98.0 (Tm 98.3), BP: 114/57 (98-127/48-65), HR: 63
(53-74), RR: 18 (___), O2 sat: 95% (91-98), O2 delivery: Ra
(2L
NC-2.5L), Wt: 209.22 lb/94.9 kg
GENERAL: Elderly man sitting up in chair, no acute distress
HEENT: Sclera anicteric. Conjunctiva pink.
CARDIAC: Normal rate and rhythm with occasional premature beats.
Grade ___ systolic murmur.
LUNGS: Faint inspiratory crackles bilaterally at the right lung
base. No wheezes or rhonchi. No increased work of breathing.
ABDOMEN: Soft, NTND.
EXTREMITIES: Warm, well perfused. 1+ pitting edema in bilateral
lower extremities into shin.
NEURO: Alert, easily arousable. Moving all limbs with purpose.
Pertinent Results:
ADMISSION LABS:
==============
___ 04:59AM BLOOD WBC-10.0 RBC-3.87* Hgb-9.6* Hct-33.4*
MCV-86 MCH-24.8* MCHC-28.7* RDW-16.2* RDWSD-50.4* Plt ___
___ 04:59AM BLOOD Neuts-76.6* Lymphs-14.4* Monos-7.8
Eos-0.7* Baso-0.2 Im ___ AbsNeut-7.63* AbsLymp-1.44
AbsMono-0.78 AbsEos-0.07 AbsBaso-0.02
___ 04:59AM BLOOD ___ PTT-40.9* ___
___ 04:59AM BLOOD Glucose-38* UreaN-36* Creat-1.3* Na-143
K-5.4 Cl-95* HCO3-32 AnGap-16
___ 04:59AM BLOOD proBNP-591
___ 04:59AM BLOOD cTropnT-<0.01
___ 08:33AM BLOOD cTropnT-<0.01
___ 04:59AM BLOOD Calcium-9.1 Phos-3.5 Mg-2.0
___ 05:13AM BLOOD Lactate-1.5 K-4.7
DISCHARGE LABS:
==============
___ 06:41AM BLOOD WBC-8.5 RBC-3.81* Hgb-9.3* Hct-33.4*
MCV-88 MCH-24.4* MCHC-27.8* RDW-16.1* RDWSD-51.4* Plt ___
___ 06:41AM BLOOD Glucose-131* UreaN-35* Creat-1.2 Na-145
K-4.3 Cl-99 HCO3-40* AnGap-6*
IMAGING:
=======
CXR ___
IMPRESSION:
Moderate pulmonary vascular congestion without pulmonary edema.
Bibasilar
atelectasis.
URINE STUDIES:
============
___ 07:48AM URINE Color-Straw Appear-Clear Sp ___
___ 07:48AM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG
___ 7:48 am URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
Brief Hospital Course:
___ year old man with a history of CAD s/p CABG (___), mitral
valve repair ___, type II DM, CHF (EF?), atrial flutter s/p CV
x2 (most recently ___ on warfarin admitted out of concern
for bradycardia and dizziness. Found to have no evidence of
bradyarrhythmia on telemetry, but did have hypoglycemia on
presentation, which was likely contributing to his dizziness.
TRANSITIONAL ISSUES:
====================
[ ] Discharged with ___ monitoring
[ ] Has outpatient cardiology follow-up scheduled, can consider
stress
testing vs. further rhythm monitoring.
[ ] Consider reducing insulin dose in outpatient setting to
minimize hypoglycemia risk. Please ensure that patient is
checking blood sugars regularly.
[ ] Outpatient follow up for iron infusions PRN, given stable
anemia
[ ] Cr 1.2 at discharge
[ ] Discharge weight: 94.9kg (209.22 lbs)
[ ] Note that per Atrius records, it appears patient is supposed
to be taking metoprolol tartrate 150mg daily, but is only taking
100mg daily. Did not increase dose while inpatient, given
concern for bradycardia.
ACUTE ISSUES:
=============
#Concern for bradycardia
Patient hemodynamically stable since arrival to ___. Patient
seen by cardiologist in ED, who felt that he was not having true
bryadycardia, as monitor was not capturing PVCs. No evidence of
bradyarrhythmia on telemetry overnight. Electrolytes normal.
Will plan for discharge with close follow up with Dr. ___
___ monitoring.
#Chest discomfort
#Dizziness
#Hypoglycemia
Patient with known stable angina. Suspect that his dizziness on
presentation may have been related to hypoglycemia, as patient
had a blood sugar of 38 on initial BMP. Discussed with patient
importance of checking blood sugar at home. He states he
typically gets readings of 120-150 at home, but appears to have
been asymptomatic when he had a low sugar.
#Anemia
Patient with known chronic anemia, has been getting iron
infusions in the outpatient setting. Hemoglobin close to
baseline. No signs of acute blood loss.
#CKD
Patient with Cr at most recent baseline. Unlikely to represent
___ at this time. Cr 1.2 at discharge.
CHRONIC ISSUES:
===============
#T2DM
Patient was hypoglycemic in ED requiring dextrose. Held home
standing insulin due to hypoglycemia on presentation to ED. Held
home metformin, restarted on discharge. Patient educated on
importance of checking blood sugars prior to discharge.
#CAD s/p CABG
#CHF
-Continued home aspirin 81mg daily
-Continued home pravastatin 20mg daily
-Continued home metoprolol
-Continued home torsemide 80mg BID
#Atrial fibrillation
-Rate control with metoprolol, as above
-Anticoagulation with home warfarin, patient has follow-up INR
check on ___
#GERD
-Continue home omeprazole and ranitidine
#CODE: Full, presumed
#CONTACT: ___ (Wife) ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. TraZODone 50 mg PO QHS
2. Torsemide 80 mg PO BID
3. Metoprolol Succinate XL 100 mg PO DAILY
4. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
5. 70/30 20 Units Breakfast
70/30 20 Units Bedtime
6. Omeprazole 20 mg PO DAILY
7. MetFORMIN (Glucophage) 1000 mg PO BID
8. Pravastatin 20 mg PO QPM
9. Warfarin 5 mg PO 6X/WEEK (___)
10. Aspirin 81 mg PO DAILY
11. Warfarin 3.75 mg PO 1X/WEEK (WE)
Discharge Medications:
1. 70/30 20 Units Breakfast
70/30 20 Units Bedtime
2. Aspirin 81 mg PO DAILY
3. MetFORMIN (Glucophage) 1000 mg PO BID
4. Metoprolol Succinate XL 100 mg PO DAILY
5. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
6. Omeprazole 20 mg PO DAILY
7. Pravastatin 20 mg PO QPM
8. Torsemide 80 mg PO BID
9. TraZODone 50 mg PO QHS
10. Warfarin 3.75 mg PO 1X/WEEK (WE)
11. Warfarin 5 mg PO 6X/WEEK (___)
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS
=================
Atrial Fibrillation with PVCs
Hypoglycemia
Lightheadedness
SECONDARY DIAGNOSIS
===================
T2DM
#CAD s/p CABG
#CHF
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
======================
DISCHARGE INSTRUCTIONS
======================
Dear Mr. ___,
It was a privilege caring for you at ___.
WHY WAS I IN THE HOSPITAL?
- You felt dizzy and had mild chest discomfort, and your heart
rate was low when you checked it manually at home.
WHAT HAPPENED TO ME IN THE HOSPITAL?
- We monitored your heart activity on telemetry, and you had a
normal heart rate, but you had some irregular beats, which may
have been causing your heart rate to read lower than it actually
was.
- We found that your blood sugar was very low, which is likely
why you were feeling dizzy.
- We gave you a heart monitor called a ___, which Dr. ___
will follow up. This will look for slow or irregular heart
rates.
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
- Please continue to take all of your medications and follow-up
with your appointments as listed below.
- Please check your blood sugar at least 4 times daily at home,
to ensure that your sugar levels are not dropping too low.
- Weigh yourself every morning, call MD if weight goes up more
than 3 lbs.
We wish you the best!
Followup Instructions:
___
|
19678269-DS-10
| 19,678,269 | 29,215,690 |
DS
| 10 |
2187-02-15 00:00:00
|
2187-02-16 17:02:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins / metformin / glypizide / Aciphex / blood pressure
medications / perfume / black dye
Attending: ___.
Chief Complaint:
fatigue
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ yo M with history of HTN, HLD, IDDM2, inflammatory colitis,
and inflammatory arthritis presenting with persistent severe
fatigue.
Patient reports that he has had persistent fatigue, severe
enough to prevent him from working for the last 10 weeks. He
reports that he thinks the initial symptoms started in
___ after starting on Cimzia (certolizumab for
inflammatory colitis and arthritis). His last dose of cimzia was
given in ___ however his symptoms have persisted since that
time with multiple ED visits and PCP appointments for extensive
work-up.
In terms of patient's description of symptoms, he reports he
gets extreme fatigue with any movement and exertion. He has had
to stop working due to extreme fatigue, unable to stand for long
periods of time due to his symptoms. He denies symptoms of
fevers, chills, cough, chest pain, palpitations, abdominal pain,
nausea, vomiting, focal weakness or parasthesias. He does note
dyspnea on exertion wtihout orthopnea or PND, related to his
fatigue. He also describes a ___ weight gain since ___,
dizziness after walking for long periods and frontal headaches
with walking for long period.
In terms of medications, patient reports that after stopping
cimzia, he was started on prednisone for symptoms of
colitis/arthritis in ___ (initially 20mg dialy, now down to
15mg daily). He has also been taking benadryl for last several
months due to "hay fever". He notes significant allergies to
drugs and food, currently on a no gluten, no soy, no lactose
diet for last several years due to self-diagnosed allergies.
Patient's outpatient work-up to date has included evaluation by
PCP, rheumatology and gastroenterology. He has had work-up for
pancreatic mass thought to be most likely related to prior
pancreatitis but not definitively diagnosed. His labs have
included the following in ___ system per review by ___
(resident) on prior ED evaluation in ___:
-transaminitis 100-200 in ___ negative hepatitis screen
-EBV IgG pos, IgM neg
-CMV IgG, IgM negative
-Ceruloplasmin normal
-A1AT normal
-TTG IgA normal
-___, Antismooth muscule normal
-AM cortisoL 12.8, within normal range
-CK within normal limits
-CRP normal
-heterophile antibody negative
-vitamin 25OH D low (18), calcium 9.6
-Abdominal ultrasound with evidence of fatty infiltration,
complex cyst in left kidney
Todya, patient presented to PCP with worsening fatigue such that
he had an episode where he almost fell due to fatigue (no
dizziness) prompting referal to ED for evaluation and admission.
In the ED initial vitals were: 97.7 156/50 89 18 94%RA.
- Labs were significant for WBC 10.0 with normal H/H and
platelets. Normal chemistries, ALT mildly elevated at 45, other
LFTs stable, CRP 5.9, CK 325 and trop <0.01 with lactate 1.0. UA
negative for UTI.
-CXR without evidence of acute disease
- Patient was given 1L NS, prednisone 15mg (home dose), home PO
and PR mesalamine.
-Patient was seen by neurology who did complete exam including
provocative maneuvers for myasthenia and guillane-baire and felt
that without inducible weakness and given time line of symptoms
with normal neuro exam, would be incredibly unlikely to be
either diagnosis.
-Due to the fact taht patient has had prolonged work-up for
cause of patient's significant fatigue, patient's PCP felt
strongly that patient should be admitted for further evaluation,
particularly because of debilitating nature of patient's
symptoms. Particularly, PCP hoping for evaluation by neurology,
possible GI evaluation for colitis progression leading to
symptoms and possible EUS for pancreatic mass.
Vitals prior to transfer were: 98 88 125/85 16 96% RA.
On the floor, initial vitasl 97.7 156/50 89 18 94%RA. Patient
reports mild headache but otherwise feels somewhat improved
given he has been resting in ED all day.
Past Medical History:
-Hypertension
-Hyperlipidemia
-Insulin-dependent diabetes type 2
-Inflammatory colitis
-Inflammatory arthritis
-Transaminitis
-History of tobacco abuse
Social History:
___
Family History:
Colon cancer in father
Physical Exam:
=================
ADMISSION EXAM
=================
Vitals - 97.7 156/50 89 18 94%RA
GENERAL: NAD, lying comfortably in bed, pleasant, mildly anxious
HEENT: EOMI, PERRL, anicteric sclera, pink conjunctiva, MMM,
good dentition
NECK: nontender supple neck, no LAD, JVD to just above clavicle
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs
LUNG: CTAB, no wheezes, rales, rhonchi, good air movement
ABDOMEN: nondistended, hyperactive bowel sounds, nontender in
all quadrants, no rebound/guarding, no hepatosplenomegaly
EXTREMITIES: trace edema at ankles bilaterally, moving all 4
extremities with purpose
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact, ___ strength in b/l upper and lower
extremities, normal sensation to light touch over b/l lower
extremities
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
=================
DISCHARGE EXAM
=================
Vitals: T: 97.9 BP: 130-160/50-80s P: 80-90s R: 18 O2: 98% on RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, ruddy cheeks
Neck: supple, no LAD, JVD 2cm above clavicle
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: central adioposity, soft, non-tender, non-distended,
bowel sounds present, no rebound tenderness or guarding, no
organomegaly
Ext: thin extremities relative to torso, Warm, well perfused, 2+
pulses, no clubbing, cyanosis or edema
Neuro: A&Ox3, ___ strength upper and lower extremities, CN2-12
intact, ambulating.
Pertinent Results:
===================
ADMISSION LABS:
===================
___ 05:00PM BLOOD WBC-10.0 RBC-5.12 Hgb-16.2 Hct-48.6
MCV-95 MCH-31.7 MCHC-33.4 RDW-14.3 Plt ___
___ 05:00PM BLOOD Neuts-81.5* Lymphs-10.5* Monos-5.6
Eos-1.9 Baso-0.5
___ 05:00PM BLOOD Glucose-178* UreaN-21* Creat-0.9 Na-139
K-3.9 Cl-102 HCO3-24 AnGap-17
___ 05:00PM BLOOD ALT-45* AST-27 CK(CPK)-325* AlkPhos-60
TotBili-0.4
___ 05:00PM BLOOD cTropnT-<0.01
___ 05:00PM BLOOD Lipase-22
___ 05:00PM BLOOD Albumin-4.5 Calcium-9.9 Phos-2.7 Mg-2.1
___ 05:00PM BLOOD CRP-5.9*
___ 05:19PM BLOOD Lactate-1.9
=================
IMAGING
=================
CXR ___: FINDINGS: The heart is normal in size. The
mediastinal and hilar contours appears within normal limits.
The lungs appear clear. There is no pleural effusions or
pneumothorax.
IMPRESSION: No evidence of acute disease.
=================
DISCHARGE LABS
=================
___ 06:05AM BLOOD WBC-9.1 RBC-4.88 Hgb-15.3 Hct-46.5 MCV-95
MCH-31.4 MCHC-32.9 RDW-14.3 Plt ___
___ 06:05AM BLOOD ___ PTT-28.1 ___
___ 06:05AM BLOOD Glucose-72 UreaN-14 Creat-0.8 Na-141
K-3.9 Cl-104 HCO3-27 AnGap-14
___ 06:05AM BLOOD ALT-41* AST-27 AlkPhos-56 TotBili-0.6
___ 06:05AM BLOOD Calcium-9.4 Phos-3.2 Mg-2.3
================
Workup to date:
================
LABS:
___:
Heterophile (monospot) : negative
Cortisol AM : normal
Blood culture : no growth, 5 days
CRP Quantitative : Normal
CK assapy (CPK) : Normal
Vitamin D 25-hydroxy total plus D2 D3: Deficient 18 (___)
EGFR > 60
___:
LFTs: AST 107, ALT 232
___:
___ screen: negative
Anti-smooth muscle antibody IgG: negative
(looking for autoimmune hepatitis)
___:
IgA : normal
TTG IgA: negative
EBV antibody panel : consistent with previous infection
CMV antibodies (IgG and IgM) : negative
Alpha 1 antitrypsin : normal
Ceruloplasmin : normal
Hepatitis Screen: Patient not immune to infection with HBV; no
evidence of infection with HAV, HBV or HCV
Hepatic function panel: AST 90, ALT 185; alk phos, bili,
albumin, total protein wnl
___:
Hepatic function panel: AST 36, ALT 73; alk phos, bili, albumin,
total protein wnl
___:
TSH: normal
___:
Serum lipase: normal
Amylase: normal
Anaplasma (IgG, IgM): no significant antibodies detected
Babesia (IgG, IgM): no significant antibodies detected
Ehrlichia (IgG, IgM): no significant antibodies detected
Lyme antibody: negative
Ca ___: elevated 48.1 (0.0 - 36.9 U/mL)
Hepatic function panel: AST, ALT, alk phos, bili, albumin, total
protein wnl
Blood culture (2 specimens sent) : no growth, 5 days
___:
LDH: normal
TSH: normal
Cortisol serum: low, 2.7 (6.7 - 22.6 ug/dL)
___:
Manual differential:
NEUTROPHILS-MANUAL (45 - 73) % 74 (H)
BANDS (0 - 8) % 4
LYMPHOCYTES MANUAL (25 - 50) % 7 (L)
MONOCYTES MANUAL (1 - 10) % 10
EOSINOPHILS MANUAL (1 - 3) % 2
ATYPICAL LYMPH( 0 - 2) % 1
MYELOCYTE % 2 (A)
PLATELET ESTIMATE Appears Normal
MORPHOLOGY Normal
CRP: normal
ESR: elevated 17 (0-15mm/hr)
CK assay: normal
Pending (drawn ___:
Lyme disease screen w/ reflex western blot
Acetylcholine receptor antibody
Anti-striated muscle antibody
Blood culture (2 samples)
IMAGING:
___: Referred for flexible sigmoidoscopy, not followed up
___: Abdominal US
1. Diffuse fatty infiltration of liver is documented.
2. Possible new complex cystic focus in the lower pole of the
left kidney, not present on the prior CT and warranting further
assessment with contrast-enhanced CT or MRI.
___: Abdomen CT w and w/o contrast
1. Abnormal appearance of the pancreas. MRI evaluation is
recommended with contrast to exclude a pancreatic mass.
2. No CT evidence of renal lesion. As the previously noted left
renal abnormality is demonstrated sonographically followup left
renal ultrasound is recommended in 3 months to document
stability.
___: ABDOMEN / MRCP MRI W/O + W/ CONTRAST
Findings are compatible with chronic pancreatitis with likely
superimposed recent acute pancreatitis in the pancreatic body
and tail and resulting focal area of necrosis in the pancreatic
tail. In the pancreatic head and uncinate process no focal
lesion is noted. Followup CT of the abdomen with pancreatic
protocol is recommended in 3 months.
Brief Hospital Course:
___ yo M with history of HTN, HLD, IDDM2, inflammatory colitis,
and inflammatory arthritis presenting with persistent severe
fatigue. His symptoms improved after discontinuing
diphenhydramine and he was discharged home.
==============
ACUTE ISSUES:
==============
#Severe Fatigue: He was referred to the ED due to worsening of
his fatigue of the last 10 weeks. He was evaluated by neurology
who felt pt's condition was not due to myasthenia ___,
Guillain-Barré syndrome, or any other neurological condition.
Labs were checked which were notable for a normal troponin,
normal WBC count, mildly elevated CRP at 5.9, unremarkable UA
and CXR. Pt noted that he had been taking diphenhydramine 25mg
q6h for several months, and given the possible contribution to
his fatigue, this was stopped. Pt denied symptoms consistent
with UC flare. Over the course of his admission, pt reported
great improvement in his symptoms, and was able to walk around
the unit to another building without assistance. As it was a
___, pt was unable to obtain EUS or stress ECHO as
requested by PCP. Pt preferred to leave the hospital rather than
wait until ___ for these studies, especially given his great
improvement.
==============
CHRONIC ISSUES:
==============
# Ulcerative colitis: Continued mesalamine 800mg BID, Continued
prednisone 15mg daily, consider tapering in future. Continued
canasa 1000mg rectally qpm
# Inflammatory arthritis:
-Continue ibuprofen prn:
TRANSITIONAL ISSUES:
-pt's diphenhydramine was stopped given its contribution to his
fatigue
-consider EUS, stress ECHO as an outpatient
-consider tapering prednisone in the future as it may contribute
to fatigue
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. DiphenhydrAMINE 25 mg PO Q6H:PRN hay fever
2. Mesalamine (Rectal) 1000 mg PR HS
3. Bismuth Subsalicylate 15 mL PO TID:PRN upset stomach
4. Ibuprofen 600 mg PO Q8H:PRN joint pain
5. Glargine 65 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
6. PredniSONE 15 mg PO DAILY
7. Mesalamine ___ 800 mg PO BID
Discharge Medications:
1. Ibuprofen 600 mg PO Q8H:PRN joint pain
2. Mesalamine ___ 800 mg PO BID
3. Mesalamine (Rectal) 1000 mg PR HS
4. PredniSONE 15 mg PO DAILY
5. Bismuth Subsalicylate 15 mL PO TID:PRN upset stomach
6. Glargine 65 Units Dinner
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
severe fatigue
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was our pleasure caring for you during your recent
hospitalization at ___. You
were admitted due to severe fatigue. You were seen by the
neurology team, who felt your symptoms were not due any
neurological dysfunction. We checked labs, which were within
normal limits. We stopped the benadryl you were taking, and you
started feeling better after that, and were able to walk around
the hospital floor.
You should follow-up with your primary care doctor about getting
the endoscopic ultrasound to look at your pancreas, and the
stress ECHO test to look at the heart's function.
Please do not take benadryl anymore, as it seems that you had a
severe reaction to it.
We wish you all the best.
-Your ___ Team
Followup Instructions:
___
|
19678533-DS-11
| 19,678,533 | 21,425,254 |
DS
| 11 |
2114-10-21 00:00:00
|
2114-10-22 22:46:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
Facial Droop/ Dysarthria
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ year old female with history of dementia,
hypertension, frequent falls, who initially presented to ___
___ on ___ with right facial droop and slurred speech,
code stroke called, with ___ showing possible 3 mm right
lateral medulla petechial hemorrhage versus artifact. She
was also noted to have severe anemia with Hb/HCT 3.6/___,
transfused 2 units PRBC and transferred to ___ for further
management given severe anemia and possible acute stroke.
Past Medical History:
Hypertension
Dementia
Hyponatremia
Hypothyroidism
Left fifth metatarsal fracture
T11 compression fracture
Right BRCA
Status post cholecystectomy
Right Bell palsy
Social History:
___
Family History:
Non-contributory
Physical Exam:
ADMISSION PHYSICAL EXAM
=======================
Vitals: T 97.6 149/65 104 18 97 Ra
GENERAL: Comfortable, in NAD
HEENT: NC/AT, PERRLA, EOMI. Scleral pallor
NECK: Supple, no lymphadenopathy, no elevated JVD
CARDIAC: Tachycardic, regular rhythm, no murmurs, rubs, or
gallops
LUNGS: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
ABDOMEN: Soft, NT/ND. Normoactive bowel sounds. No evidence of
organomegaly
EXTREMITIES: 2+ peripheral pulses, no C/C/AT
NEUROLOGIC: +right facial drop. Dysarthria. Other CN intact.
Motor strength ___ in all 4 extremities. Sensation intact
SKIN: No rashes, ulceration, or evidence of skin breakdown
DISCHARGE PHYSICAL EXAM
=======================
Vitals: ___ 0734 Temp: 97.6 PO BP: 122/64 HR: 77 RR: 18 O2
sat: 94% O2 delivery: Ra
PHYSICAL EXAM:
GENERAL: Elderly female resting in bed in NAD. Has EEG leads on.
HEENT: NC/AT, EOMI. Scleral pallor, Moist mucous membranes.
NECK: Supple, no lymphadenopathy, JVP not elevated.
CARDIAC: Regular rate, regular rhythm, no murmurs, rubs, or
gallops
LUNGS: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
ABDOMEN: Soft, non-tender, non-distended. +Bowel Sounds.
EXTREMITIES: 2+ peripheral pulses, no C/C/AT
NEUROLOGIC: +right facial drop. +tongue deviation to right.
Dysarthria. Other CN intact. Motor strength ___ in all 4
extremities. Sensation intact.
SKIN: No rashes, ulceration, or evidence of skin breakdown
Pertinent Results:
DISCHARGE LAB WORK
==================
___ 07:20AM BLOOD WBC-6.7 RBC-3.11* Hgb-7.7* Hct-25.6*
MCV-82 MCH-24.8* MCHC-30.1* RDW-22.2* RDWSD-63.1* Plt ___
___ 07:20AM BLOOD Plt ___
___ 07:20AM BLOOD ___ PTT-25.4 ___
___ 07:20AM BLOOD Glucose-89 UreaN-14 Creat-0.8 Na-137
K-4.2 Cl-105 HCO3-22 AnGap-10
___ 07:20AM BLOOD Calcium-8.1* Phos-2.2* Mg-2.2
ADMISSION LAB WORK:
===================
___ 06:25PM BLOOD WBC-9.1 RBC-2.34* Hgb-5.2* Hct-17.6*
MCV-75* MCH-
22.2* MCHC-29.5* RDW-18.0* RDWSD-49.0* Plt ___
___ 06:25PM BLOOD Neuts-70.4 Lymphs-18.6* Monos-9.5
Eos-0.7* Baso-0.2 NRBC-0.9* Im ___ AbsNeut-6.40*
AbsLymp-1.69 AbsMono-0.86* AbsEos-0.06 AbsBaso-0.02
___ 06:25PM BLOOD Plt ___
___ 06:25PM BLOOD Ret Aut-1.70 Abs Ret-0.0413
___ 06:25PM BLOOD Glucose-102* UreaN-37* Creat-0.9 Na-142
K-4.7 Cl-108 HCO3-19* AnGap-15
___ 06:25PM BLOOD ALT-9 AST-15 AlkPhos-55 TotBili-1.0
___ 11:30PM BLOOD CK-MB-<1 cTropnT-<0.01
___ 06:25PM BLOOD cTropnT-<0.01
___ 06:25PM BLOOD Albumin-3.4* Calcium-9.1 Phos-4.0 Mg-2.3
Iron-56
___ 06:25PM BLOOD calTIBC-394 VitB12-1757* Folate->20
___ Ferritn-5.2* TRF-303
___ 07:20AM BLOOD %HbA1c-5.0 eAG-97
___ 07:20AM BLOOD Triglyc-97 HDL-47 CHOL/HD-2.5 LDLcalc-50
___ 06:25PM BLOOD cTropnT-<0.01
___ 11:30PM BLOOD CK-MB-<1 cTropnT-<0.01
IMAGING AND OTHER STUDIES:
==========================
* CT Head WO Contrast (___) ___:
1. No subacute infarct identified.
2. Question of a 3 mm area of petechial hemorrhage versus
artifact in the right lateral medulla.
* CXR ___: No acute pulmonary infiltrates.
* MRI HEAD
-----------
There is no evidence of acute infarction. No intracranial
hemorrhage. No
mass, mass effect, edema or midline shift. The ventricles and
sulci are enlarged. Periventricular and subcortical white
matter FLAIR hyperintensities are noted, a nonspecific finding
that most likely represents the sequelae of chronic small
vessel ischemic disease. There is gross preservation of the
principal intracranial vascular flow voids. Mild mucosal
thickening is seen throughout scattered ethmoid air cells and
within the bilateral maxillary sinuses. The frontal sinuses are
underpneumatized. The remainder of the visualized paranasal
sinuses, middle ear cavities, and mastoid air cells are well
aerated and clear. Patient is status post bilateral lens
replacement.
1. No evidence for vascular territorial infarction. No acute
intracranial
hemorrhage.
2. Global parenchymal volume loss and evidence of chronic small
vessel
ischemic disease.
* EEG:
------
This is an abnormal continuous ICU EEG monitoring study because
of slow background activity in the theta/delta range with poorly
sustained
slow posterior dominant rhythm. This is indicative of mild to
moderate
diffuse encephalopathy. Common causes are medications effect,
toxic metabolic disturbances, or infections. This recording
captured no pushbutton activations, epileptiform discharges or
electrographic seizures.
* CTA HEAD AND NECK
-------------------
CT HEAD WITHOUT CONTRAST:
There is no evidence of acute large territory infarction,
hemorrhage, edema, or mass. The ventricles and sulci are
prominent compatible with age-related involutional changes. The
visualized portion of the paranasal sinuses, mastoid air cells,
and middle ear cavities are clear. The visualized portion of the
orbits are unremarkable.
CTA HEAD: Punctate vascular arteriosclerotic calcifications are
visualized in the carotid siphons bilaterally, however, the
vessels of the circle of ___ and their principal intracranial
branches appear patent l without stenosis, occlusion, or
aneurysm formation. The dural venous sinuses are patent.
CTA NECK: Atherosclerotic calcifications are visualized within
the bilateral bulbs and carotid side with no substantial
stenosis or occlusion identified. The vertebral arteries and
their major branches appear normal with no evidence of stenosis
or occlusion. There is no evidence of internal carotid stenosis
by NASCET criteria. Motion artifacts are visualized in the
ascending aorta (image 1, series 3), partially evaluated in this
exam, if clinically warranted, correlation with CTA of the chest
is recommended.
OTHER:
Bilateral scarring is visualized the lung apices. The
visualized portion of the thyroid gland is prominent though
otherwise within normal limits. There is no lymphadenopathy by
CT size criteria.
IMPRESSION:
1. No acute intracranial abnormality identified.
2. No focal stenosis, occlusion, or aneurysm formation
identified within the head or neck.
Brief Hospital Course:
Ms. ___ is a ___ year old female with history of dementia,
hypertension, and frequent falls, who initially presented to ___
___ on ___ with right facial droop and slurred speech
and NCHCT showing possible 3 mm right lateral medulla petechial
hemorrhage versus artifact. She was also found to have severe
anemia HgB/HCT 3.6/15. She received 2U PRBC prior to transfer
with post transfusion hemoglobin 5.2 and was admitted to ___
for possible stroke and anemia workup.
#Anemia
#?Lower GI Bleed
The patient initially presented with severe anemia HgB/HCT
___ at ___. She received a 2 U PRBC transfusion with
a post-transfusion HgB of 5.2. Upon arrival to ___ she
received an additional 2units with bump to 8.1. The patient was
found to be stool guaiac positive in the ED and GI was
consulted. Per GI, no role for urgent scope given the
possibility of acute stroke at that time. She was started on an
IV PPI BID, her aspirin was held, and she was admitted to
medicine. Her stroke work up was negative (see below), and GI
was reconsulted. The patient's family was unsure if having an
endoscopy was within the patient's goals of care, and given that
the patient's HgB had stabilized between 7.5-8.5 and that she
was hemodynamically stable, the decision was made to defer an
endoscopy while inpatient and have close follow up with GI. The
patient's iron studies were consistent with severe iron
deficiency anemia and she was given one dose of IV iron and
started on PO iron supplementation upon discharge. Prior to
discharge she was restarted on ASA at a lower dose (81mg PO QD
instead of her home 325mg PO QD). She was discharged with
instructions to follow up with her PCP and GI next week and with
plans for a repeat CBC early next week. Of note, on the day of
discharge, the patient endorsed having vaginal bleeding and
"periods" prior to this admission (although no vaginal bleeding
noted while inpatient). She should have a follow up appointment
with GYN or GYN/ONC to evaluate for a possible uterine/GU
malignancy as a cause of her severe anemia.
#R facial droop
#Dysarthria
The patient initially presented to ___ with right-sided
facial droop and dysarthria. A code stroke was called and she
had a ___ showing a possible 3 mm right lateral medulla
petechial hemorrhage versus artifact. She was transferred to
___ and neurology was consulted in the ED and recommended a
CTA. The CTA Head and Neck showed no obvious medulla hemorrhage
or other acute findings. The patient subsequently had a MRI
brain which did not show any evidence of an acute stroke. Per
neurology recommendations, an EEG was done which showed diffuse
slowing but no seizure activity. Upon speaking with her family,
they felt that her neurologic state and exam was consistent with
her baseline and did not notice any acute changes. Given the
negative work up as detailed above, the patient's symptoms were
thought to be secondary to a TIA vs. secondary to severe anemia
vs. progression of her known neurologic deficits and facial
droop.
# EKG Changes
On arrival to the medical floor the patient had an EKG showing
TWI v1-v6, with ___epressions in anterolateral leads which
were new compared to an EKG done upon presentation to ___
___. The patient had no chest pain and her previous
troponins drawn in ED were negative. This was thought to be
demand EKG changes in the setting of severe anemia.
#HTN
The patient is on Amlodipine 5mg PO QD and Lisinopril 10mg PO QD
per fill history which were held while inpatient, but resumed
upon discharge,
TRANSITIONAL ISSUES:
[] The patient should follow up with her PCP (appointment
arranged) and will need to have a CBC drawn early next week
(___). If down trending patient may need more urgent GI
intervention appointment. If down trending ASA should be
stopped.
[] The patient needs to have GYN follow up or GYN/ONC follow up.
On the day of discharge she endorsed having vaginal bleeding and
periods while at home prior to admission. Concerned for possible
GU malignancy contributing to her anemia.
[] Patient will need GI follow up and possible EGD - family is
still discussing whether this will be within goals of care:
[] Discuss goals of care and if procedures such as an EGD are
within her goals of care
[] Discuss utility of adding on a statin given patient's
vascular disease (including possible TIA, aortic and other major
blood vessel calcification on CTA).
[] Discuss long term utility of ASA
[] Amlodipine and lisinopril held; restart if needed for BP
control (has been normotensive without them here)
[] recheck A1c and lipids as outpatient
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. QUEtiapine Fumarate 25 mg PO QHS
2. Lisinopril 10 mg PO DAILY
3. amLODIPine 5 mg PO DAILY
4. Aspirin 325 mg PO DAILY
5. Vitamin D 1000 UNIT PO DAILY
6. Metoprolol Tartrate 25 mg PO BID
Discharge Medications:
1. Omeprazole 40 mg PO BID
RX *omeprazole 40 mg 1 capsule(s) by mouth twice a day Disp #*60
Capsule Refills:*2
2. Aspirin 81 mg PO DAILY
3. amLODIPine 5 mg PO DAILY
4. Lisinopril 10 mg PO DAILY
5. Metoprolol Tartrate 25 mg PO BID
6. QUEtiapine Fumarate 25 mg PO QHS
7. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Acute GI Bleed
TIA
Bells Palsy
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. ___,
It was a pleasure caring for you at ___.
WHY WAS I IN THE HOSPITAL?
- You were admitted to the hospital because you were found to
have new signs and symptoms concerning for a stroke as well as
very low blood levels (anemia)
WHAT HAPPENED TO ME IN THE HOSPITAL?
- While you were in the hospital you had multiple scans of your
head (including 2 CT scans and an MRI) which showed that you did
not have a stroke.
- Our neurologists saw you and recommended getting a study
called an EEG to see if your signs & symptoms were due to a
seizure. This showed no seizures.
- You were given 4 units of blood which helped correct your
anemia (low blood levels)
- You were seen by the GI doctors who ___ that your low blood
levels were due to bleeding from you gastrointestinal tract.
- You were given a medication to help stop/prevent bleeding.
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
- Continue to take all your medicines and keep your
appointments.
- You need to follow up with your primary care doctor and the
gastroenterology (GI) doctors.
- You should continue to take all of your medications exactly as
prescribed.
- See the sections as below for a list of all of your follow up
appointments and medications
We wish you the best!
Sincerely,
Your ___ Team
Followup Instructions:
___
|
19678553-DS-15
| 19,678,553 | 24,470,757 |
DS
| 15 |
2121-06-21 00:00:00
|
2121-06-21 21:33:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
L ankle pain
Major Surgical or Invasive Procedure:
ORIF left ankle fracture
History of Present Illness:
___ is a ___ female with hx of osteoporosis depression who
presents status post mechanical fall on ice with immediate onset
left ankle pain. Inability to bear weight. Denies head strike
or LOC. Denies any numbness or tingling in the left foot.
Past Medical History:
osteoporosis
depression
Social History:
___
Family History:
non-contributory
Physical Exam:
Exam: alert to voice, no distress
Vitals: ___ ___ Temp: 100.7 PO BP: 137/71 R Lying HR: 80
RR: 24 O2 sat: 94% O2 delivery: room air
General: Well-appearing, breathing comfortably
MSK: LLE: moves toes spontaneously, sensation slowly returning
per pt; well-perfused in splint
Pertinent Results:
none
Brief Hospital Course:
The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have a left ankle fracture and was admitted to the orthopedic
surgery service. The patient was taken to the operating room on
___ for ORIF left ankle, which the patient tolerated well. For
full details of the procedure please see the separately dictated
operative report. The patient was taken from the OR to the PACU
in stable condition and after satisfactory recovery from
anesthesia was transferred to the floor. The patient was
initially given IV fluids and IV pain medications, and
progressed to a regular diet and oral medications by POD#1. The
patient was given ___ antibiotics and anticoagulation
per routine. The patient's home medications were continued
throughout this hospitalization. The patient worked with ___ who
determined that discharge to home was appropriate. The ___
hospital course was otherwise unremarkable.
At the time of discharge the patient's pain was well controlled
with oral medications, incisions were clean/dry/intact, and the
patient was voiding/moving bowels spontaneously. The patient is
nonweightbearing in the left lower extremity, and will be
discharged on aspirin for DVT prophylaxis. The patient will
follow up with Dr. ___ routine. A thorough discussion
was had with the patient regarding the diagnosis and expected
post-discharge course including reasons to call the office or
return to the hospital, and all questions were answered. The
patient was also given written instructions concerning
precautionary instructions and the appropriate follow-up care.
The patient expressed readiness for discharge.
Medications on Admission:
Medications - Prescription
ALENDRONATE - alendronate 70 mg tablet. 1 Tablet(s) by mouth q
week - (Prescribed by Other Provider)
FLUOXETINE - fluoxetine 20 mg tablet. 1 tablet(s) by mouth daily
- (Prescribed by Other Provider; Dose adjustment - no new Rx)
Medications - OTC
DEXTRAN 70-HYPROMELLOSE [ARTIFICIAL ___ -
Artificial Tears (dextran 70-hypromellose) 0.1 %-0.3 % eye
drops.
1 drop both eyes four times a day
LORATADINE [CLARITIN] - Claritin 10 mg tablet. 1 tablet(s) by
mouth as needed - (___)
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
RX *acetaminophen 500 mg 2 tablet(s) by mouth q8hr Disp #*90
Tablet Refills:*0
2. Aspirin 325 mg PO DAILY
RX *aspirin 325 mg 1 tablet(s) by mouth once a day Disp #*28
Tablet Refills:*0
3. Calcium Carbonate 1250 mg PO TID
RX *calcium carbonate 500 mg calcium (1,250 mg) 1 tablet(s) by
mouth three times a day Disp #*90 Tablet Refills:*0
4. 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
5. OxyCODONE (Immediate Release) 2.5-5 mg PO Q4H:PRN Pain -
Severe
RX *oxycodone 5 mg ___ tablet(s) by mouth q4hr Disp #*15
Tablet Refills:*0
6. Senna 8.6 mg PO BID
RX *sennosides [Evac-U-Gen (sennosides)] 8.6 mg 1 tablet by
mouth twice a day Disp #*60 Tablet Refills:*0
7. Vitamin D 800 UNIT PO DAILY
RX *ergocalciferol (vitamin D2) 400 unit 2 tablet(s) by mouth
once a day Disp #*60 Tablet Refills:*0
8. FLUoxetine 20 mg PO DAILY
9. Loratadine 10 mg PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Left ankle fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY:
- You were in the hospital for orthopedic surgery. It is normal
to feel tired or "washed out" after surgery, and this feeling
should improve over the first few days to week.
- Resume your regular activities as tolerated, but please follow
your weight bearing precautions strictly at all times.
ACTIVITY AND WEIGHT BEARING:
-Nonweightbearing to the left lower extremity in a splint
MEDICATIONS:
- Please take all medications as prescribed by your physicians
at discharge.
- Continue all home medications unless specifically instructed
to stop by your surgeon.
- Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
- Narcotic pain relievers can cause constipation, so you should
drink eight 8oz glasses of water daily and take a stool softener
(colace) to prevent this side effect.
ANTICOAGULATION:
- Please take aspirin 325 mg daily for 4 weeks
WOUND CARE:
- You may shower. No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- Please remain in your dressing and do not change unless it is
visibly soaked or falling off.
- Splint must be left on until follow up appointment unless
otherwise instructed
- Do NOT get splint wet
DANGER SIGNS:
Please call your PCP or surgeon's office and/or return to the
emergency department if you experience any of the following:
- Increasing pain that is not controlled with pain medications
- Increasing redness, swelling, drainage, or other concerning
changes in your incision
- Persistent or increasing numbness, tingling, or loss of
sensation
- Fever > 101.4
- Shaking chills
- Chest pain
- Shortness of breath
- Nausea or vomiting with an inability to keep food, liquid,
medications down
- Any other medical concerns
THIS PATIENT IS EXPECTED TO REQUIRE <30 DAYS OF REHAB
FOLLOW UP:
Please follow up with your Orthopaedic Surgeon, Dr. ___.
You will have follow up with ___, NP in the
Orthopaedic Trauma Clinic 14 days post-operation for evaluation.
Call ___ to schedule appointment upon discharge.
Please follow up with your primary care doctor regarding this
admission within ___ weeks and for and any new
medications/refills.
Physical Therapy:
Nonweightbearing to the left lower extremity in a splint
Treatments Frequency:
Splint will remain in place until follow-up appointment. Please
keep splint dry. If you have any concerns with the splint,
please call the ___ clinic at the number provided.
Followup Instructions:
___
|
19678570-DS-22
| 19,678,570 | 21,638,626 |
DS
| 22 |
2161-06-15 00:00:00
|
2161-06-19 23:38:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
morphine / Demerol / Oxycodone
Attending: ___
Chief Complaint:
crushing chest pain
Major Surgical or Invasive Procedure:
cardiac catheterization ___
History of Present Illness:
___ w/ PMH of diabetes mellitus, CAD (stent in ___ at ___),
hypertension, hyperlipidemia, and L humeral fracture s/p recent
ORIF, now here with severe L sided chest and epigastric pain.
Pt reports he was awoken from sleep yesterday morning by severe
sudden onset left arm and epigastric pain. Arm pain was ___ in
intensity and did not radiate. Pt took hydromorphone 2mg po x 2
without relief. Pt also had ___ epigastric, sharp burning,
non-radiating pain, which seems to have improved with H2
blocker. Pt then came to ED for evaluation.
In the ED, initial vitals were 96.9 61 172/71 18 97%. ECG at
8.30am on ___ showed NSR w/ t-wave flattening in I, II, aVL,and
precordial leads relative to ___ ECG. Both had q waves in
inferior leads. Pt was evaluated by orthopedics, who felt that
plain films and exam suggested overuse as a cause for his arm
pain. Pt had a d-dimer ___hest was obtained, which
showed no pulmonary embolism or aortic pathology. Pt's first two
troponins were negative, and he was placed into observation for
nuclear stress test in the morning.
However, at 0400 on ___, he reported return of his arm pain and
epigastric pain. Pt was treated with GI cocktail and
hydromorphone but was found 30 minutes later w/ ___ "burning
and crushing" chest pain with dynamic EKG changes (STD/TWI v2-4,
improved with nitro, post leads negative). Cardiology was
consulted. Pt was started on heparin drip and nitro drip and
admitted to cardiology.
On arrival to the floor, patient states pain has largely
resolved.
Past Medical History:
1. CARDIAC RISK FACTORS:
-Diabetes
-Dyslipidemia
-Hypertension
2. CARDIAC HISTORY:
-PERCUTANEOUS CORONARY INTERVENTIONS: stent in ___ at ___ in
OM and DESx1 in L-PDA
3. OTHER PAST MEDICAL HISTORY:
-BPH
-Overactive bladder
-GERD
-Depression
-Smoking history
-L humeral fracture s/p ORIF
Social History:
___
Family History:
Father died from CAD, DM
Physical Exam:
PHYSICAL EXAMINATION:
VS: 99.1 157/63 76 18 100ra 126.2kg
GEN: NAD
HEENT: NC/AT, sclerae anicteric, MMM
NECK: supple, no LAD, JVP 8 cm
LUNGS: CTA bilateral
HEART: RRR; no murmurs, rubs or gallops; nl S1-S2
CHEST: mild TTP epigastrium
ABDOMEN: normal bowel sounds, soft; mild tenderness to palpation
in epigastrium
EXT: no peripheral edema, normal distal pulses
Pertinent Results:
ADMISSION
___ 08:26AM BLOOD WBC-4.0 RBC-4.42* Hgb-12.7* Hct-36.8*
MCV-83 MCH-28.9 MCHC-34.6 RDW-14.4 Plt ___
___ 08:26AM BLOOD Glucose-134* UreaN-22* Creat-0.9 Na-138
K-4.9 Cl-101 HCO3-22 AnGap-20
___ 08:26AM BLOOD ALT-23 AST-43* AlkPhos-30* TotBili-0.3
___ 08:26AM BLOOD Lipase-41
___ 10:55AM BLOOD Calcium-9.1 Phos-4.3 Mg-1.3*
PERTINENT
___ 08:26AM BLOOD D-Dimer-700*
___ 08:26AM BLOOD cTropnT-<0.01
___ 02:30PM BLOOD cTropnT-<0.01
___ 10:55AM BLOOD CK-MB-3 cTropnT-0.03*
___ 06:10PM BLOOD CK-MB-2 cTropnT-0.01
___ 10:55 am SEROLOGY/BLOOD
**FINAL REPORT ___
HELICOBACTER PYLORI ANTIBODY TEST (Final ___:
NEGATIVE BY EIA.
(Reference Range-Negative).
DISCHARGE
___ 06:18AM BLOOD WBC-3.5* RBC-4.13* Hgb-12.2* Hct-34.6*
MCV-84 MCH-29.5 MCHC-35.2* RDW-14.1 Plt ___
___ 06:18AM BLOOD Glucose-115* UreaN-14 Creat-0.9 Na-137
K-4.7 Cl-101 HCO3-27 AnGap-14
___ 06:18AM BLOOD Calcium-9.4 Phos-4.5 Mg-1.9
CTA CHEST W&W/O C&RECONS ___ 1:43 ___
COMPARISON: ___.
FINDINGS: The pulmonary arterial tree is well opacified without
evidence of
filling defect to suggest pulmonary embolus. The aorta and
major branches are
patent and normal in caliber without evidence of acute aortic
pathology.
Minimal atherosclerotic calcifications are seen. Mild to
moderate coronary
vascular calcifications are noted. The heart and pericardium are
unremarkable
with trivial pericardial fluid. The esophagus is unremarkable.
There is no
pathologic mediastinal, hilar or axillary lymphadenopathy with
unchanged
lobulated low-attenuation lesion posterior to the superior vena
cava, most
likely a bronchogenic cyst. Although the study is not tailored
for
subdiaphragmatic evaluation, the imaged upper abdomen is
unremarkable.
The trachea and central airways are patent to the segmental
level. Multiple
pulmonary nodules are unchanged (3:119, 127) including 4 and 5
mm right lower
lobe nodules (3:46 and 148). Otherwise the lungs are well
expanded and clear.
Subsegmental atelectasis is seen dependently
There is no suspicious lytic or blastic bony lesion to suggest
osseous
malignancy.
IMPRESSION:
1. No pulmonary embolism or acute aortic pathology. Mild to
moderate coronary
vascular calcifications.
2. Unchanged pulmonary nodules up to 5 mm. As mentioned on the
previous
study, for a total of 12 months stability follow up would be
recommended in
___.
3. Unchanged mediastinal cystic lesion likely bronchogenic cyst
given its
location.
Cardiac Catheterization Report
Study Date ___
Hemodynamic Measurements (mmHg)
Baseline
SiteSysDiasEndMeanA WaveV WaveHR
AO ___
Findings
ESTIMATED blood loss: < 50 cc
Hemodynamics (see above):
Coronary angiography: Left dominant
LMCA: No significant stenosis
LAD: Mild diffuse disease
LCX: OM1 and L PDA stents widely patent;
RCA: Small non-dominant
Assessment & Recommendations
1. No significant obstructive CAD
CXR ___ 4:43 AM
FINDINGS: In comparison with the study of ___, allowing for
the lower lung
volumes and AP portable position, there is little change.
Cardiac silhouette
is within normal limits and there is no vascular congestion or
pleural
effusion or acute focal pneumonia. No evidence of pneumothorax.
HUMERUS (AP & LAT) LEFT ___
The patient is status post ORIF of a mid-diaphyseal fracture of
the left
humerus transfixed by lateral plate with multiple screws. No
evidence of
hardware loosening or failure is demonstrated, and the fracture
lines remain
visible. Skin staples have been removed. Alignment is
unchanged. No new
fracture is seen.
IMPRESSION:
No significant interval change in appearance of left humeral
fracture status
post ORIF.
Brief Hospital Course:
___ w/ PMH of diabetes mellitus, CAD (stent in ___ at ___),
hypertension, hyperlipidemia, and L humeral fracture s/p recent
ORIF, now here with severe L sided chest and epigastric pain.
# Chest pain:
Patient presented with crushing chest pain at rest relieved
with nitroglycerin and new TWI in leads V2-V4 concerning for
unstable angina. In light of numerous risk factors for CAD,
including h/o PTCI with stent, the patient underwent cardiac
catheterization. This revealed no obstructive epicardial CAD,
and no intervention was performed. Cardiac enzymes remained
negative. CT chest was negative for aortic dissection or PE.
Of note, the patient was admitted in ___ with NSTEMI with
a peak troponin of 0.17. Coronary angiography at that time
showed moderate circumflex CAD, but no high grade obstructive
lesion with patent stents, and no intervention was performed,
though relatively slow flow suggestive of microvascular
dysfunction. He was medically managed by continuing isosorbide
mononitrate 120 mg daily and adding lisinopril 5 mg daily to his
home regimen. Clopidogrel was begun as part of the strategy of
medical therapy without revascularization for his NSTEMI.
No definitive etiology of chest pain was identified during this
admission. No conclusive evidence of coronary vasospasm noted
during catheterization. No historical features or typical EKG
finding suggestive of pericarditis. Microvascular disease
remains a possibility. The patient was continued on medical
therapy with metoprolol XL, isosorbide mononitrate, statin (goal
LDL <70), clopidogrel, and aspirin. Patient will follow up with
primary cardiologist for further evaluation. He will also follow
up with his PCP for continuation of work-up for non-cardiac
causes of chest pain.
#Depression/anxiety:
Patient continued on Fluoxetine 40 mg daily. However, given
interaction between clopidogrel and fluoxitine, consideration
should be given to switching to Citalopram 20mg daily.
# GERD:
Given potential interaction between Omeprazole and Clopidogrel,
this was switched to Pantoprazole.
# S/p ORIF of his left humerus nonunion on ___:
Patient evaluated by orthopedic surgery in ED for left
shoulder/chest pain likely secondary to overuse who recommended:
- Follow-up in clinic as scheduled
- Pain control (given Rx for hydromorphone on discharge)
- Gentle ROM exercises in ___ as outpatient, no strengthening
exercises
- Weightbearing to a coffee cup or under
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 325 mg PO DAILY
2. Atorvastatin 40 mg PO HS
3. Clopidogrel 75 mg PO DAILY
4. Docusate Sodium 100 mg PO BID
5. Fluoxetine 40 mg PO QAM
6. HYDROmorphone (Dilaudid) ___ mg PO Q3H:PRN Pain
7. Isosorbide Mononitrate (Extended Release) 120 mg PO DAILY
8. Lisinopril 5 mg PO DAILY
9. MetFORMIN (Glucophage) 1000 mg PO BID
10. Metoprolol Tartrate 75 mg PO BID
11. Multivitamins 1 TAB PO DAILY
12. NIFEdipine CR 30 mg PO DAILY
13. Omeprazole 20 mg PO DAILY
14. Tamsulosin 0.4 mg PO DAILY
15. Thiamine 100 mg PO DAILY
16. Tolterodine 2 mg PO BID
17. Nitroglycerin SL 0.3 mg SL PRN pain
Discharge Medications:
1. Aspirin 325 mg PO DAILY
2. Atorvastatin 40 mg PO HS
3. Clopidogrel 75 mg PO DAILY
4. Docusate Sodium 100 mg PO BID
5. Fluoxetine 40 mg PO QAM
6. HYDROmorphone (Dilaudid) ___ mg PO Q3H:PRN Pain
RX *hydromorphone 2 mg 1 to 3 tablet(s) by mouth every three (3)
hours Disp #*10 Tablet Refills:*0
7. Isosorbide Mononitrate (Extended Release) 120 mg PO DAILY
8. Lisinopril 5 mg PO DAILY
9. Multivitamins 1 TAB PO DAILY
10. NIFEdipine CR 30 mg PO DAILY
11. Tamsulosin 0.4 mg PO DAILY
12. Thiamine 100 mg PO DAILY
13. Tolterodine 2 mg PO BID
14. MetFORMIN (Glucophage) 1000 mg PO BID
15. Pantoprazole 40 mg PO Q24H
RX *pantoprazole 40 mg 1 (One) tablet,delayed release (___)
by mouth once a day Disp #*30 Tablet Refills:*0
16. Nitroglycerin SL 0.3 mg SL PRN chest pain
17. Metoprolol Succinate XL 150 mg PO DAILY
RX *metoprolol succinate 50 mg 3 (Three) tablet extended release
24 hr(s) by mouth once a day Disp #*90 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
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 to the hospital with chest pain concerning for
a heart attack. You underwent cardiac catheterization which
revealed no large blockage as a cause of your pain. It is
possible that disease in small vessels or spasm of your vessels
contribute to pain. We made some changes to your medications to
optimize this regimen and hopefully prevent further episodes.
You should use nitroglycerin sublingual as needed to treat chest
pain. You should also follow up with your PCP to further
investigate other possible sources of pain.
Followup Instructions:
___
|
19678950-DS-21
| 19,678,950 | 25,373,758 |
DS
| 21 |
2144-10-24 00:00:00
|
2144-10-24 19:44:00
|
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
___ diagnostic paracentesis
___ Large volume paracentesis
History of Present Illness:
Ms. ___ is a ___ h/o Hep C and alcoholic cirrhosis s/p
treatment with Harvoni, recent T2NSTEMI, tobacco use,
tachycardia
mediated cardiomypoathy who presents with worsening dyspnea.
On ___, the patient reported for Cardiology follow-up from a
recent hospitalization where she type II demand NSTEMI. At that
visit Dr. ___ the patient to be hypervolemic,
complaining of dyspnea on exertion and weight gain, without PND
or orthopnea. Per the outpatient note, these symptoms started
about ___ weeks ago and have progressed to the point of the
patient is now winded after walking 5 blocks. Per the
outpatient
record, the patient's weight has increased from ___ 231
pounds to ___ 260 pounds. Dr. ___ the patient
to
the ___ ED for further management.
The patient was recently admitted to ___ in
___, from the ___ of the ___, for epistaxis. Her
troponins during that hospitalization peaked at 0.12. She was
started on aspirin 81, ___, and metoprolol XL 12.5. Additional
findings from that hospitalization include chronic
encephalomalacia and lacunar infarcts in bilateral basal ganglia
(obtained on MRI/MRA when patient complained of unsteady gait),
and folate deficiency, with normal B12 levels.
Past Medical History:
-Cirrhosis secondary to chronic hepatitis C infection
-Hepatitis C status post Harvoni
-Type 2 diabetes mellitus
-Alcohol abuse
-Tobacco use disorder
-Obesity
-Colonic adenoma
-___ esophagus
-Abnormal brain MRI
-Folate deficiency
Social History:
___
Family History:
No history of liver diseases.
Physical Exam:
ADMISSION PHYSICAL EXAM:
=========================
VS: 97.6 PO 138 / 80 81 20 95 ra
GENERAL: Pleasant woman, lying on side in bed, NAD
HEENT: AT/NC, EOMI, PERRL, mildly icteric sclerae, MMM
NECK: supple, no LAD
HEART: regular rate with rare irregular beats, S1/S2 audible, no
murmurs, gallops, or rubs appreciated
LUNGS: Transmitted upper airway sounds, breathing uncomfortable
when lying on back, dullness at bilateral bases, without use of
accessory muscles
ABDOMEN: Distended, prominent epigastric veins, dullness to
percussion ___ way up bilateral flanks, dressing over
diagnostic para site is c/d/I in the RLQ; no rebound or guarding
EXTREMITIES: 3+ pitting edema in the b/l lower extremities
PULSES: 2+ DP pulses bilaterally
NEURO: A&Ox3, moving all 4 extremities with purpose, no flap
SKIN: WWP, bilateral lower extremities with erythematous venous
dermatitis
DISCHARGE PHYSICAL EXAM:
=========================
VS: ___ 0001 Temp: 98.7 PO BP: 122/75 L Lying HR: 83 RR: 20
O2 sat: 95% O2 delivery: Ra
GENERAL: lying comfortably in bed, NAD
HEENT: AT/NC, EOMI, PERRL, scleral icterus, MMM
HEART: RRR, S1/S2 audible, systolic ejection murmur throughout
precordium, no rubs or gallops
LUNGS: clear to auscultation, no increased work of breathing
ABDOMEN: soft, improved distended with fluid wave, nontender,
unable to appreciate organomegaly
EXTREMITIES: warm and well perfused, 2+ pitting edema in the b/l
lower extremities to the knees.
NEURO: A&Ox3, moving all 4 extremities with purpose, no
asterixis, DOWB intact
SKIN: large ecchymoses of the skin over the triceps muscle
bilaterally.
Pertinent Results:
ADMISSION LABS
=================
___ 08:34PM BLOOD WBC-6.0 RBC-4.09 Hgb-12.6 Hct-38.5 MCV-94
MCH-30.8 MCHC-32.7 RDW-16.2* RDWSD-55.7* Plt ___
___ 08:34PM BLOOD Neuts-63.7 Lymphs-18.4* Monos-15.6*
Eos-1.3 Baso-0.8 Im ___ AbsNeut-3.84 AbsLymp-1.11*
AbsMono-0.94* AbsEos-0.08 AbsBaso-0.05
___ 08:34PM BLOOD Plt ___
___ 06:01AM BLOOD ___ PTT-42.2* ___
___ 08:34PM BLOOD Glucose-120* UreaN-15 Creat-0.7 Na-137
K-3.7 Cl-98 HCO3-25 AnGap-14
___ 08:34PM BLOOD ALT-24 AST-57* LD(LDH)-273* AlkPhos-89
TotBili-4.7* DirBili-2.0* IndBili-2.7
___ 08:34PM BLOOD TotProt-6.7 Albumin-2.8* Globuln-3.9
Calcium-8.7 Phos-3.4 Mg-1.8
DISCHARGE LABS:
===================
___ 05:36AM BLOOD WBC-4.5 RBC-3.38* Hgb-10.7* Hct-31.3*
MCV-93 MCH-31.7 MCHC-34.2 RDW-16.8* RDWSD-57.1* Plt Ct-90*
___ 05:36AM BLOOD ___ PTT-53.8* ___
___ 05:36AM BLOOD Glucose-134* UreaN-17 Creat-0.8 Na-141
K-4.0 Cl-104 HCO3-22 AnGap-15
___ 05:36AM BLOOD ALT-24 AST-43* LD(LDH)-295* AlkPhos-74
TotBili-3.7*
___ 05:36AM BLOOD Albumin-2.7* Calcium-8.6 Phos-3.8 Mg-1.9
IMAGING
==================
CXR ___
FINDINGS:
Small, left greater than right, bilateral pleural effusions are
seen. No
evidence of pneumothorax or pulmonary edema. Mediastinal
contours are
unremarkable. Heart size is normal.
IMPRESSION:
Small bilateral, left greater than right, pleural effusions.
ECHO ___
The left atrium is moderately 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 arch is mildly dilated. The aortic valve leaflets (3) are
mildly thickened but aortic stenosis is not present. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. Trivial mitral
regurgitation is seen. The estimated pulmonary artery systolic
pressure is normal. There is no pericardial effusion. A left
pleural effusion is present.
IMPRESSION: Normal global and regional biventricular systolic
function. No pulmonary hypertension or clinically-significant
valvular disease seen. Mildly dilated ascending aorta.
___ DUPLEX ABD/PELVIS
IMPRESSION:
1. Cirrhotic liver, without evidence of focal lesion.
2. Evidence of portal hypertension with large volume ascites and
splenomegaly.
3. Patent main portal vein. Limited views of the left and right
portal veins also demonstrate flow. If there is continued
suspicion for portal vein thrombosis, consider CT.
___ LIVER US
IMPRESSION:
1. Cirrhotic liver, without evidence of focal lesion.
2. Evidence of portal hypertension with large volume ascites and
splenomegaly.
3. Patent main portal vein. Limited views of the left and right
portal veins also demonstrate flow. If there is continued
suspicion for portal vein thrombosis, consider CT.
___ PEVIC ULTRASOUND
Technically limited study due to body habitus and large volume
ascites,
demonstrating thickening and cystic change within the
endometrium concerning for hyperplasia or neoplasm. Gyn consult
is recommended for further evaluation.
___ ABD US
1. Cirrhotic liver, with stigmata of portal hypertension
including moderate ascites and splenomegaly.
2. The main portal vein is patent.
3. Sludge and stones are seen within the gallbladder. However,
no evidence of acute cholecystitis.
MICROBIOLOGY
==================
___ URINE URINE CULTURE-FINAL
___ URINE URINE CULTURE-FINAL
___ BLOOD CULTURE Blood Culture, Routine-FINAL
___ BLOOD CULTURE Blood Culture, Routine-FINAL
___ PERITONEAL FLUID GRAM STAIN-FINAL; FLUID
CULTURE-FINAL; ANAEROBIC CULTURE-FINAL
Brief Hospital Course:
PATIENT SUMMARY
================
___ with history of HCV and EtOH cirrhosis s/p treatment with
Harvoni and h/o tachycardia mediated cardiomyopathy who
presented with worsening dyspnea, ascites and anasarca,
secondary to decompensated cirrhosis. Course complicated by HE
and rising bili.
ACUTE ISSUES:
=============
# Dyspnea / # Anasarca / # Ascites: Came in with ___ months of
weight gain, edema, DOE, and ascites. New ascites, likely due to
cirrhosis given SAAG c/w portal HTN, and low acitic protein c/w
cirrhotic fluid. TTE was done to eval for CHF and was grossly
normal. Had been actively diuresing with 120 mg IV Lasix TID
until she developed ___. Held diuresis with improvement in Cr
and started PO diuretics ___ (100 mg PO Lasix, 100 mg
spironolactone). She was discharged on 100 mg spironolactone and
100 mg PO Lasix daily with goal of euvolemia.
# Decompensated HCV/EtOH cirrhosis: MELD-Na 23 on admission with
new ascites and has developed HE this admission. Last EGD ___
without varices. No prior history of ascites and no known prior
history of HE. No clear precipitant for this decompensation: may
have been a recent admission where she had an NSTEMI (thought to
be a type 2 NSTEMI I/s/o severe epistaxis). Infectious work up
was negative. HBsAg negative and HCV VL were negative. RUQ US
showed no PVT or masses. SHe was diuresed as above and treated
with lactulose with resolution of her HE. She underwent large
volume paracentesis (7.5L) which was negative for SBP.
Hepatology followed along during hospitalization.
#Postmenopausal vaginal bleeding: Patient reports vaginal
bleeding since admission that initially started as spotting and
progressed to enough blood loss to fill a pad. Pelvic U/S showed
irregular endometrial thickening concerning for
hyperplasia/malignancy. Consulted gynecology who recommended
outpatient follow-up with likely biopsy.
#Alcohol use disorder
CIWA initially in place, but discontinued after patient did not
score for several days. After discussion, would not be
interested in social work while in house.
TRANSITIONAL ISSUES
=====================
[ ] Please follow up volume status and renal function and
titrate diuretics as needed
[ ] CVA History:
- Consider uptitration of atorvastatin to 80 mg given history of
CVA.
[ ] Cirrhosis
- EGD as outpatient
- Consider outpatient CT abd/pelvis w/ contrast to better
characterize R/L portal veins
[ ] Post-menopausal bleeding:
- Transvaginal ultrasound with thickened endometrium. Will need
repeat US, biopsy as outpatient.
- Consider outpatient CT abd/pelvis with contrast to better
characterize R ovary
NEW MEDICATIONS:
Spironolactone 100 mg daily
Lasix 100 mg PO daily
Lactulose 30 mL QID
STOPPED MEDICATIONS: none
CHANGED MEDICATIONS: none
#CODE
#CONTACT
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Metoprolol Succinate XL 12.5 mg PO DAILY
2. Vitamin D 1000 UNIT PO DAILY
3. Aspirin 81 mg PO DAILY
4. Omeprazole 20 mg PO DAILY
5. Multivitamins 1 TAB PO DAILY
6. Atorvastatin 10 mg PO DAILY
Discharge Medications:
1. Furosemide 100 mg PO DAILY
RX *furosemide 20 mg 5 tablet(s) by mouth daily Disp #*150
Tablet Refills:*0
2. Lactulose 30 mL PO QID
RX *lactulose [Enulose] 10 gram/15 mL 30 ML by mouth Four times
a day Disp ___ Milliliter Refills:*0
3. Spironolactone 100 mg PO DAILY
RX *spironolactone 100 mg 1 tablet(s) by mouth DAILY Disp #*30
Tablet Refills:*0
4. Aspirin 81 mg PO DAILY
5. Atorvastatin 10 mg PO DAILY
6. Metoprolol Succinate XL 12.5 mg PO DAILY
7. Multivitamins 1 TAB PO DAILY
8. Omeprazole 20 mg PO DAILY
9. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS
Hepatitis C and Alcoholic liver cirrhosis, decompensated
SECONDARY DIAGNOSES
Ascites
Hepatic encephalopathy
Alcohol Use Disorder
Post-menopausal bleeding
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking care of you at ___!
Why was I admitted?
You were here because you have extra fluid in your lungs, on
your abdomen, and on your legs which made it hard for your to
breath and get around.
What happened to me in the hospital?
-While you were here, you had fluid drained from your belly.
-You were given an IV medicine to help remove extra fluid from
your legs.
-You were also seen by the liver doctors who helped to get you
on the right medications for your cirrohosis. This includes
"water pills" to keep fluid off, and a medicine to keep your
bowel movements regular. You will keep taking these once you
leave the hospital.
- You had an ultrasound that showed some thickening of your
uterus, which should be followed up with a second ultrasound
after you leave the hospital.
What should I do when I leave the hospital?
When you leave the hospital, it is important you attend all of
your follow-up appointments as listed below. Also make sure to
take your medications as prescribed. Weigh yourself daily and if
you gain more the 3 pounds in one day, make sure to call your
doctor's office.
We wish you the best!
Your ___ Care Team
Followup Instructions:
___
|
19678952-DS-14
| 19,678,952 | 20,636,921 |
DS
| 14 |
2160-12-14 00:00:00
|
2160-12-15 10:50:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
CC: ___ pain, cough
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ year old male, with prior history of
Alzheimers' Dementia, and ___ Disease, who is minimally
verbal at baseline, who presents with increased leg swelling,
nonproductive cough, and an episode of ? chest pain this
morning. Patient is unable to provide medical history, and
history obtained from his wife and step ___.
Patient was doing well until about 3 days ago, at which point he
started to deelop a non productive cough. Patient is taken care
of by his wife. She denies any fevers, although has never taken
a temperature. Patient at that time had no episodes of
aspiration that she could tell. Patient now presents today since
over the past 3 days hasn't had any relief in his cough. To his
wife and daughter, he sounds that he has secretions that he is
unable to clear. His chest pain episode was brought on by
coughing, and with increased back pains, patient has. This
morning, patient was drinking water and coughed while drinking
as well. His fatigue is worse than usual.
He also has lower extremity edema, however this has been a
waxing and waning presentation over the past several years when
he doesnt move around.
At baseline, patient is cared for by home nursing services and
by his wife ___. Patient requires help with eating, 1:1
sitting, requires help with ADLs. Patient does speak ___,
however minimally. Per family, he has been interactive with
family and that hasn't changed over the past 3 days.
Per EMS report, patient also gave history of clutching his
chest, however unable to vocalize specific chest pains. There is
no history of aspiration episodes or choking episodes, and eats
specifically with assistance.
In the ED, initial vitals were: 0 98 79 137/93 18 100% 2L Nasal
Cannula. Patient's labs were notable for Hgb 12.8, no
leukocytosis of 5.2, a proBNP of 66, and electrolytes signficant
for an elevated K of 6.4 (verified). Patient underwent
urinalysis which was negative, and was given Ceftriaxone and
Azithromycin. EKG at the time signficant for NSR with inf Q
waves reportedly similar to prior. Lactate drawn was 2.5.
Patient was also given 500 cc NS.
On the floor, patient reports no dyspnea. Patient was currently
on oxygen on 2L, and patient denied chest pains. He was
complaining of back pains. Family states that he usually does
not tell his family about symptoms.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, shortness of breath. Denies chest pain
or tightness, palpitations. Denies nausea, vomiting, diarrhea,
constipation or abdominal pain. No recent change in bowel or
bladder habits. No dysuria. Denies arthralgias or myalgias.
Past Medical History:
Depression
Probable ___ disease
Hypertension
Hyperlipidemia
Confusion/Delirium
Social History:
___
Family History:
Non-contributory
Physical Exam:
>> ADMISSION PHYSICAL EXAM:
Vital Signs: 95% on 3L -> 98 on 1L, 146/92, 81, 18
General: Alert, tracks with eyes. Patient minimally says yes or
no to answers. Looks towards family. Patient has loud snoring
sounds from mouth. Contracted in extremities, able to follow
commands limited with function.
HEENT: lesion on top of head, no acute bleeding. Sclera
anicteric. PERRL. Neck is thick, JVD difficult to appreciated.
No cervical LAD appreciated, although very thick neck. Unable to
fully open mouth, multiple dental work apparent, some mucous in
the posterior pharynx visualzied, however thick saliva.
Drooling.
CV: RRR, S1, S2. No extra sounds heard.
Lungs: Upper airways seem transmitted through to bases. On
posterior, mild expiratory wheeze on the left lower base,
however good air entry in upper zones. No crackles appreciated,
however very limited to poor inspiratory effort.
Abdomen: Distedned, +BS. No rebound or guarding. Wearing diaper.
GU: Wearing diaper
Neuro: Fingers contracted bilaterally.
Strength in lower extremities: unable to lift off bed by
himself. 1+ able to move side to side mildly.
2+ ___ edema in the feet bilaterally. Warm to touch.
LABS: --see below--
.
>> DISCHARGE PHYSICAL EXAM:
Vital Signs: 95 RA 97.3 165/89 16
General: Tracks with eyes, alerts, Patient is audibly having
upper airway secretions. Minimially verbal. Loud snoring sounds.
Extremities still contracted. Able to follow simple commands.
HEENT: lesion on top of head, no acute bleeding. Sclera
anicteric. PERRL. Neck is thick, JVD difficult to appreciated.
No cervical LAD appreciated, thick neck. Unable to fully open
mouth, multiple dental work apparent, some mucous in the
posterior pharynx visualzied, however thick saliva. Drooling.
CV: RRR, S1, S2. No extra sounds heard.
Lungs: Upper airways seem transmitted through to bases. On
posterior, mild expiratory wheeze on the left lower base,
however good air entry in upper zones. No crackles appreciated,
however very limited to poor inspiratory effort.
Abdomen: Distedned, +BS. No rebound or guarding. Wearing diaper.
GU: Wearing diaper
Neuro: Fingers contracted bilaterally.
Strength in lower extremities: unable to lift off bed by
himself. 1+ able to move side to side mildly.
2+ ___ edema in the feet bilaterally. Warm to touch.
Pertinent Results:
>> Admission Labs:
___ 12:03PM BLOOD WBC-5.2 RBC-4.26* Hgb-12.8* Hct-37.5*
MCV-88 MCH-30.0 MCHC-34.2 RDW-13.0 Plt ___
___ 12:03PM BLOOD Neuts-61.0 ___ Monos-9.5 Eos-6.2*
Baso-0.7
___ 12:19PM BLOOD Lactate-2.5* K-6.4*
___ 07:23PM BLOOD Lactate-1.5
.
>> Discharge Labs:
___ 07:14AM BLOOD WBC-6.0 RBC-4.31* Hgb-12.9* Hct-37.8*
MCV-88 MCH-29.9 MCHC-34.1 RDW-12.9 Plt ___
___ 07:14AM BLOOD Glucose-84 UreaN-17 Creat-1.0 Na-142
K-4.0 Cl-103 HCO3-28 AnGap-15
.
>> Pertinent Reports:
___ (PORTABLE AP): Lung volumes continue to
be low. There is increased vascular plethora and ll-defined
vascularity. Although lung volumes are low on the has a similar
volume previously when the vasculature did not appear so
engorged. Therefore there is likely an element of fluid
overload. It is difficult to assess for focal infiltrate given
the low lung volumes
IMPRESSION: Vascular plethora likely due to fluid overload
.
___ (PA & LAT): Low lung volumes cause
bronchovascular crowding. Elevation the left hemidiaphragm is
stable from multiple prior studies. Enlarged cardiac silhouette
is unchanged from multiple prior studies, likely related to
tortuous aorta and mediastinal fat. There is no focal
consolidation, pleural effusion, pneumothorax, or pulmonary
edema.
IMPRESSION: No acute cardiopulmonary process
.
>> MICROBIOLOGY:
__________________________________________________________
___ 1:20 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___: <10,000 organisms/ml.
__________________________________________________________
___ 12:05 pm BLOOD CULTURE
Blood Culture, Routine (Pending):
__________________________________________________________
___ 12:03 pm BLOOD CULTURE
Blood Culture, Routine (Pending):
Brief Hospital Course:
This is a ___ year old male with past medical history of
Alzheimers Dementia, Parkinsons Disease, admitted ___ with
> 1 week of cough, low-grade fevers, CXR with poor visualization
of lung fields, treated empirically for pneumonia with
improvement and discharged home.
.
>> ACTIVE ISSUES:
# Community Acquired Pneumonia: Patient initially presented with
3 days of non productive cough, initially hypoxic in ED; CXR had
poor visualization of lung fields due to body habitus. Patient
was initially treated with IV Ceftriaxone and Axithromycin for
CAP coverage with subsequent improvement in symptoms. He was
transitioned to PO azithromycin. He had mild wheezing on exam,
so was provided albuterol inhaler with spacer with symptomatic
improvement. Team discussed with family re: his risk of
aspiration, and whether patient would benefit from
speech/swallow consultation. Family decided knowledge of
aspiration would not change their management, and they would
prefer to take home without swallow eval, and continue current
feeding regimen with 1:1 supervision. Risks of aspiration were
discussed with family, and voiced back understanding.
.
# Hyperkalemia: Patient initially found to be hyperkalemic,
unclear origin, without EKG changes. With IVF, patient had
repeat labs checked with normal potassium levels. No clear
offenders as far as medications, or renal disease. ___ have been
result of mild prerenal azotemia.
.
# ___ Disease: Patient continued to be at neurologic
baseline per family, and was continued on carbidop-levodopa.
.
# Depression: Patient was continued on paroxetine.
.
# GERD: Patient was continued on omeprazole.
.
# History of constipation: Patient was continued on outpatient
regimen.
.
# Hyperlipidemia: Patient was continued on simvastatin.
.
# Hypertension: Patient was continued on home atenolol.
. .
>> TRANSITIONAL ISSUES:
# Goals of Care: DNR/DNI.
# Contact Information: ___ (daughter): ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atenolol 50 mg PO DAILY
2. Carbidopa-Levodopa (___) 2 TAB PO TID
3. Docusate Sodium 100 mg PO BID
4. Lactulose 15 mL PO BID
5. Omeprazole 40 mg PO DAILY
6. Paroxetine 20 mg PO DAILY
7. Simvastatin 40 mg PO QHS
Discharge Medications:
1. Atenolol 50 mg PO DAILY
2. Carbidopa-Levodopa (___) 2 TAB PO TID
3. Docusate Sodium 100 mg PO BID
4. Lactulose 15 mL PO BID
5. Omeprazole 40 mg PO DAILY
6. Paroxetine 20 mg PO DAILY
7. Simvastatin 40 mg PO QHS
8. Azithromycin 250 mg PO Q24H Duration: 4 Doses
Please take until ___
RX *azithromycin 250 mg 1 tablet(s) by mouth daily Disp #*4
Tablet Refills:*0
9. Space Chamber Plus (inhalational spacing device) 1
miscellaneous Q6H:PRN
Please use with albuterol MDI as needed
RX *inhalational spacing device Please use spacer with inhaler
every 6 hours Disp #*1 Inhaler Refills:*0
10. Albuterol Inhaler ___ PUFF IH Q6H:PRN shortness of breath
Duration: 1 Dose
Please dispense ___ MDI. Please use as needed for shortness of
breath/wheezing
RX *albuterol ___ puff IH every 6 hours Disp #*1 Inhaler
Refills:*0
11. Wheelchair
ICD9 Code: 332.0 ___ Disease
Sig: Please dispense 1 wheelchair for patient.
Duration: Lifetime.
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS: 1. Viral Upper Respiratory Illness
SECONDARY DIAGNOSES: 1. ___ Disease 2. Alzheimer's
Disease
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Bedbound.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you during your hospital stay
at ___. You were admitted to
the hospital after having a cough at home, and you underwent
chest imaging which did not show a pneumonia. We were concerned
that you likely have a viral upper respiratory illness, and
started azithromycin to help with inflammation and infection.
Please continue to take this medication as prescribed.
We were also concerned about your ability to swallow and your
risk of aspiration in the future. Please follow up with your
primary care physician and discuss this risk in the future.
Please continue to take your other home medications as
prescribed. Script for wheelchair provided, and this can be
obtained at any medical supply store.
Take Care,
Your ___ Team.
Followup Instructions:
___
|
19679141-DS-4
| 19,679,141 | 21,083,270 |
DS
| 4 |
2159-03-25 00:00:00
|
2159-03-25 18:11:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Pain s/p aborted laparoscopic hiatal hernia repair
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with Marfan syndrome and recurrent hiatal hernia, s/p
attempted hernia repair earlier today. Per report, the repair
was aborted after initial laparoscopy and lysis of adhesions,
and he was discharged home. He began having pleuritic left
chest pain around 2pm, and then developed right posterior
shoulder/scapular pain, for which he presented to the emergency
department. He took the prescribed oxycodone, which did not
improve his pain. He has not had any nausea, vomiting, or
difficulty breathing.
Past Medical History:
PMH: Marfan syndrome, depression
PSH: lap Nissen fundoplication ___, port site hernia repair x2
Social History:
___
Family History:
Family: Non-contributory
Physical Exam:
Vitals: T 98.4, HR 80, BP 121/86, O2 100 4L NC
Gen: a&o x3, nad
CV: rrr, no murmur
Resp: cta bilat; subcutaneous emphysema L lower chest
Abd: soft, NT, ND, +BS; surgical dressings in place
Extr: warm, well-perfused, 2+ pulses
Pertinent Results:
___ 11:41PM BLOOD WBC-11.3*# RBC-4.63 Hgb-13.3* Hct-40.5
MCV-88 MCH-28.8 MCHC-32.9 RDW-12.6 Plt ___
___ 11:41PM BLOOD ___ PTT-30.2 ___
___ 11:41PM BLOOD Glucose-122* UreaN-8 Creat-0.7 Na-139
K-3.9 Cl-103 HCO3-31 AnGap-9
___ 11:41PM BLOOD ALT-53* AST-37 AlkPhos-65 TotBili-0.4
___ 11:41PM BLOOD TotProt-6.4 Albumin-4.3 Globuln-2.1
Calcium-9.5 Phos-3.1 Mg-2.0
___ 11:41PM BLOOD Lipase-15
___ 11:41PM BLOOD cTropnT-<0.01
CTA Chest/Abdomen
1. No oral contrast extravasation from the esophagus to suggest
esophageal
perforation. Given the degree of pneumomediastinum and
pneumoperitoneum,
however, an occult leak cannot be excluded. If clinical
suspicion for a GI
tract injury persists, a repeat examination or swallow study
could be
performed.
2. No evidence of pulmonary embolism or aortic dissection.
3. Left thoracic wall subcutaneous air likely relates to trocar
placement.
4. Large hiatal hernia.
Brief Hospital Course:
The patient was admitted to the ___ surgical service under
Dr. ___ returning to the ER after undergoing an
aborted laparoscopic hiatal hernia repair on ___. The
patient was admitted early in the am on ___. On HD 1, POD 1
the patient was started on IV dilaudid for pain control. This
was transitioned to oral pain medication during the day. The
patient was started on a regular diet which he tolerated well.
At time of discharge on HD 1 POD 1 the patient's pain was
controlled on oral medications, tolerating a regular diet,
ambulating without assistance, voiding without difficulty. The
rest of the ___ hospital course was unevenful.
Medications on Admission:
wellbutrin sr 450'
propranolol 80'
trazodone 100'
oxycodone 5 prn
Discharge Medications:
1. hydromorphone 2 mg Tablet Sig: ___ Tablets PO every ___ hours
as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
2. bupropion HCl 150 mg Tablet Extended Release Sig: Three (3)
Tablet Extended Release PO QAM (once a day (in the morning)).
3. trazodone 50 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime)
as needed for insomnia.
4. propranolol 80 mg Capsule,Extended Release 24 hr Sig: One (1)
Capsule,Extended Release 24 hr PO DAILY (Daily).
5. ibuprofen 200 mg Tablet Sig: ___ Tablets PO every ___ hours
as needed for pain.
6. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO every six
(6) hours as needed for pain.
Discharge Disposition:
Home
Discharge Diagnosis:
Pain control s/p aborted laparoscopic hiatal hernia repair
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the ___ surgical service under Dr.
___ undergoing an aborted laparoscopic hiatal hernia
repair. You were admitted for pain control. Currently your pain
is better controlled and you are ready to continue your recover
at home.
Medications: Narcotic pain medication prescription has been
provided for you. Please take this medication as prescribed. Do
not drive while taking narcotic pain medication. You make take
tylenol for pain 650mg every 6 hours. Do not exceed 4000mg per
day. You may take ibuprofen for pain as well 600-800mg every ___
hours as needed for pain.
Diet: You may resume your home diet.
Activity: You may resume your regular activity. You may shower
but do not swim/bathe/submerge your incisions underwater until
you see Dr. ___ follow up.
Wound: You make take your dressings down tomorrow. Under your
dressings are white strips. Leave these in place. They will fall
off on their own.
Please call Dr. ___ ___ if you
experience any of the following:
Fever greater than 101
Redness that is spreading
Pain not adequately relieved with medication
Drainage from wound
Opening of incision
Nausea and vomiting
Please call Dr. ___ ___ to schedule a
follow up appointment in ___ weeks.
Followup Instructions:
___
|
19679141-DS-6
| 19,679,141 | 24,242,945 |
DS
| 6 |
2160-08-24 00:00:00
|
2160-08-25 08:02:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: PSYCHIATRY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
"I stepped in front of a car."
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
Per Dr. ___ note dated ___:
___ year M with a longstanding history of major depression
Sectioned to ED by his psychiatrist, Dr. ___
self-report of suicide attempt several days prior by jumping in
front of a car. The patient currently reports depressed mood,
multiple psychosocial stressors (fight w/ husband, risk of
losing
custody of children if he gets divorced), as well as feelings of
guilt around the attemtped suicide. He denies current SI or
plan,
and states he would like to live for his children, to repair
relationship with his husband. He plans to follow through with
ECT, a treament plan that he had discussed with Dr. ___
___ (prior to the attempt).
He reports 2 mo of neurovegative stmpoms (anhedonia, poor energy
and concentration), which are typical of his depressive
symptoms.
This past weekend, his husband called him "financially
irresponsible" which led to an argument. They are also possibly
undergoing a divorce, which raises issue of custody of chilren.
Pt. went to a bar, had ___ martinis, left feeling sad and
stepped in front of a car, was hit, suffered minor injuries (no
loss of consciousness). He did not go to a hospital, felt
ashamed
of this choice.
Denies symptoms of mania, ah/vh/ior.
Past Medical History:
Per Dr. ___ note dated ___:
PAST PSYCHIATRIC HISTORY:
Hospitalizations: hospitalized around ___ years ago at ___
for 3 days when he became depressed just after ___ was taken
away from them again
Current treaters and treatment: Dr. ___ (psychiatrist at
___), Dr. ___
___ and ECT trials: paxil, prozac, zoloft, lexapro, all
with no significant benefit
Self-injury: None
Suicide Attempts: 2 prior attempts age age ___ (one involved
driving car into a tree with seatbelt on, one involved an
overdose)
Harm to others: None
Access to weapons: None
PAST MEDICAL HISTORY:
- Marfan's syndrome with enlarged aorta
- ___ esophagus
- Transient leg paralysis at age ___ secondary to viral infection
- HTN
- clavicle fracture from suicide attempt at age ___
- s/p abdominal hernia repair x2, surgical correction of
___ esophagus, Nissen fundoplication ___
- s/p head concussion secondary to motor vehicle accident
- no history of seizures
Social History:
Per Dr. ___ note dated ___:
SUBSTANCE ABUSE HISTORY:
- Tobacco: none
- Alcohol: ___ martinis with dinner "a couple of nights a week,"
states his husband has stated he is drinking to much, reports
increased tolerance, denies withdrawal symptoms or increased
amounts of time spent using, obtaining, or recovering from
alcohol. Denies other hazardous acts while drinking in the past.
- Drugs: denies current but reports remote marijuana and cocaine
Per Dr. ___ consultation note dated ___:
He grew up in ___, ___. Has one
older sister and one younger brother. Grew up in Catholic family
and attended a ___ high school where he was secretly gay,
but the whole atmostphere was very homophobic. He believes that
he became very depressed and hopeless in high school due to his
rejecting social environemnt and being taught at school by
mentors that there was something wrong with him due to his
homosexuality. He got his BA from the ___
and started law school but dropped out after his first year. He
is now the ___ of ___ programs at the
___.
He has been married since ___, but is now going through a
divorce. He and his husband have one adopted child, ___, now
age ___ with a significant history of ADHD (was born with
craniosynostosis, born addicted to methadone). They are also
taking care of his husband's nephew, ___, since ___
intermittently before then) when his mother died. His mother was
abusive this child, and the patient has been dealing with
custody
battles in terms of remaining a caretaker for this child, which
has been a significant source of stress for him.
Family History:
Per Dr. ___ note dated ___:
- Mother and sister with depression
- Paternal uncle with schizophrenia
- ___ GM with depression with multiple suicide attempts
- Paternal GF and paternal aunts with alcoholism
- No completed suicides in family
Physical Exam:
Per Dr. ___ note dated ___:
V: 136/100 65 19 100 on RA 98.1
PE:
Gen: Tall, thin.
HEENT: MMM, neck supple, full ROM
Resp: CTAB
___: S1 S2 NRMG
EXT: WWP
Skin: No rashes
Neurological:
Strength full thoughout. Sensory Grossly intact. CN II-Xii
intact. Cerebellar exam Nl. Gait Nl. Reflexes 2+ and Symmetric
throughout.
Cognition:
Wakefulness/alertness: AOX3
*Attention (digit span, MOYB): DOWB
*Memory: ___ recall at 5 minutes
*Fund of knowledge: intact, knew past 4 presidents
Calculations: 9 quarters = $2.25
*Speech: fluent, normal v,t,r,p
*Language: fluent w/o paraphasic errors
Mental Status:
*Appearance: well groomed, tall man
Behavior: calm, pleasant and cooperative
*Mood and Affect: "depressed" / congruent, tearful at times
when
discussing Suicide attempt.
*Thought process / *associations: linear w/o LOA
*Thought Content: Negative for SI currently. Focused on divorce
and loss of access to child. No HI. No delusions
*Judgment and Insight: poor judgement and fair insight
Pertinent Results:
___ 03:50PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
___ 03:50PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
___ 03:20PM GLUCOSE-121* UREA N-12 CREAT-0.8 SODIUM-142
POTASSIUM-4.8 CHLORIDE-101 TOTAL CO2-28 ANION GAP-18
___ 03:20PM WBC-7.7 RBC-4.88 HGB-14.7 HCT-44.7 MCV-91
MCH-30.1 MCHC-32.9 RDW-12.7
___ 03:20PM NEUTS-52.1 ___ MONOS-5.8 EOS-2.3
BASOS-1.5
___ 03:20PM PLT COUNT-258
___ 03:20PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
Brief Hospital Course:
#) Psychiatric:
Depression - Mr. ___ had described, and collateral data had
confirmed, a several-year history of major depression which was
refractory to a number of pharmacological therapies, and
culminated in an impulsive suicide attempt while intoxicated
which prompted this admission at this time. As ECT had already
been discussed as a next-step option for TRD through the clinic
at ___, after further discussion of risks and benefits it was
decided to proceed with evaluation for a treatment course during
this hospitalization. The patient did experience some dizziness
early in his hospital course, as well as "zaps" running from his
back to his head along his spine. These were considered to be
related to Effexor withdrawal and dissipated rapidly during the
hospital course and no longer present by the time of discharge.
After appropriate screening by the hospital medical consultants
he received his first ECT on ___, hospital day #2. The patient
continued to have ECT treatments three times per week. After the
___ ECT session on ___, the decision was made to switch to
bilateral ECT in collaboration with inpatient team, Dr.
___ outpatient team due to continued significant
depression, hopelessness, and ongoing suicidal thoughts. The
patient experienced mild headache around the times of these
treatments early in the course (unilateral ECT) which were
treated symptomatically, but otherwise did not have any adverse
effects including memory impairment and body aches. Later in the
hospital course (with bilateral ECT), the patient did experience
some mild muscle aches and confusion but reported not to find
these symptoms too distressing and reported them to be tolerable
given the improvement in his mood symptoms. The patient
ultimately recieved 11 ECT treatment as an inpatient and
resolved to continue a course of ECT as an outpatient with
ultimate goal to do a continuation/taper.
The patient was continued on his home dose of Wellbutrin from
the time of admission. He was briefly started on Abilify but
this was discontinued after the patient noted muscular twitches
in his neck bilaterally in the area of the sternocleidomastoid.
These muscular twitches decreased after discontinuation of
Abilify but did not abate completely. Consideration was also
given to Lithium following completion of ECT as a known strategy
to help reduce relapse after a course of ECT and to help with
the prevention of suicidality, though the patient was reluctant
to start this medication as an inpatient. The patient did,
however, agree to starting augmentation with Cymbalta which was
started at 20mg Daily on the day of discharge. Risks of
hypertension (given the patient's response to Effexor) were
discussed and the patient stated that he would take his blood
pressure at home and follow-up with his outpatient psychiatrist
for further management. Other medications that were considerred
in augmentation and discussed in detail with the patient were
remeron and seroquel, but given his sensitivity to excessive
weight gain, he declined these treatment strategies for now.
The patient's concurrent alcohol use was also discussed
including its contribution to the patient's depression and
suicide attempt. By the time of discharge, ___ was able to
recognize alcohol as being a problem and had become active in AA
meetings during the hospitalization and began working to make
connections to AA outside of the hospital.
Alcohol use was also a significant point of contention between
he and his husband. A great deal of time was spent in discussion
about this adn the reasons why it was such a hot button issue
between he and his husband. Relationship stress between he and
___ and the stress associated with the raising of their two
children was one of the most significant contributors to his
depression and ultimate suicide attempt. 3 family meetings were
held during the hospitalization to address the realtionship
stress and tension around alcoholism were held during the course
of the hospitalization. During these meetings strategies to
facilitate connection and reduction of anger were discussed in
detail. Both parties expressed a commitment to one another and
to the children. ___ also expressed his belief that ___ was
a necessary presence in both Adian and ___ lives and he had
no intention of cutting ___ out of their lives. His greatest
concern had always been the safety around alcohol. Both agreed
to a dry household after discharge. Ongoing couples work was
reccommended in addition to ongoing individual thearpy.
Through out the course of hospitalization, care was coordinated
with ___, individual therapist and psychiatrist. He was
reluctant to allow the involvement of the couples therapist, but
he ultiamtely did and our social worker udated the couples
therapist about the work in the hospital.
By the time of discharge, the patient was future-oriented,
committed to continuing with outpatient treatment (including
partial hospital referral, ECT, medication management, and
continued treatment with outpatient treaters). He also reported
significant improvement in his mood and absence of thoughts of
self-harm. He was clearly commited to treamtent and was future
oriented, however nervous about a return home to the source of
stress w the relationship with ___. This was discussed at time
of discharge with he and ___ and ___ were supportive of
partial hospital program to assist with transition outside of
the hospital.
The patient was easily able to safety plan at time of discharge,
and identified a number of individuals outside ___ he could
reach out to for help should he again become overwhelmed,
relapse into drinking, or relapse into hopeless or suicidal
thoughts. He understood the option of calling 911 and/or
returning to the hosptial and felt able and appeared capable to
do this, should he feel unsafe again.
#) Medical:
- Right arm thrombophlebitis: Following the ___ ECT session, the
patient reported mild pain in his right arm without any
swelling, erythema, fever, or other signs of infection. This was
determined to be thrombophlebitis and was treated initially with
Ibuprofen PRN and warm compresses. After the patient's ___ ECT
treatment, the patient reported that the pain was worsening and
the patient noted a palpable cord up to the level of his elbow.
Medicine was consulted for further recommendations and recommend
___ days of standing Ibuprofen 400 TID (up to 600mg if limited
effect), Omeprazole 20mg Daily while on Ibuprofen (due to
concerns for esophagitis), warm compresses, and outpatient
follow-up with vascular surgery for consideration of thombectomy
if symptoms persist. Given that the patient's symptoms had
worsened despite this management prior to discharge, outpatient
follow-up was established for the patient with vascular surgery.
The patient will remain on Ibuprofen and Omeprazole until this
appointment. He understands the signs of symptoms of infection
and will return to the emergency room or call for an urgent
medical appointment if needed
- Marfan syndrome: No acute intervention was needed. The patient
was maintained on his home dose of Propranolol.
- Hypertension: Had reported to fluctuate somewhat high at home
(SBP 130s-140s), attributed to Effexor. At admission, this
continued at this level, and medicine c/s team also suggested
this lingering med effect was a likely cause. With observation
over following days, the patient's blood pressure normalized and
remained stable throughout the remainder of the admission
without further intervention.
#) Legal: ___
#) Risk Assessment: The patient has several significant chronic
risk factors including gender, chronic depression and medical
illness, alcohol abuse, h/o suicide attempt, and ongoing marital
discord. He also has numerous protective factors including
absence of current suicidal ideation, future orientation,
engagement with outpatient treaters, knowledge and ability to
access mental health in times of crisis, significant improvement
in his depression with ECT and active employment and housing.
While the patient does have a chronically elevated risk of
self-harm, he no longer represents an acutely elevated risk of
self-harm requiring further inpatient hospitalization. He does
require ongoing comprehensive mental health treatment which has
been arrange in an outpatient plan which he is motivated to
continue with. At this time there are no further modifiable
factors that can be addressed by the inpatient unit and further
hospitalization, will in fact limit his potential from ongoing
recovery and stabilization as it contributes to his tendency to
avoid ongoing work with ___. The patient understands he has an
option to not return home with ___, but he remains committed to
his family and the relationship.
#) Disposition: Home
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Wellbutrin XL *NF* (buPROPion HCl) 300 mg Oral QAM
2. Lorazepam 0.5 mg PO TID:PRN anxiety, insomnia
3. Multivitamins 1 TAB PO DAILY
4. Zinc Sulfate 100 mg PO DAILY
5. Fish Oil (Omega 3) 1000 mg PO DAILY
6. Propranolol LA 80 mg PO DAILY
Discharge Medications:
1. Fish Oil (Omega 3) 1000 mg PO DAILY
2. Multivitamins 1 TAB PO DAILY
3. Zinc Sulfate 100 mg PO DAILY
4. Propranolol LA 80 mg PO DAILY
5. Lorazepam 0.5 mg PO TID:PRN anxiety, insomnia
RX *lorazepam 0.5 mg 1 tablet by mouth three times a day Disp
#*21 Tablet Refills:*0
6. Wellbutrin XL *NF* (buPROPion HCl) 300 mg Oral QAM
RX *bupropion HCl 300 mg 1 tablet extended release 24 hr(s) by
mouth QAM Disp #*30 Tablet Refills:*0
7. Duloxetine 20 mg PO DAILY
RX *duloxetine [Cymbalta] 20 mg 1 capsule,delayed
___ by mouth Daily Disp #*30 Capsule Refills:*0
8. Ibuprofen 600 mg PO Q8H
RX *ibuprofen 600 mg 1 tablet(s) by mouth every eight (8) hours
Disp #*90 Tablet Refills:*0
9. Omeprazole 20 mg PO DAILY
RX *omeprazole 20 mg 1 capsule,delayed ___ by
mouth Daily Disp #*30 Capsule Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Major depressive disorder, alcohol abuse
Discharge Condition:
No longer with suicidal or hopeless thoughts. Future oriented
and able to articulate a clear safety plan if suicidal thoughts
reoccur. Engaged in treatment planning and motivated for ongoing
mental health treatment. Anxious about return home, but feeling
ready to leave locked inpatient unit. Reflective about ongoing
challanges in the relationship between he and ___. No evidence
of acute risk to self, but remains at chronic risk of relapse
into suicidal thoughts or unsafe drinking, which patient remains
aware of.
Discharge Instructions:
-Please follow up with all outpatient appointments as listed -
take this discharge paperwork to your appointments.
-Please continue all medications as directed.
-Please avoid abusing alcohol and any drugs--whether
prescription drugs or illegal drugs--as this can further worsen
your medical and psychiatric illnesses.
-Please contact your outpatient psychiatrist or other providers
if you have any concerns.
-Please call ___ or go to your nearest emergency room if you
feel unsafe in any way and are unable to immediately reach your
health care providers.
-It was a pleasure to have worked with you, and we wish you the
best of health.
Followup Instructions:
___
|
19679858-DS-11
| 19,679,858 | 28,530,928 |
DS
| 11 |
2159-09-05 00:00:00
|
2159-09-07 15:15:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
chest pain/shortness of breath
Major Surgical or Invasive Procedure:
Cardiac catheterization ___
Hemodialysis ___
History of Present Illness:
___ smoker w/ ESRD on HD on ___ who presents with CC of chest
pain and shortness of breath. The patient reports that he was
dropped off at ___ dialysis this morning and upon walking down
the hall to dialysis had acute onset CP and SOB. CP was
substernal ___ non-radiating, with no associated nasuea or
diaphoresis. He was found by the dialysis nurses sitting ___ the
lobby at ___ and EMS was called. Of note the patient reports
having inermittent episodes of CP and SOB of breath about 2x
daily for the last month. The CP/SOB can come at rest or with
exertion. He endorse progrssive fatigue and SOB for the last
monthand get tired doin things such as gettin dressed, going
___ shopping, doing household chores, or trying to climb
the stairs in his apartment building. The last episode of chest
pain prior to admission was last night. He reports he ususally
takes sublingual nitro for the chest pain, but had only expired
medications and used ice to releive his symptoms. He was
recently hospitlized at ___ for similar symptoms
last week. On review from records at ___ the patient's
shortness of breath was attributed to volume overload in the
setting of missign dialysis during the storm. He had an Echo
which was norable for grade 1 diastolic dysfunction with normal
LVEF and his symptoms improved with HD. There was also
suspicion that his SOB was due to underlying COPD for which he
was only on albuterol prn. He was started on Spirivia and Advair
at discharge, however the patient has not been able to fill
these prescriptions. No stress test was done. He endorses
occasional night sweats, chills, non-productive cough, and
subjective fevers. Had an excercise treadmill test at the ___ in
___ which showed notable for no ischemic changes on EKG,
and no anginal sx.
He also reports a fall w/ frontal head strike and LOC 2 days
prior to admission but did not go to the ED.
Regarding his ESRD the patient does make urine and straight
caths himself at home " when his bladder feels full". He has not
straigh cathed in the last two days
ED Course: Inital vitals in the ED were 98.3, 58, 164/75, 18,
90% 2L. He triggered for hypoxia for O2 sat of 90% in ED,
received nasal cannula ,1 SL NG with resolution of CP and
hypoxia. Labs notable for Hct 31.3 (no baseline in our system),
Cr of 12.3, Trop of 0.13. Head CT w/o contrast w/o acute
intracranial process. CXR notable for Blunting of the left
costophrenic angle, of uncertain acuity, could be due to pleural
thickening/scarring versus a trace pleural effusion.
Vitals prior to transfer were: 98.7 64 163/87 19 94% on RA
On the floor, the patient patient denies any CP or shortness of
breath
Review of systems:
(+) Per HPI
(-) Denies recent weight loss or gain. Denies headache, sinus
tenderness, rhinorrhea or congestion. Denies , palpitations.
Denies nausea, vomiting, diarrhea, constipation or abdominal
pain. No recent change in bowel or bladder habits. No dysuria.
Denies arthralgias or myalgias.
Past Medical History:
ESRD on HD ___
COPD
chronic hep c
prostate Ca
HTN
Social History:
___
Family History:
mother w/ ___. unaware of other family hx
Physical Exam:
ADMISSION PHYSICAL EXAM
Vitals: T:97.4 BP: 160/80 P: 74 R:18 O2: 95%
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: decreased air movement bilaterally
CV: ___ SEM RUSB, normal S1 + S2, no murmurs, rubs, gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: right AV fistuala with palable thrill. Warm, well perfused,
2+ pulses, no clubbing, cyanosis or edema
Skin: no rashes or lesions noted
Neuro: CN II-XII grossly intact.
DISCHARGE PHYSICAL EXAM
Vitals- T 98 Tm 98 172/89 (130-170/60-80) 73 (61-75) 18 100% RA
GEN: awake, alert, pleasant individual in NAD
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: coarse breath sounds posteriorly with intermittent
wheezing,
no air movement
CV: RRR, systolic murmur, no r/g
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: right AV fistuala with palable thrill. Warm, well perfused,
2+ pulses, no clubbing, cyanosis or edema
Skin: no rashes or lesions noted
Neuro: CN II-XII grossly intact
Pertinent Results:
ADMISSION LABS
___ 07:50AM BLOOD WBC-5.7 RBC-3.16* Hgb-9.5* Hct-31.3*
MCV-99* MCH-29.9 MCHC-30.3* RDW-16.6* Plt ___
___ 07:50AM BLOOD Neuts-66.1 ___ Monos-7.7 Eos-3.5
Baso-0.4
___ 07:50AM BLOOD Glucose-116* UreaN-63* Creat-12.3* Na-136
K-4.4 Cl-96 HCO3-23 AnGap-21*
----------
PERTINENT LABS
___:50AM BLOOD cTropnT-0.13*
___ 03:49PM BLOOD cTropnT-0.12*
___ 05:30AM BLOOD CK-MB-3 cTropnT-0.11*
___ 12:40PM BLOOD CK-MB-3 cTropnT-0.11*
___ 06:10AM BLOOD Triglyc-84 HDL-52 CHOL/HD-2.8 LDLcalc-75
___ 06:10AM BLOOD PSA-3.8
___ 09:55AM BLOOD CK-MB-4 cTropnT-0.17*
-------------
DISCHARGE LABS
___ 09:55AM BLOOD WBC-10.6 RBC-2.70* Hgb-8.4* Hct-26.9*
MCV-100* MCH-31.2 MCHC-31.4 RDW-16.8* Plt ___
___ 09:55AM BLOOD Plt ___
___ 09:55AM BLOOD Glucose-133* UreaN-30* Creat-6.8*# Na-137
K-4.2 Cl-97 HCO3-29 AnGap-15
___ 09:55AM BLOOD CK(CPK)-63
___ 09:55AM BLOOD Calcium-9.6 Phos-4.3 Mg-2.0
MICRO
NONE
REPORTS
EKG- EKG ___ Sinus rhythm. Right bundle-branch block.
Compared to the previous tracing of ___ atrial ectopy is
absent. Otherwise, no diagnostic interim change
IMAGING
CXR PA/LATERAL ___
IMPRESSION: Blunting of the left costophrenic angle, of
uncertain acuity, could be due to pleural thickening/scarring
versus a trace pleural effusion.
CT HEAD W/O CONTRAST ___
IMPRESSION: No acute intracranial process.
___
Stress MIBI
INTERPRETATION: ___ yo man with HTN, HL and current smoker, ESRD
and
grade I diastolic dysfunction was referred to evaluate an
atypical chest
discomfort and shortness of breath. The patient was administered
0.4 mg
Regadenoson (Lexiscan) IV bolus over 20 seconds. No chest, back,
neck or
arm discomforts were reported during the infusion or early
post-exercise. Late post-infusion (7 min post-inf) the patient
described
an anterior chest discomfort; ___. This discomfort resolved
slowly
following the administration of 75 mg Aminophylline IV and was
absent 14
minutes post-infusion. During the period, an additional 0.5-1.0
mm ST
segment depression was noted from baseline in leads V4-V5. The
rhythm
was sinus with occasional isolated APBs and rare isolated VPBs.
Baseline
systolic hypertension with an appropriate heart rate and blood
pressure
response to the Regadenoson infusion.
IMPRESSION: Atypical symptoms with borderline ischemic ST
segment
changes noted late post-infusion. Baseline systolic hypertension
with an
appropriate hemodynamic response to the Regadenson infusion.
Nuclear
report sent separately.
___
CARDIAC PERFUSION STUDY
INTERPRETATION:
Left ventricular cavity size is moderately increased.
Rest and stress perfusion images reveal a moderate reversible
perfusion defect in the distal inferolateral wall.
Normal wall motion in gated images.
The calculated left ventricular ejection fraction is 53%.
No prior study is available for comparison.
IMPRESSION: Moderate reversible perfusion defect in the distal
inferolateral wall. Moderate left ventricular dilatation. LVEF
53%.
___ Cardiovascular C.CATH ___
Coronary angiography: right dominant
LMCA: Normal
LAD: The ostial LAD had a 40% stenosis. The mid LAD had a
complex ___ stenosis with thrombus. There was a 100% occlusion
of the ___ diagonal branch. There was a 80% stenosis of the
very
distal LAD.
LCX: The true LCX is a diminutive vessel that appears to run in
the AV groove to the inferoposterior wall. There are apparent
faint collaterals to posterolateral branches. There is a large
OMB that has a 60% stenosis in its mid-distal portion.
RCA: 100% occluded mid portion. There are faint collaterals to
the inferior wall but it is not clear if there is right or left
dominance.
Interventional details
The patient had three vessel coronary artery disease but only
the
LAD was amenable to percutaneous or surgical revascularization.
The posterolateral branches were diminutive and the OMB1 was
diffusely diseased. As the patient is on chronic hemodialysis,
PCI was undertaken with bare metal stents.
Due to the thrombus within the LAD, unfrationated heparin and
abciximab were used for anticoagulation. The ACT was greater
than 300 seconds.
Ultimately, an ___ Fr AL2 guiding catheter was used for PCI.
There
was marked angulation of the mid LAD at the level of the
thrombus/occlusion. Aspiration thrombectomy was performed with
minimal change in the filling defect. A 2.5 mm balloon and a
3.0 mm balloon were used to predilated the lesion. With an
over-the-wire system, and predilation using a 3.0 mm balloon, a
3.0 mm x 26 mm Integrity stent was ultimately deployed in the
mid
LAD an inflated to 22 atms. A 3.5 mm x 15 mm compliant balloon
was used to post dilated the stent to 24 atms. This resulted in
no residual stenosis within the stent and TIMI 3 flow into the
distal vessel.
The distal LAD lesion was directly stented with a 2.25 mm x 14
mm
Integrity stent inflated to 18 atms. This resulted in no
residual stenosis and TIMI 3 flow into the distal vessel.
The right groin was closed with an ___ Angioseal.
Potential for Radiation Injury
This patient underwent a procedure performed under fluoroscopic
(X-ray) guidance. Procedures involving lengthy exposures to
X-rays may cause damage to the skin and/or hair. These adverse
effects may be increased if one has had previous (especially
recent) radiation exposure to the same skin area. Radiation
injury to the skin can take many forms, including an area of
redness, blistering, hair loss, or ulceration. These effects may
appear after a few weeks or even after several months. If an of
these occur on the side and back of the torso (or elsewhere),
please contact the Interventional Cardiology Section at
___ to arrange further evaluation. This patient
received a prolonged exposure to X-rays and should be monitored
more closely to see if any skin or hair changes occur.
ASSESSMENT
1.NSTEMI due to LAD thrombosis
2.Three vessel coronary artery disease
3.Successful PCI of the mid LAD with bare metal stents
PLAN
1.Abciximab for 12 hours
2.Clopidogrel 600 mg now then 75 mg daily
3.Aspirin 325 mg now then 81 mg daily
Brief Hospital Course:
ASSESSMENT AND PLAN: ___ year old male with ESRD on HD presenting
with 1 month of progrss CP and SOB concerning for unstable
angina
# unstable angina/NSTEMI: The patient reported 1 month history
of progressive CP and SOB at rest and on exertion. EKG was
notable for RBBB seen on previous EKGs from the ___ system, with
no ischemic changes. He was started on a full dose aspirin, and
atorvastatin 40mg. A lipid panel was within goal LDL of 75, so
he was subsequently switched to simvastatin 10mg. He was
continued on his home dose of labetolol, and initiation of
lisinopril was deferred given his boderline potassium probable
inability to tolerate an ACe-i in the setting of hyperkalemia.
On ___ he had an acute episode of chest pain and shortness
of breath similar to his episodes at home. His symptoms
responded to sublingual nitroglycerin x 3, and oxygen. Cardiac
enzymes were repeated and were down trending from admission (see
results). An EKG at that time showed Twave inversion in lead V3
changed from prior and progressive T wave flatterning in V4, V5,
V6 not seen in his admission EKG. A repeat EKG while he was
chest pain free showed normal upright T waves in V4-V6. He had
a stress MIBI on ___ which was notable for moderate
reversible perfusion defect in the distal inferolateral wall.
Cardiology was consulted and cardiac cath was recommended. He
underwent cath on ___ with BMSx2 to mid and distal LAD lesions.
Patient was initially on abciximab but was transitioned to
aspirin 81mg daily and started on plavix. He was started on
simvastatin, continued on IMDUR, and labatelol upon discharge.
CHRONIC STABLE ISSUES
# ESRD on HD- The patient missed dialysis the day of admission
on ___. He underwent dialysis ___, and resumed
his regular schedule of ___. He was continued on nephrocaps,
calcium acetate, and calcitriol
# COPD- the patient is on albuterol prn at home. He was recently
started on advair and spiriva at ___ but has yet to fill his
prescription. Advair and spiriva continued during his
hospitalization and on discharge.
# Prostate Cancer- the patient has a hisotry of prostate cancer
which has been managed conservatively. A PSA was checked at the
request of his outpatient NP at the ___ and was 3.8
TRANSITONAL ISSUES
1. Patient needs continued risk factor modification and
titration of medical regimen given his CAD. He was started on
nicotine patch with plans to quit smoking.
2. Patient will continue on outpatient HD schedule.
3. Patient remained full code.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO DAILY PRN pain
2. Aspirin 81 mg PO DAILY
3. Nephrocaps 1 CAP PO DAILY
4. Rocaltrol 0.5 mcg PO DAILY
5. Calcium Acetate 667 mg PO TID W/MEALS
6. Finasteride 5 mg PO DAILY
7. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
hold for SBP < 100
8. Labetalol 200 mg PO BID
hold for SBP < 100
9. Albuterol Inhaler 2 PUFF IH Q4H:PRN sob
Discharge Medications:
1. Albuterol Inhaler 2 PUFF IH Q4H:PRN sob
2. Calcium Acetate 667 mg PO TID W/MEALS
3. Finasteride 5 mg PO DAILY
4. Nephrocaps 1 CAP PO DAILY
5. Rocaltrol 0.5 mcg PO DAILY
6. Acetaminophen 650 mg PO DAILY PRN pain
7. Tiotropium Bromide 1 CAP IH DAILY
RX *tiotropium bromide [Spiriva with HandiHaler] 18 mcg 1
puff(s) INH daily Disp #*90 Capsule Refills:*0
8. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
RX *fluticasone-salmeterol [Advair Diskus] 250 mcg-50 mcg/Dose 1
puff(s) INH twice a day Disp #*9 Inhaler Refills:*0
9. Aspirin 81 mg PO DAILY
10. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
hold for SBP < 100
11. Labetalol 200 mg PO BID
hold for SBP < 100
12. Clopidogrel 75 mg PO DAILY
RX *clopidogrel 75 mg 1 tablet(s) by mouth daily Disp #*90
Tablet Refills:*0
13. Nicotine Patch 14 mg TD DAILY
RX *nicotine 21 mg/24 hour (28)-14 mg/24 hour (14)-7 mg/24 hour
(14) Apply one patch to nonhairy skin daily Disp #*1 Container
Refills:*0
14. Nitroglycerin SL 0.4 mg SL ONCE MR2
RX *nitroglycerin 0.4 mg 1 tab sublingually PRN Disp #*30 Tablet
Refills:*0
15. Simvastatin 10 mg PO DAILY
RX *simvastatin 10 mg 1 tablet(s) by mouth daily Disp #*90
Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnosis:
Acute coronary syndrome (unstable angina)
Coronary artery disease
End-stage renal disease on hemodialysis
Secondary Diagnosis:
Hypertension
Prostate Cancer
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. ___,
It was a pleasure participating in your care at ___. You were
admitted to the hospital with chest pain and shortness of
breath. We did a stress test that showed you have decreased
blood flow to a certain part of your heart. You had a procedure
called a cardiac cathetherization, which involved looking at the
blood vessels that supply blood to your heart muscle (coronary
arteries). You had a base metal stent placed to open up
blockages in one of your arteries.
Please see the attached list for changes made to your
medications.
Followup Instructions:
___
|
19679966-DS-2
| 19,679,966 | 28,413,078 |
DS
| 2 |
2154-12-19 00:00:00
|
2154-12-27 16:41:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
left sided rib pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ years old gentleman with PMH of arthritis and HTN who
presents
to the ED after a mechanical fall.
Patient was walking in the ___ parking lot picking up his
wife,
when he tripped and fell forward. He landed on his left anterior
chest wall, and developed acute onset sharp pain in that area.
Patient did not have a head strike, no loss of consciousness.
Patient is certain that this is a mechanical trip and fall, and
that he did not have an episode of syncope/near
syncope/dizziness.
Patient now has moderate to severe sharp left anterolateral rib
pain, worse with inspiration and movement. No fevers, no chills,
no headache, no visual change, no chest pain, no shortness of
breath, no cough, no abdominal pain, no nausea no vomiting.
Past Medical History:
Arthritis
HTN
Thyroid disease
HLD
PSH:
Right hip replacement
Right rotator cuff surgery
Cervical spinal fusion
Social History:
___
Family History:
non-contributory
Physical Exam:
Physical Exam: upon admission: ___:
Vitals: 97.9, 78, 117/59, 16, 97% RA
GENERAL: AAOx3 NAD
HEENT: NCAT, EOMI, PERRLA, mucosa moist, no LAD
CARDIOVASCULAR: R/R/R, S1/S2, NO M/R/G
PULMONARY: CTA ___, No crackles or rhonchi, tenderness to
palpation in left anterior chest wall
GASTROINTESTINAL: S/NT/ND. No guarding, rebound, or peritoneal
signs. +BSx4. Hematuria
EXT/MS/SKIN: No C/C/E; Feet warm. Good perfusion.
NEUROLOGICAL: Reflexes, strength, and sensation grossly intact
Pertinent Results:
___ 06:41AM BLOOD WBC-8.5 RBC-4.39* Hgb-13.1* Hct-39.8*
MCV-91 MCH-29.8 MCHC-32.9 RDW-14.3 RDWSD-47.8* Plt ___
___ 07:35AM BLOOD WBC-9.6 RBC-4.50* Hgb-13.3* Hct-40.8
MCV-91 MCH-29.6 MCHC-32.6 RDW-14.2 RDWSD-47.0* Plt ___
___ 11:24PM BLOOD WBC-10.7* RBC-4.69 Hgb-14.1 Hct-42.1
MCV-90 MCH-30.1 MCHC-33.5 RDW-14.1 RDWSD-46.1 Plt ___
___ 11:24PM BLOOD Neuts-68.3 Lymphs-18.3* Monos-11.9
Eos-0.7* Baso-0.3 Im ___ AbsNeut-7.31* AbsLymp-1.96
AbsMono-1.27* AbsEos-0.08 AbsBaso-0.03
___ 06:41AM BLOOD Glucose-95 UreaN-12 Creat-0.9 Na-142
K-4.3 Cl-105 HCO3-24 AnGap-13
___ 11:24PM BLOOD Glucose-98 UreaN-17 Creat-1.0 Na-143
K-4.3 Cl-106 HCO3-22 AnGap-15
___ 06:41AM BLOOD Calcium-8.6 Phos-3.8 Mg-2.0
___: CXR:
No acute cardiopulmonary process. No visualized rib fracture on
this
non-dedicated exam.
___ CT chest:
. Left posterior midpole renal laceration with resultant
contained left
posterior perinephric hematoma. No evidence of contrast
excretion into the hematoma to suggest injury of the left
collecting system.
2. Non-displaced/minimally displaced consecutive fractures of
the left fifth, sixth, seventh, eighth and ninth ribs.
3. No evidence of additional acute traumatic injuries.
4. Mild-to-moderate cardiomegaly with coronary artery
calcifications.
5. Indeterminate right iliac sclerotic and lytic lesions favor
benign
etiology, however correlation with PSA levels and/or bone scan
is recommended.
6. Severe bilateral shoulder degenerative joint disease.
___: CT abd/pelvis:
. Left posterior mid-pole renal laceration with resultant
contained left
posterior ___ hematoma. No evidence of contrast
excretion into the hematoma to suggest injury of the left
collecting system.
2. Non-displaced/minimally displaced consecutive fractures of
the left fifth, sixth, seventh, eighth and ninth ribs.
3. No evidence of additional acute traumatic injuries.
4. Mild-to-moderate cardiomegaly with coronary artery
calcifications.
5. Indeterminate right iliac sclerotic and lytic lesions favor
benign
etiology, however correlation with PSA levels and/or bone scan
is recommended.
6. Severe bilateral shoulder degenerative joint disease.
RECOMMENDATION(S): Correlation with PSA levels and/or bone
scan is
recommended further evaluate right iliac bone sclerotic and
lytic lesions.
___: CT head:
. No evidence of hemorrhage or fracture.
2. Para-nasal sinus inflammatory disease.
___: CT c-spine:
1. No no evidence of fracture.
2. Normal alignment peer
3. Status post cervical fusion without evidence of hardware
complication.
Brief Hospital Course:
___ year old male admitted to the hospital after a fall resulting
in left sided rib fractures and a left renal laceration. Upon
admission, the patient was made NPO, given intravenous fluids
and underwent review of imaging. Cat scan of the C-spine showed
no cervical fractures. There was no evidence of a intra-cranial
hemorrhage. Cat scan of the abdomen showed a left renal
laceration with resultant contained left posterior perinephric
hematoma. The patient underwent serial hematocrit's which
remained stable. Imaging was evident for left sided rib
fractures ___.
The patient's pain was controlled with oral analgesia. He was
instructed and encouraged to use the incentive spirometer. His
vital signs were stable and he was afebrile. He was tolerating
a regular diet and voiding without difficulty. In preparation
for discharge, the patient was evaluated by physical therapy and
recommendations were made for discharge home. The patient was
discharged home on HD #3. Discharge instructions were reviewed
and questions answered. A follow-up appointment was made in the
acute care clinic.
Medications on Admission:
Pravastatin 20 mg tablet oral
Amlodipine 5 mg tablet oral
Synthroid 50 mcg tablet oral
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
may continue this regimen for 72 hours, then take Tylenol as
needed (not to exceed 3 gms)
2. Docusate Sodium 100 mg PO BID
3. Lidocaine 5% Patch 1 PTCH TD DAILY:PRN pain
4. Polyethylene Glycol 17 g PO DAILY:PRN constipaton
5. Senna 8.6 mg PO DAILY:PRN Constipation - First Line
6. TraMADol 50 mg PO Q4H:PRN Pain - Moderate
do not drive while on this medication
RX *tramadol 50 mg 1 tablet(s) by mouth every four (4) hours
Disp #*30 Tablet Refills:*0
7. amLODIPine 5 mg PO DAILY
8. Levothyroxine Sodium 50 mcg PO DAILY
9. Pravastatin 20 mg PO QPM
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
___ left rib fractures
left renal laceration with ___ hematoma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital after a fall resulting in left
sided rib fractures and a bruise to your kidney resulting in
blood tinged urine. Your rib pain has been controlled with oral
analgesia. Your urine has become less blood tinged and your
blood count has been stable. You are preparing for discharge
home with the following instructions:
* Your injury caused left sided rib fractures which can cause
severe pain and subsequently cause you to take shallow breaths
because of the pain.
* You should take your pain medication as directed to stay
ahead of the pain otherwise you won't be able to take deep
breaths. If the pain medication is too sedating take half the
dose and notify your physician.
* Pneumonia is a complication of rib fractures. In order to
decrease your risk you must use your incentive spirometer 4
times every hour while awake. This will help expand the small
airways in your lungs and assist in coughing up secretions that
pool in the lungs.
* You will be more comfortable if you use a cough pillow to
hold against your chest and guard your rib cage while coughing
and deep breathing.
* Symptomatic relief with ice packs or heating pads for short
periods may ease the pain.
* Narcotic pain medication can cause constipation therefore you
should take a stool softener twice daily and increase your fluid
and fiber intake if possible.
* Do NOT smoke
* If your doctor allows, non steroidal antiinflammatory drugs
are very effective in controlling pain ( ie, Ibuprofen, Motrin,
Advil, Aleve, Naprosyn) but they have their own set of side
effects so make sure your doctor approves.
* Return to the Emergency Room right away for any acute
shortness of breath, increased pain or crackling sensation
around your ribs ( crepitus ).
You also sustained a bruise to your kidney resulting in
blood-tinged urine. Please notify the clinic if you have:
* bloody or blood tinged urine
* flank/back pain
* difficulty with urination
* fever
* chills, night sweats
* pain on urination or inability to pass urine
* increased swelling left flank, increased bruising left flank
Followup Instructions:
___
|
19680373-DS-10
| 19,680,373 | 24,757,218 |
DS
| 10 |
2127-03-19 00:00:00
|
2127-03-24 08:44:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Hydrocodone
Attending: ___.
Chief Complaint:
Lightheadedness and Shortness of Breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old male with a history of HTN, HLD, GERD, 45 pack-year
___ use who presents with an acute episode of
lightheadeness, unsteady gait, tremulousness, and shortness of
breath after awaking from a nap this AM. Symptoms occured
immediately after standing up after waking. He reports feeling
lightheaded but denies loss of consciousness, focal weakness,
parasthesias, or blurry vision. No dysarthria, confusion or
aphasia per wife. He has noticed increasing shortness of breath
over the last few weeks and a chronic cough with sputum
production for >6 months without recent change. Per patient and
wife, he has been increasingly fatigued over the last month and
falling asleep during conversations. Patient scheduled for sleep
study for suspected OSA (heavy snoring with apnea at night), not
yet completed. Patient notes onset of bilateral lower extremity
edema over the past month and increased pain in his legs with
walking which is relieved with rest. Currently undergoing
vascular workup. He denies chest pain, palpitations, orthopnea,
nocturnal dyspnea, nausea, vomiting.
Notes increasing difficulty falling asleep and staying asleep
over the last year which he contributes to nocturia
(___). History of chronic UTI on macrobide w/ chronic
dysuria, urgency, hesitancy, and retention. Was evaluated by
urologist years ago, but is unaware of any diagnosis apart from
chronic UTI's.
Patient called an ambulance shortly after symptoms began. EMT's
noted HTN to 200/100, 88% on RA to 97% on 4L NC. FSBG 119.
Reported resolution of symptoms with oxygen.
In the ED, initial vitals: 98.4 55 160/78 20 97% 4L NC. Labs
were notable for HCT 53, BNP 304, trop <0.01, HCO3 33. ECG
showed sinus bradycardia HR 53, t wave inversions 1, avL, V6.
Received methylprednisolone, prednisone 20mg, albuterol,
ipratropium, and azithromycin.In the ED, initial vitals: 98.4 55
160/78 20 97% 4L NC. Labs notable for HCT 53, BNP 304, trop
<0.01, HCO3 33. CXR showed COPD and possible mild pulmonary
edema. ECG showed sinus bradycardia HR 53, t wave inversions 1,
avL, V6. Received methylprednisolone, prednisone 20mg,
albuterol, ipratropium, and azithromycin. Vitals prior to
transfer: not available.
Upon arrival to the floor, he appears comfortable, talking in
full sentences. Denies current lightheadedness.
ROS: per HPI, otherwise 10 point review of systems is negative.
Past Medical History:
Hypertension
Hypercholesterolemia
GERD
Chronic UTI
Social History:
___
Family History:
Mother: ___ yo-alive with HTN/HLD and h/o MI
Father: died at ___, history of heart disease, colon cancer.
Physical Exam:
Admission Physical Exam:
VS: 98.5 161/66, 58, 22, 95% 4L NC
General: NAD, speaking in full sentences, cyanosis present on
nose (baseline per family)
HEENT: EOMI, PERRL, no O/P lesions, no cervical LAD
Neck: unable to appreciate JVP due to body habitus
CV: RRR no M/R/G
Lungs: distant quiet breath sounds, no
wheezing/rhonchi/crackles
Abdomen: obese, NABS, NT/ND, no HSM
Ext: erythema in stocking distributing b/l ___, 1+ pitting edema
to knees b/l, pulses 1+ ___ b/l, feet warm
Neuro: CN ___ intact, ___ strength all extremities, sharp and
dull sensation intact, no dysmetria on finger to nose testing,
A&O x3
Discharge Physical Exam:
VS 98.0, 150/76, 70, 20, 94% 3L NC
Orthostatics: 179/72 --> 159/98
I: 260 PO O: BRP x2
General: NAD, resting in bed, cyanosis on nose tip
HEENT: EOMI, PERRL, no O/P lesions, no cervical LAD
Neck: Supple w/o LAD, JVD not appreciated
CV: distant, RRR no M/R/G
Lungs: Barrerl chest, no accessory muscle use, distant breath
sounds, minor expiratory wheezes
Abdomen: obese, NABS, NT/ND, no HSM
Ext: venoustasis changes, b/l ___, 1+ pitting edema to knees b/l,
___ pulses 1+ b/l
Neuro: CN ___ intact, motor strenth, sensation grossly intact
throughout, A&O x3
Pertinent Results:
Admission Labs:
___ 12:15PM BLOOD WBC-8.3 RBC-5.57 Hgb-18.0 Hct-53.2*
MCV-96 MCH-32.3* MCHC-33.8 RDW-12.6 Plt ___
___ 12:15PM BLOOD ___ PTT-37.6* ___
___ 12:15PM BLOOD Glucose-105* UreaN-8 Creat-0.8 Na-136
K-4.5 Cl-95* HCO3-33* AnGap-13
___ 12:15PM BLOOD ALT-32 AST-29 AlkPhos-92 TotBili-0.5
___ 12:15PM BLOOD Lipase-24
___ 12:15PM BLOOD proBNP-304*
___ 12:15PM BLOOD cTropnT-<0.01
___ 08:45PM BLOOD CK-MB-4 cTropnT-<0.01
___ 12:15PM BLOOD Albumin-4.6 Calcium-9.4 Phos-4.6* Mg-2.1
___ 12:15PM BLOOD %HbA1c-5.9 eAG-123
___:45PM BLOOD TSH-1.1
Interval cardiac labs:
___ 12:15PM BLOOD cTropnT-<0.01
___ 08:45PM BLOOD CK-MB-4 cTropnT-<0.01
___ 02:08AM BLOOD CK-MB-4 cTropnT-<0.01
___ 07:12AM BLOOD CK-MB-3 cTropnT-<0.01
___ 08:45PM BLOOD CK(CPK)-77
___ 02:08AM BLOOD CK(CPK)-65
___ 07:12AM BLOOD CK(CPK)-58
Discharge Labs:
___ 07:12AM BLOOD WBC-11.3* RBC-5.29 Hgb-17.3 Hct-50.8
MCV-96 MCH-32.7* MCHC-34.1 RDW-12.7 Plt ___
___ 07:12AM BLOOD Glucose-144* UreaN-10 Creat-0.7 Na-141
K-4.8 Cl-98 HCO3-32 AnGap-16
___ 07:12AM BLOOD Calcium-9.3 Phos-4.4 Mg-2.1
Additional Studies:
EKG ___
Sinus bradycardia. Prior anteroseptal myocardial infarction. ST
segment
depressions and T wave inversions in leads I and aVL with
biphasic to inverted T waves in leads V5-V6. Slight ST segment
elevation in leads III amnd aVF, recorded on a tracing with
baseline artifact. The Q-T interval is prolonged. These findings
suggest acute inferolateral ischemia. Followup and clinical
correlation are suggested.
TRACING #1
Read by: ___
___ Axes
Rate PR QRS QT/QTc P QRS T
53 ___ 48 56 115
Chest x ray ___
FINDINGS: PA and lateral views of the chest were provided. The
lungs are hyperinflated. There is no overt edema or signs of
pneumonia. There is minimal diffuse ground-glass opacity which
could represent a very mild
pulmonary edema. Cardiomediastinal silhouette is normal. Bony
structures are intact. No free air below the right
hemidiaphragm. The heart is top normal in size.
IMPRESSION: COPD, possible mild pulmonary edema.
___ TTE
Conclusions
The left atrium is mildly dilated. No atrial septal defect is
seen by 2D or color Doppler. Left ventricular wall thicknesses
are normal. The left ventricular cavity size is normal. Regional
left ventricular wall motion is normal. Left ventricular
systolic function is hyperdynamic (EF>75%). 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 valve is mildly thickened and probably bicuspid. There is
mild aortic valve stenosis (valve area 1.2-1.9cm2). No aortic
regurgitation is seen. The mitral valve appears structurally
normal with trivial mitral regurgitation. There is no mitral
valve prolapse. The pulmonary artery systolic pressure could not
be determined. There is no pericardial effusion.
Brief Hospital Course:
___ year old man with a history of hypertension, hyperlipidemia,
gastroesophogeal reflux, and a 45 pack-year smoking history who
presented with an episode of lightheadedness, shortness of
breath, and unsteady gait in the setting of increased
sleepiness, and chronic cough over the preceding 6 months to ___
year and increased lower extremity edema over the last 1 month.
Patient was awaiting CPAP machine in the mail and was currently
undergoing vascular assessment for suspected venous
insufficiency as an outpatient. Patient presented by ambulance
from his home. Symptoms improved with oxygen in the ambulance.
In the Emergency department, patient was hypertensive to 200/100
and saturating 97% on 4 liters by nasal cannula. He was
transferred to the medical floor in stable condition.
#COPD: Chronic cough and subjective shortness of breath
secondary to undiagnosed and untreated COPD without past
spirometry. In the ED, the patient received methylprednisolone,
prednisone 20mg, albuterol, ipratropium, and azithromycin. His
chest X-ray, physical exam, and labs (Hematocrit 53.2, HCO3- 33)
were classic for COPD. Given his chronically stable cough
without change in sputum production, bronchospasm, or evidence
of infection it was felt that he was not having a COPD
exacerbation, but rather untreated COPD was contributing to his
complaints of daytime sleepiness and shortness of breath.
Patient was given albuterol and ipatropium nebulizers during his
hospitalization and his oxygenation and subjective feeling of
shortness of breath improved. He was discharged with
prescriptions for albuterol and ipatropium, received inhaler
education, and scheduled for an outpatient pulmonology
appointment. He expressed a desire to quit smoking and was
prescribed a nicotine patch and education on quitting. He was
provided with close follow-up with his primary care physician.
#Obstructive Sleep Apnea(OSA): Patient with multiple risk
factors for OSA who stated he was suppose to be receiving a CPAP
machine in the mail and was to be fitted. History of daytime
sleepiness, fatigue, night time awakenings, and snoring was
consistent with obstructive sleep apnea. He was provided with a
CPAP machine overnight and slept well with subsequent
improvement in symptoms. Likely OSA played a large part in his
symptoms including his suspected pulmonary hypertension, heart
failure, and lower extremity edema. He will benefit from CPAP at
home, which he stated was to be arriving soon. He was scheduled
for outpatient pulmonology and primary care appointments to
further assess his disease.
#Diastolic Congestive Heart Failure: Left sided diastolic
congestive heart failure in the setting of hypertension likely
contributing to dyspnea and lower extremity edema. An EKG was
performed which showed evidence of prior anteroseptal myocardial
infarction and suggestion of acute inferolateral ischemia.
Cardiac enzymes were trended and remained negative times 3 with
a BNP of 304. He was monitored on telemetry throughout his
hospitalization without any events. A transthoracic echo was
performed showing a LVEF >75% and left atrial enlargement,
consistent with diastolic dysfunction. A chest X-Ray showed
pulmonary edema which was also consistent with congestive heart
failure and worsening shortness of breath. His lisinopril was
upped from 20mg to 40 mg daily and his atenolol was decreased to
25mg. He was provide with close cardiology follow-up at
discharge.
#Smoking cessation: ___ pack year history, was smoking
approximately 1 pack of cigarettes a day. Patient stated he had
been trying to quit and was previously successful for greater
than ___ years. He stated his primary care physician was suppose
to be mailing him a medication to assist him with smoking
cessation, but he has not received it in the mail. He requested
and received a nicotine patch in the hospital as well as further
education on smoking cessation. He was asked to follow-up with
his primary care physician regarding continued use of the patch
and slow down titration.
Patient remained stable throughout the course of his
hospitalization. He was discharged home with close follow-up
with his primary care physician, ___, and pulmonology.
All other chronic conditions were managed without complications.
He remained full code throughout his admission.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 325 mg PO DAILY
2. NexIUM *NF* (esomeprazole magnesium) 40 mg Oral daily
3. Atenolol 50 mg PO DAILY
hold for HR<60 or SBP<90
4. Lisinopril 20 mg PO DAILY
hold for SBP <90
5. Amlodipine 5 mg PO DAILY
hold for SBP <90
6. Atorvastatin 10 mg PO DAILY
7. Clopidogrel 75 mg PO DAILY
8. Nitrofurantoin (Macrodantin) 100 mg PO DAILY
Discharge Medications:
1. Amlodipine 5 mg PO DAILY
2. Atorvastatin 10 mg PO DAILY
3. Clopidogrel 75 mg PO DAILY
4. Lisinopril 40 mg PO DAILY
RX *lisinopril 40 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
5. Atenolol 25 mg PO DAILY
RX *atenolol 25 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
6. Nicotine Patch 21 mg TD DAILY
RX *nicotine 21 mg/24 hour (28)-14 mg/24 hour (14)-7 mg/24 hour
(14) 1 patch daily as directed Disp #*56 Transdermal Patch
Refills:*0
7. NexIUM *NF* (esomeprazole magnesium) 40 mg ORAL DAILY
8. Nitrofurantoin (Macrodantin) 100 mg PO DAILY
9. Aspirin 81 mg PO DAILY
RX *aspirin 81 mg 1 tablet,delayed release (___) by mouth
daily Disp #*30 Tablet Refills:*0
10. Albuterol Inhaler 2 PUFF IH Q4H:PRN SOB or wheezing
please dispense with a spacer
RX *albuterol sulfate 90 mcg 2 puff inh q4H PRN Disp #*1 Inhaler
Refills:*0
11. Tiotropium Bromide 1 CAP IH DAILY
RX *tiotropium bromide [Spiriva with HandiHaler] 18 mcg 1 puff
inh daily Disp #*30 Capsule Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnoses:
COPD
OSA
Diastolic CHF
Secondary
Venous Stasis
Lower Extremity Edema
Hypertension
Hypercholesterolemia
Alcohol Abuse
Smoking
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you at ___
___.
You were admitted for lightheadedness, shortness of breath, and
increasing fatigue. Chest X-ray and blood labs were consistent
with Chronic Obstructive Pulmonary Disease (COPD) which partly
explains your chronic cough, shortness of breath, and fatigue.
The most important step to improving COPD is to quit smoking and
to use the inhalers as prescribed. You were given education in
the hospital on how to use these inhalers. You will be sent home
with a prescription for nicotine patches to help you quit
smoking and will need to follow-up with your primary care
physician. Also, it will be important for you to follow-up with
the pulmonologist to get the appropriate lung test and optimize
your medication regimen for your COPD.
We also feel obstructive sleep apnea is contributing to your
frequent night time awakenings, daytime sleepiness, high blood
pressure, and shortness of breath. You were started on a CPAP
machine during the night of your hospitalization with
improvement in your sleep and daytime symptoms. Please make sure
to get fit for your CPAP and use it while sleeping to improve
your breathing.
We were also concerned with your heart given your lower leg
swelling and high blood pressure. An EKG was performed which did
now show evidence of an acute heart attack. However, you have
likely suffered a small heart attack in the past based on the
EKG findings. The ultrasound of your heart is consistent with
congestive heart failure. Congestive heart failure can cause
symptoms of shortness of breath, cough, and swelling in the
legs. It will be important for you to follow up with a
cardiologist to further evaluate your heart disease. Your
Lisinopril was increased to 40mg once daily. Your atenolol was
decreased to 25mg once a day. Please take these medications as
prescribed.
We also discussed our concern over your alcohol consumption and
potential implications on your liver and other organs. We
advised you decreased your alcohol consumption to less than 14
drinks per week and less than ___ drinks per day.
Thank you for allowing us to participate in your care.
Followup Instructions:
___
|
Subsets and Splits
No community queries yet
The top public SQL queries from the community will appear here once available.