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19680373-DS-12
| 19,680,373 | 26,125,693 |
DS
| 12 |
2128-02-20 00:00:00
|
2128-02-25 16:54:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Hydrocodone
Attending: ___.
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with a PMH signficant for diastolic heart failure with
hyperdynamic left ventricular function (EF 75%),bicuspid AV with
mild AS, 45-pack year history of ___, invasive lung adenoCA
s/p VATS with RUL wedge resection ___, and COPD (baseline
___ O2), OSA on CPAP p/w DOE in the setting of missed home
furosemide. The patient reports a 1 wk history of DOE with
minimal exertion (walking a few steps to the bathroom) and
bilateral lower extremity edema. He has also required continuous
O2 at home while at baseline he uses ___ only on exertion. He
is generally compliant with medications, but forgot to add his
home furosemide to his daily meds at the last refill because his
wife filled the prescription and estimates that he missed at
least 6 days of the medication. He has been taking it for the
past 5 days, but has noted only minimal improvementin his DOE.
He estimates that his dry weight is 270 lbs. He denies chest
pain, cough fever or chills.
.
The patient was diagnosed in with invasive lung adenocarcinoma
in ___ following an episode of bronchitis. The patient
underwent RUL wedge resection and mediastinal lymph node
dissection on ___.
.
In the ED, initial vitals were as follows: 98, 58, 143/52, 20,
93% 3L, with desaturation to 90% on 4L NC. BNP and D-dimer were
elevated. EKG done after pain resolved: SR @62, NANI, no STE,
inf Q, lat TWI in I & aVL, stp. CTPE was negative for PE but
revealed R sided loculated pleural effusion and CXR revealed
consolidation. The patient was given one dose of IV Lasix in the
ED. Thoracic surgery was consulted and recommended admission to
medicine for diuresis. Vitals prior to transfer were as follows:
98.3, 62, 155/61, 16, 97% RA. At the time of exam the patient
was breathing comfortably on supplemental oxygen.
.
ROS: 10-point ROS negative unless otherwise mentioned in above
HPI
Past Medical History:
HTN
HL
Bicuspid aortic valve with mild aortic stenosis
Heart failure (EF 75%)secondary to ischemic heart disease s/p
cardiac cath in ___ 70% stenosis of LAD (diagonal branches),
followed by Dr. ___ at ___ Cardiology
COPD, Home O2 ___ at baseline)
Lung adenoCa, s/p VATS RUL wedge, mediastinal LND ___
Chronic UTI on suppressive abx
OSA on CPAP at night
GERD
H/o viral meningitis ___
Lap ventral hernia repair ___ yrs ago @ ___
Knee surgery ___ yrs ago
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:
Vitals- 98.3 163/57 68 20 94%2L
General- Alert, oriented, no acute distress
HEENT- Sclera anicteric, MMM, oropharynx clear
Neck- Supple, JVP not elevated, no LAD
Lungs- Coarse crackles loudest at the R base, dullness to
percussion over the right base
CV- RRR, Nl S1, S2, No MRG
Abdomen- Soft, NT/ND bowel sounds present, no rebound tenderness
or guarding
Ext- Warm, well perfused, 2+ pulses, 2+ pitting edema
Neuro- CNs2-12 intact, motor function grossly normal
DISCHARGE PHYSICAL EXAM:
Vitals- Tm 98.8 ___ 18 92%RA 94%2L
94%4Lw/Ambulation 1120/2475 ___
General- Alert, oriented, no acute distress
HEENT- Sclera anicteric, MMM, oropharynx clear
Neck- Supple, JVP not elevated, no LAD
Lungs- Coarse crackles loudest at the R base, dullness to
percussion over the right base
CV- RRR, Nl S1, S2, No MRG
Abdomen- Soft, NT/ND bowel sounds present, no rebound tenderness
or guarding
Ext- Warm, well perfused, 2+ pulses, 2+ pitting edema
Neuro- CNs2-12 intact, motor function grossly normal
Pertinent Results:
ADMISSION LABS
___ 05:55PM cTropnT-<0.01
___ 01:21PM D-DIMER-895*
___ 12:09PM GLUCOSE-100 UREA N-13 CREAT-0.7 SODIUM-142
POTASSIUM-4.0 CHLORIDE-100 TOTAL CO2-34* ANION GAP-12
___ 12:09PM estGFR-Using this
___ 12:09PM proBNP-275*
___ 12:09PM WBC-8.5 RBC-4.30* HGB-13.8* HCT-40.4 MCV-94
MCH-32.1* MCHC-34.1 RDW-12.9
___ 12:09PM NEUTS-71.0* LYMPHS-15.7* MONOS-8.3 EOS-4.1*
BASOS-0.8
___ 12:09PM PLT COUNT-166
___ 12:09PM ___ PTT-35.0 ___
PERTINENT LABS
___ 12:09PM proBNP-275*
___ 04:38AM BLOOD Glucose-131* UreaN-14 Creat-0.6 Na-144
K-3.7 Cl-99 HCO3-34* AnGap-15
DISCHARGE LABS
___ 04:27AM BLOOD WBC-7.8 RBC-4.28* Hgb-13.6* Hct-41.1
MCV-96 MCH-31.7 MCHC-33.0 RDW-13.5 Plt ___
___ 04:27AM BLOOD Plt ___
___ 04:38AM BLOOD Glucose-131* UreaN-14 Creat-0.6 Na-144
K-3.7 Cl-99 HCO3-34* AnGap-15
___ 04:38AM BLOOD Calcium-9.3 Phos-4.4 Mg-2.0
CULTURES
None
IMAGING
___ Imaging CTA CHEST W&W/O C&RECON
1. No evidence of pulmonary embolism or other acute
cardiopulmonary process.
2. ___ opacity in the right upper lobe which is likely
post-operative change from prior wedge resection but attention
on follow-up is recommended.
3. Small to moderate loculated right pleural effusion with
adjacent compressive atelectasis.
___ Imaging CHEST (PA & LAT)
Moderate-sized loculated right pleural effusion. Please refer
to the most recent CT for further findings in the chest.
Brief Hospital Course:
___ h/o dCHF (EF 75%),bicuspid aortic valve with mild aortic
stenosis, 45-pack year history of ___, invasive lung
adenocarcinoma s/p VATS with RUL wedge resection ___, and
COPD (baseline ___ O2), OSA on CPAP presenting with dyspnea in
the setting of missed home furosemide consistent with CHF
exacerbation.
#Acute on Chronic Diastolic CHF: The patient has a history of
diastolic heart failure with hyperdynamic left ventricular
function (EF 75%) secondary to ischemic heart disease. Presented
with dyspnea, increased O2 requirement (2L with exertion at
baseline) and weight gain after missing several days of home
furosemide. CXR with pulmonary edema, CTA was negative for PE,
but did reveal a small loculated pleural effusion as discussed
below. He was diuresed with IV furosemide boluses and nutrition
was consulted to review sodium restricted heart healthy diet. O2
requirement returned to baseline and pt was transitioned to
Furosemide 40mg PO (up from 20mg home dose). Discharge weight
was 127.6kg.
#Right Sided Pleural Effusion: CT Chest revealed a right sided
loculated pleural effusion which may be contributing to the
patient's dyspnea. No infectious signs/symptoms or leukocytosis
to suggest infection. Thoracic surgery was consulted and felt
that appearance was unconcerning, likely due to post-surgical
changes.
#Bradycardia: Several asymptomatic episodes of bradycardia to
___ on telemetry while sleeping. Home CPAP was started and
atenolol was held. Remained hemodynamically stable. After
discussion with his outpatient cardiologist, discharged off of
atenolol with plan to resume at half dose starting ___ until
scheduled follow up with cardiology.
Chronic Issues:
#HTN: Continued Lisinopril 40mg, Amlodipine 10mg
#HLD: Continued Atorvastatin 10mg, ASA 81mg
#COPD on ___ Home O2: Continued Albuterol inh,
fluticasone-salmeterol 500/50mcg, tiotropium bromide 18mcg,
#Chronic UTI on Abx: Continued Nitrofurantoin 100mg
#OSA on CPAP: Continued CPAP
#GERD: Continued PPI, but substituted Nexium 40mg
(non-formulary) with Omeprazole 20mg
# CODE STATUS: Full
# CONTACT: ___ (wife) ___
#TRANSITIONAL ISSUES
-Will need to have chem 10 checked in 1 week on new dose of
furosemide.
-Monitor weight as outpatient
-Monitor BP and consider increasing beta blocker as tolerated
-repeat chest imaging to f/u RUL opacity and right sided
effusion seen on CTA chest
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amlodipine 10 mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Atenolol 50 mg PO DAILY
4. Atorvastatin 10 mg PO DAILY
5. Clopidogrel 75 mg PO DAILY
6. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
7. Furosemide 20 mg PO DAILY
8. Lisinopril 40 mg PO DAILY
9. Tiotropium Bromide 1 CAP IH DAILY
10. albuterol sulfate 90 mcg/actuation inhalation QID prn SOB
11. nitrofurantoin macrocrystal 100 mg oral Q AM
Discharge Medications:
1. Amlodipine 10 mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 10 mg PO DAILY
4. Clopidogrel 75 mg PO DAILY
5. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
6. Furosemide 40 mg PO DAILY
RX *furosemide 40 mg 1 tablet(s) by mouth Daily Disp #*30 Tablet
Refills:*0
7. Lisinopril 40 mg PO DAILY
8. nitrofurantoin macrocrystal 100 mg oral Q AM
9. Tiotropium Bromide 1 CAP IH DAILY
10. albuterol sulfate 90 mcg/actuation inhalation QID prn SOB
11. Atenolol 25 mg PO DAILY
Per Dr. ___: Stop until ___, then take half a 50mg pill
daily until followup appt.
Discharge Disposition:
Home
Discharge Diagnosis:
Acute on Chronic Diastolic Congestive Heart Failure
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you at ___. You were admitted
to the hospital for difficulty breathing from having too much
fluid in your body as a result of not taking your furosemide.
You improved with IV furosemide and you will go home on the
tablet form at a higher dose (40mg). We held one of your blood
pressure medications, atenolol, due to a slow heart rate while
you were in the hospital. We spoke to your cardiologist, Dr.
___ recommends restarting atenolol at half your normal
dose on ___ until you see him in clinic.
You have a right sided pleural effusion (fluid at the base of
your right lung) which the thoracic surgeons believe is related
to your lung surgery.
Please follow a low salt diet and take all of your medications
as prescribed. You should check your weight daily and call your
doctor if it increases by 3 pounds or more in a day. Follow up
with your PCP and ___ (details of your appointments are
listed below). You will need to have labs checked in 1 week.
-Your Care Team
Followup Instructions:
___
|
19680373-DS-13
| 19,680,373 | 28,157,201 |
DS
| 13 |
2130-11-23 00:00:00
|
2130-12-05 14:23:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Hydrocodone
Attending: ___
Chief Complaint:
Fevers, Chills, Night Sweats, Weakness
Major Surgical or Invasive Procedure:
Endoscopic ultrasound with biopsy on ___
History of Present Illness:
Mr ___ is a ___ male with past medical history
significant for obesity, possible alcoholic cirrhosis, lung
cancer status post resection, COPD, heart murmur p/w multiple
complaints.
The patient reports that he has had month long symptoms of
weakness, fatigue, sweats, and occasional, intermittent
abdominal pains. At first, he thought this was possibly related
to his history of recurrent urinary tract infections, but his
PCP performed ___ UA which was negative for infection, but notable
for high levels of bilirubin. He was referred to ___ for
hepatology consultation, and saw Dr. ___ as an
outpatient, with plan for ___ in the future. He also noted
increased abdominal girth during this time, which is new for
him. He presented to his cardiologist for this, who felt that
his issues did not represent a primary cardiac issue, and
prompted him to present to the ED for evaluation.
In the ED, initial vitals were: T98.3 103 131/68 18 96% RA
- Exam notable for: Bedside ultrasound w/Large Volume ascites
- Labs notable for: WBC 12.6, Hb 12.9, Plt 183, INR 1.4, BNP
735, AST 59
- Imaging was notable for:
CT-Torso ___
1. No acute abnormality in the chest, abdomen, or pelvis.
2. Small amount of intraperitoneal free-fluid. Trace pericardial
effusion.
3. Findings compatible with prior right upper lobe pulmonary
wedge resection.
4. Splenomegaly.
5. Focal contour abnormality with hypodense area at the
pancreatic tailraising possibility of an underlying lesion.
6. Possible 9 mm left adrenal nodule. This can be further
characterized at time of MRI.
CXR: neg
- Patient was given: N/A
- Hepatology consulted, recommended therapeutic para
- VS prior to transfer: T98.7 98 101/42 18 96% RA
REVIEW OF SYSTEMS:
(+) Per HPI
(-) 10 point ROS reviewed and negative unless stated above in
HPI
Past Medical History:
HTN
HL
Bicuspid aortic valve with mild aortic stenosis
Heart failure (EF 75%)secondary to ischemic heart disease s/p
cardiac cath in ___ 70% stenosis of LAD (diagonal branches),
followed by Dr. ___ at ___ Card___
COPD, Home O2 ___ at baseline)
Lung adenoCa, s/p VATS RUL wedge, mediastinal LND ___
Chronic UTI on suppressive abx
OSA on CPAP at night
GERD
H/o viral meningitis ___
Lap ventral hernia repair ___ yrs ago @ ___
Knee surgery ___ yrs ago
Social History:
___
Family History:
Mother: ___ yo - alive with HTN/HLD and h/o MI
Father: died at ___, history of heart disease, colon cancer.
No FMHx of liver disease
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
VITAL SIGNS: 97.9 117/71 106 18 94% Ra
GENERAL: NAD, non-toxic appearing sitting comfortably in bed
HEENT: PERRL without scleral icterus, OP without lesions or
thrush
NECK: supple, no JVD
CARDIAC: RRR, ___ systolic murmur, no rubs
LUNGS: distant, difficult to appreciate basilar sounds,
otherwise CTAB
ABDOMEN: severely distended, soft, nild ttp throughout without
rebound or guarding, non-peritoneal
EXTREMITIES: 1+ pitting edema to knees, wwp
NEUROLOGIC: AOx3, no asterixis, moves all extremities
purposefully
DISCHARGE PHYSICAL EXAM:
=======================
VITAL SIGNS: 98.2 PO 132 / 68 92 18 91 Ra
GENERAL: NAD, well appearing sitting in bed
HEENT: no scleral icterus, MMM
CARDIAC: RRR, ___ systolic murmur, no rubs
LUNGS: CTAB, no wheezes/crackles
ABDOMEN: significantly distended, soft, no tenderness, no
rebound or gaurding
EXTREMITIES: 2+ pitting edema to mid shins with venous stasis
changes, WWP
NEUROLOGIC: AOx3, no asterixis, moves all extremities
purposefully
Pertinent Results:
ADMISSION LABS:
===============
___ 01:35PM ___ PTT-39.1* ___
___ 01:35PM PLT COUNT-183
___ 01:35PM NEUTS-82.4* LYMPHS-7.8* MONOS-7.7 EOS-0.8*
BASOS-0.2 IM ___ AbsNeut-10.33* AbsLymp-0.98* AbsMono-0.97*
AbsEos-0.10 AbsBaso-0.03
___ 01:35PM WBC-12.6* RBC-4.22* HGB-12.9* HCT-39.5*
MCV-94 MCH-30.6 MCHC-32.7 RDW-13.3 RDWSD-45.3
___ 01:35PM ALBUMIN-3.7
___ 01:35PM proBNP-735*
___ 01:35PM LIPASE-32
___ 01:35PM ALT(SGPT)-36 AST(SGOT)-59* ALK PHOS-140* TOT
BILI-1.0
___ 01:35PM estGFR-Using this
___ 01:35PM GLUCOSE-125* UREA N-11 CREAT-0.7 SODIUM-133
POTASSIUM-4.5 CHLORIDE-97 TOTAL CO2-22 ANION GAP-19
___ 01:45PM LACTATE-2.0
___ 06:35PM ASCITES WBC-1071* RBC-809* POLYS-53*
LYMPHS-11* MONOS-12* MESOTHELI-8* MACROPHAG-16*
___ 06:35PM ASCITES TOT PROT-3.4 GLUCOSE-131 ALBUMIN-1.9
___ 07:30PM URINE RBC-7* WBC-0 BACTERIA-NONE YEAST-NONE
EPI-2
___ 07:30PM URINE BLOOD-SM NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-4* PH-6.5
LEUK-NEG
___ 07:30PM URINE COLOR-Yellow APPEAR-Clear SP
___
___ 07:30PM URINE UHOLD-HOLD
___ 07:30PM URINE HOURS-RANDOM
DISCHARGE/PERTINENT LABS:
=========================
___ 04:56AM BLOOD WBC-10.1* RBC-3.50* Hgb-10.7* Hct-32.8*
MCV-94 MCH-30.6 MCHC-32.6 RDW-13.9 RDWSD-47.2* Plt ___
___ 04:56AM BLOOD ___ PTT-38.3* ___
___ 04:56AM BLOOD Glucose-128* UreaN-11 Creat-0.7 Na-133
K-4.0 Cl-95* HCO3-23 AnGap-19
___ 04:56AM BLOOD ALT-30 AST-39 LD(LDH)-273* AlkPhos-130
TotBili-1.0
___ 04:56AM BLOOD Calcium-8.9 Phos-3.6 Mg-2.2
MICROBIOLOGY:
=============
___ 6:35 pm PERITONEAL FLUID PERITONEAL FLUID.
**FINAL REPORT ___
GRAM STAIN (Final ___:
3+ ___ per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
This is a concentrated smear made by cytospin method,
please refer to
hematology for a quantitative white blood cell count..
FLUID CULTURE (Final ___: NO GROWTH.
ANAEROBIC CULTURE (Final ___: NO GROWTH.
___ 1:35 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___:
ENTEROCOCCUS FAECIUM. FINAL SENSITIVITIES.
Daptomycin MIC 3.0 MCG/ML.
Daptomycin Sensitivity testing performed by Etest.
SPECIATION PERFORMED AT ___, REPORTED
___.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROCOCCUS FAECIUM
|
AMPICILLIN------------ <=2 S
DAPTOMYCIN------------ S
PENICILLIN G----------<=0.12 S
VANCOMYCIN------------ 1 S
Aerobic Bottle Gram Stain (Final ___:
GRAM POSITIVE COCCI IN CHAINS.
Reported to and read back by ___ ___ ___
14:55.
Anaerobic Bottle Gram Stain (Final ___:
GRAM POSITIVE COCCI IN PAIRS AND CHAINS.
___ 7:30 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___: < 10,000 CFU/mL.
___ 3:15 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
IMAGING:
========
TTE ___
The left atrium is mildly dilated. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity is
moderately dilated. Due to suboptimal technical quality, a focal
wall motion abnormality cannot be fully excluded. Left
ventricular systolic function is hyperdynamic (EF = 75%). The
ascending aorta is mildly dilated. The number of aortic valve
leaflets cannot be determined. The aortic valve leaflets are
moderately thickened. There is moderate aortic valve stenosis
(valve area 1.3 cm2). 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 left ventricular inflow
pattern suggests impaired relaxation. The pulmonary artery
systolic pressure could not be determined. There is a small
pericardial effusion. There are no echocardiographic signs of
tamponade.
Compared with the prior study (images reviewed) of ___,
aortic stenosis is now moderate. Left ventricle remains
hyperdynamic.
MRCP ___:
Moderately limited exam secondary to patient motion.
MRCP portion of the exam is not diagnostic.
2.1 cm pancreatic tail mass has increased since ___ when it
measured 1.6 cm.
Considered islet cell neoplasm.
Moderate ascites upper abdomen. Enlarged spleen.
RUQ U/S ___:
1. No evidence of portal vein thrombosis.
2. Coarsened and nodular liver parenchyma with large volume
ascites and
splenomegaly.
3. Gallbladder sludge without evidence of cholecystitis.
4. Known pancreatic tail lesion is not seen. Please see CT
report from ___ regarding MRCP recommendation.
RECOMMENDATION(S): Non-urgent MRCP for further evaluation of
pancreatic tail
lesion seen on recent CT.
CT Torso ___:
1. No acute abnormality in the chest, abdomen, or pelvis.
2. Small amount of intraperitoneal free-fluid. Trace
pericardial effusion.
3. Findings compatible with prior right upper lobe pulmonary
wedge resection.
4. Splenomegaly.
5. Focal contour abnormality with hypodense area at the
pancreatic tail
raising possibility of an underlying lesion.
6. Possible 9 mm left adrenal nodule. This can be further
characterized at
time of MRI.
CXR ___:
No acute cardiopulmonary abnormality.
Brief Hospital Course:
Brief Hospital Course:
Mr. ___ is a ___ male with past medical history
significant for obesity, possible alcoholic cirrhosis, lung
cancer status post resection, COPD, HFpEF, and pancreatic tail
mass who presented with abdominal pain and distension found to
have SBP in the setting of worsening ascites. The patient was
treated with Ceftriaxone x 5days (end ___, 100g albumin on
day 1 and 3, and underwent therapeutic paracentesis with ___ on
___ with removal of 3.6L of fluid. Blood culture from ___
positive for pan-sensitive enterococcus in ___ bottles. Repeat
blood cultures on ___ and ___ showed no growth. Over the
course of his hospital stay, his symptoms improved. The patient
was discharged on his home diuretics and cipro for prophylaxis.
Of note, the patient has a known pancreatic tail lesion that had
recently increased in size 1.6cm -> 2.1cm since ___. He
underwent EUS with biopsy on ___ which he tolerated well.
Pathology was pending at time of discharge with plans to
follow-up in Liver Clinic for further management.
Detailed Hospital Course:
====================
#Spontaneous Bacterial Peritonitis: Patient presented with
abdominal pain and worsening ascites found to have >250 PMNs on
diagnostic paracentesis c/f SBP. Culture showed no growth. The
patient was placed on ceftriaxone (___) later transitioned
to cipro for prophylaxis. He underwent a therapeutic
paracentesis with ___ on ___ where 3.6L were removed. Over the
course of his stay, his abdominal pain improved and he was
discharged home with plans to follow-up with liver clinic for
further management.
# Enterococcus Bacteremia: Blood culture from ___ positive for
pan-sensitive enterococcus in the setting of SBP. CXR, urine
culture and TTE all unrevealing for other source of infection.
Patient was hemodynamically stable without signs of sepsis. He
was placed on CTX for SBP as detailed above and blood cultures
from ___ and ___ returned negative. The patient was then
transitioned to ciprofloxacin ppx.
# Alcoholic Cirrhosis
# Ascites: Patient likely has newly diagnosed alcoholic
cirrhosis. MELD-Na of 14 on admission improved to 10, Childs B
(given ascites and high albumin). CT-torso w/only slight
ascites, though notes splenomegaly. RUQUS with no evidence of
PVT as source of rapid accumulation of ascites. Likely rapid
accumulation of ascites secondary to SBP.. Given high albumin
content concern for cardiac etiology. TTE showed moderate AS but
LVEF>75%. The patient was diuresed with lasix IV later
transitioned to 40mg PO. He was continued on his home
spironolactone. He underwent a therapeutic paracentesis on ___
with 3.6L removed. Patient was discharged home with plans to
follow-up with Liver Clinic for further management.
# Pancreatic Lesion: Patient has a known mass in the tail of the
pancreas. MRCP showed pancreatic tail lesion increased in size
compared to ___ (1.6cm -> 2.1cm). He underwent EUS with FNA
biopsy on ___ which he tolerated well. Biopsy results pending
at time of discharge.
CHRONIC ISSUES:
==============
# COPD
- Continued home tiotropium
- Albuterol nebs Q6H PRN
# Possible dCHF: Pt on both furosemide and spironolactone as
home medications, patient reports he does not carry formal
diagnosis of heart failure, and has never had ascites prior per
report. TTE during hospitalization notable for moderate AS and
LVEF>75%. He was continued on his home spironolactone and his
lasix was increased to 40mg daily. Will need close cardiology
follow-up.
# CAD: Continued home ASA and atorvastatin. Losartan resumed
upon discharge given resolution of SBP.
# Recurrent UTIs: Discontinued home nitrofurantoin in the
setting of starting cipro for SBP ppx.
Transitional Issues:
=====================
NEW MEDICATIONS:
-Ciprofloxacin 500mg daily
CHANGED MEDICATIONS:
-Lasix 40mg (from 20mg) daily
STOPPED MEDICATIONS:
-Nitrofurantoin
OTHER:
-Started Cipro 500mg daily for SBP prophylaxis
-Received ___ guided paracentesis with removal of 3.6 L of fluid
on ___. Received 25g albumin post-procedure. Scheduled for
repeat paracentesis on ___.
-Underwent EUS with biopsy for known pancreatic tail mass with
path pending at time of discharge. Needs liver follow-up to
discuss pathology.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 10 mg PO QAM
2. Furosemide 20 mg PO DAILY
3. Spironolactone 50 mg PO DAILY
4. Aspirin 81 mg PO DAILY
5. nitrofurantoin macrocrystal 100 mg oral DAILY
6. Losartan Potassium 50 mg PO DAILY
7. Allopurinol ___ mg PO DAILY
8. Cetirizine 10 mg PO DAILY
9. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
10. Tiotropium Bromide 1 CAP IH BID
11. Omeprazole 40 mg PO DAILY
12. Albuterol Inhaler 2 PUFF IH Q6H:PRN Shortness of breath
Discharge Medications:
1. Ciprofloxacin HCl 500 mg PO Q24H
RX *ciprofloxacin HCl [Cipro] 500 mg 1 tablet(s) by mouth daily
Disp #*30 Tablet Refills:*1
2. Furosemide 40 mg PO DAILY
RX *furosemide [Lasix] 40 mg 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*0
3. Albuterol Inhaler 2 PUFF IH Q6H:PRN Shortness of breath
4. Allopurinol ___ mg PO DAILY
5. Aspirin 81 mg PO DAILY
6. Atorvastatin 10 mg PO QAM
7. Cetirizine 10 mg PO DAILY
8. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
9. Losartan Potassium 50 mg PO DAILY
10. Omeprazole 40 mg PO DAILY
11. Spironolactone 50 mg PO DAILY
12. Tiotropium Bromide 1 CAP IH BID
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: Spontaneous bacterial peritonitis
Secondary: Probable alcoholic cirrhosis, chronic obstructive
pulmonary disease, heart failure with preserved ejection
fraction
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 the worsening abdominal
distension, fatigue, and abdominal pain you were experiencing.
It was found that you had an infection in your abdomen called
spontaneous bacterial peritonitis. This is an infection that is
common in patients with liver disease and fluid in their abdomen
called ascites. You were given antibiotics through the IV to
treat the infection and will be started on an oral antibiotic
called Ciprofloxacin to prevent future infections. To help
remove the fluid in your abdomen, you underwent a paracentesis
with the interventional radiologist. You tolerated the procedure
well and will continue your Lasix and spironolactone medications
to help prevent fluid from reaccumulating.
During your hospitalization, you underwent endoscopy with biopsy
for your pancreatic mass. Your pathology was pending at the time
of discharge, but you will discuss the results at your follow-up
appointment with your liver doctor.
Please take your medications as prescribed and call your doctor
or return to the emergency department if you develop fevers,
shortness of breath, chest pain, blood in your stool, dark tarry
stool or worsening abdominal pain or distension.
We wish you all the best!
-Your ___ Team
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs.
Followup Instructions:
___
|
19680373-DS-15
| 19,680,373 | 26,376,196 |
DS
| 15 |
2130-12-24 00:00:00
|
2130-12-25 10:24:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Hydrocodone
Attending: ___.
Chief Complaint:
Left arm swelling and bruising
Major Surgical or Invasive Procedure:
___: Right PICC placement
History of Present Illness:
___ with h/o EtOH cirrhosis (MELD 22, Child B) with recent
admission for SBP and enterococcus bacteremia found to have
aortic root abscess and 4+ aortic regurgitation now presents
with PICC-site thrombus admitted for PICC replacement.
Pt presented with PICC in L AC for aortic abscess, Now with
ecchymosis and edema since this AM. Denies any trauma or injury.
PICC pulled in ED.
In the ED, initial vitals were: 0 97.1 84 ___ 96% RA
- Exam notable for ecchymosis and swelling in his left AC
- Labs notable for normal renal function and stable CNC
- Imaging was notable for CXR with appropriately positioned PICC
line and Upper extremity u/s notable for deep vein thrombus in
the left basilic vein and thrombus within the left cephalic
vein, surrounding the PICC line.
- Patient was given: IV Heparin 1000 units/hr
- Decision was made to admit for discussion of anticoagulation.
- Vitals prior to transfer were 0 98.2 90 129/55 20 98% RA
Upon arrival to the floor, patient reports that he feels well.
Asymptomatic from clot perspective.
Past Medical History:
EtOH Cirrhosis complicated by ascites and SBP
HTN
HL
Bicuspid aortic valve with mild aortic stenosis
Heart failure (EF 75%)secondary to ischemic heart disease s/p
cardiac cath in ___ 70% stenosis of LAD (diagonal branches),
followed by Dr. ___ at ___ Cardiology
COPD, Home O2 ___ at baseline)
Lung adenoCa, s/p VATS RUL wedge, mediastinal LND ___
Chronic UTI on suppressive abx
OSA on CPAP at night
GERD
H/o viral meningitis ___
Lap ventral hernia repair ___ yrs ago @ ___
Knee surgery ___ yrs ago
Social History:
___
Family History:
Mother: ___ yo - alive with HTN/HLD and h/o MI
Father: died at ___, history of heart disease, colon cancer.
No FMHx of liver disease.
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vital Signs: 98.1 110/60 87 18 94%RA
GEN: NAD, very pleasant
HEENT: no icterus, MMM, PERRL
CV: RRR, ___ harsh systolic murmur heard best at RUSB
RESP: non-labored, CTAB
ABD: Distended, soft, non-tender
EXT: Warm, 2+ ankle edema b/l. Large ecchymosis over L elbow
extending down arm, nontender.
NEURO: Normal mental status. No asterixis
SKIN: No stigmata of cirrhosis or endocarditis
DISCHARGE PHYSICAL EXAM:
No significant change from admission other than a new PICC line
in the right upper extremity
Pertinent Results:
PERTINENT LABS
==============
___ 06:45PM ___ PTT-37.7* ___
___ 06:45PM PLT COUNT-151
___ 06:45PM NEUTS-76.1* LYMPHS-12.1* MONOS-8.1 EOS-2.3
BASOS-0.6 IM ___ AbsNeut-6.00 AbsLymp-0.95* AbsMono-0.64
AbsEos-0.18 AbsBaso-0.05
___ 06:45PM WBC-7.9 RBC-3.61* HGB-10.8* HCT-34.0* MCV-94
MCH-29.9 MCHC-31.8* RDW-15.6* RDWSD-53.8*
___ 06:45PM estGFR-Using this
___ 06:45PM GLUCOSE-101* UREA N-10 CREAT-0.8 SODIUM-140
POTASSIUM-3.5 CHLORIDE-100 TOTAL CO2-25 ANION GAP-19
STUDIES AND REPORTS
===================
CHEST (PA & LAT) Study Date of ___ 3:54 ___
FINDINGS:
There is a left upper extremity access PICC line with its tip
located in the mid SVC region. Lung volumes are low with mild
bibasilar atelectasis. There is no evidence of pneumonia or
overt edema. The heart appears mildly enlarged. The hila
appear mildly prominent though unchanged from prior.
Mediastinal contour is within normal limits. Bony structures
are intact.
IMPRESSION:
Appropriately positioned PICC line. Mild bibasilar atelectasis.
UNILAT UP EXT VEINS US LEFT Study Date of ___ 5:30 ___
FINDINGS:
There is normal flow with respiratory variation in the bilateral
subclavian vein.
The left internal jugular and axillary veins are patent, show
normal color flow and compressibility.
A PICC line is present in the left cephalic vein. Thrombus is
seen within the left basilic vein and the left cephalic vein.
The left brachial veins are patent, compressible and show normal
color flow and augmentation.
IMPRESSION:
1. PICC line in the left cephalic vein.
2. Thrombus within the left cephalic vein, surrounding the PICC
line, and the left basilic vein. These are superficial veins.
CHEST PORT. LINE PLACEMENT Study Date of ___ 10:09 AM
IMPRESSION:
Right PICC line is coiled within the axillary vein and should be
repositioned. Heart size and mediastinum are stable. Left PICC
line has been discontinued. Lungs are overall clear. No
pleural effusion or pneumothorax.
PICC/MIDLINE PLACEMENT ___ Study Date of ___ 3:12 ___
FINDINGS:
1. Existing right arm approach PICC with tip in the axillary
vein replaced with a new double lumen PIC line with tip in the
distal SVC.
IMPRESSION:
Successful placement of a 44 cm right arm approach double lumen
PowerPICC with tip in the distal SVC. The line is ready to use.
Brief Hospital Course:
Mr. ___ is a ___ gentleman with a PMH notable for
alcoholic cirrhosis and recent hospitalization for SBP and
Enterococcus bacteremia complicated by aortic root abscess and
4+ aortic regurgitation, who represents with left arm swelling
and bruising, found to have a catheter related UEDVT.
Ultrasound of the left upper arm showed thrombus within the left
cephalic vein, surrounding the PICC line, and the left basilic
vein, which are superficial veins. The PICC in that arm was
removed, and a new one was placed by Interventional Radiology in
the right arm. While normally anticoagulation would not be
recommended for catheter-related superficial vein thrombosis,
because the patient will need long term PICC placement for
antibiotics, outpatient anticoagulation was initiated to avoid
recurrent clotting around the new PICC. He was given
prescription for enoxaparin 120 mg SC Q12H as a bridge to
warfarin. He was started on warfarin 2.5 mg daily as a
conservative dose given his cirrhosis.
TRANSITIONAL ISSUE
[ ] Determine course of anticoagulation: probably only while he
has a PICC in rather than a prolonged course, such as 3 months.
[ ] Goal INR ___ for warfarin
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Ampicillin 2 g IV Q4H
2. CefTRIAXone 2 gm IV Q12H
3. Albuterol Inhaler 2 PUFF IH Q6H:PRN Shortness of breath
4. Allopurinol ___ mg PO DAILY
5. Aspirin 81 mg PO DAILY
6. Atorvastatin 10 mg PO QAM
7. Cetirizine 10 mg PO DAILY
8. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
9. Furosemide 60 mg PO DAILY
10. Losartan Potassium 25 mg PO DAILY
11. Omeprazole 40 mg PO DAILY
12. Spironolactone 100 mg PO DAILY
13. Metoprolol Succinate XL 25 mg PO DAILY
14. Tiotropium Bromide 1 CAP IH BID
Discharge Medications:
1. Enoxaparin Sodium 120 mg SC Q12H
Start: ___, First Dose: Next Routine Administration Time
RX *enoxaparin 120 mg/0.8 mL 0.8 mL SC every twelve (12) hours
Disp #*10 Syringe Refills:*1
2. Warfarin 2.5 mg PO DAILY16
RX *warfarin 2.5 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*1
3. Spironolactone 150 mg PO DAILY
RX *spironolactone 100 mg 1.5 tablet(s) by mouth daily Disp #*45
Tablet Refills:*1
4. Albuterol Inhaler 2 PUFF IH Q6H:PRN Shortness of breath
5. Allopurinol ___ mg PO DAILY
6. Ampicillin 2 g IV Q4H
7. Aspirin 81 mg PO DAILY
8. Atorvastatin 10 mg PO QAM
9. CefTRIAXone 2 gm IV Q12H
10. Cetirizine 10 mg PO DAILY
11. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
12. Furosemide 60 mg PO DAILY
13. Losartan Potassium 25 mg PO DAILY
14. Metoprolol Succinate XL 25 mg PO DAILY
15. Omeprazole 40 mg PO DAILY
16. Tiotropium Bromide 1 CAP IH BID
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY: Left upper extremity catheter related venous thrombosis
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 having swelling in your
left arm, which was caused by a blood clot that formed around
your old PICC line. We removed that catheter and replaced it
with a new one on the right side. You will need to take blood
thinners to prevent new blood clots from forming around the new
catheter. You will take warfarin (or called Coumadin) at home.
Warfarin is dosed by checking the test called INR, which should
ideally be between ___. You will need regular checks through
your primary care doctor, and we will let him know. While we
wait for your INR to get to the goal range, you will take
Lovenox (or called enoxaparin) every 12 hours.
Followup Instructions:
___
|
19680450-DS-13
| 19,680,450 | 27,197,323 |
DS
| 13 |
2181-01-17 00:00:00
|
2181-01-17 17:54:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Tylenol / Penicillins / Oxycodone / Iodinated Contrast Media -
IV Dye / MIBI / tomatoes, orange juice
Attending: ___.
Chief Complaint:
R chest pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is an ___ woman with past medical history of
chronic mesenteric ischemia s/p SMA/celiac PTA/BMS c/b
restenosis
s/p SMA/celiac PTA/celiac ICAST covered stent (___),
peripheral vascular disease, hypertension, GERD, atrial flutter,
and COPD who presents for evaluation of acute R chest pain and
subacute worsening of abdominal symptoms.
On ___ morning ___, she developed pleuritic chest pain
near the right costal margin. It came on over period of hours in
the morning when she was watching TV. It is sharp and stabbing,
worse when she takes a deep breath, but she denies associated
SOB. At one point yesterday the pain "migrated" to the R lateral
lower ribs and over the R scapula. She applied a heating bad and
took 2mg of tizanidine, which was previously prescribed for
muscle strain in the left shoulder, with reduction although not
resolution of pain. She was able to sleep but this morning the
pain was worse so she presented to the ED.
She went to water aerobics on ___ without noticing any
injuries then or any other trauma to R chest. She has had an
occasional cough since coming to the hospital but none in the
___
weeks prior. She denies nausea, diaphoresis, fever/chills,
muscle
aches other than at left shoulder ___ prior muscle strain. She
has no known cardiac history but does have a history of
peripheral vascular disease as above. She does not have upper
respiratory symptoms, cough, or hemoptysis. She has not had any
peripheral edema, calf pain, recent immobilization, or long
travel. No known sick contacts. She does not get flu shots.
Otherwise, ROS notable for worsening abdominal symptoms in the
past month that she associates with chronic mesenteric ischemia.
She describes postprandial bloating, followed by crampy
epigastric abdominal discomfort, followed by loose bowel
movement. Due to these symptoms, she has limited her oral intake
in the last month and her daughter thinks she has lost 5 pounds
in the past month. She is sometimes lightheaded immediately
after
standing.
In the ED, initial vitals were: Temp 97.1, HR 90, BP 135/57, RR
16, O2 sat 98% RA, pain 9.
- Exam notable for: heart RRR normal S1/S2, bibasilar crackles,
benign abdomen
- Labs notable for: WBC and chem 10 wnl, trop-T < 0.01, CK-MB 2,
CK 191, D-dimer 538, lactate 1.3, bland UA
- Imaging was notable for: CXR demonstrated moderate
cardiomegaly without evidence of pulmonary edema or pneumonia
- Patient was given: Morphine sulfate 2mg IV
Vascular Surgery was consulted in the ED, felt there was low
suspicion for acute on chronic mesenteric ischemia or acute
stent
thrombosis given no current abdominal pain, recommended
mesenteric duplex tomorrow. Patient was admitted to medicine for
further workup of chest pain.
Vitals on transfer: Pain 0, HR 78, BP 133/53, RR 16, O2 sat 100%
on RA
Upon arrival to the floor, patient reports that she is no longer
having chest pain but continues to feel "tightness" at the R
chest with inspiration that is very bothersome. She is not
currently having any pain at her R back, arm, jaw, or abdomen.
Her last BM was yesterday, loose stools as she has been having
over the past month. Denies bloody stools. She and her daughter
confirm the history above and share that her daughter helps her
organize her medications every day.
Past Medical History:
PMH:
aflutter, hypertension, TIA, small bowel obstruction, mesenteric
ischemia, constipation, diverticulosis, GERD, PAD with
claudication, herpes simplex, lactose intolerance, osteopenia
PSH:
- appendectomy
- total abdominal hysterectomy, oophorectomy
- hemorrhidectomy
- cholecystectomy
- rotator cuff repair
- right ___ finger ORIF ___ ___
- chronic mesenteric ischemia s/p celiac & SMA PTA/BMS (OSH ___
___
- celiac PTA/ICAST, SMA ___ ___
- left carpal tunnel release ___ ___
- left inguinal hernia repair ___ ___
Social History:
___
Family History:
mother - diabetes
sister - pancreatic cancer
Physical Exam:
ADMISSION PHYSICAL EXAM:
VITAL SIGNS: ___ 1423 Temp: 98.2 PO BP: 128/74 HR: 74 RR:
18 O2 sat: 95% O2 delivery: RA
GENERAL: Elderly woman lying in bed in NAD, breathing unlabored
and speaking in full sentences.
HEENT: NCAT, PERRLA, anicteric sclerae, MMM.
NECK: supple, symmetric, no cervical lymphadenopathy.
CARDIAC: irregular rate and rhythm, normal S1/S2.
LUNGS: CTAB, good air movement, expiratory phase not prolonged
CHEST/BACK: inferior R ribs mildly tender to palpation without
point tenderness, no tenderness over R scapula, no ecchymoses
ABDOMEN: +normal BS, soft, non-tender, non-distended
EXTREMITIES: trace bilateral extremity pitting edema, lukewarm
feet, femoral pulses palpable, ___ pulses faintly palpable
NEUROLOGIC: AOx3, moving all extremities
SKIN: no rashes or ecchymoses
DISCHARGE PHYSICAL EXAM:
VITAL SIGNS: ___ 1720 Temp: 98.3 PO BP: 115/73 L Sitting
HR: 100 RR: 18 O2 sat: 96% O2 delivery: Ra
GENERAL: Elderly woman lying in bed comfortably in NAD.
HEENT: NCAT, PERRLA, anicteric sclerae, MMM.
NECK: supple, symmetric, no cervical lymphadenopathy.
CARDIAC: irregular rate and rhythm, normal S1/S2.
LUNGS: CTAB
ABDOMEN: +normal BS, soft, non-tender, non-distended
EXTREMITIES: trace bilateral extremity pitting edema
NEUROLOGIC: AOx3, moving all extremities
SKIN: no rashes or ecchymoses
Pertinent Results:
====================
LABS
====================
ADMISSION LABS
___ 09:02AM BLOOD WBC-6.6 RBC-4.08 Hgb-13.0 Hct-38.6 MCV-95
MCH-31.9 MCHC-33.7 RDW-12.8 RDWSD-44.3 Plt ___
___ 09:02AM BLOOD Neuts-71.2* Lymphs-17.8* Monos-8.7
Eos-1.7 Baso-0.3 Im ___ AbsNeut-4.67 AbsLymp-1.17*
AbsMono-0.57 AbsEos-0.11 AbsBaso-0.02
___ 06:49AM BLOOD ___
___ 09:02AM BLOOD Glucose-114* UreaN-11 Creat-0.8 Na-142
K-3.8 Cl-100 HCO3-28 AnGap-14
___ 09:02AM BLOOD Albumin-4.2 Calcium-9.6 Phos-3.5 Mg-1.7
___ 09:02AM BLOOD ALT-14 AST-26 LD(LDH)-272* CK(CPK)-191
AlkPhos-87 TotBili-0.8
___ 09:02AM BLOOD Lipase-21
___ 09:58AM BLOOD Lactate-1.3
___ 09:02AM BLOOD CK-MB-2
___ 09:02AM BLOOD cTropnT-<0.01
___ 01:11PM BLOOD cTropnT-<0.01
___ 09:10AM BLOOD D-Dimer-538*
DISCHARGE LABS
___ 06:16AM BLOOD WBC-5.0 RBC-3.41* Hgb-10.8* Hct-33.3*
MCV-98 MCH-31.7 MCHC-32.4 RDW-12.6 RDWSD-45.1 Plt ___
___ 06:16AM BLOOD Glucose-99 UreaN-18 Creat-0.8 Na-141
K-4.1 Cl-100 HCO3-27 AnGap-14
___ 06:16AM BLOOD Calcium-9.1 Phos-4.0 Mg-1.9
====================
IMAGING
====================
___ CXR:
Moderate cardiomegaly without evidence of pulmonary edema or
pneumonia.
___ CT ABD/PELVIS WITHOUT CONTRAST:
IMPRESSION:
No urinary tract stones identified. No evidence of acute
inflammatory process in the right abdomen.
Extensive colonic diverticulosis without evidence of
diverticulitis.
___ DUPLEX DOPP ABD/PELVIS
IMPRESSION:
1. Velocities suggesting stenosis of celiac artery.
2. Normal velocities of superior mesenteric artery
Brief Hospital Course:
=======
SUMMARY
=======
Ms. ___ is an ___ with h/o chronic mesenteric ischemia s/p
stenting, PVD, HTN, GERD, atrial flutter, and COPD who presented
for evaluation of new pleuritic R chest pain and subacute
worsening of abdominal symptoms. She underwent a cardiac workup
which was negative for ACS. PE was felt to be highly unlikely as
patient is on apixaban, D-dimer was negative per age-adjusted
cut off, and had no tachycardia other EKG changes. During
admission, pain then migrated to her right flank with sensation
of 'pulling' to her groin. Obtained a CT A/P which was negative
for kidney stones or other process that could explain pain. We
assured patient that life-threatening causes of pain have been
ruled out and focused on pain management. We changed tizanidine
to cyclobenzaprine and uptitrated the gabapentin from 300mg to
600mg TID.
=============
ACUTE ISSUES:
=============
# Pleuritic R chest pain
# Lower back strain
Ms. ___ presented with pleuritic R chest pain that developed
yesterday morning without exertion. The pain improved after
receiving IV morphine in the ED however continued to have R
chest tightness with inspiration on admission. She underwent a
cardiac workup which was negative for ACS. Lipase and LFTs
normal and had a cholecystectomy in the past. PE was felt to be
highly unlikely as patient is on apixaban, D-dimer was negative
per age-adjusted cut off, and had no tachycardia other EKG
changes. During admission, pain then migrated to her right flank
with sensation of 'pulling' to her groin. Obtained a CT A/P
which was negative for kidney stones or other process that could
explain pain. We assured patient that life-threatening causes of
pain have been ruled out and focused on pain management. We
changed tizanidine to cyclobenzaprine and uptitrated the
gabapentin from 300mg to 600mg TID. Also encouraged patient to
use hot packs as needed. Her pain improved and she felt well
with normal breathing on the day of discharge.
# Chronic mesenteric ischemia
# Diarrhea
Patient is a former smoker with a history of chronic mesenteric
ischemia s/p SMA/celiac PTA/BMS c/b restenosis s/p SMA/celiac
PTA/celiac ICAST covered stent ___, Dr. ___. On
admission, reported worsening symptoms over the past month with
abdominal pain, non-bloody diarrhea, and 5 pound weight loss.
She was scheduled for abdominal duplex as an outpatient on ___
and follow up with Dr. ___ on ___. Vascular Surgery
evaluated pt in the ED and felt that there was low suspicion for
acute on chronic mesenteric ischemia or acute stent thrombosis
at this time. Underwent SMA/celiac mesenteric duplex while
admitted which showed a stenosed celiac artery and normal SMA
caliber. Vascular Surgery reviewed the duplex study and
recommended outpatient follow-up with Dr. ___ in clinic in
two weeks. Upon review of home medications, noticed patient was
not on anti-platelet medication despite have SMA/celiac stents.
After discussion with Vascular, she was restarted on aspirin
81mg daily.
===============
CHRONIC ISSUES:
===============
# Atrial flutter
- Continued home apixaban 5mg BID
- Continued home atenolol 25mg QAM
# Hypertension
- Continued home losartan 50mg BID
- Continued home hydrochlorothiazide 25mg QAM
# Peripheral vascular disease
# Claudication
Currently without rest pain.
- Continue home simvastatin 20mg QPM
- Started aspirin as above
# Lumbar radiculopathy
- Increased home gabapentin from 300mg TID to ___ TID given
pain as above.
# COPD
Has a history of asthma vs COPD.
- Continue home fluticasone-salmeterol IH BID
- Continue home albuterol inhaler Q6H PRN
# GERD
- Continue home ranitidine 150mg QHS
====================
TRANSITIONAL ISSUES
====================
[] R sided pleuritic pain/flank pain: Suspect MSK in origin vs
neuropathic. Uptitrated gabapentin to 600mg TID and changed home
tizanidine to cyclobenzaprine. ___ benefit from topical
treatment such as diclofenac gel. Sent out with prescription.
[] Chronic mesenteric ischemia: Restarted on aspirin 81mg daily.
Will need 2 week follow-up with Dr. ___ to f/u results of
SMA/celiac mesenteric duplex and possibly have angiography done.
[] Diarrhea: missed an appointment with Dr. ___
admitted, we are working on rescheduling this appointment.
# CODE: full (presumed)
# CONTACT: ___ (daughter), ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atenolol 25 mg PO QAM
2. Apixaban 5 mg PO BID
3. Hydrochlorothiazide 25 mg PO QAM
4. Losartan Potassium 50 mg PO BID
5. Ranitidine 150 mg PO QHS
6. Simvastatin 20 mg PO QPM
7. Tizanidine 2 mg PO QHS:PRN muscle pain
8. TraMADol 50 mg PO Q6H:PRN Pain - Moderate
9. Gabapentin 300 mg PO TID
10. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
11. Albuterol Inhaler 1 PUFF IH Q6H:PRN SOB
12. Vitamin D 1000 UNIT PO DAILY
13. Docusate Sodium 100 mg PO QHS
14. Multivitamins W/minerals 1 TAB PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
RX *aspirin 81 mg 1 tablet(s) by mouth once a day Disp #*60
Tablet Refills:*0
2. Gabapentin 600 mg PO TID
RX *gabapentin 600 mg 1 tablet(s) by mouth three times a day
Disp #*42 Tablet Refills:*0
3. Albuterol Inhaler 1 PUFF IH Q6H:PRN SOB
4. Apixaban 5 mg PO BID
5. Atenolol 25 mg PO QAM
6. Docusate Sodium 100 mg PO QHS
7. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
8. Hydrochlorothiazide 25 mg PO QAM
9. Losartan Potassium 50 mg PO BID
10. Multivitamins W/minerals 1 TAB PO DAILY
11. Ranitidine 150 mg PO QHS
12. Simvastatin 20 mg PO QPM
13. TraMADol 50 mg PO Q6H:PRN Pain - Moderate
14. Vitamin D 1000 UNIT PO DAILY
15. HELD- Tizanidine 2 mg PO QHS:PRN muscle pain This
medication was held. Do not restart Tizanidine until you speak
with your primary care doctor
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
=================
PRIMARY DIAGNOSIS
=================
Lower back strain
===================
SECONDARY DIAGNOSIS
===================
Chronic mesenteric ischemia
Diarrhea
Atrial Flutter
Hypertension
Peripheral vascular disease
Lumbar radiculopathy
COPD
GERD
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
======================
DISCHARGE INSTRUCTIONS
======================
Dear Ms. ___,
It was a privilege caring for you at ___.
WHY WAS I IN THE HOSPITAL?
-You were having right sided chest, back, flank, abdominal pain.
WHAT HAPPENED TO ME IN THE HOSPITAL?
-We checked an EKG and heart muscle markers which showed that
you were NOT having a heart attack.
-We also checked blood tests which reassured us that you did not
have a blood clot in your lungs.
-We checked liver function labs which showed that your liver is
healthy.
-We also checked a CT scan of your abdomen which did not show
any broken bones or any kidney stones that could cause this
pain.
-It is likely that your pain is due to a strain of your back
muscles and tendons.
-You also had an ultrasound of your abdomen which showed that
your blood vessels still have good blood flow. Dr. ___
were made aware of these findings and would like you to start
taking aspirin 81mg per day, and they will see you in 2 weeks
for further evaluation.
-We gave you a medication called cyclobenzaprine and increased
your dose of gabapentin to treat your pain. We also continued
your home tramadol.
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
-This pain will take time to improve but we are hopeful that
this will improve with time. You should continue to exercise and
do your regular daily activities as you are able.
-We scheduled an appointment this ___ with your primary
care physician, ___. Please also follow up with Dr. ___
as scheduled.
-You missed an appointment with your gastroenterologist Dr.
___ you were in the hospital. We have rescheduled this
appointment.
-Please continue to take all of your medications and follow-up
with your appointments as listed below.
We wish you the best!
Sincerely,
Your ___ Team
Followup Instructions:
___
|
19680450-DS-14
| 19,680,450 | 23,815,874 |
DS
| 14 |
2181-05-23 00:00:00
|
2181-05-23 17:23:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Tylenol / Penicillins / Oxycodone / Iodinated Contrast Media -
IV Dye / MIBI / tomatoes, orange juice
Attending: ___
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
PCI LMCA ___
History of Present Illness:
Ms. ___ is an ___ year-old female with history of mesenteric
ischemia s/p stent placement to the SMA and celiac artery,
atrial flutter on Eliquis, prior TIA, HTN, HLD, and COPD who
presents after an episode of chest pain.
The patient reports that she had an episode of chest pain for
the first time two days ago. She says the pain was located in
the ___ the chest. She rates the pain at ___. The pain
did not radiate. There were no provoking factors. She
describes the pain as a "knot," which she further describes as
"tightness." The pain was associated with shortness of breath,
but no other symptoms. She had never had pain like this before,
so she does report the occasional sensation that food is getting
stuck in the same location where she felt chest pain. The
episode lasted about 5 minutes and resolved after taking deep
breaths. Since the initial episode, she has had two other
similar episodes, the last of which was this morning. No
nausea, diaphoresis, weakness. No pleurisy. No fevers, chills,
sweats, cough, wheeze. No history of anxiety or panic attack.
Reports dyspnea on exertion after walking ___ blocks. Reports
2-pillow orthopnea at baseline, no worse recently. Denies PND.
Has chronic ankle edema that is unchanged. No recent asymmetry
in leg swelling, recent travel, or immobilization.
The patient saw her orthopedist this morning for steroid
injections for her shoulder pain but was directed to the ED via
EMS after reporting her symptoms.
Past Medical History:
PMH:
aflutter, hypertension, TIA, small bowel obstruction, mesenteric
ischemia, constipation, diverticulosis, GERD, PAD with
claudication, herpes simplex, lactose intolerance, osteopenia
PSH:
- appendectomy
- total abdominal hysterectomy, oophorectomy
- hemorrhidectomy
- cholecystectomy
- rotator cuff repair
- right ___ finger ORIF ___ ___
- chronic mesenteric ischemia s/p celiac & SMA PTA/BMS (OSH ___
___
- celiac PTA/ICAST, SMA ___ ___
- left carpal tunnel release ___ ___
- left inguinal hernia repair ___ ___
Social History:
___
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death. Mother with diabetes. Sister with
pancreatic cancer.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: T 97.7F, BP 164/72, HR 91, RR 18, SpO2 95% RA
GENERAL: Well developed, well nourished female in NAD. Mood,
affect appropriate.
HEENT: Normocephalic atraumatic. Sclera anicteric. PERRL. EOMI.
Conjunctiva were pink. No pallor or cyanosis of the oral mucosa.
NECK: Supple. No cervical lymphadenopathy. JVP visible at base
of neck with HOB at 45 degrees.
CARDIAC: Irregularly irregular. Normal S1, S2. No murmurs, rubs,
or gallops. Telemetry demonstrates A flutter.
LUNGS: No chest wall deformities or tenderness. Respiration is
unlabored with no accessory muscle use. No crackles, wheezes or
rhonchi. Decreased breath sounds in the lower lung fields
bilaterally.
ABDOMEN: Bowel sounds present throughout. Soft, non-tender,
non-distended. No hepatomegaly. No splenomegaly.
EXTREMITIES: Warm, well perfused. No clubbing or cyanosis. There
is 1+ pitting edema in the bilateral ankles.
SKIN: No significant skin lesions or rashes.
PULSES: Radial pulses 2+ and symmetric.
DISCHARGE PHYSICAL EXAM:
24 HR Data (last updated ___ @ 722)
Temp: 98.1 (Tm 98.5), BP: 126/70 (105-143/57-71), HR: 88
(67-100), RR: 18 (___), O2 sat: 96% (93-98), O2 delivery: Ra
General: seated in bedside chair, appears comfortable and in NAD
HEENT: NC/AT. PERRL. EOMI. Oral mucosa pink and moist. No JVD.
Lungs: CTA in all lung fields. No respiratory distress or
accessory muscle usage.
CV: irregularly irregular. No murmurs, rubs, or extra sounds.
Abdomen: Bowel sounds present throughout. Abd soft, NT, ND.
Ext: No peripheral edema in bilateral LEs. Radial pulses 2+ and
symmetric. All extremities are warm and appear well-perfused. R
radial access site c/d/i without palpable hematoma. No cyanosis
in hands. Sensation intact in all fingers on the R hand. R groin
site c/d/i without significant TTP, ecchymosis, hematoma or
bruit.
Pertinent Results:
ADMISISON LABS:
___ 11:40AM BLOOD WBC-4.9 RBC-4.16 Hgb-13.0 Hct-40.5 MCV-97
MCH-31.3 MCHC-32.1 RDW-12.3 RDWSD-43.8 Plt ___
___ 11:40AM BLOOD Neuts-64.9 ___ Monos-6.0 Eos-1.4
Baso-0.2 Im ___ AbsNeut-3.16 AbsLymp-1.33 AbsMono-0.29
AbsEos-0.07 AbsBaso-0.01
___ 11:40AM BLOOD ___ PTT-31.3 ___
___ 11:40AM BLOOD Glucose-101* UreaN-12 Creat-0.8 Na-139
K-4.2 Cl-98 HCO3-31 AnGap-10
DISCHARGE LABS:
___ 06:32AM BLOOD WBC-7.9 RBC-3.67* Hgb-11.4 Hct-35.4
MCV-97 MCH-31.1 MCHC-32.2 RDW-12.5 RDWSD-43.8 Plt ___
___ 06:32AM BLOOD Glucose-96 UreaN-16 Creat-0.8 Na-139
K-4.3 Cl-106 HCO3-24 AnGap-9*
___ 06:32AM BLOOD Calcium-9.9 Phos-4.0 Mg-2.0
REPORTS:
___ CHEST XRAY:
There is moderate cardiomegaly, unchanged. No acute focal
consolidation. No pneumothorax or pleural effusion. No pulmonary
edema. The visualized osseous and upper abdominal structures
are unremarkable.
___ CARDIAC CATH:
Severe left main / three vessel coronary artery disease.
___ CARDIAC CATH:
By prior coronary arteriography, there was a 90% stenosis of the
origin of the left main coronary artery with TIMI 3 flow into
the distal vessel. The patient was not a surgical candidate. She
was referred for PCI of the left main coronary artery.
Percutaneous Coronary Intervention: Percutaneous coronary
intervention (PCI) was performed on a planned basis based on
coronary angiographic findings documented on a prior angiogram.
A 6 ___ EBU3.5 guide provided adequate support. The left main
was crossed with a 0.014 BMW wire into the
distal LAD. Predilated with a 3.0 mm x 6 mm Cutting Balloon and
then deployed a 3.5 mm x 8 mm Xience DES. The stent was post
dilated with a 4.0 mm balloon to 24 atmospheres. Final
angiography revealed normal flow, no dissection and 0% residual
stenosis.
Intravascular ultrasound was performed and showed distal
incomplete stent expasion. This resulted in an additional 4.0 mm
balloon inflation to 24 atms resulting in complete balloon
inflation.
Complications: There were no clinically significant
complications.
Brief Hospital Course:
TRANSITIONAL ISSUES:
====================
[ ] Follow up blood pressures. On admission, she was taking
atenolol 25mg daily, HCTZ 25mg daily and losartan 50mg BID. All
were held during this admission. She was discharged on labetolol
200mg BID. Recent systolic BPs 100-120s.
[ ] If continued chest pain, she should get a stress test. She
may need a stent to the RCA in the future.
[ ] Physical therapy evaluated the patient and indicated it was
ok for patient to go home. Indicated that patient would be an
excellent candidate for cardiac ___ when referred by outpatient
cardiologist.
[ ] Patient is being discharged on aspirin/plavix/apixaban. She
should be on this regiment for at least one month.
___ with history of mesenteric ischemia s/p stent placement to
the SMA and celiac artery, atrial flutter on Eliquis, prior TIA,
HTN, HLD, and COPD who presented after an episode of chest pain,
s/p Xience DES of the ostium of LMCA ___.
#CAD s/p PCI LMCA
EKG in the ED demonstrated no signs of acute ischemia, but
troponins were found to be slightly elevated and peaked at 0.03.
She was taken to the cath lab for coronary angiography, which
showed 75% stenosis of the proximal LM and 80% stenosis of the
ostial RCA. Due to the involvement of the LM, no stents were
placed and CT surgery was consulted. They felt that CABG posed
too high a risk for the patient and recommended high risk PCI.
She underwent PCI to LMCA on ___. On discharge, she will be
sent out on aspirin/plavix/apixaban. She was started on 40mg
atorvastatin. Her atenolol 25mg daily was switched to labetalol
200mg BID.
#Atrial flutter
The patient has a documented history of atrial flutter on
apixaban. Labetalol was started, as above, and uptitrated to
200mg BID. Apixaban was continued on discharge.
#HTN
On arrival, the patient's losartan and HCTZ were held given
upcoming procedures involving contrast. She was started on
labetalol 200mg BID for BP control. Blood pressures should be
followed up as an outpatient.
===============
CHRONIC ISSUES:
===============
#COPD
Continued advair and albuterol inhaler prn.
#Spinal stenosis
Continued gabapentin and tramadol qHS PRN.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Apixaban 5 mg PO BID
3. Atenolol 25 mg PO DAILY
4. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
5. Gabapentin 300 mg PO TID
6. Hydrochlorothiazide 25 mg PO DAILY
7. Losartan Potassium 50 mg PO BID
8. Ranitidine 150 mg PO QHS
9. Simvastatin 20 mg PO QPM
10. Tizanidine 2 mg PO QHS:PRN muscle spasm
11. Albuterol Inhaler ___ PUFF IH Q6H:PRN wheeze
12. diclofenac sodium 1 % topical TID:PRN shoulder pain
13. Hydrocortisone Cream 2.5% 1 Appl TP DAILY
14. TraMADol ___ mg PO QHS:PRN Pain - Moderate
15. Vitamin D 1000 UNIT PO DAILY
16. Docusate Sodium 100 mg PO DAILY:PRN Constipation - First
Line
17. Multivitamins 1 TAB PO DAILY
Discharge Medications:
1. Atorvastatin 40 mg PO QPM
RX *atorvastatin 40 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*1
2. Clopidogrel 75 mg PO DAILY
RX *clopidogrel 75 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*1
3. Labetalol 200 mg PO BID
RX *labetalol 200 mg 1 tablet(s) by mouth twice a day Disp #*60
Tablet Refills:*1
4. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain/tightness
RX *nitroglycerin 0.3 mg 1 tablet(s) sublingually every five
minutes as needed for chest pain Disp #*10 Tablet Refills:*0
5. Albuterol Inhaler ___ PUFF IH Q6H:PRN wheeze
6. Apixaban 5 mg PO BID
RX *apixaban [Eliquis] 5 mg 1 tablet(s) by mouth twice a day
Disp #*60 Tablet Refills:*0
7. Aspirin 81 mg PO DAILY
8. Docusate Sodium 100 mg PO DAILY:PRN Constipation - First
Line
9. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
10. Gabapentin 300 mg PO TID
11. Hydrocortisone Cream 2.5% 1 Appl TP DAILY
12. Multivitamins 1 TAB PO DAILY
13. Ranitidine 150 mg PO QHS
14. Tizanidine 2 mg PO QHS:PRN muscle spasm
15. TraMADol ___ mg PO QHS:PRN Pain - Moderate
16. Vitamin D 1000 UNIT PO DAILY
17. HELD- Hydrochlorothiazide 25 mg PO DAILY This medication
was held. Do not restart Hydrochlorothiazide until you see your
primary care doctor
18. HELD- Losartan Potassium 50 mg PO BID This medication was
held. Do not restart Losartan Potassium until you see your
primary care doctor
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis:
Coronary artery disease
Secondary diagnoses:
Atrial flutter
Hypertension
COPD
Spinal 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. ___,
It was a pleasure taking care of you at the ___
___!
WHY WAS I IN THE HOSPITAL?
==========================
- You were admitted because you had a heart attack.
WHAT HAPPENED IN THE HOSPITAL?
==============================
- You were found to have had a heart attack. Your heart arteries
were examined (cardiac catheterization) which showed a blockage
of one of the arteries. This was opened by inflating a balloon
inside the blockage to widen the vessel.
- Because of the location of the blockage in your arteries, you
were evaluated by the cardiac surgeons for open heart surgery.
After discussing the options with you, it was felt that surgery
posed too high a risk, so they recommended you be further
evaluated for stenting of the arteries.
- On ___, you underwent stent placement to your left main
coronary artery.
WHAT SHOULD I DO WHEN I GO HOME?
================================
- You should continue to take your medications as prescribed.
- You should attend the appointments listed below.
- Seek medical attention if you have new or concerning symptoms,
especially if you develop persistent chest pain or shortness of
breath.
- If you have more chest pain, you should see your cardiologist.
You may need a stent placed in your right coronary artery at a
later time.
Thank you for allowing us to be involved in your care, we wish
you all the best!
Your ___ Healthcare Team
Followup Instructions:
___
|
19680874-DS-3
| 19,680,874 | 21,800,549 |
DS
| 3 |
2132-09-19 00:00:00
|
2132-09-20 11:39:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
levofloxacin
Attending: ___.
Chief Complaint:
aphasia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mrs. ___ is a ___ yo female with reported PMHx of AFib on ASA,
HTN, HLD, DM, and CKD who was transferred from ___ after
being found to be confused and aphasic at her nursing home
earlier today.
Reportedly, patient was in her USOH when she was last seen by a
staff member at 0100. When she woke up this morning, which
seems to have been around 0700, she was noted to very confused,
not following commands, and aphasic. At baseline she does have
soem mild cognitive deficits (the details of which are not known
at this time), however, this was far from her baseline. Her
vitals were taken (BP 140/70, HR 88, RR 16, O2 99%) and EMS was
called.
Patient was taken to ___ where she scored ~11 on NIHSS,
primarily for aphasia and confusion. A NCHCT was performed (see
below), which did not reveal any acute intracranial
abnormalities. Basic labs were remarkable for platelets of 107,
BUN 49 and Cr 1.26 (baseline unknown). She was given a dose of
Zofran due to an episode of emesis as well as a NS bolus and
transferred to ___ for further evaluation for late clot
retrieval (Defuse 3 protocol).
Further details regarding PMHx can be found in ___
medical records. Son was later present at bedside but did not
know any information about her health history; he reports his
daughter will be by later and can provide more information.
Past Medical History:
Problems (Last Verified - None on file):
ATRIAL FIBRILLATION
HYPERTENSION
DIABETES
HYPERCHOLESTEROLEMIA
OSTEOPENIA
ABDOMINAL HERNIA
CKD (?)
Medications (Last Review: None on file): Per outside records
Lopressor 50 mg TID
Isordil 10 mg TID
Imdur 30 mg qDay
Dyazide 37.5/25 mg qDay
Cozaar 100 mg qDay
ASA 81
Zocor 20 mg qDay
Gabapentin 300 mg QID
Spiriva 18 mcg INH qDay
Duoneb 3mL q4h
Lidocaine Patch 5% qDay
Folic Acid
COPD (?)
Social History:
___
Family History:
No known family history of Strokes, DVTs, PEs
Further details unknown
Physical Exam:
===============
Admission Exam:
===============
___ Stroke Scale - Total [13]
1a. Level of Consciousness - 1
1b. LOC Questions - 2
1c. LOC Commands - 1
2. Best Gaze - 0
3. Visual Fields - 0
4. Facial Palsy - 0
5a. Motor arm, left - 1
5b. Motor arm, right - 0
6a. Motor leg, left - 3
6b. Motor leg, right - 3
7. Limb Ataxia - 0
8. Sensory - 0
9. Language - 2
10. Dysarthria - 0
11. Extinction and Neglect - 0
EXAM:
Vitals: HR 79, BP 117/55, RR 14, O2 98% RA
General: Sleepy but arousable to voice
HEENT: MMM tacky,OP clear
CV: RRR, no murmur. Well perfused.
RESP: CTAB; breathing comfortably on RA
ABD: Distended, Soft, NT, +BS
SKIN: Bruising on R lower abdomen
NEURO:
-Mental Status: Sleepy but arousable. Occasional spontaneous
eye opening but mostly keeps them closed. Quickly opens eyes
when name called. Intermittently pulls at gown. No spontaneous
speech. When asked her name, states ___ after
repetitive questioning. With further questions continues to
repeat ___. States her name clearly. Squeezes hands
on commands; does not clearly follow any other commands. No
clear neglect.
-Cranial Nerves:
II, III, IV, VI: PERRL, 3 -->2. Horizontal EOMs grossly intact;
no nystagmus. Blinks to threat bilaterally.
VII: No facial asymmetry appreciated
VIII: Turns head to voice bilaterally
XII: Tongue protrudes in midline.
-Sensorimotor: Normal bulk, tone throughout. When passively
raised, maintains R arm antigravity > 10 sec. L arm starts to
drift downwards after ~5 seconds. Does not maintain legs
antigravity when passively raised. Bends knees slightly with
noxious stimuli to ___, but no clear antigravity
movement. Grimaces to noxious stimuli throughout.
-DTRs:
Bi ___ Pat Ach
L 2 1 * 1
R 2 1 * 1
*Difficult to assess as patient jerks leg every time reflexes
are attempted.
Toes upgoing bilaterally
-Coordination: Unable to assess due to patient cooperation
-Gait: Deferred
===============
Discharge Exam:
===============
Tmax 99.0, Tcurrent 98.0, BP 97-149/45-74. HR 74-96.
RR: 18, 02 91 RA.
Gen: awake, lying in bed
HEENT: NC/AT, mucous membranes dry
Neuro:
MS: alert, opens eyes to voice quickly. Oriented to self, month
and year, able to follow midline and appendicular commands, no
R/L confusion. Able to name, repeat. Unable to explain why she
was in the hospital but able to tell me the names of her
children.
CNs: PERRL, EOMI, face symmetric, hearing intact, tongue
protrudes midline.
Motor: Symmetric bilateral slight pronation without drift. ___
strength in all muscle groups.
Sensory: Intact to light touch
Coordination: Slight intention tremor on finger nose finger but
otherwise intact with no dysmetria.
Pertinent Results:
===============
Admission Labs:
===============
___ 11:28AM BLOOD WBC-6.2 RBC-3.55* Hgb-10.9* Hct-34.0
MCV-96 MCH-30.7 MCHC-32.1 RDW-17.1* RDWSD-59.8* Plt Ct-98*
___ 07:16PM BLOOD WBC-4.7 RBC-3.60* Hgb-11.1* Hct-34.6
MCV-96 MCH-30.8 MCHC-32.1 RDW-17.3* RDWSD-60.5* Plt ___
___ 07:16PM BLOOD Neuts-65.2 ___ Monos-8.4 Eos-1.3
Baso-0.2 NRBC-0.4* Im ___ AbsNeut-3.04 AbsLymp-1.09*
AbsMono-0.39 AbsEos-0.06 AbsBaso-0.01
___ 07:16PM BLOOD Glucose-115* UreaN-41* Creat-1.1 Na-136
K-4.3 Cl-98 HCO3-23 AnGap-19
___ 07:16PM BLOOD ALT-87* AST-59* LD(LDH)-288* AlkPhos-313*
TotBili-1.6*
___ 07:16PM BLOOD TotProt-6.1* Albumin-3.1* Globuln-3.0
Cholest-149
___ 07:16PM BLOOD ___ PTT-26.0 ___
===============
Stroke Work-Up:
===============
___ 07:16PM BLOOD Cholest-149 Triglyc-144 HDL-46
CHOL/HD-3.2 LDLcalc-74
___ 07:16PM BLOOD %HbA1c-8.8* eAG-206*
___ 07:16PM BLOOD TSH-1.4
___ 11:28AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
===============
Discharge Labs:
===============
***
========
Imaging:
========
CT Head:
FINDINGS:
CT Head: There is no evidence of hemorrhage, mass effect, edema,
or
infarction. The ventricles and sulci are normal in size and
configuration. There is age-appropriate diffuse parenchymal
volume loss with commensurate
prominence of the ventricles and sulci. There is nonspecific
periventricular and subcortical white matter hypodensities,
likely sequela of chronic small vessel microangiopathy.
Aerosolized secretions are seen in the left posterior ethmoid
air cells. Mild mucosal thickening is noted in the right
posterior ethmoid air cells.
Otherwise, the remaining paranasal sinuses and mastoid air cells
are clear. The orbits are unremarkable.
CTA head: The major intracranial arterial vasculature is patent
without
evidence of stenosis, occlusion, or aneurysm. There is an azygos
anterior
cerebral artery, which is a normal variant. A fenestration is
noted along the right A1 branch of the anterior cerebral artery,
adjacent to confluence of the right and left A1 branches (series
4: Image 242). A small infundibulum is noted at the origin of
the left internal choroidal artery.
CT Perfusion: The perfusion maps appear unremarkable. There is
no evidence of delayed transit time, or reduced blood volume, or
reduced blood flow.
CTA Neck: The common carotid and vertebral arteries and their
major branches are patent with no evidence of stenoses. There is
calcified atherosclerotic plaque in the distal common carotid
artery extending to the origins of the right internal and
external carotid arteries. There is no evidence of right
internal carotid by NASCET criteria. There is calcified and
noncalcified plaque at the origin of the left internal carotid
artery with an approximately 50% stenosis by NASCET criteria.
Atherosclerotic calcifications are seen in the aortic arch,
bilateral
vertebral artery origins, bilateral carotid siphons, and carotid
bifurcations. There is a 3 vessel aortic arch. Tiny
subcentimeter hypodensities are seen in the right thyroid lobe,
likely thyroid nodules. ___ College of Radiology
guidelines do not suggest further evaluation for incidental
thyroid nodules of this size. Emphysematous changes are seen in
the bilateral lung apices. Respiratory motion artifact limits
evaluation for small pulmonary nodules.
IMPRESSION:
1. No evidence of infarction or hemorrhage.
2. 50% stenosis at the origin of the left internal carotid
artery.
3. The major intracranial arterial vasculature is patent without
evidence of stenosis, occlusion, or aneurysm.
4. The carotid and vertebral arteries and their major branches
are patent
without evidence of stenoses.
5. Chronic small vessel ischemic disease and age appropriate
involutional
changes.
6. Emphysematous changes are incidentally seen in the bilateral
lung apices.
MRI Brain:
FINDINGS:
Examination is moderately degraded by motion. Within these
confines:
Extensive scattered punctate and more confluent periventricular,
subcortical, and deep white matter foci of T2/FLAIR hyperintense
signal without associated slow diffusion with a predominantly
frontoparietal distribution are nonspecific, but most likely
sequelae of chronic microangiopathy in a patient of this age.
There is no evidence of hemorrhage, edema, mass, mass effect,
midline shift or acute infarction. There is a small chronic
lacunar infarction in the left basal ganglia (04:19). Prominence
of the ventricles and sulci is in keeping with global atrophy.
Mild mucosal thickening in the left frontal, posterior ethmoid
sinuses and
partial fluid opacification of bilateral mastoid air cells are
noted. The
orbits are unremarkable.
IMPRESSION:
1. Study is moderately degraded by motion.
2. Chronic small vessel ischemic changes and global atrophy.
3. No acute intracranial abnormality, with no evidence of acute
infarct.
4. Paranasal sinus disease and nonspecific mastoid fluid, as
described.
Abdominal US:
FINDINGS:
LIVER: The liver is coarsened and nodular in echotexture. The
contour of the liver is smooth. There is no focal liver mass.
The main portal vein is patent with hepatopetal flow. There is
no ascites.
BILE DUCTS: There is no intrahepatic biliary dilation. The CBD
is dilated and measures 1.4 cm. There are no stones or masses
identified in the CBD.
GALLBLADDER: The patient is presumed to be status post
cholecystectomy given presence of right upper quadrant abdominal
scar and the finding of small remnant cystic duct.
PANCREAS: The imaged portion of the pancreas appears within
normal limits,
without masses or pancreatic ductal dilation, with portions of
the pancreatic tail obscured by overlying bowel gas.
SPLEEN: Normal echogenicity, mildly enlarged measuring 13.1 cm.
KIDNEYS: The right kidney measures 12.5 cm. The left kidney
measures 10.6 cm. Normal cortical echogenicity and
corticomedullary differentiation is seen bilaterally. There is
no evidence of masses, stones, or hydronephrosis in the kidneys.
In the upper pole the right kidney there is a large simple cyst
measuring 5.6 x 5.5 x 4.6 cm. Beneath the lower pole of the
right kidney, there is a large adjacent simple cystic structure
that does not appear to originate from the kidney itself,
measuring approximately 11.0 x 7.8 cm, possibly representing a
retroperitoneal cyst. A simple cyst is also noted in the upper
pole of the left kidney, measuring 1.3 x 1.2 x 1.5 cm.
RETROPERITONEUM: The visualized portions of aorta and IVC are
within normal limits.
IMPRESSION:
1. Coarse and nodular liver echotexture with a mildly enlarged
spleen, which may represent chronic liver disease including
cirrhosis or fibrosis.
2. Dilated common bile duct without evidence of stones or
masses. The lack of intrahepatic biliary dilation does not
suggest the presence of biliary blockage.
3. Simple cysts in the kidneys and likely right retroperitoneal
cyst, as
described above.
Brief Hospital Course:
Ms. ___ is a ___ woman with a past medical
history of afib on aspirin, htn, hld, diabetes mellitus and CKD
who was transferred from ___ after she was noted to
be aphasic and confused at her nursing home. The patient was
admitted to the Stroke service here at ___ for further
work-up of her symptoms.
#AMS with aphasia:
-She was worked up for infarct with head imaging including CT,
CTA and MRI of the brain. No stroke or other intracranial
abnormalities to explain her symptoms were found.
-Lab work that was done included mildly elevated BUN/CR,
thrombocytopenia, and elevated LFTs and coags.
-Patient's neurologic examination did not reveal any patterns of
weakness that correlated with an aphasia which made large
vascular territory stroke less likely.
-EEG was also conducted to look for seizure activity as an
explanation. EEG was also negative for seizure activity, but
revealed diffuse slowing.
-Concurrently during her neurologic work-up, UTI and elevated
hepatic enzymes were noted on lab work which could have also
contributed to her symptomatology.
-The patient began to improve shortly during hospitalization and
speech output returned to near baseline. No other focal
neurologic deficits were noted during hospitalization.
- thiamine was also given and level was checked which is still
pending.
#UTI:
-During the patient's hospitalization, urine was collected which
was initially negative for any infection.
- A second sample was collected which did reveal infection, and
was sent for culture which ultimately grew out klebsiella.
Patient was started on IV ceftriaxone which initially was only
for 3 doses, however it was extended to cover 7 days given that
the patient had a foley in place and had difficulty with
urinating.
-Patient's urinary status improved while receiving ceftriaxone
and after foley removal.
#Elevated hepatic enzymes, anemia, and thrombocytopenia:
-Patient was noted to have elevated liver enzymes. RUQ
ultrasound showed nodules and liver appearance was consistent
with cirrhosis/fibrosis. Medicine colleagues were consulted for
further work-up and recommendations.
-Patient's enzymes were trended and started to improve. She has
follow up with hepatology in the outpatient setting for ___
___ at 3pm.
#afib:
Stable, continued aspirin.
TRANSITIONS OF CARE
- patient to follow up with PCP ___ ___ weeks, please schedule.
PCP to follow up thiamine level.
- Patient has follow up appointment with hepatology/ GI for
___ at 3pm. Anemia and EGD should be considered
at this appointment as patient has not had this screening.
- continue all other meds as prescribed.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Metoprolol Tartrate 50 mg PO TID
2. Isordil (isosorbide dinitrate) 10 mg oral TID
3. Triamterene-HCTZ (37.5/25) 1 CAP PO DAILY
4. Losartan Potassium 100 mg PO DAILY
5. Aspirin 81 mg PO DAILY
6. Simvastatin 20 mg PO QPM
7. Gabapentin 300 mg PO QID
8. Tiotropium Bromide 1 CAP IH DAILY
9. Ipratropium-Albuterol Neb 1 NEB NEB Q4H
10. Lidocaine 5% Patch 1 PTCH TD QAM
11. FoLIC Acid 1 mg PO Frequency is Unknown
12. Clotrimazole 1 TROC PO 5 TIMES PER DAY
13. Milk of Magnesia 30 mL PO DAILY:PRN constipation
14. Bisacodyl 10 mg PR QHS:PRN constipation
15. Fleet Enema ___AILY:PRN constipation
16. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
17. Acetaminophen 650 mg PR Q6H:PRN Pain/Fever
18. GuaiFENesin 5 mL PO Q6H:PRN cough
19. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
20. Omeprazole 20 mg PO DAILY
21. Multivitamins W/minerals 1 TAB PO DAILY
22. Insulin SC
Sliding Scale
Insulin SC Sliding Scale using HUM Insulin
23. Glargine 32 Units Breakfast
Discharge Medications:
1. CefTRIAXone 1 gm IV Q24H Duration: 7 Doses
one dose daily until ___. Lactulose 30 mL PO Q12H:PRN constipation
3. FoLIC Acid 1 mg PO DAILY
4. Insulin SC
Sliding Scale
Insulin SC Sliding Scale using HUM Insulin
5. Glargine 32 Units Breakfast
6. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
7. Acetaminophen 650 mg PR Q6H:PRN Pain/Fever
8. Aspirin 81 mg PO DAILY
9. Bisacodyl 10 mg PR QHS:PRN constipation
10. Clotrimazole 1 TROC PO 5 TIMES PER DAY
11. Fleet Enema ___AILY:PRN constipation
12. Gabapentin 300 mg PO QID
13. GuaiFENesin 5 mL PO Q6H:PRN cough
14. Ipratropium-Albuterol Neb 1 NEB NEB Q4H
15. Isordil (isosorbide dinitrate) 10 mg oral TID
16. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
17. Lidocaine 5% Patch 1 PTCH TD QAM
18. Losartan Potassium 100 mg PO DAILY
19. Metoprolol Tartrate 50 mg PO TID
20. Milk of Magnesia 30 mL PO DAILY:PRN constipation
21. Multivitamins W/minerals 1 TAB PO DAILY
22. Omeprazole 20 mg PO DAILY
23. Simvastatin 20 mg PO QPM
24. Tiotropium Bromide 1 CAP IH DAILY
25. Triamterene-HCTZ (37.5/25) 1 CAP PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Altered mental status due to infection
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. ___,
You were admitted for difficulty with language, memory, and
confusion which improved over the course of your
hospitalization. You had an extensive work-up for causes of your
acute neurologic symptoms including MRI of the brain which did
not show any strokes, tumors, or other lesions that would
explain your symptoms. In addition, EEG was placed which did not
show any seizure activity.
You were however found to have a urinary tract infection as
well as elevated liver enzymes of unknown etiology which may
have contributed to your mental status.
You will continue the IV antibiotics for your urinary tract
infection for a total of 7 days (to end on ___.
In addition, you have been scheduled to follow up with the
outpatient GI/Hepatology team to monitor your liver function
tests to continue to evaluate the etiology of this abnormality.
Lastly, you should follow-up with your PCP ___ ___ weeks.
Continue your other home medications as prescribed.
Followup Instructions:
___
|
19680874-DS-5
| 19,680,874 | 21,182,544 |
DS
| 5 |
2134-06-24 00:00:00
|
2134-06-24 23:12:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
levofloxacin / morphine
Attending: ___
Chief Complaint:
Confusion, Abdominal Pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ with past medical history notable for NASH
cirrhosis, Childs C, MELD-Na 21 on admission, c/b HE and
non-occlusive thrombus of SMV/PV (not on anticoagulation),
HFpEF,
CKDIII, IDDM, HTN, and COPD, who presents as a transfer from
___ s/p fall with abdominal pain and confusion
concerning for colitis and hepatic encephalopathy.
Patient states that yesterday, she began feeling generally weak
and cold. She was walking to the bathroom and her son was
helping
to support her when her legs gave out and she fell to the
ground.
Denied any head strike or injury. Denies shortness of breath,
new
cough, chest pain, nausea, vomiting, diarrhea, or abdominal
pain.
She went to ___ where she was reportedly febrile to
102.3, tachycardic, and satting 90% on room air. CT head and
C-spine were negative for traumatic injury. CT abdomen showed
pneumatosis of the large colon. Patient reportedly refused urine
catheterization despite repeated attempts. Bedside ultrasound
showed no tappable pocket of ascites. She was initiated on
broad-spectrum antibiotics with vancomycin and meropenem given
her history of ESBL urine and received 2L IVF with improvement
in
her lactate. She was then transferred to ___ for hepatology
and
surgical evaluation.
Notably, she had a recent admission at ___ from ___ for
abdominal pain and confusion and was found to have enterococcal
bacteremia of unclear etiology, possibly ___ colitis. She was
treated with vancomycin and ultimately discharged on ampicillin
for a 7d course of treatment (end date ___.
In the ED initial vitals: T 97.3 HR 76 BP 96/56 RR 17 O2 96% RA
Exam notable for:
- AAOx3. Sclera anicteric.
- Diffuse areas of ecchymosis on her upper extremities
- Abdomen large, soft, ND, NT but seems like it maybe fluid
filled.
- Lower extremities with +2 pitting edema and skin color changes
consistent with chronic edema
- Rectal exam guiac positive
Labs notable for:
- ___ labs:
- WBC 14, Hgb 9.7, Plt 100
- Na 130, BUN 23, Cr 1.46
- Lactate 3.5 --> 2.4
- ALT 57, AST 16, AP 228, Tbili 3.9, Alb 1.7
- ___ labs:
- WBC 9.1, Hgb 7.8, Plt 67
- INR 2.0
- BUN 24, Cr 1.2, Ca 7.6, Mg 1.4
- pro-BNP 1539
- Lactate 2.3
- UA >182 WBCs, lg leuks, few bacteria, 65 RBCs, mod bld, few
yeast 18 epi, 100 protein, hyaline casts
Imaging notable for:
___ imaging from ___:
- CT C-spine:
No evidence of acute cervical spine fracture.
- CT A&P w/o contrast:
1. Cirrhosis with splenomegaly and small amount of ascites.
2. Pneumatosis within loops of colon, a nonspecific finding. In
the
large bowel, pneumatosis is often incidental finding, but
correlation with physical exam and clinical findings recommended
to exclude ischemic bowel.
- CT head w/o contrast:
No acute abnormality.
- CXR:
No acute abnormality.
- CT chest:
1. Chronic severe emphysema.
2. Extensive coronary artery calcifications.
3. No acute abnormality identified.
___ imaging from ___:
- Abdominal US with Doppler:
1. Cirrhotic liver morphology with moderate volume simple
ascites. No focal liver lesions.
2. Patent hepatic vasculature.
3. Unchanged 4.3 cm right perinephric simple cyst.
4. Surgically absent gallbladder with stable prominent 13 mm
common hepatic duct, unchanged since ___.
- CXR:
Comparison to ___. Lung volumes have decreased.
Increased
vascular markings and bigger diameters of the pulmonary vessels
are indicative of mild to moderate pulmonary edema. Low lung
volumes and moderate cardiomegaly persists. No pleural
effusions.
Consults:
- Hepatology: Admit to ET, consider TTE, abdominal US with
Doppler, diagnostic paracentesis to r/o SBP, blood/urine
cultures, broad spectrum antibiotics, second read on CT, surgery
consult re: pneumotosis
- Transplant surgery: Admit to ET for IVF, bowel rest,
antibiotics
Patient was given:
- Albuterol nebs, ipratropium bromide nebs, IV meropenem 1000mg,
IV vancomycin 1000mg, lactulose 30mL, rifaxamin 550mg, SC
insulin
4u, IV magnesium sulfate 2g, acetaminophen 1000mg, SC insulin 4u
Upon arrival to the floor, patient endorses the above history.
She denies fevers, chills, or abdominal pain currently. Feels
mild abdominal pain with movement. Reports frequent orange
diarrhea due to taking her lactulose. Denies melena,
hematochezia, hematuria, or hematemesis. Denies DOE, orthopnea,
or PND.
Past Medical History:
- ___ cirrhosis c/b HE and non-occlusive SMV/PVT (not on AC)
- HFpEF
- Left bundle branch block
- CKDIII (baseline Cr 1.1-1.4)
- HTN
- HLD
- T2DM
- COPD
- ?CAD
Social History:
___
Family History:
No known family history of strokes, DVTs, PEs
Physical Exam:
ADMISSION PHYSICAL EXAMINATION:
VS: 97.9 100/50 89 18 95 RA
GENERAL: Well-appearing, resting in bed comfortably, in NAD
HEENT: NC/AT, EOMIC, PERRL, anicteric sclera, MMM
NECK: Supple, JVD at base of neck at 90 degrees
HEART: RRR, S1/S2, no murmurs, gallops, or rubs
LUNGS: Bibasilar crackles R>L, otherwise CTAB, no wheezes or
rhonci
ABDOMEN: Large mildly distended abdomen, soft, active bowel
sounds, mild TTP diffusely L>R without rebound or guarding,
shiftness dullness appreciated, no hepatomegaly
EXTREMITIES: 3+ pitting edema extending into thighs bilaterally
SKIN: Diffuse echymossis scattered throughout, most notable on
anterior chest wall, 3mm ulceration on L foot with surrounding
edema, no erythema or draining purulence
NEURO: A&Ox3, no asterixis, moving all 4 extremities with
purpose
DISCHARGE PHYSICAL EXAMINATION:
VITALS: ___ 0743 Temp: 97.9 PO BP: 134/67 HR: 79 RR: 18 O2
sat: 94% O2 delivery: RA
HEENT: NC/AT, anicteric sclera, MMM
NECK: Supple, JVD at 9 cm
HEART: RRR, S1/S2, no murmurs, gallops, or rubs
LUNGS: Minimal R basal crackles; otherwise CTAB
ABDOMEN: Large mildly distended abdomen, soft, active bowel
sounds, no TTP. Large R-sided and umbilical scar from prior
colectomy.
EXTREMITIES: no lower leg edema, chronic skin darkening on arms
and legs
SKIN: Diffuse ecchymosis scattered throughout, most notable on
anterior chest wall, 3mm ulceration on R heel with surrounding
edema, no erythema or draining purulence. Excoriations and mild
ulcerations across L antecubital fossa, L forearm, R forearm,
and
L leg, bandaged with dressings c/d/i.
NEURO: A&Ox3, no asterixis, moving all 4 extremities with
purpose
Pertinent Results:
ADMISSION LABS:
___ 09:37AM URINE RBC-65* WBC->182* Bacteri-FEW* Yeast-FEW*
Epi-18
___ 01:37PM URINE RBC-47* WBC->182* Bacteri-FEW*
Yeast-MANY* Epi-3 TransE-3
___ 08:22AM BLOOD WBC-9.1 RBC-2.46* Hgb-7.8* Hct-23.8*
MCV-97 MCH-31.7 MCHC-32.8 RDW-18.0* RDWSD-62.2* Plt Ct-67*
___ 08:22AM BLOOD Neuts-81.6* Lymphs-11.6* Monos-5.9
Eos-0.0* Baso-0.2 Im ___ AbsNeut-7.42* AbsLymp-1.05*
AbsMono-0.54 AbsEos-0.00* AbsBaso-0.02
___ 08:22AM BLOOD ___ PTT-30.2 ___
___ 08:22AM BLOOD Glucose-230* UreaN-24* Creat-1.2* Na-138
K-4.4 Cl-102 HCO3-23 AnGap-13
___ 06:26AM BLOOD ALT-11 AST-37 LD(LDH)-207 AlkPhos-182*
TotBili-3.3*
___ 08:22AM BLOOD proBNP-1539*
___ 08:22AM BLOOD Calcium-7.6* Phos-3.3 Mg-1.4*
___ 08:40AM BLOOD Lactate-2.3*
INTERVAL LABS:
___ 05:20PM URINE RBC-2 WBC-153* Bacteri-NONE Yeast-NONE
Epi-0
___ 03:54PM BLOOD Lactate-2.3*
___ 04:49PM BLOOD Lactate-3.0*
___ 03:50PM BLOOD ___ pO2-82* pCO2-38 pH-7.42
calTCO2-25 Base XS-0 Comment-GREEN TOP
___ 04:22AM BLOOD TSH-2.7
___ 05:14AM BLOOD %HbA1c-7.1* eAG-157*
___ 05:40PM BLOOD Hapto-37
___ 07:25AM BLOOD Albumin-2.2* Calcium-8.4 Phos-3.2 Mg-1.3*
___ 04:22AM BLOOD Calcium-8.8 Phos-3.8 Mg-1.6
___ 06:30AM BLOOD Albumin-3.0* Calcium-8.3* Phos-3.0 Mg-2.0
___ 06:15AM BLOOD Calcium-9.0 Phos-2.3* Mg-1.6
___ 08:20AM BLOOD ALT-12 AST-50* LD(___)-275* AlkPhos-285*
TotBili-2.8*
___ 07:25AM BLOOD ALT-12 AST-57* LD(___)-364* AlkPhos-268*
TotBili-3.0*
___ 06:30AM BLOOD ALT-10 AST-39 LD(___)-167 AlkPhos-170*
TotBili-4.0*
___ 05:14AM BLOOD Glucose-374* UreaN-24* Creat-1.1 Na-129*
K-5.5* Cl-94* HCO3-25 AnGap-10
___ 01:00PM BLOOD Glucose-251* UreaN-25* Creat-1.1 Na-132*
K-5.0 Cl-95* HCO3-26 AnGap-11
___ 04:30AM BLOOD Glucose-137* UreaN-26* Creat-1.1 Na-131*
K-5.8* Cl-97 HCO3-25 AnGap-9*
___ 06:30PM BLOOD Glucose-194* UreaN-28* Creat-1.1 Na-131*
K-5.6* Cl-98 HCO3-24 AnGap-9*
___ 04:47AM BLOOD Glucose-102* UreaN-27* Creat-1.3* Na-134*
K-6.0* Cl-99 HCO3-24 AnGap-11
___ 04:22AM BLOOD Glucose-219* UreaN-26* Creat-1.1 Na-134*
K-5.3 Cl-98 HCO3-25 AnGap-11
___ 06:30AM BLOOD Glucose-175* UreaN-22* Creat-1.1 Na-137
K-3.7 Cl-101 HCO3-26 AnGap-10
___ 05:28PM BLOOD Glucose-286* UreaN-22* Creat-1.1 Na-138
K-3.9 Cl-99 HCO3-27 AnGap-12
___ 05:40PM BLOOD WBC-6.1 RBC-2.05* Hgb-6.6* Hct-20.2*
MCV-99* MCH-32.2* MCHC-32.7 RDW-20.2* RDWSD-71.6* Plt ___
Cortisol Testing:
___ 04:47AM BLOOD Cortsol-1.7* (AM cortisol)
___ 04:22AM BLOOD Cortsol-0.8* (AM cortisol)
___ 09:00AM BLOOD Cortsol-0.8* (before Cosyntropin)
___ 10:10AM BLOOD Cortsol-4.6 (30 mins after Cosyntropin)
___ 10:40AM BLOOD Cortsol-5.9 (60 mins after Cosyntropin)
URINE CULTURE (Final ___:
YEAST. >100,000 CFU/mL.
IMAGING:
___ (PORTABLE AP)
Comparison to ___. Lung volumes have decreased.
Increased
vascular markings and bigger diameters of the pulmonary vessels
are indicative
of mild to moderate pulmonary edema. Low lung volumes and
moderate
cardiomegaly persists. No pleural effusions.
___ DOPP ABD/PEL
1. Cirrhotic liver morphology with moderate volume simple
ascites. No focal
liver lesions.
2. Patent hepatic vasculature.
3. Unchanged 4.3 cm right perinephric simple cyst.
4. Post cholecystectomy. 13 mm common hepatic duct is unchanged
since ___.
___ (PORTABLE AP)
Mild pulmonary edema. New right basilar opacities could reflect
atelectasis
and/or pneumonia.
Studies from ___:
___ C-SPINE
___ HEAD
___ ABDOMEN
___ CHEST
___ CHEST
DISCHARGE LABS:
___:30AM BLOOD WBC-6.2 RBC-2.89* Hgb-9.0* Hct-27.9*
MCV-97 MCH-31.1 MCHC-32.3 RDW-20.8* RDWSD-70.0* Plt Ct-95*
___ 06:30AM BLOOD ___ PTT-29.5 ___
___ 06:30AM BLOOD Glucose-171* UreaN-25* Creat-1.2* Na-138
K-4.8 Cl-99 HCO3-28 AnGap-11
___ 06:15AM BLOOD ALT-11 AST-44* LD(LDH)-194 AlkPhos-193*
TotBili-3.6*
___ 06:30AM BLOOD Calcium-9.3 Phos-2.9 Mg-1.4*
Brief Hospital Course:
Ms. ___ is a ___ with past medical history notable for NASH
cirrhosis (Childs C, MELD-Na 21 on admission, c/b HE and
non-occlusive thrombus of SMV/PV not on anticoagulation), and
recent admission at ___ for enterococcus bacteremia ___
colitis who presented as a transfer from ___ w/ shock,
thought to be secondary to a UTI. She also had ___ on
admission. She was treated with 7 days of IV antibiotics, but
her hospital course was further complicated by hyponatremia and
hyperkalemia; she was also diagnosed with adrenal insufficiency.
ACTIVE ISSUES:
==============
# Shock, now resolved
The patient was hypotensive and tachycardic at ___ with
elevated lactate, consistent with shock. Etiology likely due to
sepsis given fevers and initial leukocytosis with neutrophilic
predominance. Blood pressures and lactate improved with IVF and
broad spectrum antibiotics. Most likely source is urinary,
as described below.
# Bacteriuria, concerning for UTI
# Yeast Infection
The patient has a history of enterococcus and ESBL UTI
sensitive to vancomycin and carbapenems, and on admission was
found to have a UA with significant bacteriuria. She was started
on vancomycin/meropenem to
cover same species, and finished her course on ___. Urine
culture was drawn after starting antibiotics, never grew
bacteria but not diagnostic. The culture eventually grew yeast,
and the patient was given a one-time dose of fluconazole on ___
to treat a likely yeast infection, after she developed new
symptoms of vaginal itching; after the dose, her symptoms
resolved.
# Electrolyte Abnormalities
# Hypomagnesemia
The patient's hypomagnesemia appears to be chronic, possibly ___
diuretic use vs limited PO intake, as she has been taking
magnesium oxide supplements twice daily at home prior to
admission (and required several IV infusions while inpatient).
# Hyponatremia
Her hyponatremia does not appear to have been a problem in the
past, in review of past records. Her Na initially down-trended
throughout her hospitalization, from 138 on admission to a low
of 127 on ___. This was thought to be ___ her poor PO intake
and her diuretic regimen, and after diuretic dose was decreased,
her Na recovered to 134. The patient was also restarted on her
home sodium bicarbonate on ___ (unclear why she was taking this
at home, she could not recall).
# Hyperkalemia
The patient's hyperkalemia also does not seem to have been an
issue prior to this hospitalization; it up-trended from 4.4 on
admission to 6.0 on ___. Initially treated with her home
furosemide regimen, then received 2 doses of kayexalate and
standing albuterol (which she reportedly takes at home).
Initially attributed to her spironolactone, with a possible
component of type IV renal tubular acidosis from her underlying
cirrhosis as well. She was evaluated for primary adrenal
insufficiency per below.
# Primary adrenal insufficiency
However, an AM cortisol from 8.22 revealed a cortisol of 1.7,
highly suggestive of adrenal insufficiency. A consyntropin
stimulation test was performed on ___, which revealed that
she likely has primary adrenal insufficiency. AM ACTH level was
24, indicated primary adrenal insufficiency. TSH was wnl.
Endocrinology evaluated the patient and thought her electrolyte
abnormalities were less likely due her primary adrenal
insufficiency and more likely due to medication effects and
hyperglycemia. Adrenal insufficiency contributed to her
high-dose inhaled corticosteroids. W/u with free cortisol draws
with cosyntropin testing pending at time of discharge which will
be forwarded to PCP to ___. She was discharged with a rx for
stress dose steroids in case of emergencies. If she were to
develop need for daily replacement and Primary AI is ruled out,
we would consider dex to minimize mineralocorticoid effect. She
will
# Abdominal pain
# Pneumotosis intestinalis
The patient had a CT scan that showed colitis and possible
pneumotosis intestinalis, although her abdominal exam was fairly
benign throughout admission, so bowel ischemia, obstruction, or
perforation were all considered unlikely. Transplant surgery
evaluated the patient, and just recommended continuing the same
antibiotics to treat her UTI, and advancing diet as tolerated.
The patient did not have a tappable fluid pocket in the ED, so a
diagnostic paracentesis to rule out SBP was not obtained. It was
ultimately felt that the imaging findings of pneumatosis were
possibly secondary to her underlying cirrhosis/fluid shifts.
# Decompensated NASH cirrhosis
# NASH cirrhosis c/b HE and non-occlusive thrombus of SMV/PV
On admission, the patient was decompensated by excess volume and
possible infection. She had moderate ascites, mild pulmonary
edema, and significant peripheral edema on exam. Initially held
diuretics due to her hypotension and recent shock, but
eventually restarted her diuretics at low doses, after which her
volume status improved significantly. The patient was reportedly
confused at ___, although she mentated well throughout
admission, so concern for HE was very low. She was continued on
lactulose. Patient discharged on lower dose of diuretics w/
concerns ___ for uptitration after discharge pending weight
and resolution of ___.
# HFpEF exacerbation
As above - presented with worsening ___ edema, mild pulmonary
edema
and L pleural effusion on imaging, and pro-BNP elevated to 1500
(though no prior results to compare to). Likely triggered by
infection, as above. Restarted her furosemide and spironolactone
on ___, and her fluid status improved significantly. Eventually
held her spironolactone due to her hyperkalemia and decreased
her furosemide dose ___ hyponatremia, but despite these changes
she did not become significantly volume-overloaded.
# ___ on CKD
Reported history of Stage III CKD with baseline Cr of 1.1-1.4,
though review of records shows recent Cr of 0.9-1.1 in ___.
Likely pre-renal given reduced PO intake; improved after
receiving 2L IVF at
___ and 50g albumin on ___, then restarting her home
diuretics on ___. Her Cr fluctuated during hospitalization and
was improving at discharge.
# T2DM
Pt was initially not ordered for her home glargine due to an
error in placing the order the day of her admission. She
subsequently became hyperglycemic, but fortunately this was
caught, and resolved after was was properly ordered for her home
glargine dose with a ISS on ___. Her blood sugar control was
also difficult due to snacking between meals.
# Pressure Ulcer
Pt had developed a pressure ulcer on her right heel at rehab 3
weeks prior. We consulted Wound Care, who dressed the wound
appropriately.
# Acute on chronic anemia
Likely secondary to underlying cirrhosis, Hgb stable in the
7.7-8.6 range throughout admission. There was initial concern
for blood loss given guiac positive stools (though no frank
melena or hematochezia). The patient remained hemodynamically
stable, and never required a transfusion throughout admission.
She received 2 units of pRBC without signs of acute blood loss.
# Malnutrition
Nutrition team evaluated the patient, and were concerned about
her poor PO intake. She refused supplements on admission,
although stated she drinks Ensure/Glucerna at home. The
patient's hyponatremia was attributed in part to her poor PO
intake and refusal of supplements, and improved after she
started drinking Glucerna and Nepro.
CHRONIC ISSUES:
===============
# COPD
- Continued home Tiotropium 1 CAP daily, Albuterol nebulizers
TID,
and Advair 500/50 IH BID
# HTN
- Continued home nadolol 20mg daily
# HLD
- Continued simvastatin 20 mg qPM
# GERD
- Continued omeprazole 20 mg BID
# Peripheral neuropathy
- Continued gabapentin 300 mg TID
TRANSITIONAL ISSUES:
=================
#Malnutrition
[]Pt evaluated by nutrition team, who were very concerned about
her reduced PO intake. Recommended Nepro and Glucerna
supplements, please encourage her to drink these at home.
#Anemia
[]Pt should get repeat labs within 1 week of discharge to
document her hemoglobin, which was low but stable throughout her
admission.
#Diuretic Dosing
[]Pt will likely need titration of her diuretic balance going
forward, taking into account her electrolyte abnormalities and
her risk of HF exacerbation/fluid overload, and decompensation
of cirrhosis.
[]Discharge on lasix dose reduced to 20mg PO daily due to
concerns for ___. Would uptitrate if weight increasing and when
Cr downtrends. Discharge creatinine: 1.2.
[]Held spironolactone due to concerns for hyperkalemia
#Electrolyte Abnormalities
[]Please get 2 days s/p discharge to adjust diuretics
#Adrenal sufficiency
[] Discharged with stress dose steroids in case of emergency
# CODE STATUS: FULL
# HEALTH CARE PROXY:
___ (Daughter)
Phone number: ___
Cell phone: ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Rifaximin 550 mg PO BID
2. Albuterol 0.083% Neb Soln 1 NEB IH TID shortness of breath
3. Aspirin 81 mg PO DAILY
4. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH DAILY
5. Furosemide 60 mg PO DAILY
6. Gabapentin 300 mg PO TID
7. Lactulose 30 mL PO TID
8. Nadolol 20 mg PO DAILY
9. Simvastatin 20 mg PO QPM
10. Spironolactone 100 mg PO DAILY
11. Vitamin D ___ UNIT PO DAILY
12. MagOx (magnesium oxide) 400 mg oral BID
13. Omeprazole 20 mg PO BID
14. Glargine 15 Units Breakfast
Insulin SC Sliding Scale using novolog Insulin
15. Tiotropium Bromide 1 CAP IH BID
16. Sodium Bicarbonate Dose is Unknown PO BID
Discharge Medications:
1. BD ___ Syringe (syringe (disposable);<br>syringe with
needle) 3 mL 23 x 1 miscellaneous ONCE:PRN
RX *syringe (disposable) 3 mL Use to inject stress dose steroid
Once Disp #*1 Syringe Refills:*0
2. Furosemide 20 mg PO DAILY
RX *furosemide 20 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
3. Solu-CORTEF (PF) (hydrocorTISone Sod Succ (PF)) 100 mg/2 mL
injection ONCE:PRN stress/illness
RX *hydrocortisone sod succ (PF) [Solu-Cortef (PF)] 100 mg/2 mL
100 mg SQ Once Disp #*1 Vial Refills:*0
4. Glargine 15 Units Breakfast
Insulin SC Sliding Scale using novolog Insulin
5. Sodium Bicarbonate 650 mg PO BID
6. Albuterol 0.083% Neb Soln 1 NEB IH TID shortness of breath
7. Aspirin 81 mg PO DAILY
8. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH DAILY
9. Gabapentin 300 mg PO TID
10. Lactulose 30 mL PO TID
11. MagOx (magnesium oxide) 400 mg oral BID
12. Nadolol 20 mg PO DAILY
13. Omeprazole 20 mg PO BID
14. Rifaximin 550 mg PO BID
15. Simvastatin 20 mg PO QPM
16. Tiotropium Bromide 1 CAP IH BID
17. Vitamin D ___ UNIT PO DAILY
18.Outpatient Lab Work
Please draw BMP 2 days after discharge (___)
Dx: Decompensated cirrhosis. ICD 10 K74.69
Please fax to PCP, ___: ___
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS
================
Urinary Tract Infection
SECONDARY DIAGNOSES
===================
- ___
- ___ Cirrhosis
- Decompensation of Heart Failure
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. ___,
You were admitted to the hospital because you were confused and
had some abdominal pain.
WHAT HAPPENED WHILE YOU WERE IN THE HOSPITAL?
- Urine studies showed that you likely had a urinary tract
infection (UTI).
- Your kidneys were initially sick as well, but improved.
- You were treated with 7 days of IV antibiotics.
- You were also treated for high blood sugars, high potassium
levels, found to have adrenal insufficiency, and given diuresis
for fluid overload.
- You improved and were ready to leave the hospital.
WHAT DO YOU NEED TO DO WHEN YOU LEAVE THE HOSPITAL?
- Take all of your medications as prescribed (listed below)
- Keep your follow up appointments with your doctors
- Weigh yourself every morning, before you eat or take your
medications. Call your doctor if your weight changes by more
than 3 pounds
- Please stick to a low salt diet and monitor your fluid intake
- Drink at least one Ensure supplement a day.
- If you experience any of the danger signs listed below please
call your primary care doctor or come to the emergency
department immediately.
It was a pleasure participating in your care. We wish you the
best!
- Your ___ Care Team
Followup Instructions:
___
|
19680953-DS-2
| 19,680,953 | 24,193,033 |
DS
| 2 |
2149-06-27 00:00:00
|
2149-06-27 14:11:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
peanut / egg / almond
Attending: ___.
Chief Complaint:
weakness, abnormal labs, acute renal failure
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr ___ is a ___ yo M w/pmhx of ischemic cardiomyopathy (EF
___ s/p ICD placement), stage 2 CKD ___ creatinine ___,
atrial fibrillation on warfarin, who is presenting with newly
elevated creatinine to 5.6. Pt notes
that he had viral illness last week w/ cough, myalgias,
diziness, rhinnorhea, one episode of diarhea and decreased PO
intake as well as a fever to 104 over the weekend. Since ___ he
has been feeling better, near ___ now with resolved fevers, cough
and myalgias. He went to his PCP's office today and was noted to
have softer blood pressures (90/60s) and a Cr of 5. A peripheral
IV was placed and he was given 1L IVF before being transferred
here. He denies dysuria, urinary urgency/frequency or other BPH
symptoms. He denies gross hematuria or flank pain.
In the ED, initial vitals were: 83 104/63 19 98% RA. Labs were
notable for creatinine of 5.6, AGMA. Renal US was performed and
showed no abnormalities. Pt was given 1 L NS.
On the floor, pt feels well with no ongoing URI sxs. Tells me
he did not get influenza vaccine due to allergy. Urination had
slowed down but now improved since getting fluids.
Review of systems:
(+) Per HPI
(-) Denies chills, night sweats, recent weight loss or gain.
Denies headache, sinus tenderness, rhinorrhea or congestion.
Denies chest pain or tightness, palpitations. Denies
nausea,vomiting, constipation or abdominal pain. No recent
change in bowel habits. No dysuria. Denies arthralgias or
myalgias. 10 pt
ros otherwise negative.
Past Medical History:
Asthma
Gout
History of rectal cancer, in remission
Hypertension, essential, benign
MR ___ regurgitation)
ICD (implantable cardioverter-defibrillator), dual, ___
Anemia of chronic renal failure, stage 2 (mild)
Hyperparathyroidism due to renal insufficiency
Vitamin D deficiency
Paroxysmal atrial fibrillation
Tubular adenoma
Hyperplastic colon polyp
Ischemic cardiomyopathy
Social History:
___
Family History:
mother with breast ca
Physical Exam:
Admission exam
Vitals: 98.6 PO112 / 66 R ___
Constitutional: Alert, oriented, no acute distress
EYES: Sclera anicteric, EOMI, PERRL
ENMT: MMM, oropharynx clear, normal hearing, normal nares
CV: Irregular, normal S1 + S2, no murmurs, rubs, gallops
Respiratory: Clear to auscultation bilaterally, no wheezes,
rales, rhonchi
GI: Soft, non-tender, non-distended, bowel sounds present, no
organomegaly, no rebound or guarding
GU: No foley
EXT: Warm, well perfused, no CCE
NEURO: aaox3 CNII-XII and strength grossly intact
SKIN: no rashes or lesions
Discharge exam
VITALS: Afebrile and vital signs stable (see eFlowsheet)
GENERAL: Alert and in no apparent distress
EYES: Anicteric, pupils equally round
ENT: Ears and nose without visible erythema, masses, or trauma.
Oropharynx without visible lesion, erythema or exudate
CV: Heart regular, no murmur, no S3, no S4. No JVD.
RESP: Lungs clear to auscultation with good air movement
bilaterally. Breathing is non-labored
GI: Abdomen soft, non-distended, non-tender to palpation. Bowel
sounds present. No HSM
GU: No suprapubic fullness or tenderness to palpation
MSK: Neck supple, moves all extremities, strength grossly full
and symmetric bilaterally in all limbs
SKIN: No rashes or ulcerations noted
NEURO: Alert, oriented, face symmetric, gaze conjugate with
EOMI,
speech fluent, moves all limbs, sensation to light touch grossly
intact throughout
PSYCH: pleasant, appropriate affect
Pertinent Results:
Admission labs
___ 08:17PM BLOOD WBC-7.5 RBC-3.98* Hgb-12.4* Hct-37.1*
MCV-93 MCH-31.2 MCHC-33.4 RDW-13.4 RDWSD-45.8 Plt ___
___ 08:17PM BLOOD Glucose-123* UreaN-94* Creat-5.6*# Na-136
K-3.4* Cl-100 HCO3-17* AnGap-19*
___ 08:17PM BLOOD Albumin-3.7 Calcium-9.1 Phos-3.9 Mg-2.5
___ 08:17PM BLOOD ALT-25 AST-30 AlkPhos-67 TotBili-0.4
___ 09:49AM BLOOD ___ PTT-41.6* ___
Discharge labs
___ 05:02AM BLOOD WBC-5.7 RBC-3.35* Hgb-10.6* Hct-31.1*
MCV-93 MCH-31.6 MCHC-34.1 RDW-13.3 RDWSD-45.6 Plt ___
___ 05:02AM BLOOD Glucose-103* UreaN-76* Creat-3.2*# Na-140
K-3.7 Cl-108 HCO3-20* AnGap-12
___ 05:02AM BLOOD ___
___ 05:02AM BLOOD Calcium-8.3* Phos-2.6* Mg-2.0
Imaging
========================
Renal US ___
COMPARISON: No relevant comparison identified.
FINDINGS:
There is no hydronephrosis, large stones, or worrisome masses
bilaterally.
Normal cortical echogenicity and corticomedullary
differentiation are seen
bilaterally. There is a tiny, 7 mm anechoic structure in the
lower pole left kidney, likely a tiny cyst.
Right kidney: 9.4 cm
Left kidney: 9.4 cm
The bladder is moderately well distended and normal in
appearance.
IMPRESSION:
Essentially normal renal ultrasound. No hydronephrosis.
Brief Hospital Course:
___ yo M with hx of ischemic cardiomyopathy, afib on Coumadin now
presenting with ___ I/s/o recent viral illness.
# ___, AGMA: Cr up to 5.6 from baseline of 1. His history was
concerning for pre-renal etiology given poor PO intake I/s/o
influenza, no e/o obstruction on US, although urine lytes more
consistent with intrinsic renal cause, possibly ATN from
pre-renal ___. His was given IVF with improvement in his Cr and
UOP. Cr down to 3 at time of discharge and patient taking good
POs. He will follow up with his PCP for repeat labs.
# influenza: sxs now resolved. Given patient presented several
days after symptom onset, he was not treated with Tamiflu.
# ischemic cardiomyopathy: no e/o volume overload on admission,
appeared euvolemic. He was continued on his BB, lisinopril was
held in setting of ___.
#Supratherapeutic INR
# Afib on Coumadin: rate contolled, continue metoprolol.
CHADSVASC 2 for HTN and CHF. INR noted to be 6 on admission,
given 2.5 mg of vitamin K. Per discussion with pharmacy, patient
should take 3 mg warfarin on discharge. He will follow up with
his ___ clinic on ___ for INR check.
# HTN: hold lisinopril given ___, held amlodipine for
normotension
# GERD: cont omeprazole
# HLD: cont statin
# GOUT: pt not taking allopurinol regularly, will hold until
follows up with PCP
# asthma - cont albuterol, inhaled steroid
# anemia: normocytic, chronic, stable, likely due to CKD
Transitional care issues
[ ] resume lisinopril once Cr normalized
[ ] patient should have labs checked ___ or ___
[ ] discuss with PCP need for allopurinol
[ ] hold amlodipine until BP improves/ patient becomes
hypertensive
Greater than 30 minutes were spent providing and coordinating
care for this patient on day of discharge.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. amLODIPine 10 mg PO DAILY
2. Lisinopril 20 mg PO DAILY
3. Metoprolol Succinate XL 100 mg PO DAILY
4. Atorvastatin 80 mg PO QPM
5. Omeprazole 20 mg PO DAILY
6. Colchicine 0.6 mg PO AS NEEDED
7. Allopurinol ___ mg PO DAILY
8. beclomethasone dipropionate 40 mcg/actuation inhalation 4
puffs BID
9. Warfarin 5 mg PO 5X/WEEK (___)
10. Warfarin 6.25 mg PO 2X/WEEK (___)
Discharge Medications:
1. Warfarin 3 mg PO 5X/WEEK (___)
***Please take 3 mg on evening of ___ and ___ and ___, have INR
checked on ___. Atorvastatin 80 mg PO QPM
3. beclomethasone dipropionate 40 mcg/actuation inhalation 4
puffs BID
4. Colchicine 0.6 mg PO AS NEEDED
5. Metoprolol Succinate XL 100 mg PO DAILY
6. Omeprazole 20 mg PO DAILY
7. HELD- Allopurinol ___ mg PO DAILY This medication was held.
Do not restart Allopurinol until labs are rechecked and kidney
function is normal
8. HELD- amLODIPine 10 mg PO DAILY This medication was held. Do
not restart amLODIPine until seen in clinic
9. HELD- Lisinopril 20 mg PO DAILY This medication was held. Do
not restart Lisinopril until seen in clinic
10. HELD- Warfarin 6.25 mg PO 2X/WEEK (___) This medication
was held. Do not restart Warfarin until seen in ___
clinic
Discharge Disposition:
Home
Discharge Diagnosis:
Acute renal failure
Supratherapeutic INR
Influenza A infection
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___
You were admitted for acute kidney failure which was related to
dehydration from the influenza virus. You were given IV fluids
with improvement in your kidney function. Your warfarin was held
due to a supratherapeutic INR. Please resume your coumadin when
you go home. TAKE 3 MG WARFARIN THIS EVENING. Have your primary
doctor check your kidney function and INR next week.
Thank you for allowing us to participate in your care,
Your ___ team
Followup Instructions:
___
|
19681115-DS-6
| 19,681,115 | 28,292,244 |
DS
| 6 |
2140-05-22 00:00:00
|
2140-05-22 16:32:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
s/p diagnostic angiogram
Cath: LAD diffuse 90% with faint filling by retrograde LIMA,
proximal D1 90%, LCx T.O. prior to OM2 (fills by patent SVG),
RCA
with serial 80-90%. PDA likely occluded (fills by SVG).
Consider somewhat complex PCI of distal RCA if medical
management
fails
IMPRESSION:
1. Unstable angina versus gastroesophageal reflux with
intermediate risk nuclear perfusion study. Known underlying CAD
with prior CABG.
2. Mixed dyslipidemia
3. Type 2 diabetes
4. End-stage renal disease
History of Present Illness:
Mr. ___ is a ___ year old man with a history of coronary
artery
disease status post CABG who presented with substernal chest
pain
described as burning 3 hours into his hemodialysis session
___. The pain was relieved with oral TUMS and says that it was
consistent with prior heartburn. He was reportedly diaphoretic
but had no shortness of breath. trops flat at 0.06. P MIBI on
the day of admission showed Reversible severe inferior and
inferolateral defect with globally decreased wall motion and
ejection fraction of 47%
Past Medical History:
Hypertension - noncompliant w/ meds
type II DM diagnosed in ___ - noncompliant and
supposed to be on insulin
? of atrial fibrillation (started on warfarin - but says he's
never heard this diagnosis)
CHF (unknown EF)
Social History:
___
Family History:
Father - DM, HTN
Mother - healthy, smoker
2 daughters - healthy
Physical ___:
ON ADMISSION:
VITALS: BP 107/69, HR 87, RR 20, O2 sat 97% room air
HEENT: Sclear anicteric, MMM
NECK: Jugular venous pressure less than 10, carotid upstrokes
are
full and brisk without bruits
CHEST: Lungs clear to auscultation
CV: Very distant heart sounds. Normal S1 and S2 no pathologic
murmurs, rubs or gallops
ABD: Soft, NT, ND
EXT: Warm, no edema
ON DISCHARGE:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
VS: 98.3 128/72 87 22 96% RA
Gen: ___ yr old man in NAD. Denies SOB,CP, palpitations,
dizziness at rest or with ambualation
Neck: Unable to assess JVD
Heart: S1S2 regular, no MRG
Lungs:CTAB, no wheezes or rhonchi
Abd: soft, non-tender, BS +
PV: right femoral site is soft, angiosealed. No bleeding or
hematoma. ___: palpable. No edema. Extremities are warm and
well perfused.
Neuro: Alert and oriented, no focal deficits or asymmetries
noted
Pertinent Results:
___ 12:40PM BLOOD WBC-11.0* RBC-3.24*# Hgb-10.3*#
Hct-30.1*# MCV-93# MCH-31.8 MCHC-34.2 RDW-13.1 RDWSD-44.1 Plt
___
___ 07:30AM BLOOD WBC-8.8 RBC-3.12* Hgb-9.9* Hct-29.6*
MCV-95 MCH-31.7 MCHC-33.4 RDW-13.3 RDWSD-45.7 Plt ___
___ 12:40PM BLOOD Glucose-207* UreaN-36* Creat-4.7*#
Na-130* K-5.2* Cl-94* HCO3-19* AnGap-22*
___ 07:30AM BLOOD Glucose-144* UreaN-32* Creat-6.2*# Na-133
K-4.3 Cl-92* HCO3-25 AnGap-20
___ 06:35PM BLOOD CK(CPK)-50
___ 12:40PM BLOOD cTropnT-0.06*
___ 06:35PM BLOOD CK-MB-3
___ 06:35PM BLOOD cTropnT-0.06*
___ 06:15AM BLOOD cTropnT-0.06*
___ 06:15AM BLOOD Cholest-212*
___ 05:39AM BLOOD Calcium-8.8 Phos-6.2* Mg-3.2*
___ 07:30AM BLOOD Mg-2.3
___ 02:20PM BLOOD %HbA1c-7.9* eAG-180*
___ 06:15AM BLOOD Triglyc-469* HDL-30 CHOL/HD-7.1
LDLmeas-123
Brief Hospital Course:
Mr. ___ is a ___ year old man with a PMH of of CAD,
Hypertension, ESRD on HD, DM, currently diet controlled who
developed chest "burning" during HD. Trops 0.06. He underwent a
stress MIBI, which was notable for severe inferior &
inferolateral defect; EF 47%. He was taken for a coronary
angiogram which showed patent grafts and distal RCA disease. The
pt was started on ASA (recently stopped taking at home) and low
dose Lisinipril. His Simvastatin was changed to Atorvastatin,
and his Metoprolol was increased from 25 to 50 mg. He remained
pain free after his angiogram. He will be considered for a RCA
PCI if he has recurrent symptoms after optimal medical
management. A Hgb A1C was 7.9%. Pt was on insulin in the past
for DM, but was no longer needed after a 50 lbs wt loss. The pt
has since regained the weight while waiting for hip surgery. He
was seen by ___ and deemed safe for ___ home with no services. Mr.
___ was DC'd home in stable condition. He has follow up in
place with his PCP next week, who will then refer him to an
outpatient cardiologist.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Metoprolol Succinate XL 25 mg PO DAILY
2. Simvastatin 40 mg PO QPM
Discharge Medications:
1. Aspirin 325 mg PO DAILY
2. Atorvastatin 80 mg PO QPM
3. Lisinopril 2.5 mg PO DAILY
4. Metoprolol Succinate XL 50 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
CAD
ESRD on HD
DM A1C 7.9%
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
VS: 98.3 128/72 87 22 96% RA
Gen: ___ yr old man in NAD. Denies SOB,CP, palpitations,
dizziness at rest or with ambualation
Neck: Unable to assess JVD
Heart: S1S2 regular, no MRG
Lungs:CTAB, no wheezes or rhonchi
Abd: soft, non-tender, BS +
PV: right femoral site is soft, angiosealed. No bleeding or
hematoma. ___: palpable. No edema. Extremities are warm and
well perfused.
Neuro: Alert and oriented, no focal deficits or asymmetries
noted
A/P:
: ___ year old male with history of CAD, HTN, CKD on HD who
presents to the CDAc for evaluation of chest pain. His CAD will
be medically managed with possible PCI of distal RCA if pt
becomes symptomatic
# NSTEMI - trops stable at 0.06- Positive P MIBI yesterday, s/p
cath with patent grafts and distal RCA lesion to be medically
managed
- cont aspirin 325mg daily (pt stopped taking at home because
he forgot). Has been CP free since admission
- cont lisinipril 2.5mg daily
- increased Toprol to 50mg daily
- changed simvastatin to atorvastatin 80mg daily
- consider addition of CCB for persistent pain
# Hypertension:
- controlled, continue metoprolol
- start low dose lisinopril
-Dr. ___ will refer to outpatient cardiologist.
# ESRD- HD ___ Th ___-
- HD today prior to cath, resume usual schedule as outpatient
on ___
# DM- diet controlled. HgbA1c 7.9%
- follow up with outpatient
PCP
# ___
- changed simvastatin to atorvastatin 80mg daily
# Disp
-DC home
Discharge Instructions:
You were admitted to the cardiac direct access care unit for
evaluation of chest pain. You had a stress test that was
positive for ischemic changes. You underwent a catheterization
that showed your grafts from your CABG were patent. There was a
lesion noted in your right coronary artery, however this will be
medically managed with medicines. If you continue to have
episodes of chest pain you can discuss the possibility of a
procedure to open up the blockage with your cardiologist.
You were on medication for diabetes in the past, but it was
stopped because you had lost weight. Your Hgb A1c, which is a
marker for diabetes is elevated. You may need to resume
medication for diabetes. Please speak to Dr. ___ this
at your appointment
The following medication changes have been made to your regimen:
ADD:
Aspririn 325 mg daily
Lisinopril 2.5 mg daily
INCREASE:
Metoprolol 25 mg to 50 mg
CHANGE:
Simvastatin to Atorvastatin
Activity restrictions and care of your groin site will be
included in your discharge instructions. Please resume your home
hemodialysis schedule.
Followup Instructions:
___
|
19681149-DS-9
| 19,681,149 | 24,849,017 |
DS
| 9 |
2165-03-27 00:00:00
|
2165-03-28 14:55:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
fall with amnesia
Major Surgical or Invasive Procedure:
Coronary angiogram
History of Present Illness:
___ woman with past medical history of atrial
fibrillation on Xarelto, recent
admission for GI bleed, heart failure recently switched from
Lasix to torsemide, stage IIIC colorectal adenocarcinoma s/p
___ (not on active chemo) who presents as a transfer for
NSTEMI after an unwitnessed fall. She does not remember going to
sleep last night and has a very vague memory of this morning.
When she did not show to breakfast at her assisted living
facility, she was found on the ground in her room. She was taken
to ___. Labs were remarkable for an elevated troponin to
0.11 and a mildly elevated CK to 547. She was also noted to be
hyponatremic to 127. CT imaging of her head, neck and plain
films
of her chest and hip revealed no acute injury; however, the
x-ray
showed evidence of pulmonary edema with bilateral pleural
effusions. Given the elevated troponin she was sent to the ___
ED for concern of an STEMI. She received 324 mg of aspirin by
mouth.
Of note, in the weeks prior to presentation, she had phone calls
with her cardiologist regarding poorly controlled heart failure.
She had her furosemide dose increased prior to switching to
torsemide 20mg daily which she recently started.
On arrival to the ___ ED, she was alert and oriented with no
memory of the night prior to presentation or the morning of
presentation. She denied any recent illnesses, urinary symptoms,
upper respiratory tract infection-like symptoms. She denies any
chest pain, arm pain, jaw pain, palpitations, dyspnea, back
pain,
abdominal pain, increased output from her colostomy, rashes,
paresthesias, or difficulty ambulating from her baseline.
Initial vitals in the ED: T 97.1, BP 97/60, HR 100, O2 sat 95%
RA
Labs notable for:
Repeat trop: 0.10
Na: 131
WBC: 10.3
INR: 3.0
EKG: afib with poor baseline and poor R-wave progression
___ Imaging:
Hip Xray:
Normal bones, joints of the right and left hip. No tumor or
pubic
fracture, no lateralizing arthropathy seen
CXR:
1. Mild cardiomegaly. Pleural effusions larger on left. Mild
CHF.
On a background of mildly hyperinflated chest.
2. Alveolar densities, RUL, LLL perhaps alveolar pulmonary
edema,
pneumonia cannot be excluded however.
3. Port-A-Cath, which is new from ___.
4. Accentuated thoracic kyphosis.
CT Cspine
1. No acute cervical fracture or definite traumatic
misalignment.
2. Cervical DDD, facet DJD. Anterior atlantoaxial DJD.
3. Degenerative central, foraminal stenosis, as detailed above.
4. Degenerative Anterolisthesis at C3/4, C7/T1 and
retrolisthesis
C4/5. Additional incidental findings as noted.
NCHCT:
1. Involution, minimal small vessel ischemic
leukoencephalopathy.
Otherwise, normal noncontrast CT scan of the head.
2. No acute hemorrhage, acute infarction, edema, mass, mass
effect, or fracture.
3. Incidental findings of the paranasal sinuses described above.
Upon arrival to the floor, patient is pleasant and denies memory
of the evening prior to presentation. Her daughter explains that
she most recently saw her at 7pm prior to the fall and that she
believes the patient fell around 9pm as her bed was still made
when she was found in the morning. Per her daughter, she spent
the night on the floor. She is typically very lucid, takes all
of
her own medications and is able to care for herself mostly.
However, she was recently discharged from the hospital 2 days
prior to presentation when she was hospitalized for heart
failure
exacerbation and hyponatremia.
At this time, she complains of arm stiffness but otherwise
denies
pain. Her daughter notes that she was lightheaded when standing
from seated position on day prior to presentation. She denies
chest pain, SOB, ___.
REVIEW OF SYSTEMS:
Cardiac review of systems is notable for absence of chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
ankle edema, palpitations, syncope, or presyncope.
On further review of systems, denies any prior history of
stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. Denies exertional buttock or calf pain.
Denies recent fevers, chills or rigors. All of the other review
of systems were negative.
Past Medical History:
Past medical history:
1. GERD
2. Hyperlipidemia
3. Breast cancer status post lumpectomy greater than ___ years
ago with use of Arimidex
4. Status post pheochromocytoma removal at age ___ in ___
5. Subclinical hypothyroid
6. Osteoarthritis in bilateral hands
7. Pneumonia, viral with sepsis and ARDS? Requiring intubation
and tracheotomy while in ___ at age ___
8. PE and DVT in ___ now on Xarelto
9. Hyponatremia in ___
10. A. fib ___
11. Rectal CA ___, now with permanent colostomy
12. dilastolic heart failure (EF55%)
Social History:
___
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death.
Physical Exam:
========================================
ADMISSION PHYSICAL EXAM
========================================
VITALS: 24 HR Data (last updated ___ @ ___)
Temp: 97.7 (Tm 97.7), BP: 94/59, HR: 93, RR: 17, O2 sat:
94%,
O2 delivery: Ra, Wt: 104.5 lb/47.4 kg
GEN: alert, oriented and in no acute distress. thin, pleasant.
HEENT: NCAT. PERRLA, no icterus or injection with pallor
bilaterally.
NECK: JVP appears to be at 8cm but difficult exam ___ TR
CV: irregularly irregular. NMRG. 2+ radial and DP pulses
bilateral.
PULM: Breathing comfortably on RA. No incr WOB. Bibasilar
crackles.
CHEST: accessed port in left upper chest with no surrounding
erythema or tenderness
ABD: Soft, Nontender, Nondistended with no organomegaly; no
rebound tenderness or guarding. Colostomy in LLQ with no
tenderness or surrounding erythema.
EXT: ___ with 1+ dependent edema bilaterally.
NEURO: AOx3, speech fluent, no obvious facial asymmetry, moves
all 4 ext to command.
PSYCH: Normal mentation
========================================
DISCHARGE PHYSICAL EXAM
========================================
___ 0744 Temp: 98.1 PO BP: 128/69 L Lying HR: 82 RR: 17 O2
sat: 95% O2 delivery: Ra
GEN: alert, oriented and in no acute distress. thin, pleasant.
HEENT: NCAT. PERRLA, no icterus or injection with pallor
bilaterally.
NECK: no JVD noted at 90 degrees but difficult exam ___ TR
CV: irregularly irregular. NMRG. 2+ radial and DP pulses
bilateral.
PULM: Breathing comfortably on RA. No increased WOB. Fine
crackles throughout, improved aeration.
CHEST: accessed port in left upper chest with no surrounding
erythema or tenderness
ABD: Soft, Nontender, Nondistended with no organomegaly; no
rebound tenderness or guarding. Colostomy in LLQ with no
tenderness or surrounding erythema.
EXT: ___ with no edema bilaterally.
NEURO: AOx3, speech fluent, no obvious facial asymmetry, moves
all 4 ext to command.
PSYCH: Normal mentation
Pertinent Results:
====================================
ADMISSION LABS
====================================
___ 02:46PM BLOOD WBC-10.3* RBC-2.76* Hgb-8.0* Hct-25.3*
MCV-92 MCH-29.0 MCHC-31.6* RDW-16.1* RDWSD-53.0* Plt ___
___ 02:46PM BLOOD Neuts-87.2* Lymphs-5.5* Monos-4.5*
Eos-0.1* Baso-0.2 Im ___ AbsNeut-8.98* AbsLymp-0.57*
AbsMono-0.46 AbsEos-0.01* AbsBaso-0.02
___ 02:46PM BLOOD ___ PTT-35.8 ___
___ 02:46PM BLOOD Glucose-113* UreaN-19 Creat-0.8 Na-131*
K-4.7 Cl-94* HCO3-22 AnGap-15
___ 06:26AM BLOOD ALT-17 AST-26 LD(LDH)-180 CK(CPK)-304*
AlkPhos-79 TotBili-0.4
====================================
PERTINENT INTERVAL LABS
====================================
___ 06:26AM BLOOD CK-MB-6 proBNP-9076*
___ 09:17PM BLOOD cTropnT-0.05*
___ 02:46PM BLOOD cTropnT-0.10*
___ 05:38AM BLOOD Digoxin-2.0*
___ 06:42AM BLOOD Digoxin-2.9*
___ 06:12AM BLOOD Digoxin-4.1*
====================================
DISCHARGE LABS
====================================
___ 05:38AM BLOOD WBC-6.8 RBC-2.97* Hgb-8.3* Hct-27.5*
MCV-93 MCH-27.9 MCHC-30.2* RDW-15.5 RDWSD-52.7* Plt ___
___ 05:38AM BLOOD Glucose-111* UreaN-12 Creat-0.5 Na-132*
K-4.0 Cl-93* HCO3-31 AnGap-8*
___ 05:38AM BLOOD Calcium-8.7 Phos-3.3 Mg-1.9
====================================
PROCEDURES/STUDIES/IMAGING
====================================
Coronary angiogram
Normal left and right heart filling pressures.
Mild coronary coronary artery disease.
No flow limiting epicardial CAD. Slow flow in all epicardial
vessels, despite normal LVEDP
suggestive of microvascular disfynction.
ECHO
Normal global/regional left ventricular systolic function.
Bilateral pleural effusions. Top normal/mildly dilated right
ventricle with mild global hypokinesis. Mild pulmonary
hypertension. Increased PVR.
Shoulder x ray
Essentially nondisplaced fracture at the base of the greater
tuberosity of the left proximal humerus.
KUB
Moderate distal burden. Non-obstructive bowel gas pattern.
Brief Hospital Course:
===========================
BRIEF SUMMARY
===========================
In summary, this is a ___ woman with past medical
history of atrial fibrillation on Xarelto, recent admission for
GI bleed, heart failure recently switched from Lasix to
torsemide, stage IIIC colorectal adenocarcinoma s/p radiation
followed by permanent ___ admitted for NSTEMI
after an unwitnessed fall with loss of consciousness and
amnesia.
She was found to be in rapid atrial fibrillation and to have a
HFpEF exacerbation. We started her on digoxin for rate control
and diursed her to a dry weight of 98 pounds (confirmed by LVEDP
pressures on coronary angiogram). Her troponin was positive and
an ECHO did not show any wall motion abnormality but given her
dynamic EKG changes she was taken for coronary angiogram which
showed no epicardial disease, just evidence of microvascular
dysfunction, with a normal LVEDP at a weight of 98 pounds. As
such, we stopped her aspirin (which was started given her
presentation of NSTEMI) while she continued her anticoagulation
for atrial fibrillation.
She also was noted to have a nondisplaced left shoulder fracture
which is to be managed conservatively per the orthopedics team.
Additionally, she had no ostomy output since a colonoscopy done
___ and was seen by colorectal surgery who after ruling out
obstruction felt she most likely had an ileus from anemia and
immobility, and that there was no further acute surgical needs
and this can be followed by an outpatient.
===========================
TRANSITIONAL ISSUES
===========================
# CODE: DNR/DNI
# CONTACT/HCP:
Next of Kin: ___
Relationship: DAUGHTER
Phone: ___
Other Phone: ___
[]New meds: digoxin
[]Changed meds: diltiazem (dose decrease)
[]Please make sure digoxin level (new medication for rate
control) and chem 10 are drawn on teus___ and sent to the
office of Dr. ___
[]Please weight every day and make sure weight is around 98
pounds
[]Please contact the office of colorectal surgery and ask to
speak with Dr. ___ there is no ostomy output over the
next couple days or the pain starts to show signs of obstruction
such as nausea, vomiting, or abdominal pain.
[]Follow-up with orthopedic team in clinic in 2 weeks, encourage
sling for comfort, WBAT, ROMAT.
[]Recommend iron infusion and upper endoscopy to evaluate for
cause of iron deficiency (had colonoscopy last month)
[]Consider repeat TSH in ___ months
===========================
PROBLEM-BASED SUMMARY
===========================
#Fall with amesia
Patient with no memory of event. She had no evidence of head
bleed
or c-spine injury on admission imaging, we did identify a non
displaced left shoulder fracture (see below). Ultimately unclear
etiology of fall, perhaps she had a mild concussion as a result
leading to amnesia but the underlying cause is still not clear.
Per daughter, had symptoms on day prior to admission consistent
with orthostasis, that she describes as dizziness upon standing
from seated position so this may also have contributed. We
discussed this with the family and said it may be useful to have
24 hour blood pressure monitor or wear a rhythm as further
workup as an outpatient.
#NSTEMI
Troponins peaked at 0.11 and then downtrended. TTE was done ___
with normal EF, no wall motion abnormality. EKG on morning of
___ with new T wave inversions. Given new EKG findings, cardiac
cath was done on ___ and showed no epicardial coronary artery
disease, just microvascular disease with a normal LVEDP of ___.
As such, we stopped her aspirin and continued rosuvastatin 20
mg. The cause of the NSTEMI may have been a combination of
volume overload, rapid atrial fibrillation, and underlying
microvascular disease.
#HFpEF exacerbation
Most recent EF 55-60% ___. BNP was elevated to 9076, much
higher than most recent baseline, she was actively diursed with
Lasix 40mg IV boluses to a dry weight of 98 pounds (confirmed by
LVEDP of ___ on her left heart cath). She was then restarted on
home torsemide 20mg daily as she was felt to be euvolemic.
#Rapid atrial fibrillation
On diltiazem ER and xarelto at home. Heart rates were elevated
to 110s on
admission but remained asymptomatic. She was started on digoxin
given rapid rates. Following initiation, her rates slowed and
she was noted to have brief (10 second) episodes of bradycardia
with question of junctional escape. Her digoxin level was
elevated. Digoxin was held following this, and on the day of
discharge had decreased to 2, and we planned to start digoxin
0.0625mg daily on ___ and have a digoxin level checked early
next week and sent to her cardiologist Dr. ___. She was
continued on home Diltiazem which was decreased slightly from
240mg to 180mg daily .
#Stage IIIC colorectal adenocarcinoma
Patient is s/p resection and permanent colostomy with curative
intent. She had a recent colonoscopy at OSH given concerns for
GI bleeding showing no lesions or obstruction. However, she had
no further ostomy output since the colonoscopy. The site of the
colostomy was intact. Given lack of output, we obtained a KUB
which showed no evidence of obstruction. We consulted colorectal
surgery who recommended monitoring closely, thinking she likely
has an asymptomatic ileus.
#Left shoulder fracture
Xray showed essentially non-displaced fracture at the base of
the greater tuberosity of the left proximal humerus, no
neurovascular injury, orthopedics recommended sling for comfort,
weight bearing as tolerated, range of motion as tolerated, and
follow-up in clinic in two weeks with Dr. ___.
#CK elevation
Noted on admission. Most likely consistent with rhabdomyolysis
with recent fall and presumably stayed down for 12 hours.
# Acute on Chronic Hyponatremia
Na 127 on presentation at OSH. Nadired at 117 at last admission,
felt to be ___ hypervolemia in the setting of CHF as improved
with diuresis. She has a chem 10 scheduled early next week to be
follow up by her cardiologist.
# Anemia
Patient noted to be anemic to Hg 6.8 at recent presentation.
Following 1 unit pRBCs, Hg stabilized around 7.6-8.0 which is
consistent with current Hg. Recent iron studies consistent with
iron deficiency anemia and
likely concurrent anemia of inflammation. She underwent
colonoscopy on ___ which did not show any obvious source of
bleeding and felt was safe to resume xarelto. We continued to
hold celecoxib and did not repeat iron studies as they had been
recently done. We recommend an outpatient iron infusion and EGD
to further workup the etiology as she already had a colonoscopy.
#Subclinical hypothyroidism
Found to have elevated TSH to 10.1 on recent admission. Free T4
was normal at 1.1. Consider repeat TSH in ___ months.
#GERD
Continued home omeprazole
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Diltiazem Extended-Release 240 mg PO QPM
2. Torsemide 20 mg PO DAILY
3. Omeprazole 20 mg PO BID
4. Rivaroxaban 20 mg PO QPM
5. iron 159 mg (45 mg iron) oral QHS
6. Klor-Con 10 (potassium chloride) 40 meq oral DAILY
Discharge Medications:
1. Digoxin 0.0625 mg PO DAILY (to start ___
2. Diltiazem 60 mg PO TID
3. Rosuvastatin Calcium 20 mg PO QPM
4. iron 159 mg (45 mg iron) oral QHS
5. Klor-Con 10 (potassium chloride) 40 meq oral DAILY
6. Omeprazole 20 mg PO BID
7. Rivaroxaban 20 mg PO QPM
8. Torsemide 20 mg PO DAILY
9.Outpatient Lab Work
ICD code: ___.81, I50
Chem 10, digoxin level
Fax results to ___ (CardioVascular Institute ___,
___
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS
NSTEMI
SECONDARY DIAGNOSIS
Shoulder fracture
Ileus
Atrial Fibrillation
HFpEF (EF 55%)
CAD
stage IIIC colorectal adenocarcinoma
Anemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking care of you at ___
___.
===========================================
WHY WAS I ADMITTED TO THE HOSPITAL?
===========================================
- You were admitted to the hospital because had a fall and lost
consciousness
===========================================
WHAT HAPPENED WHILE I WAS IN THE HOSPITAL?
===========================================
- We never figured out the exact reason you lost consciousness,
and this was discussed in detail with your daughter
- We diagnosed you with a mild shoulder fracture and the
orthopedics team evaluated you and said there were no major
activity restrictions
- Your ostomy did not have any output, but there was no evidence
of obstruction and after discussing with your colorectal surgeon
Dr. ___ decided this okay monitor further outside of the
hospital.
- You had a blood test that showed mild damaged to the heart
muscle, but an ultrasound of the heart showed no pumping
problems and an angiogram showed no blockages of the arteries
that supply the heart muscle. This is good news!
===========================================
WHAT SHOULD I DO WHEN I GO HOME?
===========================================
- Take the medications as prescribed and make all the follow up
appointments
- Try to limit salt intake and keep the weight around 98 pounds
- If the episodes continue, you can discuss wearing a blood
pressure monitor or a heart rhythm monitor with your doctors
We ___ the best!
Your ___ Care Team
Followup Instructions:
___
|
19681202-DS-21
| 19,681,202 | 29,224,714 |
DS
| 21 |
2140-08-09 00:00:00
|
2140-08-09 20:09:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Erythromycin Base / Penicillins / Gentamicin / Latex /
Iodine-Iodine Containing / Hydromorphone / Phenylbutazone /
Efavirenz / Quinolones / Macrolide Antibiotics / G6PD deficient
/ Cephalosporins / clindamycin / Daunorubicin / Diazepam /
Celecoxib / isoniazid
Attending: ___
Chief Complaint:
Fever, shortness of breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ yo female with HIV (CD4 676 in ___, DM c/b gastroparesis,
G6PD deficiency, CMV retinitis and possible CMV colitis,
presenting with two weeks of dyspnea, cough, fevers.
Patient reports recent week-long hospitalization ___ for
fevers, cough, generalized weakness. Records are not available
from this hospitalization, but patient states she was prescribed
doxycycline for a tooth abscess, which is now improved.
However, she continued to experience high fevers at ___, up to
101.2, as well as cough - mostly dry and hacking, but
occasionally productive of cloudy/yellow sputum. Reports
episodic dyspnea that wakes her up from sleep, wheezing. States
she noticed "black specks" in her sputum, but no blood. No
weight loss. Endorses hot flashes but no drenching night
sweats. She also reports generalized fatigue and dyspnea on
exertion.
She also reports hematuria, LLQ pain, urinary frequency, similar
to when she had a kidney stone in the past. She also has
epigastric pain radiating to the back, associated with nausea
but no vomiting. She reports headache / pressure and pain in
the right side of her neck but no photosensitivity or
meningismus.
In the ED, initial vital signs were T 100.6 BP 128/76 HR 122 R
20 Sat 94% on RA. Labs notable for Hgb 7.0, Hct 21.6, LDH 299,
Hapto 180. She was transfused 2 units PRBCs with appropriate
response.
ROS: Full 10 point ROS otherwise negative in detail
Past Medical History:
- HIV - followed by Dr. ___ and Dr. ___
- G6PD DEFICIENCY
- Diabetes mellitus with gastroparesis
- CMV retinitis/iritis
- Latent tuberculosis
- Asthma
- Nephrolithiasis
- Chronic diarrhea status post follow-up with Dr. ___ at ___
with GI workup that was unrevealing and improving with tincture
of opium.
- Status post hysterectomy in ___ for uterine cancer
- Status post motor vehicle accident with right lower extremity
trauma and pin in place.
Social History:
___
Family History:
- PGM - breast cancer
- Maternal aunt - uterine cancer
- ___ relative - colon cancer
- ___ uncle - stomach CA
Physical Exam:
Admission exam:
VS: 99.0 130 / 80 110 18 97 RA
GEN: No acute distress, comfortable appearing
HEENT: NCAT, anicteric sclera, no thrush or tonsillar exudates,
poor dentition / multiple chipped teeth, but no visible abscess.
No meningismus
LYMPH: No cervical or axillary lymphadenopathy
CV: Normal S1, S2, no murmurs
RESP: Good air entry, no rales or wheezes
GI: Normal bowel sounds, soft, minimally tender in the
epigastrum, negative ___ sign, non-distended, no
rebound/guarding;
MSK: No edema. Intact pulses.
DERM: No rash.
NEURO: Face symmetric, speech fluent, non-focal
PSYCH: Calm, cooperative
Discharge exam:
vitals: 98.0 121/77 91 18 96% RA
GEN: No acute distress, seen ambulating around the room without
any dyspnea or distress, comfortable appearing
HEENT: NCAT, anicteric sclera, neck is supple
CV: Normal S1, S2, no murmurs
RESP: clear bilaterally
GI: soft, nontender throughout
NEURO: Face symmetric, speech fluent, non-focal
PSYCH: appropriate affect and mood this morning
Pertinent Results:
LABS
============================================
ADMISSION LABS
___ 09:06PM BLOOD WBC-5.8 RBC-2.25*# Hgb-7.0*# Hct-21.6*#
MCV-96 MCH-31.1 MCHC-32.4 RDW-11.9 RDWSD-40.9 Plt ___
___ 09:06PM BLOOD Neuts-65.5 ___ Monos-6.8 Eos-3.7
Baso-0.2 Im ___ AbsNeut-3.77 AbsLymp-1.34 AbsMono-0.39
AbsEos-0.21 AbsBaso-0.01
___ 01:30AM BLOOD WBC-5.6 Lymph-33 Abs ___ CD3%-78
Abs CD3-1444 CD4%-30 Abs CD4-558 CD8%-44 Abs CD8-809*
CD4/CD8-.69*
___ 01:30AM BLOOD Ret Aut-4.2* Abs Ret-0.13*
___ 09:06PM BLOOD Glucose-252* UreaN-25* Creat-1.1 Na-134
K-4.5 Cl-98 HCO3-22 AnGap-19
___ 09:06PM BLOOD ALT-57* AST-29 LD(LDH)-299* AlkPhos-242*
TotBili-0.2
___ 09:06PM BLOOD Lipase-68*
DISCHARGE LABS:
___ 07:45AM BLOOD WBC-7.0 RBC-3.12* Hgb-9.6* Hct-29.2*
MCV-94 MCH-30.8 MCHC-32.9 RDW-12.8 RDWSD-43.4 Plt ___
___ 07:45AM BLOOD Glucose-234* UreaN-26* Creat-1.0 Na-137
K-4.6 Cl-102 HCO3-21* AnGap-19
___ 07:45AM BLOOD ALT-70* AST-48* AlkPhos-215* TotBili-0.2
OTHER RELEVANT LABS
___ 09:14AM BLOOD HIV Viral load: detected < 1.3
___ 09:03AM BLOOD EBV PCR-229
___ 09:03AM BLOOD CMV VL-NOT DETECT
___ 06:25AM BLOOD CRP-13.0*
___ 06:25AM BLOOD Sed Rate-65
___ 08:00AM BLOOD ASPERGILLUS GALACTOMANNAN ANTIGEN-Neg
___ 08:00AM BLOOD B-GLUCAN- 366 (H)
___ 06:20AM BLOOD Pertussis serology - PENDING
___ 08:00AM BLOOD B-GLUCAN- <31 NEGATIVE
___ 06:20AM BLOOD Triglyc-483* HDL-37 CHOL/HD-5.8
LDLmeas-130*
___ 06:20AM BLOOD Cholest-213*
MICROBIOLOGY
============================================
___ urine culture: no growth
___ 11:11 am SPUTUM Site: INDUCED Source: Induced.
MTB DIRECT AMPLIFICATION ADDED ON PER ___
(___) AT 1334
ON ___.
ACID FAST SMEAR (Final ___:
NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.
ACID FAST CULTURE (Pending):
MTB Direct Amplification (Final ___:
M. TUBERCULOSIS DNA NOT DETECTED BY NAAT: A negative NAAT
cannot rule
out TB or other mycobacterial infection.
.
NAAT results will be followed by confirmatory testing with
conventional culture and DST methods. This TB NAAT method
has not
been approved by FDA for clinical diagnostic purposes.
However, ___
Laboratory Institute (___) has established assay
performance by
in-house validation in accordance with CLIA standards.
.
Test done at ___ Mycobacteriology
Laboratory
___ 9:52 am Rapid Respiratory Viral Screen & Culture
Source: Nasopharyngeal swab.
**FINAL REPORT ___
Respiratory Viral Culture (Final ___:
No respiratory viruses isolated.
Culture screened for Adenovirus, Influenza A & B,
Parainfluenza type
1,2 & 3, and Respiratory Syncytial Virus..
Detection of viruses other than those listed above will
only be
performed on specific request. Please call Virology at
___
within 1 week if additional testing is needed.
Respiratory Viral Antigen Screen (Final ___:
Negative for Respiratory Viral Antigen.
Specimen screened for: Adeno, Parainfluenza 1, 2, 3,
Influenza A, B,
and RSV by immunofluorescence.
Refer to respiratory viral culture and/or Influenza PCR
(results
listed under "OTHER" tab) for further information..
___ 3:05 pm SPUTUM Source: Induced.
GRAM STAIN (Final ___:
<10 PMNs and >10 epithelial cells/100X field.
Gram stain indicates extensive contamination with upper
respiratory
secretions. Bacterial culture results are invalid.
PLEASE SUBMIT ANOTHER SPECIMEN.
RESPIRATORY CULTURE (Final ___:
TEST CANCELLED, PATIENT CREDITED.
Immunoflourescent test for Pneumocystis jirovecii (carinii)
(Final
___: NEGATIVE for Pneumocystis jirovecii
(carinii).
FUNGAL CULTURE (Preliminary):
GRAM STAIN OF THIS SPECIMEN INDICATES CONTAMINATION WITH
OROPHARYNGEAL SECRETIONS AND INVALIDATES RESULTS.
Specimen is only screened for Cryptococcus species. New
specimen is
recommended.
ACID FAST CULTURE (Preliminary):
ACID FAST SMEAR (Final ___:
NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.
___ 10:29 pm SPUTUM Source: Induced.
ACID FAST SMEAR (Final ___:
NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.
ACID FAST CULTURE (Preliminary):
IMAGING
============================================
___ CHEST X-RAY: No acute intrathoracic process.
___ CT CHEST: Nonspecific inflammatory findings, mild
localized bronchiolitis, right lower lobe, and mild alveolitis
left upper lobe. Suggest concurrent chest radiograph in
follow-up if symptoms persist. Severe coronary atherosclerosis.
___ CT ABDOMEN/PELVIS:
1. No acute intra-abdominal findings.
2. Small nonobstructing stones in the left kidney, unchanged.
___ 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. Regional left ventricular wall motion is
normal. Overall left ventricular systolic function is mildly
depressed (LVEF= 45-50 %). The estimated cardiac index is normal
(>=2.5L/min/m2). Right ventricular chamber size and free wall
motion are normal. The aortic valve leaflets (?#) appear
structurally normal with good leaflet excursion. No masses or
vegetations are seen on the aortic valve. There is no aortic
valve stenosis. No aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. There is no mitral valve
prolapse. No mass or vegetation is seen on the mitral valve.
Trivial mitral regurgitation is seen. There is borderline
pulmonary artery systolic hypertension. There is a small
pericardial effusion. The effusion appears circumferential.
There are no echocardiographic signs of tamponade.
IMPRESSION: No echocardiographic evidence of endocarditis.
Mildly depressed left ventricular systolic function. Small
circumferential pericardial effusion.
Compared with the prior study (images reviewed) of ___,
pericardial effusion is present. Pulmonary artery pressures are
lower.
___ Stress
IMPRESSION: No anginal type symptoms or ischemic EKG changes.
Nuclear
report sent separately.
___ Cardiac Perfusion Study
IMPRESSION: Normal myocardial perfusion study.
Brief Hospital Course:
Ms. ___ is a ___ yo woman with HIV (CD4 676 in ___, DM c/b
gastroparesis, G6PD deficiency, CMV retinitis and possible CMV
colitis, presenting with two weeks of dyspnea, cough, fevers.
# viral infection
# asthma exacerbation
Patient presented with 2 weeks of fevers, cough, dyspnea. No
infiltrates on chest x-ray. During a recent admission, she was
treated with a 7 day course of vancomycin and ceftazidime for
presumed pneumonia but symptoms persisted. Per report, CD4 count
at OSH was in the 180s, but CD4 count was re-checked this
admission and was 558. There was thus a lower suspicion for
opportunistic infections. ID was consuled. She has a history of
untreated latent tuberculosis, but suspicion for TB was low
(endorsed hot flashes / night sweats related to menopause but no
weight loss, hemoptysis, or classic radiographic findings to
suggest active TB). Nonetheless, we obtained 3 induced sputum
samples which were negative for AFB and MTB NAAT was also
negative. Influenza negative at ___ on ___ and
respiratory viral panel during this hospitalization was
negative. Pertussis serology was pending at discharge. B-glucan
was elevated, and CT torso showed non-specific inflammatory
changes, so pulmonology was consulted. Repeat beta-glucan was
negative. PJP thought to be much less likely as CD4 count was in
the ~500 range. Pulmonary believed symptoms were most likely
viral in etiology with component of asthma exacerbation
contributing to dyspnea and cough. Patient refused steroids,
either systemic or inhaled. Symptoms gradually improved and she
was no longer hypoxic, either at rest or with ambulation, at
discharge.
# Pericardial effusion: Small pericardial effusion may be
related to viral infection. No evidence of tamponade. Vague
chest discomfort may be due to mild pericarditis. Case discussed
with cardiology and given dyspnea as well as vague epigastric
discomfort in this high risk patient, she had inpatient nuclear
stress test, which was negative. Patient started on aspirin 81mg
for primary prevention given her risk factors and severe CAD
seen on CT scan. She was encouraged to start a statin but
refused. She should have repeat TTE as outpatient to monitor
effusion and EF.
# Epigastric pain
# Abnormal liver function tests
Mild elevation in transaminases, alk phos, and lipase, may all
be due to viral syndrome. No biliary abnormalities found on CT
torso. Patient has seen GI both here and at ___, and has a
history of SIBO and gastroparesis. Given elevated beta-glucan,
esophageal candidiasis was also considered but repeat
beta-glucan was negative. Recommend outpatient GI referral and
EGD if persistent symptoms.
# HIV: Last CD4 in our system 676 in ___, per ED report was
180 at ___ (unavailable for my review), but is now ___ on
repeat here. HIV viral load was detectable at <1.3. Patient is
followed by Dr. ___ Dr. ___ and
Dolutegravir were continued. ID was consulted as above
# Tooth abscess: Continued doxycycline 100mg BID to complete 5
day course she was prescribed as an outpatient
# Acute on chronic anemia
# Iron deficiency:
# G6PD deficiency:
Elevated LDH but normal Tbili and haptoglobin makes hemolysis
unlikely. She received just one dose of bactrim prior to
transfer here and this medication is considered "probably safe"
in patients with G6PD deficiency. Medical illness, including
viral infection, may induce hemolysis in G6PD deficient
patients. Suspect a component of anemia of chronic inflammation.
Transfused 2 units PRBCs in the emergency department with
appropriate response. Reticulocyte production index is 1.3%,
which suggests a slightly suboptimal response for this degree of
anemia. She had pancytopenia in ___ when first diagnosed with
HIV and underwent bone marrow biopsy, which has since improved.
___ iron supplementation was continued. H/h remained stable
throughout hospitalization. Recommend outpatient hematology
evaluation given repeated episodes of anemia requiring
transfusion.
# History of CMV retinitis, iritis, possible CMV colitis, HSV:
___ acyclovir continued for chronic suppression.
# Diabetes mellitus: ___ Januvia held while inpatient and
maintained on sliding scale insulin; resumed on discharge.
> 30 minutes were spent on discharge care, planning, and
coordination.
TRANSITIONAL ISSUES:
- repeat TTE as outpatient
- refer to hematology as outpatient given anemia requiring
transfusions
- refer to gastroenterologist given epigastric pain and possible
need for EGD; recommend trending LFTs as outpatient to ensure
resolution of transaminitis
- consider starting statin as outpatient after discussion with
patient and normalization of LFTs
- consider starting inhaled steroid for asthma (patient declined
this admission)
- Pertussis serology is pending at discharge
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Montelukast 10 mg PO DAILY
2. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation
Q6H:PRN shortness of breath
3. Emtricitabine-Tenofovir (___) 1 TAB PO DAILY
4. Dolutegravir 50 mg PO DAILY
5. Vitamin D ___ UNIT PO DAILY
6. Calcium Carbonate 500 mg PO BID
7. Multivitamins W/minerals 1 TAB PO DAILY
8. Januvia (SITagliptin) 100 mg oral DAILY
9. Nasacort (triamcinolone acetonide) 55 mcg nasal DAILY
10. Loratadine 10 mg PO DAILY
11. Ferrous Sulfate 325 mg PO TID
12. Insulin SC
Sliding Scale
Insulin SC Sliding Scale using HUM Insulin
13. Pantoprazole 40 mg PO Q24H
14. Losartan Potassium 25 mg PO DAILY
15. Fyavolv (norethindrone ac-eth estradiol) 0.5-2.5 mg-mcg oral
DAILY
16. Vitamin B Complex 1 CAP PO DAILY
17. Acyclovir 400 mg PO Q12H
Discharge Medications:
1. Aspirin 81 mg PO DAILY
RX *aspirin 81 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
2. Zolpidem Tartrate 5 mg PO QHS:PRN insomnia
RX *zolpidem 5 mg 1 tablet(s) by mouth QHS:prn Disp #*10 Tablet
Refills:*0
3. Acyclovir 400 mg PO Q12H
4. Calcium Carbonate 500 mg PO BID
5. Dolutegravir 50 mg PO DAILY
6. Emtricitabine-Tenofovir (___) 1 TAB PO DAILY
7. Ferrous Sulfate 325 mg PO TID
8. Fyavolv (norethindrone ac-eth estradiol) 0.5-2.5 mg-mcg oral
DAILY
9. Insulin SC
Sliding Scale
Insulin SC Sliding Scale using HUM Insulin
10. Januvia (SITagliptin) 100 mg oral DAILY
11. Loratadine 10 mg PO DAILY
12. Losartan Potassium 25 mg PO DAILY
13. Montelukast 10 mg PO DAILY
14. Multivitamins W/minerals 1 TAB PO DAILY
15. Nasacort (triamcinolone acetonide) 55 mcg nasal DAILY
16. Pantoprazole 40 mg PO Q24H
17. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation
Q6H:PRN shortness of breath
18. Vitamin B Complex 1 CAP PO DAILY
19. Vitamin D ___ UNIT PO DAILY
Discharge Disposition:
___
Discharge Diagnosis:
acute viral infection
asthma exacerbation
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 your stay at ___
___. You were hospitalized for cough,
shortness of breath, fevers, and abdominal pain. You were
evaluated by infectious disease and pulmonary specialists. It
was thought that your symptoms were caused by a viral infection.
You were also seen by the cardiologist and gastroenterologists.
You had a stress test in the hospital and it was normal. The
gastroenterologists recommended that you follow-up with your
outpatient specialist for endoscopy, if it is still needed.
You should ask your PCP for ___ referral to a hematologist for
further work-up for your anemia (low RBC counts). You should
also see your cardiologist after discharge.
Please take care,
Your ___ Team
Followup Instructions:
___
|
19681434-DS-12
| 19,681,434 | 22,584,253 |
DS
| 12 |
2173-03-11 00:00:00
|
2173-03-16 08:36:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
___ Complaint:
Colorvesicular fistula
Major Surgical or Invasive Procedure:
___
Laparoscopic sigmoid resection with end colostomy
___ resection).
History of Present Illness:
Mr. ___ is a ___ y.o. man with a history of
metastatic colorectal cancer who was transferred to the ___ today from his scheduled chemotherapy appointment in
___ after presenting with a five-day history of dysuria,
brown urinary discharge with sediment, and left lower quadrant
abdominal pain. He started noticing dysuric symptoms and a
sensation of burning while peeing last ___.
He reports noticing brown penile discharge which normally occurs
immediately after voiding. He also reports noticing some solid
content in his urinary voids. He denies any pneumaturia or
offensive odor to his urine or discharge. He reports urinary
frequency but has had this for two decades due to BPH.
After reporting these symptoms to his providers in ___, he
underwent a CT scan (full results below) indicating likely
colovesical fistula and an abscess on the superior aspect of the
patient's bladder. He was given a dose of Zosyn at ___ prior
to transfer her to ___ ED.
Patient also reports that he was treated for suspected
diverticulitis in late ___ with a course of metronidazole
and
ciprofloxacin which he only recently discontinued.
Past Medical History:
1) DM type II
2) Lower extremity neuropathy ___ DM
3) Benign prostatic hyperplasia
PSH:
1) Pilonidal cyst removal at age ___
2) Left lower extremity laceration repair at age ___
3) Bilateral prophylactic tonsillectomy in early childhood
Social History:
___
Family History:
Mother with diverticulitis who died of (likely)
melanoma in ___, father died of CAD and CVA in his ___, brother
with ulcerative colitis
Physical Exam:
Discharge Physical Exam:
Gen: AAOx3, NAD
HEENT: MMM, no scleral icterus
Resp: nl effort, CTABL, no wheezes/rales/rhonchi
CV: RRR, nl S1/S2, no S3/S4, no murmurs/rubs/gallops
Abd: +BS, soft, NT/ND; incisions C/D/I, colostomy pink with
stool and flatus
Ext: WWP, no edema
Pertinent Results:
___ 01:41PM URINE TYPE-RANDOM COLOR-Yellow APPEAR-Cloudy
SP ___
___ 01:41PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-100
GLUCOSE-NEG KETONE-15 BILIRUBIN-NEG UROBILNGN-0.2 PH-7.0 LEUK-LG
___ 01:41PM URINE ___ WBC->50 BACTERIA-MOD
YEAST-NONE EPI-<1
___ 10:52AM UREA N-13 CREAT-0.8 SODIUM-138 POTASSIUM-3.4
CHLORIDE-100 TOTAL CO2-23 ANION GAP-18
___ 10:52AM estGFR-Using this
___ 10:52AM ALT(SGPT)-11 AST(SGOT)-25 ALK PHOS-114 TOT
BILI-0.4
___ 10:52AM CALCIUM-8.8 PHOSPHATE-3.6 MAGNESIUM-1.1*
___ 10:52AM CEA-8.7*
___ 10:52AM WBC-6.4 RBC-3.83* HGB-11.3* HCT-33.8* MCV-88
MCH-29.5 MCHC-33.4 RDW-16.1* RDWSD-52.2*
___ 10:52AM AbsNeut-3.83
___ 10:52AM PLT COUNT-308
___ 02:35PM BLOOD WBC-10.6* RBC-3.18* Hgb-9.4* Hct-28.9*
MCV-91 MCH-29.6 MCHC-32.5 RDW-16.4* RDWSD-54.2* Plt ___
___ 11:33AM BLOOD WBC-9.4 RBC-3.14* Hgb-9.1* Hct-28.0*
MCV-89 MCH-29.0 MCHC-32.5 RDW-16.0* RDWSD-51.5* Plt ___
___ 06:40AM BLOOD WBC-10.2* RBC-3.23* Hgb-9.4* Hct-28.7*
MCV-89 MCH-29.1 MCHC-32.8 RDW-15.9* RDWSD-50.9* Plt ___
___ 05:03AM BLOOD WBC-11.5* RBC-3.30* Hgb-9.6* Hct-29.6*
MCV-90 MCH-29.1 MCHC-32.4 RDW-15.6* RDWSD-51.2* Plt ___
___ 06:17AM BLOOD WBC-9.8 RBC-3.35* Hgb-9.8* Hct-29.9*
MCV-89 MCH-29.3 MCHC-32.8 RDW-15.4 RDWSD-49.8* Plt ___
___ 04:53AM BLOOD WBC-10.5* RBC-3.18* Hgb-9.3* Hct-28.7*
MCV-90 MCH-29.2 MCHC-32.4 RDW-15.4 RDWSD-50.5* Plt ___
___ 05:50AM BLOOD WBC-10.8* RBC-3.25* Hgb-9.2* Hct-29.2*
MCV-90 MCH-28.3 MCHC-31.5* RDW-15.6* RDWSD-50.9* Plt ___
___ 05:41AM BLOOD WBC-16.7* RBC-3.57* Hgb-10.3* Hct-32.0*
MCV-90 MCH-28.9 MCHC-32.2 RDW-15.5 RDWSD-50.5* Plt ___
___ 11:11AM BLOOD WBC-12.1*# RBC-3.44* Hgb-10.0* Hct-31.0*
MCV-90 MCH-29.1 MCHC-32.3 RDW-15.5 RDWSD-51.4* Plt ___
___ 05:15AM BLOOD WBC-8.0 RBC-3.04* Hgb-8.7* Hct-27.4*
MCV-90 MCH-28.6 MCHC-31.8* RDW-15.5 RDWSD-51.6* Plt ___
___ 05:50AM BLOOD WBC-10.8* RBC-3.25* Hgb-9.2* Hct-29.2*
MCV-90 MCH-28.3 MCHC-31.5* RDW-15.6* RDWSD-50.9* Plt ___
___ 05:41AM BLOOD WBC-16.7* RBC-3.57* Hgb-10.3* Hct-32.0*
MCV-90 MCH-28.9 MCHC-32.2 RDW-15.5 RDWSD-50.5* Plt ___
___ 04:58AM BLOOD Glucose-140* UreaN-14 Creat-0.8 Na-135
K-3.6 Cl-105 HCO3-21* AnGap-13
___ 05:24AM BLOOD Glucose-135* UreaN-22* Creat-0.8 Na-134
K-4.3 Cl-104 HCO3-21* AnGap-13
___ 05:11PM BLOOD Glucose-149* UreaN-27* Creat-0.8 Na-135
K-4.6 Cl-103 HCO3-21* AnGap-16
___ 05:28AM BLOOD Glucose-137* UreaN-22* Creat-0.7 Na-130*
K-4.4 Cl-98 HCO3-24 AnGap-12
___ 05:00AM BLOOD Glucose-105* UreaN-20 Creat-0.7 Na-136
K-4.1 Cl-103 HCO3-24 AnGap-13
___ 06:40AM BLOOD Glucose-140* UreaN-19 Creat-0.7 Na-136
K-4.0 Cl-104 HCO3-22 AnGap-14
___ 05:03AM BLOOD Glucose-196* UreaN-18 Creat-0.7 Na-139
K-4.1 Cl-107 HCO3-22 AnGap-14
___ 05:20AM BLOOD Glucose-199* UreaN-17 Creat-0.7 Na-138
K-3.5 Cl-105 HCO3-24 AnGap-13
___ 04:53AM BLOOD Glucose-199* UreaN-15 Creat-0.8 Na-138
K-3.7 Cl-104 HCO3-24 AnGap-14
___ 05:41AM BLOOD Glucose-178* UreaN-20 Creat-1.5* Na-137
K-4.2 Cl-101 HCO3-20* AnGap-20
___ 11:11AM BLOOD Glucose-128* UreaN-12 Creat-1.0 Na-138
K-4.1 Cl-101 HCO3-21* AnGap-20
___ 04:58AM BLOOD Calcium-8.2* Phos-3.4 Mg-1.2*
___ 05:24AM BLOOD Calcium-8.2* Phos-3.5 Mg-1.3*
___ 05:11PM BLOOD Calcium-8.1* Phos-3.8 Mg-1.7
___ 05:28AM BLOOD Calcium-8.0* Phos-3.8 Mg-1.9
___ 05:00AM BLOOD Calcium-8.2* Phos-3.6 Mg-2.2
___ 06:40AM BLOOD Calcium-8.2* Phos-3.6 Mg-1.9
CT ABD & PELVIS WITH CONTRAST Study Date of ___ 3:54 ___
IMPRESSION:
1. Post sigmoidectomy and end colostomy changes as described
above. A 3.8 cm focus of probable extraluminal gas superior to
the rectal stump is concerning for contained leak or less likely
residual postoperative gas.
2. Mildly dilated loops of small bowel in the left hemi abdomen
which may be secondary to an ileus. Continued attention on
follow-up is however
recommended to exclude a small bowel obstruction secondary to
adhesions within the pelvis.
3. New trace left pleural effusion.
Brief Hospital Course:
Mr. ___ presented to the ___ ED on ___ for a
dysuria and brown penile discharge wtih sediment and CT findings
suggestive of erosion of his known metastatic colon cancer into
the adjuacent bladder wall, with air and colonic contents in
communication with the bladder. He was initially admitted to the
hematology/oncology service, with conservative management with
IV fluids and IV antibiotics. We evaluated him for surgery and
he eventually had a laparoscopic sigmoid colectomy with end
colostomy on ___. He tolerated the procedure well without
complications (Please see operative note for further details).
After a brief and uneventful stay in the PACU, the patient was
transferred to the floor for further post-operative management.
Neuro: Pain was well controlled on oral medications by the time
of discharge. He did have some delirium post-operatively, for
which we consulted gerontology. Among other suggestions, they
helped to improve his pain control, and discontinue his home
gabapentin in the setting of acute delirium. He should resume
this medication at discharge when he sees his PCP.
CV: Vital signs were routinely monitored during the patient's
length of stay. He remained hemodynamically stable. The patient
did have one episode of hypotension after vasovagal response in
the chair. This was in the setting of restarting oxybutynin for
bladder spasm. This medicine was discontinued. He was otherwise
hemodynamically stable.
Pulm: The patient was encouraged to ambulate, sit and get out
of bed, use the incentive spirometer, and had oxygen saturation
levels monitored as indicated. He did had plueral effusions seen
on CT scan. These will continue to improve without intervention
and are likely reactive to surgery. He continued to use his
incentive spirometer and was not requiring nasal canula oxygen.
GI: The patient was initially kept NPO after the procedure. He
was then advanced to sips and clears, but reported continued
nausea and distention on POD#1. On POD#2, he did have large
volume bilious emesis and an NGT was placed. This had high
initial output. He eventually did have return of bowel function
with gas in the ostomy on ___, so the NGT was discontinued
that day. He again had an ileus requiring NGT decompression. He
was given TPN during this time related to severe malnutrition.
CT scan on ___ showed likely contained leak from the rectal
stump and he was started on antibiotics. His white blood cell
count at this time was ___. As he was treated for this the
ileus resolved and he again passed stool from the colostomy. The
NGT was removed and his diet was advanced to regular. As he
tolerated food, the TPN was discontinued. The JP drain from his
initial surgery was removed in the days prior to discharge.
GU: Patient had a Foley catheter in place post-operative for
continued decompression given the surgery in close proximity to
the bladder and the question of colovesicular fistula
pre-operatively. He also experienced fairly severe bladder
discomfort with the feeling of urgency while the foley was in
place. on ___, we added oxybutynin to help relieve possible
bladder spasm. This helped improve his symptoms drastically. On
___, a CT cystogram was obtained to check for leak,
especially around the bladder/rectal stump, of which there were
none. At this point, the foley catheter, as well as ___
drain in the rectum, were removed. mR. ___ again had
difficulty emptying his bladder and when the folwy was in place
had, significant bladder spasm. This foley catheter was removed
in the days prior to discharge and he emptied his bladder
without difficulty.
On ___ the patient was discharged to home with services.
The picc line that was in place for TPN during his admission was
removed at the time of discharge.
Post-Surgical Complications During Inpatient Admission:
[ ] Post-Operative Ileus resolving w/o NGT
[x] Post-Operative Ileus requiring management with NGT
[ ] UTI
[ ] Wound Infection
[ ] Anastomotic Leak
[ ] Staple Line Bleed
[ ] Congestive Heart failure
[ ] ARF
[x] Acute Urinary retention, failure to void after Foley D/C'd
[ ] Acute Urinary Retention requiring discharge with Foley
Catheter
[ ] DVT
[ ] Pneumonia
[ ] Abscess
[ ] None
Social Issues Causing a Delay in Discharge:
[ ] Delay in organization of ___ services
[ ] Difficulty finding appropriate rehab hospital disposition.
[ ] Lack of insurance coverage for ___ services
[ ] Lack of insurance coverage for prescribed medications.
[ ] Family not agreeable to discharge plan.
[ ] Patient knowledge deficit related to ileostomy delaying
dispo
[x] No social factors contributing in delay of discharge.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 20 mg PO QPM
2. Ciprofloxacin HCl 500 mg PO Q12H
3. Clindamycin 1% Solution 1 Appl TP BID
4. Diphenoxylate-Atropine 1 TAB PO Q6H:PRN diarrhea
5. Doxycycline Hyclate 100 mg PO Q24H
6. Gabapentin 300 mg PO TID
7. GlipiZIDE 5 mg PO BID
8. Hydrocortisone Cream 2.5% 1 Appl TP BID
9. MetroNIDAZOLE 500 mg PO TID
10. Ondansetron 8 mg PO Q8H:PRN nausea
11. OxyCODONE (Immediate Release) ___ mg PO Q6H:PRN Pain -
Moderate
12. Potassium Chloride 20 mEq PO DAILY
13. Prazosin 5 mg PO TID
14. Prochlorperazine 10 mg PO Q6H:PRN nausea
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild
2. Heparin Flush (10 units/ml) 5 mL IV DAILY and PRN, line
flush
3. Heparin Flush (100 units/ml) 5 mL IV PRN DE-ACCESSING port
4. Magnesium Oxide 400 mg PO BID
RX *magnesium oxide 400 mg 1 capsule(s) by mouth twice daily
Disp #*60 Capsule Refills:*0
5. Pantoprazole 40 mg PO Q24H
RX *pantoprazole 40 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
6. Tamsulosin 0.4 mg PO QHS
RX *tamsulosin 0.4 mg 1 capsule(s) by mouth daily Disp #*14
Capsule Refills:*0
7. OxyCODONE (Immediate Release) 5 mg PO Q3H:PRN Pain - Severe
8. Atorvastatin 20 mg PO QPM
9. Clindamycin 1% Solution 1 Appl TP BID
10. Gabapentin 300 mg PO TID
RX *gabapentin 300 mg 1 capsule(s) by mouth three times a day
Disp #*60 Capsule Refills:*0
11. GlipiZIDE 5 mg PO BID
12. Hydrocortisone Cream 2.5% 1 Appl TP BID
13. Potassium Chloride 20 mEq PO DAILY
14. Prazosin 5 mg PO TID
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Colovesicular fistula either due to perforated cancer or
diverticulitis.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
___ were admitted to the hospital after a laparoscopic sigmoid
colectomy and end colostomy for surgical management of your
colovesicular fistula. ___ have recovered from this procedure
well and ___ are now ready to return home. Samples from your
colon were taken and this tissue has been sent to the pathology
department for analysis. ___ will receive these pathology
results at your follow-up appointment. If there is an urgent
need for the surgeon to contact ___ regarding these results they
will contact ___ before this time. ___ have tolerated a regular
diet, are passing gas and your pain is controlled with pain
medications by mouth. ___ may return home to finish your
recovery.
Please monitor your bowel function closely. ___ have a new
colostomy. It is important to monitor the output from this
stoma. It is expected that the stool from this ostomy will be
solid and formed like regular stool. ___ should have ___ bowel
movements daily. If ___ notice that ___ have not had any stool
from your stoma in ___ days, please call the office. ___ may
take an over the counter stool softener such as Colace if ___
find that ___ are becoming constipated from narcotic pain
medications. Please watch the appearance of the stoma, it should
be beefy red/pink, if ___ notice that the stoma is turning
darker blue or purple, or dark red please call the office for
advice. The stoma (intestine that protrudes outside of your
abdomen) should be beefy red or pink, it may ooze small amounts
of blood at times when touched and this should subside with
time. The skin around the ostomy site should be kept clean and
intact. Monitor the skin around the stoma for bulging or signs
of infection listed above. Please care for the ostomy as ___
have been instructed by the wound/ostomy nurses. ___ will be
able to make an appointment with the ostomy nurse in the clinic
7 days after surgery. ___ will have a visiting nurse at home for
the next few weeks helping to monitor your ostomy until ___ are
comfortable caring for it on your own.
___ have ___ laparoscopic surgical incisions on your abdomen
which are closed with internal sutures and a skin glue called
Dermabond. These are healing well however it is important that
___ monitor these areas for signs and symptoms of infection
including: increasing redness of the incision lines,
white/green/yellow/malodorous drainage, increased pain at the
incision, increased warmth of the skin at the incision, or
swelling of the area. Please call the office if ___ develop any
of these symptoms or a fever. ___ may go to the emergency room
if your symptoms are severe.
___ may shower; pat the incisions dry with a towel, do not rub.
The small incisions may be left open to the air. If closed with
steri-strips (little white adhesive strips) instead of
Dermabond, these will fall off over time, please do not remove
them. Please no baths or swimming for 6 weeks after surgery
unless told otherwise by Dr. ___ Dr. ___ will be prescribed a small amount of the pain medication
oxycodone. Please take this medication exactly as prescribed.
___ may take Tylenol as recommended for pain. Please do not take
more than 4000mg of Tylenol daily. Do not drink alcohol while
taking narcotic pain medication or Tylenol. Please do not drive
a car while taking narcotic pain medication.
No heavy lifting greater than 6 lbs for until your first
post-operative visit after surgery. Please no strenuous activity
until this time unless instructed otherwise by Dr. ___ Dr.
___.
Thank ___ for allowing us to participate in your care! Our hope
is that ___ will have a quick return to your life and usual
activities. Good luck!
Followup Instructions:
___
|
19681495-DS-9
| 19,681,495 | 22,010,033 |
DS
| 9 |
2122-09-10 00:00:00
|
2122-09-10 19:44:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
blood in urine
Major Surgical or Invasive Procedure:
___ Videoswallow evaluation
History of Present Illness:
___ male with h/o a fib (on Warfrain and aspirin),
prostatectomy( ___ transferred to ___ d/t frank
hematuria. Attempted insertion of 3 way catheter but unable to
place so was transferred for urology placement of catheter.
Per ___ note patient had a similar presentation in
___ and currently sees Dr. ___ in Urology. Cystoscopy
showed "mild prostatic regrowth, friable prostate mucosa, mild
bladder neck contracture, moderate trabeculation of bladder and
significant sediment/mucous in floor of bladder. In ___
he had TURP and pathology from prostate showed BPD and chronic
inflammation.
In ___ he had a Renal CT that showed nodular and linear
foci of hyperdensity within the bladder suggesting blood and
possible tumor. There also was no definite renal or ureteral
calculus on either side and hypodense bilateral renal lesions
are
probably cysts Also found possible small pseudoaneurysm in the
right groin. This looks similar to the previous pelvic CT
___.
In the ED, initial vital signs were: 98.1, 81, 151/83, 16, 99%
RA
- Exam notable for:1+ radial pulses Frank hematuria (bw tomato
juice and merlot, no visible clots in sample) 421cc in bladder,
2+ pitting edema bilaterally
- Labs were notable for: Hbg 10.2, MCV 78, WBC 10.7
(neutrophilic predominance), INR 2.0, lactate 1.6
Na 129
UA: mod leuks, lg blood, neg nitr, 300 protein, neg gluc, 10
ketones, >182 RBCs, 124 WBC, many bacteria
- Studies performed include no imaging
- Patient was given:
___ 04:29 IV Morphine Sulfate 4 mg
___ 08:29 IV CefTRIAXone1gm
___ 11:14 IV Morphine Sulfate 4 mg
___ 12:00 IV Fentanyl Citrate 50 mcg
___ 12:00 PO Phenazopyridine 200 mg
___ 12:32 IV HYDROmorphone (Dilaudid) 1 mg
- Patient was seen by urology in the ED, who performed urethral
dilation and placement of ___ council tip 2-way catheter over
wire at bedside. 100cc of old clots was irrigated from the
bladder.
- Vitals prior to transfer: 98.6, 80, 142/76, 18, 99% RA
Upon arrival to the floor, the patient was quite somnolent. He
would open eyes to voice and touch but would fall back asleep
within a few words. He responded with ___ words. He
hemodynamically stable, saturating well on room air and able to
protect airway. Per family he has not slept well in 2 days d/t
being in ED and pain in legs. In addition he received a fair
amount of pain medication in the ED prior to coming to the
floor.
When family was in the room he was more interactive but still
sleepy.
Per family, yesterday he started having pain in lower abdomen
and
noticed increased blood in his urine. He immediately went to ED.
His abdominal pain was described as severe but he denied any
back
or side pain. He was unable to describe pain further d/t
somnolence. He had noticed blood in urine 3 weeks ago associated
with dysuria. Per family he was having no fevers, chills, night
sweats, SOB, or increased cough.
Patient has a prior history of gross hematuria last year that
was
worked up by out patient urologist. He thought it was due to
enlarged prostate and he underwent TURP in ___. After the
surgery he was doing well with some mild discomfort that went
away. He also has been improving in his ability to control
urine.
In addition, he has a history of heavy smoking and no formal
diagnosis of COPD but family describes frequent coughing with
large amounts of sputum production for years. He also was
recently started on Lasix for new lower extremity swelling but
don't remember dose or if any other work up was done.
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:
- hypercholesterolemia
- Stroke- residual right sided weakness
- DM type 2
- atrial fibrillation
- CKD
- Prior severe C diff infections requiring 2 stool transplants
___
years ago)
- Neuropathy
- COPD?
- PVD s/p bilateral stents ___ years ago)
- s/p prostatectomy (TURP ___
- s/p CCY
Social History:
___
Family History:
Diabetes on his father's side
Mother: died of ovarian cancer
Father: committed suicide
Brother: ___ disease
Physical Exam:
ADMISSION PHYSICAL EXAM:
VITALS:97.3, 130/73, 85, 18, 97%RA
General: Somnolent but arousable with voice and touch, alert to
place and self but not date
HEENT: Sclerae anicteric, MMM, oropharynx clear, EOMI, PERRL,
neck supple, JVP not elevated
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Breathing comfortably on room air, some course upper
airway sounds, no wheezes or crackles
Abdomen: Soft, mildly distended, no tenderness to palpation, no
guarding or rebound
GU: Foley in place draining "fruit punch" colored urine
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis, 1+
pitting edema in bilateral legs (L>R), no lesions on feet
Skin: Warm, dry, no rashes or notable lesions.
Neuro: CNII-XII intact, EOMI, pupils are small but equal and
mildly reactive, moves all extremities equally, patient too
sedated to participate in exam.
DISCHARGE PHYSICAL EXAM:
VITALS:98.2 PO 122 / 59 70 18 95 ra
General: NAD, conversational, happy laying in bed
HEENT: Sclerae anicteric, MMM, oropharynx clear, EOMI, PERRL,
neck supple, JVP not elevated
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Breathing comfortably on room air, crackles in right
base.
Abdomen: Soft, mildly distended, no tenderness to palpation, no
guarding or rebound
GU: Foley in place draining dark urine
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis, 1+
pitting edema in bilateral legs (L>R), no lesions on feet
Skin: Warm, dry, no rashes or notable lesions.
Neuro: CNII-XII intact, EOMI, pupils are small but equal and
mildly reactive, moves all extremities equally.
Pertinent Results:
ADMISSION LABS:
==============
___ 04:48AM BLOOD WBC-10.7* RBC-4.03* Hgb-10.2* Hct-31.4*
MCV-78* MCH-25.3* MCHC-32.5 RDW-17.3* RDWSD-48.9* Plt ___
___ 04:48AM BLOOD Neuts-76.0* Lymphs-11.3* Monos-11.4
Eos-0.6* Baso-0.3 Im ___ AbsNeut-8.14* AbsLymp-1.21
AbsMono-1.22* AbsEos-0.06 AbsBaso-0.03
___ 04:48AM BLOOD ___ PTT-39.5* ___
___ 04:48AM BLOOD Glucose-101* UreaN-9 Creat-0.9 Na-129*
K-4.8 Cl-93* HCO3-20* AnGap-16
___ 07:50AM BLOOD Calcium-8.2* Phos-3.6 Mg-1.6
DISCHARGE LABS:
===============
___ 07:10AM BLOOD WBC-10.4* RBC-3.39* Hgb-8.6* Hct-27.9*
MCV-82 MCH-25.4* MCHC-30.8* RDW-18.4* RDWSD-55.3* Plt ___
___ 07:40AM BLOOD ___ PTT-28.5 ___
___ 07:10AM BLOOD Glucose-251* UreaN-13 Creat-0.9 Na-139
K-4.8 Cl-99 HCO3-20* AnGap-20*
___ 07:10AM BLOOD Calcium-8.6 Phos-2.9 Mg-1.6
MICROBIOLOGY:
=============
___ urine culture negative
___ blood cultures pending
___ urine culture
**FINAL REPORT ___
URINE CULTURE (Final ___:
GRAM POSITIVE COCCUS(COCCI). ~1000 CFU/mL.
SUGGESTING STAPHYLOCOCCI.
RELEVANT IMAGING:
=================
CXR ___
Final Report
EXAMINATION: Portable chest x-ray
INDICATION: ___ year old man with cough// eval for edema or pNA
TECHNIQUE: Portable chest x-ray
COMPARISON: None
FINDINGS:
The lungs are hyperaerated. There are minimally increased
interstitial
markings at the lung bases. This likely represents atelectasis
however
developing pneumonia cannot be excluded. The trachea is
midline. There are
no large pleural effusions. The aorta is atherosclerotic and
tortuous.
IMPRESSION:
Hyperaeration. Minimally increased interstitial markings at the
lung bases,
possibly atelectasis. Evolving pneumonia cannot be excluded.
___ ECHO
Conclusions
The left atrial volume index is normal. 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 %) secondary to extensive, concentric apical
hypokinesis with focal apical akinesis. 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. There are focal
calcifications in the aortic arch. 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. Trivial mitral regurgitation is seen. There is
moderate pulmonary artery systolic hypertension. There is no
pericardial effusion.
___ Video Swallow Evaluation
*** UNAPPROVED (PRELIMINARY) REPORT ***
EXAMINATION: Video oropharyngeal swallow
INDICATION: ___ year old man with cough when eating. Concern for
aspiration//
? aspiration
TECHNIQUE: Oropharyngeal swallowing videofluoroscopy was
performed in
conjunction with the speech and swallow division. Multiple
consistencies of
barium were administered.
DOSE: Fluoro time: 4 minutes 18 seconds.
COMPARISON: None.
FINDINGS:
Nectar thick liquids: Silent aspiration with head in neutral
position. There
is silent aspiration before swallow with chin tuck method
secondary to swallow
delay. Laryngeal penetration during first breath hold and silent
aspiration
before the swallow during the second attempted breath hold.
Honey thick liquids: Silent penetration without evidence of
aspiration during
the first swallow.
Pudding thick liquids: One episode of silent aspiration after
swallow from
oral residue pooled in the piriform sinuses.
No evidence of aspiration or penetration with ground solids.
Mild oral residue with all consistencies.
IMPRESSION:
Silent penetration and aspiration with nectar thick liquids and
honey thick
liquids. No evidence of aspiration or penetration with ground
solids. Mild
or residue with all consistencies.
Please refer to the speech and swallow division note in OMR for
full details,
assessment, and recommendations.
Brief Hospital Course:
___ male with h/o a fib (on Warfrain and asa), h/o stroke with
residual right sided weakness, PVD s/p bilateral stent (___),
and prior hematuria thought to be due to prostate enlargement
s/p ___ transferred to ___ d/t frank hematuria
found to have stress cardiomyopathy and aspiration during the
admission.
The patient was admitted from an OSH with hematuria and a
difficulty foley to place. Urology was consulted and a 3 way
foley was placed in the ED. He had CBI and his urine cleared.
Due to a drop in his hemoglobin, the patient had an NSTEMI with
Takotsubo cardiomyopathy. He was started on metoprolol and a
high dose statin. He initially had heparin anticoagulation, but
that was discontinued after stress cardiomyopathy was diagnosed.
The patient had coughing and difficulty eating according to his
family and nurses so ___ speech and swallow evaluation was
completed. He required a video swallow evaluation in which he
did poorly. Due to the chronic nature of his cough and
difficulties eating, we do not think this was an acute change.
Goals of care were discussed with the patient and the family and
the patient decided he was happy to eat a modified diet and
under go aspiration precautions to minimize risk of aspiration.
The patient understood that he could still develop a pneumonia
which may or may not be treatable. He was discharged to rehab
with stable urinary and cardiac function, with a 2 way foley.
#Hematuria
DDX includes bladder mass vs irritation from UTI vs prostate
obstruction and irritation vs kidney stone or kidney pathology.
Patient endorsed pain in lower abdomen but no pain to palpation
on exam, he denied any flank pain. Mass in bladder on CT could
he thrombus from bleeding or a mass. Unlikely to be mass that
developed in 7 months after nothing seen on cystoscopy. Prior
presentation in ___ was similar and thought to be due to
enlarged prostate. He had a TURP done in ___ of this year
with no recurrence of hematuria. There was no evidence of stone
or obstruction on CT. While inpatient, urology was consulted and
placed 3 way catheter with CBI that was maintained until clot
decreased. The patient was discharged with a 3 way catheter with
one of the ends capped. He will require outpatient follow up for
ongoing foley need and hematuria work up. He will see his
outpatient urologist.
#Aspiration Risk
Patient had speech and swallow eval on ___ coughing with
eating noticed by nurses and family. Family noted that this was
an on going problem for many months. He did poorly at bedside so
was sent to video speech and swallow where he did poorly. Speech
and swallow with concern for acute event as they believe patient
would have had multiple aspiration pneumonias previously if this
was more chronic, but family and patient state his problems have
been happening for months thus it is likely as a result of an
older, not acute event. The patient and family was presented
with the various options for on going feeding. They were
informed the patient could be continued on a regular diet. If he
does that then he would be very likely to have an aspiration
event. He could follow a modified diet that is often not
satisfying for patients, but would reduce, not eliminate
aspiration risk. Finally, he could continue to be NPO and get a
feeding tube for on going nutrition. The family and patient
elected to continue feedings with modified diet. The patient and
family voiced understanding that he very well could aspirate
again and get a pneumonia that cannot be treated resulted in
death. The patient is willing to accept that risk.
#NSTEMI Type 1, Takotsubo cardiomyopathy: The patient had
epigastric pain and had EKG changes. He had a resulting
troponemia from the event. Cardiolgy was consulted, heparin was
initiated, metoprolol was initiated as was high dose statin
therapy. ASA was continued. Cardiology thought the event was
likely stress cardiomyopathy in setting of ongoing
hematuria/anemia. He was found to have characteristics of
Takotsubo cardiomyopathy on ECHO. He will require a repeat ECHO
in 8 weeks to ensure resolution. Additionally, he could possibly
have a stress test or catherization when stabilized.
#Diabetes Mellitus: Patient has type II DM. He is on both basal
and bolus dosing at home. He was started on his basal dose while
in the hospital, but became hypoglycemic likely in the setting
of being NPO during his NSTEMI. Lantus was discontinued. Now
that the patient is eating again, he will require redosing of
his insulin regimen.
#Positive Urine Analysis: His urine analysis appeared grossly
infected with +leuk, protein, WBC, and bacteria. The patient was
afebrile with no CVA tenderness but he did initially have
dysuria and hematuria. Repeat urine analysis also was positive..
Both cultures were negative (the second culture grew staph, but
had <1000 colonies). He received one dose ceftriaxone in the ED,
but it was not continued on the floor.
#Hyponatremia: Likely hypovolemic hyponatremia even though it
was thought to be chronic. Improved during hospitalization with
1.5 L combined NS and consistent PO intake.
#Leg swelling: Patient on lasix at home for leg swelling. Unsure
about heart failure history. Lasix was not restarted and edema
did not develop during admission.
# HLD - transitioned to high intensity statin in setting of
NSTEMI.
# A fib: Patient is on warfarin and ASA. CHADSVASC score of 6.
He was hemodynamically stable, but had large volume hematuria
and was supratheraputic. He was started on heparin during his
NSTEMI, this was discontinued with dropping blood counts and no
need to continue with stress carrdiomyopathy. He was restarted
on 2 mg warfarin prior to discharge and will require outpatient
titration to goal of ___.
#Neuropathy, #PVD: Stents placed about ___ years ago in b/l
lower extremity. Patient remained vasculary intact. He is on
gabapentin at home but had been having increased pain in
bilateral legs because of his neuropathy. Gabapentin was
increased to 300 TID.
TRANSITIONAL ISSUES:
- will need repeat TTE in ~8 weeks to ensure resolution of
takotsubo cardiomyopathy
- patient has decreased appetite could consider appetite
stimulating medication in outpatient setting
- follow up with your urologist Dr. ___ to monitor bladder
mass (thought to be secondary to thrombus)
- For a second opinion from a different urologist, they can call
___ to set up an appointment at ___ if desired
- Consider outpatient stress test if indicated
- On going discussion regarding aspiration risks, patient
accepts the risks and wishes to continue eating
- Subtheraputic INR at discharge, please dose warfarin daily
- If decreased urine output, please do a bladder scan, if
retaining/ obstructing, irrigate foley with flush
- If patient has bladder spasms, consider irrigating foley
- Follow up CBC, WBC 10.4, Hgb 8.6 on discharge
- Starting insulin 10U lantus at bed time, and sliding scale,
please uptitrate as needed
- Furosemide 20mg PO held during this admission and on
discharge. Consider restarting if needed.
-ECHO
The left ventricular cavity size is normal. Overall left
ventricular systolic function is moderately depressed (LVEF= 35
%) secondary to extensive, concentric apical hypokinesis with
focal apical akinesis.
-Aspiration information:
1. Pureed solids with honey thick liquids
2. Medications crushed in pureed solids
3. Oral care before and after meals
4. Aspiration Precautions:
- 1:1 assistance with all PO
- Sit upright for all PO
- Small bites/Single sips
- Swallow 3x per bolus
5. Follow-up in rehab with SLP to train in breath-hold maneuver.
This technique should not be used until he is consistently able
to demonstrate this strategy. When successfully demonstrated
during yesterday's videoswallow, it reduced aspiration risk.
When unsuccessfully used, it resulted in aspiration.
Code status: Full (presumed)
HCP Wife ___ ___, ___ ___
Blood cultures pending on discharge returned as negative
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Furosemide 20 mg PO DAILY
2. Gabapentin 200 mg PO BID
3. Warfarin ___ mg PO DAILY
4. Pravastatin 20 mg PO QPM
5. HumaLOG (insulin lispro) 1 unit subcutaneous Daily
6. Lantus (insulin glargine) 20 Units subcutaneous Daily
7. Aspirin 81 mg PO DAILY
8. Multivitamins 1 TAB PO DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO TID
2. Atorvastatin 80 mg PO QPM
3. Bisacodyl 10 mg PO DAILY:PRN constipation
4. Glargine 10 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
5. Metoprolol Tartrate 12.5 mg PO Q6H
6. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
7. Senna 17.2 mg PO BID constipation
8. Gabapentin 300 mg PO TID
9. Aspirin 81 mg PO DAILY
10. Multivitamins 1 TAB PO DAILY
11. Warfarin ___ mg PO DAILY
12. HELD- Furosemide 20 mg PO DAILY This medication was held.
Do not restart Furosemide until you see your PCP, you had no leg
swelling during this admission
Discharge Disposition:
Extended Care
Facility:
___
___ Diagnosis:
PRIMARY DIAGNOSIS:
Hematuria
NSTEMI secondary to Takotsubo cardiomyopathy
Aspiration
SECONDARY DIAGNOSIS:
Anemia
Type II diabetes
Atrial Fibrillation
Neuropathy
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you at ___!
Why were you admitted?
- You had blood in your urine
What did we do while you were here?
- We treated your bloody urine by washing the clot out of your
bladder
- We found that your heart was stressed likely because you had
blood loss in your urine.
- We took pictures of your heart that were consistent with it
being stressed
- We also found that you were swallowing some of your food into
your lungs.
- You said that the coughing and difficulty eating has been
happening for a long time thus we do not think that he had an
acute stroke
- We did change your diet to a modified diet to minimize how
much you will swallow into your lungs.
- You may swallow food into your lungs in the future and get an
infection that is hard to treat, but in the setting of many
medical problems it was decided that eating was important to
your quality of life.
What will happen when you leave the hospital?
- You will go to a rehab facility to get stronger
- You will have follow up with your urologist Dr. ___ in
___ days for the blood in your urine
- Your family mentioned they may want a second opinion from a
different urologist, they can call ___ to set up an
appointment if desired
- You will have follow up with a cardiologist because of your
stressed heart
- You should continue to eat pureed solids and honey thick
liquids on discharge. You should also use the recommendations
the speech specialists gave you (below).
* Patient to have modified diet of pureed solids with HONEY
thick liquid using breath hold maneuver. Give medications
crushed in pureed solids. Swallow ___ per bolus. Repeat video
swallowing study as warranted.
We wish you the best!
Your ___ team!
Followup Instructions:
___
|
19681724-DS-10
| 19,681,724 | 21,541,632 |
DS
| 10 |
2180-11-09 00:00:00
|
2180-11-14 08:43:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Ativan / Zofran (as hydrochloride)
Attending: ___
Chief Complaint:
Nausea/vomiting
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with hx of EtOH abuse, ID Type 1 DM with prior presentation
for DKA, PVD s/p toe amp who presented to ED with N/V for
48hours. Patient reports that he feels these symptoms feel like
a previous episode of DKA. Patient states he has been poorly
complaint with insulin and has not used regularly when drinking.
Stopped drinking on ___ as was feeling ill and thought that
he was "going into DKA." Also states that he has withdrawn from
EtOH before and had shakes but deneis any prior episodes of
seizures. He does report one episode where he was in the ICU at
___ for over 10 days for withdrawel but he cannot
recall any of this course as states that he was confused and not
himself. Patient denies any recent fevers, chills or bloody
emesis. He has been unable to tolerate POs since he became
vomiting.
In the ED, initial vitals: 96.0 112 165/93 18 100% RA. Labs
notable for K 3.9, Glu 241, AG 41. Initial VBG ___. UA
with >1000 glucose, + ketones, trace blood but otherwise without
evidence of UTI. Trop negative. Patient given 2L NS and
transitioned to D5NS at ___ prior to transfer. Started on
Insulin gtt at 3unit/hr. Also received Thiamine/Folate, Zofran
x2 and compazine.
On transfer, vitals were: 98.5 128 132/76 18 100% RA.
On arrival to the MICU, patient comfotable but persistantly
tachy and hypertesive and diaphoretic. States that not currently
nauseated but feels bloated.
Past Medical History:
ALCOHOLISM
INSULIN DEPENDENT DIABETES MELLITUS
HYPERTENSION
TACHYCARDIA
ERECTILE DYSFUNCTION
PROSTATE CANCER s/p radical prostatectomy in ___, ___
3+3, urologist Dr. ___
H/O ALOPECIA AREATA
H/O Left great toe osteomyelitis s/p amputation
Social History:
___
Family History:
Notable for lung cancer and metastatic prostate cancer in his
father, who was diagnosed of prostate cancer in his ___. His
mother has arthritis, so does his sister. It was unclear what
kind of arthritis his sister has. His older brother has
hyperthyroidism. There is no family history of colon cancer.
His maternal grandmother died of myelodysplastic syndrome, which
eventually turned into a full blown leukemia.
Physical Exam:
On admission:
Vitals: T99; BP 160/70s; HR 130; RR 18; 98%RA
GENERAL: Alert, oriented, no acute distress
HEENT: Sclera anicteric, dry MM, oropharynx clear. Tongue
fasciculations
NECK: supple, JVP not elevated, no LAD
LUNGS: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: tachycardic, normal S1 S2, no murmurs, rubs, gallops
appreciated
ABD: soft, non-tender, non-distended, bowel sounds present, no
rebound tenderness or guarding, no organomegaly
EXT: Warm, well perfused, no clubbing, cyanosis or edema. L
great toe amputated. Area of scabbing from non-healing
ulceration but in tact, no drainage, fluctuance or erythema
SKIN: No lesions rashes noted
NEURO: A&Ox3. Bilateral resting tremor and intention tremor.
Otherwise grossly in tact.
On discharge:
Vitals- 98.___/86 99 16 100% RA
General- Alert, oriented, no acute distress
HEENT- Sclera anicteric, MMM, oropharynx clear. Tongue
fasciculations
Neck- supple, JVP not elevated, no LAD
Lungs- Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV- tachycardic and regular, 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, no clubbing, cyanosis or edema. L
great toe amputated. Area of scabbing from non-healing
ulceration but intact, no drainage, fluctuance or erythema
Skin: No lesions rashes noted
Neuro- CNs2-12 intact, motor function grossly normal
Pertinent Results:
On admission:
___ 04:15PM BLOOD WBC-8.6# RBC-4.31* Hgb-14.6 Hct-41.4
MCV-96 MCH-33.9* MCHC-35.3 RDW-13.1 RDWSD-46.2 Plt ___
___ 01:58AM BLOOD ___ PTT-25.7 ___
___ 04:15PM BLOOD Glucose-241* UreaN-17 Creat-1.1 Na-139
K-3.9 Cl-86* HCO3-12* AnGap-45*
___ 01:58AM BLOOD ALT-64* AST-51* LD(LDH)-291* AlkPhos-188*
TotBili-1.3
___ 07:50PM BLOOD cTropnT-<0.01
___ 01:58AM BLOOD Albumin-4.1 Calcium-8.8 Phos-1.8* Mg-1.5*
___ 06:01PM BLOOD pO2-27* pCO2-31* pH-7.30* calTCO2-16*
Base XS--10 Comment-SAMPLE TYP
On discharge:
___ 07:30AM BLOOD WBC-3.3* RBC-3.26* Hgb-10.9* Hct-31.6*
MCV-97 MCH-33.4* MCHC-34.5 RDW-13.3 RDWSD-46.5* Plt Ct-94*
___ 07:30AM BLOOD ___
___ 07:30AM BLOOD Glucose-278* UreaN-7 Creat-0.8 Na-136
K-3.8 Cl-100 HCO3-25 AnGap-15
___ 07:30AM BLOOD ALT-63* AST-84* AlkPhos-160* TotBili-0.6
___ 07:30AM BLOOD Calcium-8.7 Phos-2.7 Mg-1.8
Reports:
CHEST (PORTABLE AP) Study Date of ___ 3:23 AM
IMPRESSION:
As compared to the previous radiograph, no relevant change is
seen. Normal lung volumes. Normal appearance of the cardiac
silhouette and of the hilar and mediastinal structures. No
pneumonia, no pulmonary edema.
Brief Hospital Course:
___ yo M with hx of EtOH abuse and IDDM who presents with N/V
found to have DKA.
# DKA- [t presented with significant gap acidosis, profound
glucosuria and symptoms similar to prior events. However, given
EtOH hx, must also consider alternative etiologies such as
withdrawel or toxic EtOH ingestion. Finally also consider
component of starvation ketosis as patient not eating since
stopped drinking and likely poor nutrition while drinking. He
was started initially on an insulin gtt until his anion gap
closed. His potassium was aggressively repleted. When his anion
gap closed he was started on subcutaneous insulin and this dose
was titrated for his hyperglycemia with consult from the ___
diabetes service.
# EtOH Abuse - Pt stopped drinking 3d PTA which resulted in
excessive vomiting, likely precipitating this episode of DKA. No
evidence of seizure activity on arrival. He was started on a
phenobarb taper in the ICU which was completed by the time of
discharge.
CHRONIC ISSUES:
#Depression/Psych - continue home venlafaxine and trazadone PRN
#HTN - hold home metoprolol and lisinopril; consider restart in
AM
Transitional Issues:
- Follow up with ___ titration of insulin
titration in the outpatient setting.
- Alcohol dependence treatment
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Metoprolol Succinate XL 25 mg PO DAILY
2. TraZODone 50-100 mg PO QHS:PRN insomnia
3. Venlafaxine XR 225 mg PO DAILY
4. B Complex (vit B2-niac-B-6-B12-D-panth;<br>vitamin B complex)
1 tablet oral DAILY
5. Lisinopril 10 mg PO DAILY
6. Glargine 20 Units Breakfast
Insulin SC Sliding Scale using HUM Insulin
Discharge Medications:
1. Lisinopril 10 mg PO DAILY
RX *lisinopril 10 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
2. TraZODone 50-100 mg PO QHS:PRN insomnia
RX *trazodone 50 mg ___ tablet(s) by mouth at bedtime Disp #*30
Tablet Refills:*0
3. Venlafaxine XR 225 mg PO DAILY
4. FoLIC Acid 1 mg PO DAILY
RX *folic acid 1 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*3
5. B Complex (vit B2-niac-B-6-B12-D-panth;<br>vitamin B complex)
1 tablet oral DAILY
6. Metoprolol Succinate XL 25 mg PO DAILY
7. Thiamine 100 mg PO DAILY
RX *thiamine HCl 100 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*3
8. Multivitamins 1 TAB PO DAILY
RX *multivitamin 1 tablet(s) by mouth daily Disp #*100 Tablet
Refills:*3
9. Glargine 20 Units Breakfast
Humalog 5 Units Breakfast
Humalog 5 Units Lunch
Humalog 5 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Diabetic ketoacidosis
Alcohol withdrawal
Secondary:
Hypertension
Depression
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr. ___,
You were recently admitted to the ___ for an episode of
diabetic ketoacidosis, for which you were treated in the ICU.
You were given phenobarbital to treat alcohol withdrawal. You
were also given your usual medications to control your chronic
medical conditions.
Please continue your medications as prescribed. Please continue
to seek care for your alcohol use to maintain abstinence.
We wish you the best in your health,
- your ___ medical team
Followup Instructions:
___
|
19681724-DS-11
| 19,681,724 | 27,669,120 |
DS
| 11 |
2180-12-02 00:00:00
|
2180-12-02 14:20:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Ativan / Zofran (as hydrochloride)
Attending: ___.
Chief Complaint:
Hyperglycemia, L Leg Cellulitis
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ year old male with DM/neuropathy/charcot with a recent
admission in ___ for DKA and EtOH withdrawal presents w/
bilateral foot ulcerations and erythema and admitted to the ICU
for alcohol withdrawal.
Patient states that roughly 2 weeks prior patient received new
specialty shoes. He states the shoes rubbed his feet "raw to the
bone" and noted erythema roughly 5 days prior to admission. The
erythema and associated swelling worsened over the last 2 days.
He also endorses 2 days of nausea and vomiting, with last
episode of emesis 1 day prior to admission. He states his
Glucose fingersticks were elevated to 300s despite uptitrating
his humalog.
He presented to ___ clinic for evaluation and was
recommended to come to ED for admition for IV antibiotics.
Initial vitals were: 98.6 64 151/93 18 96% RA Glucose 309.
Patient was found to be "jittery" with out of body feeling. On
recheck his fingerstick glucose was 66 and patient was given
dextrose with recheck of 133.
Initial labs were: WBC 8.8, Hgb 13.4, Plts 148, 75%N, 12.9%, Na
132, K 4, Cl 89, bicarb 25, Cr 1, Gap 18, 10 ketones in UA,
Lactate 2.3, VBG ___. Patient was given 3L NS, 650mg
tylenol, 1gm vancomycin, 10mg diazepam, 25gm Dextrose 50%.
Of note, he has had prior foot infections with Staph Aureus
(MRSA as well as resistant to clindamycin and erythromycin in
the ___ and enterococcus.
He has is a 1pint/vodka per day and has had prior admissions
requiring phenobarbital dosing. He denies history of DTs or
seizures. His last drink was 2 days prior to admission.
On arrival to the MICU, Patient states he feels fine with mild
pain in foot. He is slightly tremulous but able to follow
commands and answer questions appropriately
Past Medical History:
ALCOHOLISM
INSULIN DEPENDENT DIABETES MELLITUS
HYPERTENSION
TACHYCARDIA
ERECTILE DYSFUNCTION
PROSTATE CANCER s/p radical prostatectomy in ___, ___ 3+3,
urologist Dr. ___
H/O ALOPECIA AREATA
H/O Left great toe osteomyelitis s/p amputation
Social History:
___
Family History:
Notable for lung cancer and metastatic prostate cancer in his
father, who was diagnosed of prostate cancer in his ___. His
mother has arthritis, so does his sister. It was unclear what
kind of arthritis his sister has. His older brother has
hyperthyroidism. There is no family history of colon cancer.
His maternal grandmother died of myelodysplastic syndrome, which
eventually turned into a full blown leukemia.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: 98.6 163/94 99 19 99% RA
Gen: NAD, pleasant male resting in bed
HEENT: clear oropharynx, MMM, sclera anicteric
CV: Tachycardic, regular, no m/r/g
Pulm: CTA b/l, no w/r/r
Abd: Soft, NTND (+) BS
GU: no foley
Ext: 1+ pitting edema
Neuro: alert and conversant, able to move all extremities,
decreased sensation in ___, mild tremulousness, no tongue
fasciculations
Psych: normal affect
Skin: L leg w/ erythema up mid calf with worse erythema at foot.
Warm to touch. 2cx3cm wound on lateral aspect near
metacarpal,serous drainage. Left ___ toe amputation. No
fluctuance, purulence noted. R foot w/ slight erythema up to
lower calf, significantly less than L. small 1cm diameter wound
on lateral malleolus. healing abrasions on R knee and R palm
DISCHARGE EXAM:
Pertinent Results:
ADMISSION LABS:
===============
___ 03:40PM BLOOD WBC-8.8# RBC-3.98* Hgb-13.4* Hct-38.6*
MCV-97 MCH-33.7* MCHC-34.7 RDW-13.8 RDWSD-48.0* Plt ___
___ 03:40PM BLOOD Neuts-75.1* Lymphs-12.9* Monos-9.9
Eos-0.9* Baso-0.6 Im ___ AbsNeut-6.57* AbsLymp-1.13*
AbsMono-0.87* AbsEos-0.08 AbsBaso-0.05
___ 02:50AM BLOOD ___ PTT-29.8 ___
___ 03:40PM BLOOD Glucose-322* UreaN-12 Creat-1.0 Na-132*
K-4.0 Cl-89* HCO3-25 AnGap-22*
___ 02:50AM BLOOD Calcium-8.1* Phos-2.7 Mg-1.5*
___ 03:47PM BLOOD ___ pO2-22* pCO2-42 pH-7.44
calTCO2-29 Base XS-2
___ 03:47PM BLOOD Lactate-2.3*
___ 03:47PM BLOOD O2 Sat-34
PERTINENT FINDINGS:
===================
FOOT AP/LAT/Oblique X-ray
- No definite radiographic evidence for osteomyelitis. No
substantial interval change from the previous examination.
RECOMMENDATION(S): MRI would be more sensitive for the
detection of
osteomyelitis.
Brief Hospital Course:
___ year old male with DM, charcot, frequent foot infecitons with
a recent admission in ___ for DKA and EtOH withdrawal
presents w/ L foot ulceration(s), cellulitis being admitted to
the ICU for alcohol withdrawal.
#Alcohol withdrawal- Patient with significant alcohol abuse
presents 2 days after his last drink with signs of
tremulousness. His last hospitalization in ___ required
Phenobarbital protocol. On admission to the ___ patient had
minor tremors, no other signs of dysautonomia (per patient, last
drink 2 days prior to admission). Phenobarbital protocol was
started as well as thiamine, and folate. He was advised to cease
etoh.
#L Foot infection- Pt w/ chronic foot wounds and infections sent
in from podiatry being followed by Podiatry for worsening
redness and swelling in L leg concerning for cellulitis.
Bilateral foot x-rays showed no definitive xray evidence of
osteomyelitis, but would need MRI for rule out. Patient was
started on Vancomycin and Zosyn (___) and wounds were cleaned
and dressed wet to dry. Podiatry re-evaluated wounds, decided
no indication for further imaging, and recommended transition to
PO antibiotics. Patient was started on augmentin and bactrim to
complete a ___nd planned for follow up in ___
clinic.
#Labile Diabetes- Patient is Type I diabetec with recent DKA
admission. Initially, there was concern for DKA given Ketones
and gap of 18, however on recheck fingerstick in ED glucose was
60. ___ consult was placed, recommended contniuing home
glargine, initially holding home humalog/carb counting but then
transitioned back to glargine with humalog scale. A follow up
appointment was scheduled with ___ on ___.
.
#Hypertension - Normotensive. Continued lisinopril and
metoprolol.
#Depression- No Suicidal ideations. Continued venlafaxine
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lisinopril 10 mg PO DAILY
2. TraZODone 50-100 mg PO QHS:PRN insomnia
3. Venlafaxine XR 225 mg PO DAILY
4. B Complex (vit B2-niac-B-6-B12-D-panth;<br>vitamin B complex)
1 tablet oral DAILY
5. Metoprolol Succinate XL 25 mg PO DAILY
6. Multivitamins 1 TAB PO DAILY
7. Glargine 22 Units Breakfast
Humalog 5 Units Breakfast
Humalog 5 Units Lunch
Humalog 5 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
Discharge Medications:
1. Glargine 22 Units Breakfast
Humalog 5 Units Breakfast
Humalog 5 Units Lunch
Humalog 5 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
2. Lisinopril 10 mg PO DAILY
3. Metoprolol Succinate XL 25 mg PO DAILY
4. Multivitamins 1 TAB PO DAILY
5. TraZODone 50-100 mg PO QHS:PRN insomnia
6. Venlafaxine XR 225 mg PO DAILY
7. FoLIC Acid 1 mg PO DAILY
RX *folic acid 1 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
8. Thiamine 100 mg PO DAILY
RX *thiamine HCl 100 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
9. B Complex (vit B2-niac-B-6-B12-D-panth;<br>vitamin B complex)
1 tablet oral DAILY
10. PHENObarbital Alcohol Withdrawal Dose Taper (Days ___ 22 mg
PO/NG BID Duration: 2 Doses
Start: Today - ___, First Dose: Next Routine Administration
Time
This is dose # 1 of 4 tapered doses
11. PHENObarbital Alcohol Withdrawal Dose Taper (Days ___ 11 mg
PO BID Duration: 2 Doses
Start: After 22 mg BID tapered dose
This is dose # 2 of 4 tapered doses
RX *phenobarbital 20 mg/5 mL ASDIR mL by mouth twice a day
Refills:*0
12. PHENObarbital Alcohol Withdrawal Dose Taper (Days ___ 6 mg
PO/NG BID Duration: 2 Doses
Start: After 11 mg BID tapered dose
This is dose # 3 of 4 tapered doses
13. PHENObarbital Alcohol Withdrawal Dose Taper (Days ___ 0 mg
PO/NG BID Duration: 2 Doses
Start: After 6 mg BID tapered dose
This is dose # 4 of 4 tapered doses
14. Amoxicillin-Clavulanic Acid ___ mg PO Q12H
RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tab by mouth
twice a day Disp #*12 Tablet Refills:*0
15. Sulfameth/Trimethoprim DS 1 TAB PO BID
RX *sulfamethoxazole-trimethoprim [Bactrim DS] 800 mg-160 mg 1
tablet(s) by mouth twice a day Disp #*12 Tablet Refills:*0
16. Acetaminophen-Caff-Butalbital ___ TAB PO Q6H:PRN headache
RX *butalbital-acetaminophen-caff [Fioricet] 50 mg-300 mg-40 mg
1 capsule(s) by mouth q6 Disp #*20 Capsule Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Cellulitis
alcohol withdrawal
diabetic ketoacidosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear ___ was a pleasure caring for you. You were admitted because you
had a skin infection of your feet. For this you received
antibiotics. You were also treated for alcohol withdrawal. We
advise you to stop drinking alcohol. You were also treated for
mild diabetic ketoacidosis. You should continue your antibiotics
to the completion of the course. Please follow up with your
podiatrist this week as previously scheduled. You also have an
appointment with ___ on ___ at 330 ___.
Followup Instructions:
___
|
19681724-DS-13
| 19,681,724 | 24,146,256 |
DS
| 13 |
2181-05-21 00:00:00
|
2181-05-23 12:50:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Ativan / Zofran (as hydrochloride)
Attending: ___.
Chief Complaint:
nausea, emesis, ketone-positive urine at home
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. ___ is a ___ yo man with a PMH of alcoholism,
insulin-dependent
diabetes since age ___ with retinopathy and neuropathy (followed
by ___, who presents to the ED with DKA and alcohol
withdrawal.
Of note, he has been followed by Dr. ___ at ___ with his most
recent appointment on ___. At that appointment, he noted
that he had checked himself into the hospital on ___ for
alcohol withdrawal. His plan was to go back to AA meetings. He
felt that his drinking was due to personal stressors such as his
mother's rapid decline into dementia. He also had a C. difficile
infection during his hospitalization in ___ and was treated
with metronidazole. Of note, he has chronic Dupuytren's
contractures of the L palm.
2 pints etoh per day x3 weeks, last drink at midnight.
Nausea/non-bloody emesis. Tachy to 130's and BP 170's. Got 10
valium. 4L fluid and insulin drip. 10 valium again now. No UOP
in ED.
-Mental health: Dr. ___: Dr. ___: followed at ___
-In the ED, initial vitals: 97.5 171/81 136 16 100%RA FSBG 473
-On transfer, vitals were: 97.7 114/60 134 114/60 18 100%RA
FSBG trend
1720: ___: ___: 368
On arrival to the MICU, pt is feeling slightly anxious,
otherwise no acute complaints. He reports going on a 3 week
"bender" drinking 2 pints of hard alcohol daily. Last drink at
___ 0001. He has been keeping up with his insulin (22U
glargine qHS and SSI Humalog with carb counting) up until the
past 2 days when he lost track due to alcohol intoxication. He
took 12U glargine at 1000 on ___ and sought medical care due
to intractable nausea and emesis and detecting ketones in his
home test. He denied fevers/chills, abdominal pain (aside from
soreness from wretching), diarrhea, constipation, dysuria,
frequency.
Past Medical History:
ALCOHOLISM
INSULIN DEPENDENT DIABETES MELLITUS
HYPERTENSION
TACHYCARDIA
ERECTILE DYSFUNCTION
PROSTATE CANCER s/p radical prostatectomy in ___, ___ 3+3,
urologist Dr. ___
H/O ALOPECIA AREATA
H/O Left great toe osteomyelitis s/p amputation
Social History:
___
Family History:
Notable for lung cancer and metastatic prostate cancer in his
father, who was diagnosed of prostate cancer in his ___. His
mother has arthritis, so does his sister. It was unclear what
kind of arthritis his sister has. His older brother has
hyperthyroidism. There is no family history of colon cancer.
His maternal grandmother died of myelodysplastic syndrome, which
eventually turned into a full blown leukemia.
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: T: 98.2 BP: 165/66 P: 143 R: 36 O2: 100%RA FSBG 310
GENERAL: Alert, oriented, tremulous, shaky voice, endorses
anxiety
HEENT: Sclera anicteric, MMM, oropharynx clear
NECK: supple, JVP not elevated, no LAD
LUNGS: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: tachycardic rate and regular rhythm, normal S1 S2, no
murmurs, rubs, gallops
ABD: soft, non-tender, non-distended, bowel sounds present, no
rebound tenderness or guarding, no organomegaly
EXT: L foot/lower leg in hard cast, R leg with clean/dry/intact
dressing over ulcer
NEURO: A&Ox3, CN II-XII intact, no focal deficits, gait deferred
DISCHARGE PHYSICAL EXAM:
VS - Vitals: 98.3 130/69 95 18 99%
General: NAD, well appearing male in NAD
HEENT: EOMI, PERRL, no scleral pallor or icterus, MMM
Neck: No LAD, no JVD
CV: no m/r/g, ns1s2, tachycardic
Lungs: CTAB, no w/r/r
Abdomen: Soft, distended, no fluid wave. No HSM, nontender to
palpation, no sequlae of liver disease
Ext: Left great toe amputated, ___ ulcers wrapped in bandage
in various states of healing. NO edema
Neuro: II-XII, no asterixis, no tremor
Pertinent Results:
ADMISSION LABS:
===============
___ 05:40PM BLOOD WBC-13.8*# RBC-3.95* Hgb-12.8* Hct-39.4*
MCV-100* MCH-32.4* MCHC-32.5 RDW-15.3 RDWSD-55.7* Plt ___
___ 05:40PM BLOOD Neuts-87.6* Lymphs-5.0* Monos-6.4
Eos-0.0* Baso-0.4 Im ___ AbsNeut-12.13* AbsLymp-0.69*
AbsMono-0.88* AbsEos-0.00* AbsBaso-0.06
___ 05:40PM BLOOD ___ PTT-26.6 ___
___ 05:40PM BLOOD Glucose-571* UreaN-25* Creat-1.4* Na-135
K-5.5* Cl-85* HCO3-8* AnGap-48*
___ 05:40PM BLOOD ALT-27 AST-26 AlkPhos-218* TotBili-1.0
___ 05:40PM BLOOD Lipase-13
___ 05:40PM BLOOD Albumin-4.7
___ 10:53PM BLOOD Calcium-8.1* Phos-5.3*# Mg-2.1
___ 05:40PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 05:52PM BLOOD ___ pO2-43* pCO2-28* pH-7.18*
calTCO2-11* Base XS--17
___ 05:52PM BLOOD Lactate-6.5*
___ 11:04PM BLOOD freeCa-1.02*
OTHER PERTINENT/DISCHARGE LABS:
===============================
___ 05:52PM BLOOD ___ pO2-43* pCO2-28* pH-7.18*
calTCO2-11* Base XS--17
___ 11:04PM BLOOD ___ pO2-82* pCO2-27* pH-7.15*
calTCO2-10* Base XS--18
___ 03:11AM BLOOD ___ pO2-148* pCO2-29* pH-7.38
calTCO2-18* Base XS--6 Comment-GREEN TOP
___ 10:53PM BLOOD Glucose-325* UreaN-25* Creat-1.2 Na-136
K-8.4* Cl-98 HCO3-8* AnGap-38*
___ 07:18AM BLOOD WBC-4.9# RBC-3.45* Hgb-11.2* Hct-32.6*
MCV-95 MCH-32.5* MCHC-34.4 RDW-15.9* RDWSD-53.9* Plt ___
___ 07:18AM BLOOD Glucose-148* UreaN-12 Creat-0.9 Na-141
K-3.7 Cl-105 HCO3-26 AnGap-14
___ 07:18AM BLOOD ALT-30 AST-57* AlkPhos-171* TotBili-0.4
___ 07:18AM BLOOD cTropnT-<0.01
___ 07:18AM BLOOD Albumin-3.5 Calcium-8.6 Phos-2.0* Mg-1.9
IMAGING:
==========
CXR (portable AP) ___
No acute cardiopulmonary process.
MICRO:
==========
___ - Blood culture - NGTD
___ - Urine culture - No Growth
___ - MRSA screen - Negative
Brief Hospital Course:
___ with history of EtOH abuse, IDDM c/b retinopathy,
neuropathy, PVD, and ___ ulcers presented for DKA and EtOH
intoxication. Patient reported increased Etoh over past 3 weeks
in response to a friend dying of alcohol intoxication. He
stopped insulin days prior to admission. In the ED, had
significant nausea, vomiting and tachycardia. He had a gap of 48
in ED, bicarb to 8 and glucose to 500s. In MICU, he received an
insulin drip and was placed on phenobarbital protocol. Insulin
drip and D5 were stopped at 1pm ___ and he was transitioned to
home long acting insulin at that time. Infectious workup
negative including CXR, urine culture, blood culture, and ulcer
exam. He was discharged with ___, PCP, and podiatry followup.
#DKA: Secondary to alcohol abuse and insulin noncompliance.
Negative infectious workup to date, including podiatric exam.
Resolved after aggressive fluid resuscitation and insulin drip
in ICU. He was transitioned to home glargine and carb counted
Humalog with meals per ___ recommendations.
#Hyperkalemia:
K 8 moderately hemolyzed on admission. Repeat EKG without
changes consistent with hyperkalemia. Insulin gtt per DKA
protocol, 2g calcium gluconate. Repeat K improved to 4.1.
#EtOH withdrawal: Patient reports long history of alcohol use
and dependence. He reports drinking 2 pints of 100proof vodka
for the past 3 weeks since a friend his age died from alcohol.
Has had periods of sobriety in setting of AA. Patient maintained
on phenobarbital protocol and supplemented with thiamine and
folate repletion.
#Atypical Chest pain: Had several episodes of chest pain when
eating, pain was subxiphoid pressure. It resolved on its own.
EKG without ST change and troponin negative x2
#Hyperkalemia: resolved with treatment of DKA. EKG without
findings consistent with hyperkalemia.
#Leukocytosis: Patient with leukocytosis to 13.8 on admission.
Infectious workup negative including CXR, urine culture, blood
culture, and ulcer exam. Resolved with treatment of DKA
#Insomnia: Trazodone 50-100mg qHS PRN
#Depression:: continued home venlafaxine ER 225mg qday
#Hyperlipidemia: Continued home atorvastatin
#L foot infection:
Evaluated by podiatry on ___. Hard cast removed. No evidence of
infection.
#HTN: Continued home metoprolol XL and lisinopril
TRANSITIONAL ISSUES
===================
-Patient needs outpatient colonoscopy rescheduled
-Patient will be discharged on PO thiamine and folate
-Further management of insulin by ___ and PCP
-___ to endorse alcohol abstinence and sobriety, consider
AA ___.
-Pt discharged with CAM walking boot per podiatry
recommendations
# Communication: HCP: ___ (sister) ___
# Code: Full, confirmed
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 10 mg PO QPM
2. Lisinopril 10 mg PO QHS
3. Metoprolol Succinate XL 25 mg PO DAILY
4. TraZODone 50-100 mg PO QHS:PRN insomnia
5. Venlafaxine XR 225 mg PO DAILY
6. Multivitamins 1 TAB PO DAILY
7. B Complex (vit B2-niac-B-6-B12-D-panth;<br>vitamin B complex)
1 tablet oral DAILY
8. Glargine 22 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
9. Excedrin Migraine (aspirin-acetaminophen-caffeine) 250-250-65
mg oral DAILY:PRN headache
Discharge Medications:
1. Atorvastatin 10 mg PO QPM
2. Glargine 22 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
3. Lisinopril 10 mg PO QHS
4. Metoprolol Succinate XL 25 mg PO DAILY
5. Multivitamins 1 TAB PO DAILY
6. TraZODone 50-100 mg PO QHS:PRN insomnia
7. Venlafaxine XR 225 mg PO DAILY
8. FoLIC Acid 1 mg PO DAILY
RX *folic acid 1 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
9. Excedrin Migraine (aspirin-acetaminophen-caffeine) 250-250-65
mg ORAL DAILY:PRN headache
10. B Complex (vit B2-niac-B-6-B12-D-panth;<br>vitamin B
complex) 1 tablet oral DAILY
11. Thiamine 100 mg PO DAILY
RX *thiamine HCl (vitamin B1) 100 mg 1 tablet(s) by mouth once a
day Disp #*30 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnoses:
Type 1 Diabetes Mellitus complicated by Diabetic Ketoacidosis
Alcohol Abuse
Hyperkalemia
IDDM complicated by retinopathy, neuropathy
Secondary Diagnoses:
Insomnia
Depression
Hypertension
Chronic foot ulcers
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 Diabetic Ketoacidosis (DKA), a
serious complication of not taking your insulin. This was in the
setting of alcohol abuse. You had significant dehydration and
lab abnormalities on admission that have since corrected.
What was done?
==============
-You were rehydrated with intravenous fluids
-Your sugars normalized on an insulin drip that was transitioned
to your home insulin
-You were given medications for alcohol withdrawal
-Social work was consulted to give information about sobriety.
What should I do next?
======================
-Take all medications as prescribed, especially your insulin
-Follow up with outpatient appointments scheduled, including
___, podiatry and your PCP
-___ stop alcohol use to prevent further damage to your
liver.
-Please reschedule your colonoscopy. Call the
___ at ___ to schedule this
important procedure.
-___ medical attention if you develop further nausea, vomiting,
fevers, chills, or abdominal pain.
Wishing you the best of health moving forward,
Your ___ team
Followup Instructions:
___
|
19681724-DS-15
| 19,681,724 | 26,281,505 |
DS
| 15 |
2182-04-22 00:00:00
|
2182-04-22 20:19:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Shoulder pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ is a ___ man with a history of type I DM,
multiple prior episodes of DKA ___ insulin non compliance, ETOH
abuse w/ h/o alcoholic ketoacidosis, foot ulcer presenting with
R shoulder pain from fall and decreased urine output, found to
be in DKA in the ED and admitted to the FICU for management. He
fell walking to his car evening ___, presumably drunk. He took
his lantus that evening but took no Humalog ___ as he was not
eating due to pain. Alcohol intake in last two days per patient
consists of 2 12 oz beers yesterday and 1 mixed drink this AM.
He last urinated at 3 ___ today.
In the ED:
- Initial vitals T 98.6 HR 116 BP 146/70 RR 18 O2 96% on RA
- Exam notable for R shoulder swollen and decreased ROM, and the
LLE wrapped at site of chronic diabetic foot ulcer
- Labs were notable for:
o Na 128 / Cl 87 / K 5.5 / HCO3 12 / BUN 34 / Cr 1.6 / Glc 572
o NaCorrected 136 / Anion Gap 37
o Lactate 4.9
o WBC 9.2 / Hgb 9.9 / Plt 167
o Neutrophils 86% Lymphocytes 6.6%
- Imaging:
o CXR: Low lung volumes with subtle left base opacity most
likely related to atelectasis. No definite focal
consolidation.
o Glenohumeral XR: Comminuted proximal right humeral fracture
involving the surgical neck and possibly the greater tuberosity.
No right shoulder dislocation.
- Patient was given:
o ___ 17:37 IVF NS (1000 mL ordered)
o ___ 17:47 IV Morphine Sulfate 4 mg
o ___ 19:35 IV Morphine Sulfate 4 mg
o ___ 19:41 IV DRIP Insulin ___ UNIT/HR ordered)
Started 9 UNIT/HR
- Orthopedics was consulted and recommended no acute surgical
intervention, with sling immobilization, NWB.
On arrival to the MICU, he is alert and calm with ongoing
shoulder pain helped only minimally by morphine in ED. Denies
fevers/chills, n/v/d, chest pain, dyspnea.
Of note recently seen in ED ___ for EtOH withdrawal, alcoholic
ketoacidosis and discharged with phenobarb taper which he
reports completing, first drinks ___ ___ as above.
Past Medical History:
-EtOH abuse- history of anxiety and hallucinosis with
withdrawal. No seizures
-IDDM- type 1, previously followed with ___ and ___ pump
usage. Complicated by L foot ulcer and charcot joint. Numerous
admissions for DKA. Retinopathy and neuropathy
-HTN
-Prostate cancer s/p prostatectomy
-L great toe osteomyelitis s/p amputation
Social History:
___
Family History:
Notable for lung cancer and metastatic prostate cancer in his
father, who was diagnosed of prostate cancer in his ___. His
mother has arthritis, so does his sister. It was unclear what
kind of arthritis his sister has. His older brother has
hyperthyroidism. There is no family history of colon cancer.
His maternal grandmother died of myelodysplastic syndrome, which
eventually turned into a full blown leukemia.
Physical Exam:
ADMISSION PHYSICAL EXAM:
=========================
VITALS: T 98.7 HR 127 BP 127/63, RR 22, O2 99% RA
GENERAL: Well appearing, conversive, NAD
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MM mildly dry
NECK: nontender supple neck, no LAD, no JVD
CARDIAC: Tachycardic, RR, 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: R shoulder TTP, R arm in sling. SILT R hand. L foot
in walking boot. No ___ edema R leg
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact
DISCHARGE PHYSICAL EXAM:
=========================
VITALS: 97.5 153/82 89 18 95% RA
GEN: Sitting up in bed, comfortable appearing, in NAD
HEENT: EOMI, sclerae anicteric, MMM, OP clear
NECK: No LAD, no JVD
CARDIAC: RRR, no M/R/G
PULM: normal effort, no accessory muscle use, LCAB
GI: soft, NT, ND, NABS
MSK: Right arm swollen, wrapped in sling, full sensation in
hand,
1+ radial pulse
DERM: No visible rash. No jaundice.
NEURO: AAOx3.
PSYCH: Full range of affect
EXTREMITIES: Left foot with healed ulcer on the plantar aspect
Pertinent Results:
ADMISSION LABS:
===============
___ 05:15PM BLOOD WBC-9.2# RBC-2.98* Hgb-9.9* Hct-29.5*
MCV-99* MCH-33.2* MCHC-33.6 RDW-13.7 RDWSD-48.5* Plt ___
___ 05:15PM BLOOD Glucose-572* UreaN-34* Creat-1.6* Na-128*
K-5.5* Cl-87* HCO3-12* AnGap-35*
___ 11:30PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-6*
Bnzodzp-NEG Barbitr-POS* Tricycl-NEG
___ 05:15PM BLOOD VitB12-294 Folate-14
___ 05:43PM BLOOD Lactate-4.9* K-5.3*
___ 05:41PM BLOOD ___ pO2-38* pCO2-34* pH-7.26*
calTCO2-16* Base XS--11
PERTINENT LABS:
================
___ 05:15PM BLOOD Ret Aut-3.1* Abs Ret-0.09
___ 07:40AM BLOOD calTIBC-256* Ferritn-126 TRF-197*
___ 05:15PM BLOOD VitB12-294 Folate-14
___ 11:30PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-6*
Bnzodzp-NEG Barbitr-POS* Tricycl-NEG
___ 05:43PM BLOOD Lactate-4.9* K-5.3*
___ 09:07PM BLOOD Glucose-370* Na-132* K-4.3 Cl-98
calHCO3-16*
___ 11:40PM BLOOD Lactate-2.2*
___ 02:21AM BLOOD Lactate-2.8*
___ 05:37AM BLOOD Lactate-1.9
DISCHARGE LABS:
================
___ 07:00AM BLOOD WBC-4.7 RBC-2.63* Hgb-8.7* Hct-26.0*
MCV-99* MCH-33.1* MCHC-33.5 RDW-14.4 RDWSD-49.2* Plt ___
___ 07:00AM BLOOD Plt ___
___ 07:00AM BLOOD Glucose-117* UreaN-16 Creat-0.7 Na-140
K-4.2 Cl-104 HCO3-24 AnGap-16
___ 07:00AM BLOOD Calcium-9.1 Phos-3.4 Mg-2.0
___ 05:37AM BLOOD Lactate-1.9
IMAGING/STUDIES:
================
___ Humerus
Comminuted proximal right humeral fracture involving the
surgical neck and
possibly the greater tuberosity. No right shoulder dislocation.
___ Glenohumeral
Comminuted proximal right humeral fracture involving the
surgical neck and
possibly the greater tuberosity. No right shoulder dislocation.
___ CXR
Low lung volumes with subtle left base opacity most likely
related to
atelectasis. No definite focal consolidation. If continued
concern for
pneumonia, consider dedicated PA and lateral views when/if
patient able for
further evaluation.
Re- demonstrated partially imaged comminuted fracture of the
proximal right
humerus.
Brief Hospital Course:
___ is a ___ year old man with a history of T1DM and
frequent episodes of DKA ___ insulin non-compliance, as well as
alcoholism and frequent episodes of alcoholic ketoacidosis who
presented after a fall for R shoulder pain, found to have a R
proximal humerus fracture, as well as DKA, initially admitted to
the ICU for management of DKA, subsequently called out to the
medical floor.
ICU COURSE ___:
==================
#DIABETIC KETOACIDOSIS: Secondary to poor insulin compliance, PO
intake, acute shoulder pain, and alcohol abuse. No infectious
symptoms, no leukocytosis. Completed antibiotics for ___
cellulitis with no signs of cellulitis on admission. Treated
with insulin gtt in the ICU. ___ was consulted and assisted
with insulin control. Discharged on:
Glargine 22 units QHS
Humalog 6 units with meals along with sliding scale starting at
140 with a 20:1
(ordered as 40:2) correction factor, which he uses at home.
On discharge he will require close follow up with his PCP for
ongoing insulin management.
#R PROXIMAL HUMERUS FX: Xray with R proximal humerus fracture.
Evaluated by ortho who recommend immobilization with sling, f/u
with ortho trauma in 1 week, and pain control. Pain control with
standing Tylenol, ibuprofen, oxycodone PRN. On discharge from
rehab he should be weaned off of oxycodone if possible.
#ALCOHOL ABUSE: Longstanding history with prior dual diagnosis
treatment. Reports completing 7 day phenobarb taper prescribed
___ (though last day would be ___ and first drink of 2 beers
___. Last drink ___ AM. Monitored on CIWA scale, SW consulted,
started on high dose thiamine for 3 days, folate, multivitamin.
Did not score on CIWA while hospitalized. Provided with
outpatient resources to assist with abstinence.
#ACUTE KIDNEY INJURY: No known CKD and baseline creatinine ~0.9
___. Likely pre-renal in setting of hypovolemia from poor PO
intake and DKA. Resolved with IVF
#SINUS TACHYCARDIA: Tachy to 120s and regular. On home
metoprolol succinate 25 mg daily. Likely ___ pain from shoulder
fracture, and hypovolemia from DKA. No chest pain or dyspnea to
indicate PE and ECG otherwise normal. Resolved prior to
discharge.
#ANEMIA: Borderline macrocytic anemia, baseline appears ___,
newly depressed to 9.9 this admission. No signs of bleeding on
exam or per history. Possibly due to marrow suppression in
setting of alcoholism, though platelets normal. B12 level
borderline low, started on PO supplementation. Iron studies
consistent with combination of iron deficiency anemia and anemia
of chronic disease. No evidence of GI bleed in-house and guiaic
serially negative. Will require outpatient colonoscopy for
routine screening.
#Charcot foot complicated by pressure ulcer: Followed by
podiatry. Cast was removed on the day of discharge. Ulcer
healed. Scheduled for outpatient podiatry follow up.
Transitional:
# Will require close follow up with PCP on discharge from rehab
for ongoing diabetes management
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lisinopril 10 mg PO QHS
2. Atorvastatin 10 mg PO QPM
3. FoLIC Acid 1 mg PO DAILY
4. Metoprolol Succinate XL 25 mg PO QAM
5. Naltrexone 50 mg PO DAILY
6. TraZODone 50-100 mg PO QHS:PRN Insomnia
7. Glargine 24 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
8. Venlafaxine XR 225 mg PO DAILY
9. Multi Complete with Iron (multivitamin-iron-folic acid)
___ mg-mcg oral DAILY
10. Thiamine 100 mg PO DAILY
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
2. Cyanocobalamin 1000 mcg PO DAILY
3. Ibuprofen 600 mg PO Q8H:PRN Pain - Moderate
4. OxyCODONE (Immediate Release) ___ mg PO Q6H:PRN Pain -
Moderate
To be used while working with ___ at rehab
RX *oxycodone 5 mg ___ tablet(s) by mouth every 6 hours Disp
#*30 Tablet Refills:*0
5. Glargine 22 Units Bedtime
Humalog 6 Units Breakfast
Humalog 6 Units Lunch
Humalog 6 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
6. Atorvastatin 10 mg PO QPM
7. FoLIC Acid 1 mg PO DAILY
8. Lisinopril 10 mg PO QHS
9. Metoprolol Succinate XL 25 mg PO QAM
10. Multi Complete with Iron (multivitamin-iron-folic acid)
___ mg-mcg oral DAILY
11. Thiamine 100 mg PO DAILY
12. TraZODone 50-100 mg PO QHS:PRN Insomnia
13. Venlafaxine XR 225 mg PO DAILY
14. HELD- Naltrexone 50 mg PO DAILY This medication was held.
Do not restart Naltrexone until you are discharged from rehab
and are no longer taking oxycodone
Discharge Disposition:
Extended Care
Facility:
___
___)
Discharge Diagnosis:
___
ETOH abuse
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 the hospital after a fall. You suffered a
fracture of your arm and were also found to be in ___. You were
treated in the ICU for DKA and then transferred to the medical
floor. You were seen by the ___ team who assisted with your
insulin management. You will require ongoing outpatient follow
up in their clinic.
You were seen by the social worker for your alcohol use and were
provided with resources to assist with abstinence.
You were also evaluated by the orthopedic team, who advised
follow up in the trauma clinic 1 week after your discharge. You
are scheduled for these appointments.
While you were here the orthopedic tech removed the cast on your
foot, but you should follow up with your podiatrist as below.
It was a pleasure to be a part of your care,
Your ___ treatment team
Followup Instructions:
___
|
19681724-DS-18
| 19,681,724 | 28,243,811 |
DS
| 18 |
2183-02-22 00:00:00
|
2183-02-22 13:51:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: PODIATRY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Left Foot Infection
Major Surgical or Invasive Procedure:
___: L foot debridement w vac
___: Left Lower Extremity Angiogram
___: Left Foot Achilles tendon lengthening, Anterior
tibialis tendon lengthening, Wound debridement
History of Present Illness:
___ type 1 diabetes with left foot Charcot, well-known to the
podiatry service presents for evaluation of a chronic left foot
wound. He presented to clinic today and was found to have a
worsening wound that now probes to bone to the left foot. There
was also found to be some surrounding erythema/edema. It was
recommended he be admitted for IV abx and will likely require
surgical debridement with possible resection of bone. Labs from
earlier today ordered by PCP shows ___ WBC 12.0. He has been
ambulating ___ a CAM boot. He denies any f/c/n/v/
Past Medical History:
-EtOH abuse- history of anxiety and hallucinosis with
withdrawal. No seizures
-IDDM- type 1, previously followed with ___ and ___ pump
usage. Complicated by L foot ulcer and charcot joint. Numerous
admissions for DKA. Retinopathy and neuropathy
-HTN
-Prostate cancer s/p prostatectomy
-L great toe osteomyelitis s/p amputation
Social History:
___
Family History:
Notable for lung cancer and metastatic prostate cancer ___ his
father, who was diagnosed of prostate cancer ___ his ___. His
mother has arthritis, so does his sister. It was unclear what
kind of arthritis his sister has. His older brother has
hyperthyroidism. There is no family history of colon cancer.
His maternal grandmother died of myelodysplastic syndrome, which
eventually turned into a full blown leukemia.
Physical Exam:
Admission Physical Exam:
Vitals:
General: A&Ox3, NAD, Pleasant
HEENT: Anicteric, no pallor
HEART: RRR
LUNGS: No Resp distress, CTAB
ABD: Soft, Non-tender, non-distended
___:
___ normal palpable bilaterally Refill less than 3 seconds to
all remaining digits. Gross sensation diminished left plantar
lateral midfoot full-thickness ulceration with red granular
base. Central lateral portion of the wound with necrotic
appearance, probes to bone which is also exposed, likely the
cuboid. Hyperkeratotic macerated borders. Erythema present
surrounding the wound. No purulence appreciated. Foot is warm
to touch. Erythema is localized to area around the wound and is
not streaking. No signs of any obvious fluctuance or fluid
collections. No signs of any soft tissue crepitus.
Discharge Physical Exam:
Vitals:AVSS
General: A&Ox3, NAD, Pleasant
HEENT: Anicteric, no pallor
HEART: RRR
LUNGS: No Resp distress, CTAB
ABD: Soft, Non-tender, non-distended
___: Dry surgical dressing intact with Bi valve cast ___ place
Pertinent Results:
___ 10:08AM BLOOD WBC-12.0*# RBC-4.06* Hgb-11.4* Hct-35.4*
MCV-87 MCH-28.1 MCHC-32.2 RDW-13.8 RDWSD-43.8 Plt ___
___ 06:02PM BLOOD Neuts-73.9* Lymphs-14.9* Monos-7.8
Eos-1.7 Baso-0.9 Im ___ AbsNeut-8.03* AbsLymp-1.62
AbsMono-0.85* AbsEos-0.18 AbsBaso-0.10*
___ 10:08AM BLOOD UreaN-24* Creat-1.3* Na-142 K-4.8 Cl-101
HCO3-25 AnGap-16
___ 10:08AM BLOOD Glucose-174*
___ 10:08AM BLOOD ALT-18 AST-17 AlkPhos-174* TotBili-<0.2
___ 10:08AM BLOOD Albumin-4.1 Calcium-9.6 Mg-2.3
Cholest-140
___ 10:08AM BLOOD %HbA1c-8.6* eAG-200*
___ 06:25PM BLOOD Lactate-1.8
IMAGING:
Left Foot Xray ___:
Impression: Deep soft tissue ulceration at the level of the base
of fifth metatarsal with apparent uncovered bone demonstrating
subtle cortical lucency, difficult to exclude early
osteomyelitis at this level
Discharge:
___ 05:25AM BLOOD WBC-10.4*# RBC-3.56* Hgb-9.8* Hct-30.7*
MCV-86 MCH-27.5 MCHC-31.9* RDW-13.8 RDWSD-43.3 Plt ___
___ 05:25AM BLOOD Plt ___
___ 05:25AM BLOOD Glucose-135* UreaN-17 Creat-1.0 Na-142
K-4.2 Cl-105 HCO3-26 AnGap-11
___ 05:25AM BLOOD Calcium-9.0 Phos-3.3 Mg-1.8
Micro:
___ 12:45 pm TISSUE Site: FOOT LEFT FOOT BONE.
**FINAL REPORT ___
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
2+ ___ per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS AND SINGLY.
1+ (<1 per 1000X FIELD): GRAM POSITIVE ROD(S).
TISSUE (Final ___:
MIXED BACTERIAL FLORA.
This culture contains mixed bacterial types (>=3) so an
abbreviated workup is performed. Any growth of
P.aeruginosa,
S.aureus and beta hemolytic streptococci will be
reported. IF
THESE BACTERIA ARE NOT REPORTED, THEY ARE NOT PRESENT
___ this
culture.
ACINETOBACTER BAUMANNII COMPLEX. SPARSE GROWTH.
"Note, for Amp/sulbactam, higher-than-standard dosing
needs to be
used, since therapeutic efficacy relies on intrinsic
activity of
the sulbactam component".
STAPH AUREUS COAG +. RARE GROWTH.
Staphylococcus species may develop resistance during
prolonged
therapy with quinolones. Therefore, isolates that are
initially
susceptible may become resistant within three to four
days after
initiation of therapy. Testing of repeat isolates may
be
warranted.
SENSITIVITIES: MIC expressed ___
MCG/ML
_________________________________________________________
ACINETOBACTER BAUMANNII COMPLEX
| STAPH AUREUS COAG +
| |
AMPICILLIN/SULBACTAM-- <=2 S
CEFEPIME-------------- 2 S
CEFTAZIDIME----------- 4 S
CIPROFLOXACIN--------- =>4 R
CLINDAMYCIN----------- <=0.25 S
ERYTHROMYCIN---------- <=0.25 S
GENTAMICIN------------ <=1 S <=0.5 S
LEVOFLOXACIN---------- 4 I 0.25 S
MEROPENEM-------------<=0.25 S
OXACILLIN------------- 0.5 S
PIPERACILLIN/TAZO----- <=4 S
TETRACYCLINE---------- <=1 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S <=0.5 S
ANAEROBIC CULTURE (Final ___: NO ANAEROBES ISOLATED.
Brief Hospital Course:
The patient was admitted to the podiatric surgery service from
clinic on ___ for a R foot infection. On admission, he was
started on broad spectrum antibiotics. He was taking to the OR
for a L foot debridement w/vac on ___. Pt was evaluated by
anesthesia and taken to the operating room. There were no
adverse events ___ the operating room; please see the operative
note for details. Afterwards, pt was taken to the PACU ___ stable
condition, then transferred to the ward for observation.
He was taking to the OR for a an angiogram with vascular surgery
on ___. Pt was evaluated by anesthesia and taken to the
operating room. There were no adverse events ___ the operating
room; please see the operative note for details. Afterwards, pt
was taken to the PACU ___ stable condition, then transferred to
the ward for observation.
He was taking to the OR for debridement, TAL, ATL on ___.
Pt was evaluated by anesthesia and taken to the operating room.
There were no adverse events ___ the operating room; please see
the operative note for details. Afterwards, pt was taken to the
PACU ___ stable condition, then transferred to the ward for
observation.
Post-operatively, the patient remained afebrile with stable
vital signs; pain was well controlled oral pain medication on a
PRN basis. The patient remained stable from both a
cardiovascular and pulmonary standpoint. He was placed on
Unasyn while hospitalized and discharged with IV antibiotics.
His intake and output were closely monitored and noted to be
adequate. The patient received
Lovenox throughout admission; early and frequent ambulation were
strongly encouraged. ___ was consulted and managed your
glucose levels while you were ___ house. Vascular surgery was
consulted and recommended an angio. Infectious disease was
consulted and recommended 6weeks of Iv antibiotics and follow up
with them. Orthopedic Surgery was consulted and the pt is able
to use crutches without any restriction. ___ was consulted and
the patient will be going home with services.
The patient was subsequently discharged to home on POD 13 with
IV antibiotics, ___ for vac changes, and home physical therapy.
The patient received discharge teaching and follow-up
instructions with understanding verbalized and agreement with
the discharge plan.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin-Caffeine-Butalbital ___ CAP PO Q6H:PRN Headache
2. Acetaminophen 650 mg PO Q4H:PRN Pain - Mild
3. Atorvastatin 20 mg PO QPM
4. Famotidine 20 mg PO BID
5. FoLIC Acid 1 mg PO DAILY
6. LamoTRIgine 100 mg PO DAILY
7. Lisinopril 20 mg PO QHS
8. Metoprolol Succinate XL 75 mg PO DAILY
9. Multivitamins 1 TAB PO DAILY
10. Thiamine 100 mg PO DAILY
11. Topiramate (Topamax) 25 mg PO QHS curb cravings
12. Venlafaxine XR 225 mg PO DAILY
13. Glargine 34 Units Bedtime
Humalog 7 Units Breakfast
Humalog 7 Units Lunch
Humalog 7 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
Discharge Medications:
1. Ampicillin-Sulbactam 3 g IV Q6H
RX *ampicillin-sulbactam 3 gram 1 vial every six (6) hours Disp
#*126 Vial Refills:*0
2. Aspirin-Caffeine-Butalbital ___ CAP PO Q6H:PRN Headache
Do not exceed 6 tablets/day
3. OxyCODONE (Immediate Release) ___ mg PO Q6H:PRN Pain -
Moderate
RX *oxycodone 5 mg ___ tablet(s) by mouth Q4-6H:PRN Disp #*30
Tablet Refills:*0
4. Glargine 28 Units Bedtime
Humalog 10 Units Breakfast
Humalog 10 Units Lunch
Humalog 10 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
5. Acetaminophen 650 mg PO Q4H:PRN Pain - Mild
6. Atorvastatin 20 mg PO QPM
7. Famotidine 20 mg PO BID
8. FoLIC Acid 1 mg PO DAILY
9. LamoTRIgine 100 mg PO DAILY
10. Lisinopril 20 mg PO QHS
11. Metoprolol Succinate XL 75 mg PO DAILY
12. Multivitamins 1 TAB PO DAILY
13. Thiamine 100 mg PO DAILY
14. Topiramate (Topamax) 25 mg PO QHS curb cravings
15. Venlafaxine XR 225 mg PO DAILY
16.Outpatient Physical Therapy
Crutches
DX:Left Foot Infection
PX: Good
___: 13 months
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Left Foot Infection
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr. ___,
It was a pleasure taking care of you at ___. You were admitted
to the Podiatric Surgery service for your left foot surgery. You
were given IV antibiotics while here. You are being discharged
home with the following instructions:
ACTIVITY:
There are restrictions on activity. Please remain non weight
bearing to your L foot until your follow up appointment. You
should keep this site elevated when ever possible (above the
level of the heart!)
No driving until cleared by your Surgeon.
PLEASE CALL US IMMEDIATELY FOR ANY OF THE FOLLOWING PROBLEMS:
Redness ___ or drainage from your leg wound(s).
New pain, numbness or discoloration of your foot or toes.
Watch for signs and symptoms of infection. These are: a fever
greater than 101 degrees, chills, increased redness, or pus
draining from the incision site. If you experience any of these
or bleeding at the incision site, CALL THE DOCTOR.
Exercise:
Limit strenuous activity for 6 weeks.
No heavy lifting greater than 20 pounds for the next ___ days.
Try to keep leg elevated when able.
BATHING/SHOWERING:
You may shower immediately upon coming home, but you must keep
your dressing CLEAN, DRY and INTACT. You can use a shower bag
taped around your ankle/leg or hang your foot/leg outside of the
bathtub.
Avoid taking a tub bath, swimming, or soaking ___ a hot tub for 4
weeks after surgery or until cleared by your physician.
MEDICATIONS:
Unless told otherwise you should resume taking all of the
medications you were taking before surgery.
Remember that narcotic pain meds can be constipating and you
should increase the fluid and bulk foods ___ your diet. (Check
with your physician if you have fluid restrictions.) If you feel
that you are constipated, do not strain at the toilet. You may
use over the counter Metamucil or Milk of Magnesia. Appetite
suppression may occur; this will improve with time. Eat small
balanced meals throughout the day.
DIET:
There are no special restrictions on your diet postoperatively.
Poor appetite is not unusual for several weeks and small,
frequent meals may be preferred.
FOLLOW-UP APPOINTMENT:
Be sure to keep your medical appointments.
If a follow up appointment was not made prior to your discharge,
please call the office on the first working day after your
discharge from the hospital to schedule a follow-up visit. This
should be scheduled on the calendar for seven to fourteen days
after discharge. Normal office hours are ___
through ___.
PLEASE FEEL FREE TO CALL THE OFFICE WITH ANY OTHER CONCERNS OR
QUESTIONS THAT MIGHT ARISE.
Followup Instructions:
___
|
19681724-DS-19
| 19,681,724 | 21,134,366 |
DS
| 19 |
2184-12-14 00:00:00
|
2184-12-14 14:49:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
L foot ulceration and infection
Major Surgical or Invasive Procedure:
Wound debridement, osteoectomy, VAC dressg placement
History of Present Illness:
Mr. ___ is a ___ male who is followed ___ ___ clinic for a
chronic plantar left foot wound secondary to Charcot foot. The
wound has been showing signs of healing and granulation.
However, upon presentation to the clinic today, there was
concern for deeper involvement given a tunnel to bone. It was
decided that he would benefit from presentation to the ED,
admission to the
hospital, and eventual surgical debridement of the wound.
___ the ED, initial VS were 99.6 98 124/66 16 98% RA.
Labs notable for BUN/Cr of ___. H/H of 10.8/33.2.
The patient received IV vancomycin and NS.
He was seen by podiatry who recommended admission to medicine,
non-invasive arterial studies, and then vascular surgery
consult. They do not plan to take him to the OR tomorrow
pending.
Upon arrival to the floor, the patient reports his wound "looks
like a ___ He has noted bony protuberances at 12 oclock
and 6 oclock. He reports that his wound is always draining and
is very sensitive. He manages the pain at home with 650 mg
aspirin because he found it to be the most effective over the
counter regimen. He denies fevers, chills, chest pain, shortness
of
breath, abdominal pain, diarrhea. He denies changes ___ urinary
frequency. He reports that his sugars have recently been
trending up.
Past Medical History:
- EtOH abuse - history of anxiety and hallucinosis with
withdrawal
- IDDM- type 1, previously followed with ___ and ___ pump
usage. Complicated by L foot ulcer and charcot joint. Numerous
admissions for DKA. Retinopathy and neuropathy
- HTN
- Prostate cancer s/p prostatectomy
- L great toe osteomyelitis s/p amputation
- Erectile dysfunction
- Prostate Cancer s;p radical prostatectomy
- Multiple foot surgeries
- Penile prosthesis placement
Social History:
___
Family History:
Father with lung cancer and prostate cancer.
Physical Exam:
ADMISSION EXAM
VITALS: Afebrile and vital signs stable (see eFlowsheet)
GENERAL: Alert and ___ no apparent distress
EYES: Anicteric, pupils equally round
ENT: Ears and nose without visible erythema, masses, or trauma.
Oropharynx without visible lesion, erythema or exudate
Mucous membranes moist
CV: Heart regular, no murmur
RESP: Lungs clear to auscultation with good air movement
bilaterally
BACK: No CVA tenderness
GI: Abdomen soft, non-distended, non-tender to palpation
MSK: Neck supple, moves all extremities, strength grossly full
and symmetric bilaterally ___ all limbs
SKIN: 4.5 x 4.5 x 0.5 ulcer noted on plantar surface of left
foot, with white granulation tissue surrounding, bone appears
visible
NEURO: Alert, oriented, face symmetric, gaze conjugate with
EOMI,
speech fluent, moves all limbs
PSYCH: pleasant, appropriate affect
DISCHARGE EXAM
Vital Signs: 98.3 ___ RA
glucose:
.
GEN: NAD, well-appearing, lying ___ bed, interactive, pleasant
EYES: PERRL, EOMI, conjunctiva clear, anicteric
ENT: moist mucous membranes, no exudates
NECK: supple
CV: RRR s1s2 nl, no m/r/g
PULM: CTA, no r/r/w
GI: normal BS, NT/ND, no HSM
SKIN: VAC dressing ___ place. c/d/i
SKIN: no rashes
NEURO: alert, oriented x 3, answers ? appropriately, follows
commands, non focal
PSYCH: appropriate
ACCESS: PICC line
Pertinent Results:
ADMISSION LABS
==============
___ 06:00PM BLOOD WBC-8.8 RBC-3.59* Hgb-10.8* Hct-33.2*
MCV-93 MCH-30.1 MCHC-32.5 RDW-12.6 RDWSD-42.5 Plt ___
___ 06:00PM BLOOD ___ PTT-31.8 ___
___ 06:00PM BLOOD Glucose-239* UreaN-29* Creat-1.1 Na-142
K-4.7 Cl-97 HCO3-28 AnGap-17
___ 06:20AM BLOOD Calcium-8.4 Phos-2.6*
___ 06:00PM BLOOD CRP-80.2*
IMAGING/DIAGNOSTICS
===================
# Noninvasive Arterial study ___:
Normal triphasic flow on the right side.
Tibial disease on the left side with monophasic flow.
# Angiogram (___): 1. Real-time ultrasound-guided retrograde
access to the right common femoral artery and placement of a
___ sheath. 2. Selective catheterization of the left
external iliac artery, second order vessel. 3. Left lower
extremity angiogram.
FINDINGS: 1. Patent left common femoral, profunda femoris and
superficial femoral arteries.
2. Patent popliteal artery.
3. Three-vessel runoff to the foot via the anterior tibial
artery, posterior tibial artery and peroneal artery. There is
evidence of diffuse small vessel disease within the foot with a
hyperemic enhancement of the plantar foot ulcer area. The left
posterior tibial artery did appear disease throughout its
course; however, there was no flow-limiting stenoses.
Therefore, no intervention was attempted.
# L plantar foot wound debridement, ostectomy, wound vac
placement ___.
# L PICC line ___
MICRO
=====
___ 1:18 pm SWAB Source: L foot.
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
3+ ___ per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS AND SINGLY.
3+ ___ per 1000X FIELD): GRAM NEGATIVE ROD(S).
WOUND CULTURE (Preliminary):
WORKUP OF ANY VIRIDANS STREP SPECIES REQUESTED BY ___
___
___.
MIXED BACTERIAL FLORA.
This culture contains mixed bacterial types (>=3) so an
abbreviated workup is performed. Any growth of
P.aeruginosa,
S.aureus and beta hemolytic streptococci will be
reported. IF
THESE BACTERIA ARE NOT REPORTED, THEY ARE NOT PRESENT
___ this
culture.
STREPTOCOCCUS MITIS/ORALIS. SPARSE GROWTH.
SENSITIVITIES: MIC expressed ___
MCG/ML
_________________________________________________________
STREPTOCOCCUS MITIS/ORALIS
|
CEFTRIAXONE-----------<=0.12 S
CLINDAMYCIN----------- =>1 R
ERYTHROMYCIN---------- =>8 R
PENICILLIN G----------<=0.06 S
VANCOMYCIN------------ 0.5 S
ANAEROBIC CULTURE (Final ___: NO ANAEROBES ISOLATED.
___ 10:00 am BLOOD CULTURE 2 OF 2.
**FINAL REPORT ___
Blood Culture, Routine (Final ___:
STREPTOCOCCUS MITIS/ORALIS. FINAL SENSITIVITIES.
SENSITIVITIES: MIC expressed ___
MCG/ML
_________________________________________________________
STREPTOCOCCUS MITIS/ORALIS
|
CEFTRIAXONE-----------<=0.12 S
CLINDAMYCIN----------- =>1 R
ERYTHROMYCIN---------- =>8 R
PENICILLIN G----------<=0.06 S
VANCOMYCIN------------ 0.5 S
Aerobic Bottle Gram Stain (Final ___:
GRAM POSITIVE COCCI ___ PAIRS AND CHAINS.
Reported to and read back by ___ ___ ___ 8:30AM.
___ 11:57 am TISSUE Site: FOOT LEFT FOOT BONE.
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
SMEAR REVIEWED; RESULTS CONFIRMED.
TISSUE (Preliminary):
MIXED BACTERIAL FLORA.
This culture contains mixed bacterial types (>=3) so an
abbreviated workup is performed. Any growth of
P.aeruginosa,
S.aureus and beta hemolytic streptococci will be
reported. IF
THESE BACTERIA ARE NOT REPORTED, THEY ARE NOT PRESENT
___ this
culture.
ENTEROCOCCUS SP.. RARE GROWTH.
WORK UP REQUESTED PER ___ (___) ___ 17:13.
ANAEROBIC CULTURE (Final ___: NO ANAEROBES ISOLATED.
Brief Hospital Course:
HOSPITAL COURSE: Mr. ___ is a ___ h/o DM1, charcot
foot, and chronic plantar left foot wound, admitted due to
concern for osteomyelitis and infected foot ulcer.
# Infected foot wound with suspected osteomyelitis
# Sepsis and GPC bacteremia
# PVD with LLE tibial disease
MR. ___ was admitted with infected L plantar foot ulcer. Given
size and deep probing to the bone, likely osteomyelitis. He was
initially treated with IV vanco/cefepime/flagyl. While ___ the
hospital, he had high fevers ___ while on abx with associated
rigors, tachycardia, headache, and vomiting. Improved after
Tylenol and Zofran, and resolved after >24 hours on abx. Blood
cx returned positive for strep mitis (from time of fever)
sensitive to vanco. He was continued on the abx - and seen by
vascular and podiatry surgery. Due to concerns regarding blood
perfusion, he underwent angiography ___ - which revealed no
clear intervenable lesion (no revascularization). On ___, he
underwent L plantar foot wound debridement, ostectomy, wound vac
placement without complications. PICC line was placed ___.
The tissue from the operation revealed multiple bacteria,
including possibly enterococcus. For this reason, he was
transitoned to IV Zosyn and then later Dapto and Ertapenem. The
Dapto is for likely VRE (enterococcus vanco sensitivities still
pending).
After the debridement, there was bone exposure - and thus
wound vac dressing was recommended by podiatry until adequate
granulation/healing was noted. He was given an outpt vac
dressing on discharge - and will be changed with assistance of
___. Podiatry reportedly will consider the option of graft
over the wound, once the abx course is completed. He is - NWB
LLE while vac ___ place. ___ consult was obtained and a commode
was provided for him to minimze pressure applied onto the foot.
Training on IV abx was provided. Due to the interaction
between daptomycin and statin, the statin was held - and can be
resumed once the abx course is completed.
# Type I DM:
Patient takes 17 units of glargine QHS and takes Humalog based
on carbohydrate counting and sliding scale. He was continued on
glargine 17 units QHS, meal coverage (estimating needs since
patient notes insulin/carb ratio not feasible ___ hospital), SSI.
He was kept on Diabetic diet with supplements
# Anemia:
Admission H/H of 10.8/33.2, within prior baseline. No signs or
symptoms of active bleeding. This was monitored during the
hospitalization.
# Depression/mental health:
- Continue Venlafaxine XR 225 mg PO DAILY
- Continue LamoTRIgine 100 mg PO DAILY
# HTN:
- Continue Lisinopril 20 mg PO QHS
- Continue Metoprolol Succinate XL 75 mg PO DAILY
# HLD:
- Continue Atorvastatin 40 mg PO QPM
GENERAL/SUPPORTIVE CARE:
# VTE prophylaxis: subQ heparin
# Contacts/HCP/Surrogate and Communication:
Name of health care proxy: ___
Relationship: sister
Phone number: ___
# Code Status/ACP: full presumed
# Disposition:
- Anticipate discharge to: Home w/services
- Anticipated discharge date: today
=============================
=============================
>30 minutes spent ___ patient care and coordination of discharge
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. LamoTRIgine 100 mg PO DAILY
2. Venlafaxine XR 225 mg PO DAILY
3. Lisinopril 20 mg PO QHS
4. Atorvastatin 40 mg PO QPM
5. Metoprolol Succinate XL 75 mg PO DAILY
6. Multivitamins 1 TAB PO DAILY
7. B Complex 1 (vitamin B complex) oral DAILY
8. Glargine 17 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
9. Aspirin 650 mg PO DAILY:PRN pain medications
10. TraZODone 100 mg PO QHS:PRN sleep
Discharge Medications:
1. Daptomycin 450 mg IV Q24H
RX *daptomycin 500 mg 450 mg IV Q24H Disp #*37 Vial Refills:*0
2. Ertapenem Sodium 1 g IV ONCE Duration: 1 Dose
DAILY
RX *ertapenem 1 gram 1 gm IV Q24H Disp #*37 Vial Refills:*0
3. B Complex 1 (vitamin B complex) 1 tab oral DAILY
4. Glargine 17 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
5. Metoprolol Succinate XL 50 mg PO DAILY
6. Aspirin 650 mg PO DAILY:PRN pain medications
7. LamoTRIgine 100 mg PO DAILY
8. Lisinopril 20 mg PO QHS
9. Multivitamins 1 TAB PO DAILY
10. TraZODone 100 mg PO QHS:PRN sleep
11. Venlafaxine XR 225 mg PO DAILY
12. HELD- Atorvastatin 40 mg PO QPM This medication was held.
Do not restart Atorvastatin until the end of daptomycin
13.Commode
Beside Commode
Dx: chronic plantar foot ulceration
Px: Good
___: 13 months
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
L foot plantar ulcer, osteomyelitis
DM type 1
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 looking after you. As you know, you were
admitted with a worsening foot infection. You underwent
debridement, bone resection (part of infection), and vac
dressing placement. Cultures of the wound revealed multiple
bacteria - which will be treated with the antibiotics
(Daptomycin and Ertapenem). This should be taken for total of 6
weeks. You will be followed by the infectious disease and
podiatry teams to follow up on your wound progress and to decide
the duration of the antibiotics and whether any additional
treatment/interventions are needed.
Due to the interaction between daptomycin and atorvastatin,
we would recommend holding the statin for the time you are on
the IV daptomycin. You may restart it thereafter.
Your other medications otherwise remain unchanged. We wish
you good health and quick recovery.
Your ___ Team
Followup Instructions:
___
|
19681724-DS-20
| 19,681,724 | 27,272,777 |
DS
| 20 |
2185-02-26 00:00:00
|
2185-02-28 23:56:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
amoxicillin
Attending: ___.
Major Surgical or Invasive Procedure:
Left PICC placement ___
Left foot debridement, resection ___ metatarsal base, ___
metatarsal bone biospy, vac application ___
attach
Pertinent Results:
ADMISSION LABS:
===============
___ 06:05PM BLOOD WBC-13.5* RBC-3.76* Hgb-10.0* Hct-31.6*
MCV-84 MCH-26.6 MCHC-31.6* RDW-14.3 RDWSD-44.1 Plt ___
___ 06:05PM BLOOD Neuts-79.7* Lymphs-10.3* Monos-6.9
Eos-1.9 Baso-0.4 Im ___ AbsNeut-10.72* AbsLymp-1.38
AbsMono-0.93* AbsEos-0.25 AbsBaso-0.06
___ 06:05PM BLOOD Glucose-181* UreaN-31* Creat-1.5* Na-139
K-4.5 Cl-99 HCO3-24 AnGap-16
___ 06:36AM BLOOD Calcium-8.7 Phos-2.7 Mg-1.7
___ 06:21PM BLOOD Lactate-1.4
MICRO:
======
___ 11:21PM STOOL CDIFPCR-NEG
___ 1:15 pm TISSUE
**FINAL REPORT ___
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
TISSUE (Final ___:
WORK UP REQUESTED PER ___ ___ ___.
MIXED BACTERIAL FLORA.
This culture contains mixed bacterial types (>=3) so an
abbreviated workup is performed. Any growth of
P.aeruginosa,
S.aureus and beta hemolytic streptococci will be
reported. IF
THESE BACTERIA ARE NOT REPORTED, THEY ARE NOT PRESENT
in this
culture.
STAPH AUREUS COAG +. SPARSE GROWTH.
Oxacillin RESISTANT Staphylococci MUST be reported as
also
RESISTANT to other penicillins, cephalosporins,
carbacephems,
carbapenems, and beta-lactamase inhibitor combinations.
RIFAMPIN should not be used alone for therapy.
Daptomycin Susceptibility testing requested per ___.
___
(___) ___.
Daptomycin MIC 1 MCG/ML test result performed by Etest.
VIRIDANS STREPTOCOCCI. SPARSE GROWTH.
ENTEROCOCCUS SP.. RARE GROWTH.
Daptomycin & Susceptibility testing requested per ___.
___ (___)
___.
Daptomycin MIC 2.0 MCG/ML = SUSCEPTIBLE test result
performed by
Etest.
CORYNEBACTERIUM SPECIES (DIPHTHEROIDS). RARE GROWTH.
OF TWO COLONIAL MORPHOLOGIES.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
| ENTEROCOCCUS SP.
| |
AMPICILLIN------------ <=2 S
CLINDAMYCIN----------- =>8 R
DAPTOMYCIN------------ S
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- =>8 R
OXACILLIN------------- =>4 R
PENICILLIN G---------- 1 S
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------ 1 S <=0.5 S
ANAEROBIC CULTURE (Final ___: NO ANAEROBES ISOLATED.
IMAGING:
=========
DX ANKLE & FOOT ___
Large ulceration along the plantar and lateral aspect of the
midfoot with osteomyelitis of the fourth and fifth metatarsals
and cuboid.
FOOT AP,LAT & OBL LEFT ___
S/p debridement and wound VAC placement at the fourth and fifth
tarsometatarsal joints. Diffuse demineralization. Status post
prior
resection of the first metatarsal, unchanged from prior. Severe
degenerative changes of the second metatarsophalangeal joint.
Diffuse demineralization. Osseous fragment and long the
proximal aspect of the base of fifth metatarsal, may be related
to prior trauma. Deformity of the second and third metatarsals,
may be related to prior trauma. Atherosclerotic vascular
calcifications. Scattered degenerative changes of the foot.
Large skin defect is noted along the lateral aspect of the
distal midfoot at the level of tarsometatarsal joint.
Evaluation of the base of fourth and fifth metatarsals is
limited due to overlying densities.
PATHOLOGIC DIAGNOSIS:
1. Fifth metatarsal base, left, resection:
- Acute osteomyelitis.
2. Fourth metatarsal base, left, biopsy:
- Acute osteomyelitis.
DISCHARGE LABS:
===============
___ 06:20AM BLOOD WBC-7.6 RBC-3.43* Hgb-9.1* Hct-29.1*
MCV-85 MCH-26.5 MCHC-31.3* RDW-14.9 RDWSD-44.8 Plt ___
___ 06:20AM BLOOD Glucose-341* UreaN-21* Creat-0.9 Na-139
K-4.8 Cl-104 HCO3-28 AnGap-7*
___ 06:37AM BLOOD CK(CPK)-26*
___ 06:20AM BLOOD Calcium-8.8 Phos-3.0 Mg-2.0
Brief Hospital Course:
PATIENT SUMMARY
=================
Mr. ___ is a ___ yo man with history of T1DM, charcot foot, and
chronic plantar left foot wound, admitted for management of
osteomyelitis and infected foot ulcer. He underwent
uncomplicated left foot debridement. ID was consulted and he was
started on a 6-week course of Daptomycin (Cubicin) and Ertapenem
(Invanz).
TRANSITIONAL ISSUES
====================
[] OPAT instructions:
LAB MONITORING RECOMMENDATIONS: NOTE: For lab work to be drawn
after discharge, a specific standing order for Outpatient Lab
Work is required to be placed in the Discharge Worksheet -
Post-Discharge Orders. Please place an order for Outpatient Labs
based on the MEDICATION SPECIFIC GUIDELINE listed below:
ALL LAB RESULTS SHOULD BE SENT TO:
ATTN: ___ CLINIC - FAX: ___
NAFCILLIN,CEFTRIAXONE,MEROPENEM,ERTAPEMEN: WEEKLY: CBC with
differential, BUN, Cr, AST, ALT, Total Bili, ALK PHOS
DAPTOMYCIN: WEEKLY: CBC with differential, BUN, Cr, CPK
ADDITIONAL ORDERS:
*PLEASE OBTAIN WEEKLY CRP for patients with bone/joint
infections
and endocarditis or endovascular infections
[] Patient was recommended to be non-weight bearing on his left
foot for optimal healing, however has been partial weight
bearing - podiatry aware
[] Glucose sensor is not functioning appropriately - recommend
to do finger stick BG checks in the meantime. Additionally BGs
have been poorly controlled and pt may need insulin adjustment
as outpatient. Attempted to facilitate appointment at ___
however was unable - patient instructed to call to make
appointment.
MEDICATION CHANGES:
- NEW:
- Loperamide, Daptomycin, Ertapenem
- CHANGED
- Insulin: Glargine 17U bedtime, Humalog 10U TID with meals and
sliding scale
ACUTE ISSUES
=============
___ and ___ metatarsal osteomyelitis
#Peripheral vascular disease
Probed to bone in clinic prior to admission. Patient presented
without fevers, but did have leukocytosis and XR findings
consistent with osteomyelitis. He underwent uncomlpicated left
foot debridement, resection ___ metatarsal base, ___ metatarsal
bone biospy, and vac application on ___. He was initially
treated with vanc/zosyn, then IV vanc, ceftriaxone, and PO
metronidazole. ID was consulted and he was discharged on
Daptomycin (Cubicin) and Ertapenem (Invanz) with plan for a 6
week course (projected end date ___.
#Type I DM
Last A1c 10.5% ___. Follows with endocrinologist at
___.
Treated with glargine 17 units QHS, humalog 10 units with meals
and SSI (Start @150, 20:1 correction). Of note, glucose sensor
is not functioning as does not correlate with finger sticks or
serum BGs. Attempted to facilitate outpatient follow-up at
___ but no appointments available until ___. Pt instructed
to call to schedule appointment.
#Diarrhea
C diff negative. Likely due to antibiotics given timing and
history of diarrhea in setting of antibiotics. Managed
symptomatically with loperamide PRN.
#Acute kidney injury
Likely pre-renal given history of decrease PO intake and
improvement with IVFs. Cr remained stable and wnl for remainder
of admission.
CHRONIC ISSUES:
===============
# Anemia:
Admission H/H within prior baseline. No signs or symptoms of
active bleeding. This was monitored during the hospitalization
and remained stable.
# Depression
- Continued venlafaxine XR 225 mg PO DAILY
- Continued lamotrigine 100 mg PO DAILY
# HTN
- Initially held lisinopril in setting of ___. Restarted once
___ resolved.
- Continued metoprolol succinate XL 75 mg PO DAILY
# HLD
- Continued atorvastatin 40 mg PO ___ 81mg qd
This patient was prescribed, or continued on, an opioid pain
medication at the time of discharge (please see the attached
medication list for details). As part of our safe opioid
prescribing process, all patients are provided with an opioid
risks and treatment resource education sheet and encouraged to
discuss this therapy with their outpatient providers to
determine if opioid pain medication is still indicated.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Metoprolol Succinate XL 75 mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 40 mg PO ___
4. Lisinopril 20 mg PO DAILY
5. LamoTRIgine 100 mg PO DAILY
6. Glargine 17 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
7. TraZODone 50-100 mg PO QHS:PRN insomnia
8. Multi-Betic (multivit-min-FA-lycop-lutn-ala) 0.2-1.5-0.5-50
mg oral DAILY
9. vitamin B complex-folic acid 0.4 mg oral DAILY
10. Venlafaxine XR 225 mg PO DAILY
Discharge Medications:
1. Daptomycin 450 mg IV Q24H
2. Ertapenem Sodium 1 g IV ONCE Duration: 1 Dose
daily
3. LOPERamide 2 mg PO QID:PRN diarrhea
4. OxyCODONE (Immediate Release) 5 mg PO Q8H:PRN Pain -
Moderate
RX *oxycodone 5 mg 1 tablet(s) by mouth q8hrs Disp #*5 Tablet
Refills:*0
5. Glargine 17 Units Bedtime
Humalog 10 Units Breakfast
Humalog 10 Units Lunch
Humalog 10 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
6. Aspirin 81 mg PO DAILY
7. Atorvastatin 40 mg PO ___
8. LamoTRIgine 100 mg PO DAILY
9. Lisinopril 20 mg PO DAILY
10. Metoprolol Succinate XL 75 mg PO DAILY
11. Multi-Betic (multivit-min-FA-lycop-lutn-ala) 0.2-1.5-0.5-50
mg oral DAILY
12. TraZODone 50-100 mg PO QHS:PRN insomnia
13. Venlafaxine XR 225 mg PO DAILY
14. vitamin B complex-folic acid 0.4 mg oral DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary diagnosis:
Osteomyelitis
Secondary diagnoses:
Acute kidney injury
Type 1 diabetes mellitus
-Anemia
-Diarrhea
-Depression
-Hypertension
-Hyperlipidemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a privilege taking care of you at ___
___.
WHY WAS I IN THE HOSPITAL?
-You were admitted because you were found to have an infection
in your foot.
WHAT HAPPENED TO ME IN THE HOSPITAL?
You were treated with IV antibiotics and you had surgery to
remove the infected portion of your foot.
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
- Continue to take all your medicines and keep your
appointments.
- Cultures of the wound revealed multiple bacteria - which will
be treated with the antibiotics Daptomycin (Cubicin) and
Ertapenem (Invanz). This should be taken for total of 6 weeks.
You will be followed by the infectious disease and podiatry
teams to follow up on your wound progress and to decide the
duration of the antibiotics and whether any additional
treatment/interventions are needed.
We wish you the best.
Sincerely,
Your ___ Team
Followup Instructions:
___
|
19681894-DS-14
| 19,681,894 | 22,469,577 |
DS
| 14 |
2201-01-03 00:00:00
|
2201-01-03 18:09:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Irinotecan / barium
Attending: ___
Chief Complaint:
Urinary Retention
Major Surgical or Invasive Procedure:
Foley catheter placed ___
2U PRBC Transfusion ___
History of Present Illness:
See admission h&p. In short ___ w/ metastatic rectal cancer s/p
resection of liver metastases, RUL lobectomy, mediastinal LN
dissection, 2 endobronchial ablation and several cycles
chemotherapy (started panitunumab on ___ c/b b/l
hydronephrosis s/p on ___ b/l double-J ureteral stents who is
p/w urinary retention found to have renal failure.
Past Medical History:
Past ONCOLOGY history per OMR: She presented with
rectal bleeding and was treated with surgery and adjuvant ___
and radiation. In ___, she was found to have liver metastases,
which were resected, and she was treated with adjuvant
irinotecan. Several years later, scan showed increasing lung
nodules and she was started on bevacizumab and irinotecan.
Eventually, she progressed and in ___ had a right upper
lobectomy with mediastinal lymph node dissection by Dr.
___. She also required a left mainstem endobronchial
lesion ablation in late ___ and again in ___. Because of
progression in multiple sites by ___, she was given irinotecan
and she had a severe allergic reaction. In ___, she was
transitioned to capecitabine, which might have precipitated
arrhythmia. Sometime in ___, she had a rash which was
attributed to the capecitabine, so she was transitioned to
Avastin. The Avastin eventually caused hypertension and it
looked like her disease progressed on it. She was then put onto
capecitabine again on ___, and she has stayed on
that continuously and she has done quite well on it over ___
and
___, tolerating it well without rashes; however, she has had a
slow rise in her CEA, and a CT scan on ___, which
showed a few millimeters of progression and multiple lung
nodules.
___ Cycle #1 CapeOx (___ ___ 50% for ant. tol)
___ Cycle #2 CapeOx (___ ___ 67% for ant. tol)
___ Cycle #3 CapeOx (oxali ___ 67% for ant. tolerance)
___: CapeOx held, GI, rising markers
___ Cycle #1 W#1 Cetuxumab
___ C#1 W#2 cetuximab
___ C#1 W#3 cetuximab
___ C#1 W#4 cetuximab
___ C#2 W#1 cetuximab
___ C#2 W#2 cetuximab
___ C#2 W#3 cetuximab
___: C2 W4 Cetiximab
___: C3 W1 Cetiximab
___: C3 W#3 cetuximab
___ C#3 W#4 cetuximab
___ CT + response, C#4 two week dose start today
___ C5 D#1 & D15
___ C6 D#1 & D15
___ C7 D#1 & D#15
___ restaging CT: progression
___ capecitabine 1000mg bid x 14d, weekly cetuximab
___ C#1 d#8 ___ & cetux
___ C#1 D#15 cetux
___ C#1 D#22 cetux
___ Admit ___ flank pain, CT bilat
hydronephrosis
___ Stents placed Dr. ___ & d/c home
___ Transfuse 2U PRBC, give Mg, hold cetuximab
Social History:
___
Family History:
Mother had colon cancer, father had a stroke. She has two
healthy brothers.
Physical Exam:
VITAL SIGNS: 98 118/76
General: NAD, resting in bed comfortably
HEENT: MMD
PULM: CTAB, respirations unlabored
ABD: BS+, soft, NTND
LIMBS: No ___, no calf tenderness
SKIN: + warm erythema along the right antecubital area that is
within the marked borders seems slightly improved today with new
few petechia and now new small patch of erythema that is warm on
the left antecubital area
NEURO: Grossly WNL
GU: Foley in place draining clear pink urine
DERMATOLOGY CONSULT NOTE EXAM:
Skin Type: II
- on right antecubital fossa is a warm, edematous erythematous
plaque with deeper red center and lighter periphery. Mild
fissuring and crust in center. Erythema extends beyond drawn
marker.
- on the left antecubital fossa are pink papules coalescing in
to
plaques with mild scale
- on the lower mucosal lip are two punched out erosions
- diffuse xerosis
- no nail changes
Pertinent Results:
___ 05:30AM BLOOD WBC-5.3 RBC-2.79* Hgb-8.6* Hct-26.4*
MCV-95 MCH-30.8 MCHC-32.6 RDW-20.3* RDWSD-69.2* Plt ___
___ 05:30AM BLOOD Glucose-95 UreaN-21* Creat-1.8* Na-138
K-4.4 Cl-111* HCO3-20* AnGap-11
___ 05:43AM BLOOD ALT-11 AST-22 LD(LDH)-156 AlkPhos-107*
TotBili-0.2
___ 05:30AM BLOOD Calcium-8.5 Phos-3.9 Mg-1.5*
___ 05:43AM BLOOD calTIBC-283 VitB12-178* Folate-19.1
Ferritn-79 TRF-218
___ 05:43AM BLOOD TSH-2.3
___ 09:25AM BLOOD CEA-50*
Brief Hospital Course:
___ w/ metastatic rectal cancer s/p resection of liver
metastases, RUL lobectomy, mediastinal LN dissection, 2
endobronchial ablation and several cycles chemotherapy (started
panitunumab on ___ c/b b/l hydronephrosis s/p on ___ b/l
double-J ureteral stents who is p/w urinary retention.
#Urinary Retention
Has known locally advanced and metastatic rectal cancer c/b b/l
obstruction s/p double-J ureteral stents ___. Was taking
oxybutynin for bladder spasms which may have lead to the urinary
retention ___. No UTI. Urology recommended 7 day course of a
foley and outpatient f/u w/ urology to discuss nephrostomy tubes
- received daily foley teaching
- oxybutynin prn bladder spasms
- D1 foley: ___
#R Arm Erythema
#L Arm erythema
She developed on ___ RUE erythema right above the antecubital
fossa. It
appeared to be a classic cellulitis. However on ___ she
developed the same
rash on the left antecubital fossa. She has not had venipuncture
or IV
access since over a month ago. ___ ruled out DVT or
abscess.
Atypical for Panitumumab rash or drug rash. Was seen
by dermatology who thought this was most likely Eczematous
dermatitis
with a possible component of cellulitis. She was treated with
Cefazolin
on ___ when the rash first appeared on the R arm and she was
instructed to
continue a ten day course of Keflex. She was also started on
triamcinolone ointment.
- continue wound care
- f/u Lyme serologies
- continue eucerin, cera ve, or cetaphil
- she was given the phone number to Dermatology to f/u PRN
#Acute Kidney Injury
Likely due to post-renal obstruction, exacerbated by ACEI.
Improving.
- discontinued lisinopril
- cont foley until urology follow up
#Rectal Cancer
On C1 Panitumumab (Vectibix).
- f/u Dr. ___ week
#Atrial Flutter
#SVT
- cont asa 81
- stopped lisinopril
#Hypomagnasemia
Potentially can be caused/exacerbated by Panitumumab
- repleting judiciously in setting ___ but now ___,
___ need to watch closely
#Anemia
Slightly macrocytic. Likely from antineoplastic therapy. Also
had
blood loss yesterday from foley trauma. B12 low and was started
on repletion. MMA was not checked as it is a send-out and will
be elevated in setting of renal failure.
- 2U PRBC on ___
- initiated B12 repletion ___
DVT PROPHYLAXIS: HSQ BID
CODE STATUS: Full
ACCESS: PORT
DISPO: home w/ ___
BILLING: >30 min spent coordinating care for discharge
______________
___, D.O.
Heme/___ Hospitalist
___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lisinopril 5 mg PO DAILY
2. Lorazepam 0.5-1 mg PO Q4H:PRN nausea or anxiety or insomnia
3. Oxybutynin 5 mg PO DAILY:PRN bladder spasms
4. Prochlorperazine 10 mg PO Q6H:PRN nausea
5. Diazepam 2.5 mg PO QHS
6. Aspirin 81 mg PO DAILY
7. Magnesium Oxide 400 mg PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Diazepam 2.5 mg PO QHS
3. Lorazepam 0.5-1 mg PO Q4H:PRN nausea or anxiety or insomnia
RX *lorazepam 0.5 mg ___ tabs by mouth q4h prn Disp #*30 Tablet
Refills:*0
4. Oxybutynin 5 mg PO DAILY:PRN bladder spasms
5. Prochlorperazine 10 mg PO Q6H:PRN nausea
6. Cyanocobalamin 1000 mcg PO DAILY
RX *cyanocobalamin (vitamin B-12) 1,000 mcg 1 tablet(s) by mouth
daily Disp #*30 Tablet Refills:*0
7. Hydrocerin 1 Appl TP BID
RX *white petrolatum-mineral oil [Eucerin] apply BID
Refills:*0
8. Triamcinolone Acetonide 0.1% Ointment 1 Appl TP BID
RX *triamcinolone acetonide 0.1 % apply topically to b/l arm
redness twice a day Refills:*0
9. Magnesium Oxide 800 mg PO TID
RX *magnesium oxide 400 mg 2 capsule(s) by mouth three times a
day Disp #*120 Capsule Refills:*0
10. Cephalexin 500 mg PO Q8H Duration: 8 Days
RX *cephalexin 500 mg 1 tablet(s) by mouth every eight (8) hours
Disp #*23 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Acute Kidney Injury
Urinary Retention
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 retaining
urine. You had a foley inserted and you improved. You also
received 2 units of blood for your anemia. You were found to
have a very low vitamin b12 level. Please talk to your
oncologist about your vitamin b12. You also have a very low
magnesium level. Please talk to your oncologist about adjusting
the dose!
While you were here, you had an eczematous dermatitis with
possible cellulitis of both of your arms. You improved with IV
antibiotic. You were seen by dermatology and they recommended
triamcinolone ointment in addition to a moisturizer to keep your
skin moist. If you would like to follow up with dermatology, you
were seen by Dr. ___. Her clinic number is Our clinic
phone number for the patient to have: ___.
Take care,
Your ___ team
Followup Instructions:
___
|
19681894-DS-15
| 19,681,894 | 24,287,295 |
DS
| 15 |
2201-02-13 00:00:00
|
2201-02-13 14:44:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Irinotecan / barium
Attending: ___.
Chief Complaint:
hypotension, fever, ___
Major Surgical or Invasive Procedure:
___: Successful placement of bilateral ___ F percutaneous
nephrostomy tubes.
___: Bedside removal of Left Ureteral Stent, R was
attempted to be removed but failed due to significant resistance
___: Urgent cystoscopy: R stent was removed successfully
and a ___ x 26 cm JJ ureteral stent was placed in the
right side to ensure ureteral healing
___: Removal of R percutaneous nephrostomy tube
History of Present Illness:
___ with hx metastatic colon cancer s/p resections and
currently on chemo c/b ureteral obstructions s/p bilateral
stenting presenting with urosepsis. She went to ___ urology
earlier today complaining of malaise and SOB for two weeks.
While there a renal US showed new severe left sided
hydronephrosis even with bilateral stents in place. A Cr was
found to be elevated from baseline of 2.0 to 5.3.
She was transferred to ___ for further care and interventional
radiology. She had a Tmax of 102.6 while in the ER and was
given Tylenol, 2L NS and Ceftriaxone. She was sent to ___ for
bilateral percutaneous nephrostomy tubes. While in ER there was
difficult placement with the tube on the left and once placed it
started draining frank pus. She then began rigoring, became
tachycardic and had a decrease in mental status.
Notably she was diagnosed with colon cancer in ___ and had a
period of remission after lung/liver resections and chemo. In
___ she was found to have a recurrence with a large
rectal mass and obstructive acute renal failure for which
bilateral ureteral stents were placed. She is currently on
chemo, most recently getting Panitumumab on ___ with plan for
next dose in 2 days. She had a foley in place on discharge
which was removed 2 days prior to presentation but has had poor
urine output since that time.
WBC 10.3, referred in for possible nephrostomy tubes placement.
In the ED, initial vitals: 100.0 94 126/43 16 100% RA
On arrival to the MICU, pt no longer rigoring and has not
complaints except for groin ___ horse and dry mouth.
Bilateral PCN tubes and foley in place.
Past Medical History:
Past ONCOLOGY history per OMR: She presented with
rectal bleeding and was treated with surgery and adjuvant ___
and radiation. In ___, she was found to have liver metastases,
which were resected, and she was treated with adjuvant
irinotecan. Several years later, scan showed increasing lung
nodules and she was started on bevacizumab and irinotecan.
Eventually, she progressed and in ___ had a right upper
lobectomy with mediastinal lymph node dissection by Dr.
___. She also required a left mainstem endobronchial
lesion ablation in late ___ and again in ___. Because of
progression in multiple sites by ___, she was given irinotecan
and she had a severe allergic reaction. In ___, she was
transitioned to capecitabine, which might have precipitated
arrhythmia. Sometime in ___, she had a rash which was
attributed to the capecitabine, so she was transitioned to
Avastin. The Avastin eventually caused hypertension and it
looked like her disease progressed on it. She was then put onto
capecitabine again on ___, and she has stayed on
that continuously and she has done quite well on it over ___
and
___, tolerating it well without rashes; however, she has had a
slow rise in her CEA, and a CT scan on ___, which
showed a few millimeters of progression and multiple lung
nodules.
___ Cycle #1 CapeOx (___ ___ 50% for ant. tol)
___ Cycle #2 CapeOx (___ ___ 67% for ant. tol)
___ Cycle #3 CapeOx (___ ___ 67% for ant. tolerance)
___: CapeOx held, GI, rising markers
___ Cycle #1 W#1 Cetuxumab
___ C#1 W#2 cetuximab
___ C#1 W#3 cetuximab
___ C#1 W#4 cetuximab
___ C#2 W#1 cetuximab
___ C#2 W#2 cetuximab
___ C#2 W#3 cetuximab
___: C2 W4 Cetiximab
___: C3 W1 Cetiximab
___: C3 W#3 cetuximab
___ C#3 W#4 cetuximab
___ CT + response, C#4 two week dose start today
___ C5 D#1 & D15
___ C6 D#1 & D15
___ C7 D#1 & D#15
___ restaging CT: progression
___ capecitabine 1000mg bid x 14d, weekly cetuximab
___ C#1 d#8 ___ & cetux
___ C#1 D#15 cetux
___ C#1 D#22 cetux
___ Admit ___ flank pain, CT bilat
hydronephrosis
___ Stents placed Dr. ___ & d/c home
___ Transfuse 2U PRBC, give Mg, hold cetuximab
Metastatic colon cancer s/p liver and RUL resections and
endobronchial ablations, HTN, afib/SVT since age ___, ARF s/p
bilateral ureteral obstruction
Social History:
___
Family History:
Mother had colon cancer, father had a stroke. She has two
healthy brothers.
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: T: 98.3 BP: 117/44 P: 106 R: 32 O2: 99% 2L
GENERAL: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
NECK: supple, JVP not elevated, no LAD
LUNGS: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi. Mildly tachypneic
CV: tachycardic, regular rhythm, holosystolic ___ murmur, no
rubs, gallops
ABD: soft, non-tender, non-distended, bowel sounds present, no
rebound tenderness or guarding, no organomegaly. Ostomy with
soft brown stool.
GU: Foley with very scant blood tinged urine. Bilateral PCN
tubes with left with more bloody/opaque.
EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis. 2+
non-pitting edema to knees bilaterally
SKIN: right index finger with old laceration. Bilateral PCN
tubes in place.
NEURO: A&Ox3, strength ___ throughout, non-focal
DISCHARGE PHYSICAL EXAM:
VS - 98.5 144/76 94 18 98%RA
GENERAL: Well-appearing, sitting up in bed, color better today
HEENT: MMM, OP clear without lesions
CARDS: RRR no MRG
PULM: CTAB nonlabored
ABD: SNT ND Normal BS. L PCN clear yellow urine
EXT: No peripheral edema, warm
Pertinent Results:
ADMISSION Labs:
WBC 9.2 with 77% PMN, Hgb 8.0, Hct 24.2, Plt 209
___: 23.8 PTT: 35.1 INR: 2.2
Lactate:1.1
Na 129 K 4.8 Cl 98 HCO3 17 BUN 52 Cr 5.0 BG 92 AGap=19
Ca: 7.4 Mg: 1.2
LFT WNL except for albumin 2.5
CEA: 57
UA: lg blood, lg leuk, >300 protein, >182 RBC, >182 WBC, mod
bacteria
DISCHARGE LABS:
___ 05:20AM BLOOD WBC-9.1 RBC-3.20*# Hgb-9.4*# Hct-27.7*#
MCV-87 MCH-29.4 MCHC-33.9 RDW-17.2* RDWSD-53.9* Plt ___
___ 05:20AM BLOOD Glucose-77 UreaN-20 Creat-1.9* Na-133
K-3.3 Cl-107 HCO3-17* AnGap-12
___ 05:20AM BLOOD Mg-1.7
IMAGING:
Renal US (___)
No significant interval change to the appearance of the kidneys
with bilateral severe hydronephrosis and multiple renal stones.
Debris in the left collecting system is unchanged and may
reflect presence of infection.
___ PCN placmenet
FINDINGS:
1. Bilateral severe hydronephrosis. Purulent drainage from the
left kidney collecting system was obtained. Samples for
microbiology testing were sent from both collecting systems.
2. Successful placement of bilateral ___ F percutaneous
nephrostomy tubes.
___ U/S ___ IMPRESSION:
No evidence of deep venous thrombosis in the visualized right or
left lower extremity deep veins.
Echo
The left atrium is normal in size. The estimated right atrial
pressure is ___ mmHg. 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. Tissue Doppler imaging suggests a
normal left ventricular filling pressure (PCWP<12mmHg). Right
ventricular chamber size and free wall motion are normal. The
diameters of aorta at the sinus, ascending and arch levels are
normal. The aortic valve leaflets (3) appear structurally normal
with good leaflet excursion and no aortic stenosis or aortic
regurgitation. No masses or vegetations are seen on the aortic
valve, but cannot be fully excluded due to suboptimal image
quality. The mitral valve appears structurally normal with
trivial mitral regurgitation. There is no mitral valve prolapse.
No masses or vegetations are seen on the mitral valve, but
cannot be fully excluded due to suboptimal image quality. No
masses or vegetations are seen on the tricuspid valve, but
cannot be fully excluded due to suboptimal image quality. The
estimated pulmonary artery systolic pressure is normal. No
vegetation/mass is seen on the pulmonic valve. There is no
pericardial effusion.
IMPRESSION: Normal biventricular size and systolic function. No
2D echocardiographic evidence of endocarditis with the
limitation of very poor apical image quality. No pathologic
valvular flow.
Renal U/S ___
IMPRESSION:
The right nephrostomy tube may well be lying outside the
collecting system.
RECOMMENDATION(S): Right nephrostogram of a CT scan
recommended.
CT ab Nephrostogram ___
IMPRESSION:
Limited examination given noncontrast examination.
1. Malpositioned right percutaneous nephrostomy tube, with tip
outside of the renal pelvis in the posterior pararenal fat.
2. Interval improvement in bilateral hydronephrosis, though
there is
persistent right-sided hydronephrosis.
3. Large rectal mass, incompletely evaluated, with extension
towards the
bladder and presacral space, with associated with osseous
involvement of the sacrum. Peritoneal carcinomatosis is noted
particularly in the right upper quadrant.
4. Interval increase in the masslike opacity in the left lower
lobe,
concerning for progression of metastatic disease, do patient may
also have
superimposed atelectasis.
5. New small bilateral pleural effusions as well as
interlobular septal
thickening concerning for pulmonary edema.
Brief Hospital Course:
___ w/ metastatic rectal cancer with multiple complications
including b/l malginant hydronephrosis s/p b/l double-J ureteral
stents who p/w septic shock from MSSA pyelonephritis, and renal
failure s/p urgent b/l PCN ___..
#Septic shock: Pt admitted to MICU w/ fevers and hypotension
despite IVF resuscitation, did require pressors transiently.
Transferred to floor ___ and has remained HD stable. Source
control as below
#MSSA pyelonephritis w/ bacteremia - ___ have been related to
stent infection, pus present at time of PCN placement. urine and
blood cx ___ + MSSA
- Continue nafcillin 2g q4h x 4 weeks, D1 ___ (Vanc ___,
end date ___. Patient will f/u in ___ clinic
- pt underwent removal of pre-existing ureteral stents
- all subsequent cultures negative
- TTE did not show vegetations
#Malignant Hydronephrosis - ___ pelvic mass had pre-exising
ureteral stents. in setting of sepsis and renal failure
underwent
urgent bilateral PCN placement ___.
- ureteral stents removed on ___, left ureteral stent removed
on the floor followed by right ureteral stent removal in the OR
as was difficult and required urgent cystoscopy, was replaced
with new 6 x 26 cm JJ ureteral stent
- foley removed ___ and pt w/ some bladder UOP
- Renal US ___ showed possible malposition of the R
nephrostomy
which had not been draining urine, this was removed on ___,
renal function and UOP remained stable
- she will f/u in ___ clinic in ___ weeks for R stent
removal
# ___ on CKD - obstructive as above. recent Cr baseline 1.5 -
2.0, peaked at 5.3 this admission, has now gradually improved to
prior baseline. hydronephrosis improved post PCN placemenet
# Bilat ___ edema - likely due to renal dysfunction in setting of
large volume IVF resuscitation in setting of sepsis. LENIs
negative ___. cont compression stockings.
# Metabolic acidosis - ___ ___ on CKD as above. Increased sodium
bicarb on ___ w/ increasing nausea. switched to Calcium
carbonate, bicarb stable after stopping as Cr improving
# Anemia: ACD in setting of malignancy and chemotherapy.
requiring intermittent transfusions (last 2 unit PRBCs ___
# Coagulopathy: likely nutritional or related to antibiotics.
has
now resolved after total 7.5 mg vit K.
#high ostomy output: per pt this is chronic, she is typically on
loperamide and opium. C diff testing negative
# h/o Afib - s/p ablation, never on anticoag. In sinus on EKG on
admit. Cont ASA daily
# Dermatitis: has hx chronic rash. Dermatology evaluated and
recommended steroid cream and emollients, pt uses triamcinolone
and clobetasol at home
# Colorectal cancer: currently on chemo (most recently ___:
Panitumumab) and being evaluated for phase I anti-PDL1 trial
- she will f/u Dr. ___ on ___ to discuss chemo
>30 min spent coordinating care for discharge inc home care for
IV antibiotics
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Lorazepam 0.5-1 mg PO Q4H:PRN nausea or anxiety or insomnia
3. Prochlorperazine 10 mg PO Q6H:PRN nausea
4. Triamcinolone Acetonide 0.1% Ointment 1 Appl TP BID:PRN itch
5. Magnesium Oxide 400 mg PO DAILY
6. Opium Tincture (morphine 10 mg/mL) 3 mg PO Q6H:PRN pain
7. loperamide 2 mg oral TID diarrhea
8. Clobetasol Propionate 0.05% Ointment 1 Appl TP BID:PRN rash
9. Vaseline White Petroleum (white petrolatum) topical
BID:PRN rash
10. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
11. Hydrocodone-Acetaminophen (5mg-325mg) 1 TAB PO Q4H:PRN pain
Discharge Medications:
1. Nafcillin 2 g IV Q4H
RX *nafcillin in dextrose iso-osm 2 gram/100 mL 2 g IV every 4
hours Disp #*108 Intravenous Bag Refills:*0
2. Aspirin 81 mg PO DAILY
3. Lorazepam 0.5-1 mg PO Q4H:PRN nausea or anxiety or insomnia
RX *lorazepam 0.5 mg 0.5 (One half) mg by mouth every 4 hours as
needed Disp #*60 Tablet Refills:*0
4. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
RX *oxycodone 5 mg 1 tablet(s) by mouth every 4 hours as needed
Disp #*60 Tablet Refills:*0
5. Clobetasol Propionate 0.05% Ointment 1 Appl TP BID:PRN rash
6. loperamide 2 mg oral TID diarrhea
7. Magnesium Oxide 400 mg PO DAILY
8. Opium Tincture (morphine 10 mg/mL) 3 mg PO Q6H:PRN pain
can also be used to slow ostomy output
9. Prochlorperazine 10 mg PO Q6H:PRN nausea
10. Triamcinolone Acetonide 0.1% Ointment 1 Appl TP BID:PRN itch
11. Hydrocodone-Acetaminophen (5mg-325mg) 1 TAB PO Q4H:PRN pain
RX *hydrocodone-acetaminophen 5 mg-325 mg 1 tablet(s) by mouth
every 4 hours as needed Disp #*60 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Septic Shock from MSSA bacteremia and pyelonephritis
Severe Hydronephrosis
Anemia
Renal Failure
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear ___,
___ was a pleasure taking care of you in the hospital. You were
admitted because of an infection of your kidneys. You had two
nephrostomy tubes placed and you had your left ureter stent
removed. Your right ureter stent was attempted to be removed but
because it was a difficult removal, it was changed with a
different stent. The external tube on the right was then
removed.
You were found to have an infection called Staph Aureus in your
urine that spread into the blood. Hence you will need IV
antibiotics for a total of 4 weeks, with the last date
tentatively scheduled on ___.
You also had anemia which was treated with blood transfusion.
You will need to follow up with the urology team within the next
week to have your new right ureteral stent removed.
You will follow up with Dr ___ as well as scheduled.
Regards,
Your ___ Team
Followup Instructions:
___
|
19681894-DS-16
| 19,681,894 | 27,241,641 |
DS
| 16 |
2202-06-21 00:00:00
|
2202-06-21 14:41:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Irinotecan / barium / capecitabine / Readi-Cat
Attending: ___.
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
___ x5 sessions
History of Present Illness:
Ms. ___ is a ___ female with history of
diffusely metastatic colorectal cancer to the liver and lung
complicated by RML obstruction s/p tumor debridement on ___,
ureteral obstruction and CKD III s/p bilateral nephrostomy
tubes,
and colostomy who presents as a transfer from ___ with CT
concerning for mass infiltrating right pulmonary artery.
The patient reports she has been having worsening shortness of
breath over the last 2 weeks. Notes dyspnea with minimal
exertion
and even speaking few word sentences. She denies fevers. Reports
her chronic cough and mildly worse. No sick contacts. Pulse ox
via ___ ___ was 87% RA. She was unable to make it out to
clinic due to the snow storm. She presented to her outpatient
cancer clinic at ___ on ___ where she was referred to ___ for CXR and CTA with concern for possible PE. She was
hypoxic on RA to ___ with improvement with NC oxygen. The
patient
had a CXR at ___ with possible pneumonia vs. worsening
metastatic disease. She was given cefepime and vancomycin and a
CTA chest was performed. The CT revealed mass infiltrating the
right pulmonary artery. She was transferred to ___ for further
care.
Past Medical History:
Past ONCOLOGY history per OMR: She presented with
rectal bleeding and was treated with surgery and adjuvant ___
and radiation. In ___, she was found to have liver metastases,
which were resected, and she was treated with adjuvant
irinotecan. Several years later, scan showed increasing lung
nodules and she was started on bevacizumab and irinotecan.
Eventually, she progressed and in ___ had a right upper
lobectomy with mediastinal lymph node dissection by Dr.
___. She also required a left mainstem endobronchial
lesion ablation in late ___ and again in ___. Because of
progression in multiple sites by ___, she was given irinotecan
and she had a severe allergic reaction. In ___, she was
transitioned to capecitabine, which might have precipitated
arrhythmia. Sometime in ___, she had a rash which was
attributed to the capecitabine, so she was transitioned to
Avastin. The Avastin eventually caused hypertension and it
looked like her disease progressed on it. She was then put onto
capecitabine again on ___, and she has stayed on
that continuously and she has done quite well on it over ___
and
___, tolerating it well without rashes; however, she has had a
slow rise in her CEA, and a CT scan on ___, which
showed a few millimeters of progression and multiple lung
nodules.
___ Cycle #1 CapeOx (oxali ___ 50% for ant. tol)
___ Cycle #2 CapeOx (oxali ___ 67% for ant. tol)
___ Cycle #3 CapeOx (oxali ___ 67% for ant. tolerance)
___: CapeOx held, GI, rising markers
___ Cycle #1 W#1 Cetuxumab
___ C#1 W#2 cetuximab
___ C#1 W#3 cetuximab
___ C#1 W#4 cetuximab
___ C#2 W#1 cetuximab
___ C#2 W#2 cetuximab
___ C#2 W#3 cetuximab
___: C2 W4 Cetiximab
___: C3 W1 Cetiximab
___: C3 W#3 cetuximab
___ C#3 W#4 cetuximab
___ CT + response, C#4 two week dose start today
___ C5 D#1 & D15
___ C6 D#1 & D15
___ C7 D#1 & D#15
___ restaging CT: progression
___ capecitabine 1000mg bid x 14d, weekly cetuximab
___ C#1 d#8 ___ & cetux
___ C#1 D#15 cetux
___ C#1 D#22 cetux
___ Admit ___ flank pain, CT bilat
hydronephrosis
___ Stents placed Dr. ___ & d/c home
___ Transfuse 2U PRBC, give Mg, hold cetuximab
Metastatic colon cancer s/p liver and RUL resections and
endobronchial ablations, HTN, afib/SVT since age ___, ARF s/p
bilateral ureteral obstruction
Social History:
___
Family History:
Mother had colon cancer, father had a stroke. She has two
healthy brothers.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: Temp 98.4, BP 154/73, HR 104, RR 18, O2 sat 98% 2L.
GENERAL: Pleasant, lying in bed comfortably.
EYES: Anicteric sclerea, PERLL, EOMI.
ENT: Oropharynx clear without lesion, JVD not elevated.
CARDIOVASCULAR: Regular rate and rhythm, no murmurs, rubs, or
gallops; 2+ radial pulses, 2+ DP pulses.
RESPIRATORY: Appears in no respiratory distress, scattered
rhonchi and crackles but good air movement bilaterally.
GASTROINTESTINAL: Normal bowel sounds; nondistended; soft,
non-tender without rebound or guarding, colostomy in LLQ
draining
light brown stool.
GU: Bilateral nephrostomy tubes draining serosanguinous fluid.
MUSKULOSKELATAL: Warm, well perfused extremities without lower
extremity edema; Normal bulk.
NEURO: Alert, oriented, CN II-XII intact, motor and sensory
function grossly intact.
SKIN: No significant rashes.
ACCESS: Right chest wall port without erythema.
DISCHARGE PHYSICAL EXAM:
VS: 98.6 93 142/75 22 96%2L
GENERAL: Pleasant, sitting up in bed comfortably in NAD
EYES: Anicteric sclera, PERLL, EOMI.
ENT: MMM, clear oropharynx
CARDIOVASCULAR: Regular rate and rhythm, no murmurs/rubs
appreciated
RESPIRATORY: Breathing comfortably, moving air well. CTAB aside
from mild crackles at left base.
GASTROINTESTINAL: Normal bowel sounds; nondistended; soft,
non-tender without rebound or guarding, colostomy in LLQ
draining
light brown liquid stool.
GU: Bilateral nephrostomy tubes draining clear pink-red urine
EXT: Warm, well perfused extremities without lower extremity
edema
NEURO: Alert, oriented, motor and sensory exam grossly intact
Pertinent Results:
Admission labs:
___ 08:15AM GLUCOSE-138* UREA N-24* CREAT-1.6* SODIUM-136
POTASSIUM-4.2 CHLORIDE-103 TOTAL CO2-24 ANION GAP-13
___ 08:15AM CALCIUM-8.6 PHOSPHATE-4.3 MAGNESIUM-1.8
___ 08:15AM WBC-3.2* RBC-2.49* HGB-8.2* HCT-25.1*
MCV-101* MCH-32.9* MCHC-32.7 RDW-13.9 RDWSD-51.1*
___ 08:05PM GLUCOSE-88 UREA N-21* CREAT-1.2* SODIUM-137
POTASSIUM-4.1 CHLORIDE-104 TOTAL CO2-22 ANION GAP-15
___ 08:05PM CALCIUM-8.6 PHOSPHATE-3.5 MAGNESIUM-1.7
___ 08:05PM WBC-4.3 RBC-2.78* HGB-9.0* HCT-28.0* MCV-101*
MCH-32.4* MCHC-32.1 RDW-13.9 RDWSD-51.7*
___ 08:05PM NEUTS-60.7 ___ MONOS-3.7* EOS-3.7
BASOS-0.5 IM ___ AbsNeut-2.59 AbsLymp-1.32 AbsMono-0.16*
AbsEos-0.16 AbsBaso-0.02
___ 08:05PM ___ PTT-31.3 ___
___ 07:45PM URINE COLOR-Yellow APPEAR-Hazy SP ___
___ 07:45PM URINE COLOR-Yellow APPEAR-Hazy SP ___
___ 07:45PM URINE BLOOD-LG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.5
LEUK-SM
___ 07:45PM URINE BLOOD-LG NITRITE-POS PROTEIN-100
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.5
LEUK-MOD
___ 07:45PM URINE RBC->182* WBC-23* BACTERIA-FEW
YEAST-NONE EPI-0
___ 07:45PM URINE RBC->182* WBC-17* BACTERIA-FEW
YEAST-NONE EPI-0
___ 10:55AM UREA N-26* CREAT-1.4* SODIUM-133
POTASSIUM-4.1 CHLORIDE-100 TOTAL CO2-23 ANION GAP-14
___ 10:55AM ALT(SGPT)-10 AST(SGOT)-23 ALK PHOS-149* TOT
BILI-0.4
___ 10:55AM TOT PROT-8.2 ALBUMIN-3.4* GLOBULIN-4.8*
CALCIUM-8.4 PHOSPHATE-4.0 MAGNESIUM-1.8
___ 10:55AM CEA-317.7*
___ 10:55AM WBC-4.3 RBC-2.77* HGB-9.1* HCT-27.4* MCV-99*
MCH-32.9* MCHC-33.2 RDW-14.0 RDWSD-50.4*
___ 10:55AM NEUTS-67.9 ___ MONOS-3.7* EOS-2.1
BASOS-0.5 IM ___ AbsNeut-2.92 AbsLymp-1.09* AbsMono-0.16*
AbsEos-0.09 AbsBaso-0.02
DISCHARGE LABS:
___ 08:15AM BLOOD WBC-3.2* RBC-2.49* Hgb-8.2* Hct-25.1*
MCV-101* MCH-32.9* MCHC-32.7 RDW-13.9 RDWSD-51.1* Plt ___
___ 06:14AM BLOOD WBC-3.4* RBC-2.38* Hgb-7.7* Hct-23.4*
MCV-98 MCH-32.4* MCHC-32.9 RDW-13.6 RDWSD-48.7* Plt Ct-91*
___ 05:48AM BLOOD WBC-2.2* RBC-2.20* Hgb-7.1* Hct-21.7*
MCV-99* MCH-32.3* MCHC-32.7 RDW-13.5 RDWSD-47.8* Plt Ct-87*
___ 05:16AM BLOOD WBC-1.9* RBC-2.96* Hgb-9.4* Hct-28.1*
MCV-95 MCH-31.8 MCHC-33.5 RDW-16.5* RDWSD-54.9* Plt Ct-86*
___ 05:16AM BLOOD Neuts-60 Bands-0 ___ Monos-5 Eos-5
Baso-0 ___ Myelos-0 AbsNeut-1.14* AbsLymp-0.57*
AbsMono-0.10* AbsEos-0.10 AbsBaso-0.00*
___ 06:14AM BLOOD ___ PTT-30.1 ___
___ 05:16AM BLOOD Glucose-82 UreaN-20 Creat-1.4* Na-134
K-4.2 Cl-101 HCO3-26 AnGap-11
___ 05:16AM BLOOD Calcium-8.1* Phos-3.9 Mg-2.5
___ 09:45PM BLOOD calTIBC-252* Ferritn-481* TRF-194*
___ 05:11AM BLOOD VitB12-162* Folate-13
MICRO:
___ Ucx x2 no growth
IMAGING:
___ Renal US
IMPRESSION:
1. Percutaneous nephrostomy tubes are seen within the renal
pelvises
bilaterally without evidence of hydronephrosis.
2. Bilateral urothelial thickening with increased echogenicity
of the
surrounding renal sinus fat is suggestive of inflammation.
___ Abd XR
IMPRESSION:
Bilateral nephrostomy tubes present. A more accurate evaluation
of their
position within the collecting system can be done with
ultrasound.
___ CXR
FINDINGS:
Lungs are well aerated. There are multiple bilateral patchy
opacities, which
are unchanged from most recent chest x-ray dated ___,
and correspond
to masses seen on chest CT from the same date. Prominent right
hilum is
unchanged, corresponding to mass seen on chest CT. No pleural
effusions. No
pneumothorax. Stable position of right-sided Port-A-Cath.
IMPRESSION:
Unchanged appearance of multiple bilateral lung masses.
Brief Hospital Course:
___ female with history of diffusely metastatic
colorectal cancer to the liver and lung complicated by RML
obstruction s/p tumor debridement on ___, ureteral
obstruction and CKD III s/p bilateral nephrostomy tubes, and
colostomy who presents as a transfer from ___ with
hypoxia
and chest CT concerning for mass infiltrating right pulmonary
artery.
# Metastatic Tumor Invading Right Pulmonary Artery:
# Dyspnea/Hypoxic Respiratory Distress with acute hypoxic
respiratory failure:
#Cough:
Evaluated by thoracic surgery, not felt to be surgical
candidate.
No clear thrombus, so will defer anticoagulation given risks of
hemorrhage. Started ___ to right hilar and mediastinal disease
on ___, completed 5 sessions ___. She was hemodynamically
stable thoughout admission. Ambulated around unit on RA several
times during admission without issue until the very end, when
she would desatted to 86-88% with dyspnea requiring 3 minutes of
2LNC to recover to mid-90s. HR 110s during this time, improved
from OSH when per her report it was 140s. Not on O2 at baseline,
but continues to have exertional dyspnea/hypoxia. She continues
to tolerate ambulation with
O2 supplementation well, however continues to require O2
supplementation
which she did not have previously and has intermittent increased
work of
breathing/tachypnea after speaking for some time. On discussion
with outpatient onc, most likely related to tumor burden and PA
involvement as well as hx of lobectomy. Could be partially due
to atelectasis from obstruction as below. CXR unchanged without
evidence of new pathology. Sx not much improved after
transfusion so less likely related to anemia. Appreciate rad onc
recs: expect increased cough after ___ take days to weeks
for radiation of tumors to lead to sx improvement. Tachypnea
could also be partially related to hypermetabolic state.
Appreciate IP recs: no interventional pulmonary intervention
needed at this time. Continued IS and guaifenesin, discharged on
home O2. No events on telemetry during admission, though had
some runs of frequent PACs, less likely Afib.
# Right Middle Lobe Obstruction: Found to have progressive
thoracic tumor burden in ___ with associated dyspnea.
Underwent underwent flexible and rigid bronchoscopy on ___
with debridement of RML tumor and balloon dilation; pathology
was
consistent with her known cancer. Had symptomatic improvement
following procedure. Has had at least three prior bronchoscopies
with tumor debridement in the past. Exam reassuring though
continues to have some crackles at left base, likely some
atelectasis. Discharged on O2 as above.
# Ureteral Obstruction:
# Bilateral Nephrostomy Tubes:
# Pyuria/Macroscopic Hematuria: Nephrostomy tubes functioning
well. Urine culture growing mixed flora, likely colonized.
Asymptomatic. Continues to have some blood from nephrostomy
tubes
(at baseline) as well as blood on urination (new). Hgb
downtrended though may be due to pancytopenia as below. Patient
contacted outpatient urology, who recommended discussing
retrograde nephrostogram with ___. Discussed with ___: US
reassuring that tubes are in correct location, given overall
stability without pain at the site or
severe bleeding/Hgb drop, would recommend outpatient monitoring.
Discussed with rad onc, if appears that bleeding is from tumor
could consider ___. If pain, reduced flow from tubes, or severe
bleeding would contact ___. Would discuss with oncology whether
evaluation by surgical or radiation oncology for abdominal
tumors is reasonable.
# Pancytopenia: All cell lines downtrending during admission
though largely stable prior to discharge and with appropriate
bounce in Hgb after transfusion of 2 units. Likely secondary to
malignancy and relatively recent chemotherapy. Per ___ onc,
given hx rectal cancer and dietary changes inherent to that dx,
at risk for folate/B12 deficiency. B12 and folate both
relatively low so started on supplementation. Hgb drop could
also be due to ongoing hematuria as
above. Iron studies were drawn after transfusion so can not
interpret effectively. Appreciate oncology recs: Drop in cells
c/w chemotx effect,
will possible effect of B12 and folate on RBC. Given CKD, EPO
deficiency is also possible. ANC 1100 on discharge. Would follow
up CBC in one week at oncology visit.
# Metastatic Rectal Cancer: Metastatic to bone and lung. She has
been treated with various treatments over the years with FOLFOX,
FOLFIRI, cetuximab, panitumumab, capecitabine, variations, and
also regorafenib. She started Lonsurf ___ which is currently
on hold. Continued vicodin for pain.
# Diarrhea: Related to colostomy and currently well-controlled
with loperamide. Continued home loperamide
# Stage III CKD: Cr 1.2 on admission, stable around baseline Cr
1.2-1.6. Continued home bicarb.
Transitional issues:
-Patient s/p 5 sessions of ___ follow up in one week with
oncology. Should discuss future treatment options including
restarting chemo and possibly radiation therapy or surgery to
abdominal tumors.
-Patient has chronic hematuria from nephrostomy tubes, should
follow with oncology to ensure stability. If pain, reduced
output, or severe bleeding should discuss ___ regarding
replacement.
-Pancytopenic during admission, likely ___ recent chemo,
discharge WBC 1.9 with ANC 1100. Discharge Hgb 9.4 and stable
after 2 units pRBC. Plt 86 on discharge. Should follow up in one
week with CBC/DIFF at oncology visit
-Discharged with home O2 due to continued ambulatory hypoxia ___
tumor burden.
EMERGENCY CONTACT HCP: ___ (husband/HCP) ___
CODE: Full Code
>30 min spent on discharge coordination on day of discharge
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lorazepam 1 mg PO Q6H:PRN insomnia/anxiety/nausea/vomiting
2. Opium Tincture (morphine 10 mg/mL) 3 mg PO Q6H:PRN loose
stools
3. Prochlorperazine 10 mg PO Q6H:PRN nausea
4. Triamcinolone Acetonide 0.1% Ointment 1 Appl TP BID:PRN rash
5. Hydrocodone-Acetaminophen (5mg-325mg) 1 TAB PO Q4H:PRN pain
6. Vitamin D ___ UNIT PO 1X/WEEK (FR)
7. LOPERamide 4 mg PO TID
8. Hydrocortisone Cream 2.5% 1 Appl TP BID:PRN rash
9. Sodium Bicarbonate 1300 mg PO TID
10. camphor-menthol 0.5-0.5 % topical QID:PRN itching
Discharge Medications:
1. Cyanocobalamin 1000 mcg PO DAILY
RX *cyanocobalamin (vitamin B-12) 1,000 mcg 1 tablet(s) by mouth
daily Disp #*30 Tablet Refills:*0
2. FoLIC Acid 1 mg PO DAILY
RX *folic acid 1 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
3. Guaifenesin-Dextromethorphan 5 mL PO Q4H:PRN cough
RX *dextromethorphan-guaifenesin 100 mg-10 mg/5 mL ___ mL by
mouth every four (4) hours Refills:*0
4. camphor-menthol 0.5-0.5 % topical QID:PRN itching
5. Hydrocodone-Acetaminophen (5mg-325mg) 1 TAB PO Q4H:PRN pain
6. Hydrocortisone Cream 2.5% 1 Appl TP BID:PRN rash
7. LOPERamide 4 mg PO TID
8. LORazepam 1 mg PO Q6H:PRN insomnia/anxiety/nausea/vomiting
9. Opium Tincture (morphine 10 mg/mL) 3 mg PO Q6H:PRN loose
stools
10. Prochlorperazine 10 mg PO Q6H:PRN nausea
11. Sodium Bicarbonate 1300 mg PO TID
12. Triamcinolone Acetonide 0.1% Ointment 1 Appl TP BID:PRN
rash
13. Vitamin D ___ UNIT PO 1X/WEEK (FR)
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary: Metastatic tumor with pulmonary arterial invasion,
hypoxia with acute hypoxic respiratory failure, dyspnea
Secondary: Ureteral obstruction with bilateral nephrostomy
tubes, hematuria, pancytopenia, metastatic rectal cancer,
diarrhea, chronic kidney disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were admitted to ___ after presenting to ___ with
shortness of breath, where you were found to have enlargement of
your lung tumor with invasion into one of your arteries. You
were treated with 5 sessions of radiation therapy at ___ to
shrink the tumor. You were evaluated for other causes of
shortness of breath and treated with a blood transfusion, but
you continued to require oxygen as a result of the tumor. You
were discharged home with supplemental oxygen.
You were also evaluated for increase blood from your kidney
tubes, but this appears largely stable and should be followed as
an outpatient.
Please follow up with your oncologist for further treatment
plans.
It was a pleasure caring for you,
Your ___ Care Team
Followup Instructions:
___
|
19682346-DS-10
| 19,682,346 | 25,477,763 |
DS
| 10 |
2179-09-06 00:00:00
|
2179-09-05 14:44:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
morphine / adhesive tape / contrast dye / Advair Diskus / iodine
/ Bactrim
Attending: ___.
Chief Complaint:
RLE pain
Major Surgical or Invasive Procedure:
Abscess drainage and drain placement ___
PICC placement ___
History of Present Illness:
Ms ___ is a ___ year old woman with DM, PVD, AKA of R leg ___
___, c/b MRSA and VRE infections treated for osteomyelitis
___
___, hx/o DVT, remote esophageal cancer, COPD, who presented
to the ED ___ transfer after presenting to her local ED with 2
weeks of worsening pain, erythema, and swelling of her stump.
She
initially underwent TKR ___ ___, which was c/b infections and
osteomyelitis requiring multiple debridements and eventually
AKA,
after which she also had multiple wound infections and required
multiple courses of daptomycin for osteo/SSTI. She was most
recently admitted at ___ ___ ___ for recurrent infection,
after which she completed a 6 week course of daptomycin. She
reports that since that time she has not had further
complications until her stump became progressively more painful
and swollen over the past two weeks. Initially this was felt to
be a musculoskeletal injury, but today she went to the ED for
further evaluation, where she underwent CT scan that showed a
4cmx4cmx4cm fluid collection c/f abscess, as well as concern for
bony erosion. She was transferred to the ___ ED for further
evaluation.
ED: 400 mg daptomycin IV administered and IV dilaudid 1 mg x2,
VS
unremarkable. Evaluated by orthopedic team who felt patient
should have ___ drain placed ___ AM
ROS:
Const: no fevers, chills, dizziness/LH
HEENT: no HA, changes ___ hearing or vision
CV: no CP
Pulm: no dyspnea
GI: no abd pain, n/v, c/d
GU: no dysuria or changes ___ urine
MSK: no new myalgias/arthralgias (except pain at stump)
Neuro: no new weakness/numbness
Hem: no new bleeding/bruising
Endo: no heat/cold intolerance
Skin: recent diaper rash, improved
Psych: no recent mood changes
Past Medical History:
-R AKA
-osteomyelitis
-esophageal cancer (s/p chemo, radiation, surgery, remote)
-DVT (patient believes this was ___ months ago, RUE DVT,
continues to take dabigatran)
-COPD
-Hyperlipidemia
-GERD
-IDDM
-PVD
-Morbid obesity
-Asthma
-Arthritis
-L eye cataract
-hernia repair x4
-depression
Social History:
___
Family History:
Mother died of stroke at ___. Father of MI at ___. Multiple family
members w/ DM
Physical Exam:
Admission Physical Exam:
VS: 99.2 148 / 53 80 18 93RA
gen: pt ___ NAD
HEENT: NC/AT, sclera anicteric, conjunctiva noninjected, PER,
EOMI, MMMs
CV: RRR no m/r/g
Pulm: CTAB mild scattered wheeze/rhonchi
Abd: S NT ND BS+ no HSM or masses
Extr: LLE mild edema, chronic stasis changes, RLE stump w/
erythema, induration, tenderness of anterior inferior aspect
Neuro: alert and interactive; grossly intact
Skin: as per above
Psych: normal range of affect
Discharge Physical Exam:
VS: reviewed; stable/unremarkable
gen: pt ___ NAD
HEENT: NC/AT, sclera anicteric, conjunctiva noninjected, PER,
EOMI, MMMs
CV: RRR no m/r/g
Pulm: CTAB
Abd: S NT ND BS+ no HSM or masses
Extr: LLE mild edema, chronic stasis changes, RLE w/ drain ___
place draining purulent material; mild tenderness at drain site
Neuro: alert and interactive; grossly intact
Skin: as per above
Psych: normal range of affect
Pertinent Results:
Notable for:
Anemia stable around ___, similar to prior levels
CK 16
CRP 113
ESR 97
CT RLE ___ read
Chronic fluid collection adjacent to distal femoral stump, and
probable
chronic osteomyelitis of the femoral stump.
MRI could also be considered to further evaluate soft tissue and
bony changes.
___ 06:30AM BLOOD WBC-6.9 RBC-3.54* Hgb-10.1* Hct-32.2*
MCV-91 MCH-28.5 MCHC-31.4* RDW-12.8 RDWSD-43.2 Plt ___
___ 06:30AM BLOOD Glucose-164* UreaN-23* Creat-0.9 Na-140
K-3.8 Cl-100 HCO3-30 AnGap-14
Blood cultures NGTD ___
Abscess ___:
GRAM STAIN (Final ___:
4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
3+ ___ per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS AND CLUSTERS.
FLUID CULTURE (Preliminary):
STAPH AUREUS COAG +. MODERATE GROWTH.
This isolate is presumed to be resistant to clindamycin
based on
the detection of inducible resistance .
Oxacillin RESISTANT Staphylococci MUST be reported as
also
RESISTANT to other penicillins, cephalosporins,
carbacephems,
carbapenems, and beta-lactamase inhibitor combinations.
Rifampin should not be used alone for therapy.
SENSITIVITIES: MIC expressed ___
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- =>8 R
OXACILLIN------------- =>4 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------ 1 S
ANAEROBIC CULTURE (Preliminary): NO ANAEROBES ISOLATED.
Brief Hospital Course:
___ year old woman with DM, PVD, AKA of R leg ___ ___, c/b
MRSA and VRE infections treated for osteomyelitis ___ ___,
hx/o DVT, remote esophageal cancer, COPD, who presented with
worsening pain at stump site, now s/p drain placement to
abscess, also c/f chronic osteo based on CT scan. Appreciate
ortho, ID, ___ involvement. Culture grew MRSA. Plan is daptomycin
600 mg q24h likely 6 weeks (ending ___, although OPAT will
follow-up to determine definitive end date.
#Stump abscess, high suspicion for osteomyelitis
- started on dapto 600 mg q24, flagyl 500 q8, ceftaz 2 q8 after
drain placed
- MRSA growing on culture
- symptoms/exam improving
- discharged on daptomycin 600 mg q24h
- f/u ___ ___ clinic (they will set up)
- weekly CRP, ESR, CBC, CMP send to OPAT team
- ___ drain instructions/follow-up plan below
- also has orthopedics follow-up scheduled
- drain output ~50 cc on ___
- PICC ___ place, restarted on pradaxa prior to placement given
hx/o PICC associated DVT
#Other:
- no changed made to other home meds
___ drain instructions:
Follow-up imaging date: determined by drain output but should
also include discussion with surgical team. Radiology
recommends:
-When the drainage total is LESS THAN 10cc/ml for 2 days ___ a
row, please have the ___ call Interventional Radiology at ___
at ___ and page ___. This is the Radiology fellow on
call who can assist you with arranging drain pull- discussion to
include surgical team.
___ Drain Care:
-Please look at the site every day for signs of infection
(increased redness or pain, swelling, odor, yellow or bloody
discharge, warm to touch, fever).
-Note color, consistency, and amount of fluid ___ the drain. Call
the doctor, ___, or ___ nurse if the amount
increases significantly or changes ___ character.
-Be sure to empty the drain bag or bulb frequently. Record the
output daily. You should have a nurse doing this for you while
___
the hospital and at home on an every-other day basis as they
can.
-You may shower; wash the area gently with warm, soapy water.
-Keep the insertion site clean and dry otherwise.
-Avoid swimming, baths, hot tubs; do not submerge yourself ___
water.
-Change the dressing daily. Cleanse skin with ___ strength
hydrogen peroxide. Rinse with saline moistened q-tip. Apply a
DSD.
-Catheter Flushing: Do not flush the catheter.
-Catheter Security: Every shift check the patency of tube and
that the tube and drainage bag are secured to the patient.
For questions regarding care of catheter call: ___
___ out-patient call ___.
Troubleshooting: If catheter stops draining suddenly:
1) Check that the stopcock is open.
2) Remove dressing carefully and inspect to make sure that there
is no kink ___ the catheter.
3) inspect to be sure that there is no debris blocking the
catheter. If there is, then firmly flush 5 cc of sterile saline
into the catheter.
- If you develop worsening abdominal pain, fevers or chills
please call your surgeon or Interventional Radiology at ___ at
___ and page ___.
=====================================
TRANSITIONAL/FOLLOW-UP
(1) antibiotic regimen as above
(2) drain management as above
(3) weekly OPAT labs as above
(4) ___ follow-up as above
(5) no changes to prior meds
=====================================
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PR Q4H:PRN pain, fever, if unable to
take by mouth
2. Atorvastatin 20 mg PO QPM
3. Bisacodyl ___VERY 3 DAYS PRN constipation
4. Calcium Carbonate 1000 mg PO Q6H:PRN reflux
5. Cyanocobalamin 500 mcg PO DAILY
6. Docusate Sodium 100 mg PO BID
7. Dorzolamide 2% Ophth. Soln. 1 DROP LEFT EYE TID
8. Magnesium Oxide 400 mg PO DAILY
9. Montelukast 10 mg PO DAILY
10. OxyCODONE SR (OxyconTIN) 20 mg PO Q12H
11. Pantoprazole 40 mg PO Q12H
12. Paroxetine 10 mg PO DAILY
13. PrimiDONE 75 mg PO QHS
14. Senna 8.6 mg PO BID
15. Sucralfate 1.5 gm PO QID
16. Tiotropium Bromide 1 CAP IH DAILY
17. TraZODone 50 mg PO QHS
18. albuterol sulfate 2.5 mg /3 mL (0.083 %) INHALATION INAHLE
3ML Q6H:PRN SOB/wheezing
19. ___ (guaiFENesin) 100 mg/5 mL oral Q6H:PRN cough
20. Lantus (insulin glargine) 100 unit/mL subcutaneous 17 units
once daily ___ the morning
21. ___ ___ U TOPICAL TID:PRN rash
22. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation
INHALATION 2 PUFFS BID COPD
23. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN mild pain
24. Furosemide 40 mg PO BID
25. Artificial Tears Preserv. Free 2 DROP BOTH EYES BID
26. Losartan Potassium 25 mg PO DAILY
27. Metoprolol Succinate XL 75 mg PO DAILY
28. travoprost 0.004 % ophthalmic QHS
29. Maalox/Diphenhydramine/Lidocaine 10 mL PO Q6H:PRN acid
reflux
30. Dabigatran Etexilate 150 mg PO BID
31. amLODIPine 5 mg PO DAILY
32. HumaLOG (insulin lispro) unknown range units subcutaneous
TID W/MEALS
33. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
34. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN dyspnea, wheezing
Discharge Medications:
1. Daptomycin 600 mg IV Q24H
2. Acetaminophen 650 mg PR Q4H:PRN pain, fever, if unable to
take by mouth
3. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
4. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN dyspnea, wheezing
5. albuterol sulfate 2.5 mg /3 mL (0.083 %) INHALATION INAHLE
3ML Q6H:PRN SOB/wheezing
6. amLODIPine 5 mg PO DAILY
7. Artificial Tears Preserv. Free 2 DROP BOTH EYES BID
8. Atorvastatin 20 mg PO QPM
9. Bisacodyl ___VERY 3 DAYS PRN constipation
10. Calcium Carbonate 1000 mg PO Q6H:PRN reflux
11. Cyanocobalamin 500 mcg PO DAILY
12. Dabigatran Etexilate 150 mg PO BID
13. Docusate Sodium 100 mg PO BID
14. Dorzolamide 2% Ophth. Soln. 1 DROP LEFT EYE TID
15. Furosemide 40 mg PO BID
16. ___ (guaiFENesin) 100 mg/5 mL oral Q6H:PRN cough
17. HumaLOG (insulin lispro) unknown range units subcutaneous
TID W/MEALS
18. Lantus (insulin glargine) 100 unit/mL subcutaneous 17 units
once daily ___ the morning
19. Losartan Potassium 25 mg PO DAILY
20. Maalox/Diphenhydramine/Lidocaine 10 mL PO Q6H:PRN acid
reflux
21. Magnesium Oxide 400 mg PO DAILY
22. Metoprolol Succinate XL 75 mg PO DAILY
23. Montelukast 10 mg PO DAILY
24. ___ ___ U TOPICAL TID:PRN rash
25. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN mild pain
26. OxyCODONE SR (OxyconTIN) 20 mg PO Q12H
27. Pantoprazole 40 mg PO Q12H
28. PARoxetine 10 mg PO DAILY
29. PrimiDONE 75 mg PO QHS
30. Senna 8.6 mg PO BID
31. Sucralfate 1.5 gm PO QID
32. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation
INHALATION 2 PUFFS BID COPD
33. Tiotropium Bromide 1 CAP IH DAILY
34. travoprost 0.004 % ophthalmic QHS
35. TraZODone 50 mg PO QHS
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Abscess
Osteomyelitis
History of DVT
Discharge Condition:
Hemdynamically stable, improving symptoms, baseline cognitive
status
Discharge Instructions:
You were admitted to the hospital due to an abscess at your
prior amputation site of the R leg. A drain was placed to help
the infection clear and you were started on IV antibiotics. The
CT scan also showed evidence of infection ___ the bone. A PICC
was placed for you to continue getting the IV antibiotics after
you return to rehab.
Followup Instructions:
___
|
19682346-DS-6
| 19,682,346 | 27,253,587 |
DS
| 6 |
2178-09-13 00:00:00
|
2178-09-13 16:15:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
morphine / adhesive tape / contrast dye / Advair Diskus / iodine
Attending: ___.
Chief Complaint:
cellulitis
Major Surgical or Invasive Procedure:
Joint washout
Right Above the knee amputation
History of Present Illness:
___ year old female with right total knee replacement on ___
with subacute skin necrosis noted of the right lower leg, now
with expanding edema and erythema of the right leg. She also
reports cough and increased dyspnea recently, along with
generalized fatigue for the last five days. Of note, she was
recently treated for pneumonia, for which she has finished her
antibiotic course. The patient noted a fever to ___ today,
along with increased drainage from her surgical site. She was
taken to ___, found to have VS T100 ___ RR20 BP
159/90 Sat93% on 2L NC. Her WBC count was 16K. Meropenem and
vancomycin were given at the outside hospital.
In the ED, initial vitals were 98.7 87 106/62 16 96% Nasal
Cannula. On exam, she was noted to have RLE erytehma, 6x6 cm
area necrosis distal calf erythema surrounding her incision.
She was also noted to have rhonchi of lower lungs. Labs showed
WBC 14.5K, hemoglobin 9.0, lactate 1.7. Creatinine was 1.4 from
baseline 1.0. ABG showed 7.47/42/121/31. Orthopedic Surgery
saw the patient and recommended LENIs due to concern for DVT.
Leg was redressed in the ED. Albuterol and ipratropium
nebulizers were administered.
Currently, the patient complains of no leg pain, or any pain
elsewhere. She does not currently feel short of breath, but has
been coughing up thick sputum.
Review of systems:
(+) Per HPI
(-) Denies headache. 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. Ten point review of
systems is otherwise negative.
Past Medical History:
- Diabetes
- Peripheral arterial disease
- Obesity
- COPD
- Esophageal cancer s/p chemo
- HTN, HL
- s/p right knee arthroplasty ___
- Abdominal hernia repair with mesh
- s/p total right knee revision
Social History:
___
Family History:
Mother died of stroke at ___. Father of MI at ___.
Physical Exam:
Vitals: T: 98.3 BP: 152/53 P: 94 R: 20 O2: 94% on 2L
GEN: Alert, oriented to name, place and situation. Fatigued
appearing but comfortable, no acute signs of distress. Noted
myoclonus.
HEENT: NCAT, Pupils equal and reactive, sclerae anicteric, OP
clear, MM dry.
Neck: Supple, no JVD
Lymph nodes: No cervical, supraclavicular LAD.
CV: S1S2, reg rate and rhythm, no murmurs, rubs or gallops.
RESP: Good air movement bilaterally, occasional wheezes on left
side, no rhonchi.
ABD: Soft, non-tender, non-distended, + bowel sounds.
EXTR: right leg with noted 3+ edema mild erythema around
incision site and in lower leg. She has a necrotic area on her
lateral lower leg. There is some fluctuance around the right
knee. No pain to palpation of right knee. LLE with trace
edema.
Neuro: non-focal. Myoclonic jerks noted.
PSYCH: Appropriate and calm.
Pertinent Results:
Operative cultures ___ MRSA - sensitive to vancomycin, MIC 1
___ 05:52AM BLOOD WBC-8.2 RBC-2.67* Hgb-7.6* Hct-24.2*
MCV-91 MCH-28.5 MCHC-31.4* RDW-14.8 RDWSD-48.1* Plt ___
___ 08:36PM BLOOD Neuts-89.4* Lymphs-2.9* Monos-6.3
Eos-0.6* Baso-0.2 Im ___ AbsNeut-12.51* AbsLymp-0.41*
AbsMono-0.88* AbsEos-0.09 AbsBaso-0.03
___ 05:36AM BLOOD ___ PTT-53.2* ___
___ 05:36AM BLOOD Glucose-127* UreaN-14 Creat-0.8 Na-139
K-3.3 Cl-100 HCO3-33* AnGap-9
___ 04:17AM BLOOD ALT-8 AST-8 AlkPhos-94 TotBili-0.3
___ 08:36PM BLOOD cTropnT-0.02*
___ 05:36AM BLOOD Calcium-7.4* Phos-2.5* Mg-2.2
___ 8:14 pm TISSUE Site: TIBIA RIGHT TIBIA.
**FINAL REPORT ___
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
TISSUE (Final ___:
STAPH AUREUS COAG +. SPARSE GROWTH.
Oxacillin RESISTANT Staphylococci MUST be reported as
also
RESISTANT to other penicillins, cephalosporins,
carbacephems,
carbapenems, and beta-lactamase inhibitor combinations.
Rifampin should not be used alone for therapy.
This isolate is presumed to be resistant to clindamycin
based on
the detection of inducible resistance .
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN----------- R
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- =>8 R
OXACILLIN------------- =>4 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------ 1 S
ANAEROBIC CULTURE (Final ___: NO ANAEROBES ISOLATED.
INDICATION: ___ year old woman POD 6 from revision TKR now with
R foot edema
w/ decrease in sensory and motor function. Evaluate for
hematoma and nerve
compression from hematoma.
TECHNIQUE: Contiguous axial MDCT images were obtained of the
right leg
without intravenous contrast. Coronal, sagittal common bone
algorithm
reformatted images were obtained.
Dose: This study involved 3 CT acquisition phases with dose
indices as
follows:
1) CT Localizer Radiograph
2) CT Localizer Radiograph
3) Spiral Acquisition 20.6 s, 109.0 cm; CTDIvol = 28.8 mGy
(Body) DLP =
3,003.3 mGy-cm.
Total DLP (Body) = 3,003 mGy-cm.
COMPARISON: Right knee radiographs from ___
FINDINGS:
The study is partially limited by streak artifact from the right
total knee
arthroplasty hardware. Femoral and tibial components are well
seated in
medullary cavity without evidence of periprosthetic fracture.
There is
evidence of osteopenia. The fibular head is abnormal in
morphology and
appears comminuted. The distal femur, tibia, and shaft of the
fibula are
intact. There is severe diffuse patchy osteopenia about the
ankle and foot,
which could significantly limit detection of a subtle
nondisplaced fracture.
Joints in the ankle and foot remain congruent.
There is moderate edema throughout the right thigh, lower leg,
and foot but no
evidence of a significant focal fluid collection or hematoma.
The limited
evaluation of the popliteal fossa fails to demonstrate a fluid
collection
surrounding the neurovascular structures. There is heavy
atherosclerotic
calcification of the arterial structures of the right thigh,
ankle, and lower
leg. Note is made of a punctate focus of low density along the
anterior edge
of the anterior musculature at the level of the proximal tibia,
consistent
with a punctate focus of air.
In the soft tissues of the anterior lower leg, there are a few
calcified
densities (4:250, 287), which may be sequela of prior trauma.
IMPRESSION:
1. Limited evaluation of the knee secondary to streak artifact
from hardware.
2. Moderate edema throughout the imaged thigh, lower leg, and
foot, with no
evidence of fluid collection or hematoma.
3. Heavy atherosclerotic calcification of the arterial
structures of the right
leg.
4. Abnormal appearance of the proximal fibula, suggestive of a
comminuted
fibular head fracture. Clinical correlation is requested as,
there is no
apparent history of recent trauma.
Brief Hospital Course:
___ year old female s/p recent right total knee arthroplasty with
Dr. ___ ___ p/w cellulitis, wound infection. Plan for
washout by ortho in the morning.
#Sepsis from
#Right leg cellulitis
#s/p Right knee replacement:
# s/p AKA
___ was admitted with recurrent right knee infection, 3 weeks
after repeat replacement. Cultures grew MRSA. She went for
attempted washout with flap with orthopedics, but there was no
viable option for limb preservation, and as a result, she
underwent an above the knee amputation on ___ with Dr. ___.
Post operatively, she was treated with increased pain
medication, and physical therapy, and eventually discharged to
rehabilitation. She was treated with lovenox with bridge to
full coumadin per ortho recommendations. She will remain on
warfarin with goal INR ___ until deemed safe to stop by
orthopedics. She will need to follow up with Dr. ___
___ ortho within 2 weeks. Please call for an appointment.
She is also scheduled to follow up with vascular surgery.
#HCAP, chronic COPD
She had worsening respiratory status with CXR with increasing
infiltrates. She was treated with vancomcyin and cefepime for
HCAP, 7 day course to end ___. Sputum cultures showed sparse
GNR. She tolerated this well and completed her course
# Acute kidney injury: She was admitted with creatinine 1.45 at
OSH now 1.3 from
baseline 1.0, likely pre-renal. She improved with hydration and
holding of furosemide. Her furosemide was resumed at 80mg
daily. This was increased to BID home dose on discharge.
# Anemia, acute blood loss: She was noted to have a normocytic
anemia, likely related to her recent surgery as well as acute
inflammation. She was transfused 3 units perioperatively and
remained stable thereafter
Chronic issues:
# Diabetes, type 2: controlled with complication of neuropathy,
continue
- treated with home insulin glargine, SSI. Gabapentin was
stopped due to tremors.
# Hypertension:
-continued home metoprolol, furosemide held until ___ but
resumed. She remained hypertensive to 170-180s at times.
Because of this she was initiated on Lisinopril 5mg daily which
she tolerated well. Please monitor her BP and increase this
medication as needed.
# Hyperlipidemia: continued home atorvastatin
# Precautions: MRSA
# Code status: DNR/DNI, confirmed
# Contact: daughter ___ (___) ___
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Acetaminophen 1000 mg PO Q8H
2. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN shortness of
breath, wheezing
3. Atorvastatin 20 mg PO QPM
4. Bisacodyl ___X/WEEK (___)
5. Calcium Carbonate 1000 mg PO Q4H:PRN heartburn
6. Cyanocobalamin 500 mcg PO DAILY
7. DiphenhydrAMINE 25 mg PO Q4H:PRN itching
8. Docusate Sodium 100 mg PO BID
9. Dorzolamide 2% Ophth. Soln. 1 DROP LEFT EYE TID
10. Ferrous Sulfate 325 mg PO DAILY
11. Fleet Enema ___AILY:PRN constipation
12. Furosemide 80 mg PO BID
13. Gabapentin 400 mg PO TID
14. Latanoprost 0.005% Ophth. Soln. 1 DROP LEFT EYE QHS
15. Magnesium Oxide 400 mg PO BID
16. Metoprolol Tartrate 25 mg PO TID
17. Milk of Magnesia 30 mL PO Q6H:PRN constipation
18. Montelukast 10 mg PO QPM
19. Pantoprazole 40 mg PO Q12H
20. Polyethylene Glycol 17 g PO DAILY:PRN constipation
21. Potassium Chloride 20 mEq PO BID
22. PrimiDONE 50 mg PO QHS
23. Sucralfate 1 gm PO TID
24. Tiotropium Bromide 1 CAP IH DAILY
25. TraZODone 50 mg PO QHS
26. amino acids-protein hydrolys ___ gram-kcal/30 mL oral TID
27. arginine-vitamin C-vitamin E 4.5 gram-156 mg/9.2 gram oral
BID
28. budesonide-formoterol 160-4.5 mcg/actuation INHALATION BID
29. Guaifenesin 10 mL PO Q4H:PRN cough
30. Ondansetron 4 mg PO Q8H:PRN nausea
31. Paroxetine 10 mg PO DAILY
32. Senna 8.6 mg PO BID
33. OxyCODONE SR (OxyconTIN) 10 mg PO QPM
34. OxycoDONE (Immediate Release) ___ mg PO Q3H:PRN Pain
35. Warfarin 3.5 mg PO DAILY16
36. Guaifenesin ER 600 mg PO Q12H
37. Collagenase Ointment 1 Appl TP DAILY
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
2. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN shortness of
breath, wheezing
3. Atorvastatin 20 mg PO QPM
4. Bisacodyl ___X/WEEK (___)
5. Collagenase Ointment 1 Appl TP DAILY
6. Cyanocobalamin 500 mcg PO DAILY
7. Docusate Sodium 100 mg PO BID
8. Dorzolamide 2% Ophth. Soln. 1 DROP LEFT EYE TID
9. Ferrous Sulfate 325 mg PO DAILY
10. Furosemide 80 mg PO BID
11. Guaifenesin 10 mL PO Q4H:PRN cough
12. Latanoprost 0.005% Ophth. Soln. 1 DROP LEFT EYE QHS
13. Metoprolol Tartrate 25 mg PO TID
14. Montelukast 10 mg PO QPM
15. OxycoDONE (Immediate Release) 10 mg PO Q4H:PRN breakthrough
pain
RX *oxycodone 10 mg 1 tablet(s) by mouth every four (4) hours
Disp #*24 Tablet Refills:*0
16. OxyCODONE SR (OxyconTIN) 40 mg PO Q8H
RX *oxycodone [OxyContin] 40 mg 1 tablet(s) by mouth three times
a day Disp #*12 Tablet Refills:*0
17. Pantoprazole 40 mg PO Q12H
18. Paroxetine 10 mg PO DAILY
19. Polyethylene Glycol 17 g PO BID constipation
20. Potassium Chloride 40 mEq PO BID
21. PrimiDONE 50 mg PO QHS
22. Senna 8.6 mg PO BID
23. Sucralfate 1 gm PO TID
24. Tiotropium Bromide 1 CAP IH DAILY
25. TraZODone 50 mg PO QHS
26. Warfarin 3 mg PO DAILY16
27. amino acids-protein hydrolys ___ gram-kcal/30 mL oral TID
28. arginine-vitamin C-vitamin E 4.5 gram-156 mg/9.2 gram oral
BID
29. budesonide-formoterol 160-4.5 mcg/actuation INHALATION BID
30. Calcium Carbonate 1000 mg PO Q4H:PRN heartburn
31. DiphenhydrAMINE 25 mg PO Q4H:PRN itching
32. Fleet Enema ___AILY:PRN constipation
33. Magnesium Oxide 400 mg PO BID
34. Milk of Magnesia 30 mL PO Q6H:PRN constipation
35. Ondansetron 4 mg PO Q8H:PRN nausea
36. Glargine 17 Units Breakfast
Insulin SC Sliding Scale using HUM Insulin
37. Lisinopril 5 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Cellulitis
Septic joint s/p AKA
Acute renal failure
PVD
COPD
Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
You were admitted for an infection in your leg. You were given
IV antibiotics and were seen by the ortho team who felt you
needed a wash-out. You were transferred to the ortho service,
underwent a right above the knee amputation, and remained on the
medicine service for ongoing care. You were also treated for a
pneumonia which you recovered nicely from. You have been placed
back on warfarin for ongoing care.
Followup Instructions:
___
|
19682346-DS-7
| 19,682,346 | 21,338,793 |
DS
| 7 |
2178-10-11 00:00:00
|
2178-10-11 22:03:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
morphine / adhesive tape / contrast dye / Advair Diskus / iodine
Attending: ___.
Chief Complaint:
Hyperkalemia
Major Surgical or Invasive Procedure:
Endotracheal intubation on ___
History of Present Illness:
___ year old with prior right total knee replacement ___,
followed by open irrigation and debridement of right revision
total knee arthroplasty on ___ after wound infection, and
above the knee amputation ___, peripheral arterial
disease, obesity, COPD, and recent episodes of profuse watery
diarrhea presenting to ___ from rehab with altered
mental status.
At her rehab, pt was found to have lethargy and AMS which began
about 12 hours prior to presentation to the ED On arrival of EMS
to the rehab, she was found to be cool to touch, diaphoretic and
responsive only to painful stimuli. VS notable for BP 84/palp,
76, 18, 92% on RA. She was given 250 cc bolus and sent to ___
___.
At ___, she was noted to be hypotensive to 64/30 with
lactate 4.9. She was found to be hyperkalemic to 9.6 with wide
complex tachycardia, as well as numerous large bowel movements.
She was given IVF (reported 4L), 5 amps of bicarbonate, calcium
gluconate and intubated for airway protection. Other notable
labs at ___ were ___ ct 27.5, Cr 3.7, Trop-I 0.02, BNP
331. Repeat EKG showed sinus rhythm with improvements of T
waves. She was started on vancomycin and piperacillin-tazobactam
at ___. A femoral central line was placed and she was
transferred to ___ for further evaluation. In the ED initial
vitals were HR 72, B P ___, RR 16, Pulse Ox 100% on CMV FiO2
60, PEEP 8, RR 18, Vt 450. By the time of transfer to ___,
patient's potassium downtrended to 6.3, lactate 2.9, Cr 2.8, BUN
111. Patient also had labs notable for WBC 16.3, H/H 8.0/26.4,
VBG 7.22/65/45/28, serum tox screen negative. She was given 1L
normal saline, 500 mg IV flagyl, 125 mg PO vancomycin, 10 units
regular insulin. She was given fentanyl and midazolam for
sedation and started on norepinephrine.
While in the ED, renal was consulted who recommended medical
management of hyperkalemia with consideration of urgent HD if
unable.
CXR was obtained in ED which showed opacity at right base of the
lung which may represent atelectasis or aspiration in the
appropriate clinical setting.
On arrival to the ___, team notified of CXR concerning for
large left pneumothorax causing rightward mediastinal shift.
Interventional pulmonology was consulted immediately and placed
a left chest tube.
Of note, patient was seen by Orthopedics on ___ for her right
knee drainage. At that time, she was started on Bactrim double
strength BID and Keflex PO QID.
Per daughter-in-law, pt had been feeling weak and fatigued for
past week. Denies fevers or chills. Diarrhea just began about
one day ago. AMS was also new as well.
Past Medical History:
- Diabetes
- Peripheral arterial disease
- Obesity
- COPD
- Esophageal cancer s/p chemo
- HTN, HL
- s/p right knee arthroplasty ___
- Abdominal hernia repair with mesh
- s/p total right knee revision
Social History:
___
Family History:
Mother died of stroke at ___. Father of MI at ___.
Physical Exam:
ADMISSION EXAM
Vitals: 156/132 -> 141/50, 74, 100% on CMV
GENERAL: intubated, sedated
HEENT: dry MM, ETT in place
NECK: supple
LUNGS: mechanical breath sounds bialterally
CV: RRR, no MRG
ABD: obese, soft, no rebound or guarding
EXT: R stump with induration, erythema and TTP at medial stump
incisions, left ext with palpable pulses, trace edema
DISCHARGE EXAM
Vitals: T 98.0 P 88 BP 168/46 RR 18 SpO2 96% RA
GENERAL - Alert, oriented, comfortable.
HEENT: Sclerae anicteric, MMM
NECK: Supple
CHEST: Breathing comfortably on room air. Lungs clear. Good air
movement bilaterally. Focal tenderness to palpation on left
lateral breast, with minimal overlying erythema, no rash, no
palpable nodules or masses
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
ABD: +BS, obese, soft, nondistended, nontender to palpation.
Evidence of multiple abdominal/pelvic surgeries.
EXT: Warm, well perfused, 2+ pulses, 3+ pitting edema to thigh
in LLE. s/p R AKA, dressing over stump c/d/i. Drain in place
with minimal serosang fluid in bulb
NEURO: motor function grossly normal
Pertinent Results:
ADMISSION LABS
___ 04:35AM BLOOD WBC-16.3* RBC-2.90* Hgb-8.0* Hct-26.4*
MCV-91 MCH-27.6 MCHC-30.3* RDW-14.7 RDWSD-49.5* Plt ___
___ 10:02AM BLOOD Neuts-88.7* Lymphs-5.6* Monos-4.9*
Eos-0.0* Baso-0.1 Im ___ AbsNeut-19.55*# AbsLymp-1.24
AbsMono-1.07* AbsEos-0.00* AbsBaso-0.02
___ 04:35AM BLOOD Plt ___
___ 10:02AM BLOOD ___ PTT-52.0* ___
___ 10:02AM BLOOD Glucose-285* UreaN-106* Creat-2.6* Na-143
K-5.9* Cl-109* HCO3-25 AnGap-15
___ 04:35AM BLOOD LD(LDH)-332* CK(CPK)-74
___ 10:02AM BLOOD ALT-36 AST-55* AlkPhos-164* TotBili-0.2
___ 04:35AM BLOOD CK-MB-1 cTropnT-0.04*
___ 10:02AM BLOOD CK-MB-2 cTropnT-0.05*
___ 05:20PM BLOOD CK-MB-2 cTropnT-0.02*
___ 04:35AM BLOOD UricAcd-7.8*
___ 10:02AM BLOOD Albumin-3.0* Calcium-8.3* Phos-4.4#
Mg-2.4
DISCHARGE LABS:
___ 08:04AM BLOOD WBC-4.5 RBC-3.28* Hgb-8.8* Hct-28.9*
MCV-88 MCH-26.8 MCHC-30.4* RDW-15.0 RDWSD-48.3* Plt ___
___ 08:04AM BLOOD ___
___ 08:04AM BLOOD Glucose-160* UreaN-13 Creat-1.0 Na-141
K-3.8 Cl-104 HCO3-27 AnGap-14
___ 08:04AM BLOOD Calcium-8.6 Phos-4.2 Mg-1.7
IMAGING AND STUDIES
___ CXR portable
1. Large left pneumothorax causing rightward mediastinal shift.
2. Enteric tube terminates within a large hiatal hernia above
the diaphragm.
3. Opacity at the base of the right lung may represent
atelectasis or
aspiration in the appropriate clinical setting.
4. Mild pulmonary vascular congestion.
___ KUB
1. Study is moderately limited by body habitus and positioning.
2. Nonspecific bowel gas pattern without evidence of obstruction
or
pneumoperitoneum.
3. No abnormally dilated loops of bowel to suggest megacolon.
___ CT R Lower Ext
1. 4.6 x 3.8 x 5.2 cm low-density fluid collection at the
femoral amputation
margin. Smaller pockets of fluid appear to extend to the skin
surface as well
as track into the medullary cavity of the femur in location of
prior hardware.
While this may represent postoperative seroma, infection cannot
be excluded.
2. Extensive superficial soft tissue edema. No areas of
subcutaneous gas.
___ TTE
The left atrium is normal in size. Left ventricular wall
thicknesses are normal. The left ventricular cavity size is
normal. Due to suboptimal technical quality, a focal wall motion
abnormality cannot be fully excluded. Overall left ventricular
systolic function is normal (LVEF = 70%). Right ventricular
chamber size and free wall motion are normal. The number of
aortic valve leaflets cannot be determined. The aortic valve
leaflets are mildly thickened (?#). The aortic valve is not well
seen. There is a minimally increased gradient consistent with
minimal aortic valve stenosis. No 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.
___ US DRAINAGE LEG COLLECTION
Successful US-guided placement of ___ pigtail catheter into
the
collection, likely hematoma. Sample was sent for microbiology
evaluation. No immediate postprocedure complication.
___ CXR
IMPRESSION:
1. Persistent right basilar consolidation, concerning for
pneumonia in the appropriate clinical setting.
2. Mild pulmonary edema.
Brief Hospital Course:
___ year old with prior right total knee replacement in ___ s/p
revision ___ complicated by infection s/p open irrigation
and debridement and above the knee amputation ___,
peripheral arterial disease, obesity, COPD, and recent episodes
of profuse watery diarrhea presenting to ___ from rehab
with altered mental status and found to be acutely hyperkalemic.
Initially admitted to the FICU for acute management of
hyperkalemia, respiratory failure, and hypotension; also
developed a pneumonia during her stay.
#ICU COURSE: Patient presented with hypotension with SBP in ___,
hyperkalemia to 9.3, and with altered mental status. This was
thought to be due to profuse diarrhea (possibly
antibiotic-induced as C. diff was negative) causing hypovolemia,
___ and hyperkalemia, with contribution from potassium
repletion, Bactrim and ACEi use. She received volume
resuscitation, and her potassium normalized with medical
therapy. She required intubation for airway protection and was
briefly on a levophed drip, and she was extubated on ___
without complication. In the setting of hypovolemia, she had
lactic acidosis and ___ that resolved with fluid resuscitation.
She additionally had a traumatic pneumothorax in the setting of
attempted central line placement at an outside hospital, for
which she had a chest tube placed that was pulled on ___.
#R AKA WITH SEROMA: She was found to have a fluid collection at
her right AKA stump that was drained with a drain left in place.
The fluid did not look infected, and cultures were negative at
the time of discharge. She is scheduled for follow-up with Dr.
___ debridement of her wound. Her post-operative Coumadin
had been held on admission and was restarted before discharge,
with a goal INR 2.0-3.0 until ___.
#PNEUMONIA: On arrival to the floor, she had a persistent oxygen
requirement, cough with sputum production, and chest x-ray
findings consistent with RLL pneumonia. She was treated with
levofloxacin with resolution in her respiratory symptoms. She is
to receive her last dose of levoquin on ___.
#HYPERTENSION: On arrival to the floor, she had persistent
hypertension that improved with diuresis. Her home lisinopril 5
was increased to 10mg daily.
#ANEMIA: Her Hgb was low since recent surgery. She required 1 u
pRBC while in FICU for Hgb 6.0; unclear etiology but bloody
drainage from stump collection a possible source. Stool guaiac
was negative. Her Hgb was stable for the rest of her hospital
stay.
#HEMATURIA: Urinalysis on ___ and ___ showed hematuria,
possibly from traumatic Foley placement, as well as asymptomatic
bacteriuria (already on levoquin for pneumonia). Recommend
outpatient follow-up of hematuria.
#DIARRHEA
C dif negative
Unclear etiology of diarrhea, possibly non c dif infectious
course, could consider post abx diarrhea as well given course of
abx at previous admission. Resolved during admission.
Transitional Issues:
=========================
-Levofloxacin for 5 day course for pneumonia, last dose ___
-___ clinic f/u ___ with plan to schedule I+D. Drain in
place, to be pulled when output is <10cc/day for two consecutive
days
-Coumadin for goal INR 2.0-3.0 for post-operative coagulation,
to end ___. Please check INR ___ or ___
-Discharged on Lasix 80mg PO BID (prior home dose). Will need
electrolytes and renal function checked on ___ or ___ for
electrolyte repletion and furosemide titration. -Lisinopril
increased to 10mg po daily
-Hematuria found twice on UA, recommend outpatient f/u
-Left lateral breast tenderness noted on exam on day of
discharge. Please monitor for resolution.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Acetaminophen 1000 mg PO Q8H
2. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN shortness of
breath, wheezing
3. Atorvastatin 20 mg PO QPM
4. Bisacodyl ___X/WEEK (___)
5. Collagenase Ointment 1 Appl TP DAILY
6. Cyanocobalamin 500 mcg PO DAILY
7. Docusate Sodium 100 mg PO BID
8. Dorzolamide 2% Ophth. Soln. 1 DROP LEFT EYE TID
9. Ferrous Sulfate 325 mg PO DAILY
10. Furosemide 80 mg PO BID
11. Guaifenesin 10 mL PO Q4H:PRN cough
12. Latanoprost 0.005% Ophth. Soln. 1 DROP LEFT EYE QHS
13. Metoprolol Tartrate 25 mg PO TID
14. Montelukast 10 mg PO QPM
15. OxycoDONE (Immediate Release) 10 mg PO Q4H:PRN breakthrough
pain
16. OxyCODONE SR (OxyconTIN) 40 mg PO Q8H
17. Pantoprazole 40 mg PO Q12H
18. Paroxetine 10 mg PO DAILY
19. Polyethylene Glycol 17 g PO BID constipation
20. Potassium Chloride 40 mEq PO BID
21. PrimiDONE 50 mg PO QHS
22. Senna 8.6 mg PO BID
23. Sucralfate 1 gm PO TID
24. Tiotropium Bromide 1 CAP IH DAILY
25. TraZODone 50 mg PO QHS
26. Warfarin 3 mg PO DAILY16
27. amino acids-protein hydrolys ___ gram-kcal/30 mL oral TID
28. arginine-vitamin C-vitamin E 4.5 gram-156 mg/9.2 gram oral
BID
29. budesonide-formoterol 160-4.5 mcg/actuation INHALATION BID
30. Calcium Carbonate 1000 mg PO Q4H:PRN heartburn
31. DiphenhydrAMINE 25 mg PO Q4H:PRN itching
32. Fleet Enema ___AILY:PRN constipation
33. Magnesium Oxide 400 mg PO BID
34. Milk of Magnesia 30 mL PO Q6H:PRN constipation
35. Ondansetron 4 mg PO Q8H:PRN nausea
36. Lisinopril 5 mg PO DAILY
37. Glargine 17 Units Breakfast
Insulin SC Sliding Scale using HUM Insulin
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H Pain
2. Calcium Carbonate 1000 mg PO Q4H:PRN indigestion/reflux
3. Dorzolamide 2% Ophth. Soln. 1 DROP LEFT EYE TID
4. Furosemide 80 mg PO BID
5. Glargine 17 Units Breakfast
Insulin SC Sliding Scale using HUM Insulin
6. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
7. Lisinopril 10 mg PO DAILY
8. Metoprolol Tartrate 25 mg PO TID
9. Montelukast 10 mg PO DAILY
10. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN Pain
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*20 Tablet Refills:*0
11. OxyCODONE SR (OxyconTIN) 40 mg PO Q8H Pain
RX *oxycodone [OxyContin] 40 mg 1 tablet(s) by mouth every eight
(8) hours Disp #*9 Tablet Refills:*0
12. Pantoprazole 40 mg PO Q12H
13. Paroxetine 10 mg PO DAILY
14. Tiotropium Bromide 1 CAP IH DAILY
15. Warfarin 5 mg PO DAILY16
16. Levofloxacin 750 mg PO DAILY Duration: 1 Day
17. Arginaid (arginine-vitamin C-vitamin E) 4.5 gram-156 mg/9.2
gram oral BID
18. Atorvastatin 20 mg PO QPM
19. Bisacodyl 10 mg PO 3X/WEEKLY PRN if no bowel movement
20. Cyanocobalamin 500 mcg PO DAILY
21. Docusate Sodium 100 mg PO BID
22. Ferrous Sulfate 325 mg PO DAILY
23. Florastor (Saccharomyces boulardii) 500 mg oral BID
24. Gabapentin 100 mg PO TID
25. ___ (guaiFENesin) 200/10 mg/ml oral Q4H:PRN cough
26. Magnesium Oxide 400 mg PO BID
27. Potassium Chloride 40 mEq PO DAILY
Hold for K >
28. PrimiDONE 50 mg PO QHS
29. Pro-Stat Sugar Free (amino acids-protein hydrolys) ___
gram-kcal/30 mL oral TID
30. Senna 8.6 mg PO BID constipation
31. Sucralfate 1.5 gm PO TID
32. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation
INHALATION BID
33. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN SOB Wheeze
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSES:
Septic shock
Hyperkalemia
Tension pneumothorax
SECONDARY DIAGNOSES:
Acute kidney injury
Delirium
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure caring for you at ___
___. You came to the hospital because of high
potassium and low blood pressure. We gave you medications to fix
your potassium levels, and we gave you fluids to restore your
blood pressure.
While you were here, you had a lung collapse. This air was
removed with a chest tube, and your breathing recovered.
You were also found to have a fluid collection around the
incision in your right leg. We drained this collection, which
did not appear to be infected. You will follow-up with the
Orthopedics team in clinic on ___.
You developed a pneumonia while you were here, and you were
treated with antibiotics.
Please follow-up at the appointments listed below, and take your
medications as directed.
We wish you the best!
-Your ___ Team
See below for drain care instructions:
___ Drain Care:
-Please look at the site every day for signs of infection
(increased redness or pain, swelling, odor, yellow or bloody
discharge, warm to touch, fever).
-Note color, consistency, and amount of fluid in the drain. Call
the doctor, ___, or ___ nurse if the amount
increases significantly or changes in character.
-Be sure to empty the drain bag or bulb frequently. Record the
output daily. You should have a nurse doing this for you while
in
the hospital and a visting nurse at home on an every-other day
basis as they can.
-You may shower; wash the area gently with warm, soapy water.
-Keep the insertion site clean and dry otherwise.
-Avoid swimming, baths, hot tubs; do not submerge yourself in
water.
Followup Instructions:
___
|
19682438-DS-12
| 19,682,438 | 27,400,389 |
DS
| 12 |
2120-11-29 00:00:00
|
2120-12-03 07:28:00
|
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 fall
Major Surgical or Invasive Procedure:
___: OPEN REDUCTION INTERNAL FIXATION MANDIBULAR
FRACTURE SYMPHYSIS and Closed Reduction of Bilateral Condylar
fractures.
History of Present Illness:
___ Yo M with hx of illicit drug use and EtOH abuse presents
to the ED for a mandibular fracture s/p fall this evening.
Pt was in an argument with his wife where he was struck in
the jaw, when police arrived for the domestic assault. Pt
admitted to the police that he had done heroin and was
intoxicated. Pt was tased x2 when he fell onto the pavement
striking his head. Pt was originally sent to ___
where he was dx with a mandibular fracture where he was very
agitated and uncooperative. He was given Ativan bendryl,
Haldol, and ketamine. In BI ED pt endorses L sided mandible
pain and generalized myalgias. Of note, pt is in police
custody.
Past Medical History:
none
Social History:
___
Family History:
noncontributory
Physical Exam:
Admission PHYSICAL EXAMINATION
Temp: 98.7 HR: 98 BP: 102/60 Resp: 12 O(2)Sat: 98 Normal
Constitutional: Somnolent.
HEENT: Edema and deformity of the L mandible.
Oropharynx within normal limits
Chest: Clear to auscultation. No chest wall TTP
Cardiovascular: Regular Rate and Rhythm
Abdominal: Soft, Nontender
GU/Flank: No costovertebral angle tenderness
Extr/Back: No ___ edema
Skin: Laceration to the chin with dried blood. Abrasion and
ecchymosis to the L shoulder.
Neuro: No focal neuro deficits.
Psych: Follows commands and answers questions.
Discharge Physical Exam:
Vitals: 98.7 PO106 / 67 HR 66RR 18 O2 99 on RA
General: NAD
HEENT:
Head: normocephalic, atruamatic
Eyes: EOM Intact, PERRL, vision grossly normal
Ears: right ear normal, left ear normal, no external
deformities
and gross hearing intact
Nose: WNL
EOE: ___ = 20mm, lower facial ___ edema c/w procedure, TMJ
limited range of motion. 3cm lac to superior aspect of chin
sutures c/d/i
Neurology: cranial nerves II-XII grossly intact.
Neck: normal range of motion, supple, no JVD, and no
lymphadenopathy
IOE: oropharynx clear, no dysphagia, no odynophagia, FOM soft
and edematous, FOM ecchymosis present, ___ arch bars firmly
intact, intra oral incision c/d/i. MMF with elastics, occlusion
stable, midlines coincident.
CV: RRR
Resp: No respiratory distress, no accessory muscle use
Extremities: normal mobility, no deformities
Pertinent Results:
___ 05:49AM BLOOD WBC-8.8 RBC-4.45* Hgb-14.0 Hct-40.3
MCV-91 MCH-31.5 MCHC-34.7 RDW-12.7 RDWSD-41.6 Plt ___
___ 10:57PM BLOOD WBC-15.0* RBC-4.66 Hgb-13.9 Hct-42.1
MCV-90 MCH-29.8 MCHC-33.0 RDW-12.9 RDWSD-42.5 Plt ___
___ 05:49AM BLOOD Glucose-111* UreaN-13 Creat-0.7 Na-139
K-4.2 Cl-99 HCO3-24 AnGap-16
___ 10:57PM BLOOD Glucose-92 UreaN-10 Creat-0.7 Na-144
K-4.4 Cl-107 HCO3-20* AnGap-17*
Imaging:
Head CT impression: No acute abnormality evident on head CT.
Cervical spine CT impression: No acute abnormality of evident on
cervical spine CT cervical spine scoliosis.
Facial bone CT impression: Mandible is fractured at 3 sites with
displacement and dislocation of the mandibular condyles.
Left shoulder XRay:
There is no fracture or dislocation involving the glenohumeral
or AC joint.
CXR:
No acute cardiopulmonary abnormality. No displaced rib
fractures.
Mandibular Panorex:
There is a vertically-oriented fracture through the symphysis
menti, extending between the 2 central incisors. There are
possible fractures of the mandibular condyles bilaterally
CT Mandibular ___:
1. Status post ORIF for a vertically oriented fracture through
the mandibular symphysis, without evidence of hardware
complication.
2. Bilateral subcondylar mandibular fractures, with
anterolateral displacement of the distal mandible.
3. Anterior displacement the mandibular condyles bilaterally.
4. Paranasal sinus disease.
Brief Hospital Course:
___ male with no known past medical history who
sustained a complicated mandibular fracture after a fall from
standing when he was tasered by the
police the context of a domestic dispute. He does not have any
other apparent injuries and is hemodynamically stable. ___ is
consulted and the patient was taken to the OR for ORIF of
bilateral mandibular fractures. In the PACU the patient was
agitated and started on a phenobarb taper for ETOH withdrawal
with good effect.
Post-operatively, pain was well controlled. Diet was
progressively advanced as tolerated to a full liquid diet with
good tolerability. The patient voided without problem. The
patient received subcutaneous heparin and venodyne boots were
used during this stay. Antibiotics were switched to oral form to
complete a 5-day course of Keflex.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a full
liquid diet, ambulating, voiding without assistance, and pain
was well controlled. The patient was discharged to prison. The
___ team would be in contact with the facility to schedule
follow-up. The patient had instructions to continue the full
liquid diet and chlorhexidine mouth rinses. He was sent with a
small prescription for oxycodone to be taken as needed for the
next ___ days and has been instructed to wean off narcotics and
use only Tylenol or ibuoprofen for pain along with ice packs.
The chin laceration would require bacitracin twice a day until
healed.
Medications on Admission:
none
Discharge Medications:
1. Acetaminophen (Liquid) 650 mg PO Q6H
RX *acetaminophen 325 mg/10.15 mL 650 mg by mouth every six (6)
hours Disp #*1 Bottle Refills:*0
2. Bacitracin Ointment 1 Appl TP BID
3. Cephalexin 250 mg PO Q6H Duration: 5 Days
RX *cephalexin 250 mg/5 mL 250 mg by mouth every six (6) hours
Refills:*0
4. Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL BID
RX *chlorhexidine gluconate 0.12 % 15mL twice a day Refills:*0
5. OxycoDONE Liquid 5 mg PO Q4H:PRN Pain - Moderate
RX *oxycodone 5 mg/5 mL 5 mg by mouth every four (4) hours
Refills:*0
6. PHENObarbital Alcohol Withdrawal Dose Taper (Days ___ 40 mg
PO/NG BID Duration: 2 Doses
Start: Tomorrow - ___, First Dose: First Routine
Administration Time
This is dose # 1 of 4 tapered doses
7. PHENObarbital Alcohol Withdrawal Dose Taper (Days ___ 20 mg
PO/NG BID Duration: 2 Doses
Start: After 40 mg BID tapered dose
This is dose # 2 of 4 tapered doses
8. PHENObarbital Alcohol Withdrawal Dose Taper (Days ___ 10 mg
PO/NG BID Duration: 2 Doses
Start: After 20 mg BID tapered dose
This is dose # 3 of 4 tapered doses
9. PHENObarbital Alcohol Withdrawal Dose Taper (Days ___ 0 mg
PO/NG BID Duration: 2 Doses
Start: After 10 mg BID tapered dose
This is dose # 4 of 4 tapered doses
Discharge Disposition:
Home
Discharge Diagnosis:
[] Displaced right and left subcondylar, condyles not seated in
respective fossa, displaced symphysis fracture of mandible
[] Chin laceration
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to ___ after a fall. You were found to have
a fractured jaw. You were taken to the operating room with the
Oral Maxillary Facial Surgeons for repair of the fracture. You
tolerated this procedure well and are now medically cleared for
discharge. You should continue the full liquid diet for the next
4 weeks until your ___ follow-up. Please note the following
instructions:
Chin laceration: Continue bacitracin BID
Jaw fracture: Ice packs for pain, chlorhexidine mouth rinse BID,
full liquid diet, wire cutters at bedside.
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
Followup Instructions:
___
|
19682482-DS-5
| 19,682,482 | 24,817,952 |
DS
| 5 |
2127-08-04 00:00:00
|
2127-08-05 11:30:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics)
Attending: ___.
Chief Complaint:
altered mental status
Major Surgical or Invasive Procedure:
none
History of Present Illness:
This is a ___ yo female with a history of NASH cirrhosis c/b
portal hypertension, ascites, splenomegaly, h/o esophageal bleed
and COPD presenting from nursing home for altered mental status.
The patient was recently admitted to ___ from ___ to ___,
during which time she was treated for pneumonia complicated by
hypotension requiring pressors, ___ likely due to ATN, hypoxia
possibly related to COPD exacerbation, troponemia likely due to
demand ischemia and ultimately altered mental status requiring
intubation. The patient had EEG at that time which revealed that
she was actually in status epilepticus. This did not initially
resolve on Phenytoin load, but did eventually resolve with
Versed drip. She was then discharged on Dilantin and Keppra; the
Dilantin was thought to be possibly contributing to altered
mental status and was meant to be tapered as an outpatient but
had not yet been done. She also developed new onset atrial
fibrillation and was started on Coumadin.
The patient was discharged to ___ and was thought to be
altered, refusing her medications today. Given the fact that the
patient is interactive but somnolent, neurology consultants felt
that this presentation was unlikely to be status epilepticus.
Per review of ___ notes, her last BM was ___ and she had
only 3 doses of lactulose in the past 24h prior to admission due
to spitting out meds and/or somnolence.
In the ED, initial vitals: 88 120/65 23 92%
- Head CT negative.
- Chest Xray
- CBC: plt of 107, otherwise wnl except MCV 104
- Chemistry: normal except K of 5.3, Cr of 2.0 (recent baseline
1.8-2.1; prior to ___ was normal).
- LFTs: normal except AST 70, Alk Phos 145
- paracentesis: diagnostic done.
- Neurology Consult: Felt likely to be metabolic encephalopathy
and not status epilepticus; recommended Dilantin and Keppra.
Ideally wanted EEG tonight but will likely do in AM.
- Hepatology Consult: recommended lactulose and admission to
MICU for altered mental status
- No medications given.
On transfer, vitals were: 98 80 ___ 96% 2l
On arrival to the MICU, the patient is awake, somnolent,
oriented to self but nothing else. Her vital signs are stable.
She is asking for water and drinks without difficulty, taking
her pills without coughing or apparent choking. She
intermittently appropriately responds to questions but mostly
does not respond correctly.
Review of systems: unable to obtain secondary to altered mental
status, although does deny pain "anywhere" but unclear if she
understands question.
Past Medical History:
NASH Cirrhosis complicated by variceal bleed, ascites with
history of SBP.
Status Epilepticus
ATN resulting in ongoing renal insufficiency
Chest Pain with history of fixed defect on abnormal stress test
COPD
Depression
T2DM c/b retinopathy
Colonic Polyps
Pulmonary Nodules
Hernia (reducible)
HLD
LBP/Sciatica
Microscopic Hematuria
OSA on CPAP
Papillomatosis
Premature menopause
Congestive Heart Failure
Social History:
___
Family History:
CERVICAL CA (SISTER), CAD (FATHER DIED FROM MI AT ___), AODM
(SISTER).
Physical Exam:
ADMISSIION:
Vitals: T: 98.6 BP: 148/106 P: 81 R: 18 O2: 95% RA
General: Alert, no acute distress, somnolent but arousable. She
is oriented to self, but says ___ and is unaware of location.
HEENT: Sclera icteric, dry mucous membranes, oropharynx clear,
EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: irregularly irregular, normal S1 + S2, systolic murmurs, no
rubs, gallops
Lungs: wheezes, no rales, ronchi , good air movement bilaterally
Abdomen: soft, non-tender, distended, bowel sounds present,
unable to palpate liver and spleen
GU: + foley
Ext: warm, well perfused, 2+ pulses, trace pre-tibial edema
Neuro: CNII-XII intact, ___ strength upper/lower extremities,
grossly normal sensation, gait deferred, + asterixis
DISCHARGE:
VS: 98.1 129/78 93 20 96/4L ___ ___ 3BM
yesterday
General: Alert, no acute distress, oriented to person, place and
time
HEENT: Sclera icteric, dry mucous membranes, oropharynx clear
Neck: supple
CV: irregularly irregular, normal S1 + S2, systolic murmurs, no
rubs, gallops
Lungs: wheezes b/l, no rales, ronchi, good air movement
bilaterally
Abdomen: soft, non-tender, distended, no masses
Ext: +1 pitting edema to level of knees
Neuro: grossly normal sensation, gait deferred, no asterixis
Pertinent Results:
ADMISSION LABS:
___ 03:00PM BLOOD WBC-4.9 RBC-3.95* Hgb-13.3 Hct-41.0
MCV-104* MCH-33.6* MCHC-32.4 RDW-17.0* Plt ___
___ 03:00PM BLOOD Neuts-63.9 ___ Monos-10.8 Eos-1.6
Baso-0.7
___ 03:00PM BLOOD ___ PTT-46.7* ___
___ 03:00PM BLOOD Glucose-64* UreaN-49* Creat-2.0* Na-141
K-5.6* Cl-102 HCO3-30 AnGap-15
___ 03:00PM BLOOD ALT-28 AST-70* AlkPhos-145* TotBili-0.8
___ 03:00PM BLOOD Lipase-24
___ 03:00PM BLOOD Albumin-3.4*
___ 03:20PM BLOOD Ammonia-184*
___ 03:00PM BLOOD Phenyto-9.7*
___ 03:00PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 03:10PM BLOOD Lactate-1.9 K-5.3*
___ 03:00PM URINE Blood-SM Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-TR
___ 03:00PM URINE RBC-6* WBC-4 Bacteri-FEW Yeast-NONE Epi-1
___ 03:00PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG mthdone-NEG
___ 08:34PM ASCITES WBC-55* RBC-51* Polys-9* Lymphs-41*
Monos-24* Mesothe-16* Macroph-10*
PERTINENT LABS:
___ 08:34PM ASCITES WBC-55* RBC-51* Polys-9* Lymphs-41*
Monos-24* Mesothe-16* Macroph-10*
___ 06:00AM BLOOD Ret Aut-2.2
___ 03:00PM BLOOD Lipase-24
___ 06:00AM BLOOD Hapto-50
___ 03:00PM BLOOD Phenyto-9.7*
___ 06:00AM BLOOD Phenyto-11.6
___ 05:45AM BLOOD Phenyto-12.2
___ 06:15AM BLOOD Phenyto-14.7
___ 03:00PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
DISCHARGE LABS:
___ 06:15AM BLOOD WBC-2.9* RBC-2.96* Hgb-9.5* Hct-30.6*
MCV-104* MCH-32.2* MCHC-31.1 RDW-16.5* Plt Ct-59*
___ 06:15AM BLOOD ___ PTT-40.8* ___
___ 06:15AM BLOOD Glucose-54* UreaN-35* Creat-1.6* Na-142
K-3.8 Cl-98 HCO3-35* AnGap-13
___ 06:15AM BLOOD ALT-23 AST-44* AlkPhos-91 TotBili-1.3
___ 06:15AM BLOOD Calcium-8.8 Phos-2.0* Mg-2.0
___ 06:15AM BLOOD Phenyto-14.7
IMAGING/STUDIES:
CT head ___:
1) No evidence of acute intracranial process.
2) Expansile sella without definitive mass which can be seen
with intracranial hypertension, however this has not changed
since ___. Correlation with ocular examination and other
clinical factors is suggested regarding any potential clinical
relevance.
CXR ___: No definite evidence of acute cardiopulmonary
disease
ECG ___:
Atrial fibrillation with controlled ventricular response. Poor R
wave progression, likely a normal variant. Diffuse non-specific
ST-T wave changes. Low QRS voltages in the precordial leads.
Compared to the previous tracing of ___ baseline artifact
persists on both tracings. The other findings are similar,
although the heart rate is slightly slower on the current
tracing
EEG (20 minute study): report pending at time of discharge, but
prelim read negative for eliptiform waveforms
MICRO:
PERITONEAL FLUID CULTURE:
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final ___: NO GROWTH.
ANAEROBIC CULTURE (Preliminary): NO GROWTH.
URINE CULTURE (Final ___:
YEAST. >100,000 ORGANISMS/ML..
Brief Hospital Course:
___ year old woman with history of NASH cirrhosis c/b varices,
ascites with history of SBP, encephalopathy, seizures, COPD,
afib on coumadin who presented with altered mental status,
thought to be due to poor compliance with lactulose.
# Altered Mental Status, due to hepatic encephalopathy: The
patient presented with altered mental status which was most
concerning for hepatic encephalopathy or status epilepticus. Her
initial work up showed no overt signs of infection with normal
WBC without left shift. Other work up including tox screen, CXR
and head CT were unremarkable. She was given one dose of zosyn
while awaiting urine cultures, as she had been on cefpodoxime as
an outpatient for SBP ppx. When her urine culture grew yeast
zosyn was discontinued. She was treated with lactulose due to
concerns for hepatic encephalopathy. It was thought that she was
not receiving adequate amounts of lactulose at her rehab. Her
mental status improved and was at her baseline, per her family.
She was discharged on lactulose standing three times daily with
provision to given extra doses of 30ml every 2 hours to achieve
4 BMs daily. She was continued on rifaximin.
# History of seizures: The patient was found to be in status
epilepticus during her prior admission. Thus, there was concern
that the patient's AMS at presentation was status epilepticus --
although this was felt to be less likely by Neurology consults.
She received a loading dose of dilatntin 300mg on admission and
from then on was continued on her home doses. Prelim report of
her 20 minute EEG showed no eliptiform waveforms. Neurology
consult recommended dilantin 40mg suspension q8hours at
discharge. She will follow up with neurology as outpatient.
# NASH Cirrhosis complicated by encephalopathy, varices, ascites
c/b SBP: She was continued on her home medications of nadolol,
rifaximin, lactulose, lasix and spironolactone. She had
significant ascites and underwent a paracentesis in the ICU on
___ with 5.5L of straw colored fluid removed. Fluid studies
were negative for SBP. She was continued on cefpodoxime for SBP
ppx which should be continued indefinitely. Her diuretics should
be continued and dosed together for optimal administration. She
will nned an EGD in the future as an outpatient given her h/o
varices. Her nadolol was increased from 20mg qdaily to 40mg
prior to discharge.
# Atrial fibrilation: Given her CHADS2 score of 1, in the
setting of varices and her risk for falls, the decision was made
to stop coumadin. She will continue low dose aspirin therapy.
# COPD: Stable, she was continued on albuterol nebs and flonase.
Advair was started on ___.
# CAD: She has a fixed defect seen on ETT without clear history
of ischemic event and history of demand-related troponin leak.
The patient had an ECHO in ___ which showed EF>55% and
hypokinetic right ventricle. She was continued on aspirin and
pravastatin.
# Type 2 DM: Continued home NPH with home humalog sliding scale.
TRANSITIONAL ISSUES:
# Patient is interested in learning about live donor liver
program (at ___ or ___ and can discuss this at her follow up
appointment in the ___ with Dr. ___
___ PA.
# EEG report (20 minute study) was pending at the time of
discharge, but per EEG fellow, findings were not suggestive of
seizure activity.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler ___ PUFF IH Q6H:PRN shortness of breath
2. Aspirin 81 mg PO DAILY
3. Fluticasone Propionate NASAL 1 SPRY NU BID
4. Nadolol 20 mg PO DAILY
5. Pantoprazole 40 mg PO Q24H
6. Pravastatin 40 mg PO HS
7. Cefpodoxime Proxetil 100 mg PO Q12H SBP ppx
8. Albuterol-Ipratropium ___ PUFF IH Q6H:PRN SOB
9. Metoclopramide 5 mg PO QIDACHS
10. Rifaximin 550 mg PO BID
11. LeVETiracetam 500 mg PO BID
12. NPH 36 Units Breakfast
NPH 36 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
13. Lactulose 30 mL PO TID
14. Ipratropium Bromide Neb 1 NEB IH Q6H:PRN wheezing
15. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheezing
16. Nicotine Patch 7 mg TD DAILY
17. Phenytoin (Suspension) 40 mg PO Q8H
18. Warfarin 1 mg PO DAILY16
19. Furosemide 60 mg PO BID
hold for SBP < 90
20. Spironolactone 50 mg PO DAILY
hold for SBP < 90
Discharge Medications:
1. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheezing
2. Aspirin 81 mg PO DAILY
3. Cefpodoxime Proxetil 100 mg PO Q12H SBP ppx
4. Fluticasone Propionate NASAL 1 SPRY NU BID
5. Furosemide 60 mg PO BID
Administer this medication WITH spironolactone
6. Ipratropium Bromide Neb 1 NEB IH Q6H:PRN wheezing
7. Lactulose 30 mL PO TID
8. LeVETiracetam 500 mg PO BID
9. Nicotine Patch 7 mg TD DAILY
10. Pantoprazole 40 mg PO Q24H
11. Pravastatin 40 mg PO HS
12. Rifaximin 550 mg PO BID
13. Spironolactone 50 mg PO BID
14. NPH 36 Units Breakfast
NPH 36 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
15. Nadolol 40 mg PO DAILY
hold for SBP<90, HR <50
16. Lactulose 30 mL PO Q2H:PRN if <4 BM/day
17. Phenytoin (Suspension) 40 mg PO Q8H
18. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
19. Albuterol Inhaler ___ PUFF IH Q6H:PRN shortness of breath
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
___ Cirrhosis
Hepatic Encephalopathy
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:
It was a pleasure to participate in your care at ___. You came
to the hospital because of increased confusion. We believe you
were confused because you were not getting enough lactulose.
Please keep all follow up appointments. Please take all
medications as prescribed.
Followup Instructions:
___
|
19682719-DS-21
| 19,682,719 | 23,157,415 |
DS
| 21 |
2189-03-31 00:00:00
|
2189-04-11 21:02:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Gait instability and ataxia of unknown etiology
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ gentleman w/ ___ signficant for CAD w/ multiple stents,
atrial fibrillation s/p successful cardioversion and on
coumadin, CLL not on treatment, and remote CVA w/ no residual
deficit, now presents with 3 day history of ataxia and multiple
falls. Patient states he had 4x falls in the last three days and
presented to ___. Non-contrast head CT was
negative, C-spine negative. CXR negative for pneumonia or
fractures but Pt has superficial laceration on L upper head and
pain in L ribs. Left and right shoulder plain films negative. Pt
was reportedly ataxic upon eval at OSH when attempting
ambulation. Per family, patient has had worsening ataxia over
the last month. Recent diagnosis of Afib with cardioversion x2,
most recently on ___ of this week, which was reported
successful. Pacemaker since ___ for SSS. CLL followed in
___. No current treatment. Pt states that he was conscious
during the entire episode for all the falls and simply fell,
generally backwards. Pt denied any chest pain, palpitations,
chest pressure, cough, or other discomfort. No fevers, chills,
dysuria, no diarrhea.
In the ED, initial vs were: 97.2 70 116/67 18 97% RA. Labs were
remarkable for cbc 16.5k and INR 4.1. CT head and neck showed no
acute process. Neuology was consulted, who states that Pt
reported had longstanding gait issues with monthly falls
starting ___ year ago, which worsened in last ___ weeks, resulting
4 falls in last 2 weeks. On their exam, he has slightly delayed
response time but can tell a coherent story. Motor exam is
somewhat limited by pain in L arm but shows evidence of
multilevel cervical/lumbar radiculopathy. His tone is slightly
increased with cogwheeling rigidity L>R and resting/postural and
action tremor L>R. Unfortunately, due to pain in his left side,
patient did not want to ambulate in the ED. CT was reviewed and
does show diffuse atrophy including cerebellar / brainstem
atrophy but no stroke to explain the worsening symptoms in last
___ weeks. Neurology recommended admission to medicine for pain
control and safety eval.
On the floor, vs were: 97.5F, 126/80, 72, 22, 98% RA, 85.7kg.
Pt reports that he is left handed and that his handwriting has
been getting much worse, but that he doesn't know the timing. He
also reports occasional urinary incontinence over the last year,
but only ___ per year.
Review of sytems:
(+) Per HPI, falls, unsteady on feet, dyspnea on exertion
(-) 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 dysuria. Denies arthralgias
or myalgias. Ten point review of systems is otherwise negative.
Past Medical History:
Cardiac history:
___: NQWMI, cath revealing 60% RCA, T.O. LCx. PTCA of Cx
___: recurrent pain, ruled out. Repeat PTCA of Lcx
___: unstable angina, ruled out ? Repeat PTCA of Lcx
___: Cath LM normal, pLAD 60%, Cx with mild diffuse diseases,
95% OM restenosis treated with 3.0mm stent
___: Cath: LAD 30% ___, 60% mid, LCx 50% mid, RCA 60% mid. s/p
PTCA and stenting (2.5 x 23mm tetra stent) mid LAD
___. Three vessel coronary artery disease. 2. Patent OM1
stent.
3. Successful PCI of the RCA with cyper stent.
___. One vessel coronary artery disease. 2. Successful PCI
of the OM with cyper stent.
(+) HTN (+) hyperlipidemia (+) DM (+) cigarette smoking in past
Pt denies claudication, PND, orthopnea, edema, lightheadedness
PMH:
CAD
Hypertension
Hyperlipidemia
PAF
s/p CVA ___
gout
GERD
diverticulosis
spinal stenosis s/p laminectomy in ___
SSS s/p PPM ___
s/p inguinal hernia repair
total knee replacement
DM2
Social History:
___
Family History:
Parents died of MIs in ___. No neurological or gait disorders.
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: 97.5F, 126/80, 72, 22, 98% RA, 85.7kg
General: well appearing man in no acute distress
HEENT: superficial abrasions on L head, PERRL, EOMI, dry mucous
membranes
Lungs: unable to sit up or roll over to listen posterior.
anteriorly sounds clear bilaterally
CV: rrr, nl s1, s2, no m/r/g
Abdomen: soft, non-tender, normal bowel sounds
Ext: no edema, pain to palpation of L shoulder, no obvious
deformities
Skin: no rashes
Neuro: CN2-12 intact, reduced rapid motions on L hand, which is
dominant, reduced speed of L finger-nose-finger, though possibly
limited by pain. Lower extremities heel shin and toe tappig
normal bilaterally. Pt could no tolerate sitting up or standing
due to pain in chest and L shoulder.
DISCHARGE PHYSICAL EXAM:
Orthostatics:
Bed 143/79 HR70
Chair 141/69 HR70
Standing 137/74 HR70
Vitals: 97.8F, 141/84, 70, 16, 100% RA
General: well appearing man in no acute distress
HEENT: PERRL, EOMI, moist mucous membranes
Lungs: Patient able to sit up, anterior lung fields clear
bilaterally.
CV: rrr, nl s1, s2, no m/r/g
Abdomen: soft, non-tender, normal bowel sounds
Ext: no edema, pain to palpation of L shoulder, no obvious
deformities
Skin: no rashes
Neuro: CN2-12 intact, gross motor/sensation of ___ intact
Pertinent Results:
LABS ON ADMISSION:
___ 05:20PM BLOOD WBC-16.5*# RBC-4.38* Hgb-15.0 Hct-42.6
MCV-97 MCH-34.2* MCHC-35.2* RDW-14.2 Plt Ct-81*
___ 05:20PM BLOOD Neuts-44.8* Lymphs-49.9* Monos-4.5
Eos-0.3 Baso-0.6
___ 05:20PM BLOOD ___ PTT-44.6* ___
___ 05:20PM BLOOD Glucose-119* UreaN-18 Creat-1.2 Na-143
K-4.1 Cl-108 HCO3-23 AnGap-16
___ 05:20PM BLOOD TSH-6.3*
LABS ON DISCHARGE:
___ 05:50AM BLOOD WBC-16.8* RBC-3.54* Hgb-11.5* Hct-34.6*
MCV-98 MCH-32.6* MCHC-33.4 RDW-14.4 Plt Ct-92*
___ 05:50AM BLOOD Plt Ct-92*
___ 05:50AM BLOOD Glucose-119* UreaN-16 Creat-1.1 Na-142
K-3.8 Cl-108 HCO3-25 AnGap-13
PERTINENT MICRO
___ RPR negative
PERTINENT IMAGING:
___ CXR IMPRESSION: Streaky and linear bibasilar airspace
opacities most likely reflective of atelectasis.
___ CTA NECK: NECT: No acute process. CTA Neck: patent ICAs
and vertebral arteries
without dissection or hematoma. Some atherosclerosis in ICAs but
no high
grade stenosis. Retropharyngeal coarse of the right ICA is
noted. CTA Head:
Calcification of the cavernous ICAs. Circle of ___ and its
principal
branches are patent, without high grade stenosis, large
aneurysm, or vascular
malformation. Final read pending 3D recons.
___ CTA HEAD: NECT: No acute process. CTA Neck: patent ICAs
and vertebral arteries
without dissection or hematoma. Some atherosclerosis in ICAs but
no high
grade stenosis. Retropharyngeal coarse of the right ICA is
noted. CTA Head:
Calcification of the cavernous ICAs. Circle of ___ and its
principal
branches are patent, without high grade stenosis, large
aneurysm, or vascular
malformation. Final read pending 3D recons.
___ L Shoulder ___ Views
There is no definitive evidence of fracture, dislocation, lytic
or sclerotic
lesions demonstrated. Mild degenerative changes are present.
Soft tissue
ulceration is most likely present as well.
___ CT C Spine without contrast
IMPRESSION: Multilevel degenerative changes as described above
with most
pronounced canal stenosis at the level of C4-C5 and C5-6.
Brief Hospital Course:
___ gentleman with a PMH significant for afib s/p successful
cardioversion on coumadin, CAD s/p stent placement, and remote
CVA with no residual deficits who presented with multiple falls
and worsening ataxia with unclear etiology.
ACTIVE ISSUES:
# Falls, likely multifactorial, with possible contribution of
adverse effect of amiodarone (toxicity): Likely numerous
factors contributing including orthostatic changes from
decreased po intake, diuretics, amiodarone, and autonomic
instability. CT/CTA negative with no telemetry events.
Orthostatic hypotension resolved with IV fluids and decrease in
metoprolol. Patient had normal B12 and subclinical
hypothyroidism. Head CT indicates diffuse atrophy with
proportional ventriculomegaly. Seen by neuro consult, who
suggested that patient may have Parkinsons plus syndromes such
as MSA and ___ body dementia. Neuro also attributes amiodarone
and escitalopram administration as contributing factors in
worsening ataxia/falls. Amiodarone was discontinued with
agreement of primary cardiologist. Escitaloparm was also
discontinued given patient's report of unusual sleep behavior
and perceptions. He has been advised to only walk with
assistance given increased risk of falling.
# Paroxysmal afib s/p recent cardioversion on coumadin and
pacemaker placement in ___ with AV paced rhythm. Warfarin was
initially held during the hospital course for supratherapeutic
INR of 4.1 on admit and restarted on ___ at a lower dose of 2mg
daily when INR became therapeutic. Please follow up INR within 2
days (___). Given increased risk for head bleed with falls on
multiple anticoagulants and last stent placement dating more
than ___ years ago, plavix was discontinued with agreement of
primary cardiologist. Amiodarone was discontinued per neuro recs
given known side effect of worsened ataxia with medication. Home
dose of digoxin was continued during hospital stay.
# Right shoulder pain s/p fall: Imaging did not indicate acute
fracture. Patient continued to have persistent right shoulder
pain during hospital stay. Patient will be admitted to ___.
Please follow up with physical therapy exercises for management
of possible adhesive capsulitis.
#Cervical spinal stenosis: Patient advised to take tylenol as
needed for pain control.
#Sleep disturbance: Patient reported recent history of increased
sleep behavior with "wild dreams". Neuro evaluated and
suspicious for REM sleep behavior disorder and possible
underlying Dementia with ___ Bodies but reports further
evaluation outpatient is required. Lexapro was discontinued
permanently per neuro recs as it can cause REM sleep behavior
disorder in elderly patients. Patient is to f/u outpatient for a
nocturnal sleep study after rehab by neurologist Dr. ___
___ who saw him inpatient during this hospital course.
Patient had no reported nocturnal behaviors (yelling, motoric
activity suggesting dream enactment) during his hospital course
here.
CHRONIC ISSUES:
# CAD s/p multiple stents (___): Will continue home
atorvastatin. Cardiologist agrees that aspirin initiation is not
indicated given severe thrombocytopenia secondary to CLL. Plavix
discontinued in the setting of stent placement ___ years ago, in
agreement with cardiologist.
# Hypertension: Metoprolol dose was decreased to 12.5mg BID in
the setting of orthostasis. Primary care cardiologist to
reevaluate outpatient for further reduction in doses since
patient is at risk for afib with RVR. Furosemide was held during
hospital course due to orthostasis and will not be reintroduced
on discharge due to increased risk for falls. Plans to be
followed up by cardiologist.
# CLL with severe thrombocytopenia: Patient clinically stable
and plans to be followed up by primary oncologist.
# Hyperlipidemia: Clinically stable on home atorvastatin
# Gout: Clinically stable on home allopurinol
# GERD: Clinically stable on home omeprazole
# Diabetes: Held home glipizide during hospital course and was
put on insulin sliding scale. Will discharge home on glipizide.
# Anxiety: Held home dose of lorazepam given risk of fall with
increased sedation. Will discontinue and have PCP ___ for
evaluation of reinitiation of medication.
# Sick sinus syndrome s/p PPM: Documented history of this issue.
Patient remained clinically stable with plans to be followed up
by primary care cardiologist.
# Depression: Escitalopram was discontinued per neuro recs for
increased risk of abnormal sleep behavior in this elderly
gentleman.
TRANSITIONAL ISSUES:
-Please f/u patient's INR on ___ as he was supratherapeutic
during his hospital stay and coumadin was held until ___ when
it was restarted at a lower dose of 2mg daily
- Please evaluate for frozen shoulder if patient continues to
have persistent shoulder pain given limited mobility and
negative L shoulder xray imaging
- Please evaluate for further reduction in metoprolol or
reintroduction of furosemide based on patient orthostasis and
risk for falls
-Escitalopram and amiodarone were discontinued given concern for
increased abnormal sleep behavior and worsening gait ataxia.
-Furosemide and lorazapem were discontinued in the setting of
hypotension and disorientation. ___ be reinitiated in the future
as needed.
- Pleas f/u patient's digoxin level.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Metoprolol Succinate XL 37.5 mg PO BID
hold for sbp < 90 or hr < 60
2. Omeprazole 20 mg PO DAILY
3. Warfarin 2.5 mg PO DAILY16
4. Amiodarone 200 mg PO BID
5. GlipiZIDE 5 mg PO BID
6. Clopidogrel 75 mg PO DAILY
7. Allopurinol ___ mg PO DAILY
8. Furosemide 40 mg PO DAILY
hold for sbp < 90
9. Escitalopram Oxalate 20 mg PO DAILY
10. Lorazepam 0.5 mg PO BID
hold for excessive sedation or RR < 12
11. Atorvastatin 20 mg PO DAILY
12. Digoxin 0.125 mg PO DAILY
13. Nitroglycerin SL 0.3 mg SL PRN chest pain
14. Multivitamins 1 TAB PO DAILY
Discharge Medications:
1. Allopurinol ___ mg PO DAILY
2. Atorvastatin 20 mg PO DAILY
3. Digoxin 0.125 mg PO DAILY
4. Multivitamins 1 TAB PO DAILY
5. Omeprazole 20 mg PO DAILY
6. Warfarin 2 mg PO DAILY
7. Metoprolol Tartrate 12.5 mg PO BID
8. GlipiZIDE 5 mg PO BID
9. Nitroglycerin SL 0.3 mg SL PRN chest pain
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary: falls
Secondary:
atrial fibrillation on coumadin
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Patient should not ambulate without assistance given increased
risk for falls.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you at ___. You were
transferred here for further evaluation of your recent gait
instability and falls. Not eating enough and certain medications
may be contributing so we encourage you to stay well hydrated.
We discussed your metoprolol dose with Dr. ___ agreed
that it would be appropriate to decrease the dose since you were
having low blood pressure during your stay. We would like you to
remain at that dose. We have stopped your amiodarone and
escitalopram with agreement from both the neurologist and
cardiologist because these medications may also have been
contributing to your falls. There is also a possibility that you
may have a syndrome called Parkinsons plus which involves
difficulty walking and increased anxiety. You should follow up
with your neurologist who can discuss these issues further with
you. We stopped your coumadin during part of your hospital stay
because it was at too high of a level which can lead to
increased bleeding especially if you fall. Your coumadin level
is now at an appropriate level. We have restarted that
medication and would like you to follow up for an INR check in 2
days to make sure it is still at the right level.
During your stay, you were also found to have a urinary tract
infection and completed a course of antibiotics which has
cleared the infection. You were also diagnosed with spinal
stenosis based on imaging of the spine. This means you may have
periodic neck pain that you should treat with pain medications
such as tylenol.
Please follow up with both your cardiologist and neurologist
within 2 weeks when you leave the hospital.
Followup Instructions:
___
|
19682902-DS-3
| 19,682,902 | 20,938,315 |
DS
| 3 |
2166-10-15 00:00:00
|
2166-10-15 16:17:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Back Pain
Major Surgical or Invasive Procedure:
___
1. Total laminectomy of T7, 8, 9, 10 and 11.
2. Fusion T3 to L1.
3. Transpedicular decompression at T7 and T11.
4. Instrumentation T3 to L1.
5. Autograft.
___
1. Incision and drainage of epidural hematoma.
2. Revision laminectomy at T7 and T11.
History of Present Illness:
This is a ___ man with past medical history of
hyperlipidemia who presented to the emergency department for new
metastatic disease involving the ___.
Patient has had left-sided hip pain for greater than 2 months in
duration. He has been seen by his primary care doctor, a
physical therapist, and a sports medicine physician. While
getting worked up for this, concomitantly over the last month he
is developed progressive midline back pain. It specifically
started approximately ___ weeks ago when he stepped down off
of
a curb and landed very sharply. He has had progressive midline
back pain since that time. He has had no fecal incontinence, no
urinary retention, no fevers or weight loss. He has had a
recent
colonoscopy in ___ that was not concerning for malignant
polyps.
He has had screening PSAs with his most recent level 4.2. The
patient was urgently referred to orthopedics at ___ where he
underwent an MRI of the thoracic ___ without contrast.
In the ED,
vitals were:98.2 102 140/73 18 97% RA
Examination shows he is neurologically intact.
Labs:
-WBC 13.8 H/H 15.4/45.1 Plt 299
-Glc 113 BUN 24 Cr 0.9 Na 134 K 4.7 Cl 95 HCO3 25
-ALT 30 AST 35 AP 186 Tbili 0.4
-Alb 4.3 Ca ___ Phos 3.4 Mg 2.1 Lipase 34
-U/A small blood
-Urine culture pending
Studies:
MRI ___, cervical, lumbar/pelvis pending
Consults: ___, recommended operative management and medical
workup.
They were given:
___ 13:32 IV HYDROmorphone (Dilaudid) .25 mg ___
Partial Administration
___ 14:46 IV HYDROmorphone (Dilaudid) .25 mg ___
Partial Administration
On arrival to the floor, he says that ___ days before ___ he
was outside doing yardwork using a leaf blower when he felt a
sharp pain in his back while he was reaching upward. It did not
resolve so on ___ he went to an urgent care where they
obtained an XR without significant findings. His pain continued
to worsen, so he went to his PCP who referred him to a sports
medicine specialist. XR obtained on ___ showed a compression
fracture. MRI obtained on ___ w/ At___ in ___ showed
diffuse mets to thoracic ___ and ribs so he was instructed to
present to ___. He also notes left hip pain (says iliopsoas)
with sharp jolting pain radiating from gluts to calf for which
he
was seeing ___. Occasionally has small amount of blood in stool
___ known hemorrhoids. Had colonoscopy in ___ which showed a
benign polyp and was instructed to obtain repeat colonoscopy in
___
years (had a previous colonoscopy w/ precancerous findings).
Also
notes that in ___ he had a bout of strabismus that resolved on
its own, etiology unknown. Currently rates pain ___, says his
back pain radiates to his ribs. He denies fevers, CP, SOB,
abdominal pain, constipation, numbness, tingling, bowel or
bladder incontinence, urinary retention, blurry vision, flashes
or floaters, HA.
Past Medical History:
HLD
Social History:
___
Family History:
Noncontributory to presenting complaint
Physical Exam:
ADMISSIONS PHYSICAL EXAM:
=========================
VITALS: ___ 1833 Temp: 98.5 PO BP: 143/75 L Lying HR: 73
RR:
18 O2 sat: 97% O2 delivery: Ra
GENERAL: Alert and interactive. In no acute distress.
HEENT: PERRL, EOMI. Sclera anicteric and without injection. MMM.
NECK: Supple
CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No
murmurs/rubs/gallops.
LUNGS: Clear to auscultation bilaterally. No wheezes, rhonchi or
rales. No increased work of breathing.
BACK: focal nontender protrusion of mid-thoracic ___, TTP at
lower thoracic ___
ABDOMEN: Normal bowels sounds, non distended, non-tender to deep
palpation in all four quadrants. No organomegaly.
EXTREMITIES: No clubbing, cyanosis, or edema. Pulses DP/Radial
2+
bilaterally.
SKIN: Warm. Cap refill <2s. No rash.
NEUROLOGIC: AOx3. Moving all 4 limbs spontaneously. CN ___
intact. ___ strength throughout. Symmetric reflexes. Normal
sensation.
DISCHARGE PHYSICAL EXAM:
========================
24 HR Data (last updated ___ @ 2341)
Temp: 98.3 (Tm 98.4), BP: 130/63 (105-130/54-63), HR: 67
(67-70), RR: 18, O2 sat: 100% (98-100), O2 delivery: RA
GENERAL: Lying in bed in NAD
RESP: no increased WOB on room air
GI: Non-distended, nontender
EXT: warm, no edema
BACK: vesicles on posterior L T5 dermatome have resolved
SKIN: vesicular lesions at L T5 dermatome have crusted over,
with
decreased erythema at base
NEURO: Sensation intact RLE and LLE. Able to wiggle right toes.
Intermittently able to wiggle left toes (patient states this is
involuntary).
Pertinent Results:
Admission Labs:
===============
___ 12:00PM BLOOD WBC-13.8* RBC-4.85 Hgb-15.4 Hct-45.1
MCV-93 MCH-31.8 MCHC-34.1 RDW-12.2 RDWSD-42.0 Plt ___
___ 12:00PM BLOOD ___ PTT-26.0 ___
___ 12:00PM BLOOD Glucose-113* UreaN-24* Creat-0.9 Na-134*
K-4.7 Cl-95* HCO3-25 AnGap-14
___ 12:00PM BLOOD TotProt-7.7 Albumin-4.3 Globuln-3.4
Calcium-10.9* Phos-3.4 Mg-2.1
Discharge Labs:
===============
None
Notable Imaging/Studies:
========================
___ MR ___ W & W/O Contrast
IMPRESSION:
1. 1.7 cm expansile mass in the right occipital condyle, of
unclear origin
based on this imaging alone. Given the multiplicity of lesions
identified on spinal imaging, metastatic disease is a leading
possibility.
2. No evidence of hemorrhage, edema or recent infarction.
3. Right maxillary sinus disease.
___ MR ___
IMPRESSION:
1. Multiple multi-cystic expansile masses at different levels of
the ___, ribs, right occipital condyle, sacrum and left iliac
bone, in comparison with CT torso from ___, these masses
have newly appeared and rapidly progressed.
2. Although the appearance of these lesions raises a less
aggressive
alternatives including hemangioma, rapid progression argues in
favor of
metastatic disease.
3. Thoracic masses in the region the right upper chest could
represent rib
lesions, incompletely imaged in this study.
4. Partially visualized T11 vertebral body lesion causing severe
canal
narrowing is partially visualized in current study and addressed
on MRI
___ from outside hospital.
___ MR ___ & W/O Contrast
IMPRESSION:
1. Study degraded by motion and spinal fusion hardware, and
further limited with axial thoracic and lumbar ___
postcontrast imaging not obtained for this exam.
2. 4 cm long T2/STIR cord signal abnormality, beginning at and
extending
cranially from the level of the T7 lesion where there is severe
canal
narrowing and spinal cord compression. Notably, the degree of
spinal canal narrowing at this level is unchanged since ___, and the patient has now undergone interval posterior
decompression/laminectomies. Findings would be compatible with
a cord injury due to prior compression, however difficult to
exclude other etiologies (e.g., cord ischemia), as appearance is
non-specific.
3. Acute spinal subdural hematoma, 10 cm SI and 0.6 cm thick,
from C5-6 to T3 in the dorsal spinal canal; hematoma does not
appear to compress the spinal cord, but abuts its dorsal
surface, causing up to moderate to severe canal narrowing.
4. Multiple cervical, thoracic, and lumbar ___ enhancing
cystic metastases, similar to prior studies, causing areas of up
to severe spinal canal narrowing, with obliteration of neural
foramina in the cervical ___.
5. Additional probable metastatic lesions noted in the right
upper chest wall, occipital condyle, left sacrum.
6. Anasarca.
7. Bilateral pleural effusions.
8. Probable renal cysts.
Pathology:
==========
___ Bone Biopsy
PATHOLOGIC DIAGNOSIS:
Left acetabulum / inferior pubic ramus, core biopsies:
METASTATIC POORLY DIFFERENTIATED CARCINOMA, UNKNOWN PRIMARY. See
note.
Note: Tumor cells are arranged in nested, trabecular, and focal
acinar/glandular patterns. By
immunohistochemistry, tumor cells show the following staining
profile:
___ Positive: cytokeratin (AE1/3, Cam5.2), CD138.
___ Negative: CK7, CK20, glypican, CD10, polyclonal CEA,
chromogranin, synaptophysin, CD56,
PAX8, TTF1, Napsin, PSA, NKX3.1, CDX2, GATA3, p40, CD31, CD34,
ERG, inhibin, S100,
kappa light chain (ISH), lambda light chain (ISH).
___ Equivocal: HepPar1 (weak staining).
The morphology and immunophenotype are not specific as to site
of origin. The absence of both CK7
and CK20 staining can be seen in tumors of hepatocellular,
prostate, adrenal, and renal origin, but
the more lineage-specific markers for these sites are negative.
Correlation with imaging findings is
required.
___ Spinal Cord Path
PATHOLOGIC DIAGNOSIS:
1. "Tumor":
- Metastatic carcinoma most consistent with a primary of
hepatocellular origin; see note.
2. "T11 mass":
- Metastatic carcinoma most consistent with a primary of
hepatocellular origin; see note.
Note: Immunohistochemical stains performed on block ___
demonstrate that the tumor cells are
positive for cytokeratin cocktail (AE1/AE3, Cam5.2), CK7,
HepPar1 (focal), and polyclonal CEA in a
pericanalicular pattern. PAX8 shows nonspecific cytoplasmic
staining. The tumor cells are negative
for CK20, napsin, TTF1, glypican 3, glutamine synthetase, CD10,
CDX2, NKX3.1, GATA3,
synaptophysin, and S100. The histologic and immunohistochemical
findings are most consistent with
the above diagnosis.
Brief Hospital Course:
HOSPITAL COURSE SUMMARY:
========================
Mr ___ is a ___ y/o M with PMH of HLD who presented with
progressive back and hip pain for 1 month, with imaging
demonstrated diffuse metastatic cancer with metastasis to bone,
liver, lung, and brain. He had an ___ guided biopsy of bony
lesion in left hip, which revealed poorly differentiated
metastatic carcinoma of unknown primary.
He had an especially concerning lesion at T7 ___ with mass
effect on cord, and was evaluated by spinal surgery. After input
from ___ care, radiation therapy, and medical oncology,
the patient decided to pursue surgery. His surgery for
decompression was complicated by hemorrhage requiring massive
transfusion and embolization leading to cord infarction causing
paraplegia.
Post-Op course complicated by constipation felt to be
multifactorial in the setting of opioid pain medications,
post-op ileus, neurologic deficits from cord infarction. This
improved with standing bowel regimen of senna, miralax,
bisacodyl, multiple enemas, manual disimpaction, and
methylnaltrexone.
He also suffered from a neurogenic bladder due to his spinal
injury which required intermittent catheterization. He
unfortunately suffered from urethral trauma due to the
intermittent catheterizations and a indewlling catheter had to
be left in place with plans for urology follow up.
Intra-op pathology from patient's spinal surgery returned
consistent with HCC. After further discussion with oncology and
radiation oncology patient elected to pursue radiation therapy
to only his cervical ___ for palliation of cancer related
pain. Hospital course was further complicated by development of
herpes zoster infection in L T5/6 dermatome on anterior chest.
Ultimately, patient decided to go to ___ under rehab benefit
with plan for transition to home hospice after regaining some
strength and coordination.
TRANSITIONAL ISSUES:
====================
[] Foley should be exchanged on first week of ___ and every ___
weeks thereafter; given urethral injury, should NOT self-cath
due to prior urethral truama
[] No need for orthopedic follow-up unless new issues arise from
surgery site
[] Would continue prophylactic Lovenox as patient is paraplegic
and high risk for clots
# HCP/CONTACT: ___ (wife) ___
# CODE STATUS: DNR/DNI, okay for trial of NIPPV
ACUTE ISSUES:
=============
# Goals of care
Patients outpatient oncologist and inpatient team held several
family meetings to discuss goals of care and possible future
palliative treatments, including oral chemotherapy. After much
deliberation, the patient elected to forgo any additional
treatments and was discharged to a SNF with rehab to regain
upper body strength, with plan for home hospice after, and code
status DNR/DNI.
# Metastatic HCC
# Severe compression deformity @ T7
# Paraplegia ___ T7 cord infarction, cervical cord hematoma
without compression
Patient found recently to have diffuse mets to ___,
ribs, ___, liver. S/p biopsy of L hip on ___ with final path
showing poorly differentiated carcinoma of unknown primary. One
___ lesion at T7 with retropulsion and mass-effect on the
anterior cord, which was evaluated by ___.
Underwent underwent T3-L1 decompression and fusion procedure on
___ c/b hemorrhage from the tumor mass in which he lost
approximately 12L of blood requiring massive transfusion
protocol and embolization with ___. Ultimately found to have
infarcted cord at T7 leading to paraplegia. Intra-Op path
returned as likely ___ primary.
After conversation with radiation oncology he decided to undergo
radiation therapy to cervical ___ for palliation of cancer
related pain in that area. After several ___ discussions,
patient decided additional radiation and chemotherapy were no
longer in line with his desires. Patient and family decided on
d/c to SNF with plan for eventual home hospice.
# Herpes Zoster Infection
Patient noted to have dermatomal vesicular rash on erythematous
base over L anterior chest morning of ___. No evidence of rash
or lesions elsewhere on body to suggest a disseminated
infection. No pain or paresthesias associated with rash. Was
treated with valacycovir, which was transitioned to IV acyclovir
due to intolerance of PO medication, for a ___nding
___. Lesions had crusted at time of discharge.
# Radiation esophagitis: Patient previously endorsing throat
pain, improved. Ranitidine and sucralfate provided as needed.
# Nausea: Patient reported new nausea earlier in his course
coinciding with valacyclovir dose. Improved after transition to
IV acyclovir and reinitiation of sucralfate/ranitidine.
# Sacral decubitus ulcer: Pressure wound ___ paraplegia. Wound
nurse consulted.
# Scapular pain: Patient noting scapular pain due to positioning
during radiation sessions. Lower concern for additional disease
burden but initial plan to proceed with bone scan. Patient
decided no longer in line with ___, so did not pursue bone scan.
# Constipation: Patient suffered from severe constipation post
spinal surgery. Felt to be likely multifactorial in the setting
of continued opioid medications for pain, post-op ileus, SCI.
Treated with miralax, senna, bisacodyl, enemas,
methylnaltrexone, manual disimpaction. Bowel activity slowly
improved post-op.
# Neurogenic Bladder
# Urinary Retention
# Urethral Trauma
Patient w/ urinary retention requiring intermittent
catheterization since spinal surgery most likely in the setting
of neurogenic bladder. Had been a difficult cath for multiple
staff members and overnight ___ bleeding was noted with
visualized clot. Urology consulted who recommended placing
coudae catheter connected to collection bag, with plan to
exchange Foley catheter every ___ weeks.
# Acute Blood Loss Anemia
___ hemorrhage during surgery. S/P massive transfusion protocol
Hgb stabilized around ___ for remainder of hospitalization
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 40 mg PO QPM
2. Vitamin D 400 UNIT PO DAILY
3. Glucoten (glucosamine-chondroit-mv-min3) 375-300-25-0.5 mg
oral DAILY
4. TraMADol 50 mg PO Q6H:PRN Pain - Moderate
Discharge Medications:
1. Acetaminophen 650 mg PO TID
2. Enoxaparin Sodium 40 mg SC DAILY
3. Ondansetron ODT 4 mg PO Q8H:PRN Nausea/Vomiting - First Line
4. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain -
Moderate
RX *oxycodone 5 mg 1 tablet(s) by mouth every six (6) hours Disp
#*12 Tablet Refills:*0
5. Polyethylene Glycol 17 g PO DAILY
6. Ranitidine 75 mg PO TID
7. Senna 8.6 mg PO BID
8. Sucralfate 1 gm PO TID
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
==================
Metastatic HCC
Destructive lytic lesion of T7
Inferior pubic rami fracture
thoracic cord compression
paraplegia
SECONDARY DIAGNOSES:
====================
T5 Herpes zoster
Hyperlipidemia
sacral decubitus ulcer
neurogenic bladder
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure caring of you at ___.
WHY WAS I IN THE HOSPITAL?
- You were admitted to the hospital because you were found to
have metastatic cancer
WHAT HAPPENED TO ME IN THE HOSPITAL?
- You had a biopsy performed to determine the type of cancer you
have. Further imaging of your body to see where the cancer was
found that there was a significant amount around your ___
which was pushing on your spinal cord.
- You had surgery to remove the tumor from around your ___.
Unfortunately, during this surgery there was significant
unexpected blood loss requiring transfusion of blood products
and an embolization procedure leading to an injury to your
spinal cord.
- You were monitored in the ICU after your surgery and
complications until you were felt stable enough to return to the
medicine floor
- You were having trouble with bowel movements and we gave you
medications and enemas to help with this.
- You were having trouble urinating because of the injury to
your spinal cord. We intermittently catheterized you to help you
urinate. You had an injury to your urethra during one of these
catheterizations and a catheter had to be left in place to allow
your urethra to heal.
- You developed a rash on your chest which was felt to be a
shingles infection. This was treated with an antiviral
medication
- After talking with our radiation oncology team you were
transferred to our ___ and underwent 5 radiation
treatments to your cervical ___ to help with your pain.
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
- Continue to take all your medicines and keep your
appointments.
We wish you the best!
Sincerely,
Your ___ Team
Dear Mr. ___,
It was a pleasure caring of you at ___.
WHY WAS I IN THE HOSPITAL?
- You were admitted to the hospital because you were found to
have metastatic cancer
WHAT HAPPENED TO ME IN THE HOSPITAL?
- You had a biopsy performed to determine the type of cancer you
have. Further imaging of your body to see where the cancer was
found that there was a significant amount around your ___
which was pushing on your spinal cord.
- You had surgery to remove the tumor from around your ___.
Unfortunately, during this surgery there was significant
unexpected blood loss requiring transfusion of blood products
and an embolization procedure leading to an injury to your
spinal cord.
- You were monitored in the ICU after your surgery and
complications until you were felt stable enough to return to the
medicine floor
- You were having trouble with bowel movements and we gave you
medications and enemas to help with this.
- You were having trouble urinating because of the injury to
your spinal cord. We intermittently catheterized you to help you
urinate. You had an injury to your urethra during one of these
catheterizations and a catheter had to be left in place to allow
your urethra to heal.
- You developed a rash on your chest which was felt to be a
shingles infection. This was treated with an antiviral
medication
- After talking with our radiation oncology team you were
transferred to our ___ and underwent 5 radiation
treatments to your cervical ___ to help with your pain.
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
- Continue to take all your medicines and keep your
appointments.
We wish you the best!
Sincerely,
Your ___ Team
Followup Instructions:
___
|
19683695-DS-26
| 19,683,695 | 25,551,421 |
DS
| 26 |
2137-08-29 00:00:00
|
2137-09-01 22:44:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Pneumococcal Vaccine
Attending: ___.
Chief Complaint:
dyspnea
Major Surgical or Invasive Procedure:
Cardiac catheterization
History of Present Illness:
This is a ___ year old gentleman, s/p liver and kidney
transplant in ___ at ___, ___ alcoholic liver disease, PVD
s/p right BKA and multiple vascular procedures, DM, and dCHF
(last EF in ___ 50%) presentign with one week of worsening
dyspnea. Patient was recently hospitalized from ___ for
baloon angioplasty and stenting of the popliteal artery above
the left knee for chronic non-healing ulcer of the foot. Prior
to his procedure he was agressivly hydratd for renal protection.
His lasix was held until ___ at which time he resumed taking
his lasix 80mg QD. He reports that he was feeling fine on his
day of discharge, however, over the next several days he began
to develop worsening shortness of breath. .
.
This afternoon he called his PCP/Cardiologist, Dr. ___ told
him to come directly to the ___ ED. He was initially breathing
35 BPM with O2 sats in the 80's. He was initially on a
non-rebreather, trialed on BiPap, which he did not tolerate and
was palced back on non-rebreather. He was given 100mg IV lasix
and put out significant urine. He was quickly weaned off of
non-rebreather and by the time he was evaluated in the ICU he
was satting in the high 90's on 4l NC.
.
He denies any preceding chest pain, palpitations, diaphoresis or
nausea. He denies orthopnea, PND and lower extremity swelling.
At baseline he is able to play 9 holes of golf 3 x a week and 18
holes on weekends. He reports that this past winter he lived in
___ where he had his best season of golf ever.
.
Past Medical History:
Liver (ESLD ___ EtOH) and kidney transplant (ESRD ___ DM2) in
___
DMII
R leg amputation ___ severe infection in ___
PVD s/p stents in left leg
Atrial fibrillation on Coumadin
HTN
dCHF (LVEF>55% in ___
prostate ca s/p radiation last year
Social History:
___
Family History:
Father w diabetes
Physical Exam:
ADMISSION EXAM:
GENERAL: NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with JVP of 7 cm.
CARDIAC: RRR s1s2
LUNGS: Pectus excavatum, Bilateral crackles to mid thorax on
posterior lung fields with decreased breathsounds at the bases.
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
DISCHARGE EXAM:
GENERAL: no acute distress, sitting comfortably in bed
HEENT: mucous membs moist, no lymphadenopathy, no JVD
CHEST: LS clear
CV: RRR, S1 S2 clear and of good quality, no murmurs rubs or
gallops
ABD: soft, non-tender, non-distended, BS normoactive.
EXT: RLE: BKA, stump warm and dry, skin intact. LLE: left shin
with large square shape ulcer, pink wound with tan colored
drainage, edges well approximated, wound vac in place. Left foot
second toe with healing scabbed ulcer at top of toe. Mild LLE
edema present. ___ per doppler.
NEURO: ___ strength in U/L extremities
SKIN: upper left quadrant of back with dime sized wound (from
surgical cyst removal), packing with tan drainage present, wound
pink, edges well approximated. Right upper ear with healing
ulceration, scabbed.
Pertinent Results:
ADMISSION LABS:
___ 04:15PM BLOOD WBC-5.9# RBC-3.94* Hgb-9.7* Hct-34.6*
MCV-88 MCH-24.7* MCHC-28.2* RDW-17.4* Plt ___
___ 04:15PM BLOOD Plt ___
___ 04:45PM BLOOD ___
___ 04:15PM BLOOD Glucose-178* UreaN-41* Creat-2.0* Na-138
K-5.2* Cl-103 HCO3-23 AnGap-17
___ 04:15PM BLOOD cTropnT-0.07* ___
___ 08:00PM BLOOD cTropnT-0.08*
___ 04:15PM BLOOD Calcium-9.4 Phos-5.0* Mg-1.8
___ 06:10AM BLOOD tacroFK-8.7
PERTINENT INTERVAL LABS:
COMPLETE BLOOD COUNTS:
___ 06:10AM BLOOD WBC-4.2 RBC-3.86* Hgb-9.4* Hct-33.3*
MCV-86 MCH-24.4* MCHC-28.4* RDW-16.9* Plt ___
___ 07:20AM BLOOD WBC-5.1 RBC-3.88* Hgb-9.6* Hct-34.1*
MCV-88 MCH-24.7* MCHC-28.1* RDW-17.4* Plt ___
___ 05:52AM BLOOD WBC-6.7 RBC-3.86* Hgb-9.7* Hct-33.7*
MCV-87 MCH-25.0* MCHC-28.7* RDW-17.6* Plt ___
___ 08:09AM BLOOD WBC-4.5 RBC-3.93* Hgb-9.6* Hct-33.9*
MCV-86 MCH-24.3* MCHC-28.2* RDW-16.7* Plt ___
___ 05:42AM BLOOD Hct-30.8*
INR TREND:
___ 04:45PM BLOOD ___
___ 08:00PM BLOOD ___
___ 07:20AM BLOOD ___
___ 05:52AM BLOOD ___
___ 10:45AM BLOOD ___ PTT-36.4 ___
___ 08:09AM BLOOD ___ PTT-34.3 ___
___ 05:42AM BLOOD ___
___ 1.4
ELECTROLYTES/RENAL FUNCTION:
___ 06:10AM BLOOD Glucose-87 UreaN-39* Creat-2.0* Na-141
K-4.5 Cl-104 HCO3-27 AnGap-15
___ 08:00PM BLOOD Glucose-129* UreaN-41* Creat-2.3* Na-137
K-5.0 Cl-102 HCO3-24 AnGap-16
___ 07:20AM BLOOD Glucose-145* UreaN-41* Creat-2.1* Na-139
K-4.5 Cl-104 HCO3-26 AnGap-14
___ 05:52AM BLOOD Glucose-110* UreaN-40* Creat-2.2* Na-133
K-4.7 Cl-98 HCO3-24 AnGap-16
___ 07:45AM BLOOD Glucose-162* UreaN-43* Creat-2.2* Na-134
K-4.9 Cl-99 HCO3-25 AnGap-15
___ 08:09AM BLOOD Glucose-127* UreaN-49* Creat-2.3* Na-137
K-4.9 Cl-101 HCO3-25 AnGap-16
___ 11:32PM BLOOD Glucose-176* UreaN-44* Creat-2.2* Na-135
K-4.8 Cl-98 HCO3-28 AnGap-14
___ 05:42AM BLOOD UreaN-42* Creat-2.0* Na-136 K-4.9 Cl-99
___ 08:09AM BLOOD ALT-16 AST-23 LD(LDH)-214 AlkPhos-113
TotBili-0.6
CARDIAC BIOMARKERS:
___ 04:15PM BLOOD cTropnT-0.07* ___
___ 08:00PM BLOOD cTropnT-0.08*
LIPIDS :
___ 07:20AM BLOOD Triglyc-103 HDL-23 CHOL/HD-4.3 LDLcalc-55
___ 05:52AM BLOOD Triglyc-89 HDL-22 CHOL/HD-4.0 LDLcalc-49
TACRO LEVELS:
___ 07:20AM BLOOD tacroFK-7.0
___ 05:52AM BLOOD tacroFK-5.9
___ 08:09AM BLOOD tacroFK-8.2
STUDIES:
ECG ___: rate 85, Artifact is present. Atrial fibrillation
with a controlled ventricular response. Non-specific ST-T wave
changes. Compared to the previous tracing of the same date there
is no significant change.
TRACING #2
ECG ___: rate 76. Artifact is present. Probable atrial
fibrillation with a controlled ventricular response. Ventricular
ectopy versus aberrant conduction. There is a late transition
which is probably normal. Non-specific ST-T wave changes.
Compared to the previous tracing of ___ there is no
significant change. TRACING #1
CXR ___: IMPRESSION: Mild pulmonary edema with increased
moderate-sized left pleural effusion, and similar-sized right
pleural effusion. Bibasilar airspace opacities ___ reflect
compressive atelectasis, though infection cannot be excluded.
ECHO ___:
The left atrium is markedly dilated. The right atrium is
markedly dilated. There is mild symmetric left ventricular
hypertrophy with normal cavity size. Regional left ventricular
wall motion is normal. Overall left ventricular systolic
function is normal (LVEF 70%). There is considerable
beat-to-beat variability of the left ventricular ejection
fraction due to an irregular rhythm/premature beats. Tissue
Doppler imaging suggests an increased left ventricular filling
pressure (PCWP>18mmHg). The right ventricular cavity is dilated
with depressed free wall contractility. There is abnormal septal
motion/position. The aortic valve leaflets are moderately
thickened. There is severe aortic valve stenosis (valve area
1.0cm2). No aortic regurgitation is seen. There is severe mitral
annular calcification. There is a minimally increased gradient
consistent with trivial mitral stenosis. Mild (1+) mitral
regurgitation is seen. [Due to acoustic shadowing, the severity
of mitral regurgitation ___ be significantly UNDERestimated.]
The tricuspid valve leaflets are mildly thickened. Moderate [2+]
tricuspid regurgitation is seen. There is severe pulmonary
artery systolic hypertension. The branch pulmonary arteries are
dilated. There is no pericardial effusion.
Compared with the findings of the prior study (images reviewed)
of ___, severe aortic stenosis and severe pulmonary
hypertension are now present.
Cardiac Cath ___:
1. Selective coronary angiography of this right-dominant system
demonstrated 2 vessel CAD. There was no functional LMCA, as the
LAD and
LCX had separate ostia. The LAD had mild disease throughout, and
a high
diagonal branch with 90% stenosis. The LCX had a small OM1
branch with
a discrete 90% lesion. The dominant RCA was a large caliber
vessel with
mild disease, a patent RPDA, and diffuse disease in the distal
twin PLV
branches.
2. Resting hemodynamics revealed mildly elevated right and
left-sided
filling pressures with a measured RVEDP 13mmHg and LVEDP 19mmHg.
There
was moderate pulmonary artery hypertension with a mean PAP
34mmHg.
Cardiac index was preserved at 2.71 L/min/m2. Mild aortic
stenosis was
present with a measured mean gradient of 14mmHg and a calculated
valve
area of 1.45cm2.
3. Left ventriculography was deferred.
4. Successful closure of the right femoral arteriotomy site with
a ___
angioseal device.
FINAL DIAGNOSIS:
1. Two vessel CAD.
2. Medical management of CAD with addition of beta-blocker
therapy.
3. Consider increase in outpatient diuretic dose.
4. Successful closure of RCFA arteriotomy site with angioseal
device.
5. Careful post-cath hydration per renal recommendations. Only
30cc
Visipaque dye used for procedure.
Brief Hospital Course:
BRIEF CLINICAL SUMMARY:
Mr. ___ is a ___ gentleman with complex vascular history
and known diastolic CHF who presented with worsening dyspnea,
found to have acute on chronic CHF in setting of newly diagnosed
aortic valve stenosis.
ISSUES:
# Acute on chronic dCHF:
Chronic diastolic CHF with acute exacerbation during this
admission thought to be ___ aortic stenosis, also in setting of
having received IVFs the week prior during vascular procedure.
He was diuresed with lasix to which he responded well. Echo
showed severe aortic valve stenosis (valve area 1.0cm2), 1+ MR
___ be underestimated), 2+ TR. Pt went for cath on ___ to
eval aortic stenosis. He was given shortened protocol for
hydration 1 hr prior and 6 hours post with D5W + bicarb per
renal recs. Cath showed some mild D1 and OM1 dz but otherwise
normal coronaries. There was "moderate pulmonary artery
hypertension with a mean PAP 34mmHg, cardiac index was preserved
at 2.71 L/min/m2. Mild aortic stenosis was present with a
measured mean gradient of 14mmHg and a calculated valve area of
1.45cm2." No intervention was performed. He was continued on
metoprolol and started on low dose lisinopril. He was
discharged on lasix po 40mg BID. Should continue to check daily
weights at home and call cardiologist or PCP if weights increase
by >3 lbs.
# Coronary Artery Disease:
Patietn underwent Cardiac catheterization by Dr. ___ to evaluate
new aortic stenosis during this hospitalization. Left heart
cath revealed 2 vessel CAD (90% LAD, 90% OM1). He was continued
on aspirin and plavix for his peripheral vascular disease. He
was also continued on metoprolol. He is not on a statin, which
should be considered as an outpatient, though his LDL is at
goal. Of note, his HDL is very very low as well.
# Chronic Left Shin Ulcer/Peripheral Vascular Disease:
Patient has chronic non-healing left anterior shin ulcer, for
which he underwent angioplasty and stenting of popliteal artery
above the knee on ___ during previous hospitalization in
attempt to help with ulcer healing. Patient was followed by
both Plastic Surgery and Vascular Surgery teams during this
hospitalization. Plastic Surgery team placed wound vac on
___ and was left in place upon discharge. There was some
discussion about possible skin graft procedure by Plastics
surgery team in the future. He was continued on aspirin and
plavix for peripheral vascular disease.
# Atrial fibrillation:
Rate controlled and anticoagulated with warfarin. CHADS score of
3. Warfarin was held for cardiac catheterization, and he was
given 5mg of po vitamin K the day prior to procedure. Warfarin
was restarted after the procedure at home dose without bridging.
INR was 1.4 on discharge. He should have INR repeated as an
outpatient on ___.
INACTIVE ISSUES:
# s/p Liver transplant and Renal transplant
He was followed by renal transplant and hepatology teams during
this hospitalization. Tacrolimus levels were checked daily.
Tacrolimus dosing remained at prior home dose of 1mg in am and
0.5mg at night, and he was continued on cellcept 500mg BID.
# HTN:
He was continued on metoprolol but transitioned to long-acting
formulation upon discharge. Nifedipine was stopped, and
Lisinopril 5mg was started.
# Diabetes Mellitus, Type 2:
He was continued on home insulin regimen during this
hospitalization.
TRANSITIONAL ISSUES:
- Vascular Team recommended perioperative/procedural antibiotics
for all
future procedures
- Wound VAC in place left anterior shin wound upon discharge,
requiring Q3day dressing changes, followup in ___ with Dr.
___ ___
- lipid followup by cardiologist and PCP --> HDL is very low in
___ ; LDL is at goal, but consider whether statin would be
beneficial
- repeat INR on ___
Medications on Admission:
1. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Lasix 80 mg Tablet Sig: One (1) Tablet PO once a day.
3. mycophenolate mofetil 500 mg Tablet Sig: One (1) Tablet PO
BID (2 times a day).
4. nifedipine 30 mg Tablet Extended Release Sig: One (1) Tablet
Extended Release PO DAILY (Daily).
5. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
6. tacrolimus 1 mg Capsule Sig: One (1) Capsule PO QAM (once a
day (in the morning)).
7. tacrolimus 0.5 mg Capsule Sig: One (1) Capsule PO QPM (once a
day (in the evening)).
8. pregabalin 100 mg Capsule Sig: One (1) Capsule PO QHS (once a
day (at bedtime)).
9. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
10. insulin Fingerstick QACHS Insulin SC Fixed Dose Orders
Breakfast Lunch Dinner Bedtime
70 / 30 6 Units 70 / 30 6 Units
Insulin SC Sliding Scale
Breakfast Lunch Dinner Bedtime
Humalog Humalog Humalog Humalog
Glucose Insulin Dose Insulin Dose Insulin Dose Insulin Dose
___ mg/dL Proceed with hypoglycemia protocol Proceed with
hypoglycemia protocol Proceed with hypoglycemia protocol Proceed
with hypoglycemia protocol
71-150 mg/dL 0 Units 0 Units 0 Units 0 Units
151-200 mg/dL 2 Units 2 Units 2 Units 2 Units
201-250 mg/dL 4 Units 4 Units 4 Units 4 Units
251-300 mg/dL 6 Units 6 Units 6 Units 6 Units
301-350 mg/dL 8 Units 8 Units 8 Units 8 Units
11. Coumadin 4 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Medications:
1. tacrolimus 1 mg Capsule Sig: One (1) Capsule PO once a day.
2. tacrolimus 1 mg Capsule Sig: 0.5 Capsule PO at bedtime.
3. Outpatient Lab Work
Please check chem-7 and INR on ___ with results to
Dr. ___ at Phone: ___
Fax: ___
ICD-9 585.9 and 427.31
4. mycophenolate mofetil 500 mg Tablet Sig: One (1) Tablet PO
BID (2 times a day).
5. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
7. pregabalin 100 mg Capsule Sig: One (1) Capsule PO once a day.
8. warfarin 4 mg Tablet Sig: One (1) Tablet PO once a day.
9. furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
10. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
11. insulin NPH & regular human 100 unit/mL (70-30) Suspension
Sig: ___ units Subcutaneous twice a day: continue with regimen
as before.
12. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
13. metoprolol tartrate 50 mg Tablet Sig: 1.5 Tablets PO BID (2
times a day).
Disp:*90 Tablet(s)* Refills:*2*
14. atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Acute on chronic diastolic congestive heart failure
Coronary artery disease
Atrial fibrillation
Hypertension
Hyperlipidemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent. Uses prosthesis.
Discharge Instructions:
It was a privilege to provide care for you here at the ___.
You were admitted because of shortness of breath. You were
treated with diuretics and your weight is now at a dry or goal
weight of 182 pounds. Please weigh yourself every morning before
breakfast and call Dr. ___ your weight increases more than 3
pounds in 1 day or 5 pounds in 3 days. You also received a
cardiac catheterization, which showed that your aortic stenosis
is moderate and you do not need any intervention at this time.
You will go home with the wound vac and will see plastic surgery
in the next 2 weeks.
.
The following changes were made to your medications:
NEW: Lisinopril 5mg daily to lower your blood pressure
Metoprolol tartrate to lower your heart rate
Atorvastatin (Lipitor) to lower your cholesterol
CHANGED: Take furosemide 40 mg twice daily instead of 80 mg in
the morning
STOPPED: Stop taking Nifedipine
Please keep your follow-up appointments as scheduled below.
Followup Instructions:
___
|
19683695-DS-28
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DS
| 28 |
2138-08-15 00:00:00
|
2138-08-15 12:44:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
Pneumococcal Vaccine
Attending: ___.
Chief Complaint:
altered mental status, acute renal failure
Major Surgical or Invasive Procedure:
___ Left Below the Knee Amputation
History of Present Illness:
___ w/Afib on coumadin, IDDM, peripheral vasculopathy with
stents on plavix, dCHF, severe AS ___ 1.0) and also with
liver/kidney transplant in ___ on tacrolimus/mycophenolate, who
p/t OSH and found to have acute on chronic renal failure w/Cr of
3.3 (baseline 2.2) and then transferred here. Came to the ED
with sudden AMS.
Has been having ___ edema bilaterally so had lasix increased
recently to 100mg daily from 80mg daily about 2 weeks ago. As
per pt's wife, pt has been having decreased PO intake for past
few days. She thinks he intermittently becomes confused for past
few weeks but mostly A&Ox3. Today, pt had worsened R lower stump
swelling where he was unable to put on his prosthesis. PCP was
contacted and recommended that pt go to ED. Pt went to
___ and found to have acute renal failure. As
per EMS, the patient was a&ox3 and not confused, appropriately
conversant in the ambulance. Here, pt is alert/oriented only to
name.
In the ED, initial vital signs: 97.3 74 112/70 16 98% RA. Pt
noted to be A&Ox1 (oriented to self only). PCP notified and
recommended admission with vascular surgery notified while pt in
ED and concluded that there was no acute vascular issue with
plans for eventual elective left BKA this admission after
medical condtion was stabilized. .
Past Medical History:
Liver (ESLD ___ EtOH) and kidney transplant (ESRD ___ DM2) in
___
DM2
R leg amputation ___ severe infection in ___
PVD s/p stents in left leg
Atrial fibrillation on Coumadin
HTN
dCHF (LVEF>55% in ___
Severe AS
Prostate ca s/p radiation last year
Social History:
___
Family History:
Father ___ diabetes
Physical Exam:
Vitals: T: 98.2 BP: 153/72 P: 82 R: 18
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, dry MM, oropharynx clear
Neck: supple, JVP not elevated
Lungs: breath sounds clear.
CV: nontachycardic, irregular rhythm, III/VI systolic mumur
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: R stump in compression stocking, nonpitting edema to R
thigh,
L stump clean with no drainage. There is redness surrounding
the incision line likely secondary eccyhmosis.
Neuro: A&Ox3, appropriate
Pertinent Results:
Studies:
___ TTE
The left atrium is moderately dilated. The right atrium is
moderately dilated. No atrial septal defect is seen by 2D or
color Doppler. The estimated right atrial pressure is at least
15 mmHg. There is mild symmetric left ventricular hypertrophy
with normal cavity size and regional/global systolic function
(LVEF>55%). The right ventricular cavity is mildly dilated with
borderline normal free wall function. There is abnormal septal
motion/position. The aortic root is mildly dilated at the sinus
level. There is critical aortic valve stenosis (valve area
<0.8cm2). No aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. There is no mitral valve
prolapse. There is severe mitral annular calcification. There is
a minimally increased gradient consistent with trivial mitral
stenosis. Mild (1+) 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 [2+] tricuspid regurgitation is seen.
There is severe pulmonary artery systolic hypertension. There is
no pericardial effusion.
Compared with the prior study (images reviewed) of ___, the
degree of aortic stenosis has progressed from severe to
critical. Pulmonary pressures are higher. Mild aortic root
dilatation is new. Other findings are similar.
___ EKG
Atrial fibrillation and occasional ventricular ectopy and
increase in
ventricular response as compared with previous tracing of
___. Otherwise, no diagnostic interim change.
___ 05:40AM BLOOD WBC-4.9 RBC-3.28* Hgb-8.6* Hct-27.7*
MCV-85 MCH-26.2* MCHC-31.0 RDW-18.1* Plt ___
___ 02:50PM BLOOD Neuts-78* Bands-0 Lymphs-6* Monos-14*
Eos-2 Baso-0 ___ Myelos-0
___ 05:40AM BLOOD ___
___ 05:40AM BLOOD Glucose-167* UreaN-37* Creat-1.5* Na-133
K-5.0 Cl-99 HCO3-24 AnGap-15
___ 02:50PM BLOOD ALT-17 AST-18 AlkPhos-111 TotBili-0.2
___ 05:40AM BLOOD Calcium-8.2* Phos-3.9 Mg-1.7
___ 08:30AM BLOOD tacroFK-3.6*
Brief Hospital Course:
___ w/Afib on coumadin, IDDM, peripheral vasculopathy with
stents on plavix, dCHF, severe AS ___ 1.0) and also with
liver/kidney transplant in ___ on tacrolimus/mycophenolate, who
p/t OSH and found to have acute on chronic renal failure w/Cr of
3.3 (baseline 2.2) and then transferred here for further
management.
#Acute on CKD: Baseline Cr of 2.2, here with Cr of 3.3. Pt with
signs of volume overload (rales, ___ edema). 1L IVF given in ED
and Cr improved also in setting of holding ACE inhibitor. FEUrea
was 32%. Initial tacro level elevated at 8.5 and tacro was
decreased to 0.5mg BID. Diuresis was restarted with IV lasix
boluses with net negative ___ each day and Cr continued to
trend down. Lower extremity edema also significant improved so
we could proceed with BKA.
#Afib: On coumadin and CCB. CHADS2 score of 3. Coumadin was
held and heparin gtt was started perioperatively. Coumadin was
restarted on POD 3.
#Chronic Diastolic CHF: patient with EF of 70% on ___, also
with known severe AS ___ 1.0). Had lasix recently increased to
100mg daily, and here with newly developed ___. It was difficult
to assess volume status given pt without JVD and dry MM but with
rales, pulm congestion on CXR and with ___ edema. As per pt's
wife, pt had no change in wt recently, usually at 185lbs (with
prosthesis). Pt had TTE on ___ which showed worsening AS and
severe pulmonary hypertension which was difficult to interpret
given pt may be hypervolemic.
After being medical optimized with return of baseline reanl and
cardiac function, we proceeded to perform an elective left BKA
for a non healing painful left lower leg wound. THe operative
course was uncomplicated. He received 2 units of prbc for a HCT
of 22. He worked with ___ who recommended rehab. His tacro
level with be monitored weekly with results to transplant, he
will see his PCP/cardiologist in 2 weeks and Dr. ___ in
1 month. He was discharge to rehab on POD 4.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 10 mg PO DAILY
3. Clopidogrel 75 mg PO DAILY
4. Furosemide 100 mg PO DAILY
5. Metoprolol Tartrate 75 mg PO BID
6. Mycophenolate Mofetil 500 mg PO BID
7. NIFEdipine CR 30 mg PO DAILY
8. Pregabalin 100 mg PO QHS
9. Warfarin 2 mg PO DAILY16
10. 70/30 5 Units Breakfast
70/30 7 Units Dinner
11. Tacrolimus 0.5 mg PO QAM
12. Tacrolimus 1 mg PO QPM
13. Lisinopril 5 mg PO DAILY
14. Ciprofloxacin HCl Dose is Unknown PO Q12H
Discharge Medications:
1. Mycophenolate Mofetil 500 mg PO BID
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 10 mg PO DAILY
4. Furosemide 100 mg PO DAILY
5. Lisinopril 5 mg PO DAILY
6. Tacrolimus 0.5 mg PO Q12H
7. Warfarin 2.5 mg PO DAILY16
8. Pregabalin 100 mg PO QHS
9. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN pain
10. NIFEdipine CR 30 mg PO DAILY
11. Insulin SC
Sliding Scale
Fingerstick QPC2H
Insulin SC Sliding Scale using HUM Insulin
12. Amoxicillin-Clavulanic Acid ___ mg PO Q12H
for the next 7 days
13. Docusate Sodium 100 mg PO BID
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Peripheral vascular disease
Acute on chronic renal failure
Status post liver and kidney transplant
Atrial fibrillation
Diabetes mellitus
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - with assistive devices/prosthesis
Discharge Instructions:
Dear Mr. ___,
You were admitted for confusion and kidney injury. Your
confusion resolved as your kidney function improved with giving
you diuretics to help you urinate off the excess fluid. Dr. ___
___ you for surgery and you had your amputation with Dr.
___.
DIVISION OF VASCULAR AND ENDOVASCULAR SURGERY
AMPUTATION DISCHARGE INSTRUCTIONS
WOUND CARE:
It is very important that your knee remains mobile so please
continue to move/straighten the knee on the operative side as
much as possible. Please do not but any pressure on your
incision though. It may be left open to air without a dressing
if there is no drainage.
BATHING/SHOWERING:
You may shower when you get home
No tub baths or pools
Followup Instructions:
___
|
19683695-DS-29
| 19,683,695 | 29,090,267 |
DS
| 29 |
2139-08-30 00:00:00
|
2139-09-02 10:12:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Pneumococcal Vaccine / apixaban
Attending: ___
Chief Complaint:
pruritis, headache
Major Surgical or Invasive Procedure:
Transjugular liver biopsy
History of Present Illness:
Mr ___ is a ___ year old man with PMHx Liver (ESLD ___
EtOH) and kidney transplant (ESRD ___ DM2) in ___, afib on
Eliquis, HTN and DM who was transfered form ___
with new facial rash, elevated creatinine & LFTs. He reports
that several days ago he developed full doy puritis. He has had
no change in his medications. He then reports that he first
noticed redness of his face the day prior to admission. He
reports it was more severe when he woke up on the day of
admssion so he presented to ___ ED. He
reports that since the onset of the rahs he has also had puritis
over his while body. At ___, labs showed increased
BUN/Cr, elevated LFTs, so she was transferred to ___ for further
care. He is followed by both hepatology & renal services. He
reports that he currently feels well aside from itching. Denies
recent fever chills, chest pain, shortness of breath, abdominal
pain, nausea, diarrhea, dysuria, hematuria.
In the ED, initial vitals were 97.1 85 163/102 18 100%.
He recieved:Today 16:53 HydrOXYzine 25 mg Tab 1
Renal and Liver were consulted and he was admitted to the
medical transplant service. He had a u/s of the liver and of the
kidney and the results are noted below.
Vitals on transfer were: 0 97.5 87 179/102 16 98% RA
ROS: per HPI, denies fever, chills, night sweats, headache,
vision changes, rhinorrhea, congestion, sore throat, cough,
shortness of breath, chest pain, abdominal pain, nausea,
vomiting, diarrhea, constipation, BRBPR, melena, hematochezia,
dysuria, hematuria.
Past Medical History:
- Liver (ESLD ___ EtOH) and kidney transplant (ESRD ___ DM2) in
___
- DM2
- R leg amputation ___ severe infection in ___
- PVD s/p stents in left leg
- Atrial fibrillation previously on Coumadin, now on Eliquis
- HTN
- dCHF (LVEF>55% in ___
- Severe AS
- Prostate ca s/p radiation
- s/p cholecystectomy
Social History:
___
Family History:
Father w diabetes
Physical Exam:
Admission Physical Exam:
VS: 98.2, 184/71, 18, 98%RA
General: NAD, siting up in bed
HEENT: MMM, EOMI, PERRL
Neck: Supple, JVP not elevated when sitting upright
CV: Systolic ejection murmur
Lungs: CTAB, no w/r/rh
Abdomen: +BS, soft, NT, ND
Ext: Bilateral lower extmeity amputation
Neuro: CN ___ intact, gait not assessed.
Skin: Multiple small petecia on the patietn's chest and face.
Not raises, non blanching. Echemosis on the chest and right
upper extermity. No oral lesions.
Discharge Exam:
VS: Tm 98, Tc 97.4, BP 133/63 (SBP 122-165), HR 65 (65-80), RR
20, 100% RA
I/O: 1420/725out ___ since mdnt)
General: NAD, sitting up in bed
HEENT: icteric sclera, moist mucous membranes
Neck: Supple, no JVD
CV: Irregular rhythm, ___ systolic ejection murmur
Lungs: CTAB, chest with congenital deformity
Abdomen: +BS, soft, NT, ND; ___ scar well healed
Ext: bilateral BKAs.
Neuro: CN ___ intact, A&Ox3, no asterixis
Skin: Multiple non-blanching petechiae on face, chest and
forearms with mild excoriations.
Pertinent Results:
Admission Labs:
___ 05:30PM BLOOD WBC-3.5* RBC-3.99* Hgb-11.3* Hct-35.5*
MCV-89 MCH-28.4 MCHC-31.9 RDW-16.8* Plt ___
___ 05:30PM BLOOD Neuts-75.8* Lymphs-11.0* Monos-10.6
Eos-2.0 Baso-0.6
___ 05:30PM BLOOD ___ PTT-42.2* ___
___ 05:30PM BLOOD Glucose-114* UreaN-58* Creat-3.3*# Na-136
K-4.2 Cl-102 HCO3-18* AnGap-20
___ 05:30PM BLOOD ALT-159* AST-159* AlkPhos-771*
TotBili-5.9* DirBili-4.8* IndBili-1.1
___ 05:30PM BLOOD Albumin-3.7 Calcium-8.9 Phos-5.2*# Mg-1.8
___ 05:30PM BLOOD tacroFK-6.5
___ 05:42PM BLOOD Lactate-1.4
Interim trends:
Chemistry:
___ 06:30AM BLOOD Glucose-202* UreaN-61* Creat-3.8* Na-130*
K-4.1 Cl-100 HCO3-15* AnGap-19
___ 05:00AM BLOOD Glucose-239* UreaN-65* Creat-4.2* Na-128*
K-3.9 Cl-99 HCO3-19* AnGap-14
___ 04:30AM BLOOD Glucose-185* UreaN-65* Creat-3.7* Na-133
K-4.1 Cl-102 HCO3-18* AnGap-17
LFTs:
___ 05:00AM BLOOD ALT-113* AST-103* AlkPhos-628*
TotBili-4.5*
___ 04:30AM BLOOD ALT-67* AST-35 AlkPhos-589* TotBili-3.2*
Tacro:
___ 05:00AM BLOOD tacroFK-5.1
___ 06:00AM BLOOD tacroFK-6.6
Discharge Labs:
___ 05:20AM BLOOD WBC-2.5* RBC-2.89* Hgb-8.4* Hct-26.0*
MCV-90 MCH-29.2 MCHC-32.5 RDW-17.1* Plt ___
___ 05:20AM BLOOD Neuts-71.3* Lymphs-15.0* Monos-9.5
Eos-3.5 Baso-0.7
___ 05:20AM BLOOD ___ PTT-37.3* ___
___ 05:20AM BLOOD Glucose-204* UreaN-68* Creat-3.5* Na-135
K-3.9 Cl-105 HCO3-17* AnGap-17
___ 05:20AM BLOOD ALT-45* AST-22 AlkPhos-504* TotBili-2.3*
___ 05:20AM BLOOD Calcium-8.1* Phos-5.5* Mg-1.9
___ 05:20AM BLOOD tacroFK-6.0
___ 05:20AM BLOOD WBC-2.5* RBC-2.89* Hgb-8.4* Hct-26.0*
MCV-90 MCH-29.2 MCHC-32.5 RDW-17.1* Plt ___
___ 05:20AM BLOOD Neuts-71.3* Lymphs-15.0* Monos-9.5
Eos-3.5 Baso-0.7
___ 05:20AM BLOOD ___ PTT-37.3* ___
___ 05:20AM BLOOD Glucose-204* UreaN-68* Creat-3.5* Na-135
K-3.9 Cl-105 HCO3-17* AnGap-17
___ 05:20AM BLOOD ALT-45* AST-22 AlkPhos-504* TotBili-2.3*
___ 05:20AM BLOOD Calcium-8.1* Phos-5.5* Mg-1.9
___ 05:20AM BLOOD tacroFK-6.0
Imaging:
Renal U/S ___
IMPRESSION:
1. Normal appearance of the transplant kidney, without evidence
of hydronephrosis.
2. Resistive indices in the intraparenchymal arteries range from
0.78-0.85, previously ranging from 0.70-0.77 on the ultrasound
from ___.
Abdominal duplex ___
IMPRESSION:
1. Patent hepatic vasculature with appropriate directional flow.
2. No intra or extrahepatic biliary duct dilatation.
3. Small to moderate right pleural effusion.
Head CT ___
IMPRESSION:
1. No acute intracranial process.
2. Severe calcified atherosclerotic disease involving the
internal and
external carotid arterial system.
CXR ___
IMPRESSION: As compared to the previous radiograph, there is
unchanged appearance of a small left pleural effusion with
subsequent atelectasis. The lung parenchyma shows signs of mild
pulmonary edema. Borderline size of the cardiac silhouette. No
evidence of pneumonia.
Liver Trx Biopsy ___
Prelim: ductal damage with neutrophilic infiltrate c/f drug
reaction vs obstruction
Brief Hospital Course:
___ year old man with history of liver/kidney transplant (___),
DM2, dCHF and Afib, presenting with petechial rash on face and
trunk, headache, ___, HTN and cholestatic liver injury.
ACUTE
#) Liver injury: S/p liver transplant ___ ETOH cirrhosis.
Cholestatic picture concerning for rejection, thus a biopsy was
pursued. Pathology preliminarily showing neutrophilic biliary
injury, c/w drug injury vs obstruction. Liver U/s without
biliary dilatations and with patent vasculature. Potential
injury from new Rx Apixaban. Tacro levels were appropriate. CMV
was negative. ___ was attempted but there was a large amount
of artifact which was concerning for foreign material from a
prior abdominal vascular surgery. Apixiban was held and by the
time of discharge, LFTs were improving. Further use of NOACs
should be avoided in this patient given concern for drug induced
liver injury. DSA antibiodies were pending at discharge.
#) Acute on Chronic Kidney Injury: s/p renal transplant ___
complication from DM2. Baseline Cr of 1.8-2.2, presented with
Cr of 3.3 and increasing while in house. Diuresis held and given
fluid challenge without effect. FeUrea of 41%, consistent with
intrinsic process and concerning for ATN vs rejection. Spun
urine with muddy brown casts, c/w ATN. Renal u/s without
concerning findings. BK virus negative. Lisinopril and laxis
were held while in house and Cre was downtrending on discharge.
He will need to f/u in transplant clinic this week for further
lab testing.
#) Petechial Rash: Unusual distribution on face and trunk. Has
normal platelet count, but has been on Apixaban and ASA, and
platelets may be uremic given ___. Initially thought to be
possible tacro toxicity (TMA), though levels returned normal.
TMA unlikely with normal LDH and no schistocytes on smear,
though does have low haptoglobin. Likely a result of scratching
at pruritis from hyperbilirubinemia, in setting of
supratherapeutic Apixaban levels with poor renal clearance.
Improving with holding of Apixaban.
#) Headache: Head CT was negative for bleed. ___ have been
secondary to hypertension as symptom improved with BP control.
No meningismus signs or concern for CNS infection.
CHRONIC
#) DM2: Continued home basal bolus insulin
#) Atrial fibrillation previously on Coumadin, now on Apixaban:
CHADS2 score of 3. Continued metoprolol for rate control.
Apixiban held on discharge. Should consider restarting coumadin
for stroke prevention in Afib, as the transplant team feels
strongly that NOACs should be avoided in these patients.
#) HTN: Hypertensive in the ED to 170s/100s, controlled with
Labetalol. Restarted on home metoprolol on discharge.
Lisinopril and lasix held ___ ___. SBPs in 130s on discharge.
Could consider restarting lasix/lisinopril sequentially pending
normalization or at least stabilization of Cre.
#) dCHF (LVEF>55% in ___: Held home lasix ___ ___. Euvolemic
here.
TRANSITIONAL
#) repeat labs this week
#) transplant clinic f/u this week
#) holding lasix and lisinopril on discharge
#) consider restarting coumadin for stroke prevention with a fib
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Tacrolimus 1 mg PO Q12H
2. Azathioprine 50 mg PO DAILY
3. Furosemide 60 mg PO DAILY
4. Lisinopril 5 mg PO DAILY
5. Apixaban 2.5 mg PO BID
6. Aspirin 81 mg PO DAILY
7. Metoprolol Succinate XL 75 mg PO BID
8. Insulin SC
Sliding Scale
Insulin SC Sliding Scale using Humalog 70/30 Insulin
Discharge Medications:
1. Azathioprine 50 mg PO DAILY
2. Tacrolimus 1 mg PO Q12H
3. Aspirin 81 mg PO DAILY
4. Metoprolol Succinate XL 75 mg PO BID
5. Outpatient Lab Work
Chem 7 (Na, K, Cl, HCO3, BUN, Cr, Ca, Mg, Phos), ALT, AST, alk
phos, T bili, INR ICD 9: 594.0,
Transplant liver clinic/Dr ___
___
6. Insulin SC
Sliding Scale
Insulin SC Sliding Scale using Humalog 70/30 Insulin
7. Ursodiol 300 mg PO BID:PRN pruritis
RX *ursodiol 300 mg 1 capsule(s) by mouth twice a day as needed
for itching Disp #*60 Capsule Refills:*0
8. HydrOXYzine 25 mg PO Q6H:PRN itch
RX *hydroxyzine HCl 25 mg 1 tab by mouth Every 6 hours as needed
for itching Disp #*30 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Cholestatic liver injury
Acute renal failure
Petechial rash
Diabetes mellitus
Secondary:
Atrial fibrillation
Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr ___,
It was a pleasure taking care of you at ___
___. You were admitted with liver and kidney damage.
Your liver biopsy showed that it may have been damaged by a
drug. Your Eliquis (apixaban) was stopped, as this may have been
the cause. We discussed ___ of to evaluate for biliary
strictures as a cause of liver inflammation, but because we do
not have details on your splenic procedure and because your labs
were already improving, we held off on this.
Your kidney function improved. We are not certain what caused
the kidney damage, but as the numbers were improving we did not
feel that it would benefit to biopsy to your kidney.
The itching and red rash were likely due to liver damage and
build up of Eliquis. They appeared to be improving without the
medication, as your liver and kidney function improved.
Please follow up with labs on ___ and in clinic this week.
Please discontinue the Eliquis and follow up with Dr ___
___ another options for blood thinning for your atrial
fibrillation.
Please weigh yourself everyday, we are holding your furosemide
and lisinopril for now because of kidney injury.
Followup Instructions:
___
|
19683768-DS-18
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DS
| 18 |
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2125-05-25 19:30:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
lactose
Attending: ___
Chief Complaint:
CHIEF COMPLAINT: Anemia, abnormal labs
Major Surgical or Invasive Procedure:
none
History of Present Illness:
HISTORY OF PRESENTING ILLNESS:
Ms. ___ is a pleasant ___ year old female with a history of
liver transplantation in ___, with post-transplant course c/b
refractory HTN, IDDM, HLD, CKD IV, and chronic anemia (recent
baseline Hgb ___ is presenting with anemia found on labs at
recent ___ clinic visit.
Patient was found to have Hgb of 6.4 at routine follow up visit.
The hepatologist was notified and recommended ED evaluation.
Patient noted no abdominal pain, distension, or pain. No CP or
lightheadedness.
In the ED initial vitals: 98.3 71 193/83 20 96% RA
- Exam notable for:
Unremarkable exam
bedside FAST neg for free fluid
pos guaic test
- Labs notable for:
CBC: 7.9 > 6.3 / 21.0 < 406
Repeat CBC: 5.7 > 7.2 / 23.0 < 330
Chem7: 140/4.6 / ___ < 130
Repeat Chem7: 140/5.3 / ___ < 124, Ca: 9.2, Mg: 1.7,
P: 5.1
LFTs: ALT 8, AST 17, AP 76, Tbili 0.4
Coags:
Urine tox screen: negative
Urine Na 91, Osmolal 307
UA with few bact, 2 epi, 0 WBC, neg nitr, 100 prot, trace
glucose.
___ sent
VBG: 7.33 / 37 / 33
Tacro < 2.0, Cyclspr: 41
Retic index 0.47, Normal Iron stores
- Imaging notable for:
Renal ultrasound: 1. No evidence of hydronephrosis or
nephrolithiasis.
2. Multiple bilateral simple appearing cysts, including one with
a thin septation, measuring up to 4.3 cm.
RUQ u/s
1. Unremarkable liver transplant ultrasound. Patent hepatic
vasculature.
2. Gallbladder is surgically absent.
- Consults: Hepatology, who recommended a number of tests, and
admission for possible EGD
- Patient was given:
1u pRBC
PO/NG amLODIPine 5 mg
PO/NG Atorvastatin 40 mg
PO/NG AzaTHIOprine 50 mg
PO/NG HydrALAZINE 100 mg
PO Metoprolol Succinate XL 100 mg
- ED Course: Patient was transfused one unit per above, and
admitted per hepatology for further work up of anemia.
- Transfer vitals: 98.6 71 179/94 18 99% RA
On the floor, patient notes feeling at baseline and says that
she
has felt at her baseline in the recent past. She notes that she
sometimes misses doses of her medications, most notably her
Aranesp injections, which she states that she hasn't taken since
"sometime this ___" because she was on vacation and missed
her
appointments. She states that she has never had any dark or
black
stools and that she is regular with her bowel movements. She has
had no nausea or vomiting recently. She further denies any
vaginal bleeding for the past ___ years. She denies having any
abdominal pain of any kind related to timing of her meals or
otherwise. She denies any heartburn and carries no diagnosis of
gastric reflux. No headache, chest pain, nausea/vomiting, SOB,
fevers/chills, ab pain, dysuria, rashes, swelling or change in
bowel movement.
REVIEW OF SYSTEMS: Positive per HPI, remaining 10 point ROS
reviewed and negative.
Past Medical History:
Liver transplant due to unknown toxin, ___
IDDM
HLD
CKD IV
Poorly controlled HTN
Social History:
___
Family History:
Mother and father died of lung cancer
Mother, father and two brothers with type ___ DM
Physical Exam:
ADMISSION PHYSICAL EXAMINATION:
VS: 98.6 186/91 65 18 100% RA
GENERAL: NAD, pleasant female lying in bed watching television
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM
NECK: supple, no LAD, no JVD appreciated
EART: RRR, nml s1s2. No murmurs rubs or gallops appreciated
LUNGS: Some crackles at the bases b/l. Some expiratory wheezes
on
the left in the posterior fields.
ABDOMEN: obese, nondistended, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: 1+ pitting edema in ankles to mid shin
PULSES: 2+ DP and radial pulses bilaterally
NEURO: A&Ox3, moving all 4 extremities with purpose. No pronator
drift
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
DISCHARGE PHYSICAL EXAMINATION:
24 HR Data (last updated ___ @ 1510)
Temp: 98.5 (Tm 98.6), BP: 164/82 (164-181/82-98), HR: 68
(68-74), RR: 18 (___), O2 sat: 99% (93-100), O2 delivery: Ra,
Wt: 165.12 lb/74.9 kg
GENERAL: NAD, pleasant female lying in bed watching television
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM
NECK: supple, no LAD, no JVD appreciated
EART: RRR, nml s1s2. No murmurs rubs or gallops appreciated
LUNGS: Some crackles at the bases b/l. Some expiratory wheezes
on the left in the posterior fields.
ABDOMEN: obese, nondistended, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: 1+ pitting edema in ankles to mid shin
PULSES: 2+ DP and radial pulses bilaterally
NEURO: A&Ox3, moving all 4 extremities with purpose.
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
Pertinent Results:
Admit Labs
========
___ 12:20PM BLOOD WBC-6.2 RBC-2.95* Hgb-6.4* Hct-20.9*
MCV-71* MCH-21.7* MCHC-30.6* RDW-18.5* RDWSD-46.6* Plt ___
___ 12:20PM BLOOD Plt ___
___ 02:55AM BLOOD ___ PTT-32.4 ___
___ 12:20PM BLOOD UreaN-75* Creat-7.1* Na-139 K-5.0 Cl-104
HCO3-17* AnGap-18
___ 12:20PM BLOOD ALT-7 AST-15 AlkPhos-74 TotBili-0.4
DirBili-<0.2 IndBili-0.4
___ 12:20PM BLOOD TotProt-7.4 Albumin-4.2 Globuln-3.2
Calcium-9.5 Phos-4.9* Mg-1.8 Cholest-291*
___ 12:20PM BLOOD Triglyc-210* HDL-41 CHOL/HD-7.1
LDLcalc-208*
___ 02:55AM BLOOD calTIBC-254* Ferritn-294* TRF-195*
___ 12:20PM BLOOD Cyclspr-41*
___ 06:19AM BLOOD Cyclspr-67*
___ 02:51PM BLOOD ___ pO2-33* pCO2-37 pH-7.33*
calTCO2-20* Base XS--6
Discharge Labs
============
___ 05:30AM BLOOD WBC-6.4 RBC-3.50* Hgb-8.1* Hct-25.7*
MCV-73* MCH-23.1* MCHC-31.5* RDW-18.6* RDWSD-49.3* Plt ___
___ 05:30AM BLOOD ___ PTT-29.8 ___
___ 05:30AM BLOOD Glucose-125* UreaN-76* Creat-7.4* Na-138
K-4.7 Cl-104 HCO3-15* AnGap-19*
___ 05:30AM BLOOD ALT-8 AST-17 LD(LDH)-182 AlkPhos-70
TotBili-0.5
___ 05:30AM BLOOD Albumin-3.5 Calcium-9.0 Phos-5.5* Mg-1.5*
Other pertinent labs
===============
___ 05:30AM BLOOD Cyclspr-95*
___ 04:08AM BLOOD tacroFK-<2.0*
___ 07:07AM BLOOD Cyclspr-53*
___ 06:19AM BLOOD Cyclspr-67*
Imaging
=======
DUPLEX DOPP ABD/PELStudy Date of ___ 4:34 AM
Doppler evaluation:
The main portal vein is patent, with flow in the appropriate
direction.
Main portal vein velocity is 30 cm/sec.
Right and left portal veins are patent, with antegrade flow.
The main hepatic artery is patent, with appropriate waveform.
Right, middle and left hepatic veins are patent, with
appropriate waveforms.
IMPRESSION:
1. Unremarkable liver transplant ultrasound. Patent hepatic
vasculature.
2. Gallbladder is surgically absent.
RENAL U.S.Study Date of ___ 8:55 AM
FINDINGS:
There is no hydronephrosis or stones bilaterally. The bilateral
kidneys are
echogenic. Within the upper pole of the right kidney is a
simple appearing
cyst measuring 4.3 cm. A cyst within the mid pole with a thin
septation
measures 1.2 cm. Within the left kidney, in the upper pole is a
simple
appearing cyst measuring 0.6 cm.
Right kidney: 9.2 cm
Left kidney: 9.4 cm
The bladder is moderately well distended and normal in
appearance.
IMPRESSION:
1. No evidence of hydronephrosis or nephrolithiasis.
2. Multiple bilateral simple appearing cysts, including one with
a thin
septation, measuring up to 4.3 cm.
3. Bilateral echogenic kidneys compatible with chronic medical
renal disease.
Microbiology
==========
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
Brief Hospital Course:
Ms. ___ is a ___ year old female with a history of
liver transplantation in ___, with post-transplant course c/b
refractory HTN, T2DM, HLD, CKD IV, and chronic anemia (recent
baseline Hgb ___ presented with anemia found on labs at
recent ___ clinic visit. She had no history findings
raising concern for GI blood loss and has had a colonoscopy in
___ of this year without evidence of bleeding. Patient has
anemia at baseline, likely related to her underlying CKD and has
reported missing her EPO injections as an outpatient while on
vacation. She was admitted for anemia workup and discharged
stable.
#Anemia
Patient has known CKD and chronic anemia (recent baseline Hgb
___ she presented with acute on chronic anemia found on labs
at recent
___ clinic visit. Her outpatient workup for this anemia
included a colonoscopy in ___ of this year which was
remarkable
for diverticula, internal and external hemorrhoids, and two
sessile non-bleeding polyps of benign appearance. As outpatient
management of this anemia, the patient receives EPO injections
qmonth, which she reports missing a number of doses recently.
Likely her anemia is related to her CKD and lack of bone marrow
stimulation iso missing recent EPO injections, last dose in ___
per
OMR. Retic count of 0.47 and normal iron studies support this.
DDX also includes GI causes, though no history of
melena/hematochezia/hematemesis; she has never had EGD but was
guaiac positive. Hgb returned to baseline after 1pRBC on ___
and 1pRBC on ___.
#s/p Liver transplant
Patient of Dr. ___. Transplanted in ___ unclear the etiology
of her liver failure, quoted as "unknown toxin" Has been on
cyclosporine and azathioprine as immunosuppression. She takes
50mg bid of cyclosporine and 100mg of azathioprine qday
(actually
prescribed as 50mg bid). Patient is not taking Tacrolimus. Her
cyclosporine levels were mostly at goal ___, except lvl at 95
before discharge. Transitional issue to recheck cyclosporine
levels for ongoing management.
#ESRD
#CKD V
___
CKD likely ___ CNI toxicity, chronic. This is being managed
outpatient by her Nephrologist Dr. ___. Her baseline Cr is
difficult to interpret, but was 5.7 in ___. Presented with Cr
in the 7s, initially raising concern for ___. However, we
discussed her case with the renal physicians who felt this was
more representative of progression of her CKD, and she was
restarted on her home diuretics and ACEi. She should have close
follow up with her outpatient nephrologist.
#HTN
Chronic HTN and has been difficult to control. BP up to 190s
during admission but patient asymptomatic. ACE inhibitors/Lasix
were initially held in the setting of concern for ___. Increased
home hydral from 100mg qd to 50mg q8hr and amlodipine from 5mg
to 10mg qd. As Cr elevation ultimately felt to represent
progression of CKD, ACE/Lasix were added back on. Transitional
issue need for ongoing monitoring of BPs and titration of
antihypertensives.
Chronic Issues
---------------
#DMII
Not on any medications. Transitional issue to recheck A1c.
Transitional Issues
===================
Discharge creatinine 7.4
Discharge hemoglobin 8.2
MEDICATION CHANGES:
- increased hydralazine from 100mg once daily to 50mg every 8
hours
- increased amlodipine from 5mg to 10mg daily
- Sodium Bicarbonate 650 mg PO BID to ___ mg PO BID
[] Continue to monitor blood pressures and uptitrate
antihypertensives as needed. Consider uptitration of hydral, or
enalapril.
[] Check cyclosporine level in 1 week and for ongoing med
titration, as level was high at 95 before discharge
[] Check A1c as outpatient. Patient with history of diabetes
type 2 with distant A1c of 12, however not currently on meds
[] would recommend venous mapping for this patient for
consideration of dialysis in the future
[] Patient has unfortunately missed some of her EPO injections,
she will need these in the future to prevent persistent anemia.
The importance of compliance with EPO has been discussed with
patient.
[] We increased patient's bicarbonate to 1300 bid
[] Patient had guiac positive stool, recent colonoscopy in
___. Would consider for non-urgent endoscopy
[] Please follow up labs recheck (CBC, BMP, LFTs, cyclosporine)
1 week post discharge on ___.
Medications on Admission:
1. Enalapril Maleate 7.5 mg PO DAILY
2. amLODIPine 5 mg PO DAILY
3. Atorvastatin 40 mg PO QPM
4. AzaTHIOprine 50 mg PO BID
5. Calcitriol 0.25 mcg PO 3X/WEEK (___)
6. Clonidine Patch 0.3 mg/24 hr 1 PTCH TD QTHUR
7. Clonidine Patch 0.2 mg/24 hr 1 PTCH TD QTHUR
8. CycloSPORINE (Neoral) MODIFIED 50 mg PO Q12H
9. darbepoetin alfa in polysorbat 100 mcg/0.5 mL injection every
4 weeks
10. Fluticasone Propionate NASAL 2 SPRY NU DAILY
11. Furosemide 40 mg PO DAILY
12. HydrALAZINE 100 mg PO DAILY
13. Metoprolol Succinate XL 100 mg PO DAILY
14. Aspirin 81 mg PO DAILY
15. biotin 0 mg oral unknown
16. Multivitamins 1 TAB PO DAILY
17. Sodium Bicarbonate 650 mg PO BID
18. Fish Oil (Omega 3) Dose is Unknown PO DAILY
Discharge Medications:
1. amLODIPine 10 mg PO DAILY
RX *amlodipine 10 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
2. HydrALAZINE 50 mg PO Q8H
RX *hydralazine 50 mg 1 tablet(s) by mouth every 8 hours Disp
#*90 Tablet Refills:*0
3. Sodium Bicarbonate 1300 mg PO BID
RX *sodium bicarbonate 650 mg 2 tablet(s) by mouth twice daily
Disp #*120 Tablet Refills:*0
4. Aspirin 81 mg PO DAILY
5. Atorvastatin 40 mg PO QPM
6. AzaTHIOprine 50 mg PO BID
7. biotin 0 mg oral Frequency is Unknown
8. Calcitriol 0.25 mcg PO 3X/WEEK (___)
9. Clonidine Patch 0.2 mg/24 hr 1 PTCH TD QTHUR
10. Clonidine Patch 0.3 mg/24 hr 1 PTCH TD QTHUR
11. CycloSPORINE (Neoral) MODIFIED 50 mg PO Q12H
12. darbepoetin alfa in polysorbat 100 mcg/0.5 mL injection
every 4 weeks
13. Enalapril Maleate 7.5 mg PO DAILY
14. Fish Oil (Omega 3) 1000 mg PO DAILY
15. Fluticasone Propionate NASAL 2 SPRY NU DAILY
16. Furosemide 40 mg PO DAILY
17. Metoprolol Succinate XL 100 mg PO DAILY
18. Multivitamins 1 TAB PO DAILY
19.Outpatient Lab Work
ICD: Z94.4 liver transplant. DATE: ___. LABS: CBC, BMP,
LFTs, cyclosporine. FAX TO: Liver Transplant Clinic / Dr. ___
___. ___
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis:
=================
Acute on chronic anemia
Status post liver transplant
Chronic Kidney disease stage V
End-stage renal disease
Hypertension
Secondary diagnoses:
====================
Type 2 diabetes
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear ___,
You were admitted to the hospital because you were anemic
WHAT HAPPENED WHILE YOU WERE IN THE HOSPITAL?
- We gave you blood to treat your anemia
- Your blood pressure was monitored and was noted to be very
elevated. We adjusted some of your blood pressure medications
and this improved
- You improved and were ready to leave the hospital.
WHAT DO YOU NEED TO DO WHEN YOU LEAVE THE HOSPITAL?
- Take all of your medications as prescribed (listed below)
- Keep your follow up appointments with your doctors
- Be sure not to miss your appointments for your anemia
injections (EPO injections)
- Seek medical attention if you have new or concerning
symptoms.
It was a pleasure participating in your care. We wish you the
best!
- Your ___ Care Team
Followup Instructions:
___
|
19683768-DS-21
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| 21 |
2125-11-30 00:00:00
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2125-12-01 08:41:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
lactose
Attending: ___
Chief Complaint:
nausea, dyspnea on exertion, fatigue, and general malaise
Major Surgical or Invasive Procedure:
Tunneled RIJ HD Line Placement ___
History of Present Illness:
Ms. ___ is a ___ PMH CKD5 w/ Cr 12.6 on ___
___
T2DM, HTN, calcineurin inhibitor use) s/p brachiocephalic AV
fistula w/ Dr. ___ on ___, chronic anemia (has ranged ___
the last year, most recent 8.0 on ___ CKD on Epo,
cirrhosis s/p liver transplant in ___, T2DM, CAD (s/p
angioplasty in ___, presenting w/ worsening nausea, dyspnea on
exertion, fatigue, and general malaise. She has had nausea for
the past month with dry heaves but no vomiting. She also has
noticed dyspnea on exertion for the past week. She endorses
chills but no fevers, abdominal pain, chest pain, changes in
urination, or black or bloody stools. Of note, she was admitted
from ___ - ___ due to symptomatic anemia w/ a Hgb of 5.5
which improved after 3 units PRBCs.
She does have a longstanding history of low H/H given CKD. She
typically gets monthly EPO injections, which have been limited
due to her significant hypertension. Last EPO injection was
___.
For ESRD, she recently received AVF ___. She had previously
been recommended in the outpatient and inpatient setting to
obtain temporary tunneled line for HD for hypertension SBP
190s-200s, difficult to control with medications. She declined.
In the ED,
Initial Vitals: 97.9 100 180/85 20 100% RA
Exam:
Physical Exam:
General: Tired appearing, pleasant
Cardiac: RRR, no murmurs
Pulm: CTAB
Abdeomen: Soft, nontender, nondistended
Rectal: negative guaiac stool
Extremities: Left brachiocephalic fistula in antecubital fossa
with palpable thrill and continuous machine-like murmur, 1+
pitting edema in lower extremity edema
Labs:
WBC: 2.7 Hb: 4.6 Plt: 81
___: 12.8 PTT: 30.1 INR: 1.2
ALT: <5 AST: 12 AP: 48 Tbili: 0.6 Alb: 3.3 LDH: Pnd
Na: 141 K: 4.9 Cl: 99 HCO3: 18 BUN: 112 Cr: 15.9 Glu: 136
AGap=24
Ca: 8.6 Mg: 1.6 P: 9.2
Trop: 0.45 CK-MB: 4 CK: 89
Lactate: 1.1
Blood culture drawn
Imaging: CXR ___: Congestion with mild interstitial pulmonary
edema and small pleural effusions.
EKG: NSR 97 NA NI TWI inf leads No STE
Consults: None
Patient received:
___ 11:38 PO/NG Ondansetron ODT 4 mg
___ 13:35 PO/NG AzaTHIOprine 50 mg
___ 13:35 PO/NG CARVedilol 25 mg
___ 13:35 PO/NG HydrALAZINE 75 mg
___ 13:35 PO sevelamer CARBONATE 800 mg
Obtaining IV access was difficult. She received a 20g PIV.
VS Prior to Transfer: 98.1 98 152/73 22 98% RA
Patient reports she is fatigued all the time, but last couple of
weeks have been worse. She was ok when she was first discharged,
but last two weeks has been sleeping during the day and up at
night. Food has started to taste bad, some loss of appetite.
Sometimes in the morning has dry heaves but no vomiting. Has not
been taking Zofran at home that was prescribed on her last
admission. Has been feeling short of breath with minimal
activity, that's how she knew to come in. She has had a slight
dry cough, nose running, the past couple of days, but no other
respiratory symptoms. Denies BRBPR, melena, hematuria, easy
bruising, other concern for bleeding.
Patient says she was against dialysis before because she didn't
want a line in her chest but now is feeling so poorly that she
would accept it. She notes some lower extremity edema yesterday
that resolved with leg elevation. She was instructed to increase
Hydralazine to 100 mg TID at renal followup and tried this but
SBP was decreased to the 130s and she felt very symptomatic with
this (lightheadedness) so she self-decreased the dose again to
75
mg. She confirms her last dose of cyclosporine was 2 a.m. last
night. She did not receive a dose in the ED.
ROS: Positives as per HPI; otherwise negative.
Past Medical History:
Liver cirrhosis status post Liver transplant, ___, possible r/t
ETOH
Type 2 Diabetes Mellitus (No longer Insulin dependent)
Hyperlipidemia
Chronic Kidney Disease
Chronic Anemia
Hypertension
Coronary Artery Disease status post Angioplasty ___
Social History:
___
Family History:
Mother and father died of lung cancer
Mother, father and two brothers with type ___ DM
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
VS: reviewed in Metavision
GEN: appears well, NAD
HEENT: PERRL, MMM
NECK: supple
CV: RRR, S1/S2
RESP: bibasilar crackles, otherwise CTA
GI: soft, NT/ND
EXT: trace pitting edema LEs, moving all equally
SKIN: no obvious rash, WWP
NEURO: grossly nonfocal
PSYCH: pleasant mood
DISCHARGE EXAMINATION
=====================
___ 0520 Temp: 98.9 PO BP: 156/84 HR: 83 RR: 18 O2 sat: 99%
O2 delivery: RA
General: NAD
HEENT: oropharynx clear without exudate, sclera are anicteric
Neck: Supple, no jugular vein distension
Lung: clear bilaterally, no adventitious sounds
Card: RRR, holosystolic flow murmur, no rubs or gallops
Abd: Distended but soft, no guarding or rebound
Ext: Warm, well perfused
Pertinent Results:
ADMISSION LABS:
===============
___ 11:39AM BLOOD WBC-2.7* RBC-1.75* Hgb-4.6* Hct-15.7*
MCV-90 MCH-26.3 MCHC-29.3* RDW-17.5* RDWSD-57.5* Plt Ct-81*
___ 11:39AM BLOOD Neuts-47.9 ___ Monos-9.4 Eos-3.0
Baso-0.0 Im ___ AbsNeut-1.28* AbsLymp-1.05* AbsMono-0.25
AbsEos-0.08 AbsBaso-0.00*
___ 11:39AM BLOOD ___ PTT-30.1 ___
___ 07:10PM BLOOD ___
___ 11:39AM BLOOD Glucose-136* UreaN-112* Creat-15.9*#
Na-141 K-4.9 Cl-99 HCO3-18* AnGap-24*
___ 11:39AM BLOOD ALT-<5 AST-12 LD(LDH)-278* CK(CPK)-89
AlkPhos-48 TotBili-0.6
___ 11:39AM BLOOD CK-MB-4
___ 11:39AM BLOOD cTropnT-0.45*
___ 11:39AM BLOOD Albumin-3.3* Calcium-8.6 Phos-9.2* Mg-1.6
___ 07:10PM BLOOD PEP-ABNORMAL B FreeKap-139.1*
FreeLam-98.9* Fr K/L-1.4
___ 11:49AM BLOOD Lactate-1.1
___ 10:28PM URINE Hours-RANDOM Creat-59 TotProt-521
Prot/Cr-8.8*
___ 10:28PM URINE U-PEP-AWAITING F IFE-PND
DISCHARGE LABS:
===============
___ 07:00AM BLOOD WBC-2.3* RBC-2.76* Hgb-7.8* Hct-24.9*
MCV-90 MCH-28.3 MCHC-31.3* RDW-15.4 RDWSD-50.4* Plt ___
___ 07:00AM BLOOD Neuts-35.5 ___ Monos-15.9*
Eos-6.9 Baso-0.4 Im ___ AbsNeut-0.82* AbsLymp-0.95*
AbsMono-0.37 AbsEos-0.16 AbsBaso-0.01
___ 05:40AM BLOOD Anisocy-1+* Poiklo-1+* Ovalocy-1+* RBC
Mor-SLIDE REVI
___ 07:00AM BLOOD Plt ___
___ 06:23AM BLOOD Glucose-145* UreaN-41* Creat-8.5*# Na-140
K-4.2 Cl-100 HCO3-26 AnGap-14
___ 10:24AM BLOOD ALT-<5 AST-11 LD(LDH)-286* CK(CPK)-89
AlkPhos-49 TotBili-0.7
___ 10:24AM BLOOD CK-MB-5 cTropnT-0.60*
___ 06:23AM BLOOD Calcium-9.0 Phos-4.1 Mg-1.8
___ 10:24AM BLOOD PTH-___*
___ 10:24AM BLOOD 25VitD-18*
___ 01:09AM BLOOD HBsAg-NEG HBsAb-NEG HBcAb-NEG
___ 07:10PM BLOOD PEP-ABNORMAL B FreeKap-139.1*
FreeLam-98.9* Fr K/L-1.4
___ 07:00AM BLOOD Cyclspr-64*
___ 07:00AM BLOOD HCV Ab-NEG
___ 10:22PM URINE Color-Yellow Appear-Hazy* Sp ___
___ 10:22PM URINE Blood-NEG Nitrite-NEG Protein-600*
Glucose-100* Ketone-NEG Bilirub-NEG Urobiln-2* pH-8.0 Leuks-NEG
___ 10:22PM URINE RBC-1 WBC-2 Bacteri-FEW* Yeast-NONE Epi-6
TransE-<1
___ 10:22PM URINE Mucous-RARE
MICROBIOLOGY:
==============
__________________________________________________________
Time Taken Not Noted Log-In Date/Time: ___ 3:29 pm
BLOOD CULTURE Source: Line-tunneled HD line.
Blood Culture, Routine (Pending): No growth to date.
__________________________________________________________
___ 12:59 pm BLOOD CULTURE
Blood Culture, Routine (Pending): No growth to date.
__________________________________________________________
___ 11:09 pm BLOOD CULTURE
Blood Culture, Routine (Pending): No growth to date.
__________________________________________________________
___ 10:22 pm URINE Source: ___.
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
__________________________________________________________
___ 9:40 pm BLOOD CULTURE 1 OF 2.
Blood Culture, Routine (Pending): No growth to date.
__________________________________________________________
___ 11:39 am BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
IMAGING:
==========
CXR ___
Congestion with mild interstitial pulmonary edema and small
pleural effusions.
CXR ___
Interval increase in pulmonary interstitial edema and increased
size of small bilateral pleural effusions. Superimposed
aspiration would be hard to exclude in the proper clinical
context.
ABDOMINAL U/S ___. No evidence of diastolic flow in the main, right, or left
hepatic arteries,
new in the interval.
2. Patent hepatic vasculature otherwise demonstrated.
3. No evidence of splenomegaly.
4. Persistent common bile dilation up to 1 cm, unchanged from
prior.
5. Trace ascites and moderate right pleural effusion.
TUNNELED LINE PLACEMENT ___
Successful placement of a 19cm tip-to-cuff length tunneled
dialysis line. The tip of the catheter terminates in the right
atrium. The catheter is ready for use.
Radiology Report CHEST (PORTABLE AP) Study Date of ___
9:32 ___
COMPARISON: ___
FINDINGS:
Interval decrease in extent of pulmonary edema. Bilateral
pleural effusions
persist. Subjacent opacities may reflect atelectasis or
consolidation. There
is no pneumothorax. The size the cardiac silhouette is enlarged
but
unchanged.
IMPRESSION:
Bilateral pleural effusions with subjacent opacities may reflect
atelectasis
or pneumonia.
Interval decrease in extent of pulmonary edema.
Brief Hospital Course:
___ PMH ESRD w/ Cr 12.6 on ___ T2DM, HTN, calcineurin inhibitor use) s/p brachiocephalic
AV
fistula w/ Dr. ___ on ___, chronic anemia (has ranged ___
the last year, most recent 8.0 on ___ CKD on Epo,
cirrhosis s/p liver transplant in ___, T2DM, CAD (s/p
angioplasty in ___, presenting w/ worsening nausea, dyspnea on
exertion, fatigue, and general malaise, found to have acute on
chronic anemia, thrombocytopenia, and worsening CKD.
# CKD V now on HD
# s/p AVF placement
CKD ___ microvascular disease in the setting of diabetes,
hypertension and long time calcineurin inhibitor use. She
presented ___ to progressive uremic symptoms. Tunneled line
placed and she was initiated on hemodialysis which she tolerated
well. She has outpatient HD set up. Continued calcitriol,
sevelamer. Discontinued sodium bicarbonate and torsemide as no
longer needed as on HD. She has a left AVF that has not yet
matured for dialysis.
#Acute on chronic anemia
#Pancytopenia
Initial hgb of 4.6, and was admitted to the MICU. Received a
total of 4u pRBC with appropriate bump in hgb. No evidence of
active bleed. Has pancytopenia that is likely multifactorial
from immunosuppression after liver transplant and marrow
suppression from chronic illness (has MGUS).
# Cirrhosis s/p deceased donor liver transplant ___. Patient
has
been on azathioprine and cyclosporine as home medications. No
history of rejection based on recent transplant evaluation.
Continued on azathioprine and CsA with goal 50-80.
# MGUS
Monoclonal IgG gammopathy found ___ as part of transplant
workup, was due for heme/onc followup outpatient. SPEP/UPEP
elevated however checked in setting of ongoing renal failure.
Per
HemeOnc review, this is MGUS, and recommended outpatient
heme-onc f/u.
CHRONIC ISSUES
===============
# HTN
BP uncontrolled at baseline ~ 180s. Attempted to increase
hydralazine to 100 mg TID but patient was lightheaded with SBP
in
130s. Did not making any changes at this time. Continued on home
clonidine patches 0.2 and 0.3mg, hydralazine 75mg TID, Coreg 25
twice daily.
# Remote CAD history
Continued aspirin 81 mg daily, atorvastatin recently decreased
to
10 mg daily due to interaction with cyclosporine.
TRASITIONAL ISSUES
[]Patient with hx of T2DM. No longer has insulin requirement
likely because of compromise of renal function and failure to
clear insulin. ___ need insulin re-initiated on outpatient basis
after HD begins.
[]Has b/l hand pain in MCPs. Hand x-ray while hospitalized
earlier this month demonstrates evidence of possible erosions of
the 2, 3, and
___ MCP of right hand which may support dx such as Rheumatoid
Arthritis. Should receive outpatient rheumatology referral
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 10 mg PO QPM
3. AzaTHIOprine 50 mg PO DAILY
4. Calcitriol 0.5 mcg PO DAILY
5. CARVedilol 25 mg PO BID
6. Clonidine Patch 0.2 mg/24 hr 1 PTCH TD QTHUR
7. Clonidine Patch 0.3 mg/24 hr 1 PTCH TD QTHUR
8. Fish Oil (Omega 3) 1000 mg PO DAILY
9. Fluticasone Propionate NASAL 1 SPRY NU DAILY
10. HydrALAZINE 75 mg PO TID
11. sevelamer CARBONATE 800 mg PO TID W/MEALS
12. Sodium Bicarbonate 1300 mg PO TID
13. Torsemide 20 mg PO DAILY
14. Multivitamins 1 TAB PO DAILY
15. Ondansetron ODT 4 mg PO Q8H:PRN Nausea/Vomiting - First Line
Reason for PRN duplicate override: Patient is NPO or unable to
tolerate PO
16. Acetaminophen 500 mg PO Q6H:PRN Pain - Mild/Fever
17. CycloSPORINE (Neoral) MODIFIED 50 mg PO Q12H
Discharge Medications:
1. Nephrocaps 1 CAP PO DAILY
RX *B complex with C#20-folic acid ___ Caps] 1 mg 1 tab-cap by
mouth once a day Disp #*30 Capsule Refills:*0
2. Vitamin D ___ UNIT PO 1X/WEEK (___)
RX *ergocalciferol (vitamin D2) 50,000 unit 1 capsule(s) by
mouth once a week Disp #*4 Capsule Refills:*0
3. Calcitriol 1 mcg PO DAILY
RX *calcitriol 0.5 mcg 2 capsule(s) by mouth once a day Disp
#*60 Capsule Refills:*0
4. Acetaminophen 500 mg PO Q6H:PRN Pain - Mild/Fever
5. Aspirin 81 mg PO DAILY
6. Atorvastatin 10 mg PO QPM
7. AzaTHIOprine 50 mg PO DAILY
8. CARVedilol 25 mg PO BID
9. Clonidine Patch 0.2 mg/24 hr 1 PTCH TD QTHUR
10. Clonidine Patch 0.3 mg/24 hr 1 PTCH TD QTHUR
11. CycloSPORINE (Neoral) MODIFIED 50 mg PO Q12H
12. Fish Oil (Omega 3) 1000 mg PO DAILY
13. Fluticasone Propionate NASAL 1 SPRY NU DAILY
14. HydrALAZINE 75 mg PO TID
15. Multivitamins 1 TAB PO DAILY
16. Ondansetron ODT 4 mg PO Q8H:PRN Nausea/Vomiting - First
Line
Reason for PRN duplicate override: Patient is NPO or unable to
tolerate PO
17. sevelamer CARBONATE 800 mg PO TID W/MEALS
18. HELD- Torsemide 20 mg PO DAILY This medication was held. Do
not restart Torsemide until told by your doctor
Discharge Disposition:
Home
Discharge Diagnosis:
CKD V, initiation of HD
Cirrhosis s/p DDLT
Anemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear ___,
You were admitted to the hospital because your red blood cell
count was low.
WHAT HAPPENED WHILE YOU WERE IN THE HOSPITAL?
- You were given blood with improvement in your blood counts.
- You were started on hemodialysis.
- You improved and were ready to leave the hospital.
WHAT DO YOU NEED TO DO WHEN YOU LEAVE THE HOSPITAL?
- Take all of your medications as prescribed (listed below)
- Keep your follow up appointments with your doctors
- Weigh yourself every morning, before you eat or take your
medications. Call your doctor if your weight changes by more
than 3 pounds
- If you experience any of the danger signs listed below please
call your primary care doctor or come to the emergency
department immediately.
It was a pleasure participating in your care. We wish you the
best!
- Your ___ Care Team
Followup Instructions:
___
|
19683840-DS-18
| 19,683,840 | 27,241,632 |
DS
| 18 |
2180-01-31 00:00:00
|
2180-01-31 11:18:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
omeprazole
Attending: ___
Chief Complaint:
cc: AMS
Major ___ or Invasive Procedure:
ERCP
History of Present Illness:
___ year old woman who was recently diagnossed with gallbladder
CA metastatic to the liver s/p plastic stent placement at ___ in
late ___ who presents from home due to altered mental status and
abdominal pain worsening over the past two days. Pt had declined
chemotherapy at the time of diagnosis but was not set up with
hospice services at the time of discharge, which took place over
a weekend. Pt seen by usual ___ today and noted to be weak with
poor PO intake and significant pain. Pt sent to the ED.
On presentation to the ED, pt afebrile, BP 90/58, HR max 131.
WBC 17k. Pt given Vanc and Zosyn and sent to ERCP. In ERCP, pt
had two plastic stents removed. Pt noted to have tight stricture
in CHD and both intrahepatic ducts with proximal dilatation of L
IHD. Pt had a metal stent placed that transversed to L IHD. Pt
sent to floor. Pt hypotensive on presentation with BP 88/40.
Past Medical History:
Gallbladder CA w/ mets to liver -diagnosed in ___
HTN
GERD
CKD
Social History:
___
Family History:
No family history of hepatobiliary cancer.
Physical Exam:
Discharge
Vitals: 97.4 110/60 18 98%RA
Gen: NAD, jaundiced, sclera icteric
HEENT: NCAT, dry MM
CV: rrr, no r/m/g
Pulm: clear bl
Abd: soft, at most mild tenderness with palpation in RUQ
Ext: bilateral edema, 2+
Neuro: somnolent, moves all extremities spontaneously
Pertinent Results:
IMAGING
___ TTE: The left atrium is normal in size. Left ventricular
wall thickness, cavity size and regional/global systolic
function are normal (LVEF = 65%). Right ventricular chamber size
and free wall motion are normal. The diameters of aorta at the
sinus, ascending and arch levels are normal. The aortic valve
leaflets (3) appear structurally normal with good leaflet
excursion and no aortic stenosis or aortic regurgitation. The
mitral valve appears structurally normal with trivial mitral
regurgitation. There is borderline pulmonary artery systolic
hypertension. There is no pericardial effusion.
___ CT Abdomen/Pelvis:
1. Please note that the absence of IV contrast significantly
limits evaluation for vascular parenchymal organ abnormalities,
including tumor detection. Within this limitation, there are 2
biliary stents extending from the left/ central intrahepatic
bile ducts distally to the CBD, which itself does not appear
grossly dilated. It is difficult to assess the patency of the
stents. There is no pneumobilia.
2. The liver, in particular the right hepatic lobe, demonstrates
heterogeneous attenuation with areas of ill-defined
hypodensities, consistent with known hepatic metastases.
3. The gallbladder wall is irregular and calcified with an
internal calcified stone.
___ CT Head w/o contrast:
IMPRESSION:
This study is limited in part by motion artifact. However, no
acute
intracranial process seen
___ CXR
FINDINGS:
The patient is markedly rotated to the right, limiting
evaluation. Given
this, there are low lung volumes. Prominence of the
interstitial markings may
be due to mild edema. Bibasilar opacities, right greater than
left could be
due to atelectasis although underlying consolidation is not
excluded. No
large pleural effusion is seen. There is no evidence of
pneumothorax.
Cardiac silhouette is difficult to assess due to patient
rotation
MICRO
___ BCx
No Growth
___ BCx x 2
No Growth
___ 12:25 pm BLOOD CULTURE 2 OF 2.
**FINAL REPORT ___
Blood Culture, Routine (Final ___:
ENTEROCOCCUS FAECALIS.
IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE #
___
___.
KLEBSIELLA PNEUMONIAE.
IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE #
___
___.
Aerobic Bottle Gram Stain (Final ___:
THIS IS A CORRECTED REPORT ___ @ 8:50AM ).
Reported to and read back by ___ ___
___ @
7:45AM.
GRAM POSITIVE COCCI IN PAIRS AND IN SHORT CHAINS.
GRAM NEGATIVE ROD(S).
PREVIOUSLY REPORTED AS GRAM POSITIVE COCCI IN PAIRS AND IN
SHORT
CHAINS ONLY ___ @ 0708.
ORIGINAL CALL Reported to and read back by ___
@ 0708 ON
___.
Anaerobic Bottle Gram Stain (Final ___:
GRAM POSITIVE COCCI IN PAIRS AND IN SHORT CHAINS.
GRAM NEGATIVE ROD(S).
___ 12:00 pm BLOOD CULTURE 1 of 2
**FINAL REPORT ___
Blood Culture, Routine (Final ___:
ENTEROCOCCUS FAECALIS. FINAL SENSITIVITIES.
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: Susceptible to
1000mcg/ml of
streptomycin. Screen predicts possible synergy with
selected
penicillins or vancomycin. Consult ID for details..
Daptomycin MIC =3.0MCG/ML Sensitivity testing performed
by Etest.
KLEBSIELLA PNEUMONIAE. FINAL SENSITIVITIES.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROCOCCUS FAECALIS
| KLEBSIELLA PNEUMONIAE
| |
AMPICILLIN------------ <=2 S
AMPICILLIN/SULBACTAM-- 4 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN--------- =>4 R
DAPTOMYCIN------------ S
GENTAMICIN------------ <=1 S
MEROPENEM------------- <=0.25 S
PENICILLIN G---------- 2 S
PIPERACILLIN/TAZO----- 8 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
VANCOMYCIN------------ 1 S
Anaerobic Bottle Gram Stain (Final ___:
THIS IS A CORRECTED REPORT ___ @ 8:50AM).
Reported to and read back by ___ ___
___ @
7:45AM.
GRAM POSITIVE COCCI IN PAIRS AND IN SHORT CHAINS.
GRAM NEGATIVE ROD(S).
PREVIOUSLY REPORTED AS GRAM POSITIVE COCCI IN PAIRS AND IN
SHORT
CHAINS ONLY ___ 0708.
ORIGINAL CALL Reported to and read back by ___
___ @ ___ ON
___.
___ 3:24 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
KLEBSIELLA PNEUMONIAE. >100,000 ORGANISMS/ML..
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
KLEBSIELLA PNEUMONIAE
|
AMPICILLIN/SULBACTAM-- 8 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- 256 R
PIPERACILLIN/TAZO----- 8 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
ERCP:
The scout film showed two plastic stents in place.
After the stents were pulled, the bile duct was deeply
cannulated with the balloon.
Contrast was injected and there was flow through the ducts.
There was a 3 to 3.5 cm tight, irregular complex stricture
involving the CHD and IH ducts.
The right IHD did not fill with contrast.
There was post obstructive dilation of the left IHD.
The CBD was 6 mm in diameter.
A 10 mm x 80 mm WallFlex Biliary Uncovered Metal Stent (REF:
___ was placed in the main duct and into the
left IHD, traversing the stricture.
Excellent bile and contrast drainage was seen endoscopically and
fluoroscopically.
Otherwise normal ercp to third part of the duodenum
___ 07:20AM BLOOD WBC-11.9* RBC-2.99* Hgb-9.0* Hct-29.1*
MCV-97 MCH-30.1 MCHC-30.9* RDW-20.2* RDWSD-71.1* Plt ___
___ 07:20AM BLOOD Glucose-85 UreaN-15 Creat-0.8 Na-144
K-3.6 Cl-119* HCO3-18* AnGap-11
___ 07:20AM BLOOD ALT-46* AST-92* AlkPhos-___*
TotBili-3.4*
Brief Hospital Course:
___ y/o ___ speaking female with recently diagnosed
gallbladder cancer metastatic to the liver, HTN, and CKD, who
presented to ___ with abdominal pain and elevated LFTs, s/p
ERCP with stent exchange on ___ who presented with cholangitis
and septic shock. She was treated with fluids, pressors, and
antibiotics with improvement.
ACUTE ISSUES:
#Hypotension secondary to septic shock. Per the patient's
family, the patient had been jaundiced ___ days prior to
admission, and came to the ED after development of excruciating
abdominal and RUQ pain. She was initially hypotensive in the ED
but responded to IVF. she was taken to ERCP and had 2 plastic
stents replaced with metal stents. BCx grew GPCs and GNRs in ___
bottles, and she was placed on vancomycin and zosyn. Overnight,
she became hypotensive to the ___ and received 2L IVF. The
hypotension improved briefly but returned the following morning.
She received an additional 2L and was then transferred to the
MICU. Upon arrival to the MICU, her hypotension worsened to
___ and the patient became agitated. During the course of
her stay in the MICU, her hypotension was managed with fluids
and pressors for one evening. Patient was given vanc and zosyn,
later changed to zosyn and ampicillin/sulbactam and her
pressures improved. She completed course on discharge.
# Cholangitis/Stricture:
#Klebsiella / E. Faecalis bacteremia:
Patient had jaundice two days prior to admission, and came to
the ED after developing severe RUQ pain. She was taken to ERCP
and had two plastic stents replaced with metal stents. After the
procedure, her BCx grew GPCs and GNRs in ___ bottles, and she
was initially placed on vancomycin and zosyn. Once sensitivities
came back, we changed her antibiotics to zosyn and
ampicillin/sulbactam. Pain was managed with tylenol and
dilaudid.
#Altered mental status/Encephalopathy: Patient was only oriented
to person throughout her stay here, which was decreased from
baseline. Potential causes included sepsis, hypoglycemia from
sepsis and impaired gluconeogenesis, medication effect, and pain
from cholangitis. She was transferred to the floor and she
remained oriented to person only.
On the floor her mental status slowly improved. With dilaudid
made her delerious so we aggressively treated her with tylenol
and that had her pain controlled.
___: Likely secondary to hypotension. Patient has base
creatinine of 1.2, increased to 1.4 and patient experienced
diminished urine output. We gave her IVF with improvement of
creatinine and urine output. Her creatinine improved to 0.8 on
discharge
#Coagulopathy: Potentially due to impaired liver function versus
sepsis versus DIC, although latter is less likely due to
elevated fibrinogen. INR reached 1.6 but improved to 1.3 upon
discharge.
#Thrombocytopenia: potentially secondary to DIC, improved to
normal levels during course of stay.
#Anemia: Potentially secondary to blood loss from surgery vs
DIC.
#Cholangiocarcinoma: Incurable and progressing. Spoke with
family numerous regarding goals of care. They are very devoted
to their mother and understand that she is critically ill and
recognize she is going to die. After many discussions with
palliative care and team, the decision was made to discharge
home with hospice care. Though they are struggling with decision
not to bring her back if she was to become ill again. Her son
___ is key contact person. Both patient and family agreed to
not tell her with her diagnosis.
HCP ___
Relationship: son
Cell phone: ___
One issue that was very important to family was to continue the
SQ heparin. They were committed to not having a blood clot.
After much discussion we chose to discharge her home on a QD
dosing of subcutaneous heparin. I was leery of starting coumadin
or lovenox given bleeding risk and also lovenox would derail her
ability to get hospice.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheeze
2. Diclofenac Sodium ___ 50 mg PO TID:PRN pain
3. spironolacton-hydrochlorothiaz ___ mg oral DAILY
4. Acetaminophen 650 mg PO Q8H:PRN pain
5. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600
mg(1,500mg) -400 unit oral DAILY
6. Cyanocobalamin 1000 mcg PO DAILY
Discharge Medications:
1. Acetaminophen (Liquid) 1000 mg PO Q8H
2. HYDROmorphone (Dilaudid) 1 mg PO Q4H:PRN pain
3. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheeze
4. Heparin 5000 UNIT SC Q24H
RX *heparin, porcine (PF) 5,000 unit/0.5 mL 1 syringe SC once a
day Disp #*30 Syringe Refills:*4
5. ___ hose
please provide ___ hose
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Cholangocarcinoma
Cholangitis
Bacteremia
Acute renal failure
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Lethargic but arousable.
Activity Status: Bedbound.
Discharge Instructions:
It was a pleasure taking care of you during your recent
admission to ___. You were admitted with a blockage of your
bile ducts and an infection associated with this blockage. You
underwent a procedure called an ERCP and had a stent placed in
your bile duct.
Followup Instructions:
___
|
19683921-DS-5
| 19,683,921 | 22,353,971 |
DS
| 5 |
2177-12-05 00:00:00
|
2177-12-07 10:43:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
dyspnea on exertion, lightheadedness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ history of hypertension, hyperlipidemia, CAD s/p LCx stent,
atrial fibrillation comes in with shortness of breath and
lightheadedness. Patient states that for the past several months
she has been short of breath, primarily with any exertion. He
states these episodes come and go, however when they do come on
he simply rests and they usually self resolved. He denies any
chest tightness or pain with these episodes. Denies diaphoresis,
nausea, vomiting, abdominal pain. 3 days prior to presentation
he saw his cardiologist for these symptoms and was found to have
BP in the ___ in afib. At that time his cardiologist decided to
start amiodarone and try to downtitrate his atenolol. Since
then he has felt the same or worse, and this AM he woke up
feeling like his breathing was "slightly more labored" and he
continued to feel dizzy. He went to ___ initially for eval
of these symptoms. There EKG showed AF at 89 with LBBB (both
old). HD stable, lungs clear, received full ASA(81 at home, 3
additional tabs here), transfer to ___ since he is
followed here.
In the ED intial vitals were: 97 80 ___ 20 100% RA. Labs
notable for BNP >10000, Cr 1.5 (baseline 0.9-1.2), d-dimer 576.
CXR with cephalization of vessels but no overt pulmonary edema.
He was given lasix 40mg IV x1 and admitted to cardiology.
On the floor the patient is quite comfortable sitting in the
chair and in no acute distress, no current complaints. He
easily gives the above history. Adds that he has noticed weight
loss recent rather than weight gain -- used to weight 185 and
was recently 168 at his cardiologists office (and 161 today).
ROS: On review of systems, he denies any prior history of
stroke, TIA, deep venous thrombosis, pulmonary embolism,
bleeding at the time of surgery, myalgias, joint pains, cough,
hemoptysis, black stools or red stools. He denies recent fevers,
chills or rigors. S/he denies exertional buttock or calf pain.
All of the other review of systems were negative.
Cardiac review of systems is notable for dyspnea on exertion.
He denies chest pain, paroxysmal nocturnal dyspnea, orthopnea
(sleeps on 2 pillows for "comfort"), ankle edema, palpitations,
syncope or presyncope.
Past Medical History:
CORONARY ARTERY DISEASE - s/p BMS to LCx in ___
A-Fib - dx'd ___ years ago, on coumadin
Chronic systolic CHF (congestive heart failure), ___ class 3
Cardiomyopathy with EF 35%
HYPERTENSION - ESSENTIAL, BENIGN
DISC DISEASE - CERVICAL
COLONIC ADENOMA
HYPERLIPIDEMIA
HYPOTHYROIDISM, UNSPEC
Social History:
___
Family History:
Mother died of "heart attach" at ___, father died at ___ of an
"accident" and a heart attack. His sister had a stroke at age
___.
Physical Exam:
ADMISSION PHYSICAL EXAMINATION:
VS: Wt= 73.3 (161.2 lbs) T=...BP=...HR=...RR=...O2 sat=
GENERAL: elderly man sitting in chair 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 to ~8 cm, flat
CARDIAC: irregularly irregular, normal S1, S2. No m/r/g.
LUNGS: Mild kyphosis. Resp were unlabored. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: significant tortuous small veins visible, no edema
SKIN: Very dry, no stasis dermatitis
NEURO: A&Ox3, strength ___ in UE and ___, face symmetric
DISCHARGE PHYSICAL EXAM:
VS: Wt 73.4kg, 99.5, 101/65, 77, 18, 100% RA
GENERAL: elderly man sitting in chair in NAD.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI.MMM
NECK: Supple with JVP to ~10 cm
CARDIAC: irregularly irregular, normal S1, S2. No m/r/g.
LUNGS: Bibasilar inspiratory rales, no rhonchi or wheezing
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: trace edema
SKIN: dry, no stasis dermatitis
NEURO: A&Ox3, non-focal
Pertinent Results:
LABS:
On admission:
___ 11:00AM BLOOD WBC-7.1 RBC-5.15 Hgb-15.7 Hct-49.8 MCV-97
MCH-30.6 MCHC-31.6 RDW-13.6 Plt ___
___ 11:00AM BLOOD Neuts-69.0 ___ Monos-6.1 Eos-1.8
Baso-1.5
___ 11:00AM BLOOD ___ PTT-36.1 ___
___ 11:00AM BLOOD Glucose-100 UreaN-47* Creat-1.5* Na-139
K-4.5 Cl-97 HCO3-28 AnGap-19
___ 11:00AM BLOOD ___
___ 11:00AM BLOOD cTropnT-<0.01
___ 11:00AM BLOOD Calcium-9.7 Phos-4.2 Mg-2.2
___ 12:12PM BLOOD D-Dimer-576*
On discharge:
___ 05:07AM BLOOD WBC-6.3 RBC-4.77 Hgb-14.9 Hct-44.5 MCV-93
MCH-31.1 MCHC-33.4 RDW-13.4 Plt ___
___ 05:07AM BLOOD ___ PTT-39.7* ___
___ 05:07AM BLOOD Glucose-75 UreaN-46* Creat-1.2 Na-139
K-3.6 Cl-101 HCO3-27 AnGap-15
___ 05:07AM BLOOD Calcium-9.0 Phos-4.0 Mg-2.1
STUDIES:
___ CXR:
IMPRESSION:
Cephalization of the pulmonary vasculature with enlarged cardiac
silhouette. No overt pulmonary edema. Slight blunting of the
posterior costophrenic angles seen on the lateral view may be
due to trace pleural effusions.
___ ECG:
Atrial fibrillation with a controlled ventricular response. Left
axis
deviation. Left bundle-branch block. No significant change
compared to the previous tracing of ___.
Brief Hospital Course:
___ history of hypertension, hyperlipidemia, CAD s/p LCx stent,
atrial fibrillation comes in with shortness of breath and
lightheadedness.
ACTIVE ISSUES BY PROBLEM:
# ACUTE ON CHRONIC SYSTOLIC HEART FAILURE: symptoms of dyspnea
were attributed to CHF on presentation in the ER given elevated
BNP and cephalization on CXR, so he was given lasix with
improvement of symptoms. Upon arrival to the floor, however, he
appeared euvolemic and weight has been decreasing per his
resport, so it made his volume status somewhat difficult to sort
out. No evidence of occult ischemia, with stent placed in ___
and no ischemic changes on EKG. Could be related to AF but he
has been in afib for years now and symptoms have been worsening
recently. Have continued his home dose of lasix and adjusted BP
meds (see below) and discharged with plan to follow weights
daily and follow up with Dr. ___ cardiologist) next week.
# HYPOTENSION: has been relatively more hypotensive recently
with BPs generally in the 80-90s range systolic, likely
contributing to his overall fatigue and lightheadedness.
Atenolol was decreased to 50mg daily and losartan stopped for
the time being given his symptoms and mild renal dysfunction
(see below). Given his changing renal function, atenolol may no
longer be an ideal beta blocker for him and could consider
changing to metoprolol, however this decision has been deferred
to the patient's outpatient cardiologist.
# ACUTE KIDNEY INJURY: Cr up to 1.5 from recent baseline
0.9-1.2. ___ have been cardiorenal given that Cr improved the
following day to 1.2 with diuresis. Recommend keeping a close
eye on his renal function and considering changing atenolol to
metoprolol given that atenolol is renally cleared. Held
losartan on discharge given ___ and ___ BPs, but could consider
restarting this as tolerated at a low dose.
CHRONIC, INACTIVE ISSUES:
# CORONARY ARTERY DISEASE: recent BMS to LCx in ___. Previous
anginal equivalent was neck pain, but he has not had any of this
since getting the stent. No chest pain during admission.
Continued medical management with aspirin, atenolol, and
pravastatin. Losartan held on discharge due to above issues, but
can restart as tolerated.
# ATRIAL FIBRILLATION: recently started on amiodarone for rhythm
control with plan to wean off atenolol, as presumably this was
contributing to his fatigue and lightheadedness. Atenolol was
continued at 400mg daily, decreased atenolol to 50mg daily, and
continued coumadin 5mg
TRANSITIONS OF CARE:
- CHF: lasix dose kept at 40mg BID, recommend he follow weights
closely as an outpatient
- Hypotension: decreased atenolol to 50mg daily and held
losartan. Consider transition to metoprolol as an outpatient
- ___: losartan stopped for now given fluctuating renal
function, should have chem panel checked at follow up visit.
- Incidentally noted that patient may be a candidate for ICD for
primary prevention given low EF, recommend further discussion
with Dr ___.
- FULL CODE
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Losartan Potassium 50 mg PO DAILY
2. Atenolol 100 mg PO DAILY
3. Warfarin 5 mg PO DAILY16
4. Pravastatin 40 mg PO HS
5. Furosemide 40 mg PO BID
6. Aspirin 81 mg PO DAILY
7. Levothyroxine Sodium 75 mcg PO DAILY
8. Amiodarone 400 mg PO DAILY
Discharge Medications:
1. Amiodarone 400 mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Atenolol 50 mg PO DAILY
4. Levothyroxine Sodium 75 mcg PO DAILY
5. Pravastatin 40 mg PO HS
6. Warfarin 5 mg PO DAILY16
7. Furosemide 40 mg PO BID
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis:
Acute on chronic systolic heart failure
Hypotension
Acute kidney injury
Secondary diagnoses:
Atrial fibrillation
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 to the hospital due to shortness of breath,
dizziness and fatigue. You were given some extra furosemide to
get rid of some fluid in your lungs. We think your dizziness and
fatigue is from being on too much blood pressure medication, so
we have decreased those medications (please see your new
medication list).
Please weight yourself every day and call your doctor if your
weight increases or decreases by more than 2 lbs.
Followup Instructions:
___
|
19683921-DS-6
| 19,683,921 | 28,080,913 |
DS
| 6 |
2177-12-12 00:00:00
|
2177-12-22 12:04:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
dyspnea
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. ___ is a ___ with AFib on coumadin, cardiomyopathy with
an ejection fraction of 35%, hypertension, presenting with
shortness of breath. Of note patient was recently discharged
from ___ on ___ with a diagnosis of acute on chronic heart
failure. Patient felt improved after diuresis while in house and
was discharged. New medication included amiodarone, and his
cardiologist has been planning on reducing atenolol. Pt was
discharged with stable 40 bid po lasix daily.
He states that the day after his discharge he began feeling
increasingly short of breath with any exertion. Initially
attributed it to medication changes. SOB ini with exertion only,
but in past day, became notable at rest as well. SOB not worsen
w/ laying flat (though reported to night float differently) He
denies any pleuritic discomfort. He denies worsening lower
extremity edema or increase in weight. no leg pain. Denies
fevers, chills, cough. Pt did note that his UOP has been
decreasing despite same home dose. He denies difficulty
initiate streaming, but did note occassional stoping, and also
noted dribblig.
During his admission he was started on amiodarone, atenolol was
decreased he was maintained on same dose of furosemide. Hospital
course was complicated by hypotension with SBPs in 80-90s. Beta
blocker was decreased and losartan was stopped. Discharge weight
was 73.4kg.
In the ED, initial vitals were 98.6 70 96/66 22 95% 4L Nasal
Cannula. Labs were notable for BNP 13506, Cr 1.8 (baseline
1.1-1.2) and troponin negative x1. INR was 4.0.
CXR showed: Stable marked cardiomegaly with small left pleural
effusion.
On arrival to the floor, patient is comfortable. States he is no
longer short of breath but does endorse orthopnea. He is lying
on 2 pillows. pt received 40IV lasix overnight.
this am, pt reports feeling better. SOB has improved. no CP. no
f/c/n/v, cough.
Past Medical History:
CORONARY ARTERY DISEASE - s/p BMS to LCx in ___
A-Fib - dx'd ___ years ago, on coumadin
Chronic systolic CHF (congestive heart failure), ___ class 3
Cardiomyopathy with EF 35%
HYPERTENSION - ESSENTIAL, BENIGN
DISC DISEASE - CERVICAL
COLONIC ADENOMA
HYPERLIPIDEMIA
HYPOTHYROIDISM, UNSPEC
Social History:
___
Family History:
Mother died of "heart attack" at ___, father died at ___ of an
"accident" and a heart attack. His sister had a stroke at age
___.
Physical Exam:
ADMISSION PHYSICAL EXAM
VS: 97.4 110-120/82 ___ 18 98%2L weight 73.6kg i/o N/R
weight 73.6kg
General: NAD, comfortable, pleasant
HEENT: NCAT, PERRL, EOMI
Neck: supple, JVD to 8 cm H2O
CV: regular rhythm, no m/r/g
Lungs: trace crackles at bases bilaterally
Abdomen: soft, NT/ND, BS+
Ext: WWP, no c/c/e, no edema in dependent position, 2+ distal
pulses bilaterally
Neuro: moving all extremities grossly
.
DISCHARGE PHYSICAL EXAM
Pertinent Results:
TTE ___:
The left atrium is elongated. The right atrium is moderately
dilated. No atrial septal defect is seen by 2D or color Doppler.
Left ventricular wall thicknesses are normal. The left
ventricular cavity is mildly dilated. There is severe global
left ventricular hypokinesis (LVEF = 20 %). [Intrinsic left
ventricular systolic function is likely more depressed given the
severity of valvular regurgitation.] No masses or thrombi are
seen in the left ventricle. There is no ventricular septal
defect. The right ventricular cavity is mildly dilated with
depressed free wall contractility. There is abnormal septal
motion/position. The ascending aorta is mildly dilated. The
aortic valve leaflets (3) are mildly thickened. There is no
aortic valve stenosis. Mild (1+) aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. Severe (4+)
mitral regurgitation is seen. The tricuspid valve leaflets are
mildly thickened. Moderate to severe [3+] tricuspid
regurgitation is seen. There is mild pulmonary artery systolic
hypertension. [In the setting of at least moderate to severe
tricuspid regurgitation, the estimated pulmonary artery systolic
pressure ___ be underestimated due to a very high right atrial
pressure.] There is no pericardial effusion.
.
CXR
FINDINGS: PA and lateral views of the chest are provided. The
heart remains markedly enlarged. There is a small left pleural
effusion which appears slightly increased from the prior exam.
There is no pulmonary edema, focal consolidation or
pneumothorax. Bony structures are intact. Mediastinal contour
is normal. No free air below the right hemidiaphragm.
IMPRESSION: Stable marked cardiomegaly with small left pleural
effusion.
.
ADMISSION LABS
==============
___ 05:48PM BLOOD WBC-8.9 RBC-5.14 Hgb-15.7 Hct-49.2 MCV-96
MCH-30.5 MCHC-31.8 RDW-13.9 Plt ___
___ 05:48PM BLOOD Neuts-75* Bands-0 ___ Monos-7 Eos-0
Baso-0 ___ Myelos-0
___ 05:48PM BLOOD ___ PTT-43.4* ___
___ 05:48PM BLOOD Glucose-100 UreaN-53* Creat-1.8* Na-136
K-4.5 Cl-96 HCO3-27 AnGap-18
___ 06:10AM BLOOD ALT-164* AST-151* AlkPhos-85 TotBili-1.5
___ 06:25AM BLOOD ALT-151* AST-116* AlkPhos-78 TotBili-1.4
___ 05:48PM BLOOD ___
___ 05:48PM BLOOD cTropnT-<0.01
___ 06:10AM BLOOD Calcium-9.0 Phos-4.2 Mg-2.1
.
DISCHARGE LABS
==============
___ 06:39AM BLOOD WBC-7.1 RBC-4.82 Hgb-14.8 Hct-46.9 MCV-97
MCH-30.6 MCHC-31.5 RDW-14.8 Plt ___
___ 06:39AM BLOOD ___ PTT-44.1* ___
___ 06:39AM BLOOD Glucose-80 UreaN-36* Creat-1.1 Na-142
K-3.3 Cl-99 HCO3-34* AnGap-12
___ 06:39AM BLOOD proBNP-4736*
___ 06:39AM BLOOD Calcium-8.8 Phos-2.6* Mg-1.9
Brief Hospital Course:
Mr. ___ is a ___ with AFib on coumadin, cardiomyopathy with
an ejection fraction of 35%, hypertension, presenting with
shortness of breath
# Congestive heart failure with reduced ejection fraction - pt
presented with shortness of breath, esp. on exertion. BNP
elevated at ___ on admission with crackles at mid-lower lung
field ___. well's socre was 0. afib was rate controlled on
admission. ECHO showed severe global left ventricular
hypokinesis (LVEF = 20 %) with severe MR. ___ surgery
evaluation was initially in the hospital and pt is to have
follow up appointments as an outpatient with cardiac surgery as
well as cardiology to further evaluate intervention options. Of
note, it was felt that his worsening cardiac function ___ be
related to heavy etoh use. Counseling was provided prior to
discharge regarding to etoh cessation. Pt was diuresed with IV
lasix, and subsequently transitioned to torsemide 40mg BID as
new home regimen - to be further adjusted by outpatient provider
as appropriate. Pt was also instructed to have electrolytes
checked on ___. On discharge, pt was breathing
comfortably on room air. Pt was discharged home with
lisinopril, metoprolol as well as aldactone.
# severe mitral regurgitation - pt has history of MR. ___
ECHO showed severe MR with ___ ventricle enlargement. It was
unclear whether MR lead to ventricle enlargement, or if the
enlargement of ventricle ___ processes such as etoh related
cardiomyopathy lead to MR. ___ surgery was consulted, and
pt was to have evaulation as an outpatient to determine surgical
candidacy. Pt was also started on thiamine and folate given
suspicion for possible etoh related cardiomyopathy.
# ___: Pt presented with cr of 1.8, up from baseline of 1.1-1.2.
improved to 1.1 after diuresis, suggesting likely cardiorenal
etiology.
# Afib, on coumadin: INR was supratherapeutic on presentation at
4. coumadin was held initially and restarted at a lower dose of
4mg daily. amiodarone has been discontinued. pt maintained on
metoprolol for rate conrol.
# CAD s/p BMS to LCx in ___: pt was continued on ASA and
statin. His beta blocker was transitioned from atenolol to
metoprolol.
# Hyperlipidemia: stable on home pravastatin
# Hypothyroidism: stable on home levothyroxine
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amiodarone 400 mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Atenolol 50 mg PO DAILY
4. Levothyroxine Sodium 75 mcg PO DAILY
5. Pravastatin 40 mg PO HS
6. Warfarin 5 mg PO DAILY16
7. Furosemide 40 mg PO BID
8. Losartan Potassium 50 mg PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Levothyroxine Sodium 75 mcg PO DAILY
3. Pravastatin 40 mg PO HS
4. Warfarin 4 mg PO DAILY16
RX *warfarin 4 mg 1 tablet(s) by mouth daily at 4pm Disp #*30
Tablet Refills:*0
5. FoLIC Acid 1 mg PO DAILY
RX *folic acid 1 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
6. Lisinopril 10 mg PO DAILY
RX *lisinopril 10 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
7. Spironolactone 12.5 mg PO DAILY
RX *spironolactone 25 mg 0.5 (One half) tablet(s) by mouth once
per day Disp #*15 Tablet Refills:*0
8. Thiamine 100 mg PO DAILY
RX *thiamine HCl 100 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
9. Metoprolol Succinate XL 100 mg PO DAILY
RX *metoprolol succinate 100 mg 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*0
10. Torsemide 40 mg PO BID Duration: 2 Days
RX *torsemide 20 mg 2 tablet(s) by mouth Twice per day Disp #*4
Tablet Refills:*0
11. Potassium Chloride 20 mEq PO BID Duration: 2 Days
Hold for K > 4.5
RX *potassium chloride 20 mEq 1 tablet(s) by mouth Twice per day
Disp #*4 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis
Congestive heart failure with reduced ejection fraction
severe mitral regurgitation
Secondary diagnosis
acute kidney injury
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It has been our pleasure caring for you at ___. You were
admitted for worsening shortness of breath. We think it is
because of volume overload in the setting of your heart failure.
We repeated an ECHO, which showed worsening regurgitation of
your mitral valve as well as enlargement of your heart. One of
the causes of such clinical presentation is alcohol use, so we
strongly urge you to stop alcohol consumption in the future.
You will be evaluated by cardiac surgery team for further
recommendations.
Please get your electrolytes checked this ___. Please
call your cardiologist Dr. ___ ___ if you have
problems with this. Your potassium was low in the hospital, so
we started potassium pills, but you ___ not need this in the
future, depending on your labs. We also started you on torsemide
40mg twice per day, but after your lab check, this dose ___ be
adjusted by your cardiologist.
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs.
Followup Instructions:
___
|
19684272-DS-14
| 19,684,272 | 28,795,219 |
DS
| 14 |
2134-01-21 00:00:00
|
2134-01-21 11:47:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
___ Complaint:
diplopia, headache
Major Surgical or Invasive Procedure:
None (besides LP ___ and ___
History of Present Illness:
Mr. ___ is a ___ with PMHx for T-Cell lymphoma 100days s/p
SCT. He reports he recently returned from a business trip to
___. While away, he noted itching on his scalp and arms,
some on his leg. No specific rash although his face has remained
red and he has some red areas on his chest. He also reports that
he went swimming about 40 miles off shore in ___ while on a
fishing trip. He reports that he did not eat any raw food or any
shellfish. 48 hours prior to admission he presented to the
___ clinic for headache and chills. He reported he had
played basketball for a few hours and after showering noted a
headache with chills. He awoke in a sweat. He did not have a
fever by his report. He then reports on the day prior to
presentation he had reoccurance of the headache and blurry
vision that corrects when he closes one eye.
He was seen in the ED by Neuro who reported the diplopia is a
binocular horizontal diplopia that is worse at distance and on
leftward gaze. His neurlogical exam is notable for limited
abduction of right eye with horizontal nystagmus on right gaze
and slightly limited abduction of left eye. When assesing his
diplopia, he says the images are further apart horizontally when
in the distance and on the left. The outer image disappears when
covering his left eye. The remainder of his neurologic exam is
intact and nonfocal. His history is more consistent with a left
sixth nerve palsy, but his exam is more consistent with a
bilateral sixth, with the right sixth being more affected as
there is more limited abduction on the right with nystagmus on
right gaze. Given his oncologic history and immunosuppression
wiht Prednisone, he needs a lumbar puncture to assess for cells
in his CSF, opportunistic infections (viral culture, fungal
culture) and cytology and flow cytometry to asses for
leptomeningeal disease; extra CSF should be held in case further
studies needed. He will need a NCHCT prior to the LP to make
sure there is no mass lesion and that it is safe to proceed with
LP.
He recieved a NCHCT that was negative for mass or bleed and a
LP. He was given Ceftriaxone and transfered to the floor.
Past Medical History:
PAST ONCOLOGIC HISTORY:
___ is a ___ man with a history of hyperlipidemia,
who noted a pruritic rash, lymphadenopathy, and eosinophilia for
several months of unclear etiology. He has been on steroids on
again and off again since ___ and ultimately underwent
a biopsy of the left neck lymph node on ___, which
showed an atypical lymphoid proliferation containing CD30
positive cells, which was suggestive of the possibility of the
T-cell lymphoproliferative disorder. ___ then underwent
inguinal lymph node excisional biopsy on ___, which
showed atypical histiocytes and eosinophil-rich lymphoid
infiltrate. The infiltrating cells were mostly positive for
CD3, CD5, and CD7. CD20 stains primarily B cells for follicles
and CD23 highlights residual dendritic cell meshwork. TCR gene
rearrangement was positive with consistent for T-cell lymphoma,
best classified as high peripheral T-cell lymphoma, NOS.
___ was then referred to Dr. ___ for initiating
treatment of his T-cell lymphoma. Further staging with bone
marrow aspirate and biopsy on ___, showed a mildly
hypercellular bone marrow for age with an atypical T-cell rich
lymphohistiocytic infiltrate. Although corresponding T-cell
receptor clonality studies demonstrated a clonal T-cell
population including a definitive diagnosis, it was felt that a
sampling difference could be possible and given his diagnosis,
the findings of this marrow biopsy are highly suspicious for
involvement by the same T-cell process. Echocardiogram on ___, showed an LVEF of 55% with mild symmetric left
ventricular hypertrophy and normal valvular function. FDG tumor
imaging on ___, showed FDG-avid lymphadenopathy, most
intense in the left groin with axillary and iliac chain
lymphadenopathy and he initiated treatment with CHOEP with Cycle
1 on ___.
___ had an excellent response to treatment with marked
reduction in the size and number of lymph nodes following two
cycles of the therapy and given his diagnosis of peripheral
T-cell lymphoma, it was recommended that he proceed with
autologous stem cell transplantation following completion of his
treatment. ___ was seen again after he had his fifth cycle
of CHOEP, which was given on ___. Repeat CT of the
neck, chest, abdomen, and pelvis on ___, prior to his
fifth cycle showed numerous small cervical lymph nodes not
meeting CT size criteria, the pathological enlargement remain
unchanged. There were enlarged lymph nodes involving the axilla
retroperitoneal areas and iliac regions, with resolved small
bowel wall thickening.
___ underwent a bone marrow aspirate and biopsy on ___ which was negative for lymphoma. Pulmonary function
testing on ___, revealed a DLCO of 92%.
Echocardiogram revealed an EF of greater than 60%. As such,
___ received his sixth cycle of CHOEP chemotherapy on
___, which was used for stem cell mobilization
and collection. He collected his stem cells in one day on
___ for a total of over 8 million CD34cells/kg.
PAST MEDICAL/SURGICAL HISTORY:
1. Hyperlipidemia
2. GERD (chemo-associated)
Social History:
___
Family History:
Mother died of lung cancer at age ___ she was a smoker. Father
had melanoma and died at age ___. He also had a stroke at age ___.
There is no family history of other heme malignancies or
autoimmune disease. He has two brothers and one sister.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VITALS - 98.2, 120/80, 82, 18, 99%RA
GENERAL - Well-appearing middle aged M who appears comfortable,
appropriate and in NAD, laying down in bed.
HEENT - NC/AT, PERRL, EOMI, sclerae anicteric, MMM, OP clear
NECK - supple, no thyromegaly, no JVD, no carotid bruits
LUNGS - Lungs are clear to ausculatation bilaterally, moving air
well and symmetrically, resp unlabored, no accessory muscle use
HEART - PMI non-displaced, RRR, S1-S2 clear and of good quality
without murmurs, rubs or gallops
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)
NEURO - awake, A&Ox3, CN I: not tested. CN II: PERRL full visual
fields, CN III, IV, VI: Limmited abduction bilaterally. Nystgmus
on terminal gaze to left and right. CN V: Sensation intact to
light touch. CNVII: Facial muscles symeteric. CN VIII: Hearing
intact. CN IX, X: Symmertic palette elevation. CN XII: Tounge
midline.
Muscle strength ___ in both upper and lower extermities in both
proximal and distal muscle groups in flexion and extension.
Sensation intact to light touch in both upper and lower
extermities.
DISCHARGE PHYSICAL EXAM:
VITALS - 98.4, 108-132/70-80, 65-89, 98-99% RA
GENERAL - Well-appearing middle aged M who appears comfortable,
appropriate and in NAD.
HEENT - NC/AT, PERRL, EOMI, sclerae anicteric, MMM, OP clear
NECK - supple, no thyromegaly, no JVD, no carotid bruits
LUNGS - Lungs are clear to ausculatation bilaterally, moving air
well and symmetrically, resp unlabored, no accessory muscle use
HEART - PMI non-displaced, RRR, S1-S2 clear and of good quality
without murmurs, rubs or gallops
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)
NEURO - awake, A&Ox3, CN II-XII intact except for limited
abduction bilaterally (though significantly improving), muscle
strength ___ in BUE/BLE, sensation intact to light touch
Pertinent Results:
___ 10:15AM BLOOD WBC-7.8 RBC-4.06* Hgb-13.4* Hct-39.4*
MCV-97 MCH-33.0* MCHC-34.0 RDW-14.3 Plt ___
___ 10:15AM BLOOD Glucose-125* UreaN-15 Creat-0.9 Na-139
K-4.3 Cl-103 HCO3-30 AnGap-10
___ 10:15AM BLOOD B-GLUCAN-Positive 246
___ 05:55AM BLOOD ASPERGILLUS GALACTOMANNAN
ANTIGEN-Negative
___ 05:40AM BLOOD EBV PCR, QUANTITATIVE, WHOLE
BLOOD-Negative
___ 06:10AM BLOOD ANAPLASMA PHAGOCYTOPHILUM AND EHRLICHIA
CHAFFEENSIS ANTIBODY PANEL (IGM AND IGG) - Negative
___ 06:10AM BLOOD COCCIDIOIDES ANTIBODY,
IMMUNODIFFUSION-PND
___ 05:55AM BLOOD CYSTICERCOSIS ANTIBODY-PND
___ 05:55AM BLOOD TOXOCARA (T. CANIS & T. CATI)
ANTIBODY-PND
___ 05:55AM BLOOD TRICHINELLA IGG ANTIBODY-PND
___ 01:41PM BLOOD MISCELLANEOUS TESTING-PND
___ 02:01PM CEREBROSPINAL FLUID (CSF) WBC-185 RBC-55*
Polys-3 ___ Monos-2 Eos-23 ___ Macroph-1
___ 02:01PM CEREBROSPINAL FLUID (CSF) WBC-245 RBC-0 Polys-0
___ Monos-1 ___ Macroph-6
___ 02:01PM CEREBROSPINAL FLUID (CSF) TotProt-118*
Glucose-47
___ 10:15AM CEREBROSPINAL FLUID (CSF) WBC-590 RBC-80*
Polys-0 ___ Monos-0 Eos-47 ___ Macroph-6 Other-3
___ 10:15AM CEREBROSPINAL FLUID (CSF) WBC-395 RBC-3*
Polys-0 ___ Monos-1 Eos-72 Basos-1 Other-3
___ 10:15AM CEREBROSPINAL FLUID (CSF) TotProt-134*
Glucose-38
___ 08:51PM CEREBROSPINAL FLUID (CSF) WBC-265 RBC-295*
Polys-0 ___ Monos-2 ___ Macroph-1 Other-2
___ 08:51PM CEREBROSPINAL FLUID (CSF) WBC-260 RBC-1*
Polys-0 ___ Monos-4 ___ Macroph-1 Other-3
___ 08:51PM CEREBROSPINAL FLUID (CSF) TotProt-65*
Glucose-71
___ 06:38PM CEREBROSPINAL FLUID (CSF) HERPES SIMPLEX VIRUS
PCR-negative
___ 02:01PM CEREBROSPINAL FLUID (CSF) VARICELLA DNA
(PCR)-negative
___ 09:29AM CEREBROSPINAL FLUID (CSF) CYSTICERCUS
ANTIBODIES,IGG-PND
___ 09:29AM CEREBROSPINAL FLUID (CSF) ANGIOSTRONGYLUS-PND
___ 09:29AM CEREBROSPINAL FLUID (CSF) TOXOCARIASIS -PND
___ 09:29AM CEREBROSPINAL FLUID (CSF) TRICHINOSIS -PND
___ SEROLOGY/BLOOD CRYPTOCOCCAL ANTIGEN-NOT
DETECTED
___ CSF;SPINAL FLUID VIRAL CULTURE-NO VIRUS
ISOLATED
___ BLOOD CULTURE Blood Culture,
Routine-negative
___ BLOOD CULTURE Blood Culture,
Routine-negative
___ CSF;SPINAL FLUID GRAM STAIN-2+ ___ per
1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES, NO MICROORGANISMS
SEEN; FLUID CULTURE-NO GROWTH; FUNGAL CULTURE-NO FUNGUS ISOLATED
PRELIMINARY
___ Immunology (CMV) CMV Viral Load-not detected
___ CSF;SPINAL FLUID GRAM STAIN-2+ ___ per
1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES, NO MICROORGANISMS
SEEN; FLUID CULTURE-NO GROWTH; FUNGAL CULTURE-NO FUNGUS ISOLATED
PRELIMINARY; ACID FAST CULTURE-PRELIMINARY
___ CSF;SPINAL FLUID CRYPTOCOCCAL
ANTIGEN-negative
___ Blood (Toxo) TOXOPLASMA IgG
ANTIBODY-negative; TOXOPLASMA IgM ANTIBODY-negative
___ SEROLOGY/BLOOD RAPID PLASMA REAGIN
TEST-negative
___ SEROLOGY/BLOOD LYME SEROLOGY-negative
___ STOOL OVA + PARASITES-negative
___ STOOL OVA + PARASITES-PENDING
MRI head w and wo contrast ___:
No mass or other acute changes. Mild leptomeningeal enhancement
could be
post-procedural. No avid enhancement is seen.
CXR ___:
1. No acute abnormalities identified.
2. Impression on the right side of the trachea, likely
secondary to a thyroid abnormality.
CSF immunophenotyping ___:
Immunophenotypic findings consistent with involvement by
lymphoma are not seen in specimen. However, corresponding
cytospin shows abundant eosinophils and lymphocytes. Some
lymphocytes are atypical with irregular nuclear contour,
condensed chromatin, and small nucleoli. The morphology raises
the possibility of involvement by patient's known T-cell
lymphoma. Correlation with clinical findings is recommended.
Flow cytometry immunophenotyping may not detect all lymphomas
due to topography, sampling or artifacts of sample preparation.
CSF immunophenotyping ___:
Immunophenotypic findings are of a T-cell dominant lymphoid
profile with CD4-to-CD8 ratio of 0.4, and subset loss of CD7
expression. No other aberrancy identified in this limited
study. Please correlate with clinical and ancillary study (TCR
gamma PCR)
Brief Hospital Course:
___ h/o T-Cell lymphoma day +105 (___) s/p auto SCT on
prednisone for pneumonitis p/w diplopia and headache, found to
have eosinophilic meningitis.
# Diplopia/headache: Patient presented with a R sixth nerve
palsy that improved but persisted during his hospitalization.
His initial LP was concerning for WBC 245 and 43% eosinophils.
Given concerns for infection given his recent stem cell
transplant and long course of immunosuppresion with prednisone
for pneumonitis, he was initially started on vancomycin,
ceftriaxone, ampicillin, acyclovir, ambisome, fluconazole, and
ivermectin, but was quickly narrowed to ceftriaxone, acyclovir,
and fluconazole. He was taken off ceftriaxone when it was clear
that he did not have bacterial meningitis, and acyclovir when
his HSV and VZV were negative. CNS involvement of lymphoma with
reactive eosinophilic response was also considered, but his MRI
brain was normal, and CSF flow cytometry and T-cell
rearrangement were reportedly suspicious for CNS recurrence of
lymphoma. Eosinophilia from medications was also on the
differential, as his long-term suppressive bactrim and his
recent intake of excedrin could cause eosinophilia.
Ophthalmalogic exam showed no acute findings. He has also had
peripheral eosinophilia since ___. His beta-d-glucan
was found to be elevated at 246, though galactomannin was
normal. He was started on solumedrol IV 20mg q6h, and
transitioned to the equivalent oral dose, prednisone 50mg BID,
which may be tapered at follow-up if indicated.
# T-Cell lymphoma: He was day ___ s/p auto SCT on admission
(___). He has done well with his only other complication of
pneumonitis that has been steroid responsive. Since his CSF
immunophenotyping studies were reportedly suspicious for CNS
recurrence of lymphoma, he was given one dose of intrathecal
liposomal cytarabine on the night before discharge. He will
follow-up with Dr. ___ next week for continued follow-up
and management as more data returns. He will continue tamiflu,
acyclovir, and bactrim prophylaxis (bactrim originally held due
to concern for causing eosinophilia, but this appears less
likely now).
# ___: Cr increased from 0.9 to 1.5 on the day after admission,
but resolved gradually. He was hydrated before and after his
acyclovir doses.
# Pneumonitis: Likely occurred due to high dose chemo. Responded
to prednisone with taper, and was admitted on 5mg PO daily. He
was discharged on prednisone 50mg BID as above.
# GERD: He was continued on ranitidine.
TRANSITIONAL:
# Will need follow-up with Dr. ___ in hematology/oncology
regarding CSF testing with concern for CNS involvement of
lymphoma.
# Will need follow-up with infectious disease regarding his
extensive parasitic and fungal workup.
# Will need follow-up with his primary care physician regarding
nonspecific thyroid abnormality on CXR ___.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acyclovir 400 mg PO Q8H
2. Fluticasone Propionate 110mcg 2 PUFF IH BID
3. FoLIC Acid 1 mg PO DAILY
4. Lorazepam 0.5-1 mg PO HS:PRN sleeplessness/nausea
5. Oseltamivir 75 mg PO Q24H
6. PredniSONE 5 mg PO DAILY
7. Ranitidine 150 mg PO DAILY
8. Sulfameth/Trimethoprim DS 1 TAB PO DAYS (___)
Discharge Medications:
1. Acyclovir 400 mg PO Q8H
2. Fluticasone Propionate 110mcg 2 PUFF IH BID
3. FoLIC Acid 1 mg PO DAILY
4. Lorazepam 0.5-1 mg PO HS:PRN sleeplessness/nausea
5. Oseltamivir 75 mg PO Q24H
RX *oseltamivir [Tamiflu] 75 mg 1 capsule(s) by mouth daily Disp
#*10 Capsule Refills:*0
6. Ranitidine 150 mg PO DAILY
7. Fluconazole 800 mg PO Q24H
RX *fluconazole 200 mg 4 tablet(s) by mouth daily Disp #*56
Tablet Refills:*0
8. PredniSONE 50 mg PO BID
RX *prednisone 10 mg 5 tablet(s) by mouth twice a day Disp #*70
Tablet Refills:*0
9. Sulfameth/Trimethoprim DS 1 TAB PO DAYS (___)
Discharge Disposition:
Home
Discharge Diagnosis:
meningitis with peripheral and central eosinophilia, infectious
vs. neoplastic
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure participating in your care at ___. You were
admitted for a headache and double vision, which have improved
during your hospitalization. Eosinophils were found in your
spinal fluid, and you were ruled out for bacterial or viral
meningitis, though parasitic and fungal studies are still
pending. You were also given an intrathecal chemotherapy for
suspected recurrence of your lymphoma, and will go home on a
higher dose of prednisone (50mg twice a day) and an antifungal
medication (fluconazole).
Please call Dr. ___ office on ___ to schedule a follow-up
appointment on W ___ for further discussion of your work-up.
Followup Instructions:
___
|
19684582-DS-18
| 19,684,582 | 23,023,619 |
DS
| 18 |
2156-05-08 00:00:00
|
2156-05-08 11:25:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Draining enterocutaneous fistula/Crohn's Disease
Major Surgical or Invasive Procedure:
N/A
History of Present Illness:
___ year old Male with history of Crohn's disease status-post
small bowel resection the year prior to admission with
persistent enterocutaneous fistula who gets his usual GI care at
___, but is apparently unhappy with his care there so presents
to ___ for further evaluation. The patient reports progressive
abdominal pain over the 3 days prior to admission. On the day of
presentation he developed many episodes of non-bloody,
non-bilious emesis. He also notes increasing purulent drainage
from his enterocutaneous fistula. He reports having to change
his dressing 10 times daily.
Of note the patient has received 2 doses of ustekinumab
(Stelara) and in ___ received Humira, but it was discontinued
due to non-compliance. In reviewing his ___ CRS notes, in ___
he had an emergent ex-lap for lysis of adhesions for a SBO.
Post-operative course complicated by Shock, takotsubo's
cardiomyopathy, E. Coli and ___ bloodstream infections, VAP
and dysphagia. He was found with multiple abdominal abscesses
after this so drains were placed and a picc was placed for
antibiotics, and he unfortunately developed a line infection
with Raoutella spp. When they pulled the drains he developed
persistent enterocutaneous fistulas, and was placed on TPN for 8
weeks. Patient reports 20lb weight loss over the last month.
Initial vitals in the ___ ED were 97.6, 101, 104/74, 17, 100%.
He was given Zofran IV in the ED and developed an allergic
reaction, so was given 60mg of prednisone. In addition he was
given lorazepam, alprazolam, famotidine, morphine and methadone.
he was seen by ___ surgery and GI, although apparently
under the new IBD protocol, CRS is not routinely consulted, so
they have signed off pending request from GI. He underwent a CT
which did note small bowel dilation with a transition point,
although no actual obstruction is noted. Originally was
recommended for NPO, although now GI notes on the ED dashboard
state OK for clears. A CRP was ordered and is markedly high.
Past Medical History:
Appendectomy
Opioid dependence on methadone maintenance
Small bowel resection with side-to-side anastomosis
multiple lysis of adhesions
Crohn's disease
Social History:
___
Family History:
Mother: healthy
Father: ___, Bladder cancer
Physical Exam:
ADMISSION:
ROS:
GEN: - fevers, - Chills, + Weight Loss
EYES: - Photophobia, - Visual Changes
HEENT: - Oral/Gum bleeding
CARDIAC: - Chest Pain, - Palpitations, - Edema
GI: + Nausea, + Vomiting, - Diarhea, + Abdominal Pain, -
Constipation, - Hematochezia
PULM: - Dyspnea, - Cough, - Hemoptysis
HEME: - Bleeding, - Lymphadenopathy
GU: - Dysuria, - hematuria, - Incontinence
SKIN: + Rash
ENDO: - Heat/Cold Intolerance
MSK: - Myalgia, - Arthralgia, - Back Pain
NEURO: - Numbness, - Weakness, - Vertigo, - Headache
PHYSICAL EXAM:
VSS: 97.9, 108/65, 45, 19, 100%
GEN: NAD
Pain: ___
HEENT: EOMI, MMM, - OP Lesions
PUL: CTA B/L
COR: RRR, S1/S2, - MRG
ABD: Diffuse TTP, - rebound, - guarding, draining
enterocutaneous fistula with copious yellow stool drainage, ND,
+BS, - CVAT
EXT: - CCE
NEURO: CAOx3, Non-Focal
SKIN: Erythema surrounding fistula below umbilicus
DISCHARGE:
VITALS: ___ ___ Temp: 98.2 PO BP: 95/61 HR: 70 RR: 18 O2
sat: 93% O2 delivery: RA
HEENT: EOMI, MMM, - OP Lesions
PUL: CTA B/L
COR: RRR, S1/S2, - MRG
ABD: Diffuse mild TTP, - rebound, - guarding, draining
enterocutaneous fistula with copious yellow stool drainage and
air now covered with ostomy bag, ND, +BS, - CVAT
EXT: - CCE
NEURO: CAOx3, Non-Focal
SKIN: Erythema surrounding fistula below umbilicus improving
Pertinent Results:
___ 10:05PM BLOOD WBC-6.3 RBC-5.14 Hgb-12.6* Hct-40.9
MCV-80* MCH-24.5* MCHC-30.8* RDW-14.8 RDWSD-42.9 Plt ___
___ 10:05PM BLOOD Neuts-60.6 ___ Monos-10.9 Eos-5.1
Baso-0.6 Im ___ AbsNeut-3.83 AbsLymp-1.42 AbsMono-0.69
AbsEos-0.32 AbsBaso-0.04
___ 10:05PM BLOOD Glucose-109* UreaN-12 Creat-0.9 Na-139
K-4.4 Cl-99 HCO3-28 AnGap-12
___ 10:05PM BLOOD CRP-83.6*
___ 01:01AM BLOOD Lactate-1.0
___ 03:09AM URINE Color-Yellow Appear-Cloudy* Sp ___
___ 03:09AM URINE Blood-NEG Nitrite-NEG Protein-30*
Glucose-NEG Ketone-TR* Bilirub-NEG Urobiln-4* pH-6.5 Leuks-SM*
___ 03:09AM URINE RBC-6* WBC-0 Bacteri-FEW* Yeast-NONE
Epi-0
___ 12:56 am BLOOD CULTURE
Blood Culture, Routine (Pending): NGTD
___ 3:09 am URINE
URINE CULTURE: NEGATIVE
CT ABD & PELVIS WITH CONTRAST
Study Date of ___ 3:42 AM
IMPRESSION:
1. Progressive marked dilation of the small-bowel dilation
measuring up to 9.2 cm proximal to a likely transition point at
midline. Repeat study can be performed to evaluate for passage
of contrast.
2. There is extensive fecalization of the more distal small
bowel loops, which are not opacified, some of which demonstrate
pneumatosis, not in a typical appearance for acute process, and
more likely to represent benign pneumatosis. Correlate with
current medications and prior imaging.
3. A tract along the right anterior abdominal wall containing
fluid and foci of air extent to the existing opening in the skin
at midline, likely with fistulous connection to a contrast
containing loop of small bowel, as contrast is noted outside the
abdominal cavity.
4. Borderline splenomegaly.
5. There is a 3 mm nodule in the left lower lobe. For
incidentally detected single solid pulmonary nodule smaller than
6 mm, no CT follow-up is recommended in a low-risk patient, and
an optional CT in 12 months is recommended in a high-risk
patient.
See the ___ ___ Guidelines for the Management
of Pulmonary
Nodules Incidentally Detected on CT" for comments and reference:
___
CT ABD & PELVIS WITHOUT CONTRAST
Study Date of ___
IMPRESSION:
1. Resolution of small bowel obstruction, although it may be the
case that there is some degree of chronic obstruction along the
anterior upper abdominal wall with recent acute exacerbation.
2. Possible fistula between small bowel and periumbilical
region, but not well assessed with this examination, with
anatomy in fact on the recent prior study.
3. Scattered foci of extraluminal air, very similar to the prior
study and again mostly localizing to the left upper quadrant in
the setting of pneumatosis coli, although not increased.
Brief Hospital Course:
#Fistulizing Crohn's Disease: CRP elevated but this could be
high w/ obstruction. On review of outpatient records from ___,
he is due for Stelara (plan for q4 weeks) and hasn't been taking
his usual PO medications. He had been seeing ___ GI and
colorectal surgery. CT abdomen showed possible partial SBO,
otherwise no evidence of active inflammation. Ostomy team
evaluated his abdominal wound. Inpatient GI team did not believe
that patient was in flare of his Crohn's therefore we did not
treat with any antibiotics or systemic steroids. We attempted CT
fistulogram to better delineate his anatomy however patient did
not tolerate injection of contrast agent into EC fistula so
procedure was aborted. We continued his usual home PO Crohn's
medications. Colorectal surgery also evaluated patient as second
opinion about surgical intervention, who will follow up with
patient in clinic after discharge once records (including
images) have been obtained and sent to their clinic. He will
also be set up to see outpatient GI clinic at ___. He will be
d/c with ___ to help care for his wounds.
#Depression/anxiety: Patient noted long-standing symptoms of
depression and anxiety while admitted. Social work provided
supportive care. We discussed options for referral to
therapy/psychiatry and patient elected to d/w his PCP and get
referral to see somebody.
#Incidental Pulmonary Nodule: seen on CT.
"There is a 3 mm nodule in the left lower lobe. For incidentally
detected single solid pulmonary nodule smaller than 6 mm, no CT
follow-up is recommended in a low-risk patient, and an optional
CT in 12 months is recommended in a high-risk patient. See the
___ ___ Guidelines for the Management of
Pulmonary Nodules Incidentally Detected on CT" for comments and
reference: ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Ondansetron 4 mg PO Q8H:PRN nausea
2. Gabapentin 600 mg PO TID
3. Budesonide 3 mg PO TID
4. TraZODone 50 mg PO QHS:PRN insomnia
5. Senna 17.2 mg PO DAILY
6. Polyethylene Glycol 17 g PO BID:PRN Constipation - First Line
7. Narcan (naloxone) 4 mg/actuation nasal PRN Overdose
8. Methadone 88 mg PO DAILY
9. ALPRAZolam 0.5 mg PO QHS:PRN anxiety
The Preadmission Medication list is accurate and complete.
1. Ondansetron 4 mg PO Q8H:PRN nausea
2. Gabapentin 600 mg PO TID
3. Budesonide 3 mg PO TID
4. TraZODone 50 mg PO QHS:PRN insomnia
5. Senna 17.2 mg PO DAILY
6. Polyethylene Glycol 17 g PO BID:PRN Constipation - First Line
7. Narcan (naloxone) 4 mg/actuation nasal PRN Overdose
8. Methadone 88 mg PO DAILY
9. ALPRAZolam 0.5 mg PO QHS:PRN anxiety
Discharge Medications:
1. Miconazole Powder 2% 1 Appl TP TID:PRN rash
RX *miconazole nitrate 2 % apply to abdomen rash three times
daily Disp #*1 Bottle Refills:*0
2. ALPRAZolam 0.5 mg PO QHS:PRN anxiety
3. Budesonide 3 mg PO TID
4. Gabapentin 600 mg PO TID
5. Methadone 88 mg PO DAILY
Consider prescribing naloxone at discharge
6. Narcan (naloxone) 4 mg/actuation nasal PRN Overdose
7. Ondansetron 4 mg PO Q8H:PRN nausea
RX *ondansetron 4 mg 1 tablet(s) by mouth every eight hours Disp
#*30 Tablet Refills:*0
8. Polyethylene Glycol 17 g PO BID:PRN Constipation - First
Line
9. Senna 17.2 mg PO DAILY
10. TraZODone 50 mg PO QHS:PRN insomnia
11.nutrition
Boost Strawberry supplement
One bottle with each meal
Dispense 1 case with 10 refills
Discharge Disposition:
Home With Service
Facility:
___
___ Diagnosis:
Crohn's Disease
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 Crohn's disease with
draining abdominal wound likely due to an enterocutaneous
fistula. You were ween by GI, colorectal surgery and
ostomy/wound care.
It was a pleasure taking care of you!
Sincerely, your ___ team
Steps to Fistula Care/ Recommendations:
1)Cleanse skin with water and gently pat completely dry.
2)Sprinkle Miconazole powder to yeast dermatitis. Rub in and
dust
off excess.
3)Then, seal in with No Sting Barrier. Allow to completely dry.
4)Using template, firmly mold ___ ring around measured
opening.
5)Place appliance over fistula, molding into skin. Apply warm
pack for better adherence to skin.
___ connect pouching system to night drainage as needed.
**Once yeast dermatitis resolved, may stop miconazole. Then use
Stomahesive
powder.
Followup Instructions:
___
|
19684755-DS-12
| 19,684,755 | 25,007,014 |
DS
| 12 |
2177-04-16 00:00:00
|
2177-04-18 15:44:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
ibuprofen
Attending: ___.
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
HISTORY OF PRESENTING ILLNESS: ___ y/o man with a history of CAD
(s/p PCI x 3) who presented to the ___ ER this
morning with substernal chest pain radiating to both arms and
the jaw.
At the ___ the patient's EKG showed rapid aflutter vs.
afib in 140s wit diffuse ST depressions. Initial troponin was
negative. He was empirically started on heparin, given nitro x
2, ASA 325mg. The patient developed hypotension to SBP ___ with
nitro; resolved with IV fluids. He was then transferred to the
___ ___ for cardiology evaluation.
In the ___, ___ initial VS were 1 98.2 140 110/79 97% 2L NC.
EKG showed narrow complex tachycarida with ST depressions
laterally that was improved from prior OSH EKG. Shortly after
arrival BP dipped to 73/47 with HR 150. He was given 10 IV dilt
x 2 and then 60mg of PO diltiazem with improvement in the heart
rate to the ___ with BP 106/63. 30 mg PO diltiazem was repeated
1.5 hours later prior to transfer to floor. CXR was
unremarkable. The patient was then admitted to the cardiology
service for further management. Prior to admission, the patient
had an episode of tea-colored urine. He has never experienced
this before. He denies dysuria, freqency, urgency. Of note, the
patient denies previous history of arrhythmia.
On arrival to the floor, the patient is chest pain free.
Past Medical History:
NSTEMI s/p PCI x 3 at ___ in ___ in ___
Social History:
___
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.
Physical Exam:
Admission:
VS: 126/78 78 18 98%RA 108kg
General: pleasant man in NAD
HEENT: EOMI, PERRL, MMM, oropharynx clear
Neck: JVD to 8 cm; no lymphadenopathy or thyromegaly
CV: Irregularly irregular S1, S2, no MRG
Lungs: CTAB
Abdomen: Soft, non-tender, non-distended
GU: no foley in place
Ext: Non-edematous; DP and ___ 2+
Neuro: CN II - XII intact; otherwise grossly normal
Discharge:
VS: T=98.2 BP=98-126/60-78 HR=90s-100s on tele RR=18 O2
sat=96-98% RA
GENERAL: WDWN man in NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthelasma.
NECK: Supple with JVP of 10 cm.
CARDIAC: PMI located in ___ intercostal space, midclavicular
line. tachycardic, normal S1, S2. No m/r/g. No thrills, lifts.
No S3 or S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominal bruits.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
Pertinent Results:
___ 05:20AM BLOOD WBC-8.6 RBC-5.04 Hgb-15.9 Hct-44.3 MCV-88
MCH-31.6 MCHC-35.9* RDW-13.8 Plt ___
___ 06:35PM BLOOD WBC-10.9 RBC-5.13 Hgb-15.8 Hct-46.0
MCV-90 MCH-30.8 MCHC-34.3 RDW-13.2 Plt ___
___ 05:20AM BLOOD Glucose-120* UreaN-18 Creat-1.3* Na-138
K-4.2 Cl-105 HCO3-25 AnGap-12
___ 06:35PM BLOOD Glucose-115* UreaN-17 Creat-1.2 Na-141
K-4.5 Cl-107 HCO3-22 AnGap-17
___ 05:55AM BLOOD CK(CPK)-511*
___ 06:35PM BLOOD ALT-32 AST-42* AlkPhos-62 TotBili-0.7
___ 05:55AM BLOOD CK-MB-67* MB Indx-13.1* cTropnT-1.21*
___ 06:35PM BLOOD cTropnT-0.08*
___ 05:20AM BLOOD Calcium-8.7 Phos-2.8 Mg-2.0
Renal Ultrasound:
IMPRESSION: No hydronephrosis. Numerous bilateral renal stones
are visualized.
Echo:
Suboptimal image quality.The left atrium is moderately dilated.
The right atrium is moderately dilated. No atrial septal defect
is seen by 2D or color Doppler. There is moderate symmetric left
ventricular hypertrophy. The left ventricular cavity size is
normal. Due to suboptimal technical quality, a focal wall motion
abnormality cannot be fully excluded. Overall left ventricular
systolic function is normal to dynamic (LVEF>55%). There is a
mild resting left ventricular outflow tract obstruction. There
is no ventricular septal defect. Right ventricular chamber size
is normal. with borderline normal free wall function. The
diameters of aorta at the sinus, ascending and arch levels are
normal. The aortic valve leaflets (3) are mildly thickened but
aortic stenosis is not present. No aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. Mild (1+) mitral
regurgitation is seen. The tricuspid valve leaflets are mildly
thickened. The pulmonary artery systolic pressure could not be
determined. There is no pericardial effusion.
Brief Hospital Course:
___ year old man with history of MI s/p PCI x 3 in ___ admitted
with chest pain, found to have atrial flutter with rapid
ventricular response.
#AFlutter: patient initially presented as flutter, but this
turned to atrial fibrillation in house. His rates were difficult
to rate control on metoprolol, received IV dilt drip with good
response. He subsequently converted to sinus rhythm.
Due to his conversion to sinus and low CHADS score, he was not
started on anti-coagulation. He was discharged on metoprolol XL
200mg. An echo was performed and was normal.
# Chest pain/Troponemia: Likely represents demand ischemia in
the setting of tachycardia, as patient became chest-pain free
with resolution of tachycardia. Do not feel that this is ACS.
However, given his prior stent he does have risk and so was
discharged with aspirin and low-dose rosuvastatin. Recommend
obtaining nuclear stress test as outpatient to stratify his
risk.
# Tea-colored urine: New following episode of tachycardia.
Patient without symptoms of UTI. ___ represent hematuria
following intiation of anticoagulation due to an anatomic defect
or stones. A renal ultrasound showed multiple stones in both
kidneys.
HE will need an outpatient urology workup to r/o malignancy in
the urinary tract.
Transitional Issues:
-needs urology f/u for hematuria
-needs cards f/u for stress test
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. This patient is not taking any preadmission medications
Discharge Medications:
1. Metoprolol Succinate XL 200 mg PO DAILY
RX *metoprolol succinate 200 mg 1 tablet extended release 24
hr(s) by mouth daily Disp #*30 Tablet Refills:*0
2. Rosuvastatin Calcium 10 mg PO DAILY
RX *rosuvastatin [Crestor] 10 mg 1 tablet(s) by mouth Daily Disp
#*30 Tablet Refills:*0
3. Aspirin 325 mg PO DAILY
RX *aspirin 325 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis:
Atrial fibrillation
Coronary artery disease
Secondary diagnosis:
Left ventricular hypertrophy
Nephrolithiasis
Hematuria
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were admitted to ___ for chest pain and rapid heart rate.
You were found to have an abnormal rhythm called atrial
fibrillation. We were able to stop your atrial fibrillation with
medications. You need to take these medications everyday on time
in order to prevent return of the abnormal rhythm. You will also
need to take aspirin daily to prevent stroke.
Although you had chest pain and a leak of your cardiac enzymes,
we feel this was due to your rapid heart rate. Still, we
recommend you undergo outpatient nuclear stress testing to rule
out any blockages in your coronary arteries that may have caused
the chest pain.
While you were here, you also had blood in your urine. We think
this is due to multiple kidney stones which were seen on an
ultrasound of your kidneys. When you return home, please make an
appointment with a urologist for further evaluation.
Followup Instructions:
___
|
19684837-DS-11
| 19,684,837 | 27,878,671 |
DS
| 11 |
2169-03-01 00:00:00
|
2169-03-01 12:49:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
hydrochlorothiazide
Attending: ___.
Chief Complaint:
dysuria, fever
Major Surgical or Invasive Procedure:
None
History of Present Illness:
The patient is a ___ speaking ___ year old female with a
medical history including diabetes, hypertension, and low back
pain who presents with several days of dysuria, frequency, and
fever. She denies abdominal pain. She denies cough, shortness of
breath, or chest pain.
In the Emergency department she was found to have a temperature
of 102. Her urinalysis was abnormal. She had a leukocytosis. She
was given antibiotics and admitted to medicine.
Past Medical History:
Diabetes
Hypertension
back pain
hyperlipidemia
osteoarthritis
peripheral vascular disease
Social History:
___
Family History:
Reviewed. Not pertinent to this hospitalization
Physical Exam:
General: awake, comfortable
HEENT: anicteric sclera, moist membranes
Neck: no cervical LAD
CV: S1, S2 regular rhythm, normal rate
Lung: CTA bilaterally, unlabored respirations
Abdomen: soft, non-tender
Back: No CVA TTP
Ext: warm, no edema
Neuro: alert, speech fluent
Pertinent Results:
___ 07:45PM BLOOD WBC-17.2*# RBC-4.09* Hgb-12.0 Hct-37.8
MCV-92 MCH-29.4 MCHC-31.9 RDW-12.2 Plt ___
___ 07:45PM BLOOD Neuts-79.3* Lymphs-11.5* Monos-8.5
Eos-0.2 Baso-0.4
___ 07:45PM BLOOD Glucose-191* UreaN-20 Creat-1.1 Na-131*
K-4.1 Cl-95* HCO3-22 AnGap-18
___ 08:35AM BLOOD Calcium-9.1 Phos-2.2* Mg-1.8
___ 08:35AM BLOOD ALT-25 AST-32 AlkPhos-68 TotBili-0.4
___ 07:53PM BLOOD Lactate-1.6
CXRFINDINGS:
AP and lateral views of the chest. Low lung volumes are seen
with secondary crowding of the bronchovascular markings.
Streaky bibasilar opacities are most likely due to atelectasis.
Lateral view is limited secondary to motion but there is no
evidence of effusion. Cardiac silhouette is enlarged and is
accentuated by low lung volumes. Atherosclerotic calcifications
seen at the aortic arch.
IMPRESSION:
Low lung volumes without definite acute cardiopulmonary process.
___ 8:05 pm URINE
URINE CULTURE (Preliminary):
ESCHERICHIA COLI. >100,000 ORGANISMS/ML..
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ 4 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
Brief Hospital Course:
Sepsis due to E. coli UTI: Based on dysuria, frequency, and WBC
with tachycardia initially. Improved quickly with IVF and
Ceftriaxone. Urine culture grew pan sensitive E. coli, and she
was transitioned to Cipro to complete a course. Her back pain
was chronic and she was not thought to have pyelonephritis.
Hypertension, benign:
Hyperlipidemia:
Chronic back pain
- home regimen was continued.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. FoLIC Acid 1 mg PO DAILY
2. Gabapentin 300 mg PO BID
3. Gabapentin 600 mg PO HS
4. Lisinopril 40 mg PO DAILY
5. Metoprolol Succinate XL 50 mg PO DAILY
6. Omeprazole 20 mg PO DAILY
7. Simvastatin 20 mg PO DAILY
8. Aspirin 81 mg PO DAILY
9. Calcium Carbonate Dose is Unknown PO Frequency is Unknown
10. Vitamin D Dose is Unknown PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. FoLIC Acid 1 mg PO DAILY
3. Gabapentin 300 mg PO BID
4. Gabapentin 600 mg PO HS
5. Metoprolol Succinate XL 50 mg PO DAILY
6. Omeprazole 20 mg PO DAILY
7. Simvastatin 20 mg PO DAILY
8. Lisinopril 40 mg PO DAILY
9. Calcium Carbonate 1250 mg PO DAILY
10. Vitamin D 800 UNIT PO DAILY
11. Ciprofloxacin HCl 500 mg PO Q12H Duration: 4 Days
please take until you finish your pills. start evening of ___
RX *ciprofloxacin 500 mg 1 tablet(s) by mouth twice a day Disp
#*7 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
E. coli UTI
Hypertension
Chronic back pain
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You were admitted with a bacterial urinary tract infection. You
improved with antibiotics and will be sent home with antibiotics
to complete a course. Please take this until you finish the
course. Please stay well hydrated. Please resume your home
medications and follow up closely with you doctor.
Followup Instructions:
___
|
19684837-DS-12
| 19,684,837 | 28,807,219 |
DS
| 12 |
2170-01-20 00:00:00
|
2170-03-19 16:48:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
hydrochlorothiazide
Attending: ___
Chief Complaint:
confusion, difficulty speaking, urinary incontinence, gait
instability
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ year-old right-handed woman with
history of multiple cerebrovascular risk factors including HTN,
HL, NIDDM, PVD, chronic low back pain, who presents with sudden
onset confusion, apparent right neglect, and gait instability.
Due to the patients confusion, her daughters present at the
bedside provided additional information. Ms. ___ was
last seen well at 2200hrs last night by her son with whom she
lives. On ___ around 0400hrs, she was found speaking
nonsensically while sitting in a chair, with fluent phrases, but
inappropriate for the questions or commands posed by her son.
She
was also noted to have urinary incontinence which on further
questioning appeared to be her voiding in a place other than the
restroom (in a chair). She subsequently went back to bed, but
due
to concerns of the son, the patient's daughter arrived and found
in addition to her mother with a fluent aphasia, she was noted
to
have increased gait instability (which may have been due to
right
sided weakness on further questionin) when ambulating with her
walker. As a result of this the patient was brought to ___ ED
for further evaluation.
In ED, the patient was noted to have difficulty following
commands, and concern for right sided weakness, as well as
neglect.
The family endorsed no recent illnesses, trauma, or other
antecedent events. No events like this in past. Per the family
the patient is compliant with her medications, which her son
handles. She recently had Toprol XL 75mg daily added for better
HTN control.
Review of symptoms was unable to be performed due to aphasia.
Past Medical History:
PMH:
- Hyperlipidemia
- Hypertension
- Osteoarthritis
- Peripheral Vascular Disease
- Right TKA
- Diabetes off medications
- Lower Back Pain
Social History:
___
Family History:
History of cardiovascular disease, diabetes.
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
Vitals: T: 97.6 54 189/51 16 100%
General: Awake, pleasant, but fluent aphasia in ___, NAD.
HEENT: NC/AT, no scleral icterus, MMM, clear oropharynx
Neck: Supple, no nuchal rigidity. No carotid bruits
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: RRR, nl. S1S2, no M/R/G
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly.
Extremities: No C/C/E bilaterally, 2+ radial, DP pulses
bilaterally.
Skin: no rashes or lesions
Neurologic:
-Mental Status: Alert, but unable to respond to any orientation
questions. Language was in ___ with expressions using full
words (no neologisms or paraphasic errors) but inappropriate to
questions. Did not follow commands consistently. Neglect of
right evident on gaze and responding to stimuli.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 4 to 2mm and brisk. VFF to confrontation.
III, IV, VI: EOMI without nystagmus. Saccadic intrusions in all
fields of gaze. Did not gaze fully to right. Conjugate Gaze.
V: Unable to assess ___ aphasia
VII: Mild right NLF droop, with equal excursion of facial
musculature on smile.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Unable to assess ___ aphasia.
XI: Unable to assess ___ aphasia
XII: Tongue protrudes in midline but unable to comply with
strength (tongue in cheek) ___ aphasia
-Motor: Normal bulk, tone throughout. No adventitious movements.
Unable to assess pronator drift, asterixis, or individual muscle
groups due to aphasia. Observations: right upper extremity
weakness due to decreased movement of the extremity relative to
other distributions.
-Sensory: Unable to assess, but w/d to mild pain/tickle in all
-DTRs:
Bi Tri ___ Pat Ach
L 2 1 1 1 1
R 2 1 1 0* 1
* TKA performed, also all were confounded.
Plantar response was flexor bilaterally.
-Coordination: Unable to cooperate with testing.
-Gait: Did not assess.
DISCHARGE PHYSICAL EXAM:
========================
Pertinent Results:
ADMISSION LABS:
===============
___ 10:00AM BLOOD WBC-7.8 RBC-4.08* Hgb-11.8* Hct-37.2
MCV-91 MCH-28.8 MCHC-31.6 RDW-13.5 Plt ___
___ 10:00AM BLOOD Neuts-66.7 ___ Monos-5.8 Eos-4.1*
Baso-0.5
___ 10:00AM BLOOD ___ PTT-30.4 ___
___ 10:00AM BLOOD Glucose-145* UreaN-21* Creat-0.8 Na-142
K-4.4 Cl-103 HCO3-29 AnGap-14
___ 10:00AM BLOOD ALT-24 AST-32 AlkPhos-119* TotBili-0.3
___ 10:00AM BLOOD cTropnT-<0.01
___ 10:00AM BLOOD Albumin-4.1
___ 10:00AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 10:08AM BLOOD Lactate-1.2
PERTINENT LABS:
===============
___ 05:52AM BLOOD %HbA1c-6.2* eAG-131*
___ 05:52AM BLOOD Triglyc-73 HDL-67 CHOL/HD-2.5 LDLcalc-88
DISCHARGE LABS:
===============
RELEVANT STUDIES:
=================
- NCHCT/CTA HEAD&NECK (___):
1. Head CT: There is no evidence of hemorrhage midline shift or
hydrocephalus. There is loss of gray-white matter
differentiation in the left posterior frontal and anterior
parietal lobe regions indicative of an acute infarct. There is
brain atrophy and small vessel disease.
2. CTA neck:. Vascular calcifications are seen at the carotid
bifurcations and great vessels at the thoracic inlet. No
vascular occlusion or high-grade stenosis is identified
involving the carotid or vertebral arteries.
3. CTA head: There are filling defects in the posterior sylvian
branches of the left middle cerebral artery indicated intrinsic
emboli. There is an approximately 2 mm broad-based aneurysm seen
at the left middle cerebral artery bifurcation. Otherwise, no
vascular abnormalities are seen.
4. IMPRESSION: CT head shows signs of an acute left posterior
frontal infarct. Spleen defects are identified in the posterior
sylvian branches of the left middle cerebral artery indicative
of emboli. 2 mm broad-based aneurysm at the left middle
cerebral artery bifurcation.
- MRI BRAIN (___):
1. Evolving left MCA territory infarct, with evidence of local
hemorrhage.
2. No new ischemia since the prior CT on ___.
- TRANSTHORACIC CARDIAC ECHO (___):
Brief Hospital Course:
HOSPITAL COURSE: ___ RHW h/o HTN, HLD, NIDDM and PVD who
presented with acute confusion, Wernicke type aphasia, gait
instability and incontinence found on MRI to have a L MCA
infarct. Stroke was felt to likely be cardioembolic in etiology,
possibly due to undiagnosied paroxysmal Afib. Pt was kept on
telemetry, which showed no arrythmia. A TTE was done which
showed no PFO or thrombus.
- Pt was started on Asprin 325 mg qDay with plans to discontinue
in approximately 1 week when therapeutic on Coumadin. She will
also receive ___ of Hearts Monitor ambulatory cardiac event
monitoring.
- LDL 88, HbA1c 6.2%. Currently stable on home ASA, increased
home Atorvastatin (now at 80mg), and home Metoprolol.
AHA/ASA Core Measures for Ischemic Stroke and Transient Ischemic
Attack
=
=
=
=
=
=
=
================================================================
1. Dysphagia screening before any PO intake? (x) Yes [performed
and documented by Speech and Language Pathology] () No
2. DVT Prophylaxis administered by the end of hospital day 2?
(x) Yes - () No
3. Antithrombotic therapy administered by end of hospital day 2?
(x) Yes - () No
4. LDL documented (required for all patients)? (x) Yes (LDL =
88) - () No
5. Intensive statin therapy administered? (x) Yes - () No [if
LDL >= 100, reason not given: ____ ]
(intensive statin therapy = simvastatin 80mg, simvastatin
80mg/ezetemibe 10mg, atorvastatin 40mg or 80 mg, rosuvastatin
20mg or 40mg, for LDL >= 100)
6. Smoking cessation counseling given? () Yes - () No [if no,
reason: () non-smoker - (x) unable to participate]
7. Stroke education given (written form in the discharge
worksheet)? (x) Yes - () No
(stroke education = personal modifiable risk factors, how to
activate EMS for stroke, stroke warning signs and symptoms,
prescribed medications, need for followup)
8. Assessment for rehabilitation or rehab services considered?
(x) Yes - () No [if no, reason not assessed: ____ ]
9. Discharged on statin therapy? (x) Yes - () No [if LDL >= 100
or on a statin prior to hospitalization, reason not discharged
on statin: ____ ]
10. Discharged on antithrombotic therapy? (x) Yes [Type: (x)
Antiplatelet - () Anticoagulation] - () No
11. Discharged on oral anticoagulation for patients with atrial
fibrillation/flutter? () Yes - () No [if no, reason not
discharge on anticoagulation: ____ ] - () N/A
TRANSITIONAL ISSUES:
====================
- ASA increased to 325mg
- Atorvastatin increased to 80mg
- Pt was started on ASA 325 mg as a bridge to therapeutic
Coumadin 5 mg qDay. ___ was instructed to arrange for ambulatory
cardiac event monitoring with ___
- Follow-up appt made w/ Dr. ___ at ___ ___
- Follow-up appt made w/ pt's PCP
___ on ___:
The Preadmission Medication list is accurate and complete.
1. Amlodipine 10 mg PO DAILY
2. Atorvastatin 20 mg PO DAILY
3. FoLIC Acid 1 mg PO DAILY
4. Gabapentin 300 mg PO TID
5. Lisinopril 40 mg PO DAILY
6. Metoprolol Succinate XL 75 mg PO DAILY
7. Omeprazole 20 mg PO DAILY
8. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Aspirin 325 mg PO DAILY
2. Atorvastatin 80 mg PO DAILY
3. Gabapentin 300 mg PO TID
4. FoLIC Acid 1 mg PO DAILY
5. Metoprolol Succinate XL 75 mg PO DAILY
6. Omeprazole 20 mg PO DAILY
7. Amlodipine 10 mg PO DAILY
8. Lisinopril 40 mg PO DAILY
9. Warfarin 5 mg PO DAILY16
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Left inferior division MCA acute ischemic stroke
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 ___,
It was a pleasure taking care of ___ at ___.
___ were hospitalized due to symptoms of right sided weakness,
confusion, and difficulty speaking, resulting from an acute
ischemic stroke, a condition in which a blood vessel providing
oxygen and nutrients to the brain is blocked by a clot.
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:
1. High blood pressure
2. High cholesterol
3. Diabetes
4. Peripheral vascular disease
We are changing your medications as follows:
1. Increasing your aspirin from 81mg to 325mg daily
2. Increasing your atorvastatin from 20mg to 80mg daily
3. Starting Warfarin 5 mg daily to keep your blood thin and
prevent clots from forming (which may have caused your stroke)
We are also ordering a heart monitor for ___ called a ___ of
Hearts" monitor - Please call ___ on ___
to have this set up.
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:
___
|
19684837-DS-13
| 19,684,837 | 24,504,888 |
DS
| 13 |
2170-08-20 00:00:00
|
2170-08-20 12:50:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
hydrochlorothiazide
Attending: ___
Chief Complaint:
Right arm cramping and numbness
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
The patient is a ___ yo ___ right-handed F with
PMHx notable for an ischemic L MCA stroke, atrial fibrillation
on
warfarin, HTN, pre-diabetes and HLD who presents to ___ ER ___
with right arm tingling and weakness. History is obtained with
the assistance of patient's ___, as pt is a
poor historian at baseline.
Pt awoke this morning in her usual state of health. She sat down
in the kitchen and was drinking coffee when, all of a sudden,
she
yelled that her right arm was "hurting" her. She lives with her
son and her son called her ___ to bring pt to the
emergency room for evaluation. The family was primarily
concerned
because pt reported similar symptoms of discomfort with her
prior
stroke (however, symptoms were present on pt's entire right side
at that time).
In the ED, a code stroke was called. ___ showed chronic left
temporoparietal encephalomalacia without any hemorrhages or
evidence of new large territory stroke.
At time of assessment, pt reported symptoms were persistent. Pt
felt like her right arm was 'asleep' and 'cramping'. Symptoms
had
started in the right shoulder and were now throughout the entire
arm. Pt was unable to further describe how symptoms progressed
(e.g. over what time period) or if symptoms were waxing and
waning. Pt also felt that her right arm was weaker than usual.
Per ___, following the stroke, pt now prefers her
left side and has minimal right sided weakness. She walks with a
walker. Pt has not had any recent constitutional symptoms
including fevers, dysuria, cough, shortness of breath, abdominal
pain, diarrhea, nausea or vomiting. Pt was treated for a UTI 3
weeks ago. Pt had not missed any doses of warfin and, per
___, INR was "good" during her most recent check on
___.
Regarding her prior stroke, pt presented in ___ with
symptoms of sudden onset confusion, apparent right neglect, and
gait instability. She was discharged on aspirin with plans to
start warfarin in the future as stroke was presumed to be
cardioembolic (no arrhythmia was captured on telemetry during
hospitalization). She underwent ___ of Hearts monitor as an
outpatient that confirmed atrial fibrillation and pt was started
on warfarin as an outpatient. She underwent aggressive speech,
physical and occupational therapy. Family reports ongoing
cognitive issues (pt does not know birthday or date at baseline,
needs assistance with ADLs but is able to eat independently) and
must walk with a walker.
On neurologic review of systems, no headache, loss of vision,
blurred vision, diplopia, focal numbness, bladder incontinence.
On general review of systems, no fevers, chest pain, dyspnea,
cough, nausea, vomiting, diarrhea, constipation, or abdominal
pain.
Past Medical History:
PMH:
- Hyperlipidemia
- Hypertension
- Osteoarthritis
- Peripheral Vascular Disease
- Right TKA
- Diabetes off medications
- Lower Back Pain
Social History:
___
Family History:
History of cardiovascular disease, diabetes.
Physical Exam:
PHYSICAL EXAMINATION
Vitals: 97.5 84 130/75 16 100% ra
General: NAD, well-appearing
HEENT: NCAT, no oropharyngeal lesions, neck supple
___: RRR
Pulmonary: CTAB, no crackles or wheezes
Abdomen: Soft, NT, ND, +BS, no guarding
Extremities: Warm, +1 pitting edema at ankles bilaterally
Skin: Chronic skin changes at lower extremities bilaterally
Neurologic Examination:
- Mental Status - Awake, alert. Not oriented to person, place
and
time. No dysarthria. Inattentive. Able to follow simple
commands,
unable to follow complex commands. Able to name high frequency
objects, unable to name low frequency objects. No evidence of
hemineglect.
- Cranial Nerves - PERRL 3->2 brisk. BTT intact. EOMI, no
nystagmus. V1-V3 without deficits to light touch bilaterally. No
facial movement asymmetry. Palate elevation symmetric.
SCM/Trapezius strength ___ bilaterally. Tongue midline.
- Motor - Normal bulk and tone. No drift. No tremor or
asterixis.
Pt is able to provide resistance on motor testing for shoulder
abduction, elbow extension and flexion, grasp, hip flexion, knee
flexion and extesnion and plantar flexion; it is difficult to
appreciate a difference in power bilaterally as pt does not
comply ideally with testing. Pt may favor the left side,
however.
- Sensory - Pt able to close eyes and lift arm and legs as they
are pricked in different areas, no gross deficits appreciated.
-DTRs:
Bi Tri ___ Pat Ach
L 1 1 1 1 0
R 1 1 1 1 0
Plantar response flexor bilaterally.
- Coordination - No gross deficits with finger-nose-finger
bilaterally however pt with poor compliance with this part of
the
examination.
- Gait - Deferred.
LAB DATA:
Lactate:1.0
Na:142
K:3.8
Cl:103
TCO2:28
Glu:129
Cr:0.8
BUN:19
Trop-T: <0.01
Ca: 9.6 Mg: 1.8 P: 3.3
ALT: 19 AP: 110 Tbili: 0.6 Alb: 4.4 AST: 25
Serum ASA, EtOH, Acetmnphn, Benzo, Barb, Tricyc: Negative
6.7 > 12.2 < 169
___: 23.8 PTT: 35.9 INR: 2.2
UA: Unremarkable
EKG: Pending
IMAGING:
NCHCT (___):
Encephalomalacia in the left temporoparietal region, evolution
of
prior left MCA territory infarct, however no evidence of new
infarct or intracranial hemorrhage.
CXR (___):
No infiltrates, no acute disease.
Pertinent Results:
NCHCT (___):
Encephalomalacia in the left temporoparietal region, evolution
of
prior left MCA territory infarct, however no evidence of new
infarct or intracranial hemorrhage.
CXR (___):
No infiltrates, no acute disease.
MRI (___): Encephalomalacia and hemosiderin deposition in the
left parietal and left posterior lobes due to a large chronic
infarct of the left middle cerebral artery territory. No
evidence of acute on chronic infarct. Underlying moderate
chronic small vessel disease.
Brief Hospital Course:
Ms. ___ was admitted to the stroke service and
monitored closely.
Her EKG and telemetry was significant for atrial fibrillation
without any ventricular response. Her complaints of arm
discomfort and numbness resolved by the time of admission. She
had no abnormalities on neurologic exam. She had full range of
motion of her RUE, but did have some intermittent discomfort
localized to her shoulder with upward extension of her arm.
INR was therapeutic at 2.2 throughout admission.
Her CT and MRI did not show any new strokes. Based on her
history and her serial exams, the decision was made to discharge
Ms. ___ home with no changes in her medications. She
will follow-up with her primary care physician in the next few
days.
Medications on Admission:
1. Amlodipine 10 daily
2. Atorvastatin 80 qHS
3. Folic acid 1 daily
4. Lisinopril 40 daily
5. Metoprolol ER 50 daily
6. Omeprazole 20 daily
7. Warfarin 3 mg daily
8. Calcium 600 + Vitamin D 400 daily
9. Colace 100 BID
10. Senna 8.6 BID
Discharge Medications:
1. Atorvastatin 80 mg PO QPM
2. Calcium Carbonate 500 mg PO DAILY
3. FoLIC Acid 1 mg PO DAILY
4. Metoprolol Tartrate 12.5 mg PO BID
5. Omeprazole 20 mg PO DAILY
6. Vitamin D 400 UNIT PO DAILY
7. Warfarin 3 mg PO DAILY16
8. Calcium 600 + Vitamin D 400 daily
9. Colace 100 BID
10. Senna 8.6 BID
Discharge Disposition:
Home
Discharge Diagnosis:
No acute stroke
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear ___,
You were admitted to the hospital because of right arm pain and
numbness that you felt on ___. We found that you had no weakness
in that arm on exam. Head imaging did not show any new strokes.
We found that your INR was within the therapeutic range and that
you were appropriately taking your warfarin.
Your symptoms improved and you did not have any further arm
complaints during the admission. We decided to discharge you
home with no changes to your medications.
You should follow-up with your primary care doctor regarding an
outpatient workup for arm pain.
Sincerely,
Your ___ Neurology team
Followup Instructions:
___
|
19684965-DS-8
| 19,684,965 | 25,994,936 |
DS
| 8 |
2200-02-24 00:00:00
|
2200-02-24 17:04:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
Penicillins
Attending: ___
Chief Complaint:
Right sided weakness and sensory changes
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ year old male with history of hypertension, DM2, tobacco use
disorder, renal cancer s/p partial nephrectomy, thyroid cancer
s/p thyroidectomy who presents with acute onset right arm and
leg
tingling/numbness and weakness. Neurology is consulted as code
stroke.
Per patient around 1800 on ___ he developed acute onset right
sided arm and leg tingling and numbness as well as some
weakness.
He tried to walk and needed to hold on to his family to walk. He
could hold onto objects but felt like his coordination was off
on
his right hand. He checked his BG which was 413. He took some
insulin and his symptoms were a bit better but still present. He
had no vision changes, dizziness, speech problems, comprehension
issues, dysphagia. Given improving, yet ongoing symptoms he
presented to the emergency department. In the ED his BG had
improved to 100s, but he still remained with some tingling in
his
right hand and some sensation of weakness on his right leg.
He denies prior similar symptoms. His blood sugars can run up to
200s at times and he has had rare occasions with BG in 400s, but
has never had these symptoms with this. He denies recent
illness,
fevers, chills. He takes aspirin every day and took in this
morning.
Past Medical History:
DM2
HTN
HLD
renal cancer s/p partial nephrectomy
Papillary thyroid carcinoma, s/p thyroidectomy - ___
Social History:
___
Family History:
non-contributory
Physical Exam:
General: Awake, cooperative
HEENT: NC/AT, no scleral icterus noted, poor dentition
Neck: Supple, no carotid bruits appreciated
Pulmonary: Normal work of breathing.
Cardiac: RRR, warm, well-perfused.
Abdomen: Soft, non-distended.
Neurologic:
-Mental Status: Alert, oriented to person, place, time,
situation. Relates history, DOWB intact. Language fluent without
dysarthria. Able to name, read, repeat. Describes images on
stroke cards. Follows complex commands. No RL confusion, no
apraxia.
-Cranial Nerves:
II, III, IV, VI: PERRL 3 to 2mm and brisk. EOMI without
nystagmus. VFF to confrontation.
V: Facial sensation intact to light touch.
VII: Slight R NLFF without asymmetry
IX, X: Palate elevates symmetrically.
XII: Tongue protrudes in midline with good excursions. Strength
full with tongue-in-cheek testing.
-Motor: Normal bulk and tone throughout. No pronator drift.
[Delt][Bic][Tri][ECR][FEx][IP][Quad][Ham][TA][Gas]
L 5 5 5 5 5 5 5 5 5 5
R 5 5 5 5 5 5 5 5 5 5
-Sensory: No deficits to light touch, temperature, or
proprioception throughout.
-Reflexes: 1+ throughout, absent Achilles, toes down Plantar
response was flexor bilaterally.
-Coordination: Slightly slower finger taps on right. No
dysmetria.
-Gait: Able to walk on heels, toes. Narrow based. Difficulty
with tandem.
Pertinent Results:
___ 11:13PM BLOOD %HbA1c-10.5* eAG-255*
___ 08:43PM BLOOD LDLmeas-86
___ 08:43PM BLOOD TSH-<0.01*
___ 08:43PM BLOOD T4-7.8
Brief Hospital Course:
Mr. ___ was admitted with acute onset right sided arm and leg
tingling and numbness as well as weakness, and gait instability.
Blood glucose was 413. He presented to the ED after symptoms did
not completely improve even with insulin. He underwent an MRI
which did not show acute ischemic stroke, and his symptoms
completely improved within 48 hours of presentation. MRI was
obtained with contrast given his history of multiple
malignancies, but was unremarkable. Of note A1c was 10.5,
suggesting poor control. Barriers to effective therapy include
discomfort in swallowing pills. He was discharged home with
follow up appointments recommended for neurology, ___
Diabetes, and primary care provider.
Transitional Issues
[ ] Follow up appointments as above, including at ___
___ and ___.
[ ] Consider altering his medication regimen to the smallest
pill sizes available.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. CloNIDine 0.1 mg PO BID
2. Losartan Potassium 50 mg PO DAILY
3. NIFEdipine (Extended Release) 30 mg PO DAILY
4. Levothyroxine Sodium 225 mcg PO DAILY
5. Glargine 58 Units Bedtime
Humalog 20 Units Breakfast
Humalog 20 Units Lunch
6. rOPINIRole 1 mg PO QAM
7. rOPINIRole 2 mg PO QPM
8. Spironolactone 12.5 mg PO DAILY
9. FLUoxetine 40 mg PO DAILY
10. Calcitriol 0.25 mcg PO DAILY
11. Aspirin 81 mg PO DAILY
12. Simvastatin 20 mg PO QPM
Discharge Medications:
1. Glargine 58 Units Bedtime
Humalog 20 Units Breakfast
Humalog 20 Units Lunch
2. Aspirin 81 mg PO DAILY
3. Calcitriol 0.25 mcg PO DAILY
4. CloNIDine 0.1 mg PO BID
5. FLUoxetine 40 mg PO DAILY
6. Levothyroxine Sodium 225 mcg PO DAILY
7. Losartan Potassium 50 mg PO DAILY
8. NIFEdipine (Extended Release) 30 mg PO DAILY
9. rOPINIRole 1 mg PO QAM
10. rOPINIRole 2 mg PO QPM
11. Simvastatin 20 mg PO QPM
12. Spironolactone 12.5 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Hyperglycemia
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 right sided weakness. Your
MRI did not show a stroke. The most likely etiology of your
symptoms is high blood glucose, which can sometimes produce
neurologic deficits. These improved after correction of your
glucose.
The best way to avoid such symptoms is to continue to work on
blood pressure, diabetes, and cholesterol.
It was a pleasure taking care of you. We wish you the best.
___ Neurology
Followup Instructions:
___
|
19685014-DS-12
| 19,685,014 | 21,085,417 |
DS
| 12 |
2129-06-01 00:00:00
|
2129-06-10 21:13:00
|
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
transfer from OSH for UTI
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
___ h/o pancreas and kidney transplant for DM1 presenting from
___ with UTI. She has a h/o UTI on ___ and
completed 7d macrobid 4d ago - had cultures ___
___ urgent care. On ___ began noticing urine had a
foul smell, burning with urination, increased frequency, orangey
color with blood. Woke up today with chills, headache, nausea.
She then went to ___, noted to have a fever up to
___. She got 1g ceftriaxone, 1g acetaminophen, ondansetron and
was transferred to our ED.
Initial ED vitals were 99.6 80 140/50 12 96% RA. She was AOx3,
got IVF 600cc. Though not documented in the ED dash, she spiked
to 102.2 prior to transfer.
In the ED she got prednisone 5, sirolimus 0.5, tacrolimus 0.5,
aceta 1g. Urinalysis was significant for > 182 WBCs, no bacteria
(but after OSH abx), Cr 2.1 (baseline 1.7-1.9), WBC 12.9.
Lactate was 1.5.
Vitals prior to transfer were 99.2 80 120/56 18 99%. She was
admitted for IV antibiotics and transplant ultrasound.
On the floor she feels chills, is wrapped up in a hoodie in bed.
She notes otherwise generally feeling OK before two days ago.
She has not had any sexual partners for ___ years, no h/o STI.
Intermittently has diarrhea on and off, on wed/thurs was
constipated then today had a soft large BM.
ROS: Denies any new cough, endorses a "little" non productive
cough "here and there, now and then." Notes a slight headache,
no neck stiffness or pain, no photosensitivity, no vision
changes. She reports some hevay breathing yesterday which
resolved today. mild nausea, no vomiting.
Otherwise: denies vision changes, rhinorrhea, congestion, sore
throat, chest pain, abdominal pain, vomiting, constipation,
BRBPR, melena, hematochezia.
Past Medical History:
ESRD s/p renal transplant ___, Pancreas transplant ___
diabetes mellitis
breast cancer s/p mastectomy ___ yrs ago
hypertension
s/p LRKTx: one ___ years ago, LRRT ___
s/p PAK ___
Social History:
___
Family History:
Both parents and a sibling with rheumatoid arthritis. ___ uncle
and ___ GF with T2DM. Mat cousin with diabetes
Physical Exam:
ADMISSION PHYSICAL EXAMINATION:
VS: 102.1 - 142/66 - 84 - 16 - 97ra
weight 137.2#
GENERAL: Well appearing lady who appears stated age.
Comfortable, appropriate and in good humor.
HEENT: Sclera anicteric. EOMI.
NECK: supple
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: CTA bilaterally
ABDOMEN: soft with well healed midline scar w/ retained stitches
in midline of the scar, as well as older scar RLQ, newer scar
LLQ, both well healed. non-tender to palpation. no rebound.
EXTREMITIES: warm, brown macules over anterior shins. 1+ pitting
edema anterior shins which doesnt go above the knee.
DISCHARGE PHYSICAL EXAM
VS: 98 - 110/53 - 71 - 20 - 100 ra
weight 61.4kg
GENERAL: Well appearing lady who appears stated age.
Comfortable, appropriate and in good humor.
HEENT: Sclera anicteric. EOMI.
NECK: supple
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: CTA bilaterally
ABDOMEN: soft with well healed midline scar w/ retained stitches
in midline of the scar, as well as older scar RLQ, newer scar
LLQ, both well healed. non-tender to palpation. no rebound.
EXTREMITIES: warm, brown macules over anterior shins. 1+ pitting
edema anterior shins
Pertinent Results:
ADMISSION LABS
===============
___ 09:25AM BLOOD WBC-12.9*# RBC-3.18* Hgb-9.2* Hct-28.4*
MCV-89 MCH-28.9 MCHC-32.3 RDW-13.9 Plt ___
___ 09:25AM BLOOD Neuts-92.8* Lymphs-3.6* Monos-3.1 Eos-0.4
Baso-0.1
___ 09:25AM BLOOD ___ PTT-26.7 ___
___ 09:25AM BLOOD Glucose-102* UreaN-42* Creat-2.1* Na-136
K-4.4 Cl-105 HCO3-24 AnGap-11
___ 09:25AM BLOOD Amylase-112*
___ 09:25AM BLOOD Lipase-49
___ 09:25AM BLOOD Albumin-3.1*
___ 09:29AM BLOOD Lactate-1.5
IMMUNOSUPPRESSANTS
===================
___ 05:45AM BLOOD tacroFK-5.9 rapmycn-7.4
___ 08:00AM BLOOD tacroFK-6.0
DISCHARGE LABS
==============
___ 08:00AM BLOOD WBC-7.4 RBC-3.21* Hgb-9.6* Hct-28.8*
MCV-90 MCH-30.0 MCHC-33.3 RDW-14.2 Plt ___
___ 08:00AM BLOOD Glucose-90 UreaN-31* Creat-2.1* Na-140
K-4.8 Cl-105 HCO3-23 AnGap-17
___ 08:00AM BLOOD Calcium-9.4 Phos-2.5* Mg-1.7
URINE STUDIES
==============
___ 09:45AM URINE Color-Yellow Appear-Cloudy Sp ___
___ 09:45AM URINE Blood-SM Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-LG
___ 09:45AM URINE RBC-8* WBC->182* Bacteri-NONE Yeast-NONE
Epi-0
___ 07:45PM URINE Hours-RANDOM UreaN-484 Creat-62 Na-65
K-30 Cl-63
MICROBIOLOGY
=============
___ Blood Culture, Routine-FINAL
___ Blood Culture, Routine-FINAL
___ SWAB R/O VANCOMYCIN RESISTANT ENTEROCOCCUS-FINAL
___ URINE CULTURE-FINAL
PORTABLE CXR
=============
Heart size is mildly enlarged but stable. Mediastinal calcified
lymph nodes are unchanged. Lungs are clear except for minimal
opacity at the left lower lung adjacent to the left heart border
that although might represent atelectasis, in relatively
immunosuppressed patients might reflect developing infectious
process. In this specific case, correlation with chest CT is
recommended.
RENAL TRANSPLANT U/S
=====================
FINDINGS: A transplant kidney is identified in the left lower
quadrant. The renal morphology is normal. The cortical
thickness and echogenicity appear normal. The renal sinus fat
appears normal. There is no hydronephrosis. There is no
perinephric fluid collection.
The resistive index of the intrarenal arteries ranges from 0.81
to 0.88,
elevated. The acceleration times and peak systolic velocities
of the renal arteries are normal. The vascularity is symmetric
throughout the transplant.
The renal vein is patent and shows normal waveforms.
IMPRESSION:
The renal transplant appears normal without evidence of fluid
collection or abscess. There are however elevated resistive
indices within the transplant kidney.
Brief Hospital Course:
BRIEF HOSPITAL COURSE
======================
Ms. ___ is a ___ year old lady with history of DM1 (resolved
post-pacreatic transplant) and ESRD s/p 2 kidney transplants who
presented with fever and clinical symptoms of a UTI.
ACTIVE ISSUES
==============
# UTI vs pyelonephritis of transplanted kidney: She only met 1
SIRS criteria (febrile) on admission. Review of microbiology at
___ shows only CoNS and lactobacillus in ___. Urine culture
from ___ urgent care from ___ was pan-sensitive E coli.
Microbiology from ___ showed e. coli sensitive to
ciprofloxacin. Transplant renal ultrasound did not show any fat
stranding or fluid collection. She was managed with
ciprofloxacin, 14 day course to end until ___. This dose was
chosen to avoid tacrolimus interaction.
# ___ on CKI: Likely pre-renal in the setting of poor intake
(nausea), frequent sweating/chills and insensible losses.
Improved after IV hydration. FeNa 1.6% was indeterminate,
collected after IVF given. Valsartan initially held, restarted
on discharge.
CHRONIC ISSUES
===============
# ESRD s/p renal transplant ___, and ___, pancreas transplant
___. Continued prednisone, rapamycin, tacrolimus. Ultrasound
showed elevated resistive indices in transplanted kidney.
# Hypertension: Given HD stability, continued home amlodipine
while in house, but held valsartan in house due to ___,
restarted on discharge.
TRANSITIONAL ISSUES
====================
- Code status: Full code, confirmed.
- Emergency contact: ___, sister, ___.
- Studies pending on discharge: microbiology from this
hospitalization has all been finalized as negative.
- OSH urine culture grew e. coli s: cipro <0.25, started IV
ceftriax ___, then changed to PO cipro, continue until
___.
- ciprofloxacin is at 250mg BID dose because of creatinine, as
well as potential interaction with tacrolimus (QT prolongation).
- patient will get labs on ___ (standing order from Dr.
___, will call for a sooner appointment, and follows up
with ___ ___.
- Renal ultrasound shows normal transplanted kidney except with
elevated resistive indices within the transplant kidney.
- Blood cultures from here and OSH was still pending on
discharge (no growth to date). Urine culture at OSH is
finalized.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Sirolimus 1 mg PO ___
Daily dose to be administered at 6am
2. Sirolimus 0.5 mg PO MWF
Daily dose to be administered at 6am
3. PredniSONE 5 mg PO DAILY
4. Metoprolol Succinate XL 100 mg PO DAILY
at 7 am
5. Amlodipine 2.5 mg PO DAILY
at 7 am
6. Tacrolimus 0.5 mg PO Q12H
7. Valsartan 80 mg PO HS
8 pm
8. ZEMplar *NF* (paricalcitol) 1 mcg Oral every other day
9. Evista *NF* (raloxifene) 60 mg Oral daily
10. Multivitamins 1 TAB PO DAILY
11. Citracal + D *NF* (calcium phosphate-vitamin D3)
500mg/500units (2 tablets) Oral daily
12. ___ Health *NF* (lacto gasseri-B bifid-B longum)
1.5 billion cell Oral daily
13. Denosumab (Prolia) 60 mg SC Q6 MONTHS
14. Ferrous Sulfate 325 mg PO DAILY
Discharge Medications:
1. Amlodipine 2.5 mg PO DAILY
2. Evista *NF* (raloxifene) 60 mg Oral daily
3. Ferrous Sulfate 325 mg PO DAILY
4. Metoprolol Succinate XL 100 mg PO DAILY
5. Multivitamins 1 TAB PO DAILY
6. PredniSONE 5 mg PO DAILY
7. Sirolimus 1 mg PO ___
8. Sirolimus 0.5 mg PO MWF
Daily dose to be administered at 6am
9. Tacrolimus 0.5 mg PO Q12H
10. ZEMplar *NF* (paricalcitol) 1 mcg Oral every other day
11. Citracal + D *NF* (calcium phosphate-vitamin D3)
500mg/500units (2 tablets) Oral daily
12. Denosumab (Prolia) 60 mg SC Q6 MONTHS
13. ___ Health *NF* (lacto gasseri-B bifid-B longum)
1.5 billion cell Oral daily
14. Valsartan 80 mg PO HS
15. Ciprofloxacin HCl 250 mg PO Q12H Duration: 12 Days
Take until ___.
RX *ciprofloxacin 250 mg one tablet(s) by mouth twice daily Disp
#*11 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Urinary tract infection
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking part in your care at ___. You were
admitted because you had symptoms of a urinary tract infection.
The urine culture done at ___ showed e. coli, which
was sensitive to an oral antibiotic. You should continue this
antibiotic (ciprofloxacin) until ___ (start on ___.
Please have your labs checked as you usually do on ___
prior to your ___ appointment on that day. If you have
nausea/vomiting/fevers/chills/painful urination again, please
call your doctor immediately.
Please call Dr. ___ office on ___ to be seen sooner
(within the next few weeks).
Followup Instructions:
___
|
19685014-DS-17
| 19,685,014 | 28,164,128 |
DS
| 17 |
2131-11-24 00:00:00
|
2131-11-25 15:40:00
|
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
___ Stress Test with Transthoracic Echocardiography
History of Present Illness:
___ PMH DM, HTN, recent MI discharged in ___. She is
presenting today with gradual onset of chest pain that started
when she was waking up this morning. The pain is pressure like
type of pain, the same pain as when she was admitted for an MI
recently. No radiation, no shortness of breath. The pain was
relieved with nitrate SL, though not completely resolved.
Of note her recent history is notable for ___, she underwent
cath with angioplasty to the RCA. Following initial cath,
patient developed recurrent chest pain with EKG changes and had
a second catheterization with DES x2 to the RCA. Patient was
initiated on aspirin, plavix and continued on home metoprolol,
and rosuvastatin. Home ___ held in the setting of renal
transplant, CKD and large dye load. Patient was asymptomatic
following second PCI.
She denies fever, SOB, no palpitation, orthopnea, PND. Of note,
the patient did not take her usual dose of metoprolol or
amlodipine. She has taken her anti-platelet medications.
In the ED initial vitals were: 97.1 62 158/66 16 100% RA
-EKG: NSR 60bpm nl axis nl intervals no ischemic change
-Labs/studies notable for: K 5.7 (green top), Na 128/Cl 93,
BUN/Cr 42/1.9 (baseline), Hct 28.5, Trop 0.31 (CK-MB 2). UA
negative.
-CXR with stable cardiomegaly.
She was seen by Cards in the ED who recommended starting on IV
heparin and admission to ___.
On the floor, patient initially had no complaints. She did ___
___ ___ ___ dose and received it late. She developed ___ pain,
relieved with nitro SL, then returned to started on nitro gtt.
ROS:
On review of systems, denies any prior history of stroke, TIA,
deep venous thrombosis, pulmonary embolism, bleeding at the time
of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. Denies recent fevers, chills or rigors.
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:
CAD s/p STEMI and DES x2 to RCA on ___
CKD (s/p 2 renal tranpslants)
DM type 1 (s/p pancreas transplant)
Hypertension
Dysplipidemia
breast cancer s/p mastectomy and chemo ___ years ago
(cyclophosphamide,
methotrexate, and fluorouracil)
chronic sinusitis (status post b/l endoscopic sinus surgery on
___ along with a nasal septoplasty)
Interstitial lung disease
Social History:
___
Family History:
Mother: macular degeneration, arthritis
Father: ___ arthritis
No cardiac family history
Physical Exam:
ADMISSIONS PHYSICAL:
--------------------
VS: 98.2 81 130/97 16 99% RA
GENERAL: WDWN 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 no elevated JVP.
CARDIAC: PMI located in ___ intercostal space, midclavicular
line. RR, normal S1, S2. ___ SEM. No thrills, lifts. No
reproducible pain.
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: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES: Distal pulses palpable and symmetric
DISCHARGE PHYSICAL:
-------------------
VS: 97.8, 122-143/57-67, 64, 18, 96% RA
I/O: NR
Weight: NR
GENERAL: WDWN 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 no elevated JVP.
CARDIAC: PMI located in ___ intercostal space, midclavicular
line. RR, normal S1, S2. ___ SEM. No thrills, lifts. No
reproducible pain.
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: No c/c/e.
SKIN: chronic skin changes overlying chest and UE's b/l.
PULSES: Distal pulses palpable and symmetric
Pertinent Results:
ADMISSIONS LABS:
----------------
___ 05:00PM BLOOD WBC-8.8 RBC-2.98* Hgb-9.7* Hct-28.5*
MCV-96 MCH-32.6* MCHC-34.0 RDW-12.8 RDWSD-43.6 Plt ___
___ 05:00PM BLOOD Neuts-83.5* Lymphs-8.3* Monos-6.0
Eos-0.3* Baso-0.5 Im ___ AbsNeut-7.35*# AbsLymp-0.73*
AbsMono-0.53 AbsEos-0.03* AbsBaso-0.04
___ 05:00PM BLOOD ___ PTT-32.6 ___
___ 05:00PM BLOOD Glucose-126* UreaN-42* Creat-1.9* Na-128*
K-5.9* Cl-93* HCO3-23 AnGap-18
___ 11:48PM BLOOD Na-131* K-4.1 Cl-95*
___ 05:00PM BLOOD CK(CPK)-78
___ 05:00PM BLOOD CK-MB-2 cTropnT-0.31*
___ 11:48PM BLOOD CK-MB-2 cTropnT-0.28*
___ 07:50AM BLOOD CK-MB-2 cTropnT-0.28*
___ 07:50AM BLOOD Calcium-11.2* Phos-3.5 Mg-1.9
___ 07:50AM BLOOD tacroFK-8.9
IMAGING AND OTHER STUDIES:
___ CXR: Mild, stable cardiomegaly without acute
cardiopulmonary process.
___ Cardiac Stress Test: Fair exercise tolerance. No
anginal symptoms or ischemic ST segment changes. Systolic blood
pressure increased with exercise, however the response was
blunted. Blunted heart rate response to
exercise. Symptoms suggestive of leg claudication.
___ Stress TTE:
-Resting images were acquired at a heart rate of 59 bpm and a
blood pressure of 140/64 mmHg. These demonstrated normal
regional and global left ventricular systolic function. Right
ventricular free wall motion is normal. There is no pericardial
effusion. Doppler demonstrated no aortic stenosis, aortic
regurgitation or significant mitral regurgitation or resting
LVOT gradient.
-Post-stress images were acquired within 29 seconds after peak
stress at heart rates of 97 - 86 bpm. These demonstrated
appropriate augmentation of all left ventricular segments with
slight decrease in cavity size. There was augmentation of right
ventricular free wall motion.
DISCHARGE LABS:
---------------
___ 07:50AM BLOOD WBC-7.1 RBC-3.11* Hgb-10.1* Hct-30.0*
MCV-97 MCH-32.5* MCHC-33.7 RDW-13.0 RDWSD-44.5 Plt ___
___ 07:50AM BLOOD ___ PTT-52.4* ___
___ 07:56AM BLOOD Glucose-92 UreaN-41* Creat-2.1* Na-129*
K-4.4 Cl-95* HCO3-23 AnGap-15
___ 07:50AM BLOOD ALT-33 AST-33 CK(CPK)-39
___ 07:56AM BLOOD Calcium-10.9* Phos-2.6* Mg-1.8
___ 07:56AM BLOOD tacroFK-8.1
Brief Hospital Course:
Ms. ___ is a ___ y/o woman with PMH DM type ___ s/p pancreas tx
and CKD s/p renal transplant x2 with recent STEMI s/p balloon
angioplasty and DESx2 to RCA 1 week PTA, admitted with
self-resolving chest pain, unlikely to be ischemic given
negative work-up.
ACUTE PROBLEMS:
---------------
#Chest pain: Patient presented with CP, elevated troponins, but
no ischemic changes on EKG. She did have recent STEMI s/p
intervention to RCA with angioplasty and DESx2. However, there
was no evidence of in stent thrombosis with no significant EKG
changes or troponemia (lower than prior peak trop during STEMI,
normal MB, I/s/o CKD). Furthermore, patient had not missed any
anti-platelet medications. She underwent exercise stress TTE
___ negative for signs of reversible ischemia, at which point
chest pain had resolved and she was discharged home with
instructions to follow up with cardiology and her PCP.
#Hypertension: Patient has baseline hypertension, on previous
admissions with BP's consistently >160 systolic. At that point,
she was discharged home on new medication amlodipine 5mg PO
daily. On the DOA, she woke up with symptomatic relative
hypotension to ___ of 100, which based on home monitoring
trended up to 140's systolic in the ___, prior to admission.
While in the hospital, her SBP ranged 120's to 150's systolic
without any further episodes of lightheadedness or hypotension.
She was continued on her home dose of metoprolol and discharged
on a reduced dose of amlodipine 2.5mg PO daily.
#CKD s/p renal transplants x2: During this admission, she has
had stable renal function. Her tacrolimus levels were followed
with the guidance of the renal transplant team and she was
maintained on her recently changed dosages of ___ (1mg PO qAM
and 0.5mg Po qHS) in addition to prednisone and azathioprine.
She was also continued on her home cinacalcet.
CHRONIC/RESOLVED PROBLEMS:
#CAD: For her CAD, she was continued on her home ASA, Plavix,
metop, and rosuvastatin during this admission.
#DM ___ s/p pancreas transplant: Following transplant, patient's
T1DM was cured. She does have chronic pancreatic insufficiency
and was maintained on her home regimen of Creon.
#Cough: Patient was recently seen by Dr. ___ in clinic
(prior to last admission) for sx of cough. CT was performed at
that point without evidence of interstitial lung disease and
cough was thought to be likely ___ post-nasal drip, GERD, and
potential minimal reactive airway disease. For symptomatic
management, she was continued on her home Atrovent and
dextromethorphan and instructed to follow up as an outpatient
with pulmonology.
#Hyperkalemia: On admission, patient had an unclear cause of
hyperkalemia to 5.9, which upon recheck was likely ___ partial
hemolysis of blood sample. Her repeat K remained within normal
limits throughout the rest of the admission.
TRANSITIONAL ISSUES:
--------------------
-Please follow up with your PCP regarding upper leg burning for
work-up of possible peripheral vascular disease
-Please note change in amlodipine dose from 5mg PO daily to
2.5mg PO daily
-Please have follow up tacrolimus level drawn on ___ PRIOR
to am dose of tacrolimus (levels on ___ were 8.9, but
possibly falsely elevated as ___ dose of tacrolimus the night
prior was given late). Please have results sent to Dr.
___ at ___.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Azathioprine 50 mg PO DAILY
2. Benzonatate 200 mg PO TID:PRN cough
3. Cinacalcet 30 mg PO 3X WEEKLY
4. Creon ___ CAP PO TID W/MEALS
5. Ferrous Sulfate 325 mg PO BID
6. Guaifenesin-Dextromethorphan ___ mL PO QHS:PRN cough
7. Ipratropium Bromide MDI 2 PUFF IH QID cough
8. PredniSONE 5 mg PO DAILY
9. Tacrolimus 0.5 mg PO Q12H
10. Aspirin EC 81 mg PO DAILY
11. Clopidogrel 75 mg PO DAILY
12. Metoprolol Succinate XL 100 mg PO DAILY
13. Rosuvastatin Calcium 20 mg PO QPM
14. Budesonide Nasal Inhaler .___ mg/mL Other DAILY
15. Denosumab (Prolia) 60 mg SC EVERY 6 MO
16. Diphenoxylate-Atropine 3 TAB PO Q8H:PRN constipation
17. Furosemide 20 mg PO DAILY:PRN weight gain
18. icosapent ethyl 2 capsules oral BID
19. lactobacillus combination no.4 unknown ORAL Frequency is
Unknown
20. Lidocaine 5% Patch 1 PTCH TD QAM
21. Magnesium Oxide 400 mg PO DAILY
22. Multivitamins 1 TAB PO DAILY
23. Omeprazole 20 mg PO DAILY
24. Vitamin D 1000 UNIT PO DAILY
25. Amlodipine 5 mg PO DAILY
Discharge Medications:
1. Amlodipine 2.5 mg PO DAILY
RX *amlodipine 2.5 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
2. Aspirin EC 81 mg PO DAILY
3. Azathioprine 50 mg PO DAILY
4. Benzonatate 200 mg PO TID:PRN cough
5. Budesonide Nasal Inhaler .___ mg/mL Other DAILY
6. Cinacalcet 30 mg PO 3X WEEKLY
7. Clopidogrel 75 mg PO DAILY
8. Creon ___ CAP PO TID W/MEALS
9. Diphenoxylate-Atropine 3 TAB PO Q8H:PRN constipation
10. Ferrous Sulfate 325 mg PO BID
11. Guaifenesin-Dextromethorphan ___ mL PO QHS:PRN cough
12. Ipratropium Bromide MDI 2 PUFF IH QID cough
13. Lidocaine 5% Patch 1 PTCH TD QAM
14. Magnesium Oxide 400 mg PO DAILY
15. Metoprolol Succinate XL 100 mg PO DAILY
16. Multivitamins 1 TAB PO DAILY
17. Omeprazole 20 mg PO DAILY
18. PredniSONE 5 mg PO DAILY
19. Rosuvastatin Calcium 20 mg PO QPM
20. Vitamin D 1000 UNIT PO DAILY
21. Denosumab (Prolia) 60 mg SC EVERY 6 MO
22. Furosemide 20 mg PO DAILY:PRN weight gain
23. icosapent ethyl 2 capsules oral BID
24. lactobacillus combination ___ pack ORAL DAILY
25. Acetaminophen ___ mg PO Q6H:PRN pain
Please take as needed and no more than 3 grams total per 24
hours.
RX *acetaminophen 500 mg ___ tablet(s) by mouth every 6 hours
Disp #*30 Tablet Refills:*2
26. Outpatient Lab Work
Please have Tacrolimus Level drawn on ___ BEFORE morning
dose of Tacrolimus and have results faxed to Dr. ___ at
___. ICD 10 code: ___.0
27. Tacrolimus 1 mg PO QAM
28. Tacrolimus 0.5 mg PO QHS
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS/ES:
-Non-angina chest pain
SECONDARY DIAGNOSIS/ES:
-Coronary Artery Disease
-Hypertension
-Chronic Kidney Disease
-Status Post Kidney Transplant x2
-Status Post Pancreas Transplant
-Type I Diabetes Mellitus
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 the ___
___. You came in with chest pain, having
recently had a heart attack. We effectively ruled out a
recurrent heart attack, and then had you do a stress test with
imaging of your heart which was normal.
Because you were also having low blood pressures at home, your
home dose of Amlodipine was decreased as detailed below. Please
follow up with your outpatient doctors as detailed below and
note the changes to your home medications as detailed below.
Thank you for allowing us to be a part of your care,
Your ___ Team
Followup Instructions:
___
|
19685822-DS-3
| 19,685,822 | 25,661,217 |
DS
| 3 |
2176-06-09 00:00:00
|
2176-06-09 16:59:00
|
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
erythromycin (bulk) / Sulfa (Sulfonamide Antibiotics)
Attending: ___.
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
___ - laparoscopic appendectomy
History of Present Illness:
___ p/w lower abdominal pain since mid-afternoon on ___,
associated with pelvic cramping and bloating. She reports
having begun her menstrual period that afternoon and noted a low
grade temp to 100 overnight on ___. The pain resolved
overnight, and she scheduled an appointment with her PCP
___, but was able to go shopping ___ morning.
She reports that the area was still somewhat tender to palpation
when she presented for PCP evaluation yesterday (___)
afternoon, and she was referred to the ___ ED for CT
evaluation. When this was concerning for appendicitis, she
requested transfer to ___ for surgical evaluation.
Of note, Ms. ___ reports having had two prior episodes of the
same pain - the first around ___, and the second
approximately 3 weeks ago, and she has been undergoing
gynecologic workup for uterine fibroids and ovarian cysts. Last
colonoscopy normal ___.
Past Medical History:
Past Medical History: pSVT, HLD, GERD, constipation, hearing
impairment, menorrhagia
Past Surgical History: R breast biopsy (benign)
Social History:
___
Family History:
NC
Physical Exam:
Upon Discharge
Vitals: 98.3 77 107/56 18 98% RA
GEN: A&Ox3, pleasant, nontoxic, NAD
HEENT: No scleral icterus, mucus membranes moist
CV: Regular
PULM: Clear
ABD: Soft, nondistended, mild tenderness to palpation
appropriately near incisions, no rebound, incisions
clean/dry/intact with no erythema/drainage
Ext: No ___ edema, ___ warm and well perfused
Pertinent Results:
___ 03:36AM BLOOD WBC-6.3 RBC-3.66* Hgb-11.6* Hct-33.6*
MCV-92 MCH-31.6 MCHC-34.5 RDW-13.8 Plt ___
___ 03:36AM BLOOD Neuts-72.6* ___ Monos-4.3 Eos-0.5
Baso-0.6
___ 03:36AM BLOOD Plt ___
___ 03:36AM BLOOD Glucose-81 UreaN-11 Creat-0.6 Na-142
K-4.1 Cl-108 HCO3-26 AnGap-12
Brief Hospital Course:
Ms. ___ underwent a laparoscopic appendectomy on ___ for
acute appendicitis. The procedure went without complication,
reader is referred to the Operative Note for further details.
Thereafter, she returned to the general surgical floor, where
she was given a clear liquid diet to be advanced as tolerated to
regular diet. She tolerated this very well. She was given oral
pain medications, as well as essential home medications. She was
able to void independently, and was able to ambulate without
difficulty. She expressed feeling prepared to complete her
recovery at home, and was discharged home in good condition. She
will plan to follow-up in ___ clinic. She will also plan to see
her Ob-Gyn for further discussion regarding incidentally
discovered enlarging uterine fibroids
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atenolol 25 mg PO DAILY
2. Omeprazole 20 mg PO DAILY
3. Ranitidine 150 mg PO DAILY
Discharge Medications:
1. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN Pain
RX *hydromorphone 2 mg ___ tablet(s) by mouth every four (4)
hours Disp #*40 Tablet Refills:*0
2. Atenolol 25 mg PO DAILY
3. Omeprazole 20 mg PO DAILY
4. Ranitidine 150 mg PO DAILY
5. Acetaminophen 325-650 mg PO Q6H:PRN pain
Discharge Disposition:
Home
Discharge Diagnosis:
Appendicitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Ms. ___,
You were admitted to the ___ Acute Care Surgery service in the
setting of abdominal pain concerning for appendicitis. You
underwent surgery for this condition. Now that you are able to
tolerate regular diet and oral medication, you may return home
for the remainder of your recovery. Please pay close attention
to your discharge instructions.
*Wound Care*
You have several incisions on your abdomen. You may have some
small, tape like dressing over your incision. Leave these in
place - they will fall off on their own. You may shower. Do not
scrub over the incisions; wash over your incisions and allow the
soap to fall over the wounds. If you notice any redness,
increased pain, or any concerning changes in these incisions,
please notify your physician.
*Diet*
You may eat a regular diet without restrictions.
*Activity*
You may resume all of your normal daily activities. We ask that
you avoid swimming or heavy lifting for at least ___ weeks, at
least until your follow up in clinic. Avoid driving or class if
you still require narcotics for pain control.
*Medications*
Please take all medications as prescribed. If you require
narcotic medications for pain control, do not drive. You may
take tylenol or ibuprofen for pain control.
*Other*
You were incidentally found to have enlarging uterine fibroids.
Please be sure to follow-up with your Ob-Gyn doctor regarding
this.
*Warning Signs*
Below is a list of signs that you should be mindful of upon
discharge. If you notice any of these signs, please call your
physician or go to your nearest emergency department for prompt
evaluation.
Good luck with your recovery.
Followup Instructions:
___
|
19685967-DS-15
| 19,685,967 | 29,549,554 |
DS
| 15 |
2122-01-13 00:00:00
|
2122-01-13 21:50:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
Morphine / adhesive tape / Fosamax
Attending: ___
Chief Complaint:
Dysarthria, left facial numbness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
The pt is a ___ year-old right-handed woman who presents with
sudden onset dysarthria and facial numbness.
Mrs. ___ has recently been in her USOH save a herpes
labialis (which is common for her) - this was active from about
2 weeks ago until 4 days ago. 4 days ago, she had a tracheal
dilation. She has been undergoing these for the past ___ years
for tracheal stricture which occurred as a result of traumatic
intubation in ___. She woke feeling normal 3 days ago and took
her prednisone as directed. Later in the day she developed
abrupt onset left facial numbness (whole face, accd by sensation
of enlarged tongue), slurred speech and fatigue. The symptoms
had a stuttering course until one day ago when they became
constant. Most recently she developed tongue parasethesias. The
patient tried Benadryl but that did not help. Today, she
developed left lip paresthesias and was referred to the ED by
her PCP.
On neuro ROS, the pt denies headache, loss of vision, blurred
vision, diplopia (aside from chronic left ___ nerve palsy),
dysphagia, lightheadedness, vertigo, tinnitus or hearing
difficulty. Denies difficulties producing or comprehending
speech (aside from slurring). The patient's husband does think
her voice may be slightly higher pitched than prior. Denies
focal weakness, numbness, parasthesiae. No bowel or bladder
incontinence or retention. Denies difficulty with gait.
On general review of systems, the pt denies recent fever or
chills. No night sweats or recent weight loss or gain. Denies
cough, shortness of breath. Denies chest pain or tightness,
palpitations. Denies nausea, vomiting, diarrhea, constipation
or abdominal pain. No recent change in bowel or bladder habits.
No dysuria. Denies arthralgias or myalgias. Denies rash or
tick exposure.
Past Medical History:
- Oral herpes
- Vertigo: ___ years ago, resolved with Epley
- Tracheal adhesions (for last ___ years, every year): due to
traumatic intubation
- Hysterectomy - at ___ years old for fibroids
- HTN - well-controlled
- Anxiety
- spinal stenosis, lumbar, sacral and cervical - s/p multiple
surgeries, multiple joint fusions - years ago hit by a snow plow
- first surgery ___ years ago, most recent ___ years
- Dejenerative disc disease
Social History:
___
Family History:
Breast and prostate cancer in parents (both died of their
respective ca in their ___. Many other family members (parents,
aunts/uncles, siblings) with heart disease.
Physical Exam:
=====================================
ADMISSION EXAMINATION
=====================================
Physical Exam:
Vitals: 97.8 50 162/84 18 97% RA
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: No carotid bruits appreciated. No nuchal rigidity Some
difficulty bringing chin to neck because of plate, otherwise
supple.
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: RRR, nl. S1S2, no M/R/G noted. ___ systolic murmur. No
carotid, vertebral or ocular bruit.
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted.
Extremities: No C/C/E bilaterally, 2+ radial, DP pulses
bilaterally.
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented x 3. Able to relate history
without difficulty. Attentive, able to name ___ backward without
difficulty. Language is fluent with intact repetition and
comprehension. Normal prosody. There were no paraphasic errors.
Pt was able to name both high and low frequency objects. Able
to read without difficulty. Speech was noticeably dysarthric,
most with "ma" and "la" (less with "ca"). Able to follow both
midline and appendicular commands. Pt was able to register 3
objects and recall ___ at 5 minutes. The pt had good knowledge
of current events. There was no evidence of apraxia or neglect.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 2.5 to 2mm and brisk. VFF to confrontation without
extinguishing to double. Eyes conjugate.
III, IV, VI: Left side fourth nerve palsy (past medical
condition)
V: Facial sensation diminished to touch throughout the entire
left side and diminished cold top and bottom, less on middle
left side. A strong corneal reflex is present bilaterally.
VII: There is very mild attenuation of the left nasolabial fold,
but it does appear to activate fully to both command and to the
examiner's sharp sense of humor.
VIII: Hearing intact to finger-rub bilaterally. Umbo fine, no
fluids, excoriations or vesicles on either side.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline. Dysarthria as above. Difficult
to test tongue strength, but no gross asymmetry.
-Motor: Normal bulk, tone in upper extremities, mild increased
tone biltareally in lower extremities. No pronator drift
bilaterally. No pronator drift. No adventitious movements, such
as tremor, noted. No asterixis noted. Fine motor intact
symmetrically upper and lower extremities.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 5 ___ ___ 5 5 5 5 5 5 5
R 5 ___ ___ 5 5 5 5 5 5 5
Left toe is mute, Right toe is ___ on the left, none on
the right.
-Sensory: intact in toes, DSS intact bilaterally Mild diminished
temperature in the feet.
-DTRs:
Bi Tri ___ Pat Ach
L 2+ 2+ 2+ 0 0
R 2 2 2 0 0
-Coordination: No intention tremor, no dysdiadochokinesia noted.
No dysmetria on FNF or HKS bilaterally.
-Gait: Good initiation. Narrow-based, normal stride and arm
swing. Romberg absent. Some instability on standing with eyes
closed. Tandem walk is difficult. Able to walk on toes. Unable
to walk on heels.
=====================================
DISCHARGE EXAMINATION
=====================================
Patient's dysarthria was much improved per the patient and her
husband although she continued to have problems with mild
slurred speech and the sensation of numbness over her left face
and tongue.
Pertinent Results:
=================================
ADMISSION LABS
=================================
___ 01:40PM BLOOD WBC-11.8*# RBC-4.64 Hgb-14.5 Hct-43.6
MCV-94 MCH-31.3 MCHC-33.3 RDW-12.7 Plt ___
___ 01:40PM BLOOD Neuts-66.5 ___ Monos-6.8 Eos-1.8
Baso-0.7
___ 01:40PM BLOOD Plt ___
___ 01:40PM BLOOD ___ PTT-26.1 ___
___ 01:40PM BLOOD Glucose-80 UreaN-16 Creat-0.7 Na-131*
K-4.5 Cl-93* HCO3-29 AnGap-14
___ 01:40PM BLOOD ALT-36 AST-48* AlkPhos-107* TotBili-0.6
___ 06:20AM BLOOD ALT-28 AST-28 LD(___)-156 AlkPhos-103
TotBili-0.8
___ 06:20AM BLOOD CK-MB-2 cTropnT-<0.01
___ 06:20AM BLOOD Calcium-9.4 Phos-3.4 Mg-2.2 Cholest-PND
=================================
STROKE WORK-UP
=================================
A1C: 5.5
HDL: 57
LDL: 84
=================================
DISCHARGE LABS
=================================
___ 12:40PM BLOOD WBC-7.7 RBC-4.51 Hgb-14.2 Hct-42.2 MCV-94
MCH-31.4 MCHC-33.6 RDW-12.6 Plt ___
___ 12:40PM BLOOD Glucose-79 UreaN-15 Creat-0.7 Na-131*
K-3.9 Cl-94* HCO3-30 AnGap-11
___ 12:40PM BLOOD CK-MB-2 cTropnT-<0.01
___ 06:20AM BLOOD Triglyc-99 HDL-57 CHOL/HD-2.8 LDLcalc-84
Brief Hospital Course:
==================================
BRIEF HOSPITAL COURSE
==================================
Mrs. ___ was admitted with suspicion of a small vessel
stroke causing dysarthria and left facial numbness. Though the
MRI was negative, she did have a very strong story for stroke so
the final diagnosis was MRI-negative stroke.
She had a TTE, which showed normal EF and no evidence of cardiac
thrombus/mass. Speech therapy was consulted and cleared her for
a regular diet. HbA1c was 5.5 and fasting lipids were 84, so a
statin was not added. She was restarted on her home dose of
aspirin (as it was held for one week prior to the event). In
addition, she had some hyponatremia. We held her HCTZ and
recommended close PCP follow up. ___ appears that she had
discontinued her aspirin for 1 week prior to her tracheal
dilatation and onset of symptoms, and had an unfavorable
response to dipyridamole with diaphoresis, chest pressure and
difficulty breathing. All cardiac investigations following this
were normal but we eventually opted for aspirin 81mg daily upon
discharge.
==================================
ACTIVE ISSUES
==================================
# HTN: Nadolol was halved on admission to the hospital and her
HCTZ was held to allow for permissive hypertension in the
setting of acute stroke. She was restarted on her home dose of
Nadolol40/ASA81 prior to discharge. (HCTZ held till PCP follow
up)
==================================
INACTIVE ISSUES
==================================
# Tracheal adhesions/strictures: Did NOT think that this was
related to her symptoms.
==================================
AHA/ASA Core Measures for Ischemic Stroke and Transient Ischemic
Attack
1. Dysphagia screening before any PO intake? (x) Yes [performed
and documented by nurse]
2. DVT Prophylaxis administered by the end of hospital day 2?
(x) Yes
3. Antithrombotic therapy administered by end of hospital day 2?
(x) Yes
4. LDL documented (required for all patients)? (X) Yes (LDL =
84)
5. Intensive statin therapy administered? () Yes - (X) No [if
LDL < 100]
(intensive statin therapy = simvastatin 80mg, simvastatin
80mg/ezetemibe 10mg, atorvastatin 40mg or 80 mg, rosuvastatin
20mg or 40mg, for LDL >= 100)
6. Smoking cessation counseling given? () Yes - (X) No [if no,
reason: (X) non-smoker - () unable to participate]
7. Stroke education given (written form in the discharge
worksheet)? (x) Yes - () No
(stroke education = personal modifiable risk factors, how to
activate EMS for stroke, stroke warning signs and symptoms,
prescribed medications, need for followup)
8. Assessment for rehabilitation or rehab services considered?
(x) Yes - () No [if no, reason not assessed: ____ ]
9. Discharged on statin therapy? () Yes - (X) No [if LDL >= 100
or on a statin prior to hospitalization, reason not discharged
on statin: ____ ]
10. Discharged on antithrombotic therapy? (X) Yes [Type: (X)
Antiplatelet -asa81 () Anticoagulation] - () No
11. Discharged on oral anticoagulation for patients with atrial
fibrillation/flutter? () Yes - () No - (x) N/A
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acyclovir 400 mg PO DAILY
2. Escitalopram Oxalate 5 mg PO DAILY
3. Fluticasone Propionate NASAL 2 SPRY NU DAILY
4. Hydrochlorothiazide 25 mg PO DAILY
5. Nadolol 20 mg PO DAILY
6. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation
PRN SOB
7. Ascorbic Acid ___ mg PO DAILY
8. Aspirin 81 mg PO DAILY
9. Calcarb 600 With Vitamin D (calcium carbonate-vitamin D3) 600
mg(1,500mg) -200 unit oral BID
10. Cetirizine 10 mg oral daily
11. Cyanocobalamin 1000 mcg PO DAILY
12. Docusate Sodium 100 mg PO DAILY:PRN constipation
13. lactobacillus acidophilus oral daily
14. Fish Oil (Omega 3) 1000 mg PO DAILY
15. Polyethylene Glycol 17 g PO DAILY:PRN constipation
16. Citrucel (methylcellulose (laxative);<br>methylcellulose
(with sugar)) 500 mg oral daily
Discharge Medications:
1. Acyclovir 400 mg PO DAILY
2. Ascorbic Acid ___ mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. Docusate Sodium 100 mg PO DAILY:PRN constipation
5. Escitalopram Oxalate 5 mg PO DAILY
6. Nadolol 20 mg PO DAILY
7. Calcarb 600 With Vitamin D (calcium carbonate-vitamin D3) 600
mg(1,500mg) -200 unit oral BID
8. Cetirizine 10 mg oral daily
9. Citrucel (methylcellulose (laxative);<br>methylcellulose
(with sugar)) 500 mg oral daily
10. Cyanocobalamin 1000 mcg PO DAILY
11. Fish Oil (Omega 3) 1000 mg PO DAILY
12. Fluticasone Propionate NASAL 2 SPRY NU DAILY
13. lactobacillus acidophilus 0 ORAL DAILY
14. Polyethylene Glycol 17 g PO DAILY:PRN constipation
15. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation
PRN SOB
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis: MRI negative ischemic stroke
Secondary diagnosis: Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear ___,
___ was a pleasure caring for ___ while ___ were admitted to the
neurology service at the ___. ___ were
admitted to the hospital because of slurred speech and left face
numbness which we attributed to a very small stroke which was
not seen on MRI (this does occasionally happen with small
strokes). A 2d echo of your heart during this admission showed
normal cardiac function.
We restarted your baby aspirin (81mg). As your stroke occured
while off your regular dose of Aspirin, there is no indication
to increased the dose or switch ___ to a new medication. In
addition, ___ had an episode of chest pain during this
admission. Cardiac enzymes, EKG, and 2D Echo did not show any
evidence of cardiac ischemic or heart attack. Finally, your
sodium level was found to be a little low which can happen when
patients do not eat and drink adequately. It can also happen as
a side effect of your medication HCTZ. Please make sure ___ eat
a regular diet and stay well hydrated. In addition, we
recommend ___ hold your HCTZ until ___ are evaluated by your PCP
at which time it may be restarted.
We examined several of the risk factors for stroke, including a
measure of blood sugar (hemoglobin A1c = 5.5) and cholesterol
(LDL = 84) which were both normal.
We have scheduled a follow up appointment on ___ at 2:30pm
with Dr. ___ stroke doctor ___ saw while ___ were in
the hospital. We also recommned that ___ call your primary care
doctor for an appointment within the next ___ weeks.
Please call ___ or our office if ___ experience any of the
"warning signs" below including sudden weakness/numbness,
difficulty with speech/swallowing, or any other acute problems.
Followup Instructions:
___
|
19686576-DS-13
| 19,686,576 | 20,596,385 |
DS
| 13 |
2160-12-30 00:00:00
|
2161-01-03 06:06:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins / some other antibiotic
Attending: ___
Chief Complaint:
Altered Mental status
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. ___ is a ___ year old male with history of HCV/EtOH
cirrhosis with continued EtOH use c/b self-reported episodes of
hepatic encephalopathy (not on home lactulose), ascites, and no
EGD on record, HCV s/p INF treatment with undetectable viral
load, pancytopenia, DM, PTSD who presents with altered mental
status.
The patient was recently admitted from ___ for group C
streptococcus bacteremia, LLE cellulitis and chronic LLE edema
and completed a course of antibiotics.
On the day of admission, he reports that he began having
worsening, severe left leg pain with pins and needles. His
doctor at the group home reportedly gave him oxycontin and
gabapentin. He subsequently became confused and combative, and
barricaded himself in his room. He was taken to the ___ ED
room for further care and workup.
In the ED, initial vitals: 97.4 94 120/65 20 99%RA. Labs notable
for WBC 3.6, H/H 11.2/31.2, Plt 48. Chem 7 normal. LFT with ALT
32, AST 68, T. bili 2.5, Alb 2.7. Ammonia 79. Lacate 2.1. UA
negative. Serum and urine tox screen positive for opiates and
amphetamine (takes adderall and oxycodone). The patient was not
cooperative with care in the ED. He refused CXR and RUQ U/S,
though bedside U/S did not show any tappable ascites. He got
Lactulose x 2 and Furosemide 20mg and Spironolactone 50mg.
Currently, he feels less confused. He cannot clearly remember
the past day in the ED, although he remembers barricading
himself in his room. He denies fevers, chills, cough, SOB,
abdominal distension, or prior head trauma. He endorses LLE
shooting needle-like pain. He is not compliant with a low
sodium diet. He does not take lactulose at home, but has taken
it in the past when he becomes confused. He reports having had a
prior EGD in ___ ___ that had a varix that was
"removed" (not confirmed), does not take prophylaxis.
Past Medical History:
- HCV/EtOH cirrhosis
- Hepatitis C, last VL undetectable.
- EtOH abuse: drinks ___ beers Q3-4 months, previously draink 1
case per day.
- Pancytopenia: not being followed by hematology
- H/o diabetes, treated with lifestyle modification.
- Pulmonary hypertension? - patient states he underwent cardiac
cath recently.
- PTSD
Social History:
___
Family History:
- Mother is alive at ___ with Alzheimer's.
- Father died at ___ of lung cancer.
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
PHYSICAL EXAM:
VS: T 98.1 HR 93 BP 123/71 RR 18 SpO2 100RA Wt 95.6
GENERAL: Alert and oriented x3, no acute distress
HEENT: Sclerae anicteric, MMM, oropharynx clear
NECK: supple, JVP not elevated, no cervical or clavicular LAD
RESP: CTAB no wheezes, rales, rhonchi
CV: RRR, Grade ___ systolic murmur best heard at ___. Normal
S1/S2, no S3 or S4
ABD: Soft, NT/ND bowel sounds present, no rebound tenderness or
guarding, no organomegaly
GU: no foley
EXT: Bilateral lower extremity swelling L>R, with diffuse
lichenification. Evidence of chronic hemosideran deposition. No
excessive warmth, left mildly tender. No pitting or appreciable
erythema
NEURO: CNs2-12 intact, moving all extremities
SKIN: No rashes
DISCHARGE PHYSICAL EXAM:
========================
VS: T 98.1 HR 93 BP 123/71 RR 18 SpO2 100RA Wt 95.6
GENERAL: Alert and oriented x3, no acute distress
HEENT: Sclerae anicteric, MMM, oropharynx clear
NECK: supple, JVP not elevated, no cervical or clavicular LAD
RESP: CTAB no wheezes, rales, rhonchi
CV: RRR, Grade ___ systolic murmur best heard at ___. Normal
S1/S2, no S3 or S4
ABD: Soft, NT/ND bowel sounds present, no rebound tenderness or
guarding, no organomegaly
GU: no foley
EXT: Bilateral lower extremity swelling L>R, with diffuse
lichenification. Evidence of chronic hemosideran deposition. No
excessive warmth, left mildly tender. No pitting or appreciable
erythema
NEURO: CNs2-12 intact, moving all extremities
SKIN: No rashes
Pertinent Results:
ADMISSION LABS:
===============
___ 11:44PM URINE HOURS-RANDOM
___ 11:44PM URINE UHOLD-HOLD
___ 01:45AM URINE HOURS-RANDOM
___ 01:45AM URINE HOURS-RANDOM
___ 01:45AM URINE GR HOLD-HOLD
___ 01:45AM URINE bnzodzpn-NEG barbitrt-NEG opiates-POS
cocaine-NEG amphetmn-POS oxycodn-NEG mthdone-NEG
___ 01:45AM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 01:45AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN->12 PH-7.0
LEUK-NEG
___ 11:20PM LACTATE-2.1*
___ 11:10PM GLUCOSE-113* UREA N-17 CREAT-0.8 SODIUM-134
POTASSIUM-4.8 CHLORIDE-102 TOTAL CO2-22 ANION GAP-15
___ 11:10PM ALT(SGPT)-32 AST(SGOT)-68* ALK PHOS-80 TOT
BILI-2.5*
___ 11:10PM LIPASE-37
___ 11:10PM ALBUMIN-2.7* CALCIUM-8.4 PHOSPHATE-3.4
MAGNESIUM-1.7
___ 11:10PM AMMONIA-79*
___ 11:10PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
___ 11:10PM WBC-3.6* RBC-3.57* HGB-11.2* HCT-31.2* MCV-87
MCH-31.3 MCHC-35.8* RDW-16.0*
___ 11:10PM NEUTS-72.3* LYMPHS-14.6* MONOS-9.7 EOS-3.0
BASOS-0.4
___ 11:10PM PLT COUNT-48*
DISCHARGE LABS:
===============
___ 04:14AM BLOOD WBC-3.3* RBC-3.65* Hgb-11.6* Hct-32.6*
MCV-89 MCH-31.8 MCHC-35.5* RDW-15.8* Plt Ct-34*
___ 04:14AM BLOOD Glucose-125* UreaN-13 Creat-0.8 Na-136
K-3.3 Cl-107 HCO3-22 AnGap-10
___ 04:14AM BLOOD ALT-28 AST-51* LD(LDH)-246 AlkPhos-77
TotBili-2.8*
IMAGING:
========
CHEST X-RAY (___):
FINDINGS:
The lungs are clear. Heart size is normal. There is stable
enlargement of the bilateral pulmonary arteries, which is most
likely due to chronic pulmonary hypertension. There is no
pneumothorax. Bones and soft tissues are unremarkable.
IMPRESSION:
Clear lungs.
Chronic pulmonary hypertension.
LIVER AND GALLBLADDER ULTRASOUND (___)
FINDINGS:
LIVER: The hepatic parenchyma is coarsened The contour of the
liver is mildly nodular, in keeping with the history of
cirrhosis. There is a 0.8 cm simple cyst in the right lobe of
the liver. There is no worrisome focal liver mass. There is no
ascites.
HEPATIC VASCULATURE: The main portal vein, right portal vein,
and left portal vein are patent with normal direction of flow.
There is no evidence of a thrombus. Redemonstrated is a patent
umbilical vein. The right, middle, left hepatic veins are
patent. The IVC, SMV, and splenic veins are patent. The main
hepatic artery demonstrates a normal arterial waveform.
BILE DUCTS: There is no intrahepatic biliary dilation. The CBD
measures 3 mm.
GALLBLADDER: There is no evidence of stones or gallbladder wall
thickening.
PANCREAS: The pancreas is not well evaluated due to overlying
bowel gas.
SPLEEN: Normal echogenicity, measuring 18.7 cm. This is
unchanged from the prior ultrasound.
KIDNEYS: Limited views of the kidneys demonstrate no
hydronephrosis or large mass.
RETROPERITONEUM: The visualized portions of aorta and IVC are
within normal limits.
IMPRESSION:
1. Coarsened nodular hepatic parenchyma, in keeping with the
history of cirrhosis. No suspicious liver lesion is identified.
2. Patent hepatic vasculature. Unchanged patent umbilical vein.
3. Splenomegaly.
4. No ascites
CARDIOVASCULAR:
===============
ECG (___): Sinus rhythm. Prolonged P-R interval.
Non-specific septal T wave changes. Compared to the previous
tracing of ___ the findings are similar.
ECG (___):
Sinus rhythm. Non-specific septal T wave changes. Compared to
the previous tracing no change.
Brief Hospital Course:
Mr. ___ is a ___ year old male with history of HCV/EtOH
cirrhosis with continued EtOH use c/b hepatic encephalopathy not
on home lactulose, ascites, 1 self-reported varix, HCV s/p INF
treatment with undetectable viral load, pancytopenia, DM, PTSD
who presents with altered mental status with a negative work-up
that resolved with lactulose.
ACUTE ISSUES:
=============
# Hepatic encephalopathy: At his group home, Mr. ___ began
exhibiting bizarre behavior, including barricading himself in
his room. He was taken this ___ for further work-up for
hepatic encephalopathy. He does not take home
lactulose/rifaximin but does take numerous pain medications with
sedating properties including clonazepam, oxycontin, oxycodone,
flexeril, gabapentin, as well as adderall. He had a negative
infectious work-up (chest x-ray without pneumonia and no urinary
tract infection), no ascites on ultrasound, no evidence of head
trauma, no hepatic vein thromobosis, and no evidence of GI
bleed. He was ultimately thought to have developed hepatic
encephalopathy in the setting of not taking lactulose and from
his sedating medications. He was started on lactulose and
rifaximin, and his sedating meds were held. His mental status
rapidly cleared, and he was discharged home.
# Hepatitis C/Alcoholic cirrhosis: MELD score 19 on admission.
He reports having had encephalopathy and ascites in the past,
including a single varix that was removed in ___ ___. He does not take propanolol for varices prophylaxis
or lactulose. He does not appear to have an outpatient provider
managing his cirrhosis, despite numerous attempts to coordinate
his care with a provider.
# Chronic leg pain: Complains of chronic "needle-like" pain in
the legs for which he takes numerous pain medications for,
including gabapentin, oxycontin, oxycodone, tramadol, and
baclofen. His meds were initially held for his altered mental
status and resumed on discharge.
STABLE ISSUES:
==============
# Chronic bilateral leg edema: Left leg greater than right,
iccthyosis present bilaterally suggestive of chronic itching.
Swelling likely due to chronic venous stasis and cirrhosis. He
had a recent admission for cellulitis of the left leg with
bacteremia, but the leg did not seem infected here.
# History of EtOH abuse: Difficult to characterize his EtOH use,
but he likely is still drinking. He was given a multivitamin,
thiamine, and folate. There was no evidence of EtOH on his tox
screen and no evidence of withdrawal.
# Pancytopenia: Thought to be secondary to marrow suppression by
cirrhosis, alcohol, and chronic HCV infection, as well as
increased sequestration by hypersplenism. Was stable during this
admission, platelets in the ___ (baseline reportedly 70's).
# Diabetes: managed at home with diet and exercise, no meds. He
was put on the insulin sliding scale and finger stick glucoses
were <130.
TRANSITIONAL ISSUES:
====================
- Patient started on Lactulose 30 mg PO TID, which he has taken
in the past and has had generally poor compliance with. Consider
starting him on Rifaximin 550 mg PO BID as monotherapy for HE
prophylaxis.
- The patient has chronic ___ edema, L>R, which was evaluated
previously for DVT and was negative.
- Please taper down and attempt to discontinue clonazepam and
other sedating/deliriogenic medications in this patient. The
patient should not be on both long-acting morphine and
long-acting oxycodone
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amphetamine-Dextroamphetamine 20 mg PO BID
2. Baclofen 10 mg PO TID
3. ClonazePAM 1 mg PO TID
4. FoLIC Acid 1 mg PO DAILY
5. Thiamine 100 mg PO DAILY
6. TraMADOL (Ultram) 50 mg PO Q6H:PRN Pain
7. Gabapentin 300 mg PO TID
8. Furosemide 40 mg PO DAILY
9. Spironolactone 100 mg PO DAILY
10. OxyCODONE SR (OxyconTIN) 20 mg PO Q12H
11. Bacitracin Ointment 1 Appl TP QID
12. Multivitamins 1 TAB PO DAILY
13. Oxycodone-Acetaminophen (5mg-325mg) 1 TAB PO Q6H:PRN pain
14. Lactulose 15 mL PO Q6H:PRN constipation
15. Naloxone 1 mg IV ASDIR
16. EPINEPHrine (EpiPEN) 0.3 mg IM ONCE MR1
17. Aspirin 325 mg PO DAILY
18. Morphine SR (MS ___ 15 mg PO Q12H
Discharge Medications:
1. Baclofen 10 mg PO TID
2. FoLIC Acid 1 mg PO DAILY
3. Furosemide 40 mg PO DAILY
4. Gabapentin 300 mg PO TID
5. Lactulose 30 mL PO TID
RX *lactulose 10 gram/15 mL 15 mL by mouth three times a day
Refills:*0
6. OxyCODONE SR (OxyconTIN) 10 mg PO Q12H
7. Spironolactone 100 mg PO DAILY
8. Thiamine 100 mg PO DAILY
9. TraMADOL (Ultram) 50 mg PO Q6H:PRN Pain
10. Amphetamine-Dextroamphetamine 20 mg PO BID
11. Aspirin 325 mg PO DAILY
12. Bacitracin Ointment 1 Appl TP QID
13. ClonazePAM 1 mg PO BID
14. EPINEPHrine (EpiPEN) 0.3 mg IM ONCE MR1
15. Multivitamins 1 TAB PO DAILY
16. Naloxone 1 mg IV ASDIR
17. Oxycodone-Acetaminophen (5mg-325mg) 1 TAB PO Q6H:PRN pain
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSES:
==================
Hepatic Encephalopathy
Hepatitis C Virus & Alcoholic Cirrhosis
SECONDARY DIAGNOSES:
====================
Chronic Leg pain
Chronic leg edema
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was our pleasure caring for you at ___. You were admitted
to the hospital after you became confused and combative at your
rest home. We looked for infection, bleeding, and blood clots;
all of which can cause confusion in people with liver problems,
and did not find any. We gave you a medicine called lactulose
and your symptoms improved.
It is ESSENTIAL that you take this medicine (Lactulose) every
day. You need to take enough to ensure that you are having ___
bowel movements per day. This will prevent you from getting
confused in the future. Even if you are feeling well, you must
keep taking this medication.
It is also VERY IMPORTANT that you talk to your primary care
physician about decreasing the number of medications you are on
that can potentially cause confusion. Specifically, oxycontin,
oxycodone, gabapentin, clonazepam, can all cause confusion,
which can be very dangerous and potentially lethal because you
could stop breathing.
Thank you for allowing us to participate in your care.
Followup Instructions:
___
|
19686663-DS-12
| 19,686,663 | 22,530,853 |
DS
| 12 |
2116-01-03 00:00:00
|
2116-01-08 23:06:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
No Allergies/ADRs on File
Attending: ___.
Chief Complaint:
Fall
Major Surgical or Invasive Procedure:
None
History of Present Illness:
The patient is an ___ female ___ with no
significant PMH or medical care, transferred from OSH
after sustaining a mechanical fall down a flight of stairs
earlier today. Per the patient's son, she missed one stair, lost
her balance and fell backwards, landing on her butt first before
striking the back of her head. The patient is unable to recall
details of the fall, but states that she did not lose
consciousness. She had immediate onset of back pain. The patient
was taken to an OSH where CT scans revealed a small (6mm) R SDH,
T1 body fracture and a minimally displaced left sacral fracture.
She was transferred to ___ for further management and the
orthopaedic surgery service was consulted with regards to the
sacral fracture. On arrival, she endorses back pain, headache,
dizziness and mild nausea. She denies numbness, paresthesias or
weakness of her lower extremities. No incontinence of bowel or
bladder. Of note, the patient has never seen a traditional
doctor
due to her beliefs, but reports general good health. At
baseline,
she lives with her daughter and is able to perform ADLs/IDLs
without difficulties.
Past Medical History:
PMH:
1. Short-term memory loss
2. Kidney stone (passed) ___
3. Decreased vision R eye
PSH:
None
Social History:
___
Family History:
NC
Physical Exam:
Admission:
Vitals: 98.1 71 121/67 18 99% 2L
GEN: NAD, alert, oriented to person and place only
CV: RRR, no M/R/G
PULM: CTAB
ABD: Soft, NTND
Pelvis stable but painful to AP and lateral compression
Diffuse tenderness to palpation over bilateral sacrum
distributions ___ pulses,
Discharge:
Vitals: 98.1 71 121/67 18 99% 2L
GEN: NAD, A&Ox3
CV: RRR, no M/R/G
PULM: CTAB, nonlabored
ABD: Soft, NTND
Ext: moving all extremities bilaterally, intact sensation
Pertinent Results:
___ 06:01AM BLOOD WBC-9.0 RBC-3.84* Hgb-11.5* Hct-36.3
MCV-95 MCH-29.8 MCHC-31.6 RDW-13.3 Plt ___
___ 05:20AM BLOOD Hct-32.4*
___ 06:01AM BLOOD Glucose-178* UreaN-21* Creat-0.5 Na-137
K-3.5 Cl-103 HCO3-24 AnGap-14
___ 05:20AM BLOOD Glucose-137* UreaN-10 Creat-0.5 Na-139
K-3.9 Cl-107 HCO3-25 AnGap-11
___ 05:20AM BLOOD Calcium-8.4 Phos-2.8 Mg-2.0
CT T-spine:
IMPRESSION:
1. Known fracture of the anterior-inferior corner of T1 again
noted.
2. No other acute fracture or vertebral alignment.
CT L-spine:
IMPRESSION:
No acute fracture or vertebral alignment.
Osteopenia and degenerative changes
CT head ___ 10:41 AM)
IMPRESSION:
1. Limited study due to patient motion. Grossly stable, small
right frontal subdural hematoma, although not well seen due to
patient motion. No increase in hemorrhage identified. Trace
left intraventricular hemorrhage. No evidence of mass effect or
midline shift.
2. Mild thickening of the posterior mid falx, unclear whether
just thickening of the falx or related to a small amount of
subdural hemorrhage
CT head (___)
IMPRESSION:
Previously seen right frontal subdural hematoma not well
visualized on this exam. Hemorrhage in the occipital horn of
left lateral ventricle and along the posterior falx is similar
prior exam.
Brief Hospital Course:
Patient was admitted to the Acute Care Surgery service from the
Emergency department. Please refer to the HPI for details of the
initial presentation. Patient's injuries included small a small
(6mm) Right sided frontal subdural hematoma, T1 body fracture
vs a lytic lesion and a minimally displaced left sacral
fracture. Patient had CT scans at the outside hosptial however
given time gap and the presence of known injuries, a CT scans of
the L,T spine and head was repeated at ___. A repeat head CT
showed grossly stable, small right frontal
subdural hematoma with no evidence of change. Neurosurgery was
consulted and given the small size, normal neurologic exam and
patient's stability, she was recommended to take Keppra 500mg PO
BID for 7 days and follow up in ___ clinic only if she
experiences any neurologic symtpoms for over 30 days.
Orthopaedic surgery was consulted for the sacral fracture which
was minimally displaced. She was recommended pain control weight
bearing as tolerated and follow up in orthopaedic trauma clinic
in 2 weeks.
On the night of admission, there were concerns of mild
anisocoria on her serial neurologic exams (R pupil > L pupil).
She underwent a repeat CT scan without any changes and intact
serial neuroexams thereafter. She was re-evaluated by
neurosurgery with the same recommendations. A tertiary survey on
HD2 was nonrevealing. Patient was seen by physical therapy and
occupational therapy and was cleared to be discharged home with
adequate teaching. Patient was discharged home on HD2 with
follow ups for ___ clinic, Orthopaedic trauma clinic regarding
her sacral fracture and with her primary care physician to
workup ___ likely chronic/lytic lesion in her T1 spine. This was
communicated to the patient's daughter and her son as well.
Patient agreed and verbalized adequate understanding.
Medications on Admission:
None
Discharge Medications:
1. LeVETiracetam 500 mg PO BID Duration: 7 Days
RX *levetiracetam 500 mg 1 tablet(s) by mouth twice a day Disp
#*12 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Mechanical fall
Small 6, Right sided frontal subdural hematoma
Minimally displaced Sacral fracture
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to Acute Care Surgery Service after sustaining
a fall. You are recovering well and are ready to be discharged.
Please call us or come to the nearest emergency deparmtment if
you experience any of the following:
Dizziness or lightheadedness
Numbness or tingling
Change in vision
Confusion
Headache
Weakness in arm, leg, or face
Difficulty walking
Difficulty talking
Loss of balance
Incontinence of urine or stool
Followup Instructions:
___
|
19687015-DS-3
| 19,687,015 | 27,747,598 |
DS
| 3 |
2181-02-15 00:00:00
|
2181-02-15 11:51:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
MSSA Endocarditis
Major Surgical or Invasive Procedure:
___
1. Tricuspid valve repair with a 34 mm ___ Contour 3D
annuloplasty ring, serial number is ___ and model number is
690R.
2. Bovine pericardial patch of aortic annular abscess.
3. Aortic valve replacement with a 23 ___ Ease
pericardial tissue valve, model number is ___ and serial
number is ___.
History of Present Illness:
Mr ___ is a ___ yo gentleman h/o IVDU, last injected heroin
___, who was admitted to ___ ___ with TV
endocarditis, blood cultures growing MSSA. He was started on
nafcillin and subsequently signed out AMA, at which
time he discontinued his antibiotics. He re-presented ___ with
weakness and not feeling well. At ___ he was febrile and
had significant CHF with pitting ___ edema and pulmonary edema on
CXR. He had an echocardiogram which showed TV vegetation
unchanged from previous echo and significant Aortic
Insufficiently. He was transferred to ___ for further
management and Cardiac surgery was consulted for surgical
intervention.
Past Medical History:
Opioid use disorder
Hepatitis C- untreated
Hernia repair
Knee surgery
Social History:
___
Family History:
Father with cancer and diabetes
Physical Exam:
Admission Physical Exam:
Pulse:118 ST Resp:28 O2 sat:98% on 4L NC
B/P Right:106/51 Left:
Height:69" Weight:160#
General:pale, sleeping, no current distress
Skin: Dry [x] overall intact, multiple tattoos, no lesions or
rashes noted []
HEENT: PERRL [x] EOM-patient unable/unwilling to do
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear anteriorly, crackles at bases [x]
Heart: RRR [x] Irregular [] Murmur [x] grade ___ holosystolic,
loudest at L ___ intercostal space, midclavicular line
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+[x] liver margin palpated 4-5cm below costal edge, non-tender
Extremities: Warm [x], well-perfused [x]Edema [x] _pitting to
thighs
Varicosities: None [x]
Neuro: examined in ICU, patient lying in bed, sleeping, somewhat
cooperative, oriented to place, +/- date, president, vague
responses to questions about history, current infection; moves
all extremities equally, grip strength equal bilateral,
unwilling
to plantar/dorsiflex due to pain on dorsum of foot
Pulses:
DP Right:2++ Left:2++
___ Right:2++ Left:2++
Radial Right:2++ Left:2++
Carotid Bruit: Right:none Left: none
*****Discharge Physical Exam
Vital Signs:
Temp: 98.7 BP: 125/77 HR: 95 RR: 16 O2 sat: 98% RA
Wt: 75.7 kg Pre-op Wt 72.5 kg
I/O:
Last 8 hrs IN: Total 457ml, OUT: Total 925ml,
Last 24 hrs IN: Total 1852ml, OUT: Total 2385ml,
Physical Examination:
General: NAD [x]
Neurological: A/O x3 [x] non-focal [x]
HEENT: PEERL [x]
Cardiovascular: RRR [x] Irregular [] Murmur [] Rub []
Respiratory: scattered rhonchi [x] No resp distress [x]
GI/Abdomen: Bowel sounds present [x] Soft [x] ND [x] NT [x]
Extremities:
Right Upper extremity Warm [x] Edema
Left Upper extremity Warm [x] Edema
Right Lower extremity Warm [x] Edema tr
Left Lower extremity Warm [x] Edema tr
Pulses:
DP Right: 1+ Left: 1+
___ Right: Left:
Radial Right: 2+ Left: 2+
Skin/Wounds: Dry [x] intact [x]
Sternal: CDI [x] no erythema or drainage [x]
Sternum stable [x]
Other: Rt arm PICC
Pertinent Results:
Admission Labs:
___ 11:36PM ___ PTT-28.2 ___
___ 11:36PM PLT COUNT-371
___ 11:36PM WBC-24.7* RBC-4.28* HGB-11.6* HCT-36.2*
MCV-85 MCH-27.1 MCHC-32.0 RDW-16.4* RDWSD-49.2*
___ 11:36PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
tricyclic-NEG
___ 11:36PM ALBUMIN-2.3* CALCIUM-8.5
___ 11:36PM CK-MB-10 MB INDX-11.1* ___
___ 11:36PM cTropnT-0.18*
___ 11:36PM ALT(SGPT)-8 AST(SGOT)-24 CK(CPK)-90 ALK
PHOS-65 TOT BILI-0.9
___ 11:36PM LIPASE-9
___ 11:36PM GLUCOSE-103* UREA N-10 CREAT-0.9 SODIUM-133*
POTASSIUM-4.7 CHLORIDE-98 TOTAL CO2-21* ANION GAP-14
___ 04:29AM HCV VL-6.0*
___ 04:29AM HCV Ab-POS*
___ 04:29AM HBsAg-NEG HBs Ab-NEG HBc Ab-POS*
___ 11:23AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
___ 11:23AM URINE COLOR-Straw APPEAR-Clear SP ___
Discharge Labs:
___ 04:49AM BLOOD WBC-7.7 RBC-2.56* Hgb-7.1* Hct-22.8*
MCV-89 MCH-27.7 MCHC-31.1* RDW-19.5* RDWSD-63.7* Plt ___
___ 05:55AM BLOOD UreaN-16 Creat-1.1 K-4.4
___ 04:49AM BLOOD Mg-1.9
Cardiac ___ ___
The left atrial volume index is normal. There is no evidence for
an atrial septal defect by 2D/color Doppler. There is normal
left ventricular wall thickness with a moderately
increased/dilated cavity.
There is mild-moderate left ventricular regional systolic
dysfunction with akinesis of the distal ___ of the left
ventricle (see schematic) and mild global hypokinesis of the
remaining segments. The visually estimated left ventricular
ejection fraction is 35-40%. Left ventricular cardiac index is
normal (>2.5 L/min/m2). There is no resting left ventricular
outflow tract
gradient. Normal right ventricular cavity size with normal free
wall motion. Intrinsic right ventricular systolic function is
likely lower due to the severity of tricuspid regurgitation. The
aortic sinus diameter is
normal for gender. The aortic arch diameter is normal. The
aortic valve leaflets (?#) are mildly thickened and are
prolapsing into the LVOT
during diastole. No mass/vegetation seen, but cannot fully
exclude due to suboptimal image quality.
There is SEVERE [4+] aortic regurgitation. The mitral valve
leaflets are mildly thickened with no mitral valve prolapse. No
masses or vegetations are seen on the mitral valve. There is
mild to moderate [___] mitral regurgitation. The tricuspid
valve leaflets are mildly thickened. A LARGE (1.4 x 1.2
cm)echodensity is seen on the right atrial side of the tricuspid
valve. There is SEVERE [4+] tricuspid regurgitation. There is
mild pulmonary artery systolic hypertension. In the setting of
at least moderate to severe tricuspid regurgitation, the
pulmonary artery systolic
pressure may be UNDERestimated. There is a very small
pericardial effusion. A right pleural effusion is present
IMPRESSION: Moderate left ventricular cavity dilation with mild
to moderately depressed systolic dysfunction and regional
variation as described above. Large, mobile tricuspid valve
vegetation with severe tricuspid regurgitation, possible valve
perforation and hepatic vein flow
reversal. No definite aortic valve vegetation but prolapsed
aortic valve leaflet with severe aortic regurgitation and flow
reversal in the descending aorta.
Mild/moderate mitral regurgitation
without signs of valvular vegetation. At least mild/moderate
pulmonary hypertension
MR HEAD W & W/O CONTRAST ___
Final Report: Mildly motion degraded exam.
2 separate punctate foci of DWI hyperintensity in the lateral
mid right
cerebellar hemisphere, and superior right cerebellum, without
ADC correlate but associated FLAIR hyperintensity and
enhancement on the postcontrast images is most consistent with a
subacute infarcts.
Punctate focus of enhancement left vertex involving very
posterior left
frontal lobe, consistent with subacute infarct.
Additional punctate foci of DWI hyperintensity in the right
frontal lobe
posterior middle frontal gyrus and abutting anterior aspect
right lateral
ventricle (series 6, image 19, 21 and 24 with ADC correlates but
no definitive bright signal on the FLAIR sequence or enhancement
are most consistent with acute infarcts. There is no evidence of
hemorrhagic transformation. There is no evidence of acute
intracranial hemorrhage, mass effect, or midline shift. The
ventricles and sulci are normal in caliber and configuration.
Major vascular flow voids appear preserved. Major dural venous
sinuses are patent. The paranasal sinuses and mastoid air cells
are clear. The orbits appear unremarkable. Visualized portion
of the cervical spine demonstrates diffuse T1 dark signal
intensity throughout the vertebral bodies, suggestive of a
diffuse bone marrow process.
IMPRESSION:
1. Findings consistent with small 2 acute and 3 subacute
infarcts.
2. No hemorrhage.
3. Diffusely decreased T1 marrow signal, commonly seen in this
setting, may be reactive. Infiltrative process is possible,
less likely.
CT Chest: ___
IMPRESSION:
1. Multiple necrotic lung lesions, some nodular, some
consolidative, probably a disseminated infection largely due to
septic emboli
2. Diffuse septal thickening and bilateral ground-glass
opacities, likely
pulmonary edema.
3. Highly vascular, mediastinal and hilar lymphadenopathy, could
be reactive; differential diagnosis includes Castleman's disease
and angio immunoblastic lymphadenopathy.
4. Moderate bilateral pleural effusions with associated
atelectasis.
5. Please refer to the separate report of the CT abdomen and
pelvis performed on the same day for subdiaphragmatic
characterization.
CT Abd/Pelvis: ___
IMPRESSION:
1. Small infarct in the lower pole of the right kidney is
concerning for
septic embolus.
2. Mild retroperitoneal lymphadenopathy likely reactive
ECHO ___:
No spontaneous echo contrast or thrombus is seen in the body of
the left atrium or left atrial appendage. No atrial septal
defect is seen by 2D or color Doppler. Left ventricular wall
thicknesses are normal. The left ventricular cavity is
moderately dilated. There is moderate regional left ventricular
systolic dysfunction with basal and mid septal akinesis..
Overall left ventricular systolic function is moderately
depressed (LVEF= 40-45 %). [Intrinsic left ventricular systolic
function is likely more depressed given the severity of valvular
regurgitation.] with normal free wall contractility. There is no
valvular aortic stenosis. The increased transaortic velocity is
likely related to increased stroke volume due to aortic
regurgitation. Severe (4+) aortic regurgitation is seen. There
is prolapse (possible partial flail) of the Right coronary cusp
of the aortic valve into LVOT. No mass or vegetation is seen on
the mitral valve. Mild to moderate (___) mitral regurgitation
is seen. There is a moderate echodensity (RA side) on the
tricuspid valve (size 1.06X 0.637). Moderate to severe [3+]
tricuspid regurgitation is seen. The tricuspid regurgitation jet
is eccentric and may be underestimated. There is no pericardial
effusion. Small left pleural effusion is seen.
POST-BYPASS:
Pt is s/p bioprosthetic AVR and TV replacement
Rhythm: Sinus tachycardia
Infusions: Levo and Epi
1. Well seated bioprosthetic valve noted in both the Tricuspid
and Aortic position
2. No Paravalvular leak is noted in the aortic position. Mean
gradient across the prosthetic valve is 14 with a V max of 2.6
m/sec. Accelaration time across the AV is 67 msec
3. Trivial to mild TR noted.
4. LV functions appears to be moderate to severely depressed
with a visually estimated EF of ___
5. Visualized portions of the aorta remains unchanged
6. Severity of MR remains ___ ) unchanged with a vena
contracta width of < 0.3 mm
Chest X-ray: (___) ___
IMPRESSION:
The tip of the right PICC line now projects over the cavoatrial
junction. No right pneumothorax. Unchanged trace left apical
pneumothorax.
Radiology Report CHEST (PA & LAT) Study Date of ___ 10:02
AM
Final Report:
Midline sternotomy wires are intact. Right-sided PICC line seen
to terminate in the lower SVC. The patient is status post AVR
and TVR. Heart and mediastinum are stable. Small bilateral
pleural effusions. Opacities in the upper lobes are stable.
IMPRESSION:
Stable upper lobe opacities consistent with known septic emboli.
Brief Hospital Course:
___ y/o man with opioid use disorder, hepatitis C recently
hospitalized ___ for MSSA tricuspid endocarditis who left AMA
and self-discontinued antibiotics who presented to ___
with fever 103.2 and respiratory distress found to be in acute
decompensated CHF with pulmonary edema transferred to ___ for
cardiac surgery evaluation. He presented with fever, tachycardia
and leukocytosis consistent with sepsis. Initial source
suspected to most likely be tricuspid valve endocarditis given
prior MSSA bacteremia. He was started empirically on vancomycin
and zosyn. ___. ___ growing GPCs in clusters, ___
bottles at ___ growing GPCs in pairs and clusters, antibiotic
treatment narrowed to nafcillin as of ___. Repeat TTE at ___
___ with growing tricuspid valve vegetation and new aortic
valve vegetation. TTE repeated at ___ showing tricuspid valve
vegetation and severe aortic insufficiency, reduced EF 35-40%
with associated pulmonary edema. MRI brain findings consistent
with small 2 acute and 3 subacute infarcts concerning for septic
emboli , No hemorrhage. Cardiac surgery consulted, and he was
taken to the OR on ___ and underwent Tricuspid valve
repair with a 34 mm ___ Contour 3D annuloplasty ring,
bovine pericardial patch of aortic annular abscess, and Aortic
valve replacement with a 23 ___ Ease pericardial
tissue valve.
Overall the patient tolerated the procedure well and
post-operatively was transferred to the CVICU for recovery and
invasive monitoring. Given the severity of his illness, he
required ionotropic and vasopressor support post-operatively and
was kept intubated given his hemodynamic instability. He was
extubted on POD 1 and the pain service was consulted to discuss
the continuation of his methadone and opiates for pain control.
By POD 2 patient was weaned off ionotropic and vasopressor
support. The patient was neurologically intact and
hemodynamically stable. Patient had pre-operative acute kidney
injury. Unnecessary nephrotoxic drugs were avoided, adequate
hemodynamics maintained and renal function improved to baseline
by discharge. Beta blocker was initiated and the patient was
gently diuresed toward the preoperative weight. The patient was
transferred to the telemetry floor on POD3 for further recovery.
Chest tubes and pacing wires were removed per cardiac surgery
protocol without complication. Addiction medicine consulted for
recent intravenous drug use and ongoing methadone therapy.
Direct admit for out patient methadone maintenance was set up at
___ in ___.
Daily blood cultures were continued until ___. Patient
continued on nafcillin 2g q4h IV with a projected end Date of
___.
On the step-down floor the patient worked with nursing and was
evaluated by the physical therapy service for assistance with
strength and mobility. The remainder of his hospital course was
uneventful. By the time of discharge on POD 9 the patient was
ambulating freely, the wound was healing and pain was controlled
with oral analgesics. The patient was discharged to ___
___ in good condition with appropriate
follow up instructions.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. This patient is not taking any preadmission medications
Discharge Medications:
1. Acetaminophen 1000 mg PO Q6H
2. Aspirin EC 81 mg PO DAILY
3. Carvedilol 12.5 mg PO BID
4. Docusate Sodium 100 mg PO BID
5. Furosemide 40 mg PO DAILY Duration: 10 Days
6. HYDROmorphone (Dilaudid) 2 mg PO Q4H:PRN Pain - Moderate
7. Influenza Vaccine Quadrivalent 0.5 mL IM NOW ___. Methadone 40 mg PO DAILY
9. Multivitamins W/minerals 1 TAB PO DAILY
10. Nafcillin 2 g IV Q4H
11. Potassium Chloride 20 mEq PO DAILY Duration: 10 Days
12. Ramelteon 8 mg PO QHS:PRN insomnia
Should be given 30 minutes before bedtime
13. Ranitidine 150 mg PO DAILY
14. Sodium Chloride 0.9% Flush ___ mL IV DAILY and PRN, line
flush
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Tricuspid valve endocarditis
Tricuspid valve insufficiency s/p TVrepair
Aortic valve endocarditis
Aortic insufficiency s/p AVReplacement
Aortic annular abscess s/p pericardial patch of root abcess
MSSA bacteremia
Pulmonary septic emboli
Brain septic emboli
Renal septic emboli/infarct
Secondary diagnosis:
IVDU
MSSA bacteremia
HCV-untreated
Discharge Condition:
Alert and oriented x3, non-focal
Ambulating, gait steady
Sternal pain managed with oral analgesics
Sternal Incision - healing well, no erythema or drainage
Edema-trace
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:
___
|
19687015-DS-4
| 19,687,015 | 29,711,963 |
DS
| 4 |
2181-06-20 00:00:00
|
2181-06-20 11:53:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Fevers/Weakness
Major Surgical or Invasive Procedure:
___ line ___
History of Present Illness:
___ with history of opioid use disorder, untreated HCV, and MSSA
endocarditis complicated by septic pulmonary emboli, renal
infarct, and septic emboli to brain in ___, status post
TV repair, bioprosthetic AVR, and pericardial patch of aortic
annular abscess, who initially presented to ___
with fevers/weakness, found to be hypotensive and febrile,
concerning for sepsis, subsequently transferred to ___ for
further evaluation.
Patient initially presented to ___ with two days
of subjective fevers, chills, and myalgias. Over the same time
period, he reported a mild cough, not productive of sputum, but
denied shortness of breath, chest pain, nausea, vomiting,
abdominal pain, headache, or confusion. Temperature on arrival
was ___. Examination was unremarkable. Labs were notable for
Hgb
12.0, platelet 131, normal WBC, sodium 130, potassium 3.4, BUN
28, and troponin-I of 0.041. Influenza A/B negative. Blood
cultures notable for ___ bottles with gram negative bacilli.
Blood pressure was ___, requiring initiation of norepinephrine.
Transferred to ___ for further evaluation.
With regards to his previous episode of endocarditis, patient
initially presented to ___ ___ with weakness
and fevers, subsequently found to have TV endocarditis, with
blood cultures growing MSSA. Started on nafcillin, but
subsequently signed out AMA and discontinued his antibiotics.
Re-presented to ___ ___ with progressive weakness and
malaise, with examination notable for pulmonary edema and
pitting
lower extremity edema. TTE demonstrated unchanged TV vegetation
with 4+ tricuspid regurgitation, but also showed a new AV
vegetation with associated severe (4+) aortic insufficiency, and
reduced EF of 35-40%. He was transferred to ___ for cardiac
surgery evaluation. MRI brain showed two small acute and three
subacute infarcts. CT chest demonstrated with evidence of septic
emboli and pulmonary edema. CT abdomen/pelvis with small infarct
in the lower pole of right kidney. Subsequently underwent
tricuspid valve repair with annuloplasty ring, bovine
pericardial
patch of aortic annular abscess, and aortic valve replacement
with pericardial tissue valve. Post-operative course was
uncomplicated, and patient was discharged to ___.
In the ED, initial VS were notable for;
Temp 98.1 HR 88 BP 108/71 RR 18 SaO2 97% RA
Examination notable for;
Somewhat pale and slightly diaphoretic, breathing comfortably,
lungs clear bilaterally, regular rate and rhythm, systolic
murmur, soft/non-tender abdomen, no lower extremity edema, warm
and well perfused.
Labs were notable for;
WBC 17.2 Hgb 11.1 Plt 133
___ 19.1 PTT 26.6 INR 1.8
Na 138 K 3.8 Cl 107 HCO3 20 BUN 22 Cr 1.1 Gluc 138
ALT 17 AST 18 ALP 75 Lipase 10 Tbili 1.0 Alb 2.8
Ca 8.1 Mg 2.0 Phos 2.8
Trop-T <0.01 Lactate 1.4
Serum tox screen negative, urine tox screen cocaine positive
VBG: ___
Urine studies notable for negative leuks, negative nitrites, 1
WBC, no bacteria, and <1 epithelial.
ECG with rate 137bpm, sinus rhythm, left axis deviation, mildly
prolonged QTc, IVCD with right bundaloid pattern, no Q waves,
non-specific ST-T abnormalities likely due to repolarization in
setting of IVCD.
CXR with no PTX, pleural effusion, and no pulmonary edema.
Patient was given;
- 2L lactated ringer's
- IV norepinephrine 0.08 -> 0.05 -> 0.07
- IV gentamicin 80mg
- IV zosyn 4.5g
- IV vancomycin 1000mg
- IV ketorolac 15mg
- PO diazepam 10mg x2
Febrile to ___ while in the ED.
Vital signs on transfer notable for;
HR 103 BP 160/97 RR 16 SaO2 100% RA
Upon arrival to the floor, patient somnolent following two doses
of diazepam, and not responding to questions.
10-point review of systems unable to be obtained given mental
status.
Past Medical History:
- MSSA tricuspid/aortic valve endocarditis status post tricuspid
valve repair, pericardial patch of aortic annular abscess, and
bioprosthetic aortic valve replacement (___)
- Opioid use disorder
- Hepatitis C (untreated)
- Hernia repair
- Knee surgery
Social History:
___
Family History:
Father with history of cancer and diabetes mellitus.
Physical Exam:
Admission Physical Exam:
============================
VS: Temp 99 HR 102 BP 116/67 RR 23 SaO2 93% RA
GENERAL: lying in bed, no acute distress, soaked sheets from
sweat
HEENT: AT/NC, no conjunctival pallor, anicteric sclera, MMM
NECK: supple, non-tender, no JVP elevation
CV: tachycardic, S1/S2 normal, two distinct murmurs over AV/TV
RESP: CTAB, no wheezes/crackles
___: soft, non-tender, no distention, BS normoactive
EXTREMITIES: warm, well perfused, no lower extremity edema
NEURO: A/O x0 as not responding to questions, unable to assess
neurological exam
Discharge Physical Exam:
============================
GENERAL: Friendly gentleman seated on edge of hospital bed, in
no
apparent distress.
EYES: PERRL. Anicteric sclera.
CV: Regular rate and rhythm. No S3, no S4. ___
crescendo-decrescendo SEM best heard at ___. ___ dull SEM
best
heard at L MCL. No JVD.
PULM: Breathing comfortably on room air. LLL crackles. No
wheezes. Good air movement bilaterally.
GI: Bowel sounds present. Abdomen non-distended, soft,
non-tender
to palpation. No HSM appreciated.
SKIN: Vertical surgical scar on sternum. And horizontal surgical
scar over the epigastric area. No rashes, ulcerations.
EXTR: R arm with PICC.
NEURO: Alert. Oriented. Face symmetric. Speech fluent. Moves all
limbs spontaneously. No tremors or other involuntary movements
observed.
PSYCH: Pleasant, cooperative. Follows commands, answer questions
appropriately. Appropriate affect.
Pertinent Results:
Admission Labs:
___ 02:20PM BLOOD WBC-17.2* RBC-4.27* Hgb-11.1* Hct-34.8*
MCV-82 MCH-26.0 MCHC-31.9* RDW-12.8 RDWSD-38.0 Plt ___
___ 02:20PM BLOOD Neuts-87.4* Lymphs-6.6* Monos-4.6*
Eos-0.0* Baso-0.2 Im ___ AbsNeut-15.03* AbsLymp-1.13*
AbsMono-0.79 AbsEos-0.00* AbsBaso-0.03
___ 02:20PM BLOOD ___ PTT-26.6 ___
___ 02:20PM BLOOD Glucose-138* UreaN-22* Creat-1.1 Na-138
K-3.8 Cl-107 HCO3-20* AnGap-11
___ 02:20PM BLOOD Albumin-2.8* Calcium-8.1* Phos-2.8 Mg-2.0
___ 02:49PM BLOOD Lactate-1.4
Cultures:
___ 9:34 am BLOOD CULTURE Source: Line-IJ.
**FINAL REPORT ___
Blood Culture, Routine (Final ___:
SERRATIA MARCESCENS.
Identification and susceptibility testing performed on
culture # ___ ON ___.
Aerobic Bottle Gram Stain (Final ___:
GRAM NEGATIVE ROD(S).
Reported to and read back by ___ ON ___
@ ___.
___ 2:52 am BLOOD CULTURE Source: Line-right ij.
**FINAL REPORT ___
Blood Culture, Routine (Final ___:
SERRATIA MARCESCENS.
Identification and susceptibility testing performed on
culture # ___-___ (___).
Aerobic Bottle Gram Stain (Final ___:
GRAM NEGATIVE ROD(S).
___ 2:20 pm BLOOD CULTURE
Blood Culture, Routine (Preliminary):
SERRATIA MARCESCENS. FINAL SENSITIVITIES.
This organism may develop resistance to third
generation cephalosporins during prolonged therapy.
Therefore, isolates that are initially susceptible may
become resistant within three to four days after
initiation of therapy. For serious infections, repeat
culture and sensitivity testing may therefore be
warranted if third generation cephalosporins were used.
Piperacillin/Tazobactam test result performed by ___
___.
Ertapenem Susceptibility testing requested per ___.
___, MD (___), ___.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
SERRATIA MARCESCENS
|
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- S
TOBRAMYCIN------------ 2 S
TRIMETHOPRIM/SULFA---- <=1 S
Aerobic Bottle Gram Stain (Final ___:
GRAM NEGATIVE ROD(S).
Reported to and read back by ___ ___
___ 03:00.
___ 6:10 am BLOOD CULTURE #1.
Blood Culture, Routine (Pending): No growth to date.
___ 5:59 am BLOOD CULTURE
Blood Culture, Routine (Pending): No growth to date.
___ 9:05 am BLOOD CULTURE
Blood Culture, Routine (Pending): No growth to date.
Imaging:
___ TEE
CONCLUSION: No thrombus/mass is seen in the body of the left
atrium. There are no aortic arch atheroma with no atheroma in
the
descending aorta to 33 cm from the incisors. An aortic valve
bioprosthesis is present. The prosthesis is well seated with
normal leaflet motion. No masses or vegetations are seen on the
aortic valve. No abscess is seen. There is trace (normal for
prosthesis) aortic regurgitation. The mitral valve leaflets are
mildly thickened with no mitral valve prolapse. No masses or
vegetations are seen on the mitral valve. No abscess is seen.
There is physiologic mitral regurgitation. The pulmonic valve
leaflets are normal. A tricuspid annuloplasty ring is present
with no systolic prolapse. The tricuspid annuloplasty ring is
well seated with thickened leaflets but normal leaflet motion. A
possible 0.5 cm mobile mass is seen on the tricuspid valve most
c/w a VEGETATION No abscess is seen. There is physiologic
tricuspid regurgitation. Due to acoustic shadowing, the severity
of tricuspid regurgitation may be UNDERestimated.
IMPRESSION: 1) Very small mobile mass on the subvalvular
apparatus of the tricuspid valve without abscess or significant
tricuspid regurgitation.
___ TTE
No 2D echocardiographic evidence for endocarditis. If clinically
suggested, the absence of a discrete vegetation on
echocardiography does not exclude the diagnosis of endocarditis.
Compared with the prior TTE (images not available for review) of
___ , aortic valve has been replaced and tricuspid valve
repaired. Left ventricular function is improved.
___ CXR
FINDINGS:
Right internal jugular central venous catheter tip terminates in
the low SVC. No pneumothorax. Patient is status post median
sternotomy, aortic and tricuspid valve replacements. Heart size
is normal. The mediastinal and hilar contours are normal. The
pulmonary vasculature is normal. Lungs are clear. No pleural
effusion is seen. There are no acute osseous abnormalities.
IMPRESSION:
Right internal jugular central venous catheter tip in the low
SVC. No pneumothorax.
DISCHARGE LABS:
***
Brief Hospital Course:
___ yo man w/ OUD (uses IV heroin laced w/ fentanyl), untreated
HCV, and h/o MSSA endocarditis c/b septic emboli to
lungs/kidney/brain and treated with TV repair, bpAVR, and
placement of bovine pericardial patch to abscess cavity at the
right annulus (___), completed 6-week course of nafcillin at
___, subsequently relapsed on IV heroin and is now admitted
with high-grade Serratia sepsis.
# Sepsis ___ Serratia bloodstream infection with c/f
endocarditis
# Hx of MSSA endocarditis s/p AVR, TV repair, abscess patch
# HFrEF
Prior hx of MSSA endocarditis in ___ treated with nafcillin
x 6 wks. Also s/p pericardial patch of aortic annular abscess;
aortic valve replacement using 23mm Magna Ease Aortic Valve
(Tissue); tricuspid valve repair using 34mm Contour 3D Tricuspid
Anuuloplasty Ring. EF estimated at about 50%. Now bcx from ___
___ and multiple at ___ growing pan-sensitive Serratia. He
was transferred to the ICU as he required pressor support and
this was able to be weaned off. Concerning for prosthetic valve
endocarditis. TTE was negative but TEE showed a very small
mobile element on the TV, possible veg. Per ID, treatment for
presumed gram-negative prosthetic valve endocarditis should
involve a beta lactam and either an aminoglycoside or quinolone.
Since Serratia carries an inducible ampC gene, a carbapenem is
preferable to cephalosporins. Cardiac surgery consulted and
won't consider valvular surgery again currently due to active
IVDU. First negative blood culture ___ with D1 as that day for
___ompleting on ___. RUE PICC line in place and ID
is recommending meropenem 500mg IV q6hrs and levofloxacin 750mg
po daily. Please note below the recent symptoms of biceps
tendonitis. If these symptoms don't resolve over the next ___
days, would STOP levofloxacin and treat with Meropenem
monotherapy. ___ ID OPAT recommendations that while on
carbapenem patient needs weekly labs: CBC with differential,
BUN, Cr, AST, ALT, Total Bili, AlkPhos. Pt is scheduled to
follow up with ID Dr. ___ in ___
# Right antecubital biceps tendonitis: pt was reporting pain
over his right antecubital fossa specifically on the insertion
site of the biceps tendon. There was no erythema, swelling, or
concern for local abscess. Pt reports prior episodes of this
pain that has resolved with NSAIDs. This symptom was discussed
with ID given the concern for quinolone related tendonitis.
They recommended ___ days of symptomatic treatment with NSAIDs,
if the symptoms don't resolve, they would STOP the levofloxacin
all together and use Meropenem monotherapy.
# Opioid use disorder
Recent daily heroin use and regular cocaine use. He wants to
stick with methadone for now. He will need referral to a
___ clinic on discharge. He was continued on methadone
40mg PO daily and PRN clonidine.
# HCV
Untreated. He would benefit from outpatient ID or hepatology
f/up
# Anemia
Hgb 10.6-11.3 appears close to baseline. Iron studies likely c/w
iron deficiency anemia (Tsat 4%, ferritin 193 but currently
infected). Likely component of marrow suppression from sepsis.
His H/H remained stable while in the hospital. Pt was
discharged on Multivitamin with Iron.
Transitional Issues:
[] Complete a 6 week course of meropenem 500mg IV q6hrs and
levofloxacin 750mg po daily for presumed prosthetic valve
endocarditis with an end date of ___
[] Please assess for resolution of biceps tendonitis at
antecubital fossa, and if symptoms don't resolve in ___ days,
would STOP levofloxacin and continue meropenem alone though
___
[] Referral to methadone program on discharge as MAT will be a
critical part of his ongoing therapy.
[] Carvedilol held throughout admission due to low normal BPs,
could restart if BP rises.
Greater than 30 minutes was spent in care coordination,
providing verbal handoff to ___ provider and counseling on
the day of discharge.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin EC 81 mg PO DAILY
2. Carvedilol 12.5 mg PO BID
3. Docusate Sodium 100 mg PO BID
4. Famotidine 20 mg PO BID
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
2. CloNIDine 0.1 mg PO Q8H:PRN anxiety
3. Levofloxacin 750 mg PO Q24H
Completes on ___.
4. Meropenem 500 mg IV Q6H
Completes on ___.
5. Methadone 40 mg PO DAILY
RX *methadone 40 mg 1 tab by mouth Daily Disp #*3 Tablet
Refills:*0
6. Senna 8.6 mg PO BID:PRN Constipation
7. Sodium Chloride 0.9% Flush ___ mL IV Q8H and PRN, line
flush
8. Sodium Chloride 0.9% Flush ___ mL IV DAILY and PRN, line
flush
9. Aspirin EC 81 mg PO DAILY
10. Carvedilol 12.5 mg PO BID
11. Docusate Sodium 100 mg PO BID
12. Famotidine 20 mg PO BID
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
High grade Serratia sepsis with concern for endocarditis
Septic Shock
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr ___,
You were admitted to the hospital with fever and were found to
have a blood stream infection with concern for a recurrent
infection on your heart valve. You were treated with IV
antibiotics and you have improved. You will need to complete a 6
week course of IV antibiotics and will need weekly safety labs
while receiving these antibiotics to monitor for adverse
reaction.
Please note, you have been reporting right anterior elbow pain
at the site of the insertion of the biceps tendon. We are
currently treating this with Naproxen 500mg BID for ___ days to
see if it will resolve. If it doesn't resolve, we would
recommend stopping the Levofloxacin as tendonitis can be a
complication of this antibiotic. In that case, we would
recommend continuing the Meropenem alone for the 6 week course.
Please monitor right anterior elbow pain for resolution and
discuss it with your physician at the ___ as you may need
to stop the levofloxacin.
Best wishes from your team at ___
Followup Instructions:
___
|
19687154-DS-3
| 19,687,154 | 21,007,436 |
DS
| 3 |
2144-01-31 00:00:00
|
2144-02-01 06:45:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
confusion
Major Surgical or Invasive Procedure:
Lumbar puncture
History of Present Illness:
I have read and agree with nightfloat admission note. For full
history, please see admission note. Briefly, Mr. ___ is a ___
wtih PMHx smoldering MM, HTN, HLD, presenting with 1 week of
confusion. He had flu-like symptoms 1.5 weeks ago that resolved
after several days, followed by a few days of non-bloody
diarrhea, and now having confusion characterized by word-finding
difficulties and "feeling slow." He has been having difficulty
taking some of his medicaitons because of feeling unwell and
having a poor appetite. He has not eaten much for the past 10
days. His sister was concerned abut his mental status and urged
him to see his PCP. At his PCP's office, his weight was 200lb,
down from 213lb on ___. His PCP was concerned about his
deviation for baseline, noted concern for infection, possible
stroke, or progression of his MM, and he was sent to the ED for
further evaluation. In the ED, intial vitals were: 99.3 88
141/78 18 94%. Neurologic exam was non-focal except for some
slowed speech, labs notable for albumin 2.7, K+ 3.0, INR 1.8. CT
head was negative for acute process, CXR with left infiltrate,
was started on ceftriaxone and azithromycin, and given 40mEq of
K+.
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:
Smoldering IgG lambda MM - BM Bx on ___ with 30% of BM
cellularity being plasma tumor cells, skeletal survey on
___, sees heme/onc q4mo for rechecking SPEP, free light
chains, immunoglobulins, CBC, Ca++, and creatinine, as well as
skeletal survey every year
Leukopenia - Hepatitis ___ and peripheral
flow for lymphoma panel unremarkable
Hypercholesterolemia
Hypertension
Vitamin D deficiency
___ esophagus
Choroidal nevus OS ___
Social History:
___
Family History:
Father Cancer; ___ subdural hematoma
Paternal Grandmother ___ - Unknown Type
Physical Exam:
ADMISSION PHYSICAL EXAM
Vitals- 98.0 147/72 72 22 100% on RA 98.5 kg
General- Alert, oriented, no acute distress
HEENT- Sclera anicteric, MMM, oropharynx clear
Neck- supple, JVP not elevated, no LAD
Lungs- Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV- Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen- soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU- no foley
Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro- CNs2-12 intact, motor function ___ strenght throughout,
sensation intact to light touch and pinprick throughout, gait is
normal, no dysdiadokinesia or difficulty with rapid-alternating
movements, can state the days of the week backwards, simple
multiplication
DISCHARGE PHYSICAL EXAM
Vitals- 97.9 127/87 73 18 96% on RA
General- Alert and oriented x3; easily dsitracted, no acute
distress
HEENT- Sclera anicteric, MMM, oropharynx clear
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 HSM
Ext- warm, well perfused, 2+ pulses, no edema
Pertinent Results:
ADMISSION LABS
=======================
___ 09:00PM BLOOD WBC-5.7 RBC-3.74* Hgb-11.1* Hct-31.8*
MCV-85 MCH-29.6 MCHC-34.8 RDW-13.3 Plt ___
___ 09:00PM BLOOD Neuts-83.8* Lymphs-9.7* Monos-5.1 Eos-0.7
Baso-0.6
___ 09:04PM BLOOD ___ PTT-30.8 ___
___ 09:00PM BLOOD Glucose-90 UreaN-23* Creat-0.9 Na-134
K-3.0* Cl-97 HCO3-27 AnGap-13
___ 09:00PM BLOOD ALT-35 AST-127* AlkPhos-56 TotBili-0.6
___ 09:00PM BLOOD Albumin-2.7* Calcium-8.7 Phos-3.1 Mg-2.2
___ 09:00PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
PERTINENT LABS
=======================
___ 09:10AM BLOOD VitB12-1324*
___ 09:10AM BLOOD TSH-0.54
___ 07:25AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE
HBcAb-NEGATIVE
___ 07:25AM BLOOD PEP-AWAITING F IgG-1439 IgA-66* IgM-104
IFE-PND
___ 05:31PM BLOOD FreeKap-24.4* FreeLam-41.1* Fr K/L-0.59
___ 07:25AM BLOOD HCV Ab-NEGATIVE
IMAGING/STUDIES
=======================
___ CT head without contrast
No acute intracranial process.
___ Chest xray PA and Lateral
Lingula and left upper lobe opacities concerning for pneumonia.
Close imaging follow up after treatment, within no more than 1
month, is
recommended to document resolution
___ CT chest with contrast
1. Multifocal pneumonia involving the right upper, left upper,
lingula and
left lower lobes, without cavitation or air-fluid level. These
consolidation can be followed radiographically with CXR in ___
weeks. Small pleural effusion is alongside the left lower lobe.
2. Mediastinal lymph nodes are enlarged, likely reactive .
3. Note is made of multiple hypodense liver lesions, likely
cysts . Small
left kidney cyst.
___ MRI head without contrast
Unremarkable MRI examination of the brain without evidence of
infarct or other acute abnormality.
___ RUQ US and doppler
Unremarkable abdominal sonographic examination. Normal spectral
Doppler analysis of the liver vasculature.
PATHOLOGY
======================
___ CSF cytology
Negative for malignant cells
MICROBIOLOGY
======================
___ 7:40 am SEROLOGY/BLOOD
LYME SEROLOGY (Pending):
___ 5:17 pm CSF;SPINAL FLUID Source: LP TUBE 3.
**FINAL REPORT ___
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final ___: NO GROWTH.
___ 10:08 am SPUTUM Source: Expectorated.
**FINAL REPORT ___
GRAM STAIN (Final ___:
<10 PMNs and >10 epithelial cells/100X field.
Gram stain indicates extensive contamination with upper
respiratory
secretions. Bacterial culture results are invalid.
PLEASE SUBMIT ANOTHER SPECIMEN.
___ 1:40 am BLOOD CULTURE
Blood Culture, Routine (Pending):
___ 1:30 am BLOOD CULTURE
Blood Culture, Routine (Pending):
DISCHARGE LABS
==========================
___ 07:40AM BLOOD WBC-3.2* RBC-3.84* Hgb-11.1* Hct-35.6*
MCV-93 MCH-28.9 MCHC-31.2 RDW-13.6 Plt ___
___ 07:40AM BLOOD ___
___ 07:40AM BLOOD Glucose-100 UreaN-14 Creat-1.0 Na-139
K-4.7 Cl-105 HCO3-30 AnGap-9
___ 07:40AM BLOOD Calcium-9.0 Phos-3.4 Mg-1.9
Brief Hospital Course:
Mr. ___ was admitted with subacute onset of word-finding
difficulties and subjective confusion. Neurologic exam was
nonfocal; structural CNS disease, stroke,
meningitis/encephalitis, and liver disease were ruled-out. He
was found to have a left-sided penumonia and infectious
encephalopathy may have contributed to his symptoms, but it was
felt that there may be a primary neruologic cause to his
symptoms and would benefit from cognitive neurology follow-up as
an outpatient.
ACTIVE ISSUES
# Word finding difficulties
Patient describes that at baseline he is somewhat disorganized,
but this appears to be a change in the past ___ weeks prior to
admission. Verified with PCP and sister. DDx was broad. CT head
and MRI were normal and without evidence of acute or old stroke.
He had missed a few doses of venlafaxine in the prior few weeks
but resumed when hospitalized and his symptoms continued. Given
his elevated INR and low albumin, liver disease was suspected,
but RUQ showed normal liver appearance and patent vasculature.
Hepatitis serologies were negative. LP was performed to assess
for aseptic meningitis and did not have evidence of infection.
Infectious encephalopathy secondary to pneumonia may ahve
contributed to his symptoms but did not seem to fit the time
course. Neurology was consulted who felt that the would benefit
from outpatient neurocognitive assessment. He had an EEG done
which was not read at the time of discharge, but there was a low
suspicion for seizures. A follow-up appointment was made within
the ___ neurology department.
# Pneumonia
Quite imprssive left consolidation on CXR, although the patient
had no pulmonary symptoms. There was an initial question of
air-fluid levels and possible cavitation, but this was not seen
on follow-up CT. He was initially treated with azithromycin and
ceftriaxone and transitioned to levofloxacin and will complete a
7 day course of antibiotics. He should have a follow-up CXR in 1
month.
# Smoldering IgG Lambda Myeloma
BmBx in ___ with 30% plasma cells. Since that time has followed
heme/onc at ___ q4mo with stable paraproteins. Last visit was
in ___, was be overdue for routine labs. There is a risk for
progression to MM, his Cr is at baseline, slightly more anemic
from baseline. ___ heme/onc was consulted for assistance who
recommended the routine SPEP, UPEP, light chains, and
immunoglobulins. These were overall stable from prior labs
although with an elevated lambda light chain level. He initially
had early follow-up scheduled with his primary oncologist Dr.
___ given that he was being discharged to his sister's in
___, he was advised to reschedule this for ___ months
later.
# Elevated INR
Malnutrition versus liver disease, although no evidence of
cirrhosis on RUQ US. INR s/p 3 days Vit K still elevated but
improved from 1.8 to 1.3 so has a component of malnutrition.
Hepatitis serologies negative for infection.
CHRONIC ISSUES
# Hypertension
Stable, continued enalapril and ASA.
# hyperlipidemia
Continued simvastatin.
# GERD with ___
Continued omeprazole.
# Depression
Continued effexor.
TRANSITIONAL ISSUES
- Should have follow-up CXR in 1 month (~ ___ to evaluate for
resolution of left-sided pneumonia
- Non-immune to Hepatitis B
- Ensure follow-up with cognitive neurology
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Omeprazole 20 mg PO BID
2. Simvastatin 40 mg PO DAILY
3. Venlafaxine XR 300 mg PO QAM
4. Enalapril Maleate 20 mg PO DAILY
5. Aspirin 81 mg PO DAILY
6. Vitamin D 1000 UNIT PO DAILY
7. Venlafaxine XR 150 mg PO QPM
Discharge Medications:
1. Aspirin 81 mg PO DAILY
RX *aspirin [Adult Low Dose Aspirin] 81 mg 1 tablet,delayed
release (___) by mouth daily Disp #*7 Tablet Refills:*0
2. Enalapril Maleate 20 mg PO DAILY
RX *enalapril maleate 20 mg 1 tablet(s) by mouth daily Disp #*7
Tablet Refills:*0
3. Omeprazole 20 mg PO BID
RX *omeprazole 20 mg 1 capsule,delayed ___ by
mouth Two times a day Disp #*14 Capsule Refills:*0
4. Simvastatin 40 mg PO DAILY
RX *simvastatin 40 mg 1 tablet(s) by mouth daily Disp #*7 Tablet
Refills:*0
5. Venlafaxine XR 300 mg PO QAM
RX *venlafaxine 150 mg 3 capsule,extended release 24hr(s) by
mouth daily Disp #*21 Capsule Refills:*0
6. Venlafaxine XR 150 mg PO QPM
7. Vitamin D 1000 UNIT PO DAILY
RX *ergocalciferol (vitamin D2) 2,000 unit 0.5 (One half)
tablet(s) by mouth daily Disp #*4 Capsule Refills:*0
8. Levofloxacin 750 mg PO Q24H
Last dose on ___
RX *levofloxacin [Levaquin] 750 mg 1 tablet(s) by mouth daily
Disp #*2 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
- Multifocal pneumonia
- Toxic-metabolic encephalopathy
- Coagulopathy secondary to malnutrition
Secondary:
- Smoldering multiple myeloma
- Depression/anxiety
- Hypercholesterolemia
- Hypertension
- Vitamin D deficiency
- Choroidal nevus OS ___
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to ___ for difficulties finding words and
some confusion that were concerning both to you and to your PCP
and sister. You did not have a stroke, you did not have a
serious infection in your spinal fluid, and we did not find
evidence of liver disease to cause your confusion. You had a
pneumonia that was treated with antibiotics and your last dose
is on ___. This infection may have caused some confusion. You
were seen by our neurology service and they would like you to
follow-up with our cognitive neurology colleagues as an
outpatient for further evaluation. If you are unable to make
your follow-up appointments, please be sure to call your doctors
on ___ to reschedule - it is important to see your PCP and
neurology as soon as possible after your discharge.
Followup Instructions:
___
|
19687174-DS-7
| 19,687,174 | 20,290,678 |
DS
| 7 |
2190-03-19 00:00:00
|
2190-03-19 13:07:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
codeine
Attending: ___.
Chief Complaint:
Altered Mental Status
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ old woman with history of IDDM, substance abuse,
presents with altered mental status/intoxication. She was
reportedly at ___ clinic today (which she denied on
arrival to floor) then went to a nearby apartment building where
security was called. Patient was reportedly yelling at people at
the apt ___. She was picked up by EMS and was found to be
lethargic and sleepy. It was unclear if she had a recent fall or
injuries.
In the ED, initial vitals were: 97.7 80 124/80 14 98%. Initial
labs notable BUN/Cr ___, serum glucose 471, anion gap 14,
normal white count, H/H 11.7/37.8, platelets 131, serum tox
negative, urine tox positive for methadone, UA with large leuks,
negative nitrites, mod bacteria. CT c-spine was negative for
fracture, CT head negative for acute intracranial process, CXR
with bibasilar opacities - atalectasis vs aspiration vs pna per
radiology read. Patient was given CTX for the positive UA and 1L
NS and 10U regular insulin which improved ___ from 471 to 341.
Per ED, patient was initially difficult to arouse but was
responding to name and opening eyes. She was unable to state if
has additional substances on board. Subsequently patient became
alert and was without complaints.
On the floor, VS 97.9 115/79 99 18 100%RA. Initially patient was
observed watching TV appearing comfortable, sitting up in bed.
On introducing myself as the admitting MD, patient broke out
into tears and was yelling about "pain all over my body"
requesting oxycodone. She states she did not think methadone had
helped her and had been tapered off of it since earlier this
year although utox in ED was positive for methadone. She also
denied going to ___ clinic today. She declined most of the
physical examination. She does report dysuria, and hesitancy and
chills for the past ___ months which she had not had evaluated
before. She refuses to give an account of events leading up to
her presentation to the ED.
Past Medical History:
IDDM
Reports history of Hep C since ___, but states she has been
monitored and told she never needed treatment
Reports history of RA, never been seen by rheumatologist
Polysubstance abuse (crack cocaine, heroin, EtOH)
Depression
S/p amputation of left hand digit for osteomyelitis many years
ago
COPD
Hyperlipidemia
Hypertension
Social History:
___
Family History:
Mother with diabetes. One son with ___.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS 97.9 115/79 99 18 100%RA
General: Alert, oriented x 3, no acute distress but becomes
tearful and yelling about her pain.
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, pupils are
equal and round at 3mm reactive.
Neck: Supple, JVP not elevated, no LAD
CV: Difficult to auscultate as patient speaking through the
exam. Regular rhythm, mild tachycardia, no murmurs, rubs,
gallops heard.
Lungs: Faint end expiratory wheezes in upper airways, no rales,
rhonchi
Abdomen: Patient would not allow for complete examination in all
quadrants but soft, non-tender when distracted, non-distended,
bowel sounds present, no rebound or guarding, unable to examine
fully to assess for HSM.
GU: No foley
Ext: Warm, well perfused, no clubbing, cyanosis or edema.
Bilateral legs with multiple old healed ulcers (per patient,
from being splashed with "grit" by someone many years ago), and
bilateral feet with onychomycosis. Right hand with scattered
healing ulcers (per patient she was bit by a person a week ago),
no open lesions or exudates.
Neuro: Does not cooperate, stating she has to much pain but
facial movements are symmetric and moves all four extremities
equally. Gait deferred.
DISCHARGE PHYSICAL EXAM:
Vitals: Tc 97.9, HR 92, BP 124/78, RR 19, SaO2 100% RA
General: Alert and oriented, no acute distress
HEENT: Pinpoint pupils, sclera anicteric, MMM, oropharynx clear
Neck: Supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: +BS, soft, nondistended, tender in suprapubic region,
no rebound or guarding
Ext: Warm, well perfused, 1+ pulses, trace edema, missing digit
on left hand
Skin: Bilateral legs with scattered round healed ulcers,
bilateral feet with onychomycosis
Neuro: Grossly intact, moving all extremities well
Pertinent Results:
LABS:
___ 02:43PM BLOOD WBC-6.2 RBC-4.04* Hgb-11.7* Hct-37.8
MCV-93 MCH-29.0 MCHC-31.1 RDW-14.1 Plt ___
___ 02:43PM BLOOD Neuts-55.8 ___ Monos-7.6 Eos-2.8
Baso-0.3
___ 02:43PM BLOOD Plt ___
___ 02:43PM BLOOD Glucose-471* UreaN-21* Creat-0.8 Na-142
K-4.5 Cl-105 HCO3-28 AnGap-14
___ 02:43PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 06:18PM URINE Color-Yellow Appear-Hazy Sp ___
___ 06:18PM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-1000 Ketone-NEG Bilirub-NEG Urobiln-2* pH-6.0 Leuks-LG
___ 06:18PM URINE RBC-0 WBC-99* Bacteri-MOD Yeast-NONE
Epi-2
___ 06:18PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG mthdone-POS
MICRO:
URINE CULTURE (Preliminary):
ESCHERICHIA COLI. >100,000 ORGANISMS/ML..
OF TWO COLONIAL MORPHOLOGIES.
GRAM POSITIVE BACTERIA. >100,000 ORGANISMS/ML..
Alpha hemolytic colonies consistent with alpha
streptococcus or
Lactobacillus sp.
IMAGING:
CXR ___:
IMPRESSION: Bibasilar opacities, which ___ reflect atelectasis,
aspiration, or infectious pneumonia. Short-term followup
radiographs ___ be helpful in this regard.
CT CSPINE ___: IMPRESSION: No acute fracture or traumatic
malalignment.
CT HEAD ___: IMPRESSION: Slightly suboptimal study due to
patient motion. No acute intracranial process.
Brief Hospital Course:
___ with history of IDDM and polysubstance abuse admitted for
altered mental status. Patient was picked up by EMS near her
___ clinic, was noted to be lethargic at that time. In
ED, she was initially lethargic but her mentation improved
without specific intervention. She reported dysuria/suprapubic
pain and her UA was positive, so she was started on ceftriaxone
for a UTI. Preliminary urine culture is growing E. coli and
alpha hemolytic gram positive bacteria. In addition, her blood
sugars were elevated, but without anion gap or ketones in urine.
She was continued on her home glargine and started on a Humalog
sliding scale for hyperglycemia. She improved clinically and
was discharged back to ___. She will need to
complete 5 more days of cefpodoxime for treatment of complicated
UTI (complicated given h/o diabetes). Last day of antibiotics
will be ___.
Transitional Issues:
=======================
[ ] Continue cefpodoxime 200mg q12h for 5 more days (last day
___
[ ] F/u with PCP regarding diabetes management and polysubstance
abuse
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. MetFORMIN (Glucophage) 850 mg PO BID
2. Glargine 30 Units Dinner
3. Simvastatin 20 mg PO QPM
4. Tiotropium Bromide 1 CAP IH DAILY
5. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheezing
6. Lisinopril 10 mg PO DAILY
7. Bisacodyl 10 mg PO DAILY
8. Methadone 50 mg PO DAILY
9. ClonazePAM 2 mg PO QHS
10. Gabapentin 900 mg PO TID
Discharge Medications:
1. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheezing
2. Glargine 30 Units Dinner
3. Lisinopril 10 mg PO DAILY
4. Methadone 50 mg PO DAILY
5. Simvastatin 20 mg PO QPM
6. Tiotropium Bromide 1 CAP IH DAILY
7. Bisacodyl 10 mg PO DAILY
8. MetFORMIN (Glucophage) 850 mg PO BID
9. Thiamine 100 mg PO DAILY
RX *thiamine HCl 100 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*3
10. Multivitamins 1 TAB PO DAILY
RX *multivitamin 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*3
11. FoLIC Acid 1 mg PO DAILY
RX *folic acid 1 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*3
12. Cefpodoxime Proxetil 200 mg PO Q12H Duration: 5 Days
RX *cefpodoxime 200 mg 1 tablet(s) by mouth twice daily Disp
#*10 Tablet Refills:*0
13. ClonazePAM 1 mg PO QHS
RX *clonazepam 1 mg 1 tablet(s) by mouth at bedtime Disp #*4
Tablet Refills:*0
14. Gabapentin 600 mg PO TID
RX *gabapentin 600 mg 1 tablet(s) by mouth three times a day
Disp #*12 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
Urinary Tract Infection
Secondary Diagnosis:
Polysubstance abuse
Insulin Dependent Diabetes
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Ms. ___,
It was a pleasure caring for you during your admission to ___
___ ___ ___. You were admitted for
evaluation of confusion and a urinary tract infection. You were
given antibiotics for your infection and you improved. You will
need to continue to take your antibiotics for 5 days after your
discharge. Please take your other medications as prescribed. We
hope you continue to feel better.
- Your ___ Team
Followup Instructions:
___
|
19687395-DS-23
| 19,687,395 | 27,409,874 |
DS
| 23 |
2123-06-19 00:00:00
|
2123-06-19 17:03:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Hydrochlorothiazide / Vancomycin
Attending: ___.
Chief Complaint:
Migratory myaglias/arthralgias
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old female with PSC s/p
liver transplant in ___ currently on tacrolimus, UC on
mesalamine, hypothyroidism, and diet controlled DM who presented
with several month history of migratory upper extremity and
torso
pains myalgia.
Patient reports that her pains are migratory, mostly affecting
her shoulders, neck, and upper torso, including in the middle of
her chest. They are persistent but fluctuate in intensity,
usually worse at night. She describes the pain as "tearing" and
when asked if it felt like a burning sensation she
enthusiastically agreed. Pain is exacerbated by movement and
breathing. She denies any muscle weakness or stiffness. Only
aspirin has alleviated the pain, however she has not tried
acetaminophen as she prefers to avoid it given her history of
liver transplant. She states that ibuprofen has no effect.
In the ED, initial vitals: 97.7 97 111/68 15 97% RA
- Exam notable for:
CN II-XII grossly intact, PERRL-A. RUE ___ ___t elbow
and LUE ___ ___t elbow. Flexion ___ bilaterally.
Bilateral ___ strength preserved. No guttron papules, heliotrope
rash, shawl sign or other skin lesions.
- Labs notable for:
No leukocytosis. Anemia with Hgb 9.2 on presentation. Normal
LFTs. Alb 3.4. CK 31. BMP unremarkable.
- Imaging notable for: No imaging in ED
- Pt given:
NS @ 100 ml/hr
Lorazepam 0.5mg
Aspirin 81mg
Tacrolimus 2mg
Magnesium sulfate 2g IV
- Vitals prior to transfer: 98.1 78 95/58 16 97% RA
On the floor, patient endorses the above history. She states
that
she is feeling much better from a symptomatic standpoint and is
hoping to have this resolved quickly. She states that he pain is
tolerable right now and does not need any additional analgesics.
She also endorses sore thorat and nausea that is worse in the
morning. She denies fevers, chills, cough, sputum, fatigue,
abdominal pain, vomiting, vision changes, headaches, dysuria,
hematochezia, melena, and changes in bowel habits.
Past Medical History:
portal vein thrombosis
liver transplant ___ s/s psc
DM type II
hypothyroid
depression
anxiety
chronic anemia
bilateral mastectomies 89,91 for breast CA
appendectomy
laminectomy
Cholecystectomy
SBO s/p repair ___
Ulcerative colitis
Social History:
___
Family History:
Father with pancreatic cancer
Mother with breast cancer
Brother with lung cancer
Family history of DM, heart disease
Physical Exam:
ADMISSION EXAM:
VITALS: 98.1 113 / 70 91 18 96 96%RA
General: Well-developed, well-nourished female sitting
comfortably at bedside. NAD
HEENT: Normocephalic, atraumatic. MMM. Sclerae anicteric,
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: No tenderness to palpation of the bilateral shoulders,
thoracic back, bilateral trapeziuses. Well perfused, 2+ pulses,
no clubbing, cyanosis or edema
Skin: Warm, dry, no rashes or notable lesions.
Neuro: CNII-XII intact, ___ strength upper/lower extremities.
AAOx3.
DISCHARGE EXAM:
VITALS: 97.8 113/74 80 18 98 RA
General: Well-developed, well-nourished female sitting
comfortably at bedside. Appears anxious, wants to leave. NAD
HEENT: Normocephalic, atraumatic. MMM. Sclerae anicteric,
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: No tenderness to palpation of the bilateral shoulders,
thoracic back, bilateral trapeziuses. Well perfused, 2+ pulses,
no clubbing, cyanosis or edema
Skin: Warm, dry, no rashes or notable lesions.
Neuro: CNII-XII intact, ___ strength upper/lower extremities.
AAOx3.
Pertinent Results:
ADMISSION LABS:
___ 02:05PM BLOOD WBC-6.4 RBC-3.05* Hgb-9.2* Hct-27.4*
MCV-90 MCH-30.2 MCHC-33.6 RDW-13.0 RDWSD-42.4 Plt ___
___ 02:05PM BLOOD Neuts-77.0* Lymphs-14.1* Monos-7.3
Eos-0.9* Baso-0.2 Im ___ AbsNeut-4.96 AbsLymp-0.91*
AbsMono-0.47 AbsEos-0.06 AbsBaso-0.01
___ 02:05PM BLOOD Glucose-137* UreaN-20 Creat-0.8 Na-141
K-4.4 Cl-100 HCO3-23 AnGap-18
___ 02:05PM BLOOD ALT-8 AST-10 CK(CPK)-31 AlkPhos-78
TotBili-0.2
___ 02:05PM BLOOD Albumin-3.4*
___ 02:05PM BLOOD TSH-0.37
___ 02:05PM URINE Color-Yellow Appear-Clear Sp ___
___ 02:05PM URINE Blood-NEG Nitrite-NEG Protein-TR*
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
___ 02:05PM URINE RBC-2 WBC-1 Bacteri-NONE Yeast-NONE Epi-1
___ 02:05PM URINE CastHy-1*
___ 02:05PM URINE Mucous-RARE*
PERTINENT LABS:
___ 09:30PM BLOOD cTropnT-<0.01
___ 04:40AM BLOOD calTIBC-181* Ferritn-207* TRF-139*
___ 04:40AM BLOOD %HbA1c-6.4* eAG-137*
___ 04:40AM BLOOD ___ CRP-51.7*
___ 09:54AM BLOOD 25VitD-53
___ 04:40AM BLOOD ANTI-JO1 ANTIBODY-PND
IMAGING:
CT CHEST ___:
New low-density lesion in the right upper lobe measuring up to 1
cm with the appearance of adjacent post obstructive change may
reflect mucous plugging versus an endobronchial lesion. Further
evaluation with a short-term follow-up CT chest, or PET-CT is
recommended.
CT ABD and PELVIS ___:
1. No evidence of malignancy within the abdomen or pelvis. No
findings to
suggest posttransplant lymphoproliferative disease. In
particular, no hepatic
mass, splenomegaly, or lymphadenopathy.
2. Status post liver transplant with stable intrahepatic biliary
ductal
dilatation and wedge-shaped hypodensity within the right hepatic
lobe.
3. Diffuse mural thickening involving the sigmoid colon may be
related to
smooth muscle hypertrophy in the context of diverticulosis or
the result of
chronic inflammation given history of ulcerative colitis.
4. Grossly stable appearance of pancreatic cystic lesions,
likely side-branch
IPMNs.
5. Multilevel degenerative changes of the thoracolumbar spine.
DISCHARGE LABS:
___ 07:00AM BLOOD WBC-5.8 RBC-3.48* Hgb-10.3* Hct-31.6*
MCV-91 MCH-29.6 MCHC-32.6 RDW-13.0 RDWSD-42.7 Plt ___
___ 07:00AM BLOOD Plt ___
___ 07:00AM BLOOD Glucose-107* UreaN-18 Creat-0.6 Na-135
K-4.9 Cl-98 HCO3-24 AnGap-13
___ 07:00AM BLOOD Calcium-9.0 Phos-3.8 Mg-1.9
Brief Hospital Course:
SUMMARY
=======
___ year old female with PSC s/p liver transplant in ___ now on
tacrolimus, UC on mesalamine, hypothyroidism, and DM who
presents with several month history of
migratory body aches. No identifiable cause was found based on
her imaging, no overt malignancy identified. Patient will be
discharged for additional outpatient workup.
ACUTE ISSUES
============
#Pleuritic chest pain
#Migratory pains
At this point, there is a very broad differential for the
patient's pain, including atypical angina (especially in setting
of HLD and DM) vs. pleuritic pain vs. PUD vs. myopathies vs.
neuropathic pain vs. medication side effect (tacro, statin).
Given the chronicity of her complaints, infectious etiologies
seem unlikely. At this time, my concern for a rheumatologic
process such a PMR is low given her relatively benign exam (no
tenderness to palpation), as is my concern for an inflammatory
myopathy given her preserved strength throughout and normal CK.
TSH was within normal limits, making thyroid disease less
likely, troponins were negative and her EKG was unchanged from
prior comparisons. Her imaging including her CT scan and chest
xray did not show any malignancy or signs that would suggest
posttransplant lymphoproliferative disease. Her CT showed cystic
pancreatic lesions, thought to be consistent with side branch
IPMN's; stable based on imaging. CRP was elevated, ___, Anti-JO1
antibodies were pending at the time of discharge.
#Lymphadenopathy
Per outpatient hepatology noted dated ___ ___,
___ has lymphadenopathy that was initially noted by her PCP.
The location is not specified. No cervical or supraclavicular
adenopathy noted on exam. As above, no evidence of PTLD based on
her imaging studies. She did not have any significant
lymphadenopathy on her CT abdomen/pelvis.
#Anemia
___ records reveal recent baseline around ___.
Current Hgb 10.3. Patient denies melena, hematochezia. Iron
studies more suggestive of iron deficiency, however, would
expect TIBC to be higher. Guaiac was negative.
Chronic/Stable Medical Conditions
==================================
#Liver transplant
History of liver transplant in ___. Currently on tacrolimus,
goal trough ___ ___ recent outpatient
hepatology note on ___. LFTs within normal limits. She was
therapeutic on her tacrolimus throughout this hospital course.
#DM
Per patient, A1c is usually in 6 range. Currently controlled
with diet and humalin 6u in AM for BG > 120 at home. A1c
indicated good control of 6.4%. She was on sliding scale in
house.
TRANSITIONAL ISSUES
===================
- New low-density lesion in the right upper lobe measuring up to
1 cm with the appearance of adjacent post obstructive change may
reflect mucous plugging versus an endobronchial lesion. She may
need further evaluation with a short-term follow-up CT chest, or
PET-CT.
- ___ and anti-JO1 labs
- Consider EGD to rule out PUD given history of gastritis, NSAID
use
- Follow-up for her migratory pains and pleuritic chest pain.
Pending ___ need to be considered for rheumatologic
evaluation.
#Code status: Full (presumed)
#Health care proxy/emergency contact:
Name of health care proxy: ___
Relationship: friend
Phone number: ___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. Mesalamine ___ 800 mg PO TID
2. Fish Oil (Omega 3) 1000 mg PO BID
3. Glucoten (glucosamine-chondroit-mv-min3) 375-300-25-0.5 mg
oral DAILY
4. LORazepam 0.5 mg PO QHS:PRN Insomnia
5. Multivitamins 1 TAB PO DAILY
6. Tacrolimus 2 mg PO Q12H
7. Aspirin 81 mg PO DAILY
8. FoLIC Acid 1 mg PO DAILY
9. Levothyroxine Sodium 137 mcg PO DAILY
10. Simvastatin 5 mg PO QPM
11. HumuLIN 70/30 (insulin NPH and regular human) 100 unit/mL
(70-30) subcutaneous DAILY:PRN 6u for AM blood glucose > 120
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Fish Oil (Omega 3) 1000 mg PO BID
3. FoLIC Acid 1 mg PO DAILY
4. Glucoten (glucosamine-chondroit-mv-min3) 375-300-25-0.5 mg
oral DAILY
5. HumuLIN 70/30 (insulin NPH and regular human) 100 unit/mL
(70-30) subcutaneous DAILY:PRN 6u for AM blood glucose > 120
6. Levothyroxine Sodium 137 mcg PO DAILY
7. LORazepam 0.5 mg PO QHS:PRN Insomnia
8. Mesalamine ___ 800 mg PO TID
9. Multivitamins 1 TAB PO DAILY
10. Simvastatin 5 mg PO QPM
11. Tacrolimus 2 mg PO Q12H
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
undifferentiated myalgia
SECONDARY DIAGNOSIS: Ulcerative colitis, Primary sclerosing
cholangitis status post liver transplant, diabetes mellitus,
anemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear ___,
It was a pleasure caring for you at ___
___!
WHY WERE YOU ADMITTED?
- You were having some pain with breathing and muscle pain and
aches that were moving around.
WHAT HAPPENED IN THE HOSPITAL?
- We did a CT scan of your chest and abdomen that did not show
any disease that would explain your pain.
WHAT SHOULD YOU DO AT HOME?
-Please take all of your medications as prescribed.
-Please make sure to follow-up with your primary care doctor Dr.
___ at ___.
-If your pain worsens, or you start to become short of breath,
experience chest pain, nausea, vomiting, or fevers, please come
back to the hospital.
Thank you for allowing us be involved in your care, we wish you
all the best!
Your ___ Team
Followup Instructions:
___
|
19687661-DS-19
| 19,687,661 | 23,451,220 |
DS
| 19 |
2175-10-03 00:00:00
|
2175-10-03 18:25:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Codeine / Sulfa (Sulfonamide Antibiotics) / Penicillins /
Tylenol 8 Hour
Attending: ___.
Chief Complaint:
Several days of melena, associated with weakness and fatigue
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms ___ is a ___ yo F w/PMH significant for EtOH and GERD here
following recent discharge from ___ on ___. Both patient
and daughter report worsening black, tarry diarrhea since
discharge. Patient states that she feels weak, lethargic,
fatigued, and unable to care for herself. Has had decreased PO
intake today and over weekend. Of note, diarrhea stopped today
after d/c'ing tube feeds. Both patient and daughter wish to go
to acute rehab facility, however, patient believes that she
needs to cared for in hospital prior to rehab. Reports mild
abdominal pain and non-productive cough improving since last
discharge. Denies N/V, fever, chills, inability to tolerate oral
intake, HA, syncope, chest pain, SOB, wheeze,
On the floor: Pt went into bouts of SVT to 170's w/PVC's and
eventual short runs of V. tach. K WNL, but Mg not checked in ED
so given 2mg Mg and other electrolytes sent. Pt entirely
asymptomatic. Left pt in sinus rhythm w/single PVC's.
Past Medical History:
Hypertension
PVD
Social History:
___
Family History:
N/C
Physical Exam:
Admission Exam:
VS: 98 °F (36.7 °C), Pulse: 85, RR: 18, BP: 118/67, O2Sat: 98,
O2Flow: 3L NC
GENERAL: Jaundiced and in no acute distress, with NC and feeding
tube in place. Conversive and in good spirits
HEENT: Sclera icteric. Mucous membranes dry
CARDIAC: Irregularly irregular. Tachycardic. NS1&S2. NMRG
LUNGS: CTA b/l with no wheezing, rales, or rhonchi.
ABDOMEN: Mild distension and firm, with mild diffuse tenderness
to palpation No HSM appreciated.
EXTREMITIES: 3+ pitting edema. Warm and well perfused, no
clubbing or cyanosis.
NEUROLOGY: no asterixis, A+Ox3. CN ___ intact, sensation
grossly intact. moving all extremities freely.
Discharge Exam:
GENERAL: Jaundiced and breathing with accessory muscles, with NC
and feeding tube in place.
HEENT: Sclera icteric. Mucous membranes dry
CARDIAC: Irregularly irregular. Tachycardia. NS1&S2. NMRG
appreciated
LUNGS: rales at base bilaterally.
ABDOMEN: Mild distension and firm, with mild diffuse tenderness
to palpation No HSM appreciated.
EXTREMITIES: 4+ pitting edema to lower back. Warm and well
perfused, no clubbing or cyanosis.
NEUROLOGY: no asterixis, A+Ox3. CN ___ intact, sensation
grossly intact. moving all extremities freely.
Pertinent Results:
Admission Labs:
___ 12:00PM BLOOD WBC-22.0* RBC-2.63* Hgb-9.0* Hct-28.1*
MCV-107* MCH-34.1* MCHC-31.9 RDW-19.2* Plt ___
___ 12:00PM BLOOD Neuts-93.4* Lymphs-3.5* Monos-2.6 Eos-0.4
Baso-0.2
___ 12:00PM BLOOD ___ PTT-33.5 ___
___ 12:00PM BLOOD Glucose-105* UreaN-35* Creat-1.5* Na-132*
K-4.7 Cl-95* HCO3-26 AnGap-16
___ 12:00PM BLOOD ALT-57* AST-186* AlkPhos-421*
TotBili-23.1*
___ 12:00PM BLOOD Albumin-2.9* Calcium-9.1 Phos-2.8 Mg-2.0
.
Discharge Labs;
___ 03:14AM BLOOD WBC-24.5* RBC-2.42* Hgb-8.4* Hct-26.5*
MCV-110* MCH-34.9* MCHC-31.8 RDW-20.3* Plt ___
___ 03:14AM BLOOD Neuts-92.5* Lymphs-3.5* Monos-3.4 Eos-0.4
Baso-0.1
___ 03:14AM BLOOD ___ PTT-39.6* ___
___ 03:14AM BLOOD Glucose-88 UreaN-72* Creat-1.8* Na-137
K-4.5 Cl-103 HCO3-22 AnGap-17
___ 03:14AM BLOOD ALT-49* AST-148* LD(LDH)-259* CK(CPK)-16*
AlkPhos-261* TotBili-20.9*
___ 03:14AM BLOOD Albumin-2.6* Calcium-8.7 Phos-4.9* Mg-2.3
.
Pertinent Labs:
___ 08:15AM BLOOD CK-MB-2 cTropnT-<0.01
___ 11:20AM BLOOD CK-MB-2 cTropnT-<0.01
___ 03:14AM BLOOD CK-MB-2 cTropnT-<0.01
___ 07:00PM BLOOD calTIBC-177* Ferritn-439* TRF-136*
___ 02:11PM BLOOD Type-ART pO2-96 pCO2-33* pH-7.45
calTCO2-24 Base XS-0 Intubat-NOT INTUBA Comment-NASAL ___
.
Micro:
___ BLOOD CULTURE-pend
___ BLOOD CULTURE-pend
___ BLOOD CULTURE-pend
___ BLOOD CULTURE-pend
___ STOOL OVA + PARASITES-neg
___ STOOL OVA + PARASITES-neg
___ STOOL OVA + PARASITES- MICROSPORIDIA
STAIN-PRELIMINARY; CYCLOSPORA STAIN-FINAL;
Cryptosporidium/Giardia (DFA)-neg
___ STOOL C. difficile; FECAL CULTURE-FINAL;
CAMPYLOBACTER ___ URINE URINE CULTURE-neg
___ BLOOD CULTURE-neg
___ BLOOD CULTURE-neg
Imaging;
___ EKG:Sinus tachycardia with ventricular premature beats.
Low QRS voltages throughout. Diffuse ST-T wave abnormalities
grossly unchanged from previous tracing.
.
___ CHest AP: As compared to the previous radiograph, there
is minimal increase in transparency of the lung parenchyma,
potentially reflecting improved ventilation. At the right lung
base, however, a combination of pleural effusion and parenchymal
opacity persists. These changes might be consistent with
pneumonia. The changes have neither increased nor decreased in
severity and extent as compared to the previous examination.
A prexeisting retrocardiac atelectasis is less severe than on
the previous image. Unchanged moderate cardiomegaly, unchanged
course and position of a nasogastric tube.
.
___ TTE: Small to moderate circumferential pericardial
effusion without evidence for tamponade physiology. Normal
biventricular cavity sizes with preserved global and regional
biventricular systolic function.
Compared with the prior study (images reviewed) of ___,
the pericardial effusion is larger. If clinically indicated,
serial evaluation is suggested.
.
___ RUQ U/S: Echogenic liver consistent with fatty
infiltration. Other forms of liver disease, including more
significant hepatic fibrosis, cirrhosis, or steatohepatitis,
cannot be excluded on the basis of this examination. No evidence
of biliary obstruction. Stones and gallbladder sludge, but no
evidence of acute cholecystitis. Increasing splenomegaly, 15.5
cm (13.1 cm on ___. Trace left-sided pleural effusion.
.
___ CT Torso: Worsening right lower lobe consolidation,
superimposed on post-radiation changes, with trace right and
small left simple pleural effusions. Differential considerations
include increasing atelectasis or scarring, versus possibly
superimposed infection. Moderate pericardial effusion, increased
somewhat. Heterogeneous hepatic perfusion consistent with the
history of hepatitis. Cholelithiasis without evidence of
cholecystitis.
.
___ CT Head:No evidence of intracranial hemorrhage; given the
patient's history of malignancy, if metastases are of a concern,
MR is more sensitive in detecting small metastatic lesions
.
___ ___ Scan: No bilateral lower extremity deep venous
thrombosis. Extensive superficial soft tissue edema.
.
___ CXR Portable: enlargement of the cardiac silhouette with
pulmonary vascular congestion and bilateral pleural effusions
with compressive atelectasis at the bases. Intestinal tube
remains in position
Brief Hospital Course:
___ year old woman with past medical history of lung cancer s/p
chemotherpay and radiation ___ years prior, and alcohol abuse with
acute alcoholic hepatitis recently admitted with it, who
returned with worsening diarrhea and found to have worsening
liver function and renal function and respiratory status despite
treatment who changed her goals of care to comfort measures only
given her poor prognosis and is discharged home with hospice.
Active Issues:
#Alcoholic hepatitis: Pt returned to ___ for worsening
fatigue, lethargy, and diarrhea after being discharged 5 days
prior. There was no significant change in bilirubin or
leukocytosis on this admission from the last (T. bili:___,
___:22). Increased bili and WBC originally thought to be ___
occult infection, so pt placed on broad spectrum abx. CT
positive for ?RLL PNA and she was treated for HCAP with broad
spectrum antibiotics. Her hepatitis continued to worsen with
worsening bilirubin and she was started on pentoxyfilline
without improvement in her liver function.
#Tachypnea/dyspnea: Although pt had baseline need for 3L O2, she
developed progressive tachypnea and SOB during her hospital
stay. She was worked up for PE, pneumonia and pericardial
effusion. It was felt that ultimately this worsening dyspnea was
due to her anasarca and she was attempted to be diuresed.
However with her worsening renal function she was not responding
to IV diuretics and discussion with the renal team suggested
that ultrafiltration would be the next step to diuresis.
However, given that this was a form of dialysis and not in line
with the patient's goals of care this was not pursued. She was
discharged to home hospice with morphine sulfate for air hunger.
#Acute renal failure- patient was originally pre-renal on
admission, her renal function improved temporarily. In the
setting of worsening liver function and IV contrast for a CT
scan she developed worsening renal function with associated
oliguria. Renal was consulted with her oliguria and she was no
longer diuresing to higher doses of lasix. It is possible that
this represented a pre-renal azotemia vs. hepatorenal syndrome.
#Pneumonia- patient was found to have a possible new infiltrate
on her right lower lobe in the area of previous scaring from her
radiation so it was unclear if this was truely a pneumonia.
Given her clinical status and worsening respiratory complaints
she was treated for hospital associated pneumonia. Antibiotics
were discontinued at the time of discharge given her goals of
care.
#Diarrhea: Multiple stool studies performed, and all negative.
Diarrhea was dark, but not true melena. Thought to be ___
malabsorption from alcoholic GI insult and liver disease.
#Paroxysmal A.fib: Pt had multiple episodes of atrial
fibrillation with rapid ventricular rate and was started on
metoprolol 25mg po TID.
-She will be sent home on metoprolol 25mg po TID to control her
rate
Chronic Issues:
#Pericardial Effusion: H/o stable effusion. Pulsus <10, and no
signs/symptoms of tamponade
#H/o lung cancer: H/o stage III lung cancer s/p XRT and chemo.
CT findings suggest ?recurrence.
Transitional Issues:
Patient to be discharged to home with hospice.
Medications on Admission:
. Information was obtained from .
1. Isosource 1.5 Cal *NF* (lactose-free food with fiber) 40
ml/hr enteral daily
Cycle 24 hours. No residual check. Flush with 30mL water q6h
2. Albuterol 0.083% Neb Soln 1 NEB IH TID
3. Fluticasone Propionate NASAL 1 SPRY NU BID
4. FoLIC Acid 1 mg PO DAILY
5. Multivitamins 1 TAB PO DAILY
6. Omeprazole 20 mg PO BID
7. Thiamine 100 mg PO DAILY
8. Tiotropium Bromide 1 CAP IH DAILY
9. Bengay 1 Appl TP BID:PRN muscle pain
10. Aspirin (Buffered) 81 mg PO DAILY
11. Furosemide 40 mg PO DAILY
Hold for SBP<90
12. Spironolactone 100 mg PO DAILY
Hold for SBP< 90
Discharge Medications:
1. Ipratropium Bromide Neb 1 NEB IH Q6H:PRN SOB
RX *ipratropium bromide 0.2 mg/mL (0.02 %) 1 neb inhalation
every 6 hours Disp #*60 Cartridge Refills:*0
2. Lidocaine 5% Patch 1 PTCH TD DAILY
Apply to back
RX *lidocaine 5 % (700 mg/patch) apply one patch to affected
area once a day Disp #*30 Transdermal Patch Refills:*0
3. Metoprolol Tartrate 25 mg PO Q8H
hold for MAP<55 or hr<60
RX *metoprolol tartrate 25 mg 1 tablet(s) by mouth three times a
day Disp #*30 Tablet Refills:*0
4. Morphine Sulfate (Oral Soln.) ___ mg PO Q1-2H air hunger
hold for sedation or rr<10
RX *morphine 20 mg/5 mL ___ ml by mouth q1-2h Disp #*1 Bottle
Refills:*0
RX *morphine 10 mg/5 mL ___ ml by mouth q1-2h Disp #*1 Bottle
Refills:*0
5. OLANZapine (Disintegrating Tablet) 2.5-5 mg PO TID:PRN
anxiety
RX *olanzapine 5 mg ___ tablet(s) by mouth up to three times a
day Disp #*60 Tablet Refills:*0
6. Tiotropium Bromide 1 CAP IH DAILY
7. Bengay 1 Appl TP BID:PRN muscle pain
8. Albuterol 0.083% Neb Soln 1 NEB IH TID
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Acute Renal Failure
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking care of you while you were here at
___.
You were readmitted to the hospital with diarrhea and developed
worsening breathing and continued worsening function of your
liver. Your kidneys were then injured with your worsening liver
function and you decided to refocus your care to being comfort.
You are being sent home to be on hospice who will continue to
help treat your symptoms to make you feel more comfortable.
Followup Instructions:
___
|
19688039-DS-20
| 19,688,039 | 24,249,384 |
DS
| 20 |
2174-02-19 00:00:00
|
2174-02-19 14:19:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: CARDIOTHORACIC
Allergies:
Penicillins / Sulfa (Sulfonamide Antibiotics)
Attending: ___
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
___- left chest tube
___- PICC
History of Present Illness:
Ms. ___ is a ___ year old woman status post coronary
artery bypass grafting x on ___ ___. Her
postoperative course was complicated by orthostatic hypotension
which was treated with midodrine with good effect. She was
discharged to home on ___ with ___ services. She presented to
the ___ ED on ___ with ___ days of progressive shortness
of breath, and left sided, pleuritic chest and flank pain that
is distinctly different from her
pre-operative anginal symptoms. A chest x-ray demonstrated a
large left pleural effusion. A chest CT revealed a large pleural
effusion with near total collapse of the left lung. A chest tube
was placed in the emergency room and drained 2 liters of milky
fluid. She was admitted for further management.
Past Medical History:
Chylothorax
CAD, s/p CABG ___
Anxiety
Bipolar Disorder
C3-4 disc bulge
Chronic Obstructive Pulmonary Disease
Coronary Artery Disease
Degenerative Joint Disease
Diabetes Mellitus Type II
Fibromyalgia
Hepatitis C
Hyperlipidemia
Hypertension
Pyoderma Gangrenosum
Social History:
___
Family History:
Mother: arthritis, cervical and lumbar disc problems, stomach
CA, father: DM, CHF, MGM: Breast CA
Physical Exam:
Temp 97, HR 94, BP 115/94, RR 24, 98% NC
Gen: Anxious, Notably dyspnic but NAD, A&O, Pleasant and
conversant
CV: RRR, No R/G/M
Chest: Median sternotomy incision with skin dehiscence in mid
portion with clear drainage only with pressure applied. No
surrounding erythema. No purulence.
RESP: Dyspnic, Markedly decreased breath sounds in left chest,
left chest wall tender to palpation.
ABD: Soft, ND, ND
Ext: WWP BLE, no appreciable edema
Pertinent Results:
Chest CTA ___
1. Limited examination due to motion artifact. Within these
limitations, no evidence of pulmonary embolism or gross evidence
of acute aortic dissection.
2. Large nonhemorrhagic left pleural effusion with near complete
collapse of the left lung, which is new compared to the CT dated
___.
.
UNILAT UP EXT VEINS US RIGHT Study Date of ___ 2:14 ___
___ FA8 ___ 2:14 ___
UNILAT UP EXT VEINS US RIGHT Clip # ___
Reason: ___ site for thrombus
UNDERLYING MEDICAL CONDITION:
___ RUE ___ site puffy & tender
REASON FOR THIS EXAMINATION:
___ site for thrombus
Wet Read by ___ on SUN ___ 4:14 ___
1. Minimal echogenic intraluminal material within the partially
compressible
left basilic vein surrounding the left PICC may represent
nonocclusive
thrombus. Given its small size, the vein is difficult to fully
assess.
2. No evidence of deep vein thrombosis in the left upper
extremity.
Final Report
EXAMINATION: UNILAT UP EXT VEINS US
INDICATION: ___ RUE ___ site puffy tender, evaluate PICC site
for thrombus
TECHNIQUE: Grey scale and Doppler evaluation was performed on
the right upper
extremity veins.
COMPARISON: None.
FINDINGS:
There is normal flow with respiratory variation in the bilateral
subclavian
veins.
The right internal jugular and axillary veins are patent, show
normal color
flow and compressibility. The right brachial and cephalic veins
are patent,
compressible, and show normal color flow and augmentation. A
right PICC is
present within the relatively diminutive basilic vein. Minimal
color flow is
demonstrated and a small amount of echogenic material is present
within the
lumen surrounding the PICC. The vein remains partially
compressible.
IMPRESSION:
1. Minimal echogenic intraluminal material within the partially
compressible
left basilic vein surrounding the left PICC may represent
nonocclusive
thrombus. Given its small size, the vein is difficult to fully
assess.
2. No evidence of deep vein thrombosis in the left upper
extremity.
NOTIFICATION: The findings were discussed with ___,
M.D. by ___
___, M.D. on the telephone on ___ at 4:12 ___, 32
minutes after
discovery of the findings.
BY ELECTRONICALLY SIGNING THIS REPORT, I THE ATTENDING PHYSICIAN
ATTEST THAT ___ HAVE REVIEWED THE ABOVE IMAGES FOR THE ABOVE
EXAMINATION(S) AND AGREE WITH THE FINDINGS AS DOCUMENTED ABOVE.
___, MD
___, MD electronically signed on ___
8:11 AM
.
___ 06:44AM BLOOD WBC-7.9 RBC-3.67* Hgb-9.8* Hct-31.9*
MCV-87 MCH-26.7 MCHC-30.7* RDW-14.3 RDWSD-45.1 Plt ___
___ 05:35AM BLOOD WBC-13.0* RBC-4.58 Hgb-12.3 Hct-40.5
MCV-88 MCH-26.9 MCHC-30.4* RDW-14.2 RDWSD-44.8 Plt ___
___ 06:44AM BLOOD Glucose-144* UreaN-18 Creat-0.4 Na-139
K-3.8 Cl-105 HCO3-27 AnGap-11
___ 04:07AM BLOOD Glucose-186* UreaN-23* Creat-0.5 Na-138
K-3.9 Cl-106 HCO3-22 AnGap-14
___ 06:44AM BLOOD Calcium-8.1* Phos-2.9 Mg-2.1
Brief Hospital Course:
She was admitted to ___ for further care. Thoracic
surgery was consulted to aid in the management of her
chylothorax. Octreotide was initiated as well as TPN. PICC was
placed. Antibiotics started for sternal drainage. The sternal
wound was debrided at the bedside. Wound improved and by the
time of discharge she was off antibiotics. She is instructed to
continue packing the wound with wet to dry dressings daily with
___ assistance. Thoracic Surgery continued to follow
chylothorax. It was decided that she would not require thoracic
duct ligation. Chest tube was discontinued. Octreotide was
discontinued for nausea. She was discharged home with ___ on
hospital day 11 (POD 35) on a regular diet. She will follow-up
with Thoracic Surgery later this week.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 325-650 mg PO Q6H
2. Aspirin EC 81 mg PO DAILY
3. Atorvastatin 80 mg PO QPM
4. Gabapentin 600 mg PO TID
5. MetFORMIN (Glucophage) 500 mg PO BID
6. Minocycline 100 mg PO Q12H
7. Prasugrel 10 mg PO DAILY
8. Venlafaxine XR 150 mg PO BID
9. HYDROmorphone (Dilaudid) 2 mg PO Q4H:PRN Pain - Severe
10. Maalox/Diphenhydramine/Lidocaine 10 mL PO TID
11. Omeprazole 20 mg PO BID
12. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation
inhalation BID
Discharge Medications:
1. Aspirin EC 81 mg PO DAILY
RX *aspirin 81 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*1
2. Atorvastatin 80 mg PO QPM
RX *atorvastatin 80 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*1
3. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*0
4. HydrOXYzine ___ mg PO BID:PRN anxiety
RX *hydroxyzine HCl 25 mg ___ by mouth twice a day Disp #*30
Tablet Refills:*0
5. LORazepam 0.5-1 mg PO QHS:PRN sleep
RX *lorazepam 0.5 mg ___ by mouth at bedtime Disp #*20 Tablet
Refills:*0
6. Miconazole Nitrate Vag Cream 2% 1 Appl VG QHS Duration: 7
Days
RX *miconazole nitrate 2 % apply as directed at bedtime Disp #*1
Each Refills:*0
7. Miconazole Powder 2% 1 Appl TP BID
RX *miconazole nitrate [Micro-Guard] 2 % apply under breasts
twice a day Refills:*1
8. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain -
Moderate
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*40 Tablet Refills:*0
9. Acetaminophen ___ mg PO Q6H:PRN Pain - Mild
10. Gabapentin 600 mg PO TID
RX *gabapentin 600 mg 1 tablet(s) by mouth three times a day
Disp #*90 Tablet Refills:*1
11. MetFORMIN (Glucophage) 500 mg PO BID
start ___
RX *metformin 500 mg 1 tablet(s) by mouth twice a day Disp #*60
Tablet Refills:*1
12. Minocycline 100 mg PO Q12H
RX *minocycline 100 mg 1 tablet(s) by mouth every twelve (12)
hours Disp #*60 Tablet Refills:*1
13. Venlafaxine XR 150 mg PO BID
RX *venlafaxine 150 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*1
14. Omeprazole 20 mg PO BID
RX *omeprazole 20 mg 1 capsule(s) by mouth twice a day Disp #*60
Capsule Refills:*1
15. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation
inhalation BID
RX *budesonide-formoterol [Symbicort] 160 mcg-4.5 mcg/actuation
1 twice a day Disp #*1 Inhaler Refills:*1
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Chylothorax
Anxiety
Bipolar Disorder
C3-4 disc bulge
Chronic Obstructive Pulmonary Disease
Coronary Artery Disease
Degenerative Joint Disease
Diabetes Mellitus Type II
Fibromyalgia
Hepatitis C
Hyperlipidemia
Hypertension
Pyoderma Gangrenosum
Discharge Condition:
Alert and oriented x3 non-focal
Ambulating independently
Sternal pain managed with oral analgesics
Sternal Incision - no erythema
- mid-inferior portion debrided this admission- continue to pack
wet to dry daily
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:
___
|
19688213-DS-17
| 19,688,213 | 27,575,741 |
DS
| 17 |
2114-06-23 00:00:00
|
2114-06-23 14:25:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Cephalosporins / levofloxacin / amoxicillin / Augmentin / Ativan
/ Quinolones / Iodinated Contrast Media - Oral and IV Dye
Attending: ___
Chief Complaint:
dyspnea
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. ___ is a ___ yo man PMH of chronic trach secondary to
progressive neurodegenerative disorder leading to spastic
quadriplegia, blind who presented to ___ with
respiratory distress from facility (where he lives). There was
initial concern that his trach was malpositioned but this was
evaluated at ___ and found not to be the case. He was
noted to have blood tinged sputum around his trach. Per rehanb
notes also noted to be cyanotic with sat of 70% on 3L that
improved to 98% on 15 O2. Per ___ note, "on arrival to
the emergency department he is in no acute distress and nontoxic
appearing, oxygen saturation 100% on bagging and continued to be
100% with trach
mask blow by cool mist. He has no active bleeding from his
tracheostomy site but secretions are blood tinged." On the
evening of ___ his blood pressure dropped to systolic ___ and he
was given 1L of fluid without improvement in pressure and then
initiated on norepinephrine, which was weaned prior to his
arrival to ___ ED. He was also given a dose of aztreonam. He
was also noted to have troponin of 0.14 without any chest pain.
Given concern for hypoxemia, hypotension he was transferred to
___ ED for further evaluation.
On arrival to ___ ED his vital signs were 73 117/76 16 100%
RA. He was not on pressors. He was given his preadmission
medications and a dose of vancomycin. CXR showed atelectasis
vs. consolidation. CTA was performed to rule out PE and although
limited study did not show PE. Labs notable for WBC 5.5, Hg 10,
INR 13.1 but on repeat 1.1. Crt 0.4. He had hives following
receiving contrast for CTA and had an allergic reaction for
which he received Benadryl.
On arrival to the MICU, he is on trach mask.
Past Medical History:
History of: Anxiety Disorder, DVT, GERD, Depression, Pneumonia
and Seizure.
Hx Renal Disorder: N neurogenic bladder
Seizure,N progressive autoimmune neurological disorder ,
qudrapelegia, gtube,DVT,BIL UPPER/LOWER EXTREMITCONTRACTURES
Social History:
___
Family History:
unable to obtain
Physical Exam:
Admission Physical Exam:
=======================
VITALS: 97.7 85 128/87 100% 40% trach collar
GENERAL: Alert, mouthing words
HEENT: Sclera anicteric, MMM with copious secretions
NECK: supple, JVP not elevated, no LAD, trach in place, minimal
blood tinged sputum
LUNGS: Anterior Clear to auscultation bilaterally, no wheezes,
rales, rhonchi
CV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs,
gallops
ABD: soft, non-tender, non-distended, bowel sounds present, no
rebound tenderness or guarding, no organomegaly
EXT: contracted, warm, no edema
Discharge Exam:
================
GENERAL: Alert, mouthing words
HEENT: Sclera anicteric, MMM with copious secretions
NECK: supple, JVP not elevated, no LAD, trach in place, minimal
blood tinged sputum
LUNGS: Anterior Clear to auscultation bilaterally, no wheezes,
rales, rhonchi
CV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs,
gallops
ABD: soft, non-tender, non-distended, bowel sounds present, no
rebound tenderness or guarding, no organomegaly
EXT: contracted, warm, no edema
Pertinent Results:
Admission Labs:
==============
___ 08:08AM BLOOD WBC-5.5 RBC-3.46* Hgb-10.6* Hct-32.7*
MCV-95 MCH-30.6 MCHC-32.4 RDW-13.0 RDWSD-44.5 Plt ___
___ 08:08AM BLOOD Neuts-47.8 ___ Monos-8.2 Eos-3.6
Baso-0.4 Im ___ AbsNeut-2.62 AbsLymp-2.17 AbsMono-0.45
AbsEos-0.20 AbsBaso-0.02
___ 08:08AM BLOOD Glucose-99 UreaN-12 Creat-0.4* Na-143
K-3.8 Cl-102 HCO3-31 AnGap-14
___ 08:08AM BLOOD ALT-22 AST-26 AlkPhos-60 TotBili-0.3
___ 08:08AM BLOOD cTropnT-0.02*
___ 08:08AM BLOOD Albumin-3.9 Iron-63
___ 08:08AM BLOOD calTIBC-311 Ferritn-163 TRF-239
___ 06:04PM BLOOD ___ pO2-50* pCO2-63* pH-7.34*
calTCO2-35* Base XS-5
___ 08:33AM BLOOD ___ pO2-46* pCO2-71* pH-7.32*
calTCO2-38* Base XS-6
Imaging:
=======
CTA chest:
1. The study is significantly limited by low lung volumes and
respiratory
motion. No evidence of pulmonary embolism or aortic abnormality.
2. Mild right hilar and mediastinal lymphadenopathy.
3. Small right pleural effusion with associated moderate pleural
thickening and calcification at the right lung base.
Brief Hospital Course:
Mr. ___ is a ___ yo man PMH of chronic trach secondary to
progressive neurodegenerative disorder leading to spastic
quadriplegia, blind who presented to ___ with
respiratory distress from facility (where he lives). There was
initial concern that his trach was malpositioned but this was
evaluated at ___ and found not to be the case. He was
noted to have blood tinged sputum around his trach. Per rehanb
notes also noted to be cyanotic with sat of 70% on 3L that
improved to 98% on 15 O2. Per ___ note, "on arrival to
the emergency department he is in no acute distress and nontoxic
appearing, oxygen saturation 100% on bagging and continued to be
100% with trach
mask blow by cool mist. He has no active bleeding from his
tracheostomy site but secretions are blood tinged." On the
evening of ___ his blood pressure dropped to systolic ___ and he
was given 1L of fluid without improvement in pressure and then
initiated on norepinephrine, which was weaned prior to his
arrival to ___ ED. He was also given a dose of aztreonam. He
was also noted to have troponin of 0.14 without any chest pain.
Given concern for hypoxemia, hypotension he was transferred to
___ ED for further evaluation.
On arrival to ___ ED his vital signs were 73 117/76 16 100%
RA. He was not on pressors. He was given his preadmission
medications and a dose of vancomycin. CXR showed atelectasis
vs. consolidation. CTA was performed to rule out PE and although
limited study did not show PE. Labs notable for WBC 5.5, Hg 10,
INR 13.1 but on repeat 1.1. Crt 0.4. He had hives following
receiving contrast for CTA and had an allergic reaction for
which he received Benadryl.
On arrival the MICU he was hemodynamically stable and satting
100% on trach mask. He received suction overnight and was
diuresed with Lasix 20mg IV with improvement in his respiratory
status. Given his decreased Hg iron studies were sent that
showed low normal ferritin and iron.
=
=
=
=
=
=
================================================================
Transitional Issues:
=
=
=
=
=
=
================================================================
- patient preadmission medication list contains both metoprolol
and midodrine, unclear why he is on both of these medicines,
metoprolol discontinued on discharge
- would recommend against keeping patient on standing
antipsychotics
- patient did not receive his 5-hydroxytryptophan (5-HTP)) while
inpatient as this is not on formulary
- Hg at discharge was 10 from baseline 13, would recommend
further work-up upon discharge
-Patient will need repeat CT chest in ___ to monitor
pleural thickening
- HCP: ___ ___ (father)
- Code: Full
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Famotidine 20 mg PO DAILY
2. melatonin 3 mg oral QHS
3. Mirtazapine 15 mg PO QHS
4. Senna 17.2 mg PO BID
5. Tamsulosin 0.4 mg PO QHS
6. valproic acid (as sodium salt) 15 mL oral daily
7. Haloperidol 0.25 mg PO BID
8. Midodrine 10 mg PO BID
9. Diazepam 2 mg PO Q8H:PRN anxiety
10. Baclofen 20 mg PO TID
11. Gabapentin 600 mg PO TID
12. Metoprolol Tartrate 12.5 mg PO TID
13. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain -
Moderate
14. Milk of Magnesia 30 mL PO QHS
15. 5-HTP (5-hydroxytryptophan (5-HTP)) 100 mg oral Q6H:PRN
16. Albuterol 0.083% Neb Soln 1 NEB IH BID
17. valproic acid (as sodium salt) 20 mL oral QHS
Discharge Medications:
1. 5-HTP (5-hydroxytryptophan (5-HTP)) 100 mg oral Q6H:PRN
2. Albuterol 0.083% Neb Soln 1 NEB IH BID
3. Baclofen 20 mg PO TID
4. Diazepam 2 mg PO Q8H:PRN anxiety
5. Famotidine 20 mg PO DAILY
6. Gabapentin 600 mg PO TID
7. melatonin 3 mg oral QHS
8. Midodrine 10 mg PO BID
9. Milk of Magnesia 30 mL PO QHS
10. Mirtazapine 15 mg PO QHS
11. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain -
Moderate
12. Senna 17.2 mg PO BID
13. Tamsulosin 0.4 mg PO QHS
14. valproic acid (as sodium salt) 15 mL oral daily
15. valproic acid (as sodium salt) 20 mL oral QHS
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
transient hypotension
bleeding from trach site
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Lethargic but arousable.
Activity Status: Bedbound.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you at ___. You were
admitted to the hospital because of bleeding from your trach and
low blood pressure. Both of these had resolved by the time you
arrived at ___ so you were just monitored overnight.
Followup Instructions:
___
|
19688748-DS-7
| 19,688,748 | 23,403,244 |
DS
| 7 |
2174-06-23 00:00:00
|
2174-06-23 03:46:00
|
Name: ___ ___ No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROSURGERY
Allergies:
Bactrim
Attending: ___.
Chief Complaint:
Traumatic brain injury
Major Surgical ___ Invasive Procedure:
___ - Left craniectomy for subdural hematoma and
intraparenchymal hemorrhage evacuation
___ - Tracheostomy
___ - PEG tube placement
___ - Tracheostomy downsizing
___ - Tracheostomy decannulization
History of Present Illness:
___ is a ___ year old male who presented to the
Emergency Department on ___ as a transfer from an outside
facility after being found down by his family. CT of the head at
the outside facility revealed a right hemispheric subarachnoid
hemorrhage, left frontoparietal subdural hematoma, and left
frontotemporal intraparenchymal hemorrhage. Patient was
transferred to ___ for further
evaluation and management. The Neurosurgery Service was
consulted for question of acute neurosurgical intervention.
Past Medical History:
Human Immunodeficiency Virus/Acquired Immunodeficiency Syndrome,
otherwise unknown.
Social History:
___
Family History:
Unknown.
Physical Exam:
On Admission:
-------------
Vital Signs: T 104.4F, HR 114, BP 152/97, RR 23, O2Sat 99% room
air
General: Well dressed, well nourished. Moaning, no acute
distress.
Head, Eyes, Ears, Nose, Throat: Pupils equal, round, and
reactive to light.
Neck: Supple.
Extremities: Warm and well perfused. Urticarial rash on
bilateral upper extremities, inner thighs, groin. Spreading to
left face.
___ 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
[x]2 Incomprehensible sounds
[ ]3 Inappropriate words
[ ]4 Confused, disoriented
[ ]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
[x]5 Localizes to painful stimuli
[ ]6 Obeys commands
Total: 11
Intracranial Hemorrhage Score:
___ Coma Scale
[ ]2 ___ Coma Scale ___
[x]1 ___ Coma Scale ___
[ ]0 ___ Coma Scale ___
Intracranial Hemorrhage Volume
[x]1 30 mL ___ greater
[ ]0 Less than 30 mL
Intraventricular Hemorrhage
[ ]1 Present
[x]0 Absent
Infratentorial Intracranial Hemorrhage
___ Yes
[ ]0 No
Age
[ ]1 ___ years old ___ greater
[x]0 Less than ___ years old
Total: 3
Exam:
No signs of head trauma. Face appears symmetric. Eyes open
spontaneously, but closed most exam. Turning head spontaneously
on pillow and sitting self up in bed. Moaning, incomprehensible
sounds. No comprehensible speech. Does not follow commands.
Pupils: Pupils equal, round, and reactive to light, 3-2mm
bilaterally.
Motor: Slightly increased tone in the right upper extremity,
otherwise normal bulk and tone. No abnormal movements ___
tremors. Moves all extremities spontaneously and purposefully,
more brisk on the left side. Patient able to use his arms to
adjust blanket on lower extremities, also bending knees in bed.
Toes upgoing bilaterally.
On Discharge:
-------------
General:
Vital Signs: T 97.3F, HR 58, BP 104/72, RR 18, O2Sat 98% room
air
Exam:
Of note, patient is ___ speaking, was examined in ___.
Opens Eyes: [x]Spontaneous [ ]To voice [ ]To noxious
Follows Commands: [x]Simple - Intermittently [ ]Complex [ ]None
Pupils: Pupils equal, round, and reactive to light
Speech Fluent: [ ]Yes [x]No - Intermittently attempts to respond
to questions, speech is incomprehensible
Comprehension Intact: [x]Yes - Somewhat [ ]No
Motor: Right upper extremity contracted with some spontaneous
movement of fingers, briskly withdraws to noxious. Left upper
extremity moves purposefully. Spontaneous movement in bilateral
lower extremities.
Surgical Incision:
[x]Clean, dry, intact
[x]Sunken
Pertinent Results:
Please see OMR for relevant laboratory and imaging results.
Brief Hospital Course:
___ (AKA ___ Critical) is a ___ year old male who
presented to the Emergency Department on ___ as a transfer
from an outside facility after being found down by his family.
CT of the head at the outside facility revealed a right
hemispheric subarachnoid hemorrhage, left frontoparietal
subdural hematoma, and left frontotemporal intraparenchymal
hemorrhage. Patient was also febrile to 104.4F and hypertensive.
Toxicology screen was positive for cocaine. Patient was
transferred to ___ for further
evaluation and management. Patient was given levetiracetam en
route, and started on levetiracetam on arrival in the Emergency
Department. The Neurosurgery Service was consulted for question
of acute neurosurgical intervention.
#Traumatic Brain Injury
The patient was taken to the operating room emergently for a
left craniectomy subdural hematoma and intraparenchymal
hemorrhage evacuation. Please see separately dictated operative
report by Dr. ___ further details. A surgical drain was
left in place postoperatively, and subsequently removed on
___. The patient was monitored in the Neurosciences
Intensive Care Unit postoperatively. Postoperative CT of the
head revealed a new left sided extra axial hematoma with
worsening midline shift, however further neurosurgical
intervention was not indicated given the patient's poor
neurologic exam. Patient was managed medically with 3%
hypertonic saline. Patient was noted to have an enlarging left
pupil several hours after surgery, which was subsequently noted
to be nonreactive. Patient received a dose of 23% hypertonic
saline and was given 3% hypertonic saline to prevent rebound
cerebral edema. Patient was weaned off dexmedetomidine and
started on clonidine. His fentanyl drip was weaned, and he was
given boluses as needed. He was continued on levetiracetam.
Continuous electroencephalography was applied to rule out
seizures, which showed occasional left frontal epileptiform
discharges, but no electrographic seizures. Continuous
electroencephalography was discontinued on ___. Patient
remained neurologically stable and was transferred to the step
down unit on ___ and then to the floor on ___. CT of
the head with and without contrast on ___ showed a left
frontal mixed density postoperative collection with underlying
enhancement, consistent with postoperative changes, no definite
infection. Levetiracetam was discontinued on ___, as the
patient had no seizures. Another CT of the head with and without
contrast was obtained on ___ for repeat evaluation of
infection, which was again negative. Patient was started on
baclofen on ___ for right upper extremity spasticity and
was titrated up on ___. Patient continued to remain stable
on the floor with mildly increased alertness. On ___, the
patient was neurologically stable. He was afebrile with stable
vital signs, tolerating activity, tolerating a diet, voiding and
stooling without difficulty, and his pain was well controlled.
He was discharged home to ___ in stable condition. He was
given one month's worth of medications and was instructed to
establish healthcare in ___.
#Seizures
While in the Neurosciences Intensive Care Unit, the patient was
on continuous electroencephalography, which demonstrated
frequent epileptiform discharges over the left frontal region,
indicative of focal cortical irritability. However, there were
no electrographic seizures. The patient received levetiracetam
for seizure prophylaxis in the setting of his intracranial
hemorrhages, which was discontinued on ___. Patient was
restarted on levetiracetam on ___ in the setting of febrile
seizures. On ___, the patient missed his morning dose of
levetiracetam and had two episodes of bilateral upper extremity
shaking, which self resolved within 30 seconds, and patient
returned to his neurologic baseline. The patient's levetiracetam
dose was increased. On ___, patient had a seizure with
bilateral lower extremity shaking after his levetiracetam dose
was administered late. This self resolved, and patient returned
to his neurologic baseline. He was continued on levetiracetam
1000mg twice daily. Patient continued to be monitored for any
more seizures. Patient had no additional seizures during his
hospitalization.
#Hypertension
Patient was started and continued on metoprolol for hypertension
with good effect.
#Respiratory Failure
Patient was intubated in the Emergency Department. Ventilator
settings were adjusted over his stay in the ___
Intensive Care Unit. Patient had a chest x-ray on ___,
which was concerning for pulmonary edema. Patient received 20mg
of intravenous furosemide with improvement. Extubation was
discussed with the family, who agreed to attempt extubation.
Patient was extubated on ___ and was reintubated after
several minutes due to tachypnea and upper respiratory stridor.
Patient underwent a tracheostomy on ___. He required
frequent suctioning and albuterol and ipratropium nebulizers,
but remained stable. Tracheostomy sutures were removed by Acute
Care Surgery on ___. Patient began working with Speech and
Language Pathology to attempt weaning off the tracheostomy.
Patient underwent multiple failed speaking valve trials, and
Speech and Language Pathology continued to work with him while
he was hospitalized. Acute Care Surgery recommended that the
patient's tracheostomy be downsized from an 8 Portex to a 7
Portex, which was done by Respiratory Therapy on ___. On
___, the tracheostomy tube was noted to have been pulled
out about one inch, however the patient was in no respiratory
distress and had an oxygen saturation of 95% on room air.
Respiratory Therapy evaluated the tracheostomy, which was shown
to have no air flow per their end tidal carbon dioxide device.
Respiratory Therapy was unable to readvance the tracheostomy
tube and noted that the tract was likely closed behind it. Acute
Care Surgery was paged to assess the tracheostomy for possible
decannulization. The tracheostomy was decannulized on ___
by Acute Care Surgery. The patient's respiratory status remained
stable throughout the rest of his hospitalization.
#Dysphagia
Speech and Language Pathology and Nutrition were both consulted.
Patient received tube feeds throughout his hospitalization. He
underwent percutaneous endoscopic gastrostomy on ___, and
tube feeds were well tolerated. On ___, patient pulled on
the percutaneous endoscopic gastrostomy tube. An x-ray was
performed and confirmed that the percutaneous endoscopic
gastrostomy tube was in good position. Speech and Language
Pathology and Nutrition continued to follow the patient and
worked with him to advance his diet over time.
#Fevers
Patient was febrile to 104.4F on arrival to the Emergency
Department with a diffuse, spreading urticarial rash. Fever
work-up and empiric antibiotics were initiated in the
Neurosciences Intensive Care Unit. Patient was evaluated for
possible meningitis, and was continued on a course of meropenem
and vancomycin from ___ through ___. Blood cultures on
___ grew coagulase negative Staphylococci, however all
repeat blood cultures were negative. Urine culture was negative.
Sputum culture on ___ was negative. The patient continued
with intermittent fevers with an unclear source. Cefepime and
vancomycin were started on ___, which were continued
through ___ for a suspected surgical site infection per
recommendations from Infectious Disease. On ___, the
patient was febrile to 101.2F and had new onset seizures lasting
one to two minutes. He was restarted on levetiracetam.
Pancultures were unrevealing, and Infectious Disease recommended
holding off on antibiotics unless the patient became febrile
again. Patient remained afebrile for the remainder of his
hospitalization.
#Hyponatremia, Hypernatremia
The patient was started on a 3% hypertonic saline drip during
this hospitalization, which was titrated for a sodium goal of
normonatremia. Patient was weaned off the 3% hypertonic saline,
and his sodium stabilized. Patient was subsequently
hypernatremic. His free water flushes were increased, and his
sodium normalized.
#Human Immunodeficiency Virus/Acquired Immunodeficiency Syndrome
Patient came in with a history of human immunodeficiency virus,
diagnosed in ___ at ___. Per
their records, patient underwent initial antiretroviral therapy,
but was lost to follow-up since ___. Further testing
revealed that the patient has acquired immunodeficiency
syndrome. CD4 count on admission was 187 with a viral load of
400,000. Patient was started on highly active antiretroviral
therapy on ___ per Infectious Disease. He was also started
on atovaquone daily for Pneumocystis pneumonia and toxoplasmosis
prophylaxis given that the patient is allergic to
sulfamethoxazole/trimethoprim. Viral load and liver function
tests were monitored regularly during the remainder of the
patient's hospitalization.
#Groin Rash
Patient was started on miconazole cream on ___ for a groin
rash. Infectious Disease was consulted, and stated that the rash
was consistent with condyloma external genital warts secondary
human papilloma virus. Serum rapid plasma reagin with prozone
resulted nonreactive. The rash subsequently resolved.
#Right Eye Conjunctivitis
Patient was started on erythromycin ointment for conjunctivitis
in the right eye, which subsequently resolved.
#Face/Hairline Rash
Patient was noted to have a rash on his face periorally in
facial hair and along his hairline. Dermatology was consulted
and diagnosed the rash as seborrheic dermatitis. Ketaconazole
cream was started for the face, and ketaconazole shampoo was
started for the hairline. The rash subsequently resolved.
#Disposition
A family meeting was held on ___, and the family requested
more time to make a decision regarding the patient's goals of
care. The Neurosciences Intensive Care Unit attempted to contact
the patient's brother regarding goals of care. Acute Care
Surgery was consulted for consideration of tracheostomy and
percutaneous endoscopic gastrostomy on ___. A family
meeting was held on ___, and the family decided to move
forward with the tracheostomy and percutaneous endoscopic
gastrostomy, which the patient received on ___. Another
family meeting was held on ___ to determine goals of care.
The family requested additional time to process and potentially
time to work out discharge planning with family. Ongoing
discussions with case management and the family were held.
Patient's family did not wish to pursue comfort measures only ___
hospice care, however stated that they were unable to care for
the patient at home. The patient also was determined to have no
insurance benefits for rehabilitation. Guardianship was
initiated. A family meeting was held on ___, at which time
the family noted that they did not have the resources to take
the patient home. There were no rehabilitative options at that
time. The patient's brother obtained guardianship. The patient
qualified for ___ Limited, but continued to have no
rehabilitation benefits. A family meeting was scheduled for
___. Per the family meeting on ___, plan for patient
to return to ___ where he will be cared for by his mother
and siblings. Case management continued to work on arranging
appropriate resources and equipment for a safe discharge. A
series of family meetings were held for family teaching. Patient
was discharged home to ___ on ___ in stable condition.
He was given one month's worth of medications and was instructed
to establish healthcare in ___.
___ Heart ___ Stroke Association Core
Measures for Subarachnoid Hemorrhage/Intracranial Hemorrhage:
1. Water swallow test before any oral intake? [x]Yes [ ]No
2. Venous thromboembolism prophylaxis administered? [x]Yes [ ]No
3. Smoking cessation counseling given? [ ]Yes [x]No [Reason: (
)Nonsmoker (x)Unable to participate]
4. Stroke education given in written form? [x]Yes [ ]No
5. Assessment for rehabilitation ___ rehabilitation services
considered? [x]Yes [ ]No
Stroke Measures:
1. Was ___ and ___ scoring performed within six hours of
arrival? [x]Yes [ ]No
2. Was Intracranial Hemorrhage scoring performed within six
hours of arrival? [x]Yes [ ]No
3. Was a procoagulant reversal agent given? [ ]Yes [x]No
[Reason: Not clinically indicated]
4. Was nimodipine given? [ ]Yes [x]No [Reason: Not clinically
indicated]
Medications on Admission:
Unknown.
Discharge Medications:
1. Acetaminophen 325-650 mg PO/NG Q6H:PRN fever ___ pain
Do not exceed 3000mg in 24 hours.
RX *acetaminophen 325 mg ___ tablet(s) by mouth every 6 hours as
needed for pain Disp #*240 Tablet Refills:*0
2. Atovaquone Suspension 1500 mg PO/NG DAILY
RX *atovaquone 750 mg/5 mL 10 mL by mouth once daily Disp #*420
Milliliter Milliliter Refills:*0
3. Baclofen 10 mg PO/NG TID
RX *baclofen 10 mg 1 tablet(s) by mouth three times daily Disp
#*90 Tablet Refills:*0
4. Dolutegravir 50 mg PO DAILY
RX *dolutegravir [Tivicay] 50 mg 1 tablet(s) by mouth once daily
Disp #*30 Tablet Refills:*0
5. Emtricitabine-Tenofovir alafen (200mg-25mg) *DESCOVY* 1 TAB
PO DAILY
RX *emtricitabine-tenofovir alafen [Descovy] 200 mg-25 mg 1
tablet(s) by mouth once daily Disp #*30 Tablet Refills:*0
6. Enoxaparin Sodium 40 mg SC DAILY
RX *enoxaparin 40 mg/0.4 mL 0.4 mL SC once daily Disp #*30
Syringe Refills:*0
7. LevETIRAcetam 1000 mg PO BID
RX *levetiracetam [Keppra] 1,000 mg 1 tablet(s) by mouth twice
daily Disp #*60 Tablet Refills:*0
8. LORazepam 0.5-2 mg PO ONCE:PRN Anxiety while traveling
Duration: 1 Dose
RX *lorazepam 0.5 mg ___ tablet(s) by mouth once Disp #*4 Tablet
Refills:*0
9. Metoprolol Tartrate 25 mg PO Q8H
RX *metoprolol tartrate 25 mg 1 tablet(s) by mouth every 8 hours
Disp #*90 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
- Traumatic brain injury
Discharge Condition:
Mental Status: Confused, always.
Level of Consciousness: Alert and interactive.
Activity Status: Out of bed with assistance to chair ___
wheelchair.
Discharge Instructions:
Surgery:
- You underwent a surgery called a craniectomy. A portion of
your skull was removed to allow your brain to swell. You must
wear a helmet at all times when up in a chair ___ out of bed.
- It is best to keep your surgical incision open to air, but it
is okay to cover it when outside.
- Please call doctor ___ neurosurgeon if there are any signs of
infection like fever, redness, ___ drainage.
Activity:
- We recommend that you avoid heavy lifting, running, climbing,
___ other strenuous exercise.
- You make take leisurely walks and slowly increase your
activity at your own pace once you are symptom free at rest.
___ try to do too much all at once.
- You may take a shower.
- No driving.
- No contact sports.
Medications:
- Resume your normal medications, and begin new medications as
directed.
- Please do not take any blood thinning medication (aspirin,
Coumadin, ibuprofen, Plavix, etc.) until cleared by
neurosurgeon.
- You have been discharged on levetiracetam (Keppra). This
medication helps to prevent seizures. Please continue this
medication as indicated on your discharge instructions. It is
important that you take this medication consistently and on
time.
- You may use acetaminophen (Tylenol) for minor discomfort if
you are not otherwise restricted from taking this medication.
- Please do not smoke.
What You ___ Experience:
- You may have difficulty paying attention, concentrating, and
remembering new information.
- Emotional and behavioral difficulties are common.
- Feeling more tired, restlessness, irritability, and mood
swings are also common.
- Constipation is common. Be sure to drink plenty of fluids and
eat a high fiber diet.
Headaches:
- Headache is one of the most common symptoms after a traumatic
brain injury.
- Most headaches are not dangerous, but you should call
neurosurgeon if the headache gets worse, if you have increased
sleepiness, if you have nausea ___ vomiting, ___ if you develop
arm ___ leg weakness.
- Mild pain medications may be helpful with these headaches, but
avoid taking pain medications on a daily basis unless
prescribed.
- There are other things that can be done to help with your
headaches, including daily exercise, getting enough sleep,
avoiding caffeine, ice ___ heat packs, relaxation, meditation,
massage, and acupuncture.
When To Call A Doctor ___:
- Severe pain, redness, swelling, ___ drainage from the surgical
incision site
- Fever greater than 101.5 degrees Fahrenheit
- Nausea ___ vomiting
- Extreme sleepiness and not being able to stay awake
- Severe headaches not relieved by pain medications
- Seizures
- Any new problems with your vision ___ ability to speak
- Weakness ___ changes in sensation in your face, arms, ___ legs
Call An Ambulance And Go To The Nearest Emergency Department If
You Experience Any Of The Following:
- Sudden numbness ___ weakness in the face, arms, ___ legs
- Sudden confusion ___ trouble speaking ___ understanding
- Sudden trouble walking, dizziness, ___ loss of balance ___
coordination
- Sudden severe headaches with no known reason
Followup Instructions:
___
|
19688889-DS-11
| 19,688,889 | 27,930,234 |
DS
| 11 |
2152-09-24 00:00:00
|
2152-09-24 20:01:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Aspirin
Attending: ___.
Chief Complaint:
2 weeks DOE and epigastric discomfort
Major Surgical or Invasive Procedure:
___ - DC PPM via cephalic vein
History of Present Illness:
___ year old female with PMHx HTN, HLD, CKD who p/w 2wk DOE and
epigastric discomfort.
Patient reported that since 2 weeks ago she started to have SOB
on exertion like climbing stairs. It's gradual onset and has
been
progressing. Denies any chest pain on exertion, or dizziness,
lightheadedness, or fainting. Also noted that her BP has been
more elevated the last couple weeks with SBP up to 160s, when it
usually is very well controlled. This morning it was 180 and
she
reported shaking. She noticed that she has more abdominal
bloating and has gained a few pounds during the winter. She
denies orthopnea, PND, headache, worsening blurry vision,
syncope, nausea/vomiting, abdominal pain. She has been having 3
solid BMs since 2 weeks ago but no diarrhea or blood in stool or
black stool. She denies dysuria. She denies recent sickness,
changes in diet/meds/UOP. She denies recent sick contact,
fever/chills.
In the ED initial vitals were: 97.3 54 160/75 16 97% RA
Exam:
HEENT: Atraumatic, Moist mucous membranes, pupils equal and
reactive bilaterally, JVD flat
Cardiovascular: bradycardia, audible S1 and S2
Extremities: 2+ pulses bilaterally, +1 pitting edema b/l ___ up
to
shins
EKG: sinus rhythm. 2:1 AV block. PR interval: 155
Labs/studies notable for:
14.3
___ 19 AGap=13
-------------<169
4.0 25 1.3
Trop neg x2
ProBNP: ___
CXR:
1. Subtle opacification at the right lung base is nonspecific
and
may reflect atelectasis, however superimposed pneumonia would be
difficult to exclude.
2. Mild prominence of the central pulmonary vasculature without
evidence of overt edema.
On the floor patient reports history as above. States she feels
well at rest, only short of breath when going up the stairs.
REVIEW OF SYSTEMS:
On further review of systems, denies fevers or chills. Denies
any
prior history of stroke, TIA, deep venous thrombosis, pulmonary
embolism, bleeding at the time of surgery, myalgias, joint
pains,
cough, hemoptysis, black stools or red stools. Denies exertional
buttock or calf pain. All of the other review of systems were
negative.
Past Medical History:
htn
hl
unchanged from past notes with PCP, reviewed with patient
Social History:
___
Family History:
unchanged from past notes with PCP, reviewed with patient
Physical Exam:
ADMISSION PHYSICAL EXAMINATION:
=======================
VS: 98 78 137/75 18 100% RA
GENERAL: Well developed, well nourished in NAD. Oriented x3.
Mood, affect appropriate.
HEENT: PERRL. EOMI.
NECK: Supple. JVP of 12cm
CARDIAC: RRR. S1, S2. Soft systolic ejection murmur best heard
over LUSB
LUNGS: CTA b/l. Unlabored breathing
ABDOMEN: Soft, non-tender, non-distended. No hepatomegaly. No
splenomegaly.
EXTREMITIES: Warm, well perfused. 1+ edema.
SKIN: No significant skin lesions or rashes.
PULSES: Distal pulses palpable and symmetric.
DISCHARGE PHYSICAL EXAM:
=============================
VS: 98.3 PO 134 / 64R ___ ___
GEN: overweight elderly woman resting in bed in NAD
HEENT: Atraumatic, Moist mucous membranes, pupils equal and
reactive bilaterally, JVD flat
Cardiovascular: bradycardia, audible S1 and S2, no m/r/g
Pulm: CTAB, no wheezes/crackles
Abd: soft NT/ND
Extremities: 2+ pulses bilaterally, +1 pitting edema b/l ___ up
to
shins
NEURO: CN2-12 intact, no focal neuro deficits, AAOx4
Pertinent Results:
ADMISSION LABS:
=====================
___ 11:20AM BLOOD WBC-11.5* RBC-4.66 Hgb-14.2 Hct-43.8
MCV-94 MCH-30.5 MCHC-32.4 RDW-13.3 RDWSD-46.0 Plt ___
___ 11:20AM BLOOD Neuts-81.7* Lymphs-9.5* Monos-7.2
Eos-0.2* Baso-0.5 Im ___ AbsNeut-9.39* AbsLymp-1.09*
AbsMono-0.83* AbsEos-0.02* AbsBaso-0.06
___ 11:20AM BLOOD Glucose-169* UreaN-19 Creat-1.3* Na-141
K-4.0 Cl-103 HCO3-25 AnGap-13
___ 11:20AM BLOOD ___ 11:20AM BLOOD Calcium-10.7* Phos-2.4* Mg-2.3
___ 05:55AM BLOOD TSH-4.4*
___ 05:25PM BLOOD Lactate-1.3
DISCHARGE LABS:
===================
___ 06:32AM BLOOD WBC-7.0 RBC-4.10 Hgb-12.7 Hct-39.4 MCV-96
MCH-31.0 MCHC-32.2 RDW-13.3 RDWSD-47.6* Plt ___
___ 06:32AM BLOOD Glucose-130* UreaN-19 Creat-1.1 Na-143
K-4.4 Cl-110* HCO3-22 AnGap-11
IMAGING STUDIES:
======================
CXR ___:
Interval placement of left chest wall pacemaker device with
leads terminating
in the expected location of the right atrium and right
ventricle.
Stable small bilateral pleural effusions.
TTE ___:
CONCLUSION: The estimated right atrial pressure is ___ mmHg.
There is normal left ventricular wall
thickness with a normal cavity size. There is normal regional
left ventricular systolic function.
Quantitative biplane left ventricular ejection fraction is 58 %.
Normal right ventricular cavity size
with normal free wall motion. There is no aortic valve stenosis.
The increased velocity is due to high
stroke volume. There is no aortic regurgitation. There is mild
[1+] mitral regurgitation. There is mild
[1+] tricuspid regurgitation. There is mild pulmonary artery
systolic hypertension.
IMPRESSION: Suboptimal image quality. Grossly preserved
biventricular systolic function. Mild
mitral regurgitation. Mild pulmonary hypertension.
Brief Hospital Course:
=================================
BRIEF SUMMARY
=================================
___ is a ___ year old women with a history of
hypertension and hyperlipidemia who presented with a 2 week
history of new dyspnea on exertion.
She was found to have 2:1 AV block with normal PR and with 1:1
conduction at slower sinus rates (during sleep from increased
vagal tone) consistent with HPS disease. Given that her was QRS
narrow this was felt to most likely represent an intra-his
block, and since there were no reversible causes a pace maker
was placed without complication and she completed antibiotics
prior to discharge.
She was discharged to home with PCP and device clinic follow up
in place. We also restarted her metoprolol XL at a reduced dose
of 50mg daily (from 100mg daily).
=================================
TRANSITIONAL ISSUES
=================================
[]Reduced metoprolol XL from 100mg to 50mg daily
[]Follow up in device clinic in 1 week, antibiotics completed
prior to
discharge.
[]Clinic f/u with NP ___ in ___ weeks
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Metoprolol Succinate XL 100 mg PO DAILY
2. NIFEdipine (Extended Release) 30 mg PO DAILY
3. Simvastatin 80 mg PO QPM
4. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
Discharge Medications:
1. Metoprolol Succinate XL 50 mg PO DAILY
start ___
RX *metoprolol succinate 50 mg 1 tablet(s) by mouth once a day
Disp #*30 Tablet Refills:*0
2. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
3. NIFEdipine (Extended Release) 30 mg PO DAILY
4. Simvastatin 80 mg PO QPM
Discharge Disposition:
Home
Discharge Diagnosis:
2:1 AV nodal block, which started to conduct 1:1 with increased
vagal tone (sleep), prompting pace maker placement.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
==================================================
WHY DID YOU COME TO THE HOSPITAL?
==================================================
-You were getting out of breath more easily
==================================================
WHAT HAPPENED AT THE HOSPITAL?
==================================================
-We found that your heart was beating too slow, and you had a
pacemaker placed.
==================================================
WHAT NEEDS TO HAPPEN WHEN YOU LEAVE THE HOSPITAL?
==================================================
-Continue taking all of your medications as prescribed
-Follow the standard post-pacemaker instructions (provided at
discharge)
-Attend your follow up appointments (see below)
Followup Instructions:
___
|
19689065-DS-11
| 19,689,065 | 27,351,330 |
DS
| 11 |
2135-09-26 00:00:00
|
2135-09-26 16:00:00
|
Name: ___ ___ No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
right hip pain
Major Surgical or Invasive Procedure:
ORIF right acetabular fracture on ___ - ___
___ of Present Illness:
___ restrained passenger in ___, transferred from ___ for management of R Acetabular fx dislocation. + HS,
No
LOC. Pt was in the front passenger side of the car when it was
hit by another vehicle appoaching from the right and crossing
her
path while turning left. She had immediate pain in her Right
hip
as well as minor bruises/scrapes over the left side of he face.
Pt denies loss of motor function ___ upper and lower extremities
with no numbness/paresthesias. OSH XR show R acetabular
posterior fx dislocation. CT Head and CT Ch/Abd/Pelv show no
spine fxs. Interval XRays at ___ show reduced femoral
acetabular joint. She can actively log roll her R hip but
experiences some pain with movement. Her 3 remaining
extremities
are without discomfort. Denies chest pain and abdominal pain.
Past Medical History:
PMH/PSH:
Asthma
Seizures (specific type undiagnosed). Last seizure > ___ yrs ago.
Social History:
___
Family History:
N/C
Physical Exam:
Exam on discharge:
Gen: NAD, obese female
RLE:
-dressing c/d/i
-fires ___
-SILT distally
-toes WWP
Brief Hospital Course:
The patient presented to the emergency department as an OSH
transfer and was evaluated by the orthopedic surgery team. The
patient was found to have a right acetabular fracture and was
admitted to the orthopedic surgery service. The patient was
taken to the operating room on ___ for ORIF right acetabular
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 Acute Pain Service placed an
epidural for pain control postoperatively which was d/c'ed on
POD1 without issue. Please see their note for full details.
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 acute
rehab was appropriate. The ___ hospital course was
otherwise unremarkable.
At the time of discharge the patient's pain was well controlled
with oral medications, incisions were clean/dry/intact, and the
patient was voiding/moving bowels spontaneously. The patient is
TDWB in the right lower extremity, and will be discharged on
Lovenox for DVT prophylaxis. The patient will follow up with Dr.
___ routine. A thorough discussion was had with the
patient regarding the diagnosis and expected post-discharge
course including reasons to call the office or return to the
hospital, and all questions were answered. The patient was also
given written instructions concerning precautionary instructions
and the appropriate follow-up care. The patient expressed
readiness for discharge.
Medications on Admission:
Explanon contraceptive
Ibuprofen
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H
Do not exceed 4g/day.
2. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation
3. Pantoprazole 40 mg PO Q24H
4. Senna 8.6 mg PO DAILY
5. Enoxaparin Sodium 40 mg SC QPM Duration: 14 Days
Start: ___, First Dose: Next Routine Administration Time
6. HYDROmorphone (Dilaudid) ___ mg PO Q3H:PRN pain
Do not drink alcohol, drive, or use heavy machinery while
taking.
7. Docusate Sodium 100 mg PO TID
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Right acetabular fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid
Discharge Instructions:
INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY:
- You were in the hospital for orthopedic surgery. It is normal
to feel tired or "washed out" after surgery, and this feeling
should improve over the first few days to week. - Resume your
regular activities as tolerated, but please follow your weight
bearing precautions strictly at all times.
ACTIVITY AND WEIGHT BEARING:
- Touchdown weight bearing right lower extremity
MEDICATIONS:
- Please take all medications as prescribed by your physicians
at discharge.
- Continue all home medications unless specifically instructed
to stop by your surgeon.
- Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
- Narcotic pain relievers can cause constipation, so you should
drink eight 8oz glasses of water daily and take a stool softener
(colace) to prevent this side effect.
ANTICOAGULATION:
- Please take lovenox 40mg daily for 2 weeks
WOUND CARE:
- You may shower. No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- No dressing is needed if wound continues to be non-draining.
DANGER SIGNS:
Please call your PCP or surgeon's office and/or return to the
emergency department if you experience any of the following:
- Increasing pain that is not controlled with pain medications
- Increasing redness, swelling, drainage, or other concerning
changes in your incision
- Persistent or increasing numbness, tingling, or loss of
sensation
- Fever > 101.4
- Shaking chills
- Chest pain
- Shortness of breath
- Nausea or vomiting with an inability to keep food, liquid,
medications down
- Any other medical concerns
Physical Therapy:
___: touchdown weight bearing right lower extremity
Treatments Frequency:
Dry sterile dressing changes daily and as needed for staining.
Wound/staples evaluation at first follow up appointment.
Followup Instructions:
___
|
19689477-DS-5
| 19,689,477 | 20,958,184 |
DS
| 5 |
2138-10-30 00:00:00
|
2138-11-02 21:23:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Hyperkalemia
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ with diabetes, hypertension and stage V chronic kidney
disease, who was sent to the ED by her PCP for laboratory
abnormalities including hyperkalemia, hyperphosphatemia, uremia
and metabolic acidosis. Per the patient she was seen by her PCP
___ ___ and noted to have an elevated potassium of 6.6. Her
PCP instructed her to present to the ED whic she did not do
until today. The patient states she has been feeling generally
well through she did note mild chest discomfort yesterday while
lying in bed that resolved after a few minutes in addition to
some dyspnea on exertion over the ___ of the past several
weeks. She denies any fevers, chills, cough, diarrhea or nausea.
She reports regular bowel movements, last yesterday. She futher
denies any recent changes in her medications. Patient has a
known history of hyperkalemia and is supposed to take Kayexalate
at home. She however reports that she has not been recieving
these medications from the visiting nurse. however she her
husband states her visiting nurses have not been giving it to
her.
.
In the ED, initial VS: 99.3 55 142/50 16 99% on RA. Labs were
notable for K of 6.0, phos of 5.9, creatinine of 6.0. EKG did
not demonstrate peaked T waves. She was seen by nephrology who
recommened diuresis and restarting kayexalate. Vitals on
transfer were 97.9 oral, HR - 97, RR - 14, BP - 156/81, O2 Sat -
98% room air
.
Currently, patient is pain free without complaint, resting
comfortably in bed.
.
ROS: Denies fever, chills, night sweats, headache, vision
changes, rhinorrhea, congestion, sore throat, cough, shortness
of breath, chest pain, abdominal pain, nausea, vomiting,
diarrhea, constipation, BRBPR, melena, hematochezia, dysuria,
hematuria
Past Medical History:
1. Uncontrolled hypertension, likely secondary. She is followed
by Dr. ___ in the ___ clinic.
2. Diabetes with ophthalmologic and nephrologic complications.
She is followed by Dr. ___ in ___.
3. Hyperlipidemia.
4. Chronic kidney disease with baseline creatinine around 2.4.
She has nephrotic range proteinuria. She has diabetes and
hypertension as causes.
5. Vitamin D deficiency.
6. Obesity.
Social History:
___
Family History:
non- contribuatory
Physical Exam:
ADMISSION EXAM
VS - Temp ___ F, BP 186/63 , HR 66, R 20 , O2-sat 98% RA
GENERAL - well-appearing female in NAD, comfortable, appropriate
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear
NECK - supple, no thyromegaly, JVD elevated to the level of the
jaw
LUNGS - CTA bilat, no r/rh/wh, good air movement, resp
unlabored, no accessory muscle use, no crackles
HEART - PMI non-displaced, RRR, no MRG, nl S1-S2
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - WWP, 2+ peripheral pulses (radials, DPs), 2+ edema
to mid shin
SKIN - no rashes or lesions
LYMPH - no cervical LAD
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
___ throughout, sensation grossly intact throughout,
.
DISCHARGE EXAM
VS - Temp 96, BP 168/75(151/58-184/80) , HR 58 (58-96), R 18 ,
O2-sat 98% RA
GENERAL - well-appearing female in NAD, comfortable, appropriate
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear
NECK - supple, no thyromegaly, JVD at 7cm.
LUNGS - CTA bilat, no r/rh/wh, good air movement, resp
unlabored, no accessory muscle use, no crackles
HEART - PMI non-displaced, RRR, no MRG, nl S1-S2
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - WWP, 2+ peripheral pulses (radials, DPs), 1+ edema
to mid shin
SKIN - no rashes or lesions
LYMPH - no cervical LAD
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
___ throughout, sensation grossly intact throughout
Pertinent Results:
PERTINENT LABORATORY DATA
CBC
___ 01:10PM BLOOD WBC-6.3 RBC-3.20* Hgb-8.4* Hct-26.6*
MCV-83 MCH-26.4* MCHC-31.8 RDW-16.0* Plt ___
___ 01:10PM BLOOD Neuts-62.8 ___ Monos-5.6 Eos-3.6
Baso-0.8
___ 06:06AM BLOOD WBC-5.6 RBC-3.06* Hgb-8.3* Hct-24.9*
MCV-81* MCH-27.0 MCHC-33.2 RDW-16.3* Plt ___
.
CHEMISTRY
___ 01:10PM BLOOD Glucose-286* UreaN-100* Creat-3.4* Na-134
K-6.0* Cl-106 HCO3-17* AnGap-17
___ 01:10PM BLOOD Calcium-8.2* Phos-5.9*# Mg-2.4
___ 07:20AM BLOOD Glucose-184* UreaN-96* Creat-3.3* Na-142
K-4.8 Cl-108 HCO3-18* AnGap-21*
___ 07:20AM BLOOD Calcium-8.6 Phos-7.2* Mg-2.2
___ 01:20PM BLOOD Glucose-206* UreaN-91* Creat-3.0* Na-139
K-4.8 Cl-105 HCO3-19* AnGap-20
___ 01:20PM BLOOD Calcium-8.1* Phos-6.1* Mg-2.1
___ 06:06AM BLOOD Glucose-153* UreaN-91* Creat-3.0* Na-141
K-4.2 Cl-107 HCO3-22 AnGap-16
___ 06:06AM BLOOD Calcium-8.7 Phos-5.6* Mg-2.0
.
EKG- Sinus rhythm. Borderline P-R interval prolongation.
Compared to the previous tracing of ___ there is no
significant diagnostic change
.
CXR
IMPRESSION: Moderately increased heart size, developing since
next preceding chest examination eight month ago. Mild degree of
chronic pulmonary congestive pattern, but no evidence of
pneumonia.
Brief Hospital Course:
PRIMARY REASON FOR ADMISSION
___ year old woman with diabetes, hypertension and stage V
chronic kidney disease who present with hyperkalemia in the
setting of non compliance with kayexalate.
.
ACTIVE ISSUES
.
# Hyperkalemia- Patient's potassium was 6.0 on admission which
was felt to likely be secondary to worsening renal dysfunction
in the setting of medication non-compliance. The patient did not
have EKG changes and denied all symptoms. Pt has known history
of hyperkalemia for which she is supposed to be on kayexalate
but has not been receiving as an outpatient because her home ___
was not aware she was on this medication. Her tekturna was also
felt to contribute to hyperkalemia and was therefore held
throughout admission and at the time of discharge. She was given
kayexalate, 30 g every 8 hours with improvement in potassium.
Potassium was 4.2 on discharge. Patient was discharged on
kayexalate 30 grams each morning. Her ___ was notified of this
medication change. Via translator the patient vocalized
understanding of the importance of taking this medication.
.
# Hyperphosphatemia- Patient was noted to have elevated
phosphate of 5.6 on admission. This was felt to be due to her
chronic renal disease. She was initially started on calcium
carbonate. Phosphate continued to trend upward to a maximum of
7.2. She was therefore started on sevelamer. Phosphate was 5.2
at the time of discharge.
.
# Acute on Chronic renal failure- Patients creatinine was
initially elevated from baseline of 2.8 at 3.4. This was felt
to likely represent a worsening of the patients known chronic
renal disease. Per nephrology the patient will likely meet
criteria for dialysis in the near future through the patient and
her family are not interested in dialysis. The patient was
initially mildly volume overloaded on exam. Therefore her home
lasix was increased to 40 mg daily. She was also restarted on
her home calcitriol and started on NaHCO3. Patient will
follow-up with nephrology as an outpatient.
.
# Diabetes- Patients BG was noted to be chronically elevated in
the 200s on her home regimen of 10 units of 70/30 twice a day.
Therefore her home insulin was increased to 13 units BID at the
time of discharge.
.
# Hypertension- The patients home tekturna was held throughout
admission and at the time of discharge given hyperkalemia. She
was continued on her home amlodipine, carvediol. Her home
hydralazine was increased to 75 mg every 8 hours when pressures
were noted to be elevated to systolic blood pressures of the
190s. His home guanfacine was held on admission due to
formulary issues. This medication improved on discharge. Blood
pressures remained poorly controlled with systolic pressures in
the 150s-160s. The patient was asymptomatic. Patient will
follow-up with her PCP and nephrology regarding further
medication changes.
.
# Possible neglect- The patient's outpatient cardiology nurse
practitioner expressed concerns about compliance issues. She
stated she was unsure how much support the patient's husband
provided. She stated that she believed that patient was alone
often and was not able to manage her medications. This concern
was also expressed by her ___. Ultimately it was determined that
the patient would obtain services from both ___ in addition to
___. It was felt she was safe to return
home.
.
# Anemia- Patient HCT was mildly decreased from baseline of 31
to 27.5 on admission. This was felt to be related chronic anemia
resultant from her chronic renal failure. Stools were guaiac
negative. Creatinine was between ___ throughout admission.
.
TRANSITIONAL ISSUES
- Patient will follow-up with his PCP, cardiologist and
nephrologist
- Patient was full code throughout this admission
Medications on Admission:
Lipitor 40 mg Tab
1 Tablet(s) by mouth qpm
Novolog Mix 70-30 100 unit/mL (70-30) Sub-Q
10 units twice a day pt needs 2 bottles; one for home and one
for adult day care.
Tekturna 150 mg Tab
1 Tablet(s) by mouth at bedtime
aspirin 81 mg Tab, Delayed Release
1 Tablet(s) by mouth once a day
furosemide 20 mg Tab
1 Tablet(s) by mouth once a day
guanfacine 1 mg Tab
1 Tablet(s) by mouth nightly
amlodipine 10 mg Tab
1 Tablet(s) by mouth daily
carvedilol 25 mg Tab Oral
2 Tablet(s) Twice Daily
Discharge Medications:
1. calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
Disp:*60 Capsule(s)* Refills:*0*
2. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
Sig: One (1) Tablet, Chewable PO TID (3 times a day).
Disp:*90 Tablet, Chewable(s)* Refills:*0*
3. sodium bicarbonate 650 mg Tablet Sig: Two (2) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*0*
4. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*0*
5. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
6. atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. sevelamer carbonate 800 mg Tablet Sig: Two (2) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
Disp:*180 Tablet(s)* Refills:*0*
8. amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day.
9. carvedilol 12.5 mg Tablet Sig: Two (2) Tablet PO twice a day.
10. guanfacine 1 mg Tablet Sig: One (1) Tablet PO at bedtime.
11. hydralazine 25 mg Tablet Sig: Three (3) Tablet PO Q8H (every
8 hours).
Disp:*270 Tablet(s)* Refills:*0*
12. insulin NPH & regular human 100 unit/mL (70-30) Suspension
Sig: Thirteen (13) units Subcutaneous twice a day.
13. sodium polystyrene sulfonate 15 g/60 mL Suspension Sig:
Thirty (30) grams PO QAM (once a day (in the morning)).
Disp:*qs grams* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS
Hyperkalemia
Hyperphosphatemia
Acute on chronic renal failure
.
SECONDARY DIAGNOSIS
Diabetes
Hyperlipidemia
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 potassium level was very high.
This was likely because you were not taking a medication called
kayexalate. We restarted this medication and your potassium
levels improved.We also stopped one of your medications
(Tekturna) which can cause your potassium to be high. It is very
important that you take all of your medications.
You were in the hospital because of your high potassium
therefore it is VERY IMPORTANT that you take you kayexalate.
Also you blood pressure was very high therefore you MUST take
you blood pressure medications.
We made the following changes to your medications
1. STOP Tekturna
2. INCREASE Hydralazine to 75 mg every 8 hours
3. START Sodium Bicarbonate 1300 mg twice a day
4. START Calcium Carbonate 500 mg three times a day
5. START Calcitriol 0.5 mcg daily
6. START Sevelamer 1600 mg three times a day with meals
7. START Kayexalate 30g each morning
.
You should continue to take all other medications as instructed.
Please feel free to call with any questions or concerns.
Followup Instructions:
___
|
19689477-DS-6
| 19,689,477 | 21,699,057 |
DS
| 6 |
2140-11-11 00:00:00
|
2140-11-14 14:20:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
___ week progressive weakness associated with new urinary and
fecal incontinence.
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Patient is a ___ year-old female with a history of dementia, HTN,
DM, and CKD brought in by ___ and ex-husband for ___ weeks of
progressive weakness and new functional fecal/urinary
incontinence. She lives alone and was ambulatory with a walker
until 2 weeks ago, receiving significant daily help with her
ADLs from her ex-husband. She has been getting so weak that she
has not even been able to get out of her bed unassisted,
resulting in recent fecal/urinary incontinence. She has had
progressive cognitive decline over many years and is AOx1-2 at
baseline. She has had ESRD, followed in ___ clinic by Dr.
___ has resisted hemodialiysis.
Her ex-husband was adamant to bring her in to ___ for
emergency dialysis, feeling that her recent weakness and her
progressive decline in cognition was secondary to declining
kidney function. She was admitted for case ___ and
felt she would need higher level of support/supervision at home.
Past Medical History:
1. Uncontrolled hypertension, likely secondary. She is followed
by Dr. ___ in the ___ clinic.
2. Diabetes with ophthalmologic and nephrologic complications.
She is followed by Dr. ___ in ___.
3. Hyperlipidemia.
4. Chronic kidney disease stage V.
She has nephrotic range proteinuria. She has diabetes and
hypertension as causes.
5. Vitamin D deficiency.
6. Dementia
Social History:
___
Family History:
Denies any diseases in her fmaily.
Physical Exam:
Admission:
VS: 98.5 147/45 67 20 98% RA
General: well-appearing female comfortable in bed, breathing
well on room air.
HEENT: NCAT. Conjunctiva pale. MMM. OP clear.
Neck: supple no LAD
Lungs: CTAB. No w/c/r.
CV: RRR. No m/r/g.
ABD: NT/ND. BS+
GU: clear urine
Ext: trace peripheral edema, arthritis noted in toes b/l.
Neuro: Awake, alert, oriented to person and that she is in a
hospital in ___ (though unsure which one). She is not
oriented to date or year. Registration is intact. Long-term
memory ___, even when given hints and presented as multiple
choice. Concentration was limited on ___ backwards, requiring a
lot of prompting. ___ forwards intact. Able to name high and low
frequency objects. Reading deferred.
CN II-XII grossly intact.
No asterixis, pronator drift, or tremors. Finger-nose-finger
intact.
___ strength in all muscle groups.
Gait slow with walker. Needed help pushing herself off the bed.
No ataxia.
Prior to Discharge:
Vitals: 98.0 | 139/83 | 68 | 18 | 99%RA
General: Well appearing lady in no acute distress. Pt. has
difficulty standing from bed and sitting down to chair and can
walk, though unsteady, for short lengths with walker.
HEENT: Sclera anicteric, MMM, oropharynx clear, mild
conjunctival pallor
Neck: supple, JVP not elevated, no LAD
Lungs: Good expansion. Some scarce scattered crackles.
CV: Regular rate and rhythm, normal S1 + S2, I/VI holosystolic
murmur. No rubs, gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Skin: Dry and pale
Neuro: Alert. Oriented to person , not place or time. Muscular
strength: ___ in all 4 extremities and trunk. No gross sensory
deficit.
MMSE ___ (performed in ___
Pertinent Results:
___ 06:30PM PLT COUNT-239
___ 06:30PM NEUTS-78.1* LYMPHS-13.9* MONOS-7.1 EOS-0.6
BASOS-0.3
___ 06:30PM TSH-1.8
___ 06:30PM TSH-1.8
___ 06:30PM ALBUMIN-4.3 CALCIUM-9.9 PHOSPHATE-3.8#
MAGNESIUM-2.6
___ 06:30PM proBNP-2417*
___ 06:30PM ALT(SGPT)-15 AST(SGOT)-15 CK(CPK)-65 ALK
PHOS-61 TOT BILI-0.3
___ 06:30PM estGFR-Using this
___ 06:30PM GLUCOSE-140* UREA N-82* CREAT-4.7*#
SODIUM-138 POTASSIUM-3.6 CHLORIDE-98 TOTAL CO2-25 ANION GAP-19
___ 06:33PM LACTATE-1.3
___ 06:33PM COMMENTS-GREEN TOP
___ 09:15PM URINE MUCOUS-RARE
___ 09:15PM URINE AMORPH-OCC
___ 09:15PM URINE RBC-1 WBC-1 BACTERIA-FEW YEAST-NONE
EPI-0
___ 09:15PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-100
GLUCOSE-70 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
___ 09:15PM URINE COLOR-Straw APPEAR-Hazy SP ___
___ 09:15PM URINE UHOLD-HOLD
___ 09:15PM URINE HOURS-RANDOM
Brief Hospital Course:
PRIMARY REASON FOR HOSPITALIZATION:
====================================
___ year-old female with a history of dementia, HTN, T2DM, and
CKD stage V who was brought in by ___ and ex-husband for
concerns of ___ weeks of progressive weakness associated with
new functional urinary and fecal incontinence.
ACTIVE ISSUES:
===================
# WEAKNESS/FATIGUE: Appears to be secondary to global
deconditioning in the setting of her declining cognitive and
renal function. No acute infection or other reversible medical
condition was found.
- Will be discharged to rehab
# CKD Stage V: There was no indication for urgent dialysis. Of
note, the patient has repeatedly declined dialysis in the past
when her dementia was not as severe. Currently she is not
competent to make the decision. During this admission her health
care proxy requested that she be dialyzed despite this being
against her previously stated wishes. No dialysis was neccessary
during this admission and her outpatient providers were made
aware of this conflict.
-Low K and P diet
-Continue sevelamer, sodium bicarbonate
-Started nephrocaps
-Follow-up with nephrologist Dr. ___
# INCONTINENCE: Likely functional urinary incontinence, no signs
of fecal incontinence. Probably worsened by her dementia. When
she gets more disoriented/somnolent, she voids on site instead
of calling her nurse.
-___ frequently
-Scheduled voiding tid
# DEMENTIA : Documented on Cognitive Neurology evaluation in
___ as likely vascular dementia with complete work-up. MMSE
during this admission was ___.
-Re-orient frequently
# LEUKOCYTOSIS: UA and CXR were negative. Patient was afebrile
and leukocytosis resolved with no intervention.
CHRONIC ISSUES:
==========================
# T2DM:
-continued home regimen of 70/30 13u BID
# HTN:
-continued on home regimen
TRANSITIONAL ISSUES:
=====================
# CODE STATUS: Full
# CONTACT: ___ ___ (ex-husband) is Health Care
Proxy (form signed)
# ___: Patient repeatedly declined dialysis in the past
when her dementia was not as severe. Currently she is not
competent to make the decision. During this admission her health
care proxy requested that she be dialyzed despite this being
against her wishes (well documented by her outpatient
providers). Dialysis was not neccessary during this admission,
however this conflict may emerge in the future. Please involve
her nephrologist Dr. ___ in this discussion since
he has known her for a long time.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 40 mg PO DAILY
2. Calcitriol 0.5 mcg PO DAILY
3. Carvedilol 25 mg PO BID
4. Vitamin D 50,000 UNIT PO 1X/WEEK (___)
5. Furosemide 40 mg PO DAILY
6. guanFACINE 1 mg oral qhs
7. HydrALAzine 75 mg PO Q6H
8. 70/30 13 Units Breakfast
70/30 13 Units Dinner
9. NIFEdipine CR 120 mg PO DAILY
10. Renagel 2 tab Other TID
11. Aspirin 81 mg PO DAILY
12. Calcium Carbonate 500 mg PO TID
13. Ferrous Sulfate 325 mg PO BID
14. Sodium Bicarbonate 1300 mg PO BID
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 40 mg PO DAILY
3. Calcitriol 0.5 mcg PO DAILY
4. Carvedilol 25 mg PO BID
5. Ferrous Sulfate 325 mg PO BID
6. Furosemide 40 mg PO DAILY
7. 70/30 13 Units Breakfast
70/30 13 Units Dinner
8. NIFEdipine CR 120 mg PO DAILY
9. Renagel 2 tab Other TID
10. Sodium Bicarbonate 1300 mg PO BID
11. Nephrocaps 1 CAP PO DAILY
12. Calcium Carbonate 500 mg PO TID
13. guanFACINE 1 mg oral qhs
14. HydrALAzine 75 mg PO Q6H
15. Vitamin D 50,000 UNIT PO 1X/WEEK (___)
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary:
-Deconditioning
-Dementia
-Stage V CKD
Secondary:
-Type 2 Diabetes
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid
(___).
Discharge Instructions:
Ms. ___, it was a pleasure taking care of you here at
___. You were admitted to the hospital with weakness and
incontinence. Your kidneys are not working well, however there
has been no major change in your kidney function. You will do
physical therapy to work on your strength.
Followup Instructions:
___
|
19689858-DS-18
| 19,689,858 | 23,455,133 |
DS
| 18 |
2144-02-09 00:00:00
|
2144-02-10 07:20:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
RUQ pain, hypotension
Major Surgical or Invasive Procedure:
ERCP ___
History of Present Illness:
___ ___ male with PMHx of cholangitis s/p ERCP ___
yr ago in ___, who was visiting his daughter in the ___ and
reports RUQ abdominal pain for the last week and vomiting and
fever beginning today. Last week he had right sided and
epigastric abdominal pain and high fever for which he went to
the ___. They discharged him with an unknown antibiotic.
This pain worsened yesterday and today. Pt reports that the pain
is worse with greasy foods. +NBNB emesis today. Pt also reports
black stools. Fever to 102 today at home. He was seen at the
___ and transferred to ___ for concern for sepsis and
hypotension to 87/?. Per report, pt had ultrasound at outside
hospital that showed "intrahepatic stones, cholangitis and need
for ERCP". At OSH, pt received dilaudid, protonix, zosyn,
cefoxitin, flagyl and 2L NS.
As above pt states he had an ERCP last year in ___ where they
took stones out of his bile duct. No cholecystectomy.
On presentation to the ___ here, VS were T98.9, HR96, BP96/59,
R24 and 98% 3LNC. Pt received 4L NS total (2L OSH and 2L here).
BP dropped to SBP ___ and levophed was started. Labs were
notable for WBC 26.7 (89% N), INR 1.7, ALT 64, AST 216, Alk Phos
297, Tbili 2.3, Dbili 2.0, Lactate 2.1. He was admitted to the
MICU for hypotension.
Past Medical History:
h/o gallstones/cholangitis requiring removal with ERCP in ___
Social History:
___
Family History:
NC
Physical Exam:
ADMISSION EXAM:
General: Alert, awake, no acute distress
HEENT: Sclera anicteric, MM dry, oropharynx clear
Neck: supple, JVP not elevated, no LAD, RIJ in place
CV: Regular rate and rhythm, normal S1 + S2, no m/r/g
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: +BS, soft, non-distended, non-tender, no organomegaly,
no rebound or guarding
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
DISCHARGE EXAM:
98.5, 62, 90/55, 18, 96RA
Gen- alert, well appearing
Psych- nl affect/mood, pleasant and cooperative
Eyes- no icterus
Skin- no jaundice, no pallor
CV- RRR no m/g
Lung- ctab
Abd- soft. no significant tenderness to palp. Non distended.
Pertinent Results:
___ 10:15PM BLOOD WBC-26.7* RBC-3.54* Hgb-10.7* Hct-32.0*
MCV-91 MCH-30.4 MCHC-33.5 RDW-14.9 Plt ___
___ 05:00AM BLOOD WBC-7.8 RBC-3.82* Hgb-11.3* Hct-33.8*
MCV-89 MCH-29.5 MCHC-33.3 RDW-14.9 Plt ___
___ 10:15PM BLOOD ___ PTT-30.0 ___
___ 11:14AM BLOOD ___ PTT-33.1 ___
___ 05:00AM BLOOD ___
___ 10:15PM BLOOD Glucose-108* UreaN-14 Creat-0.8 Na-140
K-3.6 Cl-108 HCO3-21* AnGap-15
___ 05:00AM BLOOD Glucose-100 UreaN-11 Creat-0.5 Na-136
K-4.2 Cl-102 HCO3-28 AnGap-10
___ 10:15PM BLOOD ALT-64* AST-216* AlkPhos-297*
TotBili-2.3* DirBili-2.0* IndBili-0.3
___ 06:50AM BLOOD ALT-22 AST-16 AlkPhos-180* TotBili-0.6
___ 05:17AM BLOOD calTIBC-139* Ferritn-591* TRF-107*
___ 11:14AM BLOOD IgM HAV-NEGATIVE
___ 05:17AM BLOOD HBsAg-NEGATIVE HBsAb-BORDERLINE
HBcAb-POSITIVE HAV Ab-POSITIVE
___ 05:17AM BLOOD HCV Ab-NEGATIVE
Micro data:
blood cx pending
HCV viral load neg
HBV viral load pending
Stool ova and parasites neg
ERCP report ___
Impression: There was pus discharge from the major papilla.
Evidence of a previous sphincterotomy was noted in the major
papilla.
Multiple strictured, dilated and ectatic areas were noted in the
intrahepatic ducts.
Multiple filling defects consistent with stones were seen in the
intrahepatic ducts.
Findings suggestive of oriental cholangiohepatitis
One to two small filling defects were seen in the common bile
duct.
Sludge and pus were extracted using a balloon.
A 13cm by ___ biliary stent was placed successfully in the
right intrahepatic duct system.
A 5cm by ___ double pig tail biliary stent was placed
successfully in the left intrahepatic duct system
Recommendations: Return to ICU.
Start clears when awake and alert.
Order MRCP to further evaluate the intrahepatic stone burden and
distribution
Continue IV zosyn for now.
Patient will need total 2 weeks of antibiotics.
Repeat ERCP in ___ weeks to pull the stents, re-evaluate and
stone removal.
MRCP ___
1. Irregular regions of extensive biliary ductal
dilatation/ectasia and
stricturing involving the intrahepatic biliary system associated
with multiple stones within the dilated intrahepatic biliary
tree together with dilated common bile duct is most suggestive
of recurrent pyogenic cholangitis.
2. Confluent region of abnormal hepatic parenchymal enhancement
involving
segment VIII of the liver without evidence of liquefaction
suggestive of
phlegmonous changes, likely from adjacent biliary infectious
process given enhancement of regional biliary wall. No obvious
abscess at this time, though the adjacent regional dilated bile
ducts may not have been decompressed by the biliary stent.
Brief Hospital Course:
___ ___ male with hx of gallstones/cholangitis presents
with biliary sepsis.
# Biliary obstruction with sepsis, with underlying diagnosis of
recurrent pyogenic cholangitis. Met SIRS criteria and was
admitted to the ICU for hemodynamic resiscutation. Requred
levophed and IVF. Underwent ERCP with findings indicating
recurrent pyogenic cholangitis (aka Oriental
cholangiohepatitis). Two biliary stents placed. MRCP the
following day confirmed diagnosis of Oriental cholangiohepatitis
with hepatobiliary infection, without clear abscess. Started on
empiric zosyn. Hemodynamics improved. Pt transferred out of ICU
in good condition.
Hepatobiliary surgery team was involved, and felt pt was not a
surgical candidate given bilateral liver lobe involvement.
Blood cultures grew ___ bottles of E coli. Zosyn was initially
transitioned to PO cipro + flagyl. However, the E coli is
cipro-resistant. Will instead treat w/ single agent Augmentin,
to complete a 6 week course of antibiotics from day of ERCP (end
date ___. He was also started on Ursodiol and can continue
this, to be further managed by outpatient hepatology. He should
also have repeat ERCP in 4 wks, and repeat imaging done. He will
follow up in the Liver clinic; initially appointment recommended
with Dr. ___ but Dr. ___ is not taking new patients
so he will see Dr. ___.
He received the ___ Hepatitis B vaccine and should receive doses
2 and 3 when due.
#Elevated INR: Unclear baseline. Nutritional vs hepatic
dysfunction; lower suscipion for hepatic issue given normal
platelet count. He received Vitamin K 5mg IV with some effect,
then on ___ got 2mg vit K for INR ~ 1.3.
# Hep panel: History of Hep B and A. Hep A IgM was negative so
no recent infection. Patient is Hep C negative (antibody and
viral load both negative). Pt received first dose Hepatitis B
vaccine.
# Anemia: Unknown baseline. Pt had no clinical evidence of
bleeding. Low iron, low TIBC and high ferritin suggest anemia of
chronic disease.
# constipation: will discharge w/ bowel regimen.
Transitional issues:
[ ] continue Augmentin for total of 6 week course of abx, end
date ___
[ ] Needs the remaining Hep B vaccinations to complete full
series. First dose ___.
[ ] repeat ERCP in 4 wks and repeat hepatobiliary imaging
[ ] recommend cancer surveillance ___, CEA, AFP) given
secondary sclerosing cholangitis
[ ] repeat INR to ensure normalizing
[ ] pending micro data includes blood cultures and Hep B viral
load
Medications on Admission:
None
Discharge Medications:
1. Amoxicillin-Clavulanic Acid ___ mg PO Q12H biliary infection
end date ___
RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tablet(s) by
mouth twice a day Disp #*76 Tablet Refills:*0
2. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*30 Capsule Refills:*0
3. Senna 2 TAB PO BID
RX *senna 8.6 mg 1 tab by mouth twice a day Disp #*30 Tablet
Refills:*0
4. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
RX *oxycodone 5 mg 1 tablet(s) by mouth every four (4) hours
Disp #*10 Tablet Refills:*0
5. Ursodiol 300 mg PO BID
RX *ursodiol 300 mg 1 capsule(s) by mouth twice a day Disp #*60
Capsule Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Recurrent pyogenic cholangitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted for a disease of your liver and bile ducts
called Recurrent Pyogenic Cholangitis with infection. You
underwent a procedure (called ERCP) to place stents into your
bile ducts. You need to take antibiotics for several weeks to
treat the infection. You will need to follow up with the ERCP
team and the Liver clinic.
Followup Instructions:
___
|
19689858-DS-20
| 19,689,858 | 25,049,066 |
DS
| 20 |
2146-09-01 00:00:00
|
2146-09-01 20:08:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
CC: ___ and ___ pain
Major Surgical or Invasive Procedure:
ERCP with spyglass and lithotripsy
History of Present Illness:
___ year old ___ man with h/o recurrent pyogenic
cholangitis (oriental cholangiohepatitis), unresectable area of
structured biliary tree, prior E coli bacteremia, recently
admitted from ___ to ___ with cholangitis and MDR
pseudomonas and E coli bacteremia, s/p multiple ERCP procedures
with two stents in place. His last ERCP was performed on
___ when he became febrile, increased WBC and grew GNRs.
During this ERCP the stents were found to be in good position
and patent and thus he was referred to ___ reviewed his
imaging and did not think that there was any room for
intervention given the diffuse nature of his disease. Several
parasitic infectious etiologies have been implicated in
recurrent pyogenic cholangitis. His serology for fasciola is
mildly positive and ID thinks that he had a fasciola infection
at one point, but not ongoing infection given ERCP findings and
negative stool O&P. Per ID, treatment would not change outcome.
He was also seen by transplant surgery who did not think that he
would benefit from intervention.
.
He completed a 2 week course of meropenem as an inpt since he
did not have insurance and refused to go to the ___. He was
seen in ___ clinic on ___ and felt well. It was thought that
he would not benefit from suppressive abx.
.
In ER: (Triage Vitals:23:32 6 98.8 110 133/91 18 100% )
Meds Given: morphine 5 mg IV x 2/cipro/flagyl/meropenem/APAP
Fluids given: 1L NS
Radiology Studies: ___ US
consults called: ERCP notified via dash and d/w ___ resident- ___
would not help thus no transplant c/s
.
PAIN SCALE: ___ location:
________________________________________________________________
REVIEW OF SYSTEMS: 10 or 2 with "all otherwise negative"
CONSTITUTIONAL: [] All Normal
[ ] Fever [ ] Chills [ ] Sweats [ ] Fatigue [ ] Malaise
[ ]Anorexia [ ]Night sweats
[ ] _____ lbs. weight loss/gain over _____ months
Eyes
[] All Normal
[ ] Blurred vision [ ] Loss of vision [] Diplopia [ ]
Photophobia
ENT
[ ] Dry mouth [ ] Oral ulcers [ ] Bleeding gums [ ] Sore throat
[] Sinus pain [ ] Epistaxis [ ] Tinnitus
[ ] Decreased hearing [ ] Other:
RESPIRATORY: [] All Normal
[ ] Shortness of breath [ ] Dyspnea on exertion [ ] Can't
walk 2 flights [ ] Cough [ ] Wheeze [ ] Purulent sputum
[ ] Hemoptysis [ ]Pleuritic pain
[ ] Other:
CARDIAC: [] All Normal
[ ] Palpitations [ ] Edema [ ] PND [ ] Orthopnea [ ]
Chest Pain [ ] Dyspnea on exertion [ ] Other:
GI: [] All Normal
[ ] Nausea [] Vomiting [] Abd pain [] Abdominal swelling [
] Diarrhea [ ] Constipation [ ] Hematemesis
[ ] Blood in stool [ ] Melena [ ] Dysphagia: [ ] Solids
[ ] Liquids [ ] Odynophagia [ ] Anorexia [ ] Reflux
[ ] Other:
GU: [] All Normal
[ ] Dysuria [ ] Incontinence or retention [ ] Frequency
[ ] Hematuria []Discharge []Menorrhagia
SKIN: [] All Normal
[ ] Rash [ ] Pruritus
MS: [] All Normal
[ ] Joint pain [ ] Jt swelling [ ] Back pain [ ] Bony pain
NEURO: [] All Normal
[ ] Headache [ ] Visual changes [ ] Sensory change [
]Confusion [ ]Numbness of extremities
[ ] Seizures [ ] Weakness [ ] Dizziness/Lightheaded [ ]Vertigo
[ ] Headache
ENDOCRINE: [] All Normal
[ ] Skin changes [ ] Hair changes [ ] Heat or cold
intolerance [ ] loss of energy
HEME/LYMPH: [] All Normal
[ ] Easy bruising [ ] Easy bleeding [ ] Adenopathy
PSYCH: [] All Normal
[ ] Mood change []Suicidal Ideation [ ] Other:
ALLERGY:
[ ]Medication allergies [ ] Seasonal allergies
[]all other systems negative except as noted above
Past Medical History:
Past Medical History:
# Recurrent pyogenic cholangitis with strictured biliary tree
___ yrs in ___
# Multiple ERCPs, last in ___ ___ with two stents placed
# "Oriental cholangiohepatitis" dx ___ at ___ with E.coli
sepsis
# Hepatitis B carrier status
Social History:
___
Family History:
There is no history of biliary or liver or GI issues.
Physical Exam:
PHYSICAL EXAM:
VS: temp 98, HR 80, BP 120/70, RR 12, 98% RA
Gen: Asian male in no apparent distress
HEENT: Anicteric
Cardiac: Nl s1/s2 RRR no appreciable murmurs
Pulm: clear bilaterally
Abd: soft NT ND +BS
Ext: no edema noted
Pertinent Results:
LABS:
Lactate:1.3
___
00:05
134 98 10 149 AGap=18
------------\
4.3 22 0.6
Comments: Glucose: If Fasting, 70-100 Normal, >125 Provisional
Diabetes
.
estGFR: >75 (click for details)
Ca: 8.9 Mg: 1.7 P: 4.2
ALT: 25 AP: 88 Tbili: 1.4 Alb: 4.2
AST: 37 LDH: Dbili: TProt:
___: Lip: 20
90
13.2 ___ 13.6 207 ___
/38.4\
N:76.3 L:15.8 M:6.5 E:1.3 Bas:0.1
.
Urinalysis- None in ___
BLOOD CULTURE [x]pending []positive:
URINE CULTURE: None
OTHER DIAGNOSTICS:
___ US:
Redemonstration of numerous dilated intrahepatic bile
ducts/bilomas, some of which contain stones. Presence of
pneumobilia from biliary stents limits examination. The
gallbladder is not visualized. If further evaluation is needed,
MRCP would be the best modality.
NOTIFICATION: Redemonstration of numerous dilated intrahepatic
bile
ducts/bilomas, some of which contain stones. Presence of
pneumobilia from biliary stents limits examination. The
gallbladder is not visualized. If further evaluation is needed,
MRCP would be the best modality
ERCP: ___
2 plastic stents placed in the biliary duct were found in the
major papilla. These were removed using a rat-tooth.
Evidence of a previous sphincterotomy was noted in the major
papilla.
Cannulation of the biliary duct was successful and deep with a
sphincterotome using a free-hand technique.
Contrast medium was injected resulting in complete
opacification.
Multiple filling defects were noted within the CBD and CHD
consistent with stones. CBD was dilated, approximately 15 mm in
diameter.
At least 4 stones were extracted successfully using an
extraction balloon catheter.
A large stone in the CHD could not be extracted. The stone was
approximately 20 mm in diameter.
A 5cm by ___ plastic biliary biliary stent was placed
successfully in the left main hepatic duct and main duct.
Brisk drainage of bile and contrast from the biliary tree was
noted endoscopically and fluoroscopically.
Otherwise normal ercp to third part of the duodenum
ERCP: ___
A plastic stent placed in the biliary duct was found in the
major papilla. This was removed with a snare.
Evidence of a widely patent previous sphincterotomy was noted in
the major papilla.
Cannulation of the biliary duct was successful and deep with a
sphincterotome using a free-hand technique.
Contrast medium was injected resulting in complete
opacification.
A severe diffuse dilation was seen at the main duct and all
intrahepatic biliary branches with the CBD measuring 13 mm.
There was a large filling defect in the middle third of the
common bile duct consistent with biliary stone.
Digital Spyglass cholangioscopy was performed.
Electro hydraulic lithotripsy (___) was done for fragmentation
of the large stone and other intraductal stones.
The stones were fragmented and subsequently removed using an
extraction balloon catheter.
Villous mucosa was noted on cholangioscopy at the hepatic
bifurcation. This was biopsied using spybite forceps.
A 5 mm intraductal nodule. This was biopsied as well using the
spybite forceps.
A 5 cm by ___ FR double pigtail biliary stent was placed
successfully in the main duct and left main hepatic duct.
Brisk drainage of bile and contrast from the viliary tree was
noted endoscopically and fluoroscopically.
Otherwise normal ercp to third part of the duodenum
.
Microbiology:
___ 12:05 am BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___:
PSEUDOMONAS AERUGINOSA. FINAL SENSITIVITIES.
___. ___ COLISTIN AND
CEFTALOZANE/TAZOBACTAM
SENSITIVITIES ON ___. Colistin SENSITIVE.
Colistin sensitivity testing performed by ___.
CEFTOLOZANE/TAZOBACTAM = ___ MCG/ML = SUSCEPTIBLE.
CEFTOLOZANE/TAZOBACTAM TESTING PERFORMED BY ___
LABS.
PSEUDOMONAS AERUGINOSA. SECOND COLONY MORPHOLOGY.
FINAL SENSITIVITIES.
___. ___ COLISTIN AND
CEFTOLOZANE/TAZOBACTAM
SENSITIVITIES ON ___. Colistin SENSITIVE.
Colistin sensitivity testing performed by ___.
CEFTOLOZANE/TAZOBACTAM = ___ MCG/ML = SUSCEPTIBLE.
CEFTOLOZANE/TAZOBACTAM TESTING PERFORMED BY CUB___
LABS.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
PSEUDOMONAS AERUGINOSA
| PSEUDOMONAS AERUGINOSA
| |
CEFEPIME-------------- 4 S 4 S
CEFTAZIDIME----------- 32 R 32 R
CIPROFLOXACIN---------<=0.25 S <=0.25 S
GENTAMICIN------------ <=1 S <=1 S
MEROPENEM------------- 4 I 8 R
TOBRAMYCIN------------ <=1 S <=1 S
Aerobic Bottle Gram Stain (Final ___:
GRAM NEGATIVE ROD(S).
Reported to and read back by ___ ___ 1745
Same organisms noted ___, all subsequent cultures negative
Brief Hospital Course:
___ year old ___ male with recurrent pyogenic
cholangitis s/p recent prolonged admission for cholangitis and
ESBL Ecoli/Pseudomonas bacteremia s/p course of meropenem. Now
presents with fever, ___ pain and concerns for recurrent
cholangitis.
# Ascending cholangitis
# Pseudomonal bacteremia - 2 strains, resistant
Presented with abdominal pain and underwent ERCP with removal of
stones/PUS on ___. A large stone was not able to be removed.
He was initially treated with Ciprofloxacin, but following his
ERCP he developed high fevers, and rigors. He was given one dose
of gentamycin and then was started on Meropenem/Tobramycin which
was changed to Cefepime/tobramycin per the recommendation of ID.
Cultures were positive for two different resistant strains of
Pseudomonas. The patent underwent repeat ERCP ___ with spyglass
and lithotripsy for removal of retained stone. Surveillance
blood cultures cleared, He remained clinically stable with
symptomatic improvement, tolerating regular diet and ambulating
freely about the ward. The patient completed a two week course
of cefepime/tobramycin (___). Weekly safety labs were
checked, including cbc+diff, BMP, LFTs and tobramycin trough
with goal < 1 mcg/mL. Given prolonged course of tobramycin,
audiology evaluation was performed/scheduled on discharge. He
was continued on ursodiol. Bile duct biopsy was negative. He
will need a repeat ERCP in 4 weeks for stent pull and
reevalaution.
TRANSITIONAL ISSUES
[ ] Repeat ERCP in 4 weeks after procedure for stent pull and
re-evaluation.
[ ] Audiology appointment follow up - scheduled
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Ursodiol 600 mg PO BID
Discharge Medications:
1. Ursodiol 600 mg PO BID
2. Acetaminophen 650 mg PO Q6H:PRN pain, fever
Discharge Disposition:
Home
Discharge Diagnosis:
# Recurrent pyogenic cholangitis (oriental cholangiohepatitis),
with unresectable area of strictured biliary tree
# Pseudomonas bacteremia
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 you during your recent
admission to ___. You were admitted with another episode of
cholangitis (an infection of your bile ducts). You underwent a
procedure called an ERCP with removal of stones from your bile
ducts. The infection from your bile ducts spread to your
bloodstream. You were treated with IV antibiotics for your
infection and you finished them while you were here.
You were recommended to have a repeat ERCP, scheduled below, to
check on your stent and bile ducts.
Also, you will need to see an Audiologist to assess your hearing
function given the antibiotics we had to use to treat your
infection
Followup Instructions:
___
|
19689858-DS-22
| 19,689,858 | 21,726,320 |
DS
| 22 |
2146-10-10 00:00:00
|
2146-10-10 14:31:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
HMED Admission Note
___
CC: fever
Major ___ or Invasive Procedure:
___ ERCP with sphincterotomy, CBD stone removal, biopsy,
stent placement
History of Present Illness:
___ yo M with recurrent pyogenic cholangitis who presents with
fevers. Pt last admitted ___ following routine ERCP with
___ of CBD stones and biopsies of intraductal polyps (showed
inflammatory changes). Pt had fever post-procedure and was
covered with gentamycin and extended dosing meropenem until
cultures returned negative and pt afebrile. Pt discharged home
on ___. He was feeling at his baseline until ___ when
he developed recurrent fevers > 101 at home. Pt with additional
chills. Pt with baseline RUQ and epigastric pain which is
unchanged. No nausea, vomiting, diarrhea. No pulmonary or
urinary symptoms. Pt took antipyrectics with persistence of his
fevers, so he decided to come to the ED for evaluation.
In the ED, pt febrile to 101.6 on presentation and
hemodynamically stable with BP of 126/79, HR 98. WBC count of
6.4 with unremarkable changes in LFT's. RUQ u/s showed
intrahepatic dilatation and multiple intrahepatic stones. Pt
given 1L of NS, and gentamycin at 7mg/kg and admitted for
further care.
ROS: 10 point ROS negative except as above in HPI
Past Medical History:
# Recurrent pyogenic cholangitis (Oriental cholangiohepatitis)
with strictured biliary tree
- multiple ERCP's
- multiple episodes of bacteremia including Pseudomonas and ESBL
E. coli
# Hepatitis B carrier status
Social History:
___
Family History:
There is no history of biliary or liver or GI issues.
Physical Exam:
ADMISSION PHYSICAL EXAM
Vitals: T 99, BP 116/77, HR 82, RR 20, O2 99%RA
Gen: NAD
HEENT: NCAT, no jaudince, dry mm
CV: rrr, no r/m/g
Pulm: clear b/l
Abd: soft, miniminal tenderness in epigastrum, normal active
bowel sounds
Ext: no edema
Neuro: alert and oriented x 3
.
Pertinent Results:
ADMISSION LABS:
====================
___ 11:00PM BLOOD WBC-6.4 RBC-3.81* Hgb-11.8* Hct-34.4*
MCV-90 MCH-31.1 MCHC-34.4 RDW-15.1 Plt ___
___ 11:00PM BLOOD Glucose-126* UreaN-11 Creat-0.6 Na-134
K-4.1 Cl-98 HCO3-24 AnGap-16
___ 11:00PM BLOOD ALT-37 AST-34 AlkPhos-111 TotBili-0.8
___ 11:00PM BLOOD ___ PTT-28.8 ___
___ 11:09PM BLOOD Lactate-1.1
___ 11:00PM URINE Color-Yellow Appear-Hazy Sp ___
___ 11:00PM URINE Blood-NEG Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.5 Leuks-NEG
___ 11:00PM URINE RBC-2 WBC-5 Bacteri-FEW Yeast-NONE Epi-<1
___ 11:00PM URINE CastHy-2*
.
MICROBIOLOGY:
====================
___ Urine Culture
**FINAL REPORT ___
URINE CULTURE (Final ___:
STAPHYLOCOCCUS, COAGULASE NEGATIVE. 10,000-100,000
ORGANISMS/ML..
.
___ Blood culture x 1 set
Blood Culture, Routine (Preliminary):
ESCHERICHIA COLI. FINAL SENSITIVITIES.
Ertapenem ADD ON PER ___ ___ (___).
SENSITIVE TO Ertapenem.
Piperacillin/Tazobactam AND Ertapenem sensitivity
testing
performed by ___.
DORIPENEM AND Tigecycline Susceptibility testing
requested by
___ ___ ___.
CEFTOLOZINE/TAZOBACTAM Susceptibility testing requested
by ___
___ ___ ___.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- =>32 R
CEFAZOLIN------------- =>64 R
CEFEPIME-------------- =>64 R
CEFTAZIDIME----------- 16 R
CEFTRIAXONE----------- =>64 R
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- I
TOBRAMYCIN------------ =>16 R
TRIMETHOPRIM/SULFA---- =>16 R
Aerobic Bottle Gram Stain (Final ___:
Reported to and read back by ___ ___
2:40PM.
GRAM NEGATIVE ROD(S).
Anaerobic Bottle Gram Stain (Final ___: GRAM
NEGATIVE ROD(S).
.
___ Blood culture x 1 set: No Growth (FINAL)
___ Blood culture x 3 sets: No Growth (FINAL)
___ Stool O+P: NEGATIVE for O+P (FINAL)
___ BLOOD CULTURE Blood Culture, Routine-FINAL
INPATIENT
___ BLOOD CULTURE Blood Culture, Routine-FINAL
INPATIENT
___ BLOOD CULTURE Blood Culture, Routine-FINAL
INPATIENT
___ BLOOD CULTURE NOT PROCESSED INPATIENT
___ BLOOD CULTURE Blood Culture, Routine-FINAL
INPATIENT
___ BLOOD CULTURE Blood Culture, Routine-FINAL
INPATIENT
___ BLOOD CULTURE Blood Culture, Routine-FINAL
INPATIENT
___ STOOL OVA + PARASITES-FINAL INPATIENT
___ BLOOD CULTURE Blood Culture, Routine-FINAL
INPATIENT
___ BLOOD CULTURE Blood Culture, Routine-FINAL
INPATIENT
___ BLOOD CULTURE Blood Culture, Routine-FINAL
EMERGENCY WARD
___ BLOOD CULTURE Blood Culture, Routine-FINAL
{ESCHERICHIA COLI}; Aerobic Bottle Gram Stain-FINAL; Anaerobic
Bottle Gram Stain-FINAL EMERGENCY WARD
___ URINE URINE CULTURE-FINAL {STAPHYLOCOCCUS,
COAGULASE NEGATIVE} EMERGENCY WARD
.
IMAGING:
====================
___ RUQ US
IMPRESSION:
No significant interval change compared to ___ with
re-demonstration of numerous dilated intrahepatic bile
ducts/biloma some of which containing stones as well as
pneumobilia. Overall compatible with pyogenic cholangitis.
Gallbladder is minimally visualized on today's examination
containing air. MRCP would be helpful for further
characterization, if necessary.
.
___ MRCP
IMPRESSION:
1. Intra and extrahepatic bile duct dilation with pigmented
intrahepatic bile duct stones, in keeping with known recurrent
pyogenic cholangitis. The extent of intrahepatic bile duct
dilation has increased since ___, though the ducts are
less dilated today. No evidence of choledocholithiasis.
2. Peribiliary arterial hyperenhancement in the posterior right
hepatic lobe and segment IV, compatible with active cholangitis.
No intrahepatic abscess.
3. Delayed peripheral enhancement with capsular retraction in
keeping with hepatic fibrosis.
.
___ ERCP
Impression:
Evidence of a previous widely patent sphincterotomy was noted in
the major papilla.
Cannulation of the biliary duct was successful and deep with a
balloon using a free-hand technique. Contrast medium was
injected resulting in complete opacification.
Severe diffuse dilation was seen at the main duct, right
intrahepatic biliary branches and left intrahepatic biliary
branches with the CBD measuring 18 mm. These findings are
compatible with recurrent pyogenic cholangitis.
Large filling defect was noted in the CBD consistent with a
stone.
The large stone was removed using an extraction balloon catheter
with some sludge. Subsequent balloon sweeps were normal.
Digital Spyglass cholangioscopy was performed. A 5 mm
intraductal polyp was noted on cholangioscopy at the hepatic
bifurcation. This was biopsied using SpyBite.
Small amount of pus was noted within the biliary tree with no
stones or strictures.
A 5 cm X ___ FR double pigtail biliary stent was placed
successfully.
Brisk drainage of bile and contrast from the biliary tree was
noted fluoroscopically and endoscopically.
Otherwise normal ercp to third part of the duodenum.
.
PATHOLOGY:
====================
___ Intraductal Polyp Biopsy
Single fragment of markedly distorted biliary mucosa with
associated inflammation; no definite
dysplasia or carcinoma seen; see note.
Note: Crush artifact severely limits evaluation of this biopsy.
Five levels are examined.
.
ERCP: ___
Impression: Stent in the major papilla
The scout film showed a stent in place.
After the stent was pulled, 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 CBD was markedly dilated measuring 18 mm along with
significant IHD dilation.
No filling defects were identified in the CBD or IHD. The
biliary tree was swept with a 9-12mm balloon starting at the
bifurcation and also of the left and right intrahepatic ducts.
Sludge was removed.
The CBD and CHD were swept repeatedly until no further sludge
were seen.
A ___ x 5 cm double pigtail stent was placed in the main duct
and traversing the left IHD.
Excellent bile and contrast drainage was seen endoscopically and
fluoroscopically.
Recommendations: Follow for response and complications. If any
abdominal pain, fever, jaundice, gastrointestinal bleeding
please call ERCP fellow on call ___
Continue with antibiotics for at least ___ days.
Repeat ERCP in 3 weeks for stent pull and re-evaluation with Dr.
___.
Return to ward under ongoing care.
Follow-up with Dr. ___ as previously scheduled
.
MRCP ___:
IMPRESSION:
1. Intrahepatic irregular bile duct dilatation with pigment
stones, in keeping with known recurrent pyogenic cholangitis.
The extent of irregular intrahepatic bile duct dilatation and
the stone burden is unchanged since recent MRCP from ___.
2. New area of active cholangitis involving segment V.
Resolution of areas of active inflammation previously seen in
the left lobe and the posterior right lobe. No intrahepatic
abscess.
3. Areas of hepatic fibrosis with capsular retraction.
Brief Hospital Course:
___ yo M with recurrent pyogenic cholangitis here with fevers,
found to have recurrent cholangitis and E. coli bacteremia, now
s/p ERCP with CBD stone removal, stent placement, plan for 2
weeks of IV gentamicin.
# Recurrent pyogenic cholangitis
# E. coli (ESBL) bacteremia
Patient presented to the hospital with fevers, concerning for
recurrence of cholangitis. He was initially placed on broad
spectrum antibiotic coverage, including gentamicin, meropenem
and cefepime. Once his blood cultures from ___ returned
POSITIVE for ESBL E. coli, he was narrowed to gentamicin with
appropriate monitoring of levels under the guidance of
Infectious Disease Consult. Surveillance blood cultures from
___ and ___ were NEGATIVE for any bacteria. Bloodwork
showed stable renal function and patient without any auditory
symptoms. He then underwent successful ERCP on ___ with
sphincterotomy, removal of large CBD stone, biopsy and stent
placement. He was continued on ursodiol throughout the
hospitalization. Infectious Disease recommends a 2 week course
of IV gentamicin from the day of ERCP, so last day = ___.
The patient again developed fevers on ___ and underwent repeat
ERCP with stent exchange on ___. He was also noted to have
increasing creatinine at that time therefore gentamycin (on
___ was discontinued and the patient was started on
Tigecycline and cefepime. He continued tigecycline and cefepime
from ___, 11 more days.. Blood cultures were negative.
Antibiotics discontinued ___ (after 23 days) and pt monitored
until ___ and remained without fever, pain, leukocytosis.
Patient was also seen by the Transplant Surgery service, but
they do not recommend any additional surgical intervention at
this time. His biopsy did NOT show any evidence of malignancy.
He will follow up for another repeat ERCP in ___, already
scheduled and to f/u in transplant surgery clinic with Dr. ___
___ additional input. His case is complicated and options for
further treatment are becoming limited especially with
antibiotic therapy. It is likely that pt will have recurrence of
presentation given his disease. However, at this time after 23
days of antibiotics and 2 ERCP's, and no fever, leukocytosis, or
pain for days, will plan to dc home with outpt f/u.
# Chronic HBV - not on meds
TRANSITIONAL ISSUES:
1. Repeat ERCP for stent pull
2. f/u with Transplant Surgery
3. Needs audiology evaluation- attempted to arrange for
inpatient but no availability. patient is on cancellation list
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Ursodiol 600 mg PO BID
Discharge Medications:
1. Ursodiol 600 mg PO BID
Discharge Disposition:
Home
Discharge Diagnosis:
# cholangitis
# CBD stone / choledocholithiasis
# E. coli bacteremia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You presented to the hospital with fever. You were found to
have bacterial infection in your bloodstream (bacteremia). This
was due to infection in your bile ducts (cholangitis). You
underwent non-invasive imaging (ultrasound, MRI) which showed
gallstones, bile duct dilatation and likely infection of your
bile ducts (cholangitis). You were placed on IV antibiotics
which were given until ___. You underwent ERCP x2 with
successful removal of a large gallstone. You also had a biopsy
of the bile ducts taken, with the biopsy results showing benign
tissue. You also had a biliary stent placed. You were seen by
the Surgeons, and they do not recommend any further surgical
intervention at this time, but you should follow-up with the
surgeons in the outpatient setting. See appointment below.
.
You already have another ERCP scheduled in ___. You will need
to follow up with Dr. ___ repeat labs in about a week
following discharge.
.
You will need to have a hearing test follow your treatment with
the antibiotic gentamycin. Please see below with ___.
.
Followup Instructions:
___
|
19689858-DS-24
| 19,689,858 | 24,622,178 |
DS
| 24 |
2149-02-03 00:00:00
|
2149-02-03 20:44:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
fever, abdominal pain
Major Surgical or Invasive Procedure:
ERCP
History of Present Illness:
Mr. ___ is a ___ ___ man with a history of
recurrent pyogenic cholangitis complicated by growth of highly
resistant pathogens (E coli, pseudomonas), who presented with
fever, and epigastric/RUQ abdominal pain.
He was in his usual state of health until he had a greasy meal
the night before presentation. He developed fever to 104,
diffuse epigastric pain, and RUQ pain typical of his cholangitis
pain. It was constant, non-radiating, and associated with few
episodes of non-bloody, non-bilious emesis. He otherwise denied
cough, chest pain, SOB, diarrhea, bloody stools, dysuria,
hematuria, focal numbness, weakness or falls. He was admitted to
the MICU for concern
of ascending cholangitis with highly resistant organisms and
sepsis.
Past Medical History:
# Recurrent pyogenic cholangitis (Oriental cholangiohepatitis)
with strictured biliary tree
- multiple ERCP's
- multiple episodes of bacteremia including Pseudomonas and ESBL
E. coli
# Hepatitis B carrier status
Social History:
___
Family History:
There is no history of biliary, liver or GI issues.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VITALS: 98 55 142/69 19 95% on ra
GENERAL: sweaty, sitting comfortably in bed, nontoxic
HEENT: no scleral icterus, mmm
NECK: supple, no stiffness
LUNGS: faint crackles in b/l bases
CV: rrr, no m/r/g
ABD: soft, mild tttp in RUQ & epigastric region, no r/g, nl
bowel sounds
EXT: warm, no edema
SKIN: no rashes
NEURO: A&Ox3, moving all 4 extremities
DISCHARGE PHYSICAL EXAM:
VITALS: 97.5F, 120/82, 52, 18, 94% RA
GENERAL: well appearing, NAD, AOx3
HEENT: AT/NC, EOMI, MMM, anicteric sclera
CV: RRR, nl s1/s2, no m/r/g
RESP: soft bibasilar crackles, no wheezes, ronchi
GI: Soft, non-distended, nontender
GU: No suprapubic tenderness
MSK: WWP, non-edematous 2+ pulses
Pertinent Results:
ADMISSION LABS
===========================
___ 07:30PM BLOOD WBC-13.1* RBC-4.53* Hgb-13.3* Hct-40.2
MCV-89 MCH-29.4 MCHC-33.1 RDW-14.5 RDWSD-46.4* Plt ___
___ 09:59PM BLOOD ___ PTT-26.1 ___
___ 07:30PM BLOOD Glucose-114* UreaN-17 Creat-0.8 Na-139
K-3.4 Cl-102 HCO3-20* AnGap-17*
___ 07:30PM BLOOD ALT-16 AST-22 AlkPhos-94 TotBili-1.1
___ 07:30PM BLOOD Albumin-3.7 Calcium-8.5 Phos-1.4* Mg-1.3*
___ 09:41PM BLOOD Tobra-2.0*
___ 07:39PM BLOOD Lactate-2.2*
___ 01:36AM BLOOD O2 Sat-73
DISCHARGE LABS
===========================
___ 05:45AM BLOOD WBC-4.7 RBC-4.49* Hgb-13.1* Hct-39.4*
MCV-88 MCH-29.2 MCHC-33.2 RDW-13.9 RDWSD-44.7 Plt ___
___ 05:45AM BLOOD Glucose-101* UreaN-15 Creat-0.5 Na-140
K-4.2 Cl-105 HCO3-20* AnGap-15
___ 05:45AM BLOOD ALT-16 AST-20 AlkPhos-182* TotBili-0.5
___ 05:45AM BLOOD Albumin-3.9 Calcium-8.9 Phos-3.6 Mg-2.1
MICROBIOLOGY
==========================
Blood Culture, Routine (Preliminary):
PSEUDOMONAS AERUGINOSA.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
PSEUDOMONAS AERUGINOSA
|
CEFEPIME-------------- =>64 R
CEFTAZIDIME----------- =>64 R
CIPROFLOXACIN--------- 0.5 S
GENTAMICIN------------ 8 I
TOBRAMYCIN------------ 2 S
Aerobic Bottle Gram Stain (Final ___:
GRAM NEGATIVE ROD(S).
IMAGING
===========================
MRCP ___:
1. No mass-forming cholangiocarcinoma.
2. Cholangitis of the dilated segment 7 intrahepatic bile
ducts.
3. Progression of recurrent pyogenic cholangitis with diffuse
biliary ductal dilatation, biliary ducts stones, bilomas, and
pneumobilia.
4. No drainable collection.
5. Mildly enlarged paraesophageal, retroperitoneal, and
mesenteric lymph nodes, likely reactive.
6. 0.8 cm arterially enhancing splenic lesion, likely a flash
filling
hemangioma.
RUQ U/S ___:
1. Persistent diffuse biliary ductal dilatation/biloma and
echogenic foci in the left lobe of the liver, thought to
represent inspissated material or stone. MRCP would be helpful
for evaluation for cholangitis, which has been ordered for the
patient.
2. Unremarkable common bile duct.
3. Fatty liver. 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.
Brief Hospital Course:
___ pmhx Hep B and recurrent pyogenic cholangitis w/ highly
resistant pathogens who presented with fever and epigastric/RUQ
abdominal pain, managed initially in MICU and subsequently on
the medical floor for septic shock, cholangitis, and pseudomonas
bacteremia.
ACUTE/ACTIVE PROBLEMS:
#Abdominal Pain
#Pyogenic Cholangitis
Patient presentation was most concerning for ascending
cholangitis given symptoms consistent past episodes. He was
treated initially with vancomycin, meropenem, tobramycin and
was briefly in the MICU for vasopressors, which were then
successfully weaned. He underwent ERCP (___) which showed
filling defects consistent with obstruction. Bilateral plastic
stents were placed and a MRCP was subsequently performed for
better characterization of etiology for recurrent cholangitis
with stent placement. Infectious Disease recommended narrowing
antibiotics to meropenem. Blood cultures grew Pseudomonas
aeruginosa sensitive to ciprofloxacin. Overall, the patient
improved significantly with the stents and antibiotics and was
felt stable for discharge with ID recommending ciprofloxacin
for a total of 14 day course starting with day of ERCP (end
date ___ and GI recommendation for follow up ERCP in ___ weeks
for removal of stent.
CHRONIC/STABLE PROBLEMS: None
TRANSITIONAL ISSUES:
[] Would recommend checking a set of labs at upcoming PCP
appointment to ensure stability (CBC, LFTs, chemistry panel)
[] Continue PO ciprofloxacin 500mg q12 until ___
[] F/u ERCP in ___ weeks for stent removal.
# Communication: HCP: Daughter ___ ___
# Code: Full, confirmed on arrival
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. This patient is not taking any preadmission medications
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild
2. Ciprofloxacin HCl 500 mg PO Q12H Duration: 7 Days
RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth every 12 hours
Disp #*14 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
Pyogenic Cholangitis
Septic Shock
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you at ___.
WHY DID YOU COME TO THE HOSPITAL?
- You came to the hospital because you had abdominal pain which
was due to an infection of your bile duct, similar to your prior
admissions to the hospital.
WHAT HAPPENED WHILE YOU WERE HERE?
- You also grew bacteria in your blood
- Your infection was treated with antibiotics.
- A procedure called an "ERCP" was done to help clear out the
source of infection.
- An imaging study called an "MRCP" was done to help identify
any possible reason you have had this infection multiple times.
WHAT SHOULD YOU DO WHEN YOU LEAVE THE HOSPITAL?
Please continue to take all of your medications as directed,
and follow up with all of your doctors.
Again, it was a pleasure taking care of you!
Sincerely,
Your ___ Team
Followup Instructions:
___
|
19689884-DS-10
| 19,689,884 | 21,680,891 |
DS
| 10 |
2191-07-24 00:00:00
|
2191-07-24 15:53:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
Abdominal pain, emesis, diarrhea
Major Surgical or Invasive Procedure:
___: Colonoscopy with biopsy of sigmoid colon polyp
History of Present Illness:
Ms ___ is a ___, PMH significant for obesity, MDD, CKD, HTN,
diverticulitis, presents with CC of abdominal pain, vomiting,
diarrhea.
Patient states that she has had vomiting with some nonspecific
abdominal pain since ___. She mentions that recently she
was found to have +FOB, for which she is scheduled for a
colonoscopy. She was unable to tolerate the bowel prep and state
that she has since been feeling intermittently nauseous with
crampy abdominal pain. She feels distended and has not passed
gas since last week. However she did have bowel movement earlier
prior to arrival to ED (this was loose, and any BM she has had
over the past week were watery and not well formed). She denies
fevers or chills, SOB, or CP. Furthermore, review of system
reveals feeling generally "unwell", easily fatigued, and malaise
since rehab (for her ortho surgery in ___. She says that this
feeling had been worse over the past 2 weeks.
In the ED, she was resuscitated, with ancillary workup (where
were negative). Laboratory workup significant for leukocytosis
of 14.9. EKG: Sinus 119, NA, NI, No ST T changes
10 POINT review of systems was conducted and is negative unless
otherwise stated in the HPI
Past Medical History:
PAST MEDICAL HISTORY
HTN
HLD
BCC
Psoriasis
Rosacea
OA
Obesity
Diverticulitis
CKD
HH
OSA
Right carotid dissection (ischemic stroke sx, treated with
anticoagulation ___
PAST SURGICAL HISTORY
___ Knee replacement (___)
Social History:
___
Family History:
unknown bowel disease of maternal grandfather
Physical ___ Physical Exam:
VITAL SIGNS: 97.9 112 157/86 18 97% RA
GENERAL: AAOx3 NAD
HEENT: NCAT, EOMI, PERRLA, No scleral icterus, mucosa moist, no
LAD
CARDIOVASCULAR: R/R/R, S1/S2, NO M/R/G
PULMONARY: CTA ___, No crackles or rhonchi
GASTROINTESTINAL: S/NT/ND (states that she was previously TTP
LLQ
earlier today. Not TTP on exam). No guarding, rebound, or
peritoneal signs. +BSx4
EXT/MS/SKIN: No C/C/E; Feet warm. Good perfusion.
NEUROLOGICAL: Reflexes, strength, and sensation grossly intact
CNII-XII: WNL
Discharge Physical Exam:
VS: 98.3, 86, 145/89, 18, 97%ra
Gen: A&O xx, sitting comfortably
CV: HRR normal s1/s2
Pulm: LS ctab
GI: Abd softly distended, nontender.
Ext: no edema
Pertinent Results:
IMAGING:
___: EKG:
Sinus tachycardia. Baseline artifact. Possible prior inferior
wall
myocardial infarction. Poor R wave progression. Non-specific T
wave
flattening. Low QRS voltage in the limb leads. No previous
tracing available for comparison.
___: CT Abdomen & Pelvis:
1. Focal area of irregular wall thickening, abnormal mural
hyperenhancement,
and luminal narrowing within the sigmoid colon concerning for
malignancy
resulting in upstream large bowel obstruction. Colonoscopy is
recommended and surgical consultation is suggested.
2. Apparent mild circumferential cecal wall thickening may be
due to
underdistention, but this area should be evaluated at the time
of colonoscopy.
3. 9 mm hypodense liver lesion is indeterminate, and a
metastasis cannot be excluded. Liver MRI may be helpful pending
endoscopy results.
4. Large hiatal hernia.
___: CXR (PA&LAT):
No focal airspace opacity. Moderate hiatal hernia better
evaluated on prior study.
___: CXR:
Nasogastric drainage tube passes into a mildly distended stomach
and out of view. Atelectasis at the left lung base is mild.
Right lung is clear. Heart size top-normal. No pleural
abnormality.
___ Colonoscopy:
Diverticulosis of the sigmoid colon
In the sigmoid colon at 30-40 cm, a narrowed segment was
encountered which was edematous and with erythema, most
consistent with a segment of diverticulitis. The segment was
able to be traversed and stool was present proximally.
Polyp in the sigmoid colon (biopsy)
Otherwise normal colonoscopy to proximal sigmoid colon
Labs:
___ 07:26AM GLUCOSE-107* UREA N-23* CREAT-0.7 SODIUM-139
POTASSIUM-3.5 CHLORIDE-104 TOTAL CO2-22 ANION GAP-17
___ 07:26AM AST(SGOT)-14 ALK PHOS-81 TOT BILI-0.5
___ 07:26AM ALBUMIN-3.4* CALCIUM-8.6 PHOSPHATE-3.6
MAGNESIUM-1.8
___ 07:26AM CEA-3.6
___ 11:20PM URINE COLOR-Yellow APPEAR-Clear SP
___
___ 11:20PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-40 BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-TR
___ 11:20PM URINE RBC-2 WBC-0 BACTERIA-FEW YEAST-NONE
EPI-1
___ 11:20PM URINE MUCOUS-RARE
___ 09:00PM GLUCOSE-116* UREA N-27* CREAT-0.9 SODIUM-140
POTASSIUM-4.5 CHLORIDE-100 TOTAL CO2-24 ANION GAP-21*
___ 09:00PM ALT(SGPT)-9 AST(SGOT)-17 ALK PHOS-94 TOT
BILI-0.8
___ 09:00PM LIPASE-21
___ 09:00PM ALBUMIN-4.1
___ 09:00PM WBC-14.9* RBC-4.47 HGB-13.8 HCT-41.5 MCV-93
MCH-30.9 MCHC-33.3 RDW-12.9 RDWSD-43.8
___ 09:00PM NEUTS-90.4* LYMPHS-3.5* MONOS-5.5 EOS-0.0*
BASOS-0.1 IM ___ AbsNeut-13.44* AbsLymp-0.52* AbsMono-0.82*
AbsEos-0.00* AbsBaso-0.02
___ 09:00PM PLT COUNT-255
Brief Hospital Course:
Ms ___ is a ___ w/ PMH significant for obesity, MDD, CKD, HTN,
diverticulitis, who presented to the ___ ED on ___ w/
abdominal pain, emesis, diarrhea and fatigue. CT abdomen/pelvis
revealed a sigmoid mass with a large bowel obstruction. The
patient was hemodynamically stable. She was admitted for bowel
rest, IV fluid resuscitation, nasogastric tube for bowel
decompression, and serial abdominal exams.
GI was consulted and the patient underwent a colonoscopy on HD2.
The scope revealed a narrowed segment which was edematous and
with erythema, most consistent with a segment of diverticulitis.
A polyp was also biopsied. Given these findings, the patient was
started on cipro and flagyl for treatment of diverticulitis.
.
Pain was well controlled. The nasogastric tube was removed on
HD3 and diet was progressively advanced as tolerated to a
regular diet. The patient voided without problem. During this
hospitalization, the patient ambulated early and frequently, was
adherent with respiratory toilet and incentive spirometry, and
actively participated in the plan of care. The patient received
subcutaneous heparin and venodyne boots were used during this
stay.
.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet, ambulating, voiding without assistance, and denied pain.
The patient was discharged home without services. The patient
received discharge teaching and follow-up instructions with
understanding verbalized and agreement with the discharge plan.
She was given a prescription for antibiotics to complete a
2-week course and would follow-up with GI and with her PCP.
Medications on Admission:
Venlafaxine 37.5'
Simvastatin 20'
Omeprazoel 20'
Fluticasone 50''
Metoprolol 25'
hydroquinone 0.05%''
Hydrocortisone 2.5%''
Nystatin
Acetic acid-hydrocortisone
Ferrus sulfate 325'
MTV
Vit D3 1000'
B12 1000'
Discharge Medications:
1. Ciprofloxacin HCl 500 mg PO Q12H
RX *ciprofloxacin HCl [Cipro] 500 mg 1 tablet(s) by mouth every
twelve (12) hours Disp #*24 Tablet Refills:*0
2. MetroNIDAZOLE 500 mg PO Q8H
RX *metronidazole 500 mg 1 tablet(s) by mouth every eight (8)
hours Disp #*36 Tablet Refills:*0
3. Fluticasone Propionate NASAL 1 SPRY NU BID
4. Metoprolol Succinate XL 25 mg PO DAILY
5. Nyamyc (nystatin) 100,000 unit/gram topical BID:PRN
6. Omeprazole 20 mg PO DAILY
7. Venlafaxine XR 37.5 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Diverticulitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to ___ with abdominal pain, vomiting and
diarrhea. A CT scan showed a sigmoid mass with a large bowel
obstruction. You underwent a colonoscopy, which showed
diverticulitis and a narrowed segment of colon, which was the
source of obstruction. A polyp was also seen and biopsied. Your
diet was slowly advanced and you are now tolerating regular
food. You are ready to be discharged home to continue your
recovery. You will be prescribed a 2-week course of antibiotics
to treat your diverticulitis.
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.
Followup Instructions:
___
|
19689884-DS-11
| 19,689,884 | 24,144,529 |
DS
| 11 |
2191-11-11 00:00:00
|
2191-11-20 17:08:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
Large bowel obstruction
Major Surgical or Invasive Procedure:
___: Sigmoid resection and sigmoid colostomy and closure of
distal stump.
History of Present Illness:
Patient is a ___ F with a history of HTN, HLD, Psoriasis,
and stroke and past surgical history of appendectomy presenting
with nausea, and vomiting for several days. The patient reports
her last bowel movement was 2 weeks ago, which is difficult to
verify. She was recently admitted to the ACS service in ___
for obstructive symptoms and a colonoscopy. During that
admission
a colonoscopy was performed and an area of narrowing was noted
in
the sigmoid colon. She was discharged after she had return of
bowel function but was advised to follow up in 2 weeks, but
patient was lost to follow up. In the mean time, she has had
progressive obstructive symptoms with nausea and vomiting and
inability to tolerate food. She reports that the stools that she
has had have been watery and thin, but again denies flatus or
bowel movement x 2 weeks. Notably, she denies abdominal pain.
Because of the aforementioned symptoms, the patient presented to
the emergency department.
Past Medical History:
PAST MEDICAL HISTORY
HTN
HLD
BCC
Psoriasis
Rosacea
OA
Obesity
Diverticulitis
CKD
HH
OSA
Right carotid dissection (ischemic stroke sx, treated with
anticoagulation ___
PAST SURGICAL HISTORY
___ Knee replacement (___)
Social History:
___
Family History:
unknown bowel disease of maternal grandfather
Physical ___ Physical Exam:
Vitals: T 98.1 , HR 118, BP 100/57, RR 21, SaO2 97% RA
GEN: Alert and oriented, appropriate, interactive.
HEENT: Sclerae anicteric, dry mucous membranes
CV: Regular rate and rhythm, no audible murmurs.
PULM/CHEST: Clear to auscultation bilaterally, respirations are
unlabored on room air.
ABD: marked, profound abdominal distention and tympany. no
rebound or guarding. No focal tenderness.
Ext: No lower extremity edema, distal extremities warm and
well-perfused.
Discharge Physical Exam:
VS: T: 98.5 PO BP: 149/86 HR: 82 RR: 18 O2: 98% RA
GEN: A+Ox3, NAD
HEENT: atraumatic, MMM
CV: RRR
PULM: CTA b/l
ABD: midline abdominal incision with staples with reactive
erythema, no s/s infection. Incision well-approximated.
Colostomy with liquid brown stool and flatus in bag.
EXT: warm, well-perfused, no edema b/l
Pertinent Results:
IMAGING:
___: CXR (PA & LAT):
No acute intrathoracic process.
___: Abdominal X-ray (supine and erect):
Supine and upright views of the abdomen pelvis were provided.
Diffuse small enlarged bowel dilation noted without definite
signs for free air below the right hemidiaphragm. CT is
recommended to further assess.
___: CT Abdomen/Pelvis:
1. Obstructing sigmoid colon mass results in large bowel
obstruction with
subsequent dilated and fluid filled loops of small bowel. No
evidence of
pneumatosis.
2. Enlarged multi fibroid uterus.
3. Large hiatal hernia with and enteric tube terminating within
the hernia. Consider advancement if desired location to be
within the stomach.
___: CXR:
ET tube tip is in the carina and should be pulled back at least
3 cm. NG tube tip is in the distal esophagus and should be
advanced 15 cm.
Left central venous line tip is at the level of lower SVC.
Heart size and mediastinum are overall unchanged in appearance.
Hiatal hernia is large and the NG tube might potentially be
within the hernia.
Lungs overall clear.
PATHOLOGY: COLON/RECTUM, PARTIAL RESECTION NOT FOR TUMOR:
Sigmoid colon, resection:
- Inflammatory-type polyp, measuring 2.0 cm in greatest
dimension, in a background of diverticular
disease without associated abscesses or perforation.
- Multiple separate hyperplastic polyps.
- Unremarkable regional lymph nodes and margins.
LABS:
___ 02:28PM GLUCOSE-78 UREA N-23* CREAT-0.9 SODIUM-138
POTASSIUM-4.6 CHLORIDE-106 TOTAL CO2-15* ANION GAP-22*
___ 02:28PM CALCIUM-8.5 PHOSPHATE-3.2 MAGNESIUM-1.1*
___ 02:28PM WBC-6.0 RBC-3.99 HGB-12.0 HCT-36.7 MCV-92
MCH-30.1 MCHC-32.7 RDW-13.2 RDWSD-44.1
___ 02:28PM PLT COUNT-194
___ 02:28PM ___ PTT-24.6* ___
___ 05:48AM URINE COLOR-Yellow APPEAR-Hazy SP ___
___ 05:48AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-40 BILIRUBIN-NEG UROBILNGN-2* PH-6.0 LEUK-NEG
___ 05:48AM URINE RBC-<1 WBC-1 BACTERIA-FEW YEAST-NONE
EPI-<1
___ 05:48AM URINE HYALINE-10*
___ 05:48AM URINE MUCOUS-RARE
___ 01:00AM LACTATE-1.3
___ 12:55AM GLUCOSE-85 UREA N-27* CREAT-1.2* SODIUM-136
POTASSIUM-5.1 CHLORIDE-101 TOTAL CO2-18* ANION GAP-22*
___ 12:55AM ALT(SGPT)-8 AST(SGOT)-14 ALK PHOS-70 TOT
BILI-0.6
___ 12:55AM LIPASE-37
___ 12:55AM ALBUMIN-3.4*
___ 12:46AM LACTATE-2.8*
___ 12:30AM GLUCOSE-82 UREA N-29* CREAT-1.2* SODIUM-136
POTASSIUM-5.1 CHLORIDE-102 TOTAL CO2-15* ANION GAP-24*
___ 12:30AM ALT(SGPT)-8 AST(SGOT)-16 ALK PHOS-70 TOT
BILI-0.6
___ 12:30AM LIPASE-38
___ 12:30AM ALBUMIN-3.3*
___ 12:30AM WBC-7.2 RBC-4.45 HGB-13.2 HCT-41.1 MCV-92
MCH-29.7 MCHC-32.1 RDW-13.1 RDWSD-44.2
___ 12:30AM NEUTS-74.2* LYMPHS-10.8* MONOS-13.5* EOS-0.0*
BASOS-0.4 IM ___ AbsNeut-5.31 AbsLymp-0.77* AbsMono-0.97*
AbsEos-0.00* AbsBaso-0.03
___ 12:30AM PLT COUNT-221
___ 09:35PM LACTATE-2.7*
___ 09:22PM VoidSpec-SPECIMEN R
___ 09:22PM WBC-8.3 RBC-4.93# HGB-14.8# HCT-44.6# MCV-91
MCH-30.0 MCHC-33.2 RDW-13.1 RDWSD-43.2
___ 09:22PM NEUTS-65.3 LYMPHS-18.9* MONOS-14.3* EOS-0.2*
BASOS-0.5 IM ___ AbsNeut-5.40# AbsLymp-1.56 AbsMono-1.18*
AbsEos-0.02* AbsBaso-0.04
___ 09:22PM PLT COUNT-297
Brief Hospital Course:
The patient presented to the emergency department on ___ in
acute distress secondary to her malignant large bowel
obstruction. She was taken to the operating room for resection
of her obstructive mass and end colostomy. There were no adverse
events in the operating room; please see the operative note for
details. She was taken to the ICU intubated on pressers for
hypotension post-operatively.
ICU Course:
Neuro: The patient was intermittently alert and oriented after
extubation. Her mental status improved after she was transferred
from the ICU, where she was noted to have intermittent delirium.
Reorientation and appropriate sleep/wake cycling were used to
assist in managing her delirium; pain was initially managed with
a fentanyl drip while intubated, then intermittent IV when
extubated, and then transitioned to oral once tolerating a diet.
CV: She was slowly weaned from levophed and vasopressin
post-operatively. Once weaned completely, she was transferred to
the ward for further care.
Pulmonary: The patient remained stable from a pulmonary
standpoint; she was extubated on post-operative day one. Vital
signs were routinely monitored. Good pulmonary toilet, early
ambulation and incentive spirometry were encouraged throughout
hospitalization.
GI/GU/FEN: The patient was initially kept with a ___
tube in place for decompression while she was intubated. On
POD1, the NGT was removed when she was extubated because of poor
placement secondary to her hiatal hernia. She had appropriate
ostomy output on POD1; therefore, the diet was advanced
sequentially to a Regular diet, which was well tolerated.
Patient's intake and output were closely monitored
ID: The patient's fever curves were closely watched for signs of
infection, of which there were none.
HEME: The patient's blood counts were closely watched for signs
of bleeding, of which there were none.
Prophylaxis: The patient received subcutaneous heparin and ___
dyne boots were used during this stay and was encouraged to get
up and ambulate as early as possible.
On POD #5, the patient was transferred to the surgical floor:
Since being on the floor, the patient was alert and oriented.
Pain was well-controlled with PO acetaminophen. She remained
stable from a cardiovascular and pulmonary standpoint; vital
signs were routinely monitored. Good pulmonary toilet, early
ambulation and incentive spirometry were encouraged throughout
hospitalization. The patient tolerated a regular diet, intake
out output were closely monitored. The patient's colostomy was
productive of stool. The patient was seen by the wound ostomy
nurse and received ostomy teaching. The patient's fever curves
were closely watched for signs of infection, of which there were
none. The patient's blood counts were closely watched for signs
of bleeding, of which there were none. The patient received
subcutaneous heparin and ___ dyne boots were used during this
stay and was encouraged to get up and ambulate as early as
possible. She worked with Physical Therapy and it was
recommended that she be discharged to rehab to continue her
recovery.
At the time of discharge, the patient was doing well, afebrile
and hemodynamically stable. The patient was tolerating a diet,
ambulating, voiding without assistance, and pain was well
controlled. The patient received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with the discharge plan.
Medications on Admission:
Medications - Prescription
ALBUTEROL SULFATE [PROAIR HFA] - ProAir HFA 90 mcg/actuation
aerosol inhaler. ___ puff four times a day as needed -
(Prescribed by Other Provider)
ATENOLOL - atenolol 25 mg tablet. Tablet(s) by mouth once a day
-
(Prescribed by Other Provider)
DICLOFENAC SODIUM - diclofenac sodium 75 mg tablet,delayed
release. Tablet(s) by mouth twice a day - (Prescribed by Other
Provider)
FEXOFENADINE [ALLEGRA] - Allegra 180 mg tablet. Tablet(s) by
mouth once a day - (Prescribed by Other Provider)
FLUOXETINE - fluoxetine 20 mg capsule. 2 Capsule(s) by mouth
once
a day - (Prescribed by Other Provider)
FLUTICASONE [FLOVENT DISKUS] - Flovent Diskus 50 mcg/actuation
powder for inhalation. 1 spray ih once a day - (Prescribed by
Other Provider)
HYDROCORTISONE - hydrocortisone 2.5 % topical cream. twice a
day
- (Prescribed by Other Provider)
HYDROCORTISONE-ACETIC ACID - hydrocortisone-acetic acid 1 %-2 %
ear drops. 2 drops three times a day as needed - (Prescribed by
Other Provider)
METRONIDAZOLE - metronidazole 0.75 % topical cream. twice a day
- (Prescribed by Other Provider)
NYSTATIN-TRIAMCINOLONE - nystatin-triamcinolone 100,000
unit/g-0.1 % topical cream. twice a day - (Prescribed by Other
Provider)
OMEPRAZOLE - omeprazole 20 mg capsule,delayed release.
Capsule(s)
by mouth once a day - (Prescribed by Other Provider)
SIMVASTATIN - simvastatin 80 mg tablet. Tablet(s) by mouth once
a
day - (Prescribed by Other Provider)
Medications - OTC
ACETYLCARNITINE - Dosage uncertain - (Prescribed by Other
Provider)
ALPHA LIPOIC ACID - alpha lipoic acid ___ mg capsule. Capsule(s)
by mouth once a day - (Prescribed by Other Provider)
CALCIUM CARBONATE-VITAMIN D3 - calcium carbonate 500 mg (1,250
mg)-vitamin D3 400 unit tablet. Tablet(s) by mouth twice a day -
(Prescribed by Other Provider)
CHOLECALCIFEROL (VITAMIN D3) [VITAMIN D3] - Vitamin D3 1,000
unit
chewable tablet. Tablet(s) by mouth twice a day - (Prescribed
by
Other Provider)
MULTIVITAMIN - multivitamin capsule. Capsule(s) by mouth once a
day - (Prescribed by Other Provider)
OMEGA 3-DHA-EPA-FISH OIL - omega 3-dha-epa-fish oil 1,000 mg
(120
mg-180 mg) capsule. Capsule(s) by mouth once a day -
(Prescribed
by Other Provider)
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
2. Heparin 5000 UNIT SC TID
3. Albuterol Inhaler ___ PUFF IH Q4H:PRN wheeze
4. GuaiFENesin ___ mL PO Q6H:PRN cough/congestion
5. Metoprolol Tartrate 12.5 mg PO BID
6. Omeprazole 20 mg PO DAILY
7. Venlafaxine XR 37.5 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Large bowel obstruction.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You were admitted to ___ with abdominal pain and were found to
have a large bowel obstruction. You were taken to the operating
room and underwent a sigmoid resection and sigmoid colostomy and
closure of distal stump. After your surgery, you were monitored
closely in the intensive care unit and required some medications
for low blood pressure. Your vital signs and lab work have all
normalized. You are back on your home medications, tolerating a
regular diet, and your pain is well controlled. You are
tolerating a regular diet and your ileostomy is producing stool.
You have worked with Physical Therapy and are now medically
cleared to be discharged to rehab to continue your recovery.
Please note the following instructions:
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within ___ hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications, unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
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.
Monitoring Ostomy output/ Prevention of Dehydration:
*Keep well hydrated.
*Replace fluid loss from ostomy daily.
*Avoid only drinking plain water. Include Gatorade and/or other
vitamin drinks to replace fluid.
*Try to maintain ostomy output between 1000mL to 1500mL per day.
*If Ostomy output >1 liter, take 4mg of Imodium, repeat 2mg with
each episode of loose stool. Do not exceed 16mg/24 hours.
Followup Instructions:
___
|
19690282-DS-23
| 19,690,282 | 23,034,623 |
DS
| 23 |
2143-06-17 00:00:00
|
2143-06-17 12:32:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
memory problems, HAs, unsteady gait
Major Surgical or Invasive Procedure:
___ right craniotomy for tumor resection
History of Present Illness:
___ yo F hx rectal cancer who presents with 2 months of mild
headaches, poor memory, word finding difficulty, disorganization
and unsteady gait. Pt went to OSH where head CT showed right
sided mass and pt was transferred to ___ for neurosurgical
evaluation.
Past Medical History:
rectal cancer s/p resection, chemotherapy and radiation
laparoscopic proctectomy and low anterior resection with
diverting ileostomy on ___
Ileostomy take town ___
HTN
osteoporosis
Social History:
___
Family History:
Her family history is significant for a sister
with breast cancer around the age of ___. Another sister with
colon cancer at the age of ___. Her mother had colon cancer in
her ___, but lived to ___. She has a total four brothers and
four
sisters. Her mother's sister had breast cancer. She had
another
cousin with colon cancer at ___
Physical Exam:
On Admission:
O: T:98.6 BP: 128/68 HR:82 R:18 O2Sats:99%
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.
Language: Speech fluent with good comprehension and repetition.
Unable to name "ID/badge/name tag".
No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 3 to
2 mm bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation 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 bilaterally.
Coordination: normal on finger-nose-finger
On Discharge:
alert and oriented x3
PERRL
EOM intact
No drift
MAE ___
Incision c/d/i closed with sutures
Pertinent Results:
___ MRI Head:
1. Peripherally enhancing right parietal mass extending to the
right splenium of the corpus callosum, with central necrosis,
blood products, and subependymal spread along the right lateral
ventricle, most likely GBM, and less likely lymphoma if the
patient is immunocompromised.
2. Mild leftward shift of midline structures.
3. Entrapment of the temporal horn of the right lateral
ventricle.
___ CT Abd/Pelvis:
1. Stable appearance status post proctectomy. No evidence of
new or recurrent malignancy in the abdomen or pelvis.
2. Nonobstructing 3 mm left renal stone.
___ CT Chest:
No evidence of suspicious pulmonary nodules or masses. No
evidence of
malignant thoracic disease
___ CTA Head:
CT head: The known ill-defined right parietal mass with central
necrosis is identified and demonstrates significant surrounding
vasogenic edema and mass effect on the underlying brain
parenchyma, with 3 mm leftward shift of normally midline
structures (3:20 and 21). No acute hemorrhage or infarct is
identified. No osseous abnormality identified.
CTA head: Multiple irregular, ill-defined vessels are identified
within the mass, consistent with tumor vessels. Vessels in the
anterior and superior aspect of the mass appear to be venous in
nature, draining into the right vein of ___. The bilateral
PCAs are symmetric. No aneurysm greater than 3 mm, stenosis, or
occlusion is identified.
___ MRI head
No significant interval change in peripherally enhancing right
parietal mass. No new enhancing lesions identified.
___ CT head
1. Interval postsurgical changes related to right parietal mass
resection as described.
2. There is edema surrounding the resection cavity with
persistent leftward shift of the normal midline structures and
entrapment of the temporal horn of the right lateral ventricle,
which is similar to the preoperative exams.
___ MRI head
1. Study is mildly degraded by motion.
2. Evolving postsurgical changes related to patient's recent
right parietal lobe mass resection as described.
3. Stable 5 mm right to left midline shift with continued mass
effect on right lateral ventricle and entrapment of temple horn
of right lateral ventricle.
4. Grossly stable right temporal, parietal, and occipital
regions of edema.
5. Nonspecific enhancement and restricted diffusion along
margins of surgical bed. Residual tumor is not excluded on the
basis of this examination. Recommend attention on followup
imaging.
Brief Hospital Course:
___ y/o F with history of rectal CA presents with history of poor
memory and word finding difficulties with unsteady gait x 2
months. Head CT showed question of R parietal lesion. She was
neurologically intact on exam except for mild difficulty with
naming. She was admitted to the neurosurgical service for MRI
head and further management. On ___, patient remained intact on
exam and naming was improved. MRI head revealed a R parietal
lesion with effacement of the R occipital horn and vasogenic
edema. CT torso was negative for malignancy and neuro and
radiation oncology were consulted. She remained stable into
___.
On ___ she was seen and evaluated, underwent a CTA of the head,
and it was determined she would undergo planned surgical
resection of her lesion on ___.
On ___, the patient was stable and there were no events over
night. She was put on the OR schedule for ___ for a right
craniotomy for resection of tumor. Consent was obtained and
signed. Pre operative orders were placed. A WAND study was
ordered. She was made NPO.
On ___, the patient was stable and there were no events over
night. She went for her WAND MRI for operative planning
purposes. She was taken to the OR for a right craniotomy for
tumor resection. Post operatively patient was doing well. Post
operative CT revealed expected changes.
On ___ Routine post operative MRI was completed. Patient was
evaluated by ___ who determined they would like to see patient
___ more times.
On ___ Patient remained stable awaiting ___ re-evaluation.
On ___ Patient's pain was well controlled. ___ recommended home
with services. Family meeting was had to discuss ongoing
treatments.
On ___ She was discharged home with services with instructions
for follow up.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Lisinopril 10 mg PO DAILY
2. Gabapentin 300 mg PO BID
3. Fluticasone Propionate 110mcg 2 PUFF IH BID
4. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB
5. Alendronate Sodium 5 mg PO QSUN
6. Vitamin D ___ UNIT PO DAILY
Discharge Medications:
1. Fluticasone Propionate 110mcg 2 PUFF IH BID
2. Gabapentin 300 mg PO BID
3. Lisinopril 10 mg PO DAILY
4. Vitamin D ___ UNIT PO DAILY
5. Acetaminophen 650 mg PO Q8H:PRN pain
6. Docusate Sodium 100 mg PO BID
7. Famotidine 20 mg PO BID
RX *famotidine 20 mg 1 tablet(s) by mouth twice a day Disp #*60
Tablet Refills:*3
8. LeVETiracetam 500 mg PO BID
RX *levetiracetam 500 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*2
9. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
RX *oxycodone 5 mg ___ tablet(s) by mouth Q4-6H PRN pain Disp
#*60 Tablet Refills:*0
10. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB
11. Alendronate Sodium 5 mg PO QSUN
12. Rolling walker
Dx; right parietal brain mass
prognosis; good
length of need; 13 months
13. Dexamethasone 4 mg PO Q6H
4mg Q 6 x1 day, 4mg Q8 x1day, 4mg Q12 continue
RX *dexamethasone 4 mg 1 tablet(s) by mouth taper per
instructions Disp #*90 Tablet Refills:*2
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Right parietal mass
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Surgery
*** You underwent surgery to remove a brain lesion from your
brain.
Please keep your incision dry until your sutures are removed.
You may shower at this time but keep your incision dry.
It is best to keep your incision open to air but it is ok to
cover it when outside.
Call your surgeon if there are any signs of infection like
redness, fever, or drainage.
Activity
We recommend that you avoid heavy lifting, running, climbing,
or other strenuous exercise until your follow-up appointment.
You make take leisurely walks and slowly increase your
activity at your own pace once you are symptom free at rest.
___ try to do too much all at once.
No driving while taking any narcotic or sedating medication.
If you experienced a seizure while admitted, you are NOT
allowed to drive by law.
No contact sports until cleared by your neurosurgeon. You
should avoid contact sports for 6 months.
Medications
***Please do NOT take any blood thinning medication (Aspirin,
Ibuprofen, Plavix, Coumadin) until cleared by the neurosurgeon.
***You have been discharged on Keppra (Levetiracetam). This
medication helps to prevent seizures. Please continue this
medication as indicated on your discharge instruction. It is
important that you take this medication consistently and on
time.
You may use Acetaminophen (Tylenol) for minor discomfort if
you are not otherwise restricted from taking this medication.
What You ___ Experience:
You may experience headaches and incisional pain.
You may also experience some post-operative swelling around
your face and eyes. This is normal after surgery and most
noticeable on the second and third day of surgery. You apply
ice or a cool or warm washcloth to your eyes to help with the
swelling. The swelling will be its worse in the morning after
laying flat from sleeping but decrease when up.
You may experience soreness with chewing. This is normal from
the surgery and will improve with time. Softer foods may be
easier during this time.
Feeling more tired or restlessness is also common.
Constipation is common. Be sure to drink plenty of fluids and
eat a high-fiber diet. If you are taking narcotics (prescription
pain medications), try an over-the-counter stool softener.
When to Call Your Doctor at ___ for:
Severe pain, swelling, redness or drainage from the incision
site.
Fever greater than 101.5 degrees Fahrenheit
Nausea and/or vomiting
Extreme sleepiness and not being able to stay awake
Severe headaches not relieved by pain relievers
Seizures
Any new problems with your vision or ability to speak
Weakness or changes in sensation in your face, arms, or leg
Call ___ and go to the nearest Emergency Room if you experience
any of the following:
Sudden numbness or weakness in the face, arm, or leg
Sudden confusion or trouble speaking or understanding
Sudden trouble walking, dizziness, or loss of balance or
coordination
Sudden severe headaches with no known reason
Followup Instructions:
___
|
19690287-DS-8
| 19,690,287 | 20,448,118 |
DS
| 8 |
2182-10-05 00:00:00
|
2182-10-05 13:06:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
dyspnea
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ w asthma, GERD, HTN p/w dyspnea.
Patient was in her usual state of good health on ___ and then
on ___ evening she started having worsening wheezing beyond her
mild chronic wheezy baseline. This also involved shortness of
breath, chest tightness, cough that is productive now of yellow
sputum. Most recently, this has been associated with rhinorrhea
and watery eyes, which is similar to her seasonal allergies. The
shortness of breath and wheezing worsened over the next day to
the point where she woke up unable to breathe and had to sit up
in bed, and she noticed she was tripoding because of accessory
muscle use. She also noticed that at worst she was having
trouble speaking given her dyspnea and tachypnea. She denies
fevers, chills, nausea, vomiting, myalgias. No sick contacts,
but works in a hospital (___) and around a lot of people, and
has recently been on a plane. No ___ trauma or history of DVT/PE
but was on a flight to ___ recently (2 weeks ago). Denies
abrupt increases in weight, but gained about 8lbs from summer to
winter (weighs self very frequently) which she attributes to
decreased activity over the winter. She reports her abdomen is
larger. Denies early satiety, ___ beyond her baseline "fat legs"
with mild edema at end of day. No increase in salt or salty
foods. No recent changes in medications other than the Z pack
she started on ___ for this symptomatology as well as increased
albuterol, which was initially helpful but then wasn't helping.
Hasn't missed her controller meds. Never smoker.
In ED, 97.7 95 149/95 20 96%RA, pre peak flow 125, post 200.
87%RA at lowest. Exam notable for diffuse inspiratory and
expiratory wheezes throughout, worse on expiration, mild
baseline swelling of lower extremities. Given a neb and 125mg
metyhlprednisole with improvement. Xray unremarkable, D dimer
neg. Flu neg. Given several nebs. Given levofloxacin 750mg. On
transfer, 102 144/75 16, 93%RA. Admitted to medicine for asthma.
Past Medical History:
HTN
HLD
GERD
asthma--no PFTs available, but she reports having done as
outpatient and that there was reversibility, primarily
cold/allergen induced
seasonal allergies
bronchiectasis--reportedly idiopathic
OA of B knees, L worse than R
L knee arthroscopy
multinodular goiter--negative biopsies, managed with observation
by endocrine
colonic adenoma
G2P2
neuropathy B feet thought ___ shingles as a child
Social History:
___
Family History:
father with AS/CHF/CABG
GM bronchiectasis (presumed ___ TB)
mom alive and well
paternal GF lung cancer, unexplained death
Physical Exam:
Admission exam:
98.4 PO 143 / 91 R Sitting ___ Ra
very pleasant, NAD, speaking in full sentences
PERRL, EOMI
MMM, no LAD, no exudates
RRR no mrg, JVP difficult to assess but does not appear
elevated,
diffuse expiratory wheezing, no crackles, no dullness, moderate
air movement
sntnd, NABS
wwp, trace ___, no cords, equal LEs
A&Ox3, CN II-XII intact, ___ BUE/BLE, SILT BUE/BLE, FTN wnl
no rash
no foley
Discharge exam:
Afebrile, HR 108 --> 92, BP 115-143/69-91, RR18, 91-92% RA with
exertion
Peak flow 250 (65% predicted peak flow of 370)
Pleasant, no distress. Sitting up in bed, speaking in full
sentences without difficulty
Moist mucous membranes, intact dentition
RRR, no MRG. 2+ radial pulses ___.
Loud expiratory wheezing throughout lung fields but good air
movement, no crackles
SNTND, NABS
WWP, trace BLE edema (nonpitting)
A&Ox3, strength intact x4 limbs, normal gait
Pertinent Results:
___ 07:48AM BLOOD WBC-12.2*# RBC-5.49* Hgb-15.7 Hct-48.7*
MCV-89 MCH-28.6 MCHC-32.2 RDW-14.0 RDWSD-45.2 Plt ___
___ 07:48AM BLOOD Neuts-77.4* Lymphs-11.8* Monos-6.3
Eos-3.2 Baso-0.8 Im ___ AbsNeut-9.44* AbsLymp-1.44
AbsMono-0.77 AbsEos-0.39 AbsBaso-0.10*
___ 09:15AM BLOOD Glucose-105* UreaN-16 Creat-0.8 Na-146*
K-3.7 Cl-107 HCO3-27 AnGap-16
___ 07:48AM BLOOD Glucose-100 UreaN-17 Creat-0.9 Na-140
K-8.5* Cl-107 HCO3-19* AnGap-23*
___ 09:15AM BLOOD D-Dimer-271
___ 08:31AM OTHER BODY FLUID FluAPCR-NEGATIVE
FluBPCR-NEGATIVE
EKG: NSR at 95, nl axis, nl intervals, QTc 477, no LVH/RVH, 1mm
lateral ST deps in V3-V6, no Qs (new since ___
CXR: The lungs are clear. Heart size and mediastinal contours
are normal. No pleural effusion or pneumothorax. Osseous
structures are intact.
IMPRESSION:
No evidence of pneumonia.
Brief Hospital Course:
___ w asthma, GERD, HTN p/w dyspnea, found to have acute
asthma exacerbation.
# Asthma exacerbation:
# Mild hypoxemic respiratory failure
# Possible bronchiectasis flare
Likely viral, no pneumonia on CXR. Negative d-dimer with Wells=3
at most (if given points for immobilization given flight and for
intermittent tachycardia x1, though beta blocked) makes PE very
unlikely. She had a negative troponin and a normal BNP. Negative
flu. She rec'd methylprednisolone in the ED with rapid response
and was weaned off oxygen. She will receive 4 further days of
steroids (3 as outpatient). She was also given levofloxacin
given her h/o bronchiectasis, and will complete a 5 day course
of this (3 days as outpt). Peak flow was 250 on discharge, 65%
of predicted peak flow of 370 based on age and weight.
Ambulatory and maintaining sats > 91% on room air with
significant improvement in symptoms.
- Given that she noted a subacute progression of symptoms over
several weeks of worsening symptoms, might also consider an
atypical mycobacterium given her h/o bronchiectasis.
- She should have a follow-up chest X-ray in ___ weeks given her
h/o bronchiectasis.
- Could consider a pulmonology referral as an outpt.
# Hypernatremia:
She had mild hypernatremia to 146 on inpatient, likely ___
dehydration. This resolved with PO fluid hydration.
Co-sign addendum:
I saw the patient this day ___ with Dr. ___
___, reviewed all relevant data, and agree with
assessment and plan.
30 minutes on discharge activities including counseling and
coordination of care.
___, Hospitalist, Dept of Medicine
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheeze
2. Atorvastatin 20 mg PO QPM
3. Symbicort (budesonide-formoterol) 80-4.5 mcg/actuation
inhalation 2 puff bid
4. Metoprolol Succinate XL 50 mg PO DAILY
5. Pantoprazole 40 mg PO Q24H
6. One Daily For Women (multivit-iron-min-folic acid) ___ mg
oral DAILY
Discharge Medications:
1. Levofloxacin 750 mg PO Q24H
RX *levofloxacin 750 mg 1 tablet(s) by mouth daily Disp #*3
Tablet Refills:*0
2. PredniSONE 40 mg PO DAILY Duration: 3 Doses
RX *prednisone 20 mg 2 tablet(s) by mouth daily Disp #*6 Tablet
Refills:*0
3. Albuterol Inhaler 2 PUFF IH Q4H:PRN wheezing
4. Atorvastatin 20 mg PO QPM
5. Metoprolol Succinate XL 50 mg PO DAILY
6. One Daily For Women (multivit-iron-min-folic acid) ___ mg
oral DAILY
7. Pantoprazole 40 mg PO Q24H
8. Symbicort (budesonide-formoterol) 80-4.5 mcg/actuation
inhalation 2 PUFF BID
Discharge Disposition:
Home
Discharge Diagnosis:
Asthma exacerbation/bronchiectasis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent without use of oxygen
Discharge Instructions:
You were hospitalized with an asthma exacerbation. It is likely
that you have had a viral bronchitis for several weeks that
triggered this attack. You improved rapidly after receiving
methylprednisolone in the ED. We are sending you home with 3
more days of prednisone. We will also have you take 3 more days
of levofloxacin since you have bronchiectasis.
Followup Instructions:
___
|
19690769-DS-18
| 19,690,769 | 22,332,179 |
DS
| 18 |
2164-10-23 00:00:00
|
2164-10-27 17:44:00
|
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
morphine
Attending: ___.
Chief Complaint:
Fall
Major Surgical or Invasive Procedure:
cyberknife treatment - Radiation oncology - ___
History of Present Illness:
___ with Hx of metastatic renal cell ca s/p L radical
nephrectomy and on PD-1 trial. He presents to ED after fall at
home while going up stairs which he can typically do without
difficulty. States his legs "gave out", at first not sure if R
leg or L leg however after arrival to floor states R leg is more
weak. has chronic numbness over L thigh and L groin following
prior spinal surgery, for past 3 weeks has some new numbness
over lateral R thigh. Denies HA, neck pain or any injury assoc'd
with fall, no LOC. Denies back pain. Denies any bowel or bladder
incontinence. No fever/chills. No arm weakness or numbness.
Past Medical History:
PAST ONCOLOGIC HISTORY:
___ Presented with back pain and found to have left renal
mass
and destructive metastatic disease involving the L2 vertebral
body and the left humerus
___ - PET/CT:
1. An FDG avid solid left renal mass, concerning for malignancy.
There is no retroperitoneal lymphadenopathy. Involvement of the
left renal vein cannot be assessed on this nonenhanced CT.
2. An FDG avid destructive lesion of L2 vertebral body with
likely associated soft tissue component extending into the
spinal
canal. Consider MRI of the lumbar spine to assess for possible
cord involvement.
3. Right upper lobe nodular opacity demonstrates FDG uptake.
Right middle lobe pulmonary nodule is not FDG avid.
4. FDG avid left lung base opacities, new since prior, likely
infection, inflammation or aspiration.
5. Destructive FDG avid lesion involving the head of the left
humerus.
6. An indeterminate right adrenal gland nodule is not FDG avid
and can be further assessed with dedicated adrenal CT or MRI, if
clinically indicated.
___ - Spine MRI:
1. Large destructive L2 vertebral body metastasis, with
pathologic fracture, slight compression deformity and 4-mm soft
tissue extension/retropulsion into the ventral spinal canal,
resulting in moderate left-sided spinal canal narrowing.
Significant L2-3 left subarticular zone and neural foraminal
narrowing, and compression on the left traversing L3 and exiting
L2 nerve roots.
2. No cord compression or signal abnormality. No additional
intraosseous metastasis identified.
3. Moderate cervical, mild thoracic and mild-to-moderate lumbar
spondylosis.
___ Underwent surgery with Ortho (Dr. ___ that included:
1. L3 corpectomy for intraspinal lesion, retroperitoneal
approach.
2. Bilateral extracavitary diskectomy and fusion L2-3, L3-4.
3. Open biopsy, deep, bone.
4. Interbody reconstruction with biomechanical device.
5. Allograft, for fusion.
Pathology revealed: Metastatic tumor consistent with renal cell
carcinoma, clear cell type in the bone and in the epidural space
___ Radiation administered for ___ cGy total dose to
the left humerus and ___ cGy to the lumbar spine
___ TORSO CT showed Multiple new pulmonary nodules,
suggestive of metastatic disease.
___ Left laparoscopic radical nephrectomy and left
laparoscopic para-aortic (retroperitoneal) lymph node biopsy
with Dr. ___.
OTHER PAST MEDICAL HISTORY:
- COPD
- OSA on CPAP, not very compliant
- Hyperlipidemia
- Hernia repair
Social History:
___
Family History:
His grandfather had head and neck cancer. There is no known
family history of other malignancies or kidney problems.
Physical Exam:
Admit Physical Exam
General: NAD
VITAL SIGNS: reviwed, afeb, vss
HEENT: MMM, no OP lesions,
Neck: supple, no JVD
CV: RR, NL S1S2 no S3S4 or MRG
PULM: CTAB
ABD: BS+, soft, NTND, no masses or hepatosplenomegaly
EXT: warm well perfused, no edema
SKIN: No rashes or skin breakdown
NEURO: alert and oriented x 4, face symmetric, no tongue
deviation, full bicep flexion and shoulder shrug against
resistance, able to lift L leg off bed but R leg only few
inches. Can flex at hips against resistance bilateral. Full toe
dorsiflexion bilateral. No clonus, babinski downgoing, patellar
1+ bilateral, lack of sensation to light touch over L thigh and
L groin o/w intact.
Discharge Physical Exam
VS - 97.6 154/60 66 18 94% on RA
General: alert and oriented, nad
HEENT: PERRL, no scleral icterus, oropharynx clear, mmm
Neck: Supple, no LAD
CV: REgular rate and rhythm, no murmurs
Lungs: CTAB, non-labored
Abdomen: pos bowel sounds, nttp
Ext: 2+ pulses in extremities, normal refill, axillary lymph
nodes palpable
Neuro: CN ___ intact, Weakness in hip flexion on R side but
improved since yesterday, remaining motor function intact,
sensation present except L anterior thigh
Pertinent Results:
Admit Labs
___ 07:00PM BLOOD WBC-7.8 RBC-3.82* Hgb-11.3* Hct-34.9*
MCV-91 MCH-29.7 MCHC-32.5 RDW-14.9 Plt ___
___ 07:00PM BLOOD Neuts-81.1* Lymphs-11.4* Monos-5.5
Eos-1.4 Baso-0.5
___ 07:00PM BLOOD Glucose-83 UreaN-26* Creat-1.6* Na-138
K-5.0 Cl-104 HCO3-28 AnGap-11
Discharge Labs
___ 05:49AM BLOOD WBC-6.9 RBC-3.78* Hgb-11.3* Hct-34.8*
MCV-92 MCH-29.8 MCHC-32.4 RDW-15.0 Plt ___
___ 05:49AM BLOOD Glucose-112* UreaN-25* Creat-1.4* Na-141
K-4.7 Cl-108 HCO3-22 AnGap-16
___ 04:45AM BLOOD LD(LDH)-189
___ 04:45AM BLOOD Calcium-9.1
Pertinent Studies
EXAMINATION: MRI CERVICAL, THORACIC, AND LUMBAR
INDICATION: History: ___ with metastatic RCC, numbness and
weakness of ___,
evaluate for cord lesions // eval for metastasis
TECHNIQUE: Multisequence, multiplanar MRI of the cervical,
thoracic, and
lumbar spine without contrast.
COMPARISON: MRI cervical, thoracic, and lumbar spine ___. MRI brain ___. MRI lumbar spine ___. CT pelvis ___.
FINDINGS:
Postoperative change of prior L2 corpectomy with L1 through L3
posterior
stabilization and interbody fusion. When compared to prior exam,
there is
increased size of T1 hypointense, STIR hyperintense, expansile
mass arising
from the L2 through L4 vertebral bodies, greatest within the L3
vertebral
body, with involvement of the posterior elements, eccentric to
the left. The
mass severely narrows the spinal canal at L2-L3 and L3-L4 and
also extends
into the neural foramina at associated levels, greater on the
left side, with
near complete obliteration of the L2-L3 and L3-L4 neural
foramina affecting
the associated exiting L2 and L3 nerve roots, respectively.
There is an
additional 2.5 cm T2 hyperintense mass within the left sacral
ala which is
concerning for a new metastatic lesion.
There are additional nonspecific foci of T1 hypointensity within
T11 vertebral
body. Attention to this region during followup is recommended.
There is multilevel degenerative disc disease within the
cervical spine,
greatest at the C3-C4, C4-C5, and C5-C6 levels, including
posterior disc
protrusions and/ or disc osteophytes which indent the ventral
surface of the
cord without spinal cord signal abnormality.
The cord signal throughout the cervical, thoracic, and lumbar
spine is normal.
There is no evidence of spinal cord signal abnormality.
Bilateral adrenal metastatic lesions are better characterized on
prior CT.
Postoperative change of left nephrectomy.
The findings were discussed by Dr. ___ with Dr. ___
___ department
resident) on the telephone on ___ at 11:22 ___, 5 minutes
after discovery
of the findings.
IMPRESSION:
1. Markedly increased size of mass centered within postoperative
site of L2
through L4, highly concerning for increased metastatic disease,
with
associated severe central canal narrowing, involvement of
left-sided neural
foramen, and possible extension into paraspinous musculature.
2. New lesion within the left sacral ala concerning for
additional metastatic
disease.
3. Soft tissue adrenal metastatic lesions better characterized
on prior CT.
4. Nonspecific foci of T1 hypointensity within T11 vertebral
body. Attention
to this region during followup is recommended.
5. Multilevel degenerative changes, greatest at the C3-C4
through C5-C6 levels
where there are posterior disc protrusions and/or disc
osteophytes remodeling
the ventral surface of the cord without cord signal abnormality.
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: ___ year old man with metastatic renal cell ca with
recent fall
// r/o metastases
TECHNIQUE: Routine unenhanced head CT was performed and viewed
in brain,
intermediate and bone windows. Coronal and sagittal reformats
were also
performed.
DOSE: DLP: 979 mGy-cm
COMPARISON: MRI ___.
FINDINGS:
There is no acute intra or extra-axial hemorrhage mass effect
midline shift or
hydrocephalus. The ventricles and extra-axial spaces are normal
in size.
There are no areas of brain edema seen. Vascular calcifications
are seen. No
bony abnormality is identified.
IMPRESSION:
No acute abnormalities. No evidence of brain edema. MRI can L4
assessment of
metastatic disease if clinically indicated.
EXAMINATION: CT CHEST W/CONTRAST
INDICATION: Renal cell cancer
TECHNIQUE: Volumetric CT acquisitions over the entire thorax in
inspiration,
administration of intravenous contrast material, multiplanar
reconstructions.
DOSE: DLP: DOSE: report is given on the abdominal CT
examination.
COMPARISON: ___
FINDINGS:
NECK AND THORACIC INLET: No incidental thyroid findings, no
supraclavicular
and infraclavicular lymphadenopathy.
AXILLAE, CHEST WALL, AND BONES: Interval growth of axillary
lymph nodes. For
example the approximately 12 mm lymph node seen on the previous
examination
has grown to 25 mm on today's examination (3, 17). The osteo
destructive soft
tissue lesion of the chest wall with a large soft tissue
component, previously
35 mm now measures 45 mm in diameter (3, 26). The known
osteodestructive bone
lesions show no substantial progression.
MEDIASTINUM: The mediastinal lymph nodes, described as enlarged
on the
previous examination, are either stable in size or show minimal
growth. These
growth, however, is less obvious than the chest wall and
axillary lesion. The
large mediastinal vessels are unchanged in appearance.
HILA: Mild and overall unchanged right hilar lymphadenopathy.
HEART: Unchanged appearance of the heart.
LUNG:
-PARENCHYMA: The pre-existing pulmonary nodules show minimal
growth. For
example a left upper lobe nodule (3, 23), previously 11 mm now
measures 14 mm
in diameter. A left lower lobe nodule (3, 36), previously 8 mm
now measures
12 mm in diameter. Unchanged severe emphysema.
-AIRWAYS: The airways are patent.
-VESSELS: No incidental PE, no vascular abnormalities.
PLEURA: No pleural effusions.
UPPER ABDOMEN: Abdominal findings are given in detail in the
dedicated
abdominal CT report.
IMPRESSION:
Progression as compared to ___. Mild to moderate growth
of
pre-existing lymph nodes, chest wall lesions and pulmonary
nodules.
EXAMINATION: CT abdomen and pelvis with contrast.
INDICATION: ___ year old man with metastatic renal cell ca with
new onset
weakness // Surveillance for metastesis/extent of new tumor
burden near
L-spine
TECHNIQUE: MDCT axial images were acquired through abdomen and
pelvis
following intravenous contrast administration with split bolus
technique.
Coronal and sagittal reformations were performed and submitted
to PACS for
review.
Oral contrast was administered.
DOSE: DLP: ___.6 mGy-cm (chest, abdomen and pelvis.
COMPARISON: Comparison is made to CT of the abdomen and pelvis
from ___, as well as MRI of the cervical, thoracic and lumbar spine
from ___.
FINDINGS:
LOWER CHEST:
Please refer to separate report of CT chest performed on the
same day for
description of the thoracic findings.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous attenuation
throughout. There
is no evidence of focal lesions. There is no evidence of
intrahepatic or
extrahepatic biliary dilatation. The gallbladder is within
normal limits,
without stones or gallbladder wall thickening.
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: Bilateral adrenal metastases has slightly increased in
size since
the recent prior CT from ___, with a 20 x 17 mm hypo
enhancing lesion
arising from the left adrenal gland (06:25), which was 19 mm in
greatest
diameter previously. 2 discrete lesions in the right adrenal
gland have also
increased, including a 19 x 12 mm lesion arising from the
lateral limb
(06:23), previously 16 x 13 mm. A larger, more superior adrenal
lesion now
measures 26 x 20 mm, previously 20 x 17 mm (06:19).
URINARY: The left kidney is surgically absent. The right kidney
demonstrates
multiple millimetric hypodensities, unchanged compared to the
prior studies,
incompletely characterized. The kidney otherwise enhances
symmetrically, and
excrete contrast promptly.
GASTROINTESTINAL: Small bowel loops demonstrate normal caliber,
wall thickness
and enhancement throughout. Colon and rectum are within normal
limits. A left
inguinal hernia contains loops of small bowel (3:125), as seen
previously,
with no evidence of incarceration or obstruction.
RETROPERITONEUM: There is no evidence of retroperitoneal and
mesenteric
lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. There is no
calcium burden in
the abdominal aorta and great abdominal arteries.
PELVIS:
The urinary bladder and distal ureters are unremarkable. There
is no evidence
of pelvic or inguinal lymphadenopathy. There is no free fluid in
the pelvis.
REPRODUCTIVE ORGANS: Reproductive organs are within normal
limits
BONES AND SOFT TISSUES:
Extensive soft tissue mass involving the left aspect of the L2
through L4
vertebral levels, at the site of prior instrumented posterior
fusion
demonstrates heterogeneous enhancement (3:72). The extension
into the
adjacent paraspinal soft tissues on the left appears to have
increased
slightly since the prior study, although the overall measurement
and
assessment is limited due to artifact from adjacent orthopedic
hardware, and
extent of spinal canal invasion is better assessed on recent
prior MRI. A
lytic lesion with soft tissue component in the left aspect of
the sacrum along
the sacroiliac joint (3:86) is concerning for metastasis.
IMPRESSION:
1. Interval increase in size of bilateral adrenal metastases
since the recent
prior CT from ___.
2. Soft tissue mass involving the posteriolateral left aspect of
the L2
through L4 vertebral levels has apparently increased in size,
and involves the
paraspinal muscles to the left. Spinal canal and neural
foraminal invasion are
better characterized on MRI from yesterday.
3. Lytic lesion in the left sacrum is also concerning for
metastasis, similar
in size compared to the prior CT from ___.
Brief Hospital Course:
___ yr old male with metastatic RCC s/p radical nephrectomy and
hx lumbar fusion who is admitted following a fall with ___
weakness and MRI suggestive of increased lumbar mass with L2-4
nerve root compression. He improved with steroids and started CK
therapy this admission.
# L2-L4 mass, likely metastasis
Presented to ED with R lower leg weakness. progression of L2-L4
metastasis. Placed on decadron with improvement. MRI Torso
showed progression of L-spine mets. Rad onc consulted and
recommended cyberknife therapy. Planning with CT torso took
place and patient received ___ treatment prior to discharge with
10 treatments planned.
# Metastatic Renal Cell Ca: Patient is currently on PD-1 trial
through outpatient oncologist. Metastases as above.
# CKD: patient is s/p total nephrectomy. Patient was adequately
hydrated before and after treatments. Creatinine was stable
during this admission.
Transitional Issues
- Please follow up with with XRT
- Please follow up with steroids and taper slowly
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO Q6H pain
2. Aspirin 81 mg PO DAILY
3. Docusate Sodium 100 mg PO BID
4. Lidocaine 5% Patch 1 PTCH TD DAILY
5. Multivitamins 1 TAB PO DAILY
6. OxyCODONE SR (OxyconTIN) 15 mg PO DAILY
7. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN
breakthrough pain > ___. ClonazePAM 0.5-1 mg PO QHS:PRN anxiety, sleep
9. Gabapentin 300 mg PO HS
10. Gabapentin 200 mg PO BID
11. Mirtazapine 15 mg PO HS
12. Calcium Carbonate 500 mg PO DAILY
13. Vitamin D 1000 UNIT PO DAILY
14. Senna 8.6 mg PO DAILY
15. Lisinopril 5 mg PO DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H pain
2. Aspirin 81 mg PO DAILY
3. Calcium Carbonate 500 mg PO DAILY
4. Docusate Sodium 100 mg PO BID
5. Gabapentin 300 mg PO HS
6. Gabapentin 200 mg PO BID
7. Lidocaine 5% Patch 1 PTCH TD DAILY
8. Mirtazapine 15 mg PO HS
9. Multivitamins 1 TAB PO DAILY
10. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN
breakthrough pain > ___. OxyCODONE SR (OxyconTIN) 15 mg PO DAILY
12. Senna 8.6 mg PO DAILY
13. Vitamin D 1000 UNIT PO DAILY
14. ClonazePAM 0.5-1 mg PO QHS:PRN anxiety, sleep
15. Lisinopril 5 mg PO DAILY
16. Dexamethasone 4 mg PO Q12H
RX *dexamethasone 2 mg 2 tablet(s) by mouth every twelve (12)
hours Disp #*60 Tablet Refills:*0
17. Lorazepam 0.5 mg PO ONCE Duration: 1 Dose
please take prior to Cyberknife treatments
RX *lorazepam 0.5 mg 1 tab by mouth daily:prn Disp #*4 Tablet
Refills:*0
18. Famotidine 20 mg PO Q12H
RX *famotidine 20 mg 1 tablet(s) by mouth twice a day Disp #*60
Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Metastatic renal cell carcinoma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure participating in your care at ___
___.
You were admitted with weakness and new masses on your lower
spine. You have been arranged to receive radiation treatment to
these areas.
Followup Instructions:
___
|
19690769-DS-19
| 19,690,769 | 26,267,858 |
DS
| 19 |
2164-11-17 00:00:00
|
2164-11-18 11:45:00
|
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
morphine
Attending: ___.
Chief Complaint:
Back Pain
Major Surgical or Invasive Procedure:
NONE
History of Present Illness:
___ diagnosed ___ w/ RCC and L2-L4 metastatic mass s/p
surgical decompression/stabliziation ___, s/p 20 Gy RT
___,
and 30 Gy completed ___, who progressed on PD-1 now on
everolimus, presents w/ acute b/l leg weakness. He states his
symptoms started about three weeks ago when he had a fall and
found to have metastatic mass at L2-L4 and completed ___ round
of
cyberknife on ___. As he was finishing his steroid taper, on
___, his pain worsened in his left low back, as did his
weakness to the point he could not get out of bed on the day of
admission.
In addition to these issues, the patient was noted by his wife
to
be confused and not himself. He denies any fevers, chills CP,
SOB, but admits to a cough productive of ___ sputum over the
last ___ days. He states the cough is normal for him but the
sputum is not. Denies any abdominal complaints.
In the ED he was found to have strength ___ in proximal lower
extremities with good rectal tone. Code spine was called. MRI
Cervical, Thoracic, and Lumbar spine revealed an essentially
unchanged MRI report. He was seen by neurology, oncology,
orthopedics, and radiation oncology services. He received on 10
mg IV decadron dose and started on 4 mg q6.
Past Medical History:
-___ Presented with back pain and found to have left renal
mass and destructive metastatic disease involving the L2
vertebral
body and the left humerus
-___ - PET/CT: confirmed left renal mass, L2 vertebral
disease, left humerus disease. Also showed FDG avid left lung
base opacities
-___ - Spine MRI: Large destructive L2 vertebral body
metastasis, with pathologic fracture, No cord compression
-___ Underwent surgery with Ortho (Dr. ___ that
included:
1. L3 corpectomy for intraspinal lesion, retroperitoneal
approach.
2. Bilateral extracavitary diskectomy and fusion L2-3, L3-4.
3. Open biopsy, deep, bone.
4. Interbody reconstruction with biomechanical device.
5. Allograft, for fusion.
Pathology revealed: Metastatic tumor consistent with renal cell
carcinoma, clear cell type in the bone and in the epidural space
-___ Radiation administered for ___ cGy total dose to
the left humerus and ___ cGy to the lumbar spine
-___ TORSO CT showed Multiple new pulmonary nodules,
suggestive of metastatic disease.
-___: Zometa
-___: Left laparoscopic radical nephrectomy and para-aortic
(retroperitoneal) lymph node biopsy
-___: Admission for pain control, worsening ___ numbness.
Lymphocele noted on MRI. Some persistent L2 soft tissue, no
evidence of hardware failure.
-___: Zometa
-___: Completed 2000cGy radiation to R shoulder met
-___: started pazopanib
-___: CT Chest showed interval progression of intrathoracic
metastatic disease. New and enlarged pulmonary nodules. New and
enlarged axillary and mediastinal lymph nodes, with central
necrosis in a subcarinal node. New lytic bone lesions in the
left
4th rib and the right ___ costovertebral junction. Left humeral
head lesion, seen on prior exams in retrospect, has slightly
enlarged. Interval development of liver metastases as described,
as well as an additional metastatic focus involving the right
adrenal gland and interval involvement of the left adrenal
gland.
-___: Zometa
-___: Cycle 1, day 1 of ___ protocol ___,
randomized to anti-PD-1.
-___: Cycle 2, day 15 of anti-PD-1 therapy.
-___: CT chest showed an overall mixed pattern. The
majority of previously noted lymphadenopathy was stable or
decreased, but there were enlarged left inferior axillary lymph
nodes. Enlargement of lytic lesion in left fourth rib. New
sclerotic lesions noted in the right humerus and T10 vertebral
body without fracture. The left humeral lytic lesion and
destructive right first rib lesions are noted. Enlargement of
the main pulmonary artery suggestive of pulmonary arterial
hypertension. CT abdomen and pelvis showed interval regression
of previously identified hepatic nodules. There were stable
bilateral adrenal masses. There is no recurrence or residual
disease in the left nephrectomy bed.
-___: Cycle 3, day 1 anti-PD-1 therapy.
-___: C4D1 anti-PD1
-___: C4D15 anti-PD1
-___: CT showed mixed therapeutic response in the chest.
Axillary and mediastinal nodes are smaller though still
pathologically enlarged. Lung nodules are larger and more
numerous. Stable bone metastases, including pathologically
fractured left fourth rib with a large transthoracic soft tissue
mass, and the large lytic lesion in the head of the left
humerus.
In the abd/pelvis, metastatic disease to the bone, overall
appears to be stable compared to the prior study.
-___: C5D1 anti-PD1, Zometa
-___: C6D1 anti-PD1
-___: fell from leg giving out. Admitted. MRI spine showed
growing mass L2-L4.
-___: CT torso showed progression of disease in the chest
as
well as interval increase in size of bilateral adrenal
metastases
-___: Cybeknife to lumbar spine mass
PMH:
- COPD
- OSA
- Hyperlipidemia
- prior hernia repair
Social History:
___
Family History:
FH (per Dr. ___: His grandfather had head and neck cancer.
There is no known family history of other malignancies or kidney
problems.
Physical Exam:
ADMISSION PHYSICAL
==================
VITAL SIGNS: 97.5F, 96/50, 68, 20, 100% RA
General: NAD
HEENT: MMM, no OP lesions, no cervical, supraclavicular, or
axillary adenopathy
CV: RR, NL S1S2 no S3S4 MRG
PULM: CTAB
ABD: BS+, soft, NTND, no masses or hepatosplenomegaly
LIMBS: No edema, clubbing, tremors, or asterixis; no inguinal
adenopathy
SKIN: No rashes or skin breakdown
NEURO: Cranial nerves III-XII wnl, strength is ___ of the
proximal lower extremities, ___ in the distal LLE and ___ distal
RLE. patellar, and Achilles reflexes are ___. gait is intact. AO
to person, place and initially said it was ___ and then
retracted and said ___, can spell world backwords and
tell me the months of the year backwords, speech is fluent, eye
contact appropriate, thought process logical
DISCHARGE PHYSICAL EXAM
=======================
AFebrile, VSS
General: Lying in bed, in no acute distress
CV: RR, NL S1S2 no S3S4 MRG
PULM: CTAB
ABD: BS+, soft, NTND, no masses or hepatosplenomegaly
LIMBS: No edema, clubbing, tremors, or asterixis
SKIN: No rashes or skin breakdown
NEURO: A&Ox 3, cranial nerves III-XII wnl, strength is ___ in
proximal lower extremities, ___ in the distal LLE and ___ distal
RLE
Pertinent Results:
ADMISSION LABS
==============
___ 10:13AM BLOOD WBC-6.8 RBC-3.61* Hgb-11.0* Hct-33.6*
MCV-93 MCH-30.6 MCHC-32.9 RDW-16.5* Plt ___
___ 10:13AM BLOOD Neuts-87.5* Lymphs-6.5* Monos-5.1 Eos-0.8
Baso-0.1
___ 10:13AM BLOOD ___ PTT-30.7 ___
___ 10:13AM BLOOD Glucose-99 UreaN-35* Creat-1.4* Na-139
K-4.8 Cl-105 HCO3-23 AnGap-16
___ 10:13AM BLOOD ALT-23 AST-23 AlkPhos-78 TotBili-0.4
___ 10:13AM BLOOD Albumin-4.0
___ 03:52PM BLOOD Lactate-1.1
DISCHARGE LABS
==============
___ 07:20AM BLOOD WBC-10.2 RBC-3.69* Hgb-11.2* Hct-33.8*
MCV-92 MCH-30.4 MCHC-33.2 RDW-16.5* Plt ___
___ 07:20AM BLOOD Glucose-138* UreaN-45* Creat-1.4* Na-139
K-4.3 Cl-109* HCO3-19* AnGap-15
___ 07:20AM BLOOD Calcium-8.3* Phos-2.9 Mg-2.4
IMAGING/STUDIES
===============
EKY ___:
Sinus rhythm. Inferior wall myocardial infarction of
indeterminate age.
Delayed R wave progression. Consider anterior wall myocardial
infarction of
indeterminate age.
CXR ___:
1. Cardiomegaly and background advanced COPD.
2. Patchy opacities at both bases medially are new and the
possibility of an infectious infiltrate would be difficult to
exclude.
3. Focal density in the posterior portion of the anterior
mediastinum
anterior to the hila is noted, no correlate is convincingly
identified on the lateral view, possibly a projection of the
known rib metastases.
4. No new compression fracture is detected.
5. Upper zone redistribution and mild vascular plethora,
without overt CHF. No gross effusion.
6. Only partial imaging of known spinal fixation hardware.
7. Known pulmonary and osseous metastasis and more effectively
demonstrated on a chest CT from ___.
MRI C/T/L SPINE ___:
FINDINGS:
Patient is status post L2 corpectomy with L1 through L3
posterior
stabilization and interbody fusion. The previously seen mass
within the
operative site of L2 through L4 appears stable in size. The
motion artifact in T2 axial imaging makes the direct comparison
to prior MRI difficult, however, the severe spinal canal
narrowing appears stable. The mass is noted to be
inhomogeneously enhancing.
Bilateral lung base infiltrates seen on the axial images agree
with the chest x-ray obtained on the same day.
IMPRESSION:
the previously seen mass within the postoperative side of L2
through L4
appears stable in size. The associated severe spinal canal
narrowing also
appears stable although evaluation is limited by motion
artifact.
CT HEAD ___:
No acute intracranial abnormality. Enhanced MR examination
would be more
sensitive for intracranial metastasis.
MICRO
=====
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
Brief Hospital Course:
BRIEF SUMMARY
=============
___ diagnosed ___ w/ RCC and L2-L4 metastatic mass s/p
surgical Decompression/stabilization ___, s/p 20 Gy RT
___, and 30 Gy completed ___, who progressed on PD-1 now
Day 2 everolimus, presents w/ acute b/l leg weakness and back
pain in setting of finishing steroid taper with improving
neurological exam after receiving a burst of decadron.
ACTIVE ISSUES
=============
# Lower extremity weakness ___ metastatic renal cell carcinoma -
The patient presented with worsening lower extremity weakness.
MRI showed no cord compression but showed severe narrowing of
the spinal canal that was stable. The patient was evaluated by
orthopedic surgery, hematology oncology, neurology, and
radiation oncology consults in the emergency room. The patient
received 10 mg Decadron IV and was started on 4 mg q6h with
significant improvement in his symptoms. Per radiation oncology,
the patient would not benefit from additional radiation therapy
at this time since he was just recently treated. Furthermore,
his acute symptoms could be due to post-radiation changes. Per
spine, there is potential for debulking but at this point, will
hold off after discussion with radiation and medical oncology.
Neurology recommended Xray of the lumbosacral spine to assess
integrity of the corticol bone, but per radiology, this would
not add additional value, so the decision was made to defer this
study. The patient's outpatient oncologist, Dr. ___, proposed
to try another steroid taper for 3 weeks with outpatient
follow-up. The patient was decreased to 4 mg q12h of PO Decadron
and was discharged on a 3-week taper to be further managed by
Dr. ___ on ___. Patient was provided with a calendar of his
taper.
# Altered mental status - Patient was reported at home prior to
admission to be confused after recently started on everolimus on
___. The patient received UA, which was negative for infection.
Noncon CT head was negative for acute process. CXR showed
bilateral opacities. The patient initially reported phlegm,
which was new for him, and was started on ceftriaxone and
doxycycline initially for possible pneumonia. However, the
patient did not have any sputum the day after his admission, was
afebrile, and otherwise had no clinical signs of pneumonia, so
antibiotics were discontinued. The patient had returned to his
mental status baseline. The patient's oncologist did not believe
this was a side effect of the everolimus. His confusion was most
likely due to pain and possible increased narcotic use in the
setting of pain.
CHRONIC ISSUES
==============
# Stage III Chronic Kidney Disease - Stable Cr of 1.4 throughout
admission.
# Chronic obstructive pulmonary disease - Stable, not on any
inhalers.
TRANSITIONAL ISSUES
===================
-Discharged on 3 week PO dexamethasone taper to be managed by
outpatient oncologist Dr. ___.
-Neurology team recommended follow up with Dr. ___ in
___ clinic. Appt not yet scheduled at time of
discharges
CODE STATUS: Full
CONTACT INFORMATION: HCP wife ___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO Q6H pain
2. Aspirin 81 mg PO DAILY
3. Calcium Carbonate 500 mg PO DAILY
4. Docusate Sodium 100 mg PO BID
5. Gabapentin 300 mg PO HS
6. Gabapentin 200 mg PO BID
7. Lidocaine 5% Patch 1 PTCH TD DAILY
8. Mirtazapine 15 mg PO HS
9. Multivitamins 1 TAB PO DAILY
10. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN
breakthrough pain > ___. OxyCODONE SR (OxyconTIN) 15 mg PO DAILY
12. Senna 8.6 mg PO DAILY
13. Vitamin D 1000 UNIT PO DAILY
14. ClonazePAM 0.5-1 mg PO QHS:PRN anxiety, sleep
15. Lisinopril 5 mg PO DAILY
16. Famotidine 20 mg PO Q12H
17. Everolimus 10 mg PO DAILY
Discharge Medications:
1. Dexamethasone 4 mg PO Q12H
RX *dexamethasone 2 mg ___ tablet(s) by mouth ___ times daily
per taper Disp #*48 Tablet Refills:*0
2. Acetaminophen 650 mg PO Q6H pain
3. Aspirin 81 mg PO DAILY
4. Calcium Carbonate 500 mg PO DAILY
5. Docusate Sodium 100 mg PO BID
6. Famotidine 20 mg PO Q12H
RX *famotidine 20 mg 1 tablet(s) by mouth Twice a day Disp #*60
Tablet Refills:*0
7. Gabapentin 300 mg PO HS
8. Gabapentin 200 mg PO BID
9. Lidocaine 5% Patch 1 PTCH TD DAILY
10. Lisinopril 5 mg PO DAILY
11. Mirtazapine 15 mg PO HS
12. Multivitamins 1 TAB PO DAILY
13. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN
breakthrough pain > ___. OxyCODONE SR (OxyconTIN) 15 mg PO DAILY
RX *oxycodone [OxyContin] 15 mg 1 tablet(s) by mouth Daily Disp
#*30 Tablet Refills:*0
15. Senna 8.6 mg PO DAILY
16. Vitamin D 1000 UNIT PO DAILY
17. ClonazePAM 0.5-1 mg PO QHS:PRN anxiety, sleep
18. Everolimus 10 mg PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary: Lower extremity weakness, metastatic renal cell
carcinoma
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 to the hospital for weakness
and back pain which improved with steroids. You do not urgently
need surgery at this point. We have prescribed steroids for you
to take for the next several weeks with instructions about how
to decrease the dose. Dr. ___ will advise you about how long to
continue the steroids. If you experience any weakness or back
pain at home, call Dr. ___ away.
Followup Instructions:
___
|
19690769-DS-20
| 19,690,769 | 25,818,207 |
DS
| 20 |
2164-12-18 00:00:00
|
2164-12-18 21:09:00
|
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
morphine
Attending: ___.
Chief Complaint:
Left leg weakness/numbness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with metastatic renal cell carcinoma (dx ___ now on
evorolimus with metastatic mass at ___ s/p surgical
decompression/stabilization ___, s/p cyberknife on ___
who presented to the ED with increasing weakness and numbness of
the left leg. Pt had a recent admission about a month ago for
acute b/l leg weakness. MRI at that time showed no cord
compression but showed severe narrowing of te spinal canal that
was stable. He had recently been treated with radiation therapy
and rad onc felt he would not benefit from additional XRT at
that time. He was treated with decadron with symptomatic
improvement and discharged home on a 3-week taper which he
finished last week. Over the last 4 days he notes increasing
weakness in the left leg. Denies bowel/bladder incontinence. No
perianal sensory deficit and normal rectal tone per ED exam.
Denies fever/chills. Pt had been doing well and was up walking
around independently yesterday. Today, he could not get out of
bed secondary to weakness. He also endorses some numbness of the
left thigh which he has had for several months.
Dr. ___: ___ year old male with chief complaint of
increasing pain in the left leg, difficulty walking, and
hoarseness. Patient has known spinal metastases from renal
cancer - now s/p surgery, 2 courses of XRT. He recently finished
a slow decadron taper."
In the ED/clinic, initial vitals were: 98.9 72 143/58 18 97% RA
Exam was notable for: normal rectal tone
Labs were notable for: Cr 1.3 (baseline 1.4), WBC 3.2, Hgb 9.5
(10.4 on ___ Hct 27.7, Plt 90 (105 on ___
Imaging was notable for: lumbosacral XR showing no acute process
Pt was given: oxycodone 10mg X1
Consulting teams were: none
Recommendations were: none
Past Medical History:
-___ Presented with back pain and found to have left renal
mass and destructive metastatic disease involving the L2
vertebral
body and the left humerus
-___ - PET/CT: confirmed left renal mass, L2 vertebral
disease, left humerus disease. Also showed FDG avid left lung
base opacities
-___ - Spine MRI: Large destructive L2 vertebral body
metastasis, with pathologic fracture, No cord compression
-___ Underwent surgery with Ortho (Dr. ___ that
included:
1. L3 corpectomy for intraspinal lesion, retroperitoneal
approach.
2. Bilateral extracavitary diskectomy and fusion L2-3, L3-4.
3. Open biopsy, deep, bone.
4. Interbody reconstruction with biomechanical device.
5. Allograft, for fusion.
Pathology revealed: Metastatic tumor consistent with renal cell
carcinoma, clear cell type in the bone and in the epidural space
-___ Radiation administered for ___ cGy total dose to
the left humerus and ___ cGy to the lumbar spine
-___ TORSO CT showed Multiple new pulmonary nodules,
suggestive of metastatic disease.
-___: Zometa
-___: Left laparoscopic radical nephrectomy and para-aortic
(retroperitoneal) lymph node biopsy
-___: Admission for pain control, worsening ___ numbness.
Lymphocele noted on MRI. Some persistent L2 soft tissue, no
evidence of hardware failure.
-___: Zometa
-___: Completed 2000cGy radiation to R shoulder met
-___: started pazopanib
-___: CT Chest showed interval progression of intrathoracic
metastatic disease. New and enlarged pulmonary nodules. New and
enlarged axillary and mediastinal lymph nodes, with central
necrosis in a subcarinal node. New lytic bone lesions in the
left
4th rib and the right ___ costovertebral junction. Left humeral
head lesion, seen on prior exams in retrospect, has slightly
enlarged. Interval development of liver metastases as described,
as well as an additional metastatic focus involving the right
adrenal gland and interval involvement of the left adrenal
gland.
-___: Zometa
-___: Cycle 1, day 1 of ___ protocol ___,
randomized to anti-PD-1.
-___: Cycle 2, day 15 of anti-PD-1 therapy.
-___: CT chest showed an overall mixed pattern. The
majority of previously noted lymphadenopathy was stable or
decreased, but there were enlarged left inferior axillary lymph
nodes. Enlargement of lytic lesion in left fourth rib. New
sclerotic lesions noted in the right humerus and T10 vertebral
body without fracture. The left humeral lytic lesion and
destructive right first rib lesions are noted. Enlargement of
the main pulmonary artery suggestive of pulmonary arterial
hypertension. CT abdomen and pelvis showed interval regression
of previously identified hepatic nodules. There were stable
bilateral adrenal masses. There is no recurrence or residual
disease in the left nephrectomy bed.
-___: Cycle 3, day 1 anti-PD-1 therapy.
-___: C4D1 anti-PD1
-___: C4D15 anti-PD1
-___: CT showed mixed therapeutic response in the chest.
Axillary and mediastinal nodes are smaller though still
pathologically enlarged. Lung nodules are larger and more
numerous. Stable bone metastases, including pathologically
fractured left fourth rib with a large transthoracic soft tissue
mass, and the large lytic lesion in the head of the left
humerus.
In the abd/pelvis, metastatic disease to the bone, overall
appears to be stable compared to the prior study.
-___: C5D1 anti-PD1, Zometa
-___: C6D1 anti-PD1
-___: fell from leg giving out. Admitted. MRI spine showed
growing mass L2-L4.
-___: CT torso showed progression of disease in the chest
as
well as interval increase in size of bilateral adrenal
metastases
-___: Cybeknife to lumbar spine mass
PMH:
- COPD
- OSA
- Hyperlipidemia
- prior hernia repair
Social History:
___
Family History:
FH (per Dr. ___: His grandfather had head and neck cancer.
There is no known family history of other malignancies or kidney
problems.
Physical Exam:
VS: Tmax 98.2 HR 75 BP 120/58 RR 20 94% RA
GEN: Elderly male lying in bed, AOx3, NAD
HEENT: PERRL. MMM. no JVD.
Cards: RR S1/S2 normal. no murmurs/gallops/rubs.
Pulm: CTAB no crackles or wheezes
Abd: BS+, soft, NT, no rebound/guarding, no HSM
Extremities: wwp, no edema.
Skin: no rashes or bruising
Neuro: CNs II-XII intact. ___ equal strength in U/L extremities,
no gross sensory deficits. Lower extremities: grossly equal ___
strength in right and left lower extremities, with greater
weakness in left hip flexors. Decreased sensation to light touch
in left anterolateral thigh. Able to support weight on both
legs. Observed ambulating around OMED ward three times without
unsteadiness (using cane)
Pertinent Results:
___ 06:54AM BLOOD WBC-3.1* RBC-3.04* Hgb-9.0* Hct-26.2*
MCV-86 MCH-29.7 MCHC-34.4 RDW-15.3 Plt Ct-83*
___ 01:25PM BLOOD WBC-3.2* RBC-3.19* Hgb-9.5* Hct-27.7*
MCV-87 MCH-29.6 MCHC-34.2 RDW-15.7* Plt Ct-90*
___ 01:25PM BLOOD Neuts-72.3* Lymphs-16.1* Monos-10.6
Eos-0.9 Baso-0.1
___ 06:54AM BLOOD Plt Ct-83*
___ 06:54AM BLOOD Glucose-203* UreaN-22* Creat-1.2 Na-140
K-5.5* Cl-108 HCO3-22 AnGap-16
___ 01:25PM BLOOD Glucose-83 UreaN-22* Creat-1.3* Na-139
K-4.9 Cl-109* HCO3-22 AnGap-13
___ 06:54AM BLOOD Calcium-8.5 Phos-2.7 Mg-2.3 Iron-27*
___ 01:25PM BLOOD Calcium-8.2* Phos-3.0 Mg-2.3
___ 06:54AM BLOOD calTIBC-244* Ferritn-199 TRF-188*
IMAGES:
EXAMINATION: MRI lumbar spine without and with intravenous
contrast
Preliminary ReportINDICATION: ___ year old man with metastatic
RCC with L2-4 mass p/w increasing
Preliminary Reportleft leg weakness and numbness. // Assess for
interval change in lumbar mass
Preliminary ReportTECHNIQUE: MRI of the lumbar spine was
performed before and following the
Preliminary Reportintravenous administration of 9 cc Gadavist.
Preliminary ReportCOMPARISON: MRI lumbar spine ___
Preliminary ReportFINDINGS:
Preliminary ReportAgain seen is prior L2 corpectomy with L1
through L3 posterior fusion.
Preliminary ReportSurgical hardware appears intact with no
evidence of hardware complication,
Preliminary Reportalthough hardware is better assessed by plain
films or CT. Extensive tumor
Preliminary Reportremains present with extensive epidural tumor
causing severe spinal canal
Preliminary Reportstenosis at L1 through L2 and moderate spinal
canal stenosis at L3, unchanged
Preliminary Reportfrom prior MRI on ___. Tumor is
again noted to completely encase
Preliminary Reportthe thecal sac at L2 and L2-3, unchanged.
Tumor extensively occupies the
Preliminary Reportneural foramen bilaterally at L1-2 through
L3-4, likely compressing numerous
Preliminary Reportnerve roots. Extensive paraspinal tumor is
unchanged. There is no acute
Preliminary Reportpathologic fracture. Alignment is preserved.
No new site of tumor is
Preliminary Reportidentified.
Preliminary ReportIMPRESSION:
Preliminary ReportExtensive metastatic disease at L1 through L3
with epidural tumor causing
Preliminary Reportsevere spinal canal and foraminal stenosis at
multiple levels, unchanged from
Preliminary ___. No progressive disease or new
site of tumor involvement.
Preliminary ReportIf in the future there is a need to evaluate
symptoms with a less
Preliminary Reporttime-consuming test for the patient, initial
evaluation with plain films could
Preliminary Reportbe considered as a screening for dramatic
change.
Brief Hospital Course:
___ with metastatic renal cell carcinoma (dx ___ now on
evorolimus with metastatic mass at ___ s/p surgical
decompression/stabilization ___, s/p cyberknife on ___
who recently finished decadron taper for previous episode of leg
weakness now presenting with increasing weakness and numbness of
the left leg.
#LEFT LEG WEAKNESS AND NUMBNESS:
Pt has known metastatic tumors to L2-L4, which correlated to his
motor/sensory deficit dermatomes. His symptoms are thought to be
radiculopathy secondary to malignant impingement. Pt received a
dose of 4mg decadron on admission. by the next da he had
improved significantly and was observed ambulating around the
entire ward floor three times without any unsteadiness. MRI
lumbar showed no changes or progression of tumor from the study
performed a month prior. Pt was discharged in stable condition
to continue 4mg decadron daily, which is to be further managed
by his primary oncologist as an outpatient. Radiation oncology
was consulted and they communicated that they felt pt would not
benefit from additional radiation therapy, given he had
undergone two prior XRT at high doses.
#COUGH: Pt has radiographic evidence from prior CXR c/w severe
COPD, although he is not on home meds. The cough could be due to
worsening COPD in the setting of anemia. He was started on
albuterol inhalant with some symptomatic improvement and
discharged to continue this medication at home.
#PANCYTOPENIA: Pt's Hgb had dropped from 11.4->9.0, Plt 129->83
over the past ~1 month. This was thought to be most likely due
to side effects since being started on Everolimus (26% incidence
of anemia). He did not require any transfusions and his CBC will
be monitored on an outpatient basis.
- Stool guiaiac and Fe studies to evaluate for
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO Q6H pain
2. Aspirin 81 mg PO DAILY
3. Calcium Carbonate 500 mg PO DAILY
4. Docusate Sodium 100 mg PO BID
5. Famotidine 20 mg PO Q12H
6. Gabapentin 300 mg PO HS
7. Gabapentin 200 mg PO BID
8. Lidocaine 5% Patch 1 PTCH TD DAILY
9. Lisinopril 5 mg PO DAILY
10. Mirtazapine 15 mg PO HS
11. Multivitamins 1 TAB PO DAILY
12. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN
breakthrough pain > ___. OxyCODONE SR (OxyconTIN) 15 mg PO DAILY
14. Senna 8.6 mg PO DAILY
15. Vitamin D 1000 UNIT PO DAILY
16. ClonazePAM 0.5-1 mg PO QHS:PRN anxiety, sleep
17. Everolimus 10 mg PO DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H pain
2. Aspirin 81 mg PO DAILY
3. Calcium Carbonate 500 mg PO DAILY
4. ClonazePAM 0.5-1 mg PO QHS:PRN anxiety, sleep
5. Docusate Sodium 100 mg PO BID
6. Famotidine 20 mg PO Q12H
RX *famotidine [Acid Reducer (famotidine)] 20 mg 1 tablet(s) by
mouth twice daily Disp #*60 Tablet Refills:*0
7. Gabapentin 300 mg PO HS
8. Gabapentin 200 mg PO BID
9. Lidocaine 5% Patch 1 PTCH TD DAILY
10. Mirtazapine 15 mg PO HS
11. Multivitamins 1 TAB PO DAILY
12. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN
breakthrough pain > ___
RX *oxycodone [Oxecta] 5 mg 1 to 2 tablet(s) by mouth every 4
hrs Disp #*90 Tablet Refills:*0
13. OxyCODONE SR (OxyconTIN) 15 mg PO DAILY
RX *oxycodone [OxyContin] 15 mg 1 tablet(s) by mouth once daily
Disp #*30 Tablet Refills:*0
14. Senna 8.6 mg PO DAILY
15. Vitamin D 1000 UNIT PO DAILY
16. Albuterol Inhaler 2 PUFF IH Q6H:PRN shortness of breath
RX *albuterol 2 puffs by mouth every 6 hours Disp #*1 Inhaler
Refills:*0
17. Dexamethasone 4 mg PO DAILY
RX *dexamethasone 4 mg 1 tablet(s) by mouth once daily Disp #*30
Tablet Refills:*0
18. Everolimus 10 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
L2 Radiculopathy
Metastatic renal cell carcinoma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you at ___. You were
hospitalized for leg weakness and numbness due to the tumor in
your lumbar spine affecting the nerves to your leg. You were
treated with decadron steroid which resulted in significant
improvement of your leg weakness and numbness, allowing you to
walk around the hospital floor with a cane without concern for
falling. You will continue this steroid treatment at home.
You were discharged today in improved and stable condition. You
will follow up with the appointments scheduled below.
Thank you,
___, MD
___
Followup Instructions:
___
|
19690958-DS-15
| 19,690,958 | 21,627,706 |
DS
| 15 |
2113-06-17 00:00:00
|
2113-06-21 20:44:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
___: laparoscopic appendectomy
History of Present Illness:
___ year old male a history of IBS who presents to the emergency
department at the request of his primary doctor with 3 days of
isolated right lower quadrant
abdominal pain. He recently played softball but has had no
trauma. He ___ any fevers, chills, nausea, vomiting, or
diarrhea. He has a history of IBS and states that his stools
are baseline. He ___ any melena or hematochezia. He is
tender to palpation.
Past Medical History:
Hypothyroidism
- IBS (with loose stools)
- ? self-reported overactive bladder, urinates ___ times per
day
- car accident in ___ that resulted in C6-C7 disc herniation
Social History:
___
Family History:
non-contributory
Physical Exam:
PHYSICAL EXAMINATION: ___ upon admission
Temp: 98.7 HR: 92 BP: 115/87 Resp: 19 O(2)Sat: 100 Normal
Constitutional: General: The patient is awake and in no
apparent distress.
ENT: The head is atraumatic and normocephalic. Cranial
nerves II through XII are grossly intact.
Eyes: EOMI, Pupils are equal round and reactive to light.
Neck: Supple, no lymphadenopathy
Heart: Regular rate and rhythm, S1, S2
Lungs: clear to auscultation bilaterally
Abdomen: Soft, tenderness to palpation at ___
without guarding, nondistended, no palpable organomegaly
Extremities: Warm and well perfused, no cyanosis.
Back: no midline TTP, no CVAT
Neuro: Awake, alert, follows commands, no focal deficits,
cranial nerves are symmetric
Pertinent Results:
___ 09:35AM BLOOD WBC-7.6 RBC-4.45* Hgb-14.0 Hct-40.7
MCV-92 MCH-31.5 MCHC-34.4 RDW-11.5 RDWSD-38.5 Plt ___
___ 09:35AM BLOOD Neuts-65.6 ___ Monos-9.6 Eos-1.6
Baso-0.5 Im ___ AbsNeut-5.00 AbsLymp-1.65 AbsMono-0.73
AbsEos-0.12 AbsBaso-0.04
___ 09:35AM BLOOD Plt ___
___ 09:45AM BLOOD Lactate-0.9
___: cat scan of abdomen and pelvis:
Acute appendicitis without evidence of rupture or abscess
formation.
Brief Hospital Course:
___ year old male admitted to the hospital with right lower
quadrant pain. He underwent cat scan imaging which showed acute
appendicitis. He was taken to the operating room and underwent
a laparoscopic appendectomy.
The operative course was stable with minimal blood loss. The
patient was extubated after the procedure and monitored in the
recovery room. During the post-operative course, the patient's
incisional pain was controlled with oral analgesia. He resumed
a regular diet and was voiding without difficulty. The patient
was discharged home on POD #1 in stable condition. An
appointment for follow-up was made with Dr. ___. Discharge
instructions were reviewed at the time of discharge and
questions answered.
Medications on Admission:
Synthroid, 50 micrograms QD
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Levothyroxine Sodium 50 mcg PO DAILY
3. Docusate Sodium 100 mg PO BID
hold for diarrhea
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*30 Capsule Refills:*0
4. Senna 8.6 mg PO BID:PRN constipation
5. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN pain
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*25 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
acute appendicitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital with right lower quadrant
pain. You underwent a cat scan which showed acute appendicitis.
You were taken to the operating room to have your appendix
removed. You are slowly recovering from your surgery and you
are cleared for discharge home with the following instructions:
You were admitted to the hospital with acute appendicitis. You
were taken to the operating room and had your appendix removed
laparoscopically. You tolerated the procedure well and are now
being discharged home with the following instructions:
Please follow up at the appointment in clinic listed below. We
also generally recommend that patients follow up with their
primary care provider after having surgery. We have scheduled an
appointment for you listed below.
ACTIVITY:
Do not drive until you have stopped taking pain medicine and
feel you could respond in an emergency.
You may climb stairs.
You may go outside, but avoid traveling long distances until you
see your surgeon at your next visit.
Don't lift more than ___ lbs for ___ weeks. (This is about the
weight of a briefcase or a bag of groceries.) This applies to
lifting children, but they may sit on your lap.
You may start some light exercise when you feel comfortable.
You will need to stay out of bathtubs or swimming pools for a
time while your incision is healing. Ask your doctor when you
can resume tub baths or swimming.
HOW YOU MAY FEEL:
You may feel weak or "washed out" a couple weeks. You might want
to nap often. Simple tasks may exhaust you.
You may have a sore throat because of a tube that was in your
throat during surgery.
You could have a poor appetite for a couple days. Food may seem
unappealing.
All of these feelings and reactions are normal and should go
away in a short time. If they do not, tell your surgeon.
YOUR INCISION:
Tomorrow you may shower and remove the gauzes over your
incisions. Under these dressings you have small plastic bandages
called steristrips. Do not remove steri-strips for 2 weeks.
(These are the thin paper strips that might be on your
incision.) But if they fall off before that that's okay.
Your incisions may be slightly red around the stitches. This is
normal.
You may gently wash away dried material around your incision.
Avoid direct sun exposure to the incision area.
Do not use any ointments on the incision unless you were told
otherwise.
You may see a small amount of clear or light red fluid staining
your dressing or clothes. If the staining is severe, please call
your surgeon.
You may shower. As noted above, ask your doctor when you may
resume tub baths or swimming.
YOUR BOWELS:
Constipation is a common side effect of narcotic pain
medicaitons. If needed, you may take a stool softener (such as
Colace, one capsule) or gentle laxative (such as milk of
magnesia, 1 tbs) twice a day. You can get both of these
medicines without a prescription.
If you go 48 hours without a bowel movement, or have pain moving
the bowels, call your surgeon.
PAIN MANAGEMENT:
It is normal to feel some discomfort/pain following abdominal
surgery. This pain is often described as "soreness".
Your pain should get better day by day. If you find the pain is
getting worse instead of better, please contact your surgeon.
You will receive a prescription for pain medicine to take by
mouth. It is important to take this medicine as directed. Do not
take it more frequently than prescribed. Do not take more
medicine at one time than prescribed. Do not drink alcohol or
drive while taking narcotic pain medication.
Your pain medicine will work better if you take it before your
pain gets too severe.
Talk with your surgeon about how long you will need to take
prescription pain medicine. Please don't take any other pain
medicine, including non-prescription pain medicine, unless your
surgeon has said its okay.
If you are experiencing no pain, it is okay to skip a dose of
pain medicine.
Remember to use your "cough pillow" for splinting when you cough
or when you are doing your deep breathing exercises.
If you experience any of the following, please contact your
surgeon:
- sharp pain or any severe pain that lasts several hours
- pain that is getting worse over time
- pain accompanied by fever of more than 101
- a drastic change in nature or quality of your pain
MEDICATIONS:
Take all the medicines you were on before the operation just as
you did before, unless you have been told differently.
If you have any questions about what medicine to take or not to
take, please call your surgeon.
DANGER SIGNS:
Please call your surgeon if you develop:
- worsening abdominal pain
- sharp or severe pain that lasts several hours
- temperature of 101 degrees or higher
- severe diarrhea
- vomiting
- redness around the incision that is spreading
- increased swelling around the incision
- excessive bruising around the incision
- cloudy fluid coming from the wound
- bright red blood or foul smelling discharge coming from the
wound
- an increase in drainage from the wound
Followup Instructions:
___
|
19691651-DS-4
| 19,691,651 | 24,166,195 |
DS
| 4 |
2130-06-30 00:00:00
|
2130-06-30 18:15:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
erythromycin base
Attending: ___.
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
exploratory laparotomy with right superior mesenteric artery
embolectomy
History of Present Illness:
___ F with 1 day of abdominal pain that started at 8am
yesterday. She describes the pain as "crampy" and "all over".
She
also reports one episode of a bloody bowel movement, and no
bowel
movements since then. She describes nausea, but no
vomiting/fevers/chills/weight loss. Eating does not make the
pain
worse. She reports that she had one similar episode a few months
ago with crampy abdominal pain, one bloody bowel movement, and a
colonoscopy at that time showed internal hemorrhoids (per the
patient). She has not had any sick contacts, recent travel
outside the country, or tried any new foods lately. CTA at OSH
shows calcification at origin of SFA and clot in SFA, with flow
distal to clot. Celiac patent.
Past Medical History:
asthma, copd, diverticulosis
Social History:
___
Family History:
father: CAD, mother: colon cancer
Physical Exam:
Admit Physical Exam:
AAO NAD, appears comfortable
RRR
soft wheezing b/l
abd soft, nd, non tender to palpation in any quadrant, no
rebound/guarding, no masses palpated
+ pedal pulses b/l, warm extremities without edema
rectal exam normal tone, no frank blood, occult +
Discharge Physical Exam:
Vitals: Temp ___, BP 163/80, HR 87, RR 18, O2sat 96%RA
Gen: A&O, NAD, well apearing
CV: RRR, no M/R/G
Pulm: no crackles or rhonchi, no increased work of breathing,
soft wheezes b/l
Abd: abd soft, non-tender, non-distended, no rebound or
guarding, no palpable masses, midline incision C/D/I, no
erythema or induration, steri-strips
Ext: + pedal pulses b/l, warm and well perfused, no cyanosis,
clubing, or edema
Pertinent Results:
___ 11:16PM BLOOD WBC-7.5 RBC-4.39 Hgb-12.8 Hct-38.8 MCV-88
MCH-29.2 MCHC-33.0 RDW-13.2 RDWSD-42.6 Plt ___
___ 02:54AM BLOOD WBC-13.8* RBC-4.08 Hgb-11.7 Hct-36.7
MCV-90 MCH-28.7 MCHC-31.9* RDW-13.3 RDWSD-44.0 Plt ___
___ 04:31AM BLOOD WBC-10.4* RBC-3.72* Hgb-10.7* Hct-33.7*
MCV-91 MCH-28.8 MCHC-31.8* RDW-13.4 RDWSD-44.2 Plt ___
___ 06:00AM BLOOD ___ PTT-48.4* ___
___ 01:28AM BLOOD ___ PTT-100.1* ___
___ 10:05AM BLOOD ___ PTT-83.1* ___
___ 11:25PM BLOOD Lactate-1.4
___ 10:21AM BLOOD Glucose-156* Lactate-0.9 Na-137 K-3.4
Cl-107
CHEST (PORTABLE AP) Study Date of ___ 5:50 ___
Low lung volumes. Mild fluid overload but no overt pulmonary
edema. Moderate cardiomegaly. No pleural effusions. No
pneumonia.
CHEST (PA & LAT) Study Date of ___ 1:55 ___
Since ___, new severe pulmonary edema. New small bilateral
pleural
effusions.
CHEST (PA & LAT) Study Date of ___ 9:47 AM
Improved mild interstitial edema with moderate slightly
increased pleural
effusion.
CTA CHEST W&W/O C&RECONS, NON-CORONARY Study Date of ___
10:52 AM
Preliminary Report
1. Eccentric thrombus at the origin of SMA moderately narrows
the lumen.
2. Scattered ground-glass opacity in bilateral lungs with upper
lobe predominance may be due to pulmonary edema. Pneumonia is
possible in correct clinical setting.
3. No pulmonary embolism.
4. Small nodular pulmonary opacities may be inflammatory or
infectious in etiology, however pulmonary lesion cannot be
excluded. Follow up CT is recommended in ___ months to ensure
resolution/ stability.
5. Mild emphysema.
Brief Hospital Course:
The patient is a ___ year old female who was transfered from an
OSH with a one day history of crampy abdominal pain, nausea and
a bloody bowel movement. Pt was evaluated by upon arrival and
reasults from the CT scan were obtained which demonstrated a
superior mesenteric artery thrombus. Given findings, the
patient was taken to the operating room for exploratory
laparotomy and thrombectomy. There were no adverse events in the
operating room; please see the operative note for details. Pt
was extubated, taken to the PACU until stable, then transferred
to the ward for observation.
Neuro: The patient was alert and oriented throughout
hospitalization; pain was initially managed with a dilaudid PCA
and then transitioned to oral ___ once tolerating a diet.
CV: The patient remained stable from a cardiovascular
standpoint; vital signs were routinely monitored. On POD 1 the
patient was given a 500cc bolus of LR for low UOP. She responded
well had good urine output for the remainder of her stay. There
was no rise in creatinine.
Pulmonary: The patient has a history of COPD with prior
exacerbations. Her pulmonary status began to deteriorate POD 1
and she was started on an ipratropium/albuterol nebulizer Q6H
and cipro as emperic therapy for presumed COPD exacerbation. A
chest x-ray was also promptly obtained and revealed low lung
volumes and mild fluid overload but no overt pulmonary edema, no
pleural effusions, and no pneumonia. However, on POD 2 the
patient's pulmonary status continued to worsen and a 2-view ches
x-ray was obtained which revealed new severe pulmonary edema and
new small bilateral pleural effusions. The patient recieved
furosemide twice and responded well, with much decreased oxygen
requirements by POD 3. A repeat chest x-ray revealed improved
mild interstitial edema. Thereafter the patient remained stable
from a pulmonary standpoint; vital signs were routinely
monitored. Good pulmonary toilet, early ambulation and incentive
spirometry were encouraged throughout hospitalization.
GI/GU/FEN: The patient was initially kept NPO with a
___ tube in place for decompression. On ___ the
patient had retrun of bowel function and the diet was advanced
sequentially to a Regular diet, which was well tolerated.
Patient's intake and output were closely monitored
ID: The patient's fever curves were closely watched for signs of
infection, of which there were none.
HEME: The patient's blood counts were closely watched for signs
of bleeding, of which there were none. The patient was
anticoagulated with a heparin drip and bridged to coumadin. Her
heparin drip was discontinued when her INR reached therapeutic
level.
Prophylaxis: The patient received heparin and ___ dyne boots
were used during this stay and was encouraged to get up and
ambulate as early as possible.
At the time of discharge, the patient was doing well, afebrile
and hemodynamically stable. The patient was tolerating a diet,
ambulating, voiding without assistance, and pain was well
controlled. The patient received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with the discharge plan.
Medications on Admission:
diltiazem 360', lisinopril 20'', pro air, apiriva, topamax
prn migraines
Discharge Medications:
1. Warfarin 5 mg PO DAILY16 Please take at the same time every
day (4pm).
RX *warfarin [Coumadin] 5 mg 1 tablet(s) by mouth once a day
Disp #*6 Tablet Refills:*0
2. Tiotropium Bromide 1 CAP IH DAILY
3. OxycoDONE (Immediate Release) 10 mg PO Q3H:PRN pain Do not
drive or drink alcohol while taking this medication. RX
*oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours Disp
#*40 Tablet Refills:*0
4. Lisinopril 20 mg PO BID
5. Diltiazem Extended-Release 360 mg PO DAILY
6. Albuterol Inhaler 2 PUFF IH Q4H:PRN dyspnea
Discharge Disposition:
Home
Discharge Diagnosis:
Acute mesenteric ischemia, superior mesenteric artery
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 ___ and
underwent abdominal surgery (exploratory laparotomy with right
superior mesenteric artery embolectomy). You have now recovered
from surgery and are ready to be discharged. Please follow the
instructions below to continue your recovery:
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within ___ hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications, unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than ___ lbs until you follow-up with your
surgeon.
Avoid driving or operating heavy machinery while taking pain
medications.
Incision Care:
*Please call your doctor or nurse practitioner if you have
increased pain, swelling, redness, or drainage from the incision
site.
*Avoid swimming and baths until your follow-up appointment.
*You may shower, and wash surgical incisions with a mild soap
and warm water. Gently pat the area dry.
*If you have steri-strips, they will fall off on their own.
Please remove any remaining strips ___ days after surgery.
Followup Instructions:
___
|
19691651-DS-6
| 19,691,651 | 26,512,098 |
DS
| 6 |
2132-09-05 00:00:00
|
2132-09-05 18:25:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: CARDIOTHORACIC
Allergies:
erythromycin base
Attending: ___.
Chief Complaint:
purulent drainage from sternal wound
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms. ___ is a nice ___ year old woman with a history of aortic
stenosis, asthma, chronic obstructive pulmonary disease,
hypertension, and obesity. On ___ she underwent surgical
Aortic valve replacement with a 23 mm ___
___ Biocor Epic tissue valve and Coronary artery bypass
grafting x 3 with a left internal mammary artery graft to left
anterior descending, reverse saphenous vein graft to diagonal
branch and to ramus intermedius. Her post-op course was
unremarkable, she was discharged to rehab ___ a timely fashion.
Patient was discharged from rehab last ___ and according to
the patient she was doing well except for poor appetite.
Developed low grade fever with notable erythema lower sternal
pole past ___. Today the lower pole of her sternal wound
was
more erythematous with drainage and odor. She went to OSH and
from there was transferred to ___ for wound evaluation. ___
the
ER patient clinically seemed well. Lower sternal pole
erythematous, with odorous purulent drainage, tender to touch.
Past Medical History:
Past Medical History:
Anxiety
Aortic Stenosis
Asthma
Chronic Obstructive Pulmonary Disease
Depression
Diverticulosis
Hiatal Hernia
Hypertension
Low Back Pain
Mesenteric Ischemia
Past Surgical History:
Right superior mesenteric artery embolectomy. ___
PCI for SMA stenosis ___
Cholecystectomy
Social History:
___
Family History:
father: CAD, mother: colon cancer
Physical Exam:
Admission Exam
Weight: 183 lbs
General:
Skin: Dry [x] intact [x]sternal wound with lower pole erythema
and purulent drainage
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur [x] grade ___
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [] Pt has an incisional hernia that is reducible.
Extremities: Warm [x], well-perfused [x] Edema none [] _____
Varicosities: None [x]
Neuro: Grossly intact [x]
Pulses:
___ Right:1+ Left:1+
Radial Right:2+ Left:2+
Carotid Bruit: none bilat
Discharge PE:
Vital Signs and Intake/Output:
98.6,149/91,84,18 96% RA
Physical Examination:
General/Neuro: NAD [x] A/O x3 [X] non-focal [X]
Cardiac: RRR [X] Irregular [] Nl S1 S2 [X]
Lungs: CTA [X] No resp distress [X]
Abd: Obese, NBS [X]Soft [X] ND [X] NT [X]
Extremities: no CCE[X] Pulses doppler [] palpable [X]
Wounds: Sternal: CDI [] no erythema or drainage []
Sternum stable [X] beefy red base, no drainage,
or odor. 1 inch tunnel lower pole. Wet to dry dressing placed.
(diamond shaped wound: upper/lower poles 3cm deep, middle 5cm
deep. 9cm wide and 10cm long)
Leg: Right [X] Left[] CDI [] no erythema or drainage [X]
Pertinent Results:
STUDIES:
___ placement CXR ___
INDICATION: ___ year old woman with new R ___// 44 cm R
___
___ ___ Contact name: ___: ___
IMPRESSION:
Compared to the prior examination, there has been placement of a
right-sided PICC which terminates ___ the low SVC, satisfactory.
There remains moderate cardiomegaly with postsurgical changes
from CABG. There remains streak like atelectasis ___ the lingula
and left lung base, unchanged. Lungs are otherwise grossly
clear. There is no new consolidation. There is no large
effusion pneumothorax.
.
Bilateral ___ US: ___
No evidence of deep venous thrombosis ___ the right or left lower
extremity
veins.
.
Chest CTA ___
Patient is status post aortic valve replacement and CABG. There
is no
cardiomegaly.
Small quantity of fluid ___ the mediastinum is concentrated
around the
ascending aorta where few bubbles of air are identified (3:107)
while ___ the retrosternal fat there is only mild quantity of
fluid with fat stranding.
Sternal wires are intact and aligned, the sternal surgical
fractures are
unremarkable with no evidence of osteomyelitis. There is no
evidence of fluid collection superficial to the sternum.
The aorta and its major branch vessels are patent, with no
evidence of
stenosis, occlusion, dissection, or aneurysmal formation.
Minimal
calcifications along thoracic aorta. There is no evidence of
penetrating
atherosclerotic ulcer or aortic arch atheroma present.
The pulmonary arteries are well opacified to the subsegmental
level. Filling defect identified ___ left lower lobe
subsegmental artery (03:148). The main and right pulmonary
arteries are normal ___ caliber, and there is no evidence of
right heart strain.
There is no supraclavicular, axillary, mediastinal, or hilar
lymphadenopathy. The thyroid gland appears unremarkable.
Small bilateral layering pleural effusions with adjacent passive
atelectasis are grossly unchanged since prior.
Airways are patent to the subsegmental level, mild diffuse
airway wall
thickening and irregularity associated with bilateral mild
centrilobular and paraseptal emphysema affecting predominantly
the upper lobes. No lung
consolidations concerning for pneumonia. 0.7 x 0.4 cm right
upper lobe perifissural nodule is most probably intrapulmonary
lymph node (2:63).
Limited images of the upper abdomen are unremarkable.
No lytic or blastic osseous lesion suspicious for malignancy is
identified. Mild multilevel degenerative change of the spine.
IMPRESSION:
-Small quantity of fluid ___ the mediastinum is concentrated
around the
ascending aorta where few bubbles of air are identified, raising
concern for mediastinitis. No focal collection.
-Minimal quantity of fluid and fat stranding posterior to the
normal-appearing sternal surgical fractures and there is no
evidence of osteomyelitis.
-Pulmonary emboli ___ left lower lobe subsegmental artery.
Admit:
___ 07:40PM BLOOD WBC-10.9* RBC-3.24* Hgb-9.5* Hct-29.5*
MCV-91 MCH-29.3 MCHC-32.2 RDW-13.3 RDWSD-44.0 Plt ___
___ 07:40PM BLOOD Neuts-68.5 ___ Monos-6.1 Eos-4.9
Baso-0.8 Im ___ AbsNeut-7.46* AbsLymp-2.11 AbsMono-0.67
AbsEos-0.54 AbsBaso-0.09*
___ 08:35AM BLOOD ___
___ 07:40PM BLOOD Glucose-98 UreaN-9 Creat-0.9 Na-139 K-4.3
Cl-100 HCO3-26 AnGap-13
___ 08:35AM BLOOD Mg-1.9
Discharge:
___ 09:13AM BLOOD Vanco-17.7
___ 05:00AM BLOOD WBC-6.2 RBC-2.86* Hgb-8.2* Hct-26.3*
MCV-92 MCH-28.7 MCHC-31.2* RDW-13.2 RDWSD-43.9 Plt ___
___ 04:16AM BLOOD ___
___ 05:00AM BLOOD Glucose-88 UreaN-8 Creat-0.9 Na-140 K-4.7
Cl-104 HCO3-25 AnGap-11
___ 05:00AM BLOOD Mg-2.2
MICRO
___ 3:51 pm SWAB Source: sternal wound.
**FINAL REPORT ___
GRAM STAIN (Final ___:
2+ ___ per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
2+ ___ per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS AND SINGLY.
WOUND CULTURE (Final ___:
STAPHYLOCOCCUS, COAGULASE NEGATIVE. SPARSE GROWTH.
Oxacillin RESISTANT Staphylococci MUST be reported as
also
RESISTANT to other penicillins, cephalosporins,
carbacephems,
carbapenems, and beta-lactamase inhibitor combinations.
RIFAMPIN should not be used alone for therapy.
This isolate is presumed to be resistant to clindamycin
based on
the detection of inducible resistance .
COAG NEG STAPH does NOT require contact precautions,
regardless of
resistance.
SENSITIVITIES: MIC expressed ___
MCG/ML
_________________________________________________________
STAPHYLOCOCCUS, COAGULASE NEGATIVE
|
CLINDAMYCIN----------- R
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- =>8 R
OXACILLIN------------- =>4 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- <=1 S
VANCOMYCIN------------ <=0.5 S
ANAEROBIC CULTURE (Final ___:
ANAEROBIC GRAM POSITIVE COCCUS(I). MODERATE GROWTH.
(formerly Peptostreptococcus species).
NO FURTHER WORKUP WILL BE PERFORMED.
Blood CULTURE:
All negative finalized or NGTD, EXCEPT:
___ 7:40 pm BLOOD CULTURE
Blood Culture, Routine (Preliminary):
GRAM POSITIVE RODS.
CONSISTENT WITH CORYNEBACTERIUM OR
PROPIONIBACTERIUM SPECIES.
Aerobic Bottle Gram Stain (Final ___:
Reported to and read back by ___ @ ___ ON ___
- ___.
GRAM POSITIVE ROD(S).
CONSISTENT WITH CORYNEBACTERIUM OR
PROPIONIBACTERIUM SPECIES.
___ 8:18 pm URINE **FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
Brief Hospital Course:
Ms. ___ presented c/o 2 days of low grade fever and drainage
from surgical sternal wound. She underwent workup that included
BLE US and Chest CTA that showed no DVT, but was positive for
left lower lobe pulmonary embolism and also changes consistent
with mediastinitis but no osteomyelitis. Her initial blood
culture on ___ grew gram positive rods and her sternal wound
swab grew coagulase negative, Oxacillin resistant
staphylococcus. She was started on IV heparin and Coumadin for
her new PE. Infectious disease team was consulted and has
recommended 4 weeks of IV Vancomycin (through ___. RUE
PICC line was placed ___ without problems. Her INR is now
therapeutic (goal ___. Her sternal wound is being managed with
continuous VAC dressing (125mmHg) with q3day change plan. Her
PCP, ___ manage her Coumadin for the pulmonary
embolism. By the time of discharge on POD 21 ___ hospital
day 6), she was ambulating freely, the wound did not require
debridement today, and her pain was controlled with oral
analgesics. Due to delayed Vancomycin dosing on day of
discharge, she will not be receiving her ___ dose (due 1am on
___. I spoke with Dr. ___ ID team and made him aware of
timing problem. He agreed that next dose ___ AM with ___
would be acceptable. The patient is being asked to contact the
___ clinic with any problems ___ receiving the ___ AM Vancomycin
dose ___, alt ___. The patient was
discharged to home with ___ services ___ good condition with
appropriate follow up instructions
Medications on Admission:
1. Albuterol Inhaler 2 PUFF IH Q4H:PRN dyspnea
2. Breo Ellipta (fluticasone-vilanterol) 200-25 mcg/dose
inhalation DAILY
3. Metoprolol Tartrate 25 mg PO TID
4. Ranitidine 150 mg PO BID
5. TraMADol 50 mg PO Q6H:PRN Pain - Moderate
6. Aspirin EC 81 mg PO DAILY
7. Atorvastatin 20 mg PO QPM
8. Acetaminophen 650 mg PO Q4H:PRN Pain - Mild
Discharge Medications:
1. Atorvastatin 20 mg PO QPM
2. Docusate Sodium 100 mg PO BID:PRN constipation
3. Sodium Chloride 0.9% Flush ___ mL IV DAILY and PRN, line
flush
4. Vancomycin 1000 mg IV Q 12H sternal wound infection
Duration: 4 Weeks
through ___
RX *vancomycin 1 gram 1000 mg IV every twelve (12) hours ___
#*60 Vial Refills:*1
5. Warfarin 1 mg PO ASDIR pulmonary embolism
take as directed by Dr. ___ goal INR ___
RX *warfarin 1 mg ___ tablet(s) by mouth as directed by Dr.
___ #*60 Tablet Refills:*1
6. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild
maximum 4000mg/day please
7. Lisinopril 5 mg PO BID
RX *lisinopril 5 mg 1 tablet(s) by mouth twice a day ___ #*60
Tablet Refills:*1
8. Albuterol Inhaler 2 PUFF IH Q4H:PRN dyspnea
9. Aspirin EC 81 mg PO DAILY
10. Breo Ellipta (fluticasone-vilanterol) 200-25 mcg/dose
inhalation DAILY
11. Metoprolol Tartrate 25 mg PO TID
12. Ranitidine 150 mg PO BID
13. TraMADol 50 mg PO Q6H:PRN Pain - Moderate
RX *tramadol [Ultram] 50 mg 1 tablet(s) by mouth every six (6)
hours ___ #*20 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
sternal wound infection
new Left lower lobe pulmonary embolism
Discharge Condition:
Alert and oriented x3, non-focal
Ambulating, gait steady
Sternal pain managed with oral analgesics
Sternal Incision - beefy red base, no drainage or odor. 1 inch
tunnel lower pole. Wet to dry dressing placed, awaiting home
VAC.
Leg: Right [X] no erythema or drainage [X] C/D/I [x]
(diamond shaped wound: upper/lower poles 3cm deep, middle 5cm
deep. 9cm wide and 10cm long)
RUE ___ site: C/D/I
Edema - none
Discharge Instructions:
If you have any problems with ___ nurses providing ___
antibiotic, please call the Infectious Disease clinic at
___ or ___.
Your VAC dressing on your chest will be placed by ___ nurse on
___ and then changed every 3 days by the visiting nurse team.
Please keep this area dry while dressing is ___ place
wash other 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 ___ 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
**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:
___
|
19691837-DS-23
| 19,691,837 | 21,194,786 |
DS
| 23 |
2161-03-29 00:00:00
|
2161-04-02 05:52:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / Erythromycin Base / morphine /
codeine / Keflex / topiramate / gabapentin
Attending: ___.
Chief Complaint:
___ Swelling
Major Surgical or Invasive Procedure:
Right buttock drain placement (___)
Left chest port removal (___)
Right buttock drain removal (___)
Paracenteses, diagnostic and therapeutic ___,
___
History of Present Illness:
___ F with breast CA s/p rt mastectomy with mets to ovary who
presented to OSH c/o right leg swelling and gen pain and
erythematous buttock decub. The patient is a + smoker, hx of
drug use and and left side portacath was noted to have redness
with necrotic tissue over the top. The patient that she first
noted these symptoms about 5 days prior to admission. ___ OSH she
recieved oxycodone 30mg, zofran 8 and vanc 1 gm IV. Labs noted
for mg = 1.4 and k 2.9 and Na 128, all of which were repleated.
Patient was requesting pain medication and transfer to ___.
She was refusing everything there except pain medications.
Wouldnt get labs, US, antibiotics although later agreed to labs.
Also given morphine, xanax, and Vanco PTA. OSH labs included Hb
7.8, Hct 23.9, WBC 11.8, Plt 189. VS prior to transfer 98.2,
103/56, 98, 18
___ the ___ ED, initial VS were: 99.8, 100, 102/48, 18, 100% RA
___ foot pain. Pt appeared unwell, speaking clearly.
Labs were notable for: INR 1.6, Hct 18.9, plt 196, wbc 8.8, na
128, k 2.8, cr 0.5, lactate 2.7, alb 1.9, otherwise normal lfts,
normal UA and serum tox screen. Blood cultures were sent.
Imaging included a ___ US which showed a hematoma, and a CT
pelvis which showed another hematoma ___ the buttock.
Consults called included surgery who said no surgical
intervention.
Treatments received: IV KCL, vanco, mag sulfate 2 gm, 1L NS,
alprazolam 5 mg, dilaudid 1 mg and a unit of pRBCs. Of note,
patient afebrile ___ ED but with Tmax to 100.1.
VS prior to transfer: sleeping 98.5, 83, 114/75, 22, 98%, RA.
On arrival to the floor, patient reports significant nausea and
has dry heaves. She notes that she was not haviig N/V until this
morning. Her pain is ___ at buttock, right leg, and port site
and she thinks she is withdrawing from not having oxycodone. The
patient denies any recent IV drug use and says she was not using
her port for anything. She also denies any abuse at home. She
notes that she may have fallen on her stairs a few days ago that
could have resulted ___ the hematomas. No LOC or head strike.
REVIEW OF SYSTEMS: +VE PER HPI
Past Medical History:
PAST ONCOLOGIC HISTORY: She had initially been diagnosed with
breast cancer ___ ___ she had malignant ascites
and complex adrenal mass which occurred at the same time as the
liver failure. Pathology was consistent with malignancy and the
constellation of symptoms was most consistent with GYN primary.
So she underwent neoadjuvant treatment with single agent
carboplatin x 2 and carboplatin and Taxol x 1 followed by
surgical debulking. Final pathology was actually consistent with
recurrent breast cancer. At the moment, she is not getting any
more cancer treatment, her cancer appears to be ___ remission.
PAST MEDICAL HISTORY:
- Cirrhosis (child's class B/C) - ___ Hep B & Hep C
- Chemotherapy-induced peripheral neuropathy of the feet
- Irritable bowel syndrome
- Anxiety disorder, using Xanax
PAST SURGICAL HISTORY:
- TAH-BSO, Right mastectomy, laparoscopic left ovarian
cystectomy at ___, LEEP, D&C for previous miscarriage.
Social History:
___
Family History:
Father with colorectal carcinoma, paternal grandmother breast
ca dx ___, no other family history of gynecologic malingnancies
Physical Exam:
On admission:
VS: 98.4, 110/64, HR 85, RR 18, O2 94% RA
GENERAL: appears uncomfortable, dry heaving
HEENT: NC/AT, EOMI, PERRL, dry mucous membranes
CARDIAC: RRR, nl S1 and S2, no murmurs
CHEST: left upper chest with crusting and scabing over port site
with mild erythematous base
LUNG: CTAB no w/r/rh
ABD: +BS, soft, NT/ND, no r/g
EXT: mild edema of ___, signs of chrnoic venous stasis
bilaterally
BUTTOCK: erythematous indurant collection over right sided
buttock about ~6-7 cm ___ diameter
PULSES: 2+DP pulses bilaterally
SKIN: Warm and dry
On discharge:
VS: Tmax 98.2, Tc 97.7, BP 110-132/80-82, HR 98-105, RR ___,
SpO2 98-100%RA
GENERAL: lying ___ bed, sleepy, no distress, non-tremulous
HEENT: NC/AT, EOMI, Pupils dilated and reactive, less so than
yesterday, MMM.
CARDIAC: RRR, nl S1 and S2, no murmurs
CHEST: prior port site, no erythema or drainage, c/d/i
LUNG: CTAB no w/r/r
ABD: +BS, softer, mildly distended, non-tender but discomfort
with palpation, normoactive bowel sounds
EXT: trace to 1+ edema bilaterally; R knee with slight effusion
BUTTOCK: drain removed, site intact, dressing c/d/i
PULSES: 2+DP pulses bilaterally
SKIN: Warm and dry
Neuro: AAOx3, ocular flutter noted; CN II-XII intact, moves all
extremities well
Pertinent Results:
On admission:
___ 09:00PM BLOOD WBC-8.8# RBC-2.39*# Hgb-6.1*# Hct-18.9*#
MCV-79*# MCH-25.6* MCHC-32.4 RDW-16.5* Plt ___
___ 09:00PM BLOOD Neuts-72.5* ___ Monos-3.5 Eos-0.2
Baso-0.2
___ 09:00PM BLOOD ___ PTT-32.2 ___
___ 09:00PM BLOOD Glucose-115* UreaN-6 Creat-0.5 Na-128*
K-2.8* Cl-90* HCO3-30 AnGap-11
___ 09:00PM BLOOD ALT-9 AST-22 AlkPhos-108* TotBili-0.5
___ 09:00PM BLOOD Albumin-1.9* Calcium-7.3* Phos-3.0 Mg-1.9
___ 09:27PM BLOOD Lactate-2.7*
___ 09:00PM BLOOD Lipase-36
___ 09:00PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
Pertinent Labs:
___ 05:50AM BLOOD IgG-2625*
___ 10:47PM URINE Color-Yellow Appear-Hazy Sp ___
___ 10:47PM URINE Blood-SM Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-40 Bilirub-NEG Urobiln-4* pH-7.0 Leuks-NEG
___ 09:30AM URINE bnzodzp-POS barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG mthdone-NEG
___ 10:10AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 09:00PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 10:10AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ ___
___ CA ___ 127
On discharge:
___ 05:51AM BLOOD WBC-4.4 RBC-3.01* Hgb-9.0* Hct-25.7*
MCV-85 MCH-30.0 MCHC-35.1* RDW-21.9* Plt ___
___ 10:40PM BLOOD Neuts-71.5* ___ Monos-3.5 Eos-0.4
Baso-0.1
___ 05:51AM BLOOD ___ PTT-33.4 ___
___ 05:51AM BLOOD Glucose-98 UreaN-8 Creat-0.5 Na-133 K-3.8
Cl-100 HCO3-24 AnGap-13
___ 09:00PM BLOOD ALT-9 AST-22 AlkPhos-108* TotBili-0.5
___ 05:51AM BLOOD Calcium-7.8* Phos-4.0 Mg-1.9
Microbiology:
___ 8:30 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___:
STAPH AUREUS COAG +. OF TWO COLONIAL MORPHOLOGIES.
Consultations with ID are recommended for all blood
cultures
positive for Staphylococcus aureus, yeast or other
fungi.
FINAL SENSITIVITIES.
Staphylococcus species may develop resistance during
prolonged
therapy with quinolones. Therefore, isolates that are
initially
susceptible may become resistant within three to four
days after
initiation of therapy. Testing of repeat isolates may
be
warranted.
SENSITIVITIES: MIC expressed ___
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN----------<=0.25 S
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN----------<=0.12 S
OXACILLIN------------- 0.5 S
TRIMETHOPRIM/SULFA---- <=0.5 S
Aerobic Bottle Gram Stain (Final ___:
GRAM POSITIVE COCCI ___ CLUSTERS.
Reported to and read back by ___ ___ AT
1453.
___ 9:00 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___:
STAPH AUREUS COAG +. OF TWO COLONIAL MORPHOLOGIES.
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 ___ CLUSTERS.
Reported to and read back by ___ ___ AT
1453.
Anaerobic Bottle Gram Stain (Final ___:
GRAM POSITIVE COCCI ___ CLUSTERS.
___ 3:58 pm ABSCESS Source: right buttock.
**FINAL REPORT ___
GRAM STAIN (Final ___:
4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS AND CLUSTERS.
FLUID CULTURE (Final ___:
STAPH AUREUS COAG +. MODERATE GROWTH OF TWO COLONIAL
MORPHOLOGIES.
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 ___
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN----------<=0.25 S
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN----------<=0.12 S
OXACILLIN------------- 0.5 S
TETRACYCLINE---------- <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
ANAEROBIC CULTURE (Final ___: NO ANAEROBES ISOLATED.
Blood cultures ___: No Growth
___ Peritoneal fluid cultures: (no growth)
___ 2:13 pm PERITONEAL FLUID
**FINAL REPORT ___
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
This is a concentrated smear made by cytospin method,
please refer to
hematology for a quantitative white blood cell count..
FLUID CULTURE (Final ___: NO GROWTH.
ANAEROBIC CULTURE (Final ___: NO GROWTH.
___ 5:50 am IMMUNOLOGY
**FINAL REPORT ___
HBV Viral Load (Final ___:
104,000,000 IU/mL.
Performed using the Cobas Ampliprep / Cobas Taqman HBV
Test v2.0.
Linear range of quantification: 20 IU/mL - 170 million
IU/mL.
Limit of detection: 20 IU/mL.
___ 8:39 am STOOL CONSISTENCY: LOOSE Source:
Stool.
**FINAL REPORT ___
C. difficile DNA amplification assay (Final ___:
Negative for toxigenic C. difficile by the Illumigene DNA
amplification assay.
(Reference Range-Negative).
Imaging:
___ ___:
No evidence of deep venous thrombosis ___ the right lower
extremity veins. Calf veins not visualized. Large medial right
calf low-density collection and smaller popliteal fossa
collection are most likely resolving hematoma. Although this
would be an atypical appearance for infection, clinical
correlation is recommended to exclude abscess.
CXR ___: Intact appearance of port tubing without
discontinuity. Mild nonspecific interstitial abnormality but
suggestive of vascular congestion.
CT Pelvis w/contrast ___:
1. Intermediate density collection expanding the right gluteal
musculature with surrounding fat stranding and extension to the
right hamstring origin, where there is minimal subjacent ischial
tuberosity cortical lucency. This could reflect an organizing
hematoma but differential considerations ___ this patient with
known malignancy on chemotherapy include infection or
necrotic/hemorrhagic soft tissue metastasis. Clinical
correlation is recommended, as well as comparison to any
available prior imaging. Further assessment with MRI may help
characterize.
2. Small volume simple pelvic free fluid and pelvic
lymphadenopathy, with
thickening of the rectosigmoid junction, and enhancing
peritoneal nodules
which are concerning for malignant peritoneal infiltration.
3. Hypodense fluid within the right iliopsoas bursa,
non-specific.
EKG ___: Normal sinus rhythm. Normal tracing. No significant
change compared to the previous tracing of ___.
___ Ultrasound ___: Successful US-guided placement of ___
pigtail catheter into the right
gluteal collection. Samples were sent for microbiology
evaluation.
TTE ___: IMPRESSION: No echocardiographic evidence of
endocarditis. Normal regional and global biventricular systolic
function. Mild mitral regurgitation.
TEE ___: No valvular vegetations or masses seen with excellent
quality of 2D-images. Normal biventricular size and systolic
function. Small atrial septal defect versus stretched PFO.
CT pelvis with contrast (___):
IMPRESSION:
1. Interval decrease ___ size of the right gluteal abscess since
___ after drainage with persistent rim enhancing
fluid collection.
2. 1.5 cm rim enhancing lesion at the right ischial tuberosity
and
increasing subjacent cortical irregularity at the right ischial
tuberosity is concerning for another small abscess with
osteomyelitis. Given the short interval progression, this is
unlikely to represent a metastatic lesion.
3. Peritoneal and serosal nodules with omental thickening
compatible with metastatic disease. Interval increase ___
ascites.
4. Pelvic and left periaortic lymph nodes are more prominent
than on ___, though pelvic nodes are not enlarged by CT
size criteria, raising the possibility of metastatic
involvement.
R knee X-ray, 2 views (___):
IMPRESSION:
Substantial effusion. Given this patient's clinical history, a
possible
infectious etiology presumably necessitates diagnostic
aspiration.
CT chest with contrast (___):
IMPRESSION:
1. Prominent nodular soft tissue at the left neck base may be
related to patient positioning and thin body habitus, but
dedicated neck CT is
recommended to evaluate for lymphadenopathy.
2. Several new bilateral pulmonary nodules, ranging ___ size up
to 9 mm, highly suspicious for metastatic disease.
3. Peribronchiolar nodular consolidation ___ the superior
segment left lower lobe is more suggestive of infection or
aspiration than a neoplastic process. Attention to these
findings on followup CT is recommended.
4. Status post right mastectomy with post-treatment changes
involving the right axilla and right lung apex.
CT abdomen and pelvis with contrast (___):
IMPRESSION:
1. Significant progression of metastatic disease ___ the abdomen
and pelvis since CT Torso ___ with peritoneal, omental
and serosal implants.
2. Near complete resolution of the right gluteal fluid
collection with
drainage catheter ___ place. Stable tiny fluid collection with
osseous
destruction of the right ischial tuberosity concerning for small
abscess and osteomyelitis, unchanged from ___.
3. Progression of cirrhosis since ___ with mild
splenomegaly.
Moderate ascites has increased from ___ and may be
related to
cirrhosis or malignant ascites given the serosal implants as
above. Patent main portal vein.
4. CT Chest reported separately.
Brief Hospital Course:
___ y/o F with breast CA s/p rt mastectomy with mets to ovary who
presented to OSH c/o right leg swelling, generalized pain,
erythematous buttock, and scabbing over port. Found to have MSSA
bacteremia, abscess ___ buttock.
# MSSA Bacteremia: Source unclear- buttock abscess versus port.
Port removed at bedside by surgery. Drain placed ___ right
buttock abscess with slow improvement ___ output over time.
Culture from drain consistent with MSSA. Originally on IV vanc
prior to culture date, later changed to IV nafcillin 2g q4h. TTE
and TEE negative for valvular involvement. Patient seen by ID
with recommendation for 4 weeks total abx. Felt to be an unsafe
discharge home with PICC line so ___ rehab recommended
with patient's reluctant agreement after family meeting on ___.
ID also recommended check HBV viral load, switch from cipro to
rifaximin for SBP prophylaxis. Patient completed a total 4-week
course of nafcillin on the morning of ___. Blood cultures
were sent at the time of discharge ___ order to ensure clearance,
and were pending; these will be followed-up at her outpatient
visits with her Hem/Onc, ID, and Palliative Care providers.
# Tremulousness, Opsoclonus: ___: Patient with signs of opiate
withdrawal on exam (tremulousness, pupillary dilation,
rhinorrhea, yawning) save for absence of severe discomfort.
Vital signs stable. Unclear when was patient's last active drug
use and patient would not answer questions on the subject with
poor eye contact. Started on ___ and ___ scales. Serum and
urine tox screens negative (urine positive for benzos after
getting benzos). Room search negative. ___ patient admits she
may have been withdrawing. Seen by neurology for persistent
opsoclonus that began on ___, gradually worsened, then improved
on ___. Thought that this may have been part of withdrawal
symptomatology. Tremulousness improved throughout her stay, and
Neurology has low suspicion for seizure. Patient was also seen
by Ophthalmology, who commented that her abnormal eye
movements/opsoclonus may actually be ocular flutter, and may be
a manifestation of her breast carcinoma. No acute interventions
were warranted this admission.
# Buttock abscess: ___ consulted and drain placed with drainage
of serosanguinous fluid- culture shows MSSA as well. On interval
scans, size of abscess began to decrease. At one point the drain
fell out, and had to be replaced. When drain output was less
than 10 cc ___ 48 hours, drain was discontinued by ___.
# R knee pain: Patient developed a small R-sided knee effusion
and some mild pain with walking/sitting and standing up ___ the
chair. Initial R-knee X-ray showed a mild effusion, and no
evidence of fracture. The joint was tapped by Orthopaedics, and
fluid was negative for septic joint, and also negative for any
crystal arthropathies. She was managed symptomatically
throughout her stay.
# Cirrhosis, abdominal distention: secondary to hep B and hep C;
also new evidence of malignant ascites ___ carcinomatosis on
scans this admission. Per ID recs, d/c'd home ciprofloxacin, and
replaced with Rifaximin BID, which was continued at the time of
discharge. She was also continued home tenofovir. Patient also
had 3 diagnostic and therapeutic paracenteses this admission for
increasing abdominal distention; <3L was drained at each time.
Fluid was negative for SBP, but positive for malignant cells.
She received mild relief after each procedure. Patient was also
thought to be distended due to increased narcotic administration
without adequate bowel regimen; patient had some diarrhea while
on nafcillin, and significant PO bowel regimen was encouraged.
# Hypokalemia: persistnet since discharge, repleted with sliding
scales. Patient refusing EKG on occasion when levels
particularly low.
# Anemia: Received 1 unit PRBCs ___ ED with Hct from 18 -> 20.
Likely some bleeding into hematoma. Previous baseline appears to
be around 30. Given additional 1 unit ___ with H/H stable since
that time.
# Hyponatremia: likely hypovolemic given patient reports poor PO
intake recently. However, mother reports that patient has been
drinking 1 gallon of lemonade and ___ gallon of soda and water.
Steadily improved with IVFs, blood, and good PO.
# Malnutrition: Albumin of 1.9 -> 1.7. Nutrition consulted:
start ensure plus TID, add daily multivitamin with minerals but
patient has been refusing. Patient also has several
# Pain Control: difficult to assess pain control needs versus
narcotic-seeking behavior. Continued home regimen to avoid
further withdrawal. Added oxycontin 20 mg PO Q12H on ___ for
persistent pain, ___ and ___ initiated per above and later
discontinued. Throughout her stay, due to her complaints, pain
needs, and difficult behavior, her regimen was further adjusted
with the help of her outpatient providers Dr. ___ Dr.
___. Her Oxycontin was increased to 30 mg q12hr, and her
Oxycodone to ___ mg PO q4hr PRN (patient would always take the
30 mg dose). Patient was not accepted by any long-term
facilities this admission due to her drug abuse history and
difficult behavior, so she completed her antibiotic course
___.
CHRONIC ISSUES:
# Metastatic Breast Cancer: Per outpatient providers Dr. ___
___ Dr. ___ has been resistant to get further CT
imaging for staging as outpatient, so attempted to accomplish
while ___ house. Initial CT pelvis x 2 for buttock abscess
visualization this admission demonstrated multiple nodules,
which has inadvertently helped for staging purposes. CA-125 and
CA ___ returned high; progression of disease was discussed
with the patient by Dr. ___ she agreed to a staging CT. CT
chest/abdomen/pelvis on ___ returned with new metastases,
including pulmonary, as well as peritoneal carcinomatosis. Plan
for further chemotherapy will be determined by Dr. ___
blood cultures return clear s/p 4-week course of nafcillin this
admission.
TRANSITIONAL ISSUES:
- Completed 4-week Nafcillin course or morning of ___.
- Has close follow-up scheduled with Hem/Onc and Palliative
Care.
- Wound care recs provided ___ page 1 for sacral ulcer.
- Rifaximin BID continued for SBP prophylaxis per ID;
pre-admission Ciprofloxacin was discontinued. This can be
re-addressed at outpatient ID appointment scheduled for ___.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. ALPRAZolam 1 mg PO TID:PRN anxiety, nausea
2. Ciprofloxacin HCl 500 mg PO Q24H
3. Escitalopram Oxalate 20 mg PO DAILY
4. Ibuprofen 600 mg PO BID:PRN pain
5. OxycoDONE (Immediate Release) 30 mg PO Q6H:PRN pain
6. Tenofovir Disoproxil (Viread) 300 mg PO DAILY
Discharge Medications:
1. OxyCODONE SR (OxyconTIN) 30 mg PO Q12H
2. ALPRAZolam 1 mg PO TID:PRN anxiety, nausea
3. Tenofovir Disoproxil (Viread) 300 mg PO DAILY
4. Ibuprofen 600 mg PO BID:PRN pain
5. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
RX *oxycodone 15 mg ___ tablet(s) by mouth every four (4) hours
Disp #*80 Tablet Refills:*0
RX *oxycodone [OxyContin] 30 mg 1 tablet(s) by mouth twice a day
Disp #*16 Tablet Refills:*0
6. Bisacodyl 10 mg PO DAILY:PRN constipation
RX *bisacodyl 5 mg 2 tablet(s) by mouth once a day Disp #*60
Tablet Refills:*0
7. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*0
8. Multivitamins W/minerals 1 TAB PO DAILY
RX *multivitamin,tx-minerals 1 tablet(s) by mouth once a day
Disp #*30 Tablet Refills:*0
9. Nicotine Patch 14 mg TD DAILY
RX *nicotine 14 mg/24 hour 1 patch once a day Disp #*14 Patch
Refills:*1
10. Polyethylene Glycol 17 g PO DAILY:PRN constipation
RX *Miralax 17 gram 1 powder(s) by mouth once a day Disp #*24
Packet Refills:*0
11. Senna 8.6 mg PO BID:PRN constipation
RX *sennosides [senna] 8.6 mg 1 tablet by mouth twice a day Disp
#*60 Tablet Refills:*0
12. Simethicone 40-80 mg PO QID:PRN gas, gurgling, constipation
RX *simethicone 80 mg 0.5-1 tablets by mouth four times a day
Disp #*80 Tablet Refills:*0
13. Rifaximin 550 mg PO/NG BID
RX *rifaximin [Xifaxan] 550 mg 1 tablet(s) by mouth twice a day
Disp #*60 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Methicillin sensitive staph aureus bacteremia
Right buttock abscess
Drug withdrawal
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 stay at ___.
You were admitted for swelling of your right leg and a sore spot
on your right buttock. You were found to have an abscess ___ your
right buttock and a blood stream infection caused by staph
aureus (non-MRSA). Your left chest port also appeared infected
so it was removed. You were seen by the infectious disaese
doctors who recommended a 4 week course of antibiotics via a
PICC line. Your pain medications were also adjusted due to your
increased pain, and with the help of your outpatient providers.
You had several drainages of your abdominal fluid as well to
help with your discomfort.
Wishing you well,
Your ___ Oncology Team
Followup Instructions:
___
|
19692222-DS-29
| 19,692,222 | 25,285,141 |
DS
| 29 |
2196-09-10 00:00:00
|
2196-09-10 15:24:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROSURGERY
Allergies:
Codeine / Streptokinase / Iodine / Bee Pollens / Narcan
Attending: ___.
Chief Complaint:
"worst headache of life"
Major Surgical or Invasive Procedure:
___ Cerebral Angiogram
___ Right EVD placement
___ Right EVD catheter replacement
___ IVC filter placement
___ Ventriculoperitoneal Shunt
History of Present Illness:
This is a ___ year old man on Aspirin and Coumadin for Atrial
Fibrillation/CVA who was medflighted from ___ today
following worst headache of life 24 hours ago with a INR of ___onsistent with extensive Subarachnoid Hemorhage.
The patient was given Vitamin K 10 mg and Factor 7 to reverse
his INR. Upon arrival the patient and his daughter stated that
he has over the past ___ developed a left facial droop, slurred
speech and a droopy left eye. He has had some weakness in his
bilateral upper extremities that he has had since his care
accident approximately 3 weeks ago and his very bad fall three
days ago. His right arm is in a cast.
Past Medical History:
Type II Diabetes on oral agents
Systemic Lupus Erythematosus
Coronary Artery Disease s/p MI in ___
Hepatitis C
COPD with emphysema and asthmatic component (FEV1 60% predicted
___
Diastolic Congestive Heart Failure EF 55% in ___
Seizure disorder
TIA 199
Colon Cancer s/p resection in ___ without chemotherapy
s/p abdominal trauma with subsequent splenectomy and amputation
of digits of his left hand
Hyperlipidemia
Hypertension
h/o cocaine abuse
Neuropathy and chronic pain on methadone
Chronic Atrial Fibrillation on Coumadin
Obstructive Sleep Apnea on home CPAP
Left Total Knee Replacement ___
Social History:
___
Family History:
Adopted - Unknown birth family hx
Physical Exam:
Admission Exam:
***************
T: 96.3, BP: 142/78, HR: 98, R: 22, O2Sats:98% on 4 liters
Gen: comfortable, slurred speech
HEENT:left facial droop and left ptosis, atraumatic Pupils: %mm
EOMs5 mm bilaterally non reactive
Neck: Supple.
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert to person and place only
Orientation: Oriented to person, place, and NOT date.
Recall: unable to perform
Language: Speech is slow and slurred
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light,5
mm NON REACTIVE bilaterally.
III, IV, VI: Extraocular movements intact on right, ___
nerve palsy on LEFT, disconjugate gaze
V, VII: Facial strength LEFT facial droop
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- antigravity x 4. Pronator drift- unable to
perform- right arm cast and residual bilateral arm weakness from
fall/car accident- antigravity
Sensation: Intact to light touch bilaterally.
Reflexes: Toes downgoing bilaterally
Coordination: Unable to perform
Discharge Exam:
***************
Gen: Trach/PEG placed, NAD
HEENT: Left facial droop with left ptosis
Neck: Supple.
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert to person and place only
Orientation: Oriented to person, place, and NOT date.
Recall: unable to perform
Language: Speech is slow and slurred
Cranial Nerves:
I: Not tested
II: Pupils 4mm -> 3mm on right, EOMs 5 mm bilaterally non
reactive, rotated externally
III, IV, VI: Extraocular movements intact on right, ___
nerve palsy on LEFT, disconjugate gaze
V, VII: Facial strength LEFT facial droop
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 - in right arm and leg. Pronator drift -
unable to perform- right arm cast and residual bilateral arm
weakness from fall/car accident- antigravity
Sensation: Intact to light touch bilaterally.
Reflexes: Toes downgoing on right, equivocal on left
Coordination: Could not perform
Pertinent Results:
___ ANGIOGRAM:
1. Tiny 1-2 mm questionable infundibulum versus questionable
broad-based
focal ectasia versus tiny aneurysms noted at the level of the
anterior
communicating artery and right middle cerebral artery
bifurcation.
2. Evaluation of the right external carotid artery, left
internal carotid
artery, left external carotid artery, right vertebral artery,
and left
vertebral artery demonstrates no definite evidence of aneurysms
or vascular malformations.
___ CT HEAD W/O CONTRAST:
Status post ventriculostomy catheter placement from a right
frontal approach with tip in the third ventricle;
stable-to-slight increase in extent of subarachnoid hemorrhage
with layering intraventricular hemorrhage within the occipital
horns of the lateral ventricles
___ ECHOCARDIOGRAM:
The left atrium is moderately dilated and elongated. The right
atrium is markedly dilated. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity is mildly
dilated. Overall left ventricular systolic function is mildly
depressed (LVEF= 45-50 %) secondary to hypokinesis of the
basal-mid inferior wall, and inferior/anterior septum. The LV
apex and distal anterior wall appeared normokinetic, although
their function may be overestimated given significantly
foreshortened apical views. The right ventricle is mildly
dilated with borderline normal free wall function. The aortic
root is mildly dilated at the sinus level. The aortic valve
leaflets (3) are mildly thickened but aortic stenosis is not
present. No aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. There is no mitral valve
prolapse. Mild (1+) mitral regurgitation is seen. There is
moderate pulmonary artery systolic hypertension. There is no
pericardial effusion.
___ CXR FINDINGS:
As compared to the previous radiograph, the nasogastric tube has
been advanced. The tip of the tube now projects over the
gastroesophageal junction. To ensure correct position in the
stomach, the tube must be advanced by another 10 cm. Unchanged
position of the endotracheal tube. Unchanged moderate
cardiomegaly with mild fluid overload. The extent and severity
of the pre-existing right lower lung parenchymal opacity is
unchanged.
___ CT HEAD W/O CONTRAST (9:27 AM)
CONCLUSION:
1. Interval increase of the hemorrhage at the mid brain compared
to the previous study, concerning for hemorrhage within the mid
brain versus expanding hemorrhage at the interpeduncular
cistern.
2. Interval increase in the size of the ventricles as described
above,concerning for hydrocephalus.
___ CT UP EXT W/O Study Date (9:27 AM)
IMPRESSION:
1. Comminuted and impacted right medial clavicle fracture.
2. Severe emphysema.
3. Multinodular thyroid can be further evaluated by ultrasound,
if clinically indicated.
___ CT HEAD W/O CONTRAST Study Date of (2:05 ___
CONCLUSION:
1. The hemorrhage at the midbrain has seems to have increased in
size compared to the study from earlier this morning.
2. There is an increased amount of intraparenchymal hemorrhage
around the catheter site.
3. The size of the ventricles is unchanged compared to the study
performed
earlier this morning.
___ PORTABLE HEAD CT W/O CONTRAST (7:45 AM)
CONCLUSION:
1. Subarachnoid and intraventricular hemorrhage, unchanged
compared to the previous study.
2. No new evidence of hemorrhage, mass effect, or acute
infarction.
3. Intraparenchymal hemorrhage around the catheter site is
stable compared to the previous study.
4. Size of the ventricles is unchanged compared to the previous
study.
___ CHEST (PORTABLE AP) (10:22 AM)
IMPRESSION:
AP chest compared to ___: Relatively symmetric
infiltrative abnormality in the lower lungs is probably
pulmonary edema. Previous right lower lobe pneumonia is
improving. Pleural effusions are small if any.
Moderate-to-severe cardiomegaly is longstanding. ET tube in
standard placement. Nasogastric drainage tube passes into the
stomach and out of view. No pneumothorax.
___ EKG
Atrial fibrillation with controlled ventricular response. Poor R
wave
progression. Non-specific ST-T wave changes in the inferior and
anterolateral leads. Compared to the previous tracing of ___
the ventricular response is slower.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
88 0 96 ___
___ CT HEAD W/O CONTRAST (4:42 ___
IMPRESSION: No significant change since the prior study. No
evidence of new hemorrhage, mass effect, or infarction.
___ CHEST (PORTABLE AP) (5:20 ___
FINDINGS: In comparison with the study of ___, there is again
substantial
enlargement of the cardiac silhouette with only mild elevation
of pulmonary venous pressure. This suggests cardiomyopathy or
pericardial effusion. Endotracheal and nasogastric tubes remain
in good position. The
hemidiaphragms are more sharply seen, consistent with clearing
of the previous pulmonary edema. Mild atelectatic changes may
be present.
___ Neurophysiology Report EEG
IMPRESSION: This is an abnormal continuous ICU monitoring study
due to
generalized slowing of the background activity with ___ theta
and superimposed ___ Hz delta. There are frequent bursts of
generalized sharp waves with maximal amplitude over the frontal
regions often with shifting laterality in terms of maximal
amplitude. These findings are suggestive of moderate to severe
encephalopathy with potential underlying epileptogenic cortex.
Compared to the previous ___ study, the generalized sharp
waves are slightly less frequent and now they are more blunted
in their appearance
___ Neurophysiology Report EEG
IMPRESSION: This is an abnormal continuous ICU EEG monitoring
study due to a slow background of ___ theta with superimposed
___ Hz delta. Frontally
maximal, generalized sharp waves are frequently seen. The
background activity becomes discontinuous after 16:00 to 00:45
with alternating pattern of one to two second severe EEG
suppression and two to three seconds of diffuse 5 Hz theta
predominantly over frontal-central areas, superimposed with ___
Hz delta. These finds are suggestive of severe encephalopathy
with potential underlying epileptogenic cortex.
___ CTA HEAD W&W/O C & RECONS (10:33 AM)
IMPRESSION:
1. Improvement/stable subarachnoid and intraventricular
hemorrhage as
described above.
2. Patent Circle of ___. Patent carotid and vertebral
arteries and their major branches with no evidence of stenosis.
3. Again seen is the small 1- to 2-mm aneurysm at the level of
the ACA and right MCA bifurcation, as seen previously on the
cerebral angiography from ___. No evidence of vasospasm.
___ BILAT LOWER EXT VEINS PORT (2:24 ___
IMPRESSION: No sonographic evidence for lower extremity deep
vein thrombosis.
___ CHEST PORT. LINE PLACEMENT (5:55 ___
FINDINGS: In comparison with the study of earlier in this date,
there has
been placement of a left subclavian catheter that extends to the
upper-to-mid portion of the SVC. No evidence of pneumothorax.
The left basilar
opacification is slightly less prominent. Other monitoring and
support devices remain in place.
___ CHEST (PORTABLE AP) (4:08 AM)
FINDINGS: In comparison with the study of ___, there is
continued prominence of the cardiac silhouette without definite
pulmonary vascular congestion. There is now increasing
opacification at the right base with poor definition of the
hemidiaphragm. This suggests pleural effusion and atelectasis.
Less prominent opacification is seen at the left base. No
evidence of pneumothorax.
___ CHEST (PORTABLE AP) (4:39 AM)
IMPRESSION: AP chest compared to ___ - Right lower lobe
consolidation has improved. There is no pulmonary edema.
Moderate cardiomegaly has improved since ___. Pleural
effusions are small on the right, if any. Configuration of the
diaphragm suggests COPD.
ET tube in standard placement. Left subclavian line ends at the
junction of brachiocephalic veins and an enteric tube ends in
the upper stomach.
___ CXR: FINDINGS: As compared to the previous radiograph,
there is constant appearance of the heart and the lung
parenchyma. No interval appearance of new parenchymal
opacities. Unchanged moderate cardiomegaly without overt
pulmonary edema. The monitoring and support devices are
constant.
___ CXR: FINDINGS: As compared to the previous radiograph,
there is no relevant change. Unchanged monitoring and support
devices. Unchanged appearance of the lung parenchyma.
Unchanged appearance of the cardiac silhouette. No
pneumothorax, no pleural effusions.
___ CXR:
IMPRESSION: Status post tracheostomy and PEG placement, both of
which appear in appropriate position. Apparent increase in
right pleural effusion is likely due to patient rotation with
respect to the film.
___ CXR:
FINDING: Pulmonary vascular congestion with associated
peribronchial cuffing appears unchanged. When compared to a
similarly positioned radiograph of ___ at 4:50
a.m., there has been apparent increase in confluent opacity in
the right infrahilar region. This area is difficult to compare
to the more recent radiograph of 12:50 p.m. on the same date,
but may be improved since that time. Differential diagnosis
includes asymmetrical pulmonary edema, aspiration, and less
likely a focal infection.
___ CXR:
IMPRESSION: Right-sided pleural effusion, small to moderate in
size. Otherwise, unchanged examination of the chest.
___ BILATERAL LOWER VEIN:
IMPRESSION: Nonocclusive thrombus within the left common
femoral vein. The remainder of the veins of both legs are
normal.
___ CT HEAD W/O CONTRAST IMPRESSION:
1. Ventriculoperitoneal shunt terminating in the frontal horn
of the right lateral ventricle, as compared to within the third
ventricle on prior examination.
2. New small foci of air within the right frontal horn of the
lateral
ventricle, likely due to recent instrumentation.
3. Overall, decreased amount and density of previously seen
subarachnoid and intraventricular hemorrhage. No mass effect or
evidence of herniation. Stable ventricular size.
4. Increased opacification of the right mastoid air cells
___ CT HEAD W/O CONTRAST IMPRESSION: Stable examination
(since ___ study)
___ CXR - The ET tube tip is approximately 7 cm above the
carina. The gastrostomy projecting over the stomach consistent
with feeding tube. Heart size and mediastinum are unchanged.
Left lower lobe opacity is unchanged, associated with small
amount of pleural effusion concerning for infectious process.
No new abnormalities demonstrated.
___ CXR - IMPRESSION:
1. Left lower lung improved.
2. Mild pulmonary edema which is more evenly distributed on the
study, but overall unchanged.
___ CXR
FINDINGS: In comparison with study of ___, the left
hemidiaphragm is not as sharply seen, raising the possibility of
atelectasis or even developing
consolidation at the left base. Remainder of the study is
essentially within normal limits and the monitoring and support
devices are unchanged.
Brief Hospital Course:
___ y/o M on aspirin and coumadin for Afib presents s/p worst
headache of his life with SAH found on head CT. His INR was
elevated to 4 and was actievely reversed with factor 7 and
vitamin K. He was intubated and an EVD was placed in the ED at
the bedside. He was then admitted to neurosurgery and went for
an angiogram for evaluation of aneurysm. Angiogram was negative
for any aneurysm. Post angiogram, the patient on exam withdrew
all four extremities to noxious stimuli. His INR was stable at
1.0.
On ___, patient opened his eyes to voice, but had CN 3, 4 and
___ nerve palsy. He followed simple commands in bilateral hands
and feet. His EVD was elevated to 20cmH2O. The EVD stopped
functioning twice overnight but this was quickly resolved when
flushed.
On ___ the EVD again stopped working, but the patient remained
neurologically stable. A Head CT revealed a new hemorrhage along
the catheter tract. It was decided to replace the EVD, which was
performed without complication. Post placement CT revealed good
catheter positioning. His dilantin level was subtherapeutic so
he was re-bolused.fluid volume balance - 2 liters negative. The
serum sodium was uptrending so ICU increased intravenous fluids.
The patient stopped moving Left upper and left lower extremity.
On ___, The patient was febrile to 103 with tachycardia to 150s
in Atrial flutter. Femoral ___ was placed. A diltiazem
continuous IV drip was initiated. The patient was pan cultured.
The External Ventricular Drain was clamped at 5 pm and later
unclamped due to elevated intercranial pressures. The patient's
EVD was left open at 10 above tragus.
On ___, The external ventricular drain was open at 10 abouve
tragus. The serum sodium was 155 and the serum BUN was 30. The
patient's intravenous fluid was increased to NS at 100cc/hr.
The dilantin level was checked and repleted. Per the epilepsy
attending the EEG much improved from ___ ___ prior and there
were no seizures noted. Recomendations were made to maintain
the Dilantin level higher at 20.On exam, the patient was able to
eye open to voice. The pupils were 5mm and non reactive. Left
ptosis, dysconjugate gaze continued. The patients left upper
extremity exhibited no movement. The left lower extremity
withdrew to noxious stimulus. The right upper extremity the
patient moves fingers to commands, localizes and moves his right
lower extremity on the bed
On ___, The EEG without seizures.
On ___, The EEG showed no seizures and was stable consistent
with severe encephalopathy. The CTA Head showed no vasospasm.(
premedicated with 100 hydrocort/50 bendryl) for decreased exam.
Free water 300 q 6 hours for elevated serum sodium of 152. The
goal goal serum sodium wa 138-145. The external ventricular
drain was clamped at 0830 in ___ morning and the patient failed
the clamping trial in afternoon when he had a fever. The
dilantin level was 13.1. The patientw as febrile to 101.3.
Blood cultures were sent and venous femoral ___ cooling
catheter removed.
On ___, The patient was febrile overnight and CSF was again
sent which was consistent with ***. On exam, the patient was
slightly improved . He was wiggling his toes to command. He
was able to flicker move his right hand fingers to command. The
EVD open at 20. The Transcranial Doppler study was limited due
to EEG leads placement but there was no vasospasm of
opthalmic/vertebral or extracranial carotid arteries. The serum
sodium was elevated at 151 and at 1730 the serum sodium was up
to 153. The free water flushes were increased to 360 cc q 6
hours.Late morning the patient's fever was 102.8 and a Chest XRY
was consistent with a new right sided consolidation. A
Bronchcoscopy was performed and a BAL was sent. IV abts
vancomycin and cefipime was initiated for pneumonia. A EEG
showed no seizures but consistent severe encephalopathy. Per the
epilepsy service as there had been no seizures noted on EEG the
EEG was discontinued. On exam ,the patient opened eyes to voice.
The right pupil was 5-4.5mm reactive and the left pupil 5mm NR.
The Right Upper Extremity exhibited flicker finger movement to
command and was casted. The patient moved toes bilaterally to
command/briskly. There was no movement in the left upper
extremity which was stable.
On ___, patient was seen to have a stable examination, he was
following simple commands on his RLE, w/d RUE, spontaneous on
the LLE and no movement on his LUE. He was febrile throughout
the ___ and was cooled with a cooling blanket. His Na increased
from 151 to 153, free water was increased. His vancomycin was
also increased to 1250mg QD. He was placed on a dilt gtt for
a-fib and was being converted to PO. He was recultured for his
fevers. U/A was negative.
On ___ he was again febrile. Sputum Cultures from the ___
including a BAL were positive for staph and yeast. WBC cont to
increase to 24.3. Na was stable at 150 and dilantin was
corrected to 10.8. An MRI/MRA were ordered to evaluate for
vascular malformation and prognostication. A family meeting was
scheduled for ___ but Dr ___ met with the patient's daughter
in advance and Dr ___ spoke to the patient's wife on the
phone. Everyone was in agreement that they would like to proceed
with a trach and peg. This was scheduled for ___.
Overnight he was febrile and was suddenly hypotensive to the
___. He required Neo for a short while but this was then weaned
off. CSF was sent for culture. In the AM ___ he was
neurologically stable. His trach and peg were placed at the
bedside.
On ___ patient developed fevers again and his scheduled VPS
procedure was posponed. VPS placement was accomplished on ___.
The patient was seen ___: restarted FW bolus, thick
secretions-febilre 103 right after PICC, central line removed,
blood/sputum sent, sputum resulted in GPC in clusters with
sensitivities pending. Over the course of the ___, the
patient spiked fevers on a nightly basis for which Vancomycin
was restarted, and tailored for supratheraputic value.
Hypernatremia was noted to improve over this time on Free Water
flush ___ over the course of ___ days). Lovenox was
also restarted for DVT with a coumadin bridge both for DVT and
AFib history.
A VPS tap resulted in the findings of a leukocytosis in the CSF
(100 WBC with 89 neutro) without any organisms seen, and normal
protein/glucose. ID was consulted regarding the patients
continued fevers, with recommendation to continue Vanco for
total course of ___ days given previous Cx of GPC x2 from
sputum. Over ___ evening patient remained afebrile with
decreasing serum leukocytosis.
Spoke with Orthopedics regarding right cast, which had been
placed in ___ s/p an ORIF procedure for MVA-related
fracture. Plan to remove the cast on ___ with repeat XRays.
Patient remained afebrile and stable from a respiratory and
neurological standpoint. He was discharged to rehab on ___.
Medications on Admission:
1. Acetaminophen 650 mg PO Q6H
2. Albuterol Inhaler ___ PUFF IH Q4H:PRN wheeze
3. Aspirin 325 mg PO DAILY
4. Captopril 100 mg PO TID
5. CloniDINE 0.1 mg PO BID
6. Docusate Sodium 100 mg PO BID
7. Fluoxetine 60 mg PO DAILY
8. Gabapentin 600 mg PO QID
9. HydrALAzine 25 mg PO Q6H
10. HYDROmorphone (Dilaudid) ___ mg PO Q3H:PRN severe pain
Please wean off medication as tolerated, you can take tylenol
alone to help wean off. All future prescriptions from
outpatient chronic care provider. Do not take medication other
than prescribed
11. Hydroxychloroquine Sulfate 200 mg PO BID
12. Methadone 10 mg PO BID (10mg at 8am, 10mg at noon)
13. Methadone 20 mg PO BID (20mg at 6pm, 20mg at 10pm)
14. Metoprolol Tartrate 50 mg PO BID
15. Omeprazole 20 mg PO BID
16. Pravastatin 40 mg PO DAILY
17. Prochlorperazine 10 mg PO Q6H:PRN nausea
18. Senna 1 TAB PO BID:PRN constipation
19. Spironolactone 25 mg PO DAILY
20. Tizanidine 4 mg PO QHS
21. Torsemide 50 mg PO 12PM
22. Warfarin 2.5 mg PO QHS redose per ___ clinic
Discharge Medications:
1. Acetaminophen (Liquid) 650 mg PO Q6H:PRN headache/pain
2. Albuterol Inhaler ___ PUFF IH Q4H:PRN wheezing
3. Docusate Sodium 100 mg PO BID
4. HYDROmorphone (Dilaudid) 0.125-1 mg IV Q4H:PRN headache
for breakthru pain; hold rr < 12
Only give this medication if the patient has not already been
dosed PO Dilaudid to avoid over-administration of narcotics.
wean off medication as tolerated, you can take tylenol alone to
help wean off. All future prescriptions from outpatient chronic
care provider.
5. Gabapentin 600 mg PO TID
home medication
6. Fluoxetine 60 mg PO DAILY
7. Metoprolol Tartrate 100 mg PO BID
Hold for HR < 60bpm
8. Pravastatin 40 mg PO DAILY
9. Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL BID
10. Fluticasone Propionate 110mcg 2 PUFF IH BID
11. Nystatin Oral Suspension 5 mL PO QID:PRN thrush
12. Senna 1 TAB PO HS
13. Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY
14. Artificial Tear Ointment 1 Appl BOTH EYES QID dry eyes
15. Tizanidine 4 mg PO HS
16. Bisacodyl 10 mg PO/PR DAILY
17. Diltiazem 60 mg PO QID
Hold HR < 60 and SBP < 100.
18. Enoxaparin Sodium 60 mg SC Q12H
19. HYDROmorphone (Dilaudid) ___ mg PO Q6H:PRN headache
hold for lethargy and rr < 12
20. Ibuprofen Suspension 400-800 mg PO Q8H:PRN fever
please alternate with tylenol
21. Glargine 45 Units Q24H
Insulin SC Sliding Scale using REG Insulin
22. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush
PICC, non-heparin dependent: Flush with 10 mL Normal Saline
daily and PRN per lumen.
23. Vancomycin 750 mg IV Q 12H
24. Warfarin 7.5 mg PO DAILY16 Duration: 1 Doses
INR goal ___
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Subarachnoid Hemorrhage
Hydrocephalus
Non-occlusive L common femoral artert DVT
Hypernatremia
PNA
Respiratory failure
Dysphagia
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Bedbound.
Discharge Instructions:
Continue all other medications you were taking before surgery,
unless otherwise directed
You make take Tylenol or prescribed pain medications for any
post procedure pain or discomfort.
What activities you can and cannot do:
When you go home, you may walk and go up and down stairs.
Keep your incision dry until staple removal.
No heavy lifting, pushing or pulling (greater than 5 lbs) for
1 week (to allow groin puncture to heal).
What to report to office:
Changes in vision (loss of vision, blurring, double vision,
half vision)
Slurring of speech or difficulty finding correct words to use
Severe headache or worsening headache not controlled by pain
medication
A sudden change in the ability to move or use your arm or leg
or the ability to feel your arm or leg
Trouble swallowing, breathing, or talking
Numbness, coldness or pain in lower extremities
Temperature greater than 101.5F for 24 hours
New or increased drainage from incision or white, yellow or
green drainage from incisions
Bleeding from groin puncture site
*SUDDEN, SEVERE BLEEDING OR SWELLING
(Groin puncture site) Lie down, keep leg straight and have
someone apply firm pressure to area for 10 minutes. If bleeding
stops, call our office. If bleeding does not stop, call ___ for
transfer to closest Emergency Room!
- Lovenox bridge to Coumadin, INR goal ___
- Vancomycin thru ___
- Cast follow-up due for ___ with Ortho
Followup Instructions:
___
|
19692225-DS-15
| 19,692,225 | 26,221,686 |
DS
| 15 |
2123-06-27 00:00:00
|
2123-07-06 14:19:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
No Allergies/ADRs on File
Attending: ___.
Chief Complaint:
s/p High speed MVC
Major Surgical or Invasive Procedure:
___:
1. Real-time ultrasound-guided access to the right common
femoral artery and placement of an ___ sheath.
2. Thoracic aortogram.
3. Placement of a Zenith Alpha 26 mm x ___ mm stent graft into
the descending thoracic aorta.
4. ___ Perclose ProGlide device x 2 to the right groin.
History of Present Illness:
___ presenting as a trauma activation after unrestrained high
speed ___ transferred from ___. There she was found to have a
hemopneumothorax and a right chest tube was placed. On arrival
to ___, she became hypotensive again, but resolved after
pigtail catheter was adjusted and new chest tube placed. CTA
obtained the OSH showed a possible descending thoracic aortic
injury. She was also found to have a left-sided pelvic fracture,
with a small hematoma immediately anterior to the left sacral
___ fracture. On exam, the patient noted generalized abdominal
and back pain.
Past Medical History:
PMH: ETOH and polysubstance abuse, CVA ___ years ago), Hodgkin's
lymphoma in remission, PTSD, anxiety
PSH: splenectomy (___)
Social History:
___
Family History:
Family History:
Mother - lung cancer
Father - colon cancer
Physical Exam:
Physical Exam on Admission:
Vitals: 97.6 104 132/83 25 95%RA
GEN: NAD
HEENT: c-collar in place
CV: mild tachycardia
PULM: right chest tube in place, no respiratory distress, right
sided chest tenderness to palpation
ABD: Soft, nondistended, nontender, no rebound or guarding
Ext: No ___ edema, ___ warm and well perfused
Pulses: R: p/p/p/p L: p/p/p/p
Physical Exam on Discharge:
VS: 97.6, 124/74, 75, 18, 91% RA
GEN: NAD, A&Ox3
PSY: Mood and affect WNL
Lungs: Non-labored breathing pattern
SKIN: Warm and intact
MSK: Functionally normal and pain free range of motion of the
upper and lower extremities.
NEURO: Strength diffusely ___, sensation grossly intact to
light, touch. reflexes in upper and lower extremities
symmetrical and intact
Abdomen: soft, non tender to palpation
Pertinent Results:
TRAUMA #2 (AP CXR & PELVIS PORT): ___
1. Right chest tube in situ with small deep sulcus sign on the
right
suggesting pneumothorax.
2. No abnormal widening of the mediastinal silhouette.
3. Bilateral rib fractures, better assessed on CT.
CT CHEST W/CONTRAST Study Date of ___
1. Aortic injury at the aortic isthmus/proximal descending
thoracic aorta
including 8 mm pseudoaneurysm and at least 2 foci of small
intimal tear.
Associated small mediastinal hematoma.
2. Large right pneumothorax with leftward shift of the
mediastinum worrisome for tension pneumothorax. Subsequent
chest radiograph demonstrated chest tube in place.
3. Right-sided pulmonary contusions.
4. Multiple bilateral rib fractures include right third, fifth
through seventh and left second, fourth, fifth, seventh through
ninth.
5. Nondisplaced fracture of the proximal body of the sternum
with possible
underlying minimal retrosternal hematoma.
6. Fracture of the anterior, inferior T2 vertebral body. Mildly
displaced
left L4 transverse process fracture.
7. Comminuted, minimally displaced fracture through the left
sacral ala with associated small left pelvic hematoma.
8. Status post cholecystectomy; intra extrahepatic biliary
ductal dilatation likely relate to post cholecystectomy state.
Status post splenectomy with splenosis seen.
CHEST (PORTABLE AP): ___
Comparison to ___. The right chest tube is in correct
position.
There is no evidence for the presence of a pneumothorax. No
pleural
effusions. Minimal air inclusion at the site of tube insertion.
Improving
atelectasis at the level of the right hilus. Minimal remnant
right apical
parenchymal opacity.
CTA CHEST: ___
1. No significant change in appearance of an acute aortic injury
at the aortic isthmus/proximal descending thoracic aorta with a
small pseudoaneurysm and small associated mediastinal hematoma.
2. Trace residual right apical pneumothorax status post right
chest tube
placement, with interval resolution of previously seen leftward
midline shift.
3. Trace left pleural effusion. Bilateral atelectasis.
4. Redemonstration of multiple bilateral rib fractures as well
as a fracture of the inferior T2 vertebral body.
CXR: ___
Comparison to ___. Stable position of the right chest
tube. Stable mild cardiomegaly. New retrocardiac atelectasis
and small left pleural effusion. No pneumothorax, stable
radiographic appearance of the displaced rib fractures, which
are better appreciated on the CT from ___.
Transthoracic Echocardiogram Report: ___
Normal left ventricular wall thickness and biventricular cavity
sizes and regional/global biventricular systolic function.
Normal ___ of visualized ascending and proximal
descending aorta without dissection. Mild mitral regurgitation.
CAROTID SERIES COMPLETE PORT: ___
Right ICA: No stenosis.
Left ICA: No stenosis.
CTA CHEST: ___
1. Interval placement of endovascular stent in the descending
aorta, covering the previously noted pseudoaneurysm. No
endoleak.
2. Moderate bilateral pleural effusion with compressive
atelectasis and
anasarca, suggestive of fluid imbalance.
3. Resolution of right-sided pneumothorax and interval removal
of chest tube.
4. Stable osseous fractures including bilateral ribs, lumbar
vertebral bodies and left sacral ala.
Brief Hospital Course:
Ms. ___ was admitted to the trauma ICU overnight ___ into
___ under the acute care surgery service for further management
of her multiple traumatic injuries. She was started on cleviprex
gtt for close BP control given aortic pseudoaneurysm which was
transitioned to esmolol gtt. She did experience desaturations
requiring use of high flow nasal cannula, which was gradually
weaned to standard nasal cannula on ___. An epidural was placed
for pain control. She was seen by the orthopedics and spine
services and determined to have no activity restrictions or
plans for operative management of her spine or pelvic fractures.
After further imaging workup, on ___ she underwent TEVAR with
the vascular surgery service for her aortic injury. She was
extubated later in the day and weaned to nasal cannula. On ___,
she remained stable and was transferred from the ICU to the
surgical floor.
Upon arrival to medical/surgical unit, it was determined she
would benefit from a rehab stay, therefore case management began
to screen for appropriate placement. Then on ___ she developed
urinary frequency and urgency. Urinalysis and urine culture was
sent to the lab for evaluation and she was found to have a
urinary tract infection growing EColi. She was started on
intravenous ceftriaxone and then transitioned to oral macrobid
once sensitivities resulted.
Once pain was well controlled, and the patient experienced a
return of bowel function, their diet was advanced as tolerated.
During this hospitalization, the patient voided without
difficulty and ambulated early and frequently. The patient was
adherent with respiratory toilet and incentive spirometry and
actively participated in the plan of care. The patient received
subcutaneous heparin and venodyne boots were used during this
stay.
At the time of discharge, the patient was doing well. S/he was
afebrile and their vital signs were stable. The patient was
tolerating a regular diet, ambulating, voiding without
assistance, and their pain was well controlled. The patient was
discharged home without services. Discharge teaching was
completed and follow-up instructions were reviewed with reported
understanding and agreement.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Venlafaxine XR 150 mg PO DAILY
2. Omeprazole 20 mg PO BID:PRN acid reflux
3. HydrOXYzine 25 mg PO QID:PRN anxiety
4. Naltrexone 50 mg PO DAILY
5. ClonazePAM 0.5 mg PO TID
6. Mirtazapine 15 mg PO QHS
Discharge Medications:
1. Acetaminophen 1000 mg PO Q6H
Please limit to 4000mg in 24 hour period.
2. Gabapentin 600 mg PO TID
3. Heparin 5000 UNIT SC BID
may discontinue when ambulating frequently.
4. Lidocaine 5% Patch 1 PTCH TD QAM
Apply to affected area x 12 hours.
5. Metoprolol Tartrate 25 mg PO Q6H
hold for SBP <100, Or HR <55
6. Nitrofurantoin Monohyd (MacroBID) 100 mg PO BID
Last dose ___
7. OxyCODONE (Immediate Release) 7.5 mg PO Q4H
medication may cause drowsiness.
RX *oxycodone 5 mg 1.5 tablet(s) by mouth every four (4) hours
Disp #*25 Tablet Refills:*0
8. Polyethylene Glycol 17 g PO DAILY
Please hold for diarrhea or loose stool.
9. Senna 8.6 mg PO BID
Please hold for diarrhea or loose stool.
10. Thiamine 100 mg PO DAILY
11. Omeprazole 20 mg PO BID
12. Venlafaxine XR 225 mg PO DAILY
13. ClonazePAM 0.5 mg PO TID
Hold for RR <14
14. HydrOXYzine 25 mg PO QID:PRN anxiety
15. Mirtazapine 15 mg PO QHS
16. HELD- Naltrexone 50 mg PO DAILY This medication was held.
Do not restart Naltrexone until no longer taking opiod
medications.
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Traumatic thoracic aortic injury.
sternal fracture
Rib fractures
Pneumothorax
T2 vertebral body fracture
L4 Transverse process fracture
L sacral fracture
Urinary Tract Infection
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were admitted to ___ for
evaluation following a motor vehicle collision and were found to
have many injuries. You injuries included bilateral rib
fractures as well as sternal fractures and transverse process
fractures of the spine. You were therefore taken to the
operating room where you underwent stent placement in your
aorta. You are recovering well and are now ready for discharge.
Please follow the instructions below to continue your recovery:
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within ___ hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications, unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than ___ lbs until you follow-up with your
surgeon.
Avoid driving or operating heavy machinery while taking pain
medications.
Incision Care:
*Please call your doctor or nurse practitioner if you have
increased pain, swelling, redness, or drainage from the incision
site.
*Avoid swimming and baths until your follow-up appointment.
*You may shower, and wash surgical incisions with a mild soap
and warm water. Gently pat the area dry.
*If you have staples, they will be removed at your follow-up
appointment.
*If you have steri-strips, they will fall off on their own.
Please remove any remaining strips ___ days after surgery.
Rib Fractures:
* Your injury caused multiple rib fractures which can cause
severe pain and subsequently cause you to take shallow breaths
because of the pain.
* You should take your pain medication as directed to stay
ahead of the pain otherwise you won't be able to take deep
breaths. If the pain medication is too sedating take half the
dose and notify your physician.
* Pneumonia is a complication of rib fractures. In order to
decrease your risk you must use your incentive spirometer 4
times every hour while awake. This will help expand the small
airways in your lungs and assist in coughing up secretions that
pool in the lungs.
* You will be more comfortable if you use a cough pillow to
hold against your chest and guard your rib cage while coughing
and deep breathing.
* Symptomatic relief with ice packs or heating pads for short
periods may ease the pain.
* Narcotic pain medication can cause constipation therefore you
should take a stool softener twice daily and increase your fluid
and fiber intake if possible.
* Do NOT smoke
* If your doctor allows, non-steroidal ___ drugs
are very effective in controlling pain ( ie, Ibuprofen, Motrin,
Advil, Aleve, Naprosyn) but they have their own set of side
effects so make sure your doctor approves.
* Return to the Emergency Room right away for any acute
shortness of breath, increased pain or crackling sensation
around your ribs (crepitus).
Followup Instructions:
___
|
19692323-DS-20
| 19,692,323 | 23,031,002 |
DS
| 20 |
2175-10-09 00:00:00
|
2175-10-09 14:29:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
aspirin
Attending: ___.
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Patient is a ___ year old male from ___ with a complex
pulmonary history including pulmonary TB s/p treatment,
Aspergilloma s/p RUL resection (___) complicated by
bronchopleural fistula, bronchiectasis, recent positive
aspergillosis testing with voriconazole initiated and
questionable patient compliance, who presented to the ED via
ambulance from his PCPs office where he was found to have
worsening SOB, hypoxia to SPO2 90% on room air.
Regarding patient's recent pulmonary history, per most recent ID
note, patient was was noted to have increase size in his chronic
RUL cavitary lesion on chest CT in ___ for which he was
referred to IP and thoracics. Chest CT done in ___
demonstrated new areas of consolidation in his RUL cavity
concerning for recurrent aspergillosis. He underwent
bronchoscopy
with BAL on ___ with cultures isolating Pseudomonas and
Aspergillus. He was first evaluated in ___ clinic in ___ at
which point he endorsed chronic cough productive of yellowish
sputum since at least ___ with progressive symptoms over the
last 18 months. After his clinic visit ID reviewed patient's
imaging with radiology and, given persistent nodular changes,
worsening symptoms, intrcavitary debris seen on ___ CT, and
positive BAL culture the decision was made to initiate
voriconazole with D1 on ___ with 400 mg PO BID x1 day and
then 200 mg PO BID with weekly lab draws.
He followed with Infectious Disease in outpatient clinic ~ 3
weeks after initiation of therapy with minimal improvement in
symptoms and no adverse effects. He endorsed an ongoing cough
productive of pink colored phlegm, but otherwise denied fevers,
chills, night sweats, weight loss. He reported non-compliance
with mucinex and voriconazole for unclear reasons with
voriconazole levels subsequently checked and returning low at
<0.1. At that point Infectious Disease educated the patient on
the importance of continuing therapy and the fact that
symptomatic improvement can often take several weeks. He was
recommended to continue voriconazole for ~3 months and reassess
symptoms at that point, with close pulmonology follow up for
bronchiectasis. He was administered the flu shot and Prevnar
with
plan for follow up in ___.
On arrival to the ED, patient notes that he stopped taking his
voraconazole on ___ because he began having chills/night
sweats, worsening SOB that prohibited daily activities/walking
and felt he had developed pneumonia. He says that prior to this
point, he was taking his voriconazole twice daily (since his ID
appointment on ___.
In the ED, vitals were:
T 97.1 HR 86 BP 135/71 RR 32 SPO2 100% Non-Rebreather
Exam:
Pulmonary exam notable for crackles LLL, diminished breath
sounds
in the RUL
Labs:
CBC - Mild anemia with Hgb 10.7 (at baseline per review OMR)
BMP - Mild hyponatremia to Na 134
VBG (1) - PO2 19 PCO2 74 PH 7.28
VBG (2) - PO2 40 PCO2 62 PH 7.32 (After placed on 3L O2)
Flu - negative
Studies:
CXR:
IMPRESSION:
Postoperative changes on the right and findings compatible with
bronchiectasis. No definite new consolidation noting that subtle
changes could be missed.
They were given:
13:27IV CefTRIAXone1gm
14:26IV Azithromycin 500 mg
19:31PO/NGVoriconazole - Ordered but Not Given
On arrival to the floor, patient states he feels better after
initiation of oxygen. He states that he continues to have a
cough
productive of pink sputum. He notes that he has pain in the
lower
left chest, most prominent with movement (twisting). He is
concerned that he needs antibiotics to protect his left lung.
Patient denies recent travel (most recent travel to ___ in
___ with family traveling to ___ in ___. He denies sick
contacts/pets.
REVIEW OF SYSTEMS:
==================
Complete ROS obtained and is positive for frequency, dysuria.
Otherwise negative except as above.
Past Medical History:
PAST MEDICAL HISTORY:
# TB - s/p treatment in ___, s/p surgical resection ___
also s/p 6 months of INH @ ___ for +PPD
# Aspergilloma - s/p RU lung resection (___) and treatment with
voriconazole; complicated by pleurocutenaous fistula/empyema
with
redo right thoracotomy and flap closure (___)
# GERD
# Bronchiectasis
PAST SURGICAL HISTORY:
Surgical resection ___
RU lung resection (___) and treatment with voriconazole;
complicated by pleurocutenaous fistula/empyema with redo right
thoracotomy and flap closure (___)
Social History:
___
Family History:
No history of lung disease or infections in family.
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
VITALS: T 98.2 BP 122/73 HR 67RR 24 SPO2 100 on 3L O2
GENERAL:Cachectic gentleman lying in bed with nasal canula in
place in NAD.
HEENT: Blue discoloration of the sclera. Milky rings surrounding
___ bilaterally.
CARDIAC: RRR no M/R/G
LUNGS: Decreased breath sounds upper right lung fields. LLL with
crackles. No increased work of breathing.
ABDOMEN: Non tender, non distended, non tender to palpation in
all quadrants
EXTREMITIES: Clubbing of ___ digits of upper extremities. No
edema.
SKIN: Warm. Cap refill <2s. No rash.
NEUROLOGIC: AOx3. Moving all 4 limbs spontaneously.
DISCHARGE PHYSICAL EXAM:
24 HR Data (last updated ___ @ 1314)
Temp: 98.3 (Tm 98.3), BP: 139/78 (103-148/56-78), HR: 93
(62-107), RR: 18, O2 sat: 98% (95-98), O2 delivery: Ra
GENERAL:Cachectic gentleman sitting in chair
HEENT: Blue discoloration of the sclera. Milky rings surrounding
___ bilaterally.
CARDIAC: RRR no M/R/G
LUNGS: Decreased breath sounds upper right lung fields. LLL and
LML with mild crackles, improved from admission. Small volume
inspirations
ABDOMEN: Non tender, non distended, non tender to palpation in
all quadrants
BACK: winged scapula R side
EXTREMITIES: No edema.
SKIN: Warm. Cap refill <2s. No rash.
NEUROLOGIC: AOx3. Moving all 4 limbs spontaneously.
Pertinent Results:
ADMISSION LABS
===============================================
___ 11:40AM BLOOD WBC-5.3 RBC-4.47* Hgb-10.7* Hct-37.5*
MCV-84 MCH-23.9* MCHC-28.5* RDW-15.0 RDWSD-46.2 Plt ___
___ 11:40AM BLOOD Neuts-66.7 ___ Monos-8.8 Eos-3.4
Baso-0.8 Im ___ AbsNeut-3.55 AbsLymp-1.07* AbsMono-0.47
AbsEos-0.18 AbsBaso-0.04
___ 11:40AM BLOOD Glucose-112* UreaN-11 Creat-0.8 Na-134*
K-4.4 Cl-96 HCO3-28 AnGap-10
___ 11:40AM BLOOD Calcium-9.4 Phos-3.2 Mg-1.9
___ 11:40AM BLOOD proBNP-48
___ 11:40AM BLOOD cTropnT-<0.01
___ 05:42PM BLOOD cTropnT-<0.01
___ 07:02AM BLOOD IgG-___* IgA-357 IgM-76
___ 11:52AM BLOOD ___ pO2-19* pCO2-74* pH-7.28*
calTCO2-36* Base XS-3
___ 11:52AM BLOOD Lactate-1.2
PERTINENT STUDIES
======================
CHEST XRAY ___
FINDINGS:
Postoperative changes are noted on the right including a right
upper lobectomy
with volume loss and pleural thickening. Irregular opacities at
the right
lung base correspond to changes of bronchiectasis seen on prior
CT. Extensive
right middle lobe bronchiectasis is again noted. Pleural based
opacity
overlying the left upper lobe is seen as increased opacity seen
laterally on
today's film. No definite new consolidation. Cardiomediastinal
silhouette is
stable. Chronic changes of the right hemithorax again noted.
No acute
osseous abnormalities.
IMPRESSION:
Postoperative changes on the right and findings compatible with
bronchiectasis. No definite new consolidation noting that
subtle changes
could be missed.
CT CHEST WITH CONTRAST ___
FINDINGS:
NECK, THORACIC INLET, AXILLAE AND CHEST WALL:
The thyroid is unremarkable. No enlarged lymph nodes in the
either axilla or
thoracic inlet. Postsurgical appearance of resection of the
right anterior
chest wall, unchanged. No atherosclerotic calcifications in the
head and neck
arteries.
HEART AND VASCULATURE:
The heart is normal size and shape. Moderate atherosclerotic
calcifications
in the coronary arteries, none in the aorta or cardiac valves.
The pulmonary
arteries and aorta are normal caliber throughout.
MEDIASTINUM AND HILA:
The esophagus is unremarkable. Small mediastinal lymph nodes,
none
pathologically enlarged by CT size criteria, the largest in the
right upper
paratracheal station measuring up to 0.7 cm (302:70). No hilar
lymphadenopathy.
PLEURA:
No pleural effusions. Moderate apical scarring in the left.
LUNGS:
Status post right upper lobectomy with unremarkable bronchus
stump.
Redemonstration of a large cavity in the right apex, slightly
larger than
prior study, now containing semi liquid material. The middle
lobe is
collapsed around severe bronchiectasis. Redemonstration of
peripheral
bronchiectasis, some are larger than prior study, for example in
the right
lower lobe (302:181) with progressive wall thickening and
peribronchial
infiltration. Multiple other centrilobular nodules are noted,
more prominent
than in prior study, especially in the left lower lobe.
Peripheral confluent
small consolidations with ground-glass opacities (302:167, 198
and 210) are
larger.
___ be a small broncho pleural connection to the long-standing
large right
apical pleural air collection, 302:79.
CHEST CAGE:
Prior surgical resection of the right anterior third through
fifth ribs. No
acute fractures. No suspicious lytic sclerotic lesions.
UPPER ABDOMEN:
The limited sections of the upper abdomen show no significant
abnormal
findings.
IMPRESSION:
Findings consistent with active suppurative multifocal
bronchiectasis, worse
than in prior study, left greater than right, with an increase
in the size of
the bronchiectasis and in the extent of bronchogenic
dissemination of
infection to the left lung.
The large cavity to the right now shows new secretions and
larger size also, supporting evidence of active infection, as
well as possible small
bronchopleural connection, 302:79.
Differential diagnosis of infection includes virtually any
organism, including
bacteria, fungus, and both tuberculosis and non-tuberculous
mycobacteria.
MICRO
==========================================
___ 4:30 am SPUTUM Site: EXPECTORATED
Source: Expectorated.
REQUEST TO PROCESS CULTURE PER ___ ___ (___) ___
AT 11:30
AM. PLEASE WORK UP ANY GRAM NEGATIVE RODS, IF PRESENT.
GRAM STAIN (Final ___:
___ PMNs and >10 epithelial cells/100X field.
Gram stain indicates extensive contamination with upper
respiratory
secretions. Bacterial culture results are invalid.
PLEASE SUBMIT ANOTHER SPECIMEN.
RESPIRATORY CULTURE (Preliminary):
SPARSE GROWTH Commensal Respiratory Flora.
GRAM NEGATIVE ROD(S). SPARSE GROWTH.
FUNGAL CULTURE (Preliminary):
GRAM STAIN OF THIS SPECIMEN INDICATES CONTAMINATION WITH
OROPHARYNGEAL SECRETIONS AND INVALIDATES RESULTS.
Specimen is only screened for Cryptococcus species. New
specimen is
recommended.
___ 9:34 am SPUTUM Source: Expectorated.
GRAM STAIN, SPUTUM CULTURE, AND MTB DIRECT
AMPLIFICATION(GENEXPERT
MTB/RIF) ADDED ON PER ___. # ___ ___
@ 12:02.
GRAM STAIN (Final ___:
>25 PMNs and >10 epithelial cells/100X field.
Gram stain indicates extensive contamination with upper
respiratory
secretions. Bacterial culture results are invalid.
PLEASE SUBMIT ANOTHER SPECIMEN.
ACID FAST SMEAR (Final ___:
NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.
ACID FAST CULTURE (Preliminary):
RESPIRATORY CULTURE (Final ___:
TEST CANCELLED, PATIENT CREDITED.
MTB Direct Amplification (Preliminary):
Sent to State Lab for further testing ,___.
___ 5:58 am SPUTUM INDUCED RT.
ADDON GRAM STAIN, SPUTUM CULTURE, FUNGAL CULTURE AND MTB
DIRET
AMPLIFICATION PER ___ (___) ___.
GRAM STAIN (Final ___:
___ PMNs and >10 epithelial cells/100X field.
Gram stain indicates extensive contamination with upper
respiratory
secretions. Bacterial culture results are invalid.
PLEASE SUBMIT ANOTHER SPECIMEN.
RESPIRATORY CULTURE (Final ___:
TEST CANCELLED, PATIENT CREDITED.
ACID FAST SMEAR (Final ___:
NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.
ACID FAST CULTURE (Preliminary):
FUNGAL CULTURE (Preliminary):
MTB Direct Amplification (Final ___:
CANCELLED. PATIENT CREDITED.
Specimen received less than 7 days from previous
testing.
___ 11:53 am SPUTUM Source: Induced.
ACID FAST SMEAR (Pending):
ACID FAST CULTURE (Pending):
DISCHARGE LABS
==========================================
___ 07:43AM BLOOD WBC-5.0 RBC-4.18* Hgb-10.0* Hct-33.7*
MCV-81* MCH-23.9* MCHC-29.7* RDW-14.9 RDWSD-43.6 Plt ___
___ 07:43AM BLOOD Glucose-94 UreaN-21* Creat-0.7 Na-134*
K-4.8 Cl-94* HCO3-31 AnGap-9*
___ 07:43AM BLOOD Calcium-9.6 Phos-4.0 Mg-1.8
___ 07:51AM BLOOD ___ pO2-88 pCO2-51* pH-7.41
calTCO2-33* Base XS-5 Comment-PERIOHERAL
Brief Hospital Course:
SUMMARY STATEMENT:
====================
___ male with a history of pulmonary TB status post
treatment, aspergilloma with right upper lobe resection
complicated by bronchopleural fistula, bronchiectasis and with
recent positive aspergillosis and pseudomonas testing on
bronchoscopy ___ nonadherent with home voriconazole who
presented to the emergency department from primary care office
where he was found to have worsening shortness of breath and
hypoxia. It was determined that his symptoms were likely due to
bacterial pneumonia. Pulmonary team deferred bronchoscopy.
Sputum samples were sent for AFB smears and 2 out of 3 were
negative prior to discharge. He was treated with vancomycin,
ceftazidime and azithromycin. He was transitioned to
levofloxacin on discharge. Follow-up scheduled in ___ clinic 3
days from now, antifungal treatment was not initiated as an
inpatient.
The patient was extensively counseled on minimizing potential
exposures in the setting of a low concern for TB. He was
informed that he should wear an N95 mask when around any
children, in public, and to his infectious disease clinic
appointment on ___.
TRANSITIONAL ISSUES:
====================
[] Patient has follow-up scheduled in ___ clinic on ___.
Antifungal treatment was not initiated this admission.
[] Follow-up with pulmonology as an outpatient - scheduled for
___. Pulmonary consult recs included nebulized albuterol,
nebulized saline, Acapella device, and chest ___ which will have
to be set up as an outpatient.
[] Patient is discharged on a course of levofloxacin to be
completed ___ (7-day course)
[] Ferrous sulfate held in setting of infection. Please resume
as appropriate on follow-up.
[] Patient has 3 sputum AFBs smears, 1 of which is pending on
discharge. This should be followed up, until they are final the
patient was instructed to wear an N95 mask when around any
children, in public spaces, and to his infectious disease clinic
appointment on ___. There was overall very low suspicion for
TB by the primary, ID, and pulmonary teams.
ACTIVE ISSUES:
==============
#Community acquired pneumonia
#Pulmonary Aspergillosis
#Extensive bronchiectasis
Patient presented with dyspnea and hypoxia and worsening cough.
There was concern for new bacterial infection versus
recrudescence of aspergillosis in the setting of medication
nonadherence. He reported symptoms of visual changes and
worsening cough when he took voriconazole. He also noted pink
sputum with this medication. He had not taken it for several
days prior to presentation. CTA of the chest showed worsening
bronchiectasis and new secretions and larger sized cavity in the
right lung. Broad-spectrum antibiotics were initiated with
vancomycin, ceftazidime, azithromycin. Pulmonology and
infectious disease teams were consulted. Pulmonary team decided
to defer bronchoscopy at this time. Infectious disease team
recommended transitioning to levofloxacin to continue 7-day
course of antibiotics for suspected community acquired pneumonia
and following up in clinic as an outpatient to discuss treatment
of ongoing aspergillosis given history of medication
nonadherence. He underwent TB rule out due to CT findings
consistent with TB on the differential, although there was very
low suspicion for TB this admission due to no recent exposures
since testing negative for TB at ___ recently, and significant
clinical improvement with antibiotics. 2 smears returned
negative for AFB prior to discharge, with the third pending. He
was discharged home with instructions to wear an N95 mask around
any children, in public spaces, and to his infectious disease
clinic appointment on ___. He was scheduled for follow-up in
pulmonary clinic 2 weeks from now, where nebulizers and
additional pulmonary medications will be set up. During his
hospitalization, he also received supportive measures such as
nebs, chest ___, oxygen.
CHRONIC ISSUES:
===============
#GERD
Patient taking PPI in the past was not taking on admission.
Initiated pantoprazole once daily as it was thought that GERD
could be worsening bronchiectasis.
#Anemia
Held home ferrous sulfate due to active infection.
#Severe protein calorie malnutrition
Patient cachectic. Nutrition consulted, gave supplements and
vitamin.
#Dysuria
Patient complaining of dysuria and frequency, UA normal.
CONTACT:
Name of health care proxy: ___
Relationship: wife
Phone number: ___
CODE STATUS: full
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Ferrous Sulfate 325 mg PO BID
2. Voriconazole 200 mg PO Q12H
3. GuaiFENesin ER 1200 mg PO Q12H
4. Pantoprazole 40 mg PO DAILY:PRN acid reflux
Discharge Medications:
1. Levofloxacin 500 mg PO DAILY
RX *levofloxacin 500 mg 1 tablet(s) by mouth twice a day Disp
#*5 Tablet Refills:*0
2. GuaiFENesin ER 1200 mg PO Q12H
3. Pantoprazole 40 mg PO DAILY:PRN acid reflux
4. HELD- Ferrous Sulfate 325 mg PO BID This medication was
held. Do not restart Ferrous Sulfate until outpatient follow up
5. HELD- Voriconazole 200 mg PO Q12H This medication was held.
Do not restart Voriconazole until infectious disease clinic
appointment
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSES:
Community-acquired pneumonia
Aspergillosis
Bronchiectasis
Acute hypoxemic respiratory failure
SECONDARY DIAGNOSES:
GERD
Anemia
Severe malnutrition
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you at ___
___.
WHY WAS I ADMITTED TO THE HOSPITAL?
- You were admitted to the hospital because you had worsening
cough and shortness of breath.
WHAT HAPPENED WHILE I WAS IN THE HOSPITAL?
- In the hospital, it was determined that your symptoms were
likely due to a bacterial infection in your lung rather than
your prior fungal infection. You were treated with antibiotics
and your symptoms improved. You were discharged home.
WHAT SHOULD I DO WHEN I GO HOME?
- Please take all of your medications exactly as prescribed and
attend all of your follow-up appointments listed below.
- You have an infectious disease clinic appointment on ___,
___ where you will discuss treatment of your chronic fungal
lung infection.
- Your iron supplement was held due to concern that you have an
active infection. Please discuss whether you should resume this
medication at follow up.
- Until the results of your TB testing come back, please wear an
N95 mask around any children, when out in public, and to your
infectious disease clinic appointment.
We wish you the best!
Your ___ Care Team
Followup Instructions:
___
|
19692527-DS-10
| 19,692,527 | 29,445,116 |
DS
| 10 |
2176-09-30 00:00:00
|
2176-10-03 16:30:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins / amlodipine / benazepril
Attending: ___.
Chief Complaint:
Tachycardia
Major Surgical or Invasive Procedure:
Therapeutic paracentesis (6L removed) ___
History of Present Illness:
___ man with alcoholic cirrhosis (MELD 28) with h/o
intermittent atrial tachyarrythmia, likely AVNRT who was just
discharged ___ from ET service after his admission for
recurrent tachycardia ___ AVNRT prior to therapeutic
paracentesis who now represents for recurrent tachcyardia prior
to therapeutic paracentesis in ___ suite.
During prior admission he presented with lightheadedness and was
found to have HR 150s in ___ suite, EKG showing AVNRT. Labs
revealed leukocytosis without clear infectious cause (diag para
with 35 WBC, CXR w/small chronic left pleural effusion w/o e/o
pna, UA neg) and no fever. During admission his HRs improved to
the ___, EP evaluated patient and Metoprolol started.
He presents now again with recurrent tachyardia from ___ suite
prior to therapeutic paracentesis. Patient woke this morning and
felt palpatations and lightheadedness, took his pulse which was
130s. Took his AM metoprolol and HR improved somewhat so he
presented to ___ suite as routine. In the ___ suite found
tachycardic >130s so sent to the ED.
In the ED initial vitals were: ___ pain 98.0 68 99/64 18 100%
RA
- Labs were significant for Cr 1.3, diagnostic para negative for
SBP
- Patient was given Dilaudid
Vitals prior to transfer were: 98.0 76 101/56 16 100% ra
Past Medical History:
EtOH Cirrhosis c/b grade 1 varices, ascites, encephalopathy
Depression
Social History:
___
Family History:
No significant past medical history. No history of cirrhosis,
liver or gallbladder disease. Family has history of
hyperlipidemia.
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals - 98.1 104/59 71 18 100%RA W: 101.5kg
GENERAL: NAD, seated on edge of bed, appears well
HEENT: Icteric sclera, MMM
NECK: nontender supple neck, no LAD, no JVD
CARDIAC: RRR, S1/S2 clear and of good quality, soft systolic
murmur
LUNG: CTAB, reduced BS at bases L>R
ABDOMEN: Distended, but soft, +BS, nontender in all quadrants,
dull to persussion
EXTREMITIES: ___ bilateral ___
NEURO: CN II-XII intact, no asterixis
DISCHARGE PHYSICAL EXAM:
Vitals - 98.1 104/59 71 18 100%RA W: 101.5kg
GENERAL: NAD, seated on edge of bed, appears well
HEENT: Icteric sclera, MMM
NECK: nontender supple neck, no LAD, no JVD
CARDIAC: RRR, S1/S2 clear and of good quality, soft systolic
murmur
LUNG: CTAB, reduced BS at bases L>R
ABDOMEN: Distended, but soft, +BS, nontender in all quadrants,
dull to persussion
EXTREMITIES: ___ bilateral ___
NEURO: CN II-XII intact, no asterixis
Pertinent Results:
ADMISSION:
___ 12:06PM BLOOD WBC-14.1* RBC-2.55* Hgb-9.3* Hct-26.8*
MCV-105* MCH-36.4* MCHC-34.7 RDW-14.9 Plt Ct-82*
___ 12:06PM BLOOD Neuts-83.4* Lymphs-10.2* Monos-4.4
Eos-1.7 Baso-0.3
___ 12:23PM BLOOD ___ PTT-31.7 ___
___ 12:06PM BLOOD Glucose-142* UreaN-22* Creat-1.3* Na-134
K-4.5 Cl-98 HCO3-24 AnGap-17
___ 12:06PM BLOOD ALT-35 AST-70* AlkPhos-91 TotBili-15.4*
___ 12:06PM BLOOD Lipase-84*
___ 12:06PM BLOOD Albumin-3.6 Calcium-9.5 Phos-4.0 Mg-2.3
CXR ___
IMPRESSION:
Persistent small left effusion and left basilar atelectasis.
EKG ___
Sinus rhythm. Baseline artifact obscures lead I. Reverse R wave
progression
from leads V2-V3 of uncertain significance. Question chest wall
configuration.
Compared to the previous tracing of ___ pattern is similar
Brief Hospital Course:
___ man with alcoholic cirrhosis (MELD 27) with h/o
intermittent atrial tachyarrythmia just discharged ___ for
tachycardia in setting of planned therapeutic paracentesis now
admitted for recurrent tachycardia likely recurrent AVNRT now
resolved consistent with prior admission.
ACTIVE ISSUES:
# Tachycardia: Diagnosis of AVNRT per documentation and prior EP
consultation. Started on Metoprolol during previous admission.
Intermittent and resolved prior to admission. Currently in SR in
the ___. Possibly triggered somewhat by dehydration as patient
with hyaline casts and Cr bump vs previous baseline. Also,
patient's symptoms occurred right before scheduled to take AM
dose of Metoprolol Succinate and while normally it is a once
daily medicine, he may benefit from some ___ dosing as well to
maintain levels. Limited increase possible due to HR 60-70s
while in sinus and soft BPs. Switched to Metoprolol 50mg XL AM
and 25mg ___. Rescheduled EP follow up with Dr. ___ need
EP study for definitive treatment
# Leukocytosis: WBC 14 on admission, 15 during prior admission.
UA negative, SBP ruled out, CXR unchanged from prior. No
localizing symptoms to suggest infection. Blood cultures
negative.
# Acute Renal Failure: Likely pre-renal, potentially from large
ascites, Cr 1.3 on admission from baseline 1.1. Albumin with
large volume paracentesis
# Cirrhosis: Chronic alcohol related cirrhosis, complicated by
grade I varices, HE, portal hypertension, diuretic refractory
ascites and prior SBP MELD 27 on admission, currently on
transplant list. Continue Cipro ppx, Lactulose and Rifaximin. No
need for Nadolol given Grade 1 Varices.
TRANSITIONAL ISSUES:
- Started Metop Succinate 25mg at night in addition to 50mg in
morning. This is because episode happened at 7am, which
potentially represents time when level of drug is low (just
prior to dose)
- F/u with Cardiology
- F/u in liver clinic as previously scheduled
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. FoLIC Acid 1 mg PO DAILY
2. Gabapentin 300 mg PO QPM
3. Lactulose 15 mL PO TID
4. Multivitamins W/minerals 1 TAB PO DAILY
5. Omeprazole 20 mg PO DAILY
6. Ondansetron 4 mg PO Q8H:PRN nausea
7. OxycoDONE (Immediate Release) 5 mg PO Q12H:PRN pain
8. Rifaximin 550 mg PO BID
9. Simethicone 80 mg PO TID:PRN bloating
10. Thiamine 100 mg PO DAILY
11. Vitamin D 50,000 UNIT PO 1X/WEEK (WE)
12. Metoprolol Succinate XL 50 mg PO DAILY
13. Ciprofloxacin HCl 250 mg PO Q24H
14. Gabapentin 600 mg PO QAM
Discharge Medications:
1. Ciprofloxacin HCl 250 mg PO Q24H
2. FoLIC Acid 1 mg PO DAILY
3. Gabapentin 300 mg PO QPM
4. Gabapentin 600 mg PO QAM
5. Lactulose 15 mL PO TID
6. Multivitamins W/minerals 1 TAB PO DAILY
7. Omeprazole 20 mg PO DAILY
8. Ondansetron 4 mg PO Q8H:PRN nausea
9. OxycoDONE (Immediate Release) 5 mg PO Q12H:PRN pain
10. Rifaximin 550 mg PO BID
11. Simethicone 80 mg PO TID:PRN bloating
12. Thiamine 100 mg PO DAILY
13. Vitamin D 50,000 UNIT PO 1X/WEEK (WE)
14. Metoprolol Succinate XL 50 mg PO DAILY
15. Metoprolol Succinate XL 25 mg PO QPM
RX *metoprolol succinate 25 mg ___ tablet(s) by mouth Twice a
day Disp #*90 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: AVNRT
Secondary: Cirrhosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were admitted due to a very fast heart rate which you have
had before. This resolved when you were admitted and their was
no infection found to be responsible for this. We think it would
be best to have some Metoprolol Succinate (heart medication) in
the morning and the night to prevent this from occurring in the
morning.
We also asked the radiologists to remove some of the fluid in
your belly and they took out 6 liters. Please make sure to
follow up with the liver team and cardiology.
Followup Instructions:
___
|
19692527-DS-13
| 19,692,527 | 22,803,586 |
DS
| 13 |
2176-11-13 00:00:00
|
2176-11-13 20:07:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins / amlodipine / benazepril
Attending: ___
Chief Complaint:
BRBPR, Abdominal Pain
Major Surgical or Invasive Procedure:
___ colonoscopy
History of Present Illness:
___ yoM with PMH significant for alcohol cirrhosis (Child's ___
class C, baseline MELD 27, c/b refractory ascites, jaundice,
SBP), and h/o diverticulitis s/p partial colectomy, who presents
w/ RUQ pain and BRBPR. The patient had one BM at 3AM today with
BPBPR mixed with brown stool. This was followed by ___ episodes
of BPBPR without stool. The patient estimates ___ cup of blood.
He reported feeling lightheaded and dizzy, but no syncope. He
also complained of RUQ that began today. He states it is from
his liver stretching out. The pain is mostly sharp, but dull at
times as well. It radiates to the epigastric area. He had a
paracentesis on ___. He states he usually has RUQ pain on day
___ after a paracentesis. He takes oxycodone for pain. His
current pain is similar but more severe. The patient also
describes feeling slower, almost intoxicated, over the past few
days. He has been compliant with lactulose and rifaximin, with
___ BMs per day. He has occasional vomiting, and had one episode
of non-bloody, nonbilious vomiting today.
The patient was recently admitted on ___ for abdominal pain
and hematemsis in the setting of a viral illness, thought to be
___ tear s/p EGD ___ which showed grade I varices
and portal hypertensive gastropathy. Also is s/p para as an
outpt on ___.
In the ED, initial vitals were 99.4 70 112/55 18 100% RA.
- Labs notable for H/H 8.9/25.9 (7.7/22.1 on ___, plts 83, INR
2.2, normal chem7 (BUN 17), LFTs at baseline, neg UA, and a
normal lactate.
- CXR wnl, RUQ w/ cholelisthiasis and a cirrhotic liver w/
ascites.
- Given Dilaudid, Zofran, Pantoprazole.
- Seen by Hepatology who recommended PIV x2, TnS, PPI BID, and
blood/urine cxs.
On transfer, vitals were 69 122/62 16 100% RA.
Past Medical History:
- EtOH Cirrhosis c/b grade 1 varices, refractory ascites,
encephalopathy, SBP
- AVNRT (on metoprolol)
- Depression
- H/o diverticulitis s/p partial colectomy (at ___)
Social History:
___
Family History:
No significant past medical history. No history of cirrhosis,
liver or gallbladder disease. Family has history of
hyperlipidemia.
Physical Exam:
ADMISSION
VS: T98 93/53 (93-140 96 (72-96)16 96%
General: Sitting in bed, well appearing.
HEENT: Atraumatic. + Scleral icterus. Oropharynx clear.
Neck: Supple, no lymphadenopathy, no JVD,
CV: RRR, normal S1, S2. No murmurs, S3, S4.
Lungs: Clear to auscultation bilaterally. No wheezes, crackles,
or rhonchi.
Abdomen: Midline scar. +BS, distended. Tender to palpation in
RUQ and epigastric region without rebound or guarding.
GU: No foley.
Ext: Warm and well perfused. Pulses 2+. Trace pitting edema
(improved per patient).
Neuro: CN II-XII grossly intact.
Skin: No rash, excoriations, bruising.
======================================
DISCHARGE
PHYSICAL EXAM:
VS: T 979 (Tm 99.2) 120/62 (116-133) 83 (82-89) 18 99%RA
is/os 1220/BR
Wt 102.2 (___)
TELE: no events
General: sitting on side of bed, comfortable appearing.
HEENT: Atraumatic. + Scleral icterus. Oropharynx clear, MMM.
Neck: Supple, no JVD,
CV: RRR, normal S1, S2. No murmurs, S3, S4.
Lungs: Clear to auscultation bilaterally. No wheezes, crackles,
or rhonchi.
Abdomen: Less protuberant compared to prior, Midline scar lower
abdominal, well healed. +BS, distended. non tender to palpation,
without rebound or guarding.
Back: Tender to palpation left rib/flank area, no overlying
ecchymoses, no CVA tenderness
Ext: Warm and well perfused. Pulses 2+. 1+ pitting edema worse
on left foot. bandage over leftdorsum of foot c/d/i
Neuro: CN II-XII grossly intact. moving all extremities
spontaneously
Skin: No rash, jaundiced.
Pertinent Results:
INITIAL LABS:
___ 04:36PM PLT COUNT-83*
___ 04:36PM NEUTS-76.3* LYMPHS-14.4* MONOS-6.7 EOS-2.2
BASOS-0.3
___ 04:36PM WBC-8.2 RBC-2.60* HGB-8.9* HCT-25.9* MCV-100*
MCH-34.4* MCHC-34.5 RDW-16.3*
___ 04:36PM LIPASE-76*
___ 04:36PM LIPASE-76*
___ 04:36PM ALT(SGPT)-31 AST(SGOT)-57* ALK PHOS-113 TOT
BILI-9.9*
___ 04:36PM GLUCOSE-98 UREA N-17 CREAT-1.1 SODIUM-135
POTASSIUM-4.0 CHLORIDE-98 TOTAL CO2-26 ANION GAP-15
___ 04:42PM LACTATE-1.7
___ 04:47PM URINE MUCOUS-RARE
___ 04:47PM URINE HYALINE-13*
___ 04:47PM URINE RBC-1 WBC-1 BACTERIA-FEW YEAST-NONE
EPI-<1
___ 04:47PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-4* PH-5.5
LEUK-NEG
___ 04:47PM URINE COLOR-Amber APPEAR-Hazy SP ___
___ 04:47PM URINE GR HOLD-HOLD
___ 04:47PM URINE UHOLD-HOLD
___ 04:47PM URINE HOURS-RANDOM
___ 04:47PM URINE HOURS-RANDOM
___ 07:24PM ___ PTT-43.9* ___
___ 09:15PM PLT COUNT-72*
___ 09:15PM WBC-7.3 RBC-2.44* HGB-8.3* HCT-24.2* MCV-99*
MCH-34.1* MCHC-34.4 RDW-16.2*
DISCHARGE LABS:
___ 05:40AM BLOOD WBC-4.3 RBC-2.41* Hgb-8.3* Hct-23.6*
MCV-98 MCH-34.5* MCHC-35.2* RDW-15.7* Plt Ct-64*
___ 08:00AM BLOOD WBC-3.9* RBC-2.17* Hgb-7.2* Hct-21.5*
MCV-99* MCH-33.3* MCHC-33.6 RDW-15.3 Plt Ct-55*
___ 08:20AM BLOOD WBC-4.6 RBC-2.16* Hgb-7.5* Hct-21.5*
MCV-99* MCH-34.7* MCHC-34.9 RDW-15.2 Plt Ct-52*
___ 05:40AM BLOOD Plt Ct-64*
___ 05:40AM BLOOD ___ PTT-55.1* ___
___ 11:00AM BLOOD ___ PTT-61.7* ___
___ 08:00AM BLOOD Plt Ct-55*
___ 05:40AM BLOOD Glucose-98 UreaN-24* Creat-1.2 Na-134
K-3.8 Cl-100 HCO3-25 AnGap-13
___ 08:00AM BLOOD Glucose-85 UreaN-24* Creat-1.1 Na-134
K-4.1 Cl-101 HCO3-26 AnGap-11
___ 08:20AM BLOOD Glucose-99 UreaN-23* Creat-1.2 Na-134
K-4.0 Cl-98 HCO3-27 AnGap-13
___ 05:40AM BLOOD ALT-23 AST-51* AlkPhos-83 TotBili-11.7*
___ 08:00AM BLOOD ALT-30 AST-50* AlkPhos-86 TotBili-9.3*
___ 08:20AM BLOOD ALT-30 AST-52* AlkPhos-81 TotBili-10.2*
___ 05:40AM BLOOD Albumin-3.5 Calcium-9.2 Phos-3.0 Mg-2.1
___ 08:00AM BLOOD Albumin-3.3* Calcium-9.4 Phos-3.2 Mg-2.0
___ 08:20AM BLOOD Albumin-3.5 Calcium-9.5 Phos-3.1 Mg-2.1
============================================================
___
RIB SERIES
IMPRESSION:
Linear opacities in the left lower lobe are most likely
consistent with
atelectasis. No definitive rib fracture demonstrated. No
pneumothorax is
seen. Minimal amount of pleural effusion cannot be excluded.
Lungs are
otherwise clear and there is no right hemi thorax abnormality
demonstrated
___ CT HEAD
No acute intracranial hemorrhage identified. Extensive sinus
disease
involving the right maxillary sinus.
___ ECG
Sinus rhythm. Intraventricular conduction delay. Possible prior
lateral
myocardial infarction. No major change from previous tracing.
___ PARACENTESIS
IMPRESSION:
Successful diagnostic and therapeutic ultrasound-guided
paracentesis, yielding
6 L of clear yellow fluid.
___ CXR Small left pleural effusion.
___ RUQ US
1. Cirrhotic liver with signs of portal hypertension including
splenomegaly
and moderate amount of ascites.
2. Cholelithiasis. Similar gallbladder wall thickening is
nonspecific and may be due to chronic liver disease/ascites.
=======================================================
___
colonoscopy
Normal mucosa in the colon and 10cm into the terminal ileum
Diverticulosis of the sigmoid colon
Otherwise normal sigmoidoscopy to cecum and 10cm into the
terminal ileum
Brief Hospital Course:
___ h/o alcohol cirrhosis (Child's ___ class C, baseline MELD
27, c/b refractory ascites, jaundice, SBP) who presented with
RUQ pain and BRBPR, resolved but found to have ___
___ hospital course complicated by fall.
# Bacteroides bacteremia- Found to be bacteremic in admission
blood culture from ___, cefepime since ___, Patient was
clinically well-appearing and afebrile without leukocytosis or
localizing signs throughout entire course. Patient transitioned
to metronidazole once speciated to complete a 14-day course
# Non-immune hemolytic anemia. Patient has a history of
hemolytic anemia. Hematology was consulted during this
admission and diagnosed patient with spur cell hemolytic anemia
secondary to end stage liver disease. Patient received 1 unit
pRBCs and started on high-dose folic acid at 4mg daily per heme
recommendations. He continues to be on liver transplant list
# Rectal Bleeding. Patient presented with BRBPR. Colonoscopy
did not reveal clear cause though poor prep. He was continued
on omeprazole 20 mg PO DAILY
# EtOH Cirrhosis: Patient has EtOH cirrhosis C/b refractory
ascites, esophageal varices, h/o SBP and encephalopathy. MELD
26, which is stable. Cipro 250 mg restarted once transitioned
off cefepime. Patient was continued on Rifaximin and lactulose,
thiamine, and folate. Patient was due for scheduled therapeutic
paracentesis on ___, but done ___ prior to discharge.
# H/O AVNRT: HR was stable. Metoprolol held during this
admission due to infection restarted on discharge.
#Fall: Patient fell face down with head strike as he stood up
___ morning to go to the bathroom. He reported feeling
light headed. EKG without any changes, HR stable, CT head
negative. Patient was not orthostatic. Patient complained of
pain from left chest wall strike. left rib series was negative.
thought to be vasovagal.
#CODE: Full (confirmed)
#CONTACT: Patient, Sister/HCP ___ ___, ___ (___)
___.
Transitional Issues
- NEW medications: folic acid 4mg daily for hemolytic anemia
- Last day of antibiotics (metronidazole) ___
- Cultures from last paracentesis were pending at discharge
-Patients cardiology appointment was changed as he was scheduled
to see cardiology during this admission. He will be called with
his new appointment.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Ondansetron 4 mg PO Q8H:PRN nausea
2. Lactulose 15 mL PO TID
3. Simethicone 80 mg PO TID:PRN gas/bloating
4. Metoprolol Succinate XL 25 mg PO QPM
5. Metoprolol Succinate XL 50 mg PO QAM
6. OxycoDONE (Immediate Release) 5 mg PO Q12H:PRN pain
7. Omeprazole 20 mg PO DAILY
8. Ciprofloxacin HCl 250 mg PO Q24H
9. Rifaximin 550 mg PO BID
10. FoLIC Acid 1 mg PO DAILY
11. Thiamine 100 mg PO DAILY
12. Vitamin D 50,000 UNIT PO 1X/WEEK (WE)
Discharge Medications:
1. FoLIC Acid 4 mg PO DAILY
RX *folic acid 1 mg 4 tablet(s) by mouth daily Disp #*28 Tablet
Refills:*0
2. Lactulose 15 mL PO TID
RX *lactulose 10 gram/15 mL 15 mL by mouth three times a day
Refills:*0
3. Omeprazole 20 mg PO DAILY
RX *omeprazole 20 mg 1 capsule(s) by mouth daily Disp #*7
Capsule Refills:*0
4. Ondansetron 4 mg PO Q8H:PRN nausea
RX *ondansetron 4 mg 1 tablet(s) by mouth Q8H:PRN Disp #*8
Tablet Refills:*0
5. OxycoDONE (Immediate Release) 5 mg PO Q12H:PRN pain
RX *oxycodone 5 mg 1 capsule(s) by mouth Q12H:PRN Disp #*10
Capsule Refills:*0
6. Rifaximin 550 mg PO BID
RX *rifaximin [Xifaxan] 550 mg 1 tablet(s) by mouth twice a day
Disp #*14 Tablet Refills:*0
7. Simethicone 80 mg PO TID:PRN gas/bloating
RX *simethicone 80 mg 1 tab by mouth TID:PRN Disp #*10 Tablet
Refills:*0
8. Thiamine 100 mg PO DAILY
RX *thiamine HCl 100 mg 1 tablet(s) by mouth daily Disp #*7
Tablet Refills:*0
9. Vitamin D 50,000 UNIT PO 1X/WEEK (WE)
RX *ergocalciferol (vitamin D2) [Vitamin D2] 50,000 unit 1
capsule(s) by mouth weekly Disp #*1 Capsule Refills:*0
10. Ciprofloxacin HCl 250 mg PO Q24H
RX *ciprofloxacin HCl [Cipro] 250 mg 1 tablet(s) by mouth daily
Disp #*7 Tablet Refills:*0
11. MetRONIDAZOLE (FLagyl) 500 mg PO Q8H
RX *metronidazole [Flagyl] 500 mg 1 tablet(s) by mouth every
eight (8) hours Disp #*25 Tablet Refills:*0
12. Metoprolol Succinate XL 25 mg PO QPM
RX *metoprolol succinate 25 mg 1 tablet(s) by mouth QPM Disp #*7
Tablet Refills:*0
13. Metoprolol Succinate XL 50 mg PO QAM
RX *metoprolol succinate 50 mg 1 tablet(s) by mouth QAM Disp #*7
Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Non-immune hemolytic anemia
Bacteremia
Secondary:
Alcoholic cirrhosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were admitted to the hospital because of bleeding from your
rectum. You had a colonoscopy that did not show bleeding in your
colon. You received a blood transfusion for low blood counts
(anemia). The hematology team who specializes in blood disorders
saw you, and you have a type of anemia from your liver disease
that causes breakup of the red blood cells. The only way to cure
this is with liver transplantation. We also started you on
high-dose folic acid to help your bones make more red blood
cells. Additionally you had a paracentesis here on ___.
Your blood cultures from admission grew bacteria. This was
likely from leakage of bacteria from your bowels into your
bloodstream.
Please take your medications as listed and follow-up with your
doctors ___. It is also important to get your labs checked on
___ and have them faxed to the ___ at ___.
We wish you the best.
-Your ___ care team-
Followup Instructions:
___
|
19692527-DS-15
| 19,692,527 | 20,301,503 |
DS
| 15 |
2176-11-28 00:00:00
|
2176-11-29 11:54:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins / amlodipine / benazepril
Attending: ___.
Chief Complaint:
Acute renal failure
Major Surgical or Invasive Procedure:
Right heart catheterization ___
Paracentesis on ___ (3.8L removed)
History of Present Illness:
This is a ___ with a PMHx of EtOH cirrhosis (MELD 26, Child C,
c/b diuretic refractory ascites, prior SBP, HE, on the
transplant list) who presented to to the ED for a newly elevated
creatinine. He was admitted from with rectal bleeding, no source
found, and also treated with 14-days metronidazole for B.
fragilis bacteremia. he was admitted again from after a fall
with fib fractures. He has weekly paracenteses for ascites
because each time he was placed on diuretics he developed renal
failure and hyponatremia. However, upon discharge during his
most recent admission he was restarted on lasix 40mg daily for
leg edema. He was seen in clinic for follow-up on ___ where most
recent labs showed Cr 1.2 (from ___. Lasix was discontinued,
and repeat labs showed a Cr elevated to 1.7, so he was referred
to the ED.
Patient reports increased swelling in the lower extremities and
scrotum. Otherwise, denies fever/chills, abdominal pain, nausea,
vomiting or confusion. No blood in stools.
In the ED,
- Initial VS: T 98.0 HR 53 BP 107/36 RR 18 SaO2 100% RA
- Labs were notable for Cr 1.9, Na+ 131, K+ 5.7, phos 6.5, TBili
9.2, H/H 9.6/28.6, Plt 91, INR 2.4
- Scrotal US showed massive scrotal edema
- RUQ US showed patent portal vein and small volume ascites
- He was given 100g albumin
- Diagnostic paracentesis was unable to be performed because of
the small volume asites
- He remained in the ED for most of ___. Repeat labs were
notable for K+ of 6.6. He had peaked T waves on ECG; he received
calcium gluconate, insulin/dextrose, and kayexalate; repeat K+
was 5.8. Renal was consulted for ARF and hyperkalemia, formal
recommendations will be given in the morning.
- On ___ evening he received another 100g albumin and repeat Cr
was 1.8.
- Of note he had hypoglycemia to the ___, q1h fingersticks
improved.
- VS prior to transfer were: R 98 HR 69 BP 123/56 RR 20 SaO2
100% RA
On the floor, he is very fatigued. He complains of residual rib
soreness after fall last month and leg edema.
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:
EtOH Cirrhosis c/b grade 1 varices, diuretic-refractory
ascites,
encephalopathy, SBP
- AVNRT (on metoprolol)
- Non-immune hemolytic anemia
- Depression
- H/o diverticulitis s/p partial colectomy
Social History:
___
Family History:
No significant past medical history. No history of cirrhosis,
liver or gallbladder disease. Family has history of
hyperlipidemia.
Physical Exam:
PHYSICAL EXAM ON ADMISSION:
====================
itals: T 98.2 BP 113/60 HR 65 RR 18 SaO2 100% on RA
GENERAL: NAD, lying flat in bed
HEENT: AT/NC, EOMI, PERRL, icteric 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: sightly distended but soft, nontender, normoactive
bowel sounds, no fluid wave, no HSM appreciated
EXTREMITIES: no cyanosis or clubbing, 2+ pitting edmea of lower
extremities to sacrum, moving all 4 extremities with purpose
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact, no asterixis, says days of week
backwards
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
PHYSICAL EXAM ON DISCHARGE:
====================
Vitals: 98.4. BP 106/61, HR 61, RR 18, 98% RA
GENERAL: NAD
HEENT: AT/NC, EOMI, PERRL, icteric sclera, pink conjunctiva,
MMM, good dentition
NECK: nontender supple neck, no LAD
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs
LUNG: clear to auscultation bilaterally
ABDOMEN: sightly distended but soft, mild tenderness to
palpation in RUQ no rebound or guarding, normoactive bowel
sounds, +flank dullness but no fluid wave
EXTREMITIES: no cyanosis or clubbing, ___ pitting edema of
lower extremities to sacrum, moving all 4 extremities with
purpose
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact, no asterixis, says days of week
backwards
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
Pertinent Results:
LABS ON ADMISSION:
==============
___ 01:17AM BLOOD WBC-4.8 RBC-2.12* Hgb-7.2* Hct-21.0*
MCV-99* MCH-33.8* MCHC-34.2 RDW-14.6 Plt Ct-53*
___ 03:16PM BLOOD UreaN-47* Creat-1.7* Na-134 K-5.6* Cl-98
HCO3-25 AnGap-17
___ 01:17AM BLOOD ALT-23 AST-44* AlkPhos-72 TotBili-9.4*
___ 01:17AM BLOOD Albumin-4.8 Calcium-10.4* Phos-6.0*
Mg-2.1
LABS ON DISCHARGE:
==============
___ 07:15AM BLOOD WBC-4.6 RBC-2.41* Hgb-8.1* Hct-23.3*
MCV-96 MCH-33.5* MCHC-34.7 RDW-17.0* Plt Ct-58*
___ 07:15AM BLOOD Glucose-89 UreaN-44* Creat-1.2 Na-132*
K-4.5 Cl-102 HCO3-25 AnGap-10
___ 07:15AM BLOOD ALT-20 AST-38 AlkPhos-68 TotBili-12.8*
___ 07:15AM BLOOD Calcium-9.8 Phos-3.7 Mg-2.1
STUDIES:
======
Renal US ___:
IMPRESSION:
1. Bilateral simple renal cysts, without hydronephrosis, stone,
or mass.
2. Small amount of ascites.
3. Cirrhotic liver.
R. SIDED CARDIAC CATHETERIZATION:
==================================
elevated PCWP ~ 28
Normal PA pressure
final results pending at time of discharge
Brief Hospital Course:
This is a ___ with a PMHx of EtOH cirrhosis (MELD 26, Child C,
c/b diuretic refractory ascites, prior SBP, HE, on hold on the
transplant list) who is being admitted with acute renal failure
complicated by hyperkalemia.
# Acute Renal Failure
Patient with acute renal failure in the setting of volume
depletion and recent initiation of furosemide. Urine
electrolytes show FeNa <1% consistent with pre-renal process in
setting of recent lasix use. Urine sediment without evidence of
ATN which was reassuring. Patient was given a total of 100 grams
X 3 of albumin challenge with improvement of creatinine near
baseline. All medications were renaly dosed. All diuretics were
stopped this hospital course and it was recommended that they do
not be restarted in the future.
# Hyperkalemia
His severe hyperkalemia was felt to be due to his hemolytic
anemia in combination to reduced GFR and improved as hemolysis
decreased and renal function improved. He was educated about low
potasssium diet. While in the hospital he required kayexylate,
insulin, dextrose, and calcium gluconate. His potassium was
within normal range in the 24 hours prior to discharge. Adrenal
insufficiency also ruled out with normal cortisol stim test.
Patient with plan for repeat labs every ___ days to make sure
potassium remains stable.
#RV dilation on echocardiogram
Patient with hyperdynamic EF and RV dilation on echo in ___.
Cardiology consult obtained that felt that right heart cath was
indicated to rule out elevated right sided pressures. Cardiac
catheterization completed with elevated wedge pressure though no
evidence of right heart failure with final report pending at
time of discharge. Given extensive discussion over mild RV
dilation listed on previous echo it was felt that cardiac MRI
should be pursued as an outpatient by the hepatology team so
that mention of RV dilation on echocardiogram would not preclude
patient from being listed on the transplant list though
caridology did not feel that a cardiac MRI was indicated. The
patient will follow up with Dr. ___ Cardiology in clinic.
Final right heart cath report should be followed up.
# EtOH Cirrhosis
MELD 31 at time of admission with baseline is 26, Child C, not
on the transplant list secondary to RV dilation noted on echo.
Cirrhosis has been complicated by diuretic refractory ascites
(develops hyponatremia and ___ for which he has weekly
paracenteses, hepatic encephalopathy controlled on
lactulose/rifaximin, non-immune hemolytic anemia, and varices
(not large enough to band). The patient was not continued on
further diuretics given diuretic refractory ascites and ___ that
developed in setting of diuretic use warranting this
hospitalization. Ciprofloxacin was continued for SBP
prophylaxis. Paracentesis was completed on ___ where 3.8 L
of ascitic fluid were removed and patient was given 25 grams of
albumin post-procedure. Lactulose and rifaxamin were continued.
The patient was not encephalopathic during this hospital course.
# Non-immune hemolytic anemia
Patient with known spur-cell hemolytic anemia secondary to end
stage liver disease. During his hospital course he required a
total of 2 units of packed RBC's. CT abdomen was also done to
rule out retroperitoneal hematoma as cause of anemia.
Hyperkalemia was thought to be secondary to non-immune hemolytic
anemia.
# AVNRT
- Continued metoprolol
TRANSITIONAL ISSUES:
==============
-labs including CBC, chem-7, and LFT's should be drawn in ___
days
-patient should not have lasix or other diuretics in the future
-will follow up with cardiology at least once more
-final right heart cardiac catheterization report should be
followed up
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Ciprofloxacin HCl 250 mg PO Q24H
2. FoLIC Acid 4 mg PO DAILY
3. Lactulose 15 mL PO TID
4. Metoprolol Succinate XL 25 mg PO QPM
5. Metoprolol Succinate XL 50 mg PO QAM
6. Omeprazole 20 mg PO DAILY
7. Ondansetron 4 mg PO Q8H:PRN nausea
8. OxycoDONE (Immediate Release) 5 mg PO Q12H:PRN pain
9. Rifaximin 550 mg PO BID
10. Simethicone 80 mg PO TID:PRN gas/bloating
11. Thiamine 100 mg PO DAILY
12. Vitamin D 50,000 UNIT PO 1X/WEEK (WE)
13. Fluticasone Propionate NASAL 1 SPRY NU BID
14. Furosemide 40 mg PO DAILY
Discharge Medications:
1. Ciprofloxacin HCl 250 mg PO Q24H
2. Fluticasone Propionate NASAL 1 SPRY NU BID
3. FoLIC Acid 4 mg PO DAILY
4. Lactulose 15 mL PO TID
5. Metoprolol Succinate XL 25 mg PO QPM
6. Omeprazole 20 mg PO DAILY
7. OxycoDONE (Immediate Release) 5 mg PO Q12H:PRN pain
8. Metoprolol Succinate XL 50 mg PO QAM
9. Ondansetron 4 mg PO Q8H:PRN nausea
10. Rifaximin 550 mg PO BID
11. Thiamine 100 mg PO DAILY
12. Simethicone 80 mg PO TID:PRN gas/bloating
13. Vitamin D 50,000 UNIT PO 1X/WEEK (WE)
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Acute Kidney Injury
Spur cell hemolytic anemia
Right ventricular dilation
Hyperkalemia
Secondary:
EtOH Cirrhosis
AVNRT
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 Mr ___,
You were admitted to the hospital because of acute kidney
dysfunction thought to be secondary to lasix. Lasix was held and
you were given albumin with improvement of your kidney function.
You had dangerously high potassium levels because of the break
down of your blood from your "spur cell hemolytic anemia". This
improved before discharge. It was a pleasure being involved in
your care. It is very important that you have your labs checked
in 3 days to make sure everything is stable.
While you were here the cardiologists did a test called a
cardiac catheterization to measure the pressures in your heart
which were suggestive of extra fluid in your body but normal
heart function. You should follow up as listed below with Dr.
___ cardiologist, as part of your transplant work up.
Sincerely,
YOUR ___ TEAM
Followup Instructions:
___
|
19692527-DS-6
| 19,692,527 | 22,648,998 |
DS
| 6 |
2176-08-31 00:00:00
|
2176-09-02 17:00:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins / amlodipine / benazepril
Attending: ___
Chief Complaint:
weight gain/acites
Major Surgical or Invasive Procedure:
Paracentesis with 3.6L removed ___
History of Present Illness:
___ with cirrhosis due to alcohol, recent MELD scores ___,
decompensated with jaundice, ascites, grade 1 esophageal
varices, and history of encephalopathy, referred from clinic to
ED with abdominal distention and weight gain. He is on the liver
transplant list. He is Child's ___ class C and today's MELD
score is 27.
He had labs performed last week which showed ___ 128 and Cr 1.2
from 1.0. Dr. ___ him to stop his furosemide and
spironolactone. Over the past week, he has had a 15-lb weight
gain. He feels dehydrated and has some abdominal pain. Denies
fever, chills, nausea, vomiting, bleeding.
In the ED, initial VS were 98.8 97 137/68 20 100%. Labs were
significant for INR of 2.5 (at baseline), UA with dark amber
urine, few bacteria, no WBC, neg nitr, neg leuk, small bili. ___
was 130 with Bun/Cr of ___. LFTs with TBili 14.1, AST 72, ALT
39. WBC 8.2, H/H ___ (baseline Hgb ___, Plt 60 (baseline
70-80s). RUQ ultrasound showed cirrhosis, splenomegaly, moderate
ascites, no thrombus. Diagnostic paracentesis showed 104 WBC
with 4% PMNs.
On the floor, he has no acute complaints except for a distended
abdomen.
ROS: +Abdominal distention and pressure, weight gain. Denies
fever, chills, headache, cough, shortness of breath, chest pain,
nausea, vomiting, diarrhea, constipation, BRBPR, melena,
hematochezia, hemoptysis, dysuria, hematuria.
Past Medical History:
EtOH Cirrhosis c/b grade 1 varices, ascites, encephalopathy
Depression
Social History:
___
Family History:
No significant past medical history. No history of cirrhosis,
liver or gallbladder disease. Family has history of
hyperlipidemia.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: T97.8 BP129/61 HR84 RR14 100RA
Weight 198lbs (baseline 185 lbs)
HEENT: icteric sclera, moist mucuous membranes
CARDIAC: RRR, loud S1 with S2, ___ systolic murmur
LUNG: Clear, no wheezes, rales, rhonchi
ABD: normal bowel sounds, mildly tender RUQ with negative
___ sign, moderately distended abdomen but not tense
EXT: no ___ edema, 1+ DP and ___ pulses bilaterally
NEURO: alert and oriented x3, no asterixis
SKIN: no spider nevi or caput medusa appreciated, mild jaundice
DISCHARGE PHYSICAL EXAM
VS: T98.2 BP106/56 HR77 RR20 100RA
Weight 198lbs (baseline 185 lbs)
HEENT: icteric sclera, moist mucuous membranes
CARDIAC: RRR, loud S1 with S2, ___ systolic murmur
LUNG: Clear, no wheezes, rales, rhonchi
ABD: normal bowel sounds, mildly tender RUQ with negative
___ sign, moderately distended abdomen but not tense
EXT: no ___ edema, 1+ DP and ___ pulses bilaterally
NEURO: alert and oriented x3, no asterixis
SKIN: no spider nevi or caput medusa appreciated, mild jaundice
Pertinent Results:
ADMISSION LABS
___ 09:11PM ASCITES WBC-104* RBC-1186* POLYS-4* LYMPHS-64*
___ MESOTHELI-2* MACROPHAG-30*
___ 07:03PM ___ PTT-45.1* ___
___ 06:45PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-SM UROBILNGN-8* PH-6.5
LEUK-NEG
___ 06:45PM URINE COLOR-DKAMB APPEAR-Clear SP ___
___ 06:45PM URINE RBC-0 WBC-2 BACTERIA-FEW YEAST-NONE
EPI-0
___ 06:45PM URINE HYALINE-20*
___ 04:00PM GLUCOSE-109* UREA N-18 CREAT-0.8 SODIUM-130*
POTASSIUM-4.3 CHLORIDE-97 TOTAL CO2-23 ANION GAP-14
___ 04:00PM ALT(SGPT)-39 AST(SGOT)-72* ALK PHOS-108 TOT
BILI-14.1*
___ 04:00PM ALBUMIN-3.5 CALCIUM-9.3 PHOSPHATE-3.1
MAGNESIUM-2.0
___ 04:00PM WBC-8.2# RBC-2.11* HGB-7.7* HCT-22.0*
MCV-104* MCH-36.7* MCHC-35.2* RDW-13.6
___ 04:00PM NEUTS-75.8* LYMPHS-13.6* MONOS-7.1 EOS-2.6
BASOS-0.9
___ 04:00PM PLT COUNT-60*
DISCHARGE LABS
___ 07:10AM BLOOD WBC-8.7 RBC-2.41* Hgb-8.7* Hct-24.9*
MCV-103* MCH-35.8* MCHC-34.8 RDW-15.5 Plt Ct-67*
___ 07:10AM BLOOD Plt Ct-67*
___ 07:10AM BLOOD ___ PTT-42.5* ___
___ 07:10AM BLOOD Glucose-80 UreaN-16 Creat-0.8 ___
K-4.3 Cl-98 HCO3-26 AnGap-15
___ 07:10AM BLOOD ALT-33 AST-56* AlkPhos-105 TotBili-12.0*
___ 07:10AM BLOOD Calcium-9.5 Phos-4.0 Mg-1.9
___ 06:45AM BLOOD VitB12-___* Folate-12.0
STUDIES
___ ABD US
1. Cirrhotic appearance of the liver with splenomegaly and
moderate ascites. Patent portal vein and normal flow within the
hepatic artery.
2. Sludge and stones with mild thickening of the gallbladder
wall likely secondary to cirrhosis and ascites.
___ EGD
-grade 1 esophageal varices
-portal hypertensive gastropathy
___ COLONOSCOPY
Very mild diverticulosis of the colon, prep was fair, with a few
small areas in sigmoid suboptimal.
Brief Hospital Course:
BRIEF HOSPITAL COURSE
___ yo M with alcoholic cirrhosis presenting with hyponatremia to
130 and volume overload one week after holding diuresis that was
not tolerated. Pt was fluid restricted to 1500cc, placed on a
low sodium diet, and given diet education. Pt's sodium improved
to 135 at discharge. Pt underwent paracentesis with 3.6L
removed. In addition, pt was noted to have one episode of a
small amount of BRBPR on admission. Pt received 1 unit of RBCs
for a stable anemia to 7.___. No endoscopy was performed given
stability of pt's H/H and recent endoscopy. At discharge, pt's
H/H was stabilized at 8.7/24.9.
ACUTE ISSUES
## ASCITES: Last paracentesis was on ___ with 5.7L removed.
He has had 1 tap prior to that with 7L removed over the summer.
He is on chronic diuretics, but was asked to hold them last week
by Dr. ___ due to ___ 128 and Cr 1.2 up from 1.0. No history
of TIPS. His sodium is near baseline and renal function is
normal, so will resume diuretics and plan for tap tomorrow.
Diagnostic tap without evidence of infection. No history of SBP.
RUQ US without PV thrombus. Patient had paracentesis done in ___
on ___ with 3.6L drained; received 1 unit FFP prior to
procedure; received albumin 8mg/L of fluid removed after
procedure. We held diuretics in the setting of recent
hyponatremia and ___. The infectious workup with CXR, BCx, UCx,
f/u para culture were pending at discharge. Our nutrition team
saw the patient and did low salt diet teaching with the patient.
## BRBPR: Patient has small bright red clot in stool. Guiac
positive and rectal exam showed small amount of bright red
blood. Patient's vitals stable. Unlikely to be variceal bleed.
Last EGD showed grade 1 varices. Pt screened and consented. Pt
CBC responded appropriately to a unit of blood on ___, but
then showed a HGB point drop on ___ AM. Gave FFP x1 unit prior
to para. CBC was stable; will need f/u after discharge.
CHRONIC ISSUES
## CIRRHOSIS: Due to alcohol, Child's ___ class C, MELD 27 on
admission. Multiple complications including jaundice, ascites,
grade 1 varices, history of encephalopathy, thrombocytopenia,
coagulopathy. He is listed for transplant.
## HYPONATREMIA. ___ 130 today. Recent baseline 130-135, expected
given degree of cirrhosis. It was ___ 128 last week prompting
discontinuation of diuretics, but now improved to 130. Cr 1.2
elevated last week but now improved to 0.8. Pt had low salt
teaching by the nutrition team.
## HEPATIC ENCEPHALOPATHY: History in past, not on this
admission. Currently alert and oriented without asterixis.
Continued lactulose TID. Continued rifaximen 550mg PO BID.
## GRADE 1 ESOPHAGEAL VARICES: No bleeding history. Last EGD in
___ with grade 1 varices and portal hypertensive gastropathy.
No need for nadolol prophylaxis.
## PERIPHERAL NEUROPATHY. Stable. Continued gabapentin.
TRANSITIONAL ISSUES:
====================
# Low sodium diet and 1.5-2L fluid restriction; continue to hold
diuretics
# f/u with ___ Transplant Clinic ___
# Routine labs to be drawn ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. FoLIC Acid 1 mg PO DAILY
2. Lactulose 15 mL PO TID
3. Multivitamins 1 TAB PO DAILY
4. Omeprazole 20 mg PO DAILY
5. Ondansetron 4 mg PO Q8H:PRN nausea
6. Simethicone 80 mg PO TID:PRN gas/bloating
7. Thiamine 100 mg PO DAILY
8. Vitamin D 50,000 UNIT PO 1X/WEEK (WE)
9. Testosterone 2 mg Patch 1 PTCH TD Q24H
10. Gabapentin 600 mg PO QAM
11. Gabapentin 300 mg PO QPM
12. Rifaximin 550 mg PO BID
13. OxycoDONE (Immediate Release) 5 mg PO Q12H:PRN pain
Discharge Medications:
1. FoLIC Acid 1 mg PO DAILY
2. Gabapentin 600 mg PO QAM
3. Gabapentin 300 mg PO QPM
4. Multivitamins 1 TAB PO DAILY
5. Omeprazole 20 mg PO DAILY
6. Ondansetron 4 mg PO Q8H:PRN nausea
7. OxycoDONE (Immediate Release) 5 mg PO Q12H:PRN pain
RX *oxycodone 5 mg 1 tablet(s) by mouth every twelve (12) hours
Disp #*10 Tablet Refills:*0
8. Rifaximin 550 mg PO BID
9. Simethicone 80 mg PO TID:PRN gas/bloating
10. Testosterone 2 mg Patch 1 PTCH TD Q24H
11. Thiamine 100 mg PO DAILY
12. Vitamin D 50,000 UNIT PO 1X/WEEK (WE)
13. Lactulose 15 mL PO TID
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
==================
# Diuretic refractory ascites
# Hyponatremia
# Anemia
SECONDARY DIAGNOSIS:
====================
# Alcoholic cirrhosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr. ___,
It was a pleasure taking care of you during your stay at ___.
You presented with volume overload and ascites after having your
diuretics held. We continued to hold your diuretics given that
you did not tolerate them. We performed a paracentesis to
alleviate your ascites. Your sodium was low on presentation,
and improved during your course with fluid restriction to 1500
ml and low sodium diet. You will follow up with the Liver
Center Transplant Clinic ___, and you will need to
have labs drawn ___ at ___. Please continue to hold
your diuretics, maintain a low sodium diet, and restrict your
fluid intake to 1500-2000cc.
Followup Instructions:
___
|
19692527-DS-8
| 19,692,527 | 21,006,131 |
DS
| 8 |
2176-09-17 00:00:00
|
2176-09-17 16:44:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins / amlodipine / benazepril
Attending: ___
Chief Complaint:
Worsening ascites
Major Surgical or Invasive Procedure:
Diagnostic paracentesis ___
Therapeutic paracentesis ___
History of Present Illness:
___ year old with history of alcoholic cirrhosis c/b diuretic
refractory ascites, grade 1 esophageal varices, and history of
encephalopathy who was recently hospitalized ___ with
severe ascites, SBP, and GI bleed now presents with abdominal
pain and distension. In the ED, initial vitals were 97.9 84
145/60 16 100%. Exam notable for distension. Labs notable for
WBC 13.4, Hgb/Hct 9.1/___/2, plt 97. INR 2.6, AST 37, AST 83, AP
107, TBili 13.4.
Chem10 unchanged from baseline with Na 130, Cr 1.1.
RUQ U/S that showed cirrhosis, large volume ascites,
splenomegaly, and cholelithiasis. CXR performed showed stable
left-sided pleural effusion. Diagnostic paracentesis showed 270
WBC with 6% PMNs.
On the floor, patient reports his primary reason for
presentation is that the fluis accumulated very quickly, not
only in his belly but in his legs as well. Believes he gained
___ pounds since discharge a few days ago. His abdominal pain
is mostly bloating and vague discomfort.
He was scheduled for therapeutic paracentesis on ___ as
outpatient, but felt he was accumulating too rapidly so called
the ___ and was referred to the ED.
Has ___ daily. No confusion or changes in sleep. No new
rashes. No other localizing sources of infection.
Past Medical History:
EtOH Cirrhosis c/b grade 1 varices, ascites, encephalopathy
Depression
Social History:
___
Family History:
No significant past medical history. No history of cirrhosis,
liver or gallbladder disease. Family has history of
hyperlipidemia.
Physical Exam:
ADMISSION EXAM:
===============
VS: 98.4 124/71 78 18 100%RA
General: Pleasant gentleman in NAD lying in bed
HEENT: EOMI, PERRLA, +icterus
Neck: Supple
CV: S1, S2 regular.
Lungs: Clear to auscultation bilaterally
Abdomen: soft, distended, very mild diffuse TTP, +fluid wave
Ext: ___ bilaterallt pitting edema
Neuro: No asterixis. Moves all extremities
Skin: No acute rashes
DISCHARGE EXAM:
===============
VS: 98.6 124/68 83 18 99% on RA
General: NAD sitting up
HEENT: EOMI, PERRLA, +icterus
Neck: Supple
CV: S1, S2 regular.
Lungs: Clear to auscultation bilaterally
Abdomen: soft, distended, very mild diffuse TTP, +fluid wave
Ext: ___ bilateral pitting edema
Neuro: No asterixis. Moves all extremities
Skin: No acute rashes
Pertinent Results:
ADMISSION LABS:
===============
___ 02:45PM BLOOD WBC-13.4*# RBC-2.50* Hgb-9.1* Hct-25.2*
MCV-101* MCH-36.3* MCHC-36.0* RDW-15.9* Plt Ct-97*
___ 02:45PM BLOOD ___ PTT-40.8* ___
___ 02:45PM BLOOD Plt Ct-97*
___ 02:45PM BLOOD Glucose-114* UreaN-20 Creat-1.1 Na-130*
K-4.5 Cl-95* HCO3-24 AnGap-16
___ 02:45PM BLOOD ALT-37 AST-83* AlkPhos-107 TotBili-13.4*
___ 02:45PM BLOOD Albumin-3.8 Calcium-9.1 Phos-2.8 Mg-2.0
___ 02:44PM BLOOD Lactate-1.5
DISCHARGE LABS:
===============
___ 05:40AM BLOOD WBC-9.0 RBC-2.33* Hgb-8.2* Hct-24.0*
MCV-103* MCH-35.5* MCHC-34.4 RDW-15.5 Plt Ct-80*
___ 05:40AM BLOOD Plt Ct-80*
___ 05:40AM BLOOD ___ PTT-43.8* ___
___ 05:40AM BLOOD Glucose-109* UreaN-21* Creat-1.1 Na-131*
K-4.5 Cl-97 HCO3-27 AnGap-12
___ 05:40AM BLOOD ALT-35 AST-69* AlkPhos-81 TotBili-14.1*
___ 05:40AM BLOOD Albumin-3.3* Calcium-8.8 Phos-3.4 Mg-2.1
IMAGING:
========
RUQ Ultrasound ___
IMPRESSION:
1. Cirrhosis, large volume ascites, and splenomegaly.
2. Cholelithiasis and mild gallbladder wall thickening. Acute
cholecystitis cannot be excluded by this study, but finding of
wall thickening is typical for advanced liver disease.
Chest X-ray PA and Lateral ___
IMPRESSION:
Similar very small left-sided pleural effusion; otherwise
unremarkable.
Brief Hospital Course:
Mr. ___ is a ___ year old with history of alcoholic cirrhosis
c/b diuretic refractory ascites, grade 1 esophageal varices, and
history of encephalopathy who presents three days after
discharge with a 12 lb weight gain and increased abdominal
distension and pain due to uncontrolled ascites.
ACUTE ISSUES:
=============
# ASCITES, DIURETIC REFRACTORY: Pt presented with worsening
abdominal distension. In the ED, CXR demonstrated a small left
sided pleural effusion and disgnostic paracentesis demonstrated
270 WBC and 6% PMNs. Labs were notable for WBC 13.4 (improved to
9 on subsequent labs), stable H/H, total bili stable from last
hospitalization. Blood cultures, UA, and urine culture were
drawn. Pt reports that he had a large meal at his sister's house
for ___, and noticed that his abdomen was becoming
progressively more and more distended. He called ___ at
the ___ on ___ in hopes of having his scheduled
paracentesis moved up. He was referred to the ED and was
admitted with plans for therapeutic paracentesis. He underwent
therapeutic paracentesis with 6L removed and 50g of albumin
given. The importance of adhering to a strict sodium restricted
diet was explained to the patient. He was discharged home with
___ follow up and scheduled outpatient paracentesis.
CHRONIC ISSUES:
===============
# CIRRHOSIS: Due to alcohol, Child's ___ class C, MELD 28 on
admission. Multiple complications including jaundice, diuertic
refractory ascites (becomes hyponatremic and Cr bumps), grade 1
varices, history of encephalopathy, thrombocytopenia,
coagulopathy, and SBP. He is listed for transplant. Continued
on lactulose and rifaximin for chronic HE, ciprofloxacin for SBP
prophylaxis, and not on beta blocker given grade 1 varices.
# PERIPHERAL NEUROPATHY. Continued home gabapentin and oxycodone
TRANSITIONAL ISSUES:
====================
# Pt will follow up with ___ ___ and ___ SW
___
# Pt is scheduled for a therapeutic paracentesis ___, determine
if necessary at follow up
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. FoLIC Acid 1 mg PO DAILY
2. Gabapentin 600 mg PO QAM
3. Gabapentin 300 mg PO QPM
4. Lactulose 15 mL PO TID
5. Multivitamins 1 TAB PO DAILY
6. Ondansetron 4 mg PO Q8H:PRN nausea
7. OxycoDONE (Immediate Release) 5 mg PO Q12H:PRN pain
8. Rifaximin 550 mg PO BID
9. Simethicone 80 mg PO TID:PRN gas/bloating
10. Thiamine 100 mg PO DAILY
11. Omeprazole 20 mg PO DAILY
12. Testosterone 2 mg Patch 1 PTCH TD Q24H
13. Vitamin D 50,000 UNIT PO 1X/WEEK (WE)
14. Ciprofloxacin HCl 250 mg PO Q24H
Discharge Medications:
1. Ciprofloxacin HCl 250 mg PO Q24H
2. FoLIC Acid 1 mg PO DAILY
3. Gabapentin 600 mg PO QAM
4. Gabapentin 300 mg PO QPM
5. Lactulose 15 mL PO TID
6. Multivitamins 1 TAB PO DAILY
7. Omeprazole 20 mg PO DAILY
8. Ondansetron 4 mg PO Q8H:PRN nausea
9. OxycoDONE (Immediate Release) 5 mg PO Q12H:PRN pain
10. Rifaximin 550 mg PO BID
11. Simethicone 80 mg PO TID:PRN gas/bloating
12. Testosterone 2 mg Patch 1 PTCH TD Q24H
13. Thiamine 100 mg PO DAILY
14. Vitamin D 50,000 UNIT PO 1X/WEEK (WE)
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
==================
# Diuretic refractory ascites
# Volume overload
SECONDARY DIAGNOSIS:
====================
# Child ___ Class C Alcoholic Cirrhosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr. ___,
It was a pleasure taking care of you during your stay at ___.
You presented with volume overload and worsened ascites. An
infectious workup was negative, and you underwent a therapeutic
paracentesis. You will follow up with your scheduled Liver
Center appointment ___, as well as a scheduled paracentesis
___.
It is essential that you adhere to a strict sodium restriction
of less than 2g daily and limits total fluid intake to 1500cc
per day.
Followup Instructions:
___
|
19692739-DS-15
| 19,692,739 | 26,297,638 |
DS
| 15 |
2116-02-21 00:00:00
|
2116-02-21 14:47:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROSURGERY
Allergies:
IV Dye, Iodine Containing Contrast Media
Attending: ___.
Chief Complaint:
s/p fall - wrist fracture, visual deficit
Major Surgical or Invasive Procedure:
___ angio with coiling PCOMM / amgioseal
History of Present Illness:
This is a ___ year old female on 81 mg Aspirin daily with
known right PCOM aneurysm 7 mm as seen on MRI in ___ of
this
year was transferred from ___ following a 5
minute episode of "triple vision" , blurred vision. She
describes this as when she looked at the receptionist at ___ she saw three heads stacked upon each other
instead of one. The patient was about to be discharge from ___
with a left sprain wrist. After she experienced the triple
vision a head ct was performed which was found to be negative.
Given the patient's known right PCOM aneurysm , she was
transferred here for further evaluation and treatment by this
Neurosurgery service.
The patient originally had the MRI in ___ due to an episode
of slurred, non sensical speech. She states that she was at an
appointment and her words became garbled. She notified her PCP
who ordered an MRI. The patient was to see Neurology to discuss
the MRI findings later this week on ___.
Currently, the patient has no neurological complaints. She
denies diplopia, speech difficulty, weakness other than at the
location of her sprained left wrist. The patient denies
weakness, numbness, tingling sensation. She denies bowel or
bladder dysfunction or hearing deficit.
Past Medical History:
Right lens implant, asthma, HTN, hypothyroidism, hyperactive
bladder, renal CA with partial nephrectomy ___ years ago- treated.
Social History:
___
Family History:
___
Physical Exam:
O: T:98.4 BP: 109/96 HR: 90 R: 16 O2Sats:98% RA
Gen: comfortable, NAD.
HEENT: Pupils: Pupils are bilaterally reactive . right eye is
irregular surgical pupil 5mm and left pupil is 5-4mm EOMs:
intact
Neck: Supple.
Extrem: left wrist sprain
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 are bilaterally reactive . right eye is irregular
surgical pupil 5mm and left pupil is 5-4mm.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 EXCEPT left wrist
was
not challenged due to sprain.. No pronator drift
Sensation: Intact to light touch, proprioception bilaterally.
Toes downgoing bilaterally
Coordination: normal on finger-nose-finger, rapid alternating
movements
Upon Discharge:
Alert, oriented x3, R pupil surgical, L pupil reactive, MAE full
motor
Pertinent Results:
___
Impression:
1. No evidence of acute large vessel territorial infarct or
intracranial hemorrhage.
2. Nonspecific periventricular and subcortical white matter
hypoattenuation, likely the sequelae of microangiopathic
disease.
MRI Brain ___:
1. Right posterior communicating artery aneurysm measuring
7 mm,directed posteriorly and slightly laterally.2. Fetal
origin
of the right posterior communicating artery withnonvisualization
of the right P1 segment.3. Stenosis of the proximal right
internal carotid artery of approximately 55%.4. Mild
nonspecific
periventricular and subcortical white matter disease, likely the
sequela of small vessel ischemic change in a patient this age.
Brief Hospital Course:
Patient was admitted to Neurosurgery on ___ to the
Neurosurgery Service - ICU. On ___, she underwent the above
stated procedure. Please review dictated operative report for
details. She was transferred back to ICU in stable condition.
She did well overnight and was transferred to the SDU on ___.
On ___, she remained nonfocal, afebrile, tolerating a regular
diet and ambulating without difficulty.
Medications on Admission:
synthroid, amlodipine, vesicare, lisinopril, singulair, MVI,
calcium+D, ASA 81, benefiber
Discharge Medications:
1. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
3. levothyroxine 112 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 5 days: began ___.
Disp:*5 Tablet(s)* Refills:*0*
8. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Acetaminophen Extra Strength 500 mg Tablet Sig: ___ Tablets
PO Q6H (every 6 hours) as needed for pain.
10. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
11. Vesicare 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
12. Plavix 75 mg Tablet Sig: One (1) Tablet PO once a day: Begin
5 days prior to your angiogram.
Disp:*35 Tablet(s)* Refills:*0*
13. prednisone 20 mg Tablet Sig: Two (2) Tablet PO 16 hrs, 8
hrs, & 2 hrs prior to your angiogram for 3 doses.
Disp:*6 Tablet(s)* Refills:*0*
14. Zantac 150 mg Tablet Sig: One (1) Tablet PO twice a day for
3 doses: Begin with steroids.
Disp:*3 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Right Posterior communicating artery aneurysm
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Angiogram with Embolization
Medications:
Take Aspirin 325mg (enteric coated) once daily.
Take Plavix (Clopidogrel) 75mg once daily starting 5 days
prior to your scheduled angiogram in one month. We will provide
you with a Rx for 35 tablets as you will continue Plavix one
month post-coiling.
Continue all other medications you were taking before surgery,
unless otherwise directed
You make take Tylenol or prescribed pain medications for any
post procedure pain or discomfort.
What activities you can and cannot do:
When you go home, you may walk and go up and down stairs.
You may shower (let the soapy water run over groin 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 or
band aid over the area that is draining, as needed
No heavy lifting, pushing or pulling (greater than 5 lbs) for
1 week (to allow groin puncture to heal).
After 1 week, you may resume sexual activity.
After 1 week, gradually increase your activities and distance
walked as you can tolerate. You may return to work when you feel
ready as long as you are able to maintain the above restrictions
for 7 days.
No driving until you are no longer taking pain medications
What to report to office:
Changes in vision (loss of vision, blurring, double vision,
half vision)
Slurring of speech or difficulty finding correct words to use
Severe headache or worsening headache not controlled by pain
medication
A sudden change in the ability to move or use your arm or leg
or the ability to feel your arm or leg
Trouble swallowing, breathing, or talking
Numbness, coldness or pain in lower extremities
Temperature greater than 101.5F for 24 hours
New or increased drainage from incision or white, yellow or
green drainage from incisions
Bleeding from groin puncture site
*SUDDEN, SEVERE BLEEDING OR SWELLING
(Groin puncture site)
Lie down, keep leg straight and have someone apply firm pressure
to area for 10 minutes. If bleeding stops, call our office. If
bleeding does not stop, call ___ for transfer to closest
Emergency Room!
****** Pre-op Meds for angio in one month ******
Plavix 75 mg daily - begin 5 days prior to your angio
Prednisone 20 mg tablets (for dye allergy)
Take 2 tablets (40 mg) by mouth 16 hours prior to the
procedure or test, 8 hours prior, and 2 hours prior.
Zantac (Ranitidine) 150 mg tablets
Take 1 tablet by mouth twice daily along with the
Prednisone.
Please be sure to take 1 dose one hour prior to your
procedure or testing. (Will be given in the hospital)
Benadryl 25 mg capsules
Take 2 capsules (50 mg) by mouth one hour prior to your
procedure or testing.
Followup Instructions:
___
|
19692972-DS-18
| 19,692,972 | 28,294,099 |
DS
| 18 |
2156-08-03 00:00:00
|
2156-08-03 11:23:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Statins-Hmg-Coa Reductase Inhibitors
Attending: ___
Chief Complaint:
epigastric pain, ___ hospital transfer for biliary obstruction
Major Surgical or Invasive Procedure:
___ Endoscopic Retrograde Cholangio-Pancreatography with
Balloon sweep, Brushings, Sphincterotomy, Plastic Stent
Placement
History of Present Illness:
Mr. ___ is a ___ male with history of Mr. ___ is
a ___ with the past medical history of HL, BPH and allergic
rhinitis who presents with abdominal pain.
Patient has been having intermittent chest pain for the past
month with negative cardiopulmonary workup. More recently he has
noted worsening of this chest / epigastric pain and his brother
(who is an MD) noted new scleral icterus. He presented to
___ for these symptoms and was found to have elevated
LFTs. He underwent RUQ U/S which showed sludge in the GB with no
stones or biliary dilation, as well as dilated gallbladder with
thick wall concerning for cholecystitis, and mild intrahepatic
biliary dilatation. CXR showed RLL atelectasis and CT A/P showed
dilated thick walled GB with no definitive stone, suspicious for
cholecystitis. Slightly prominent intrahep biliary tract. He was
given zosyn and transferred to ___ ED.
Of note, patient has been having intermittent chest pain for
about a month now recently worsening. He had a CTA chest, stress
test, and CXR by his PCP that were all negative. He has tried
omeprazole 20 BID but this didn't relieve his epigastric
discomfort / chest pain though it did make him constipated so
more recently he has switched to ranitidine 150 BID. He was
scheduled for an upcoming EGD to further evaluate his symptoms.
In the ED here he was AFVSS, labs showed hyperbilirubinemia to 6
(Dbili 5) with mild leukocytosis to 12 and INR 1.6. He was given
1L NS and a dose of zosyn then admitted to floor for further
workup and inpatient ERCP consult.
On arrival to the floor temp was 100.1 but no frank fever and VS
otherwise stable.
ROS: Pertinent positives and negatives as noted in the HPI. All
other systems were reviewed and are negative.
Past Medical History:
Hyperlipidemia
Benign Prostatic Hyperplasia
Allergic Rhinitis
Recent Inguinal Hernia repair
Former smoker
Social History:
___
Family History:
Reviewed and found to be not relevant to this illness/reason for
hospitalization.
Physical Exam:
Discharge Exam:
99.0
PO 129 / 82 76 18 94 RA
GENERAL: Alert and in no apparent distress
EYES: +Scleral icterus, pupils equally round, icterus has
notably improved
ENT: Ears and nose without visible erythema. Oropharynx without
visible lesion, erythema or exudate
CV: Heart regular, no murmur, no S3, no S4. No JVD.
RESP: Lungs clear to auscultation with good air movement
bilaterally. Breathing is non-labored
GI: Abdomen soft, non-distended, tenderness in mid-epigastrium
has resolved, no rebound or guarding, negative ___ sign.
Bowel sounds present. No HSM
GU: No suprapubic fullness or tenderness to palpation
MSK: Neck supple, moves all extremities, strength
grosslysymmetric
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
Pertinent Results:
Admission Labs:
___:
WBC: 11.9* > HGB: 12.4* / HCT: 37.3* < Plt Count: 143*
INR: 1.6*
Na: 140 / K: 3.7 > Cl: 105 / CO2: 21* < BUN: 16 / Creat: 1.0
Glucose: 113*
eGFR: ___
Ca: 9.1
AST: 158*, ALT: 386*
Alk Phos: 190*, Total Bili: 6.3*; Dir Bili: 5.3*
Alb: 3.1*
___:
Micro:
All cx negative
___: ERCP with sphincterotomy, brushings, extraction of
debris/stones and plastic stent placement. Distal tapering at
level of ampulla.
___: CTA pancreas:
1. Post ERCP with common bile duct stent in place, in
satisfactory position.
2. There is thrombosis of a peripheral branch of the right
portal vein, as well as ill-defined branching opacities in the
left lobe of the liver, either related to thrombosed peripheral
portal vein branches, or mild segmental biliary dilatation.
3. Ill-defined soft tissue infiltration/fat stranding along the
hepatic hilum, without measurable lesion. While a component of
this may be related to recent ERCP, an underlying lesion such as
an infiltrative cholangiocarcinoma is of concern, as majority of
this finding was present prior to ERCP.
4. No pancreatic or periampullary lesion.
5. Hyperenhancing 2.2 cm lesion in the right lobe of the liver,
with central hypoattenuation. While this could represent a
benign entity such as an FNH, a remains incompletely
characterized on the current study.
___ 05:06AM BLOOD WBC-7.4 RBC-3.66* Hgb-11.5* Hct-34.1*
MCV-93 MCH-31.4 MCHC-33.7 RDW-13.3 RDWSD-45.7 Plt ___
___ 05:06AM BLOOD ALT-222* AST-95* AlkPhos-269*
TotBili-4.0*
Brief Hospital Course:
Mr. ___ is a ___ year-old male with history of HL, BPH and
allergic rhinitis who presented with acute on chronic epigastric
pain and new scleral icterus and ERCP discovering cholangitis.
ACUTE/ACTIVE PROBLEMS:
#Acute Cholangitis
ERCP removed pus/debris, stent placed. He was initially started
on IV zosyn but transitioned to Unasyn and then oral
ciprofloxacin for continued treatment of acute cholangitis.
Unfortunately no blood cx were positive. Transitioned easily to
full diet and abd pain resolved. Held Crestor
- will need repeat ERCP in 4 weeks for stent pull vs exchange
# Concern of underlying cancer:
- CTA pancreas had hyperenhancing 2.2 cm lesion in the right
lobe of the liver, in addition to ill-defined fat stranding
along the hepatic hilum with concern raised for potential
underlying cholangiocarcinoma per official Radiology report. On
review of imaging with the on call radiologist this evening,
these findings are concerning enough to warrant further active
workup, but they are also non-specific.
- Decision was to follow-up with a MRCP/endoscopic u/s in next
two weeks. the hope is that this will allow for more time for
inflammation to resolve and therefore better imaging.
# Incidental thrombosis in side branch of right PV discovered on
CT
- Discussed with ERCP team. Given no known malignancy, trigger
of cholangitis, asx, chose not to treat with anticoagulation.
TRANSITIONAL ISSUES:
- please check blood tests to ensure resolution of LFT
- If LFT normalized, restart Crestor
- MRCP/EUS to assess for cholangiocarcinoma
- Stent removal
- Imaging f/u of portal vein thrombosis
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Rosuvastatin Calcium 5 mg PO QPM
2. Ranitidine 150 mg PO BID
3. Fluticasone Propionate NASAL 1 SPRY NU DAILY
Discharge Medications:
1. Ciprofloxacin HCl 500 mg PO Q12H
RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth twice a day
Disp #*20 Tablet Refills:*0
2. Fluticasone Propionate NASAL 1 SPRY NU BID
3. Ranitidine 150 mg PO BID
4. HELD- Rosuvastatin Calcium 5 mg PO QPM This medication was
held. Do not restart Rosuvastatin Calcium until you see your PCP
in followup
___ Disposition:
Home
Discharge Diagnosis:
Acute Cholangitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking part in your care here at ___!
Why was I admitted to the hospital?
You had a blockage of your bile duct and this led to an
infection.
What was done for me while I was in the hospital?
We removed the stone blocking the duct and put a stent in to
make sure it drains.
What should I do when I leave the hospital?
Continue the antibiotics, follow-up with your primary care
doctor and come back for the stent removed. Also, please have
the MRI (called a MRCP), if pain/fever comes back please call
your primary care, gastroenterology team ___ page ERCP
fellow), or come back to our ED.
Sincerely,
Your ___ Care Team
It was a pleasure to participate in your care.
Followup Instructions:
___
|
19693408-DS-17
| 19,693,408 | 28,077,413 |
DS
| 17 |
2116-02-08 00:00:00
|
2116-02-08 22:58:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
___
Attending: ___.
Chief Complaint:
R distal tibia/fibula fracture
Major Surgical or Invasive Procedure:
Open reduction and internal fixation of R tibia
History of Present Illness:
From ED Admission Note:
Ms. ___ is a ___ year old female who sustained a mechanical
fall while hiking yesterday in ___ suffering a distal
tibia fracture. Patient states she slipped off a rock, felt a
snap and had immediate right leg pain and inability to ambulate.
She went to an OSH where they splinted her and recommended she
follow-up with her orthopaedic surgeon today closer to home. She
saw her surgeon today and upon reviewing the XRs recommended
coming to ___ ED for further care given the complexity of the
fracture.
At time of examination, patient only complains of pain. She
denies any numbness/tingling distally. She denies any head
strike, LOC, or other injuries.
Past Medical History:
GERD
Social History:
___
Family History:
Non contributory to this hospitalization
Physical Exam:
Admission Physical Exam:
Physical Exam:
Gen: well appearing, no acute distress. Alert and oriented x 3
CV: RRR
Lungs: breathing room air comfortably.
Right upper extremity:
- Skin intact
- No deformity, erythema, edema, induration or ecchymosis
- Soft, non-tender arm and forearm
- Full, painless AROM/PROM of shoulder, elbow, wrist, and digits
- EPL/FPL/DIO (index) fire
- SILT axillary/radial/median/ulnar nerve distributions
- 2+ radial pulse
Left upper extremity:
- Skin intact
- No deformity, erythema, edema, induration or ecchymosis
- Soft, non-tender arm and forearm
- Full, painless AROM/PROM of shoulder, elbow, wrist, and digits
- EPL/FPL/DIO (index) fire
- SILT axillary/radial/median/ulnar nerve distributions
- 2+ radial pulse
Right lower extremity:
- Skin intact, swelling about ankle
- No deformity, erythema, edema, induration or ecchymosis
- Soft, non-tender thigh and leg
- ___ fire
- SILT SPN/DPN/TN/saphenous/sural distributions
- 1+ ___ pulses, foot warm and well-perfused
Left lower extremity:
- Skin intact
- No deformity, erythema, edema, induration or ecchymosis
- Soft, non-tender thigh and leg
- Full, painless AROM/PROM of hip, knee, and ankle
- ___ fire
- SILT SPN/DPN/TN/saphenous/sural distributions
- 1+ ___ pulses, foot warm and well-perfused
Discharge Physical Exam:
Gen: AOx3, NAD
CV: RRR
Pulm: No respiratory distress
Right lower extremity:
- Skin intact, leg in OR splint
- No deformity, erythema, edema, induration or ecchymosis over
exposed skin
- Soft, non-tender thigh
- ___ fire, though difficult to assess ___ and TA due to OR
splint coverage
- SILT SPN/DPN/TN/saphenous/sural distributions
- exposed toes warm and well-perfused, unable to assess ___
due to splint
Pertinent Results:
___ 07:50PM GLUCOSE-101* UREA N-10 CREAT-0.6 SODIUM-139
POTASSIUM-3.7 CHLORIDE-102 TOTAL CO2-28 ANION GAP-13
___ 07:50PM estGFR-Using this
___ 07:50PM WBC-6.9 RBC-4.34 HGB-13.2 HCT-40.8 MCV-94
MCH-30.4 MCHC-32.4 RDW-13.5 RDWSD-46.5*
___ 07:50PM NEUTS-59.5 ___ MONOS-6.7 EOS-1.3
BASOS-0.6 IM ___ AbsNeut-4.11 AbsLymp-2.18 AbsMono-0.46
AbsEos-0.09 AbsBaso-0.04
___ 07:50PM PLT COUNT-230
___ 07:50PM ___ PTT-31.7 ___
Tibia/Fibula and Ankle XR, ___:
FINDINGS:
Overlying splint limits fine osseous detail. Again demonstrated
is a
comminuted, predominately obliquely oriented fracture involving
the distal
tibia with minimal lateral displacement of the dominant distal
fracture
fragment and ventral angulation of the fracture apex, slightly
improved in
alignment compared to the previous radiographs. The
nondisplaced comminuted
fracture involving the distal posterior tibia with
intra-articular extension
is difficult to assess on the provided views but is likely
without change.
Again noted is a comminuted fracture of the distal fibula with
mild
displacement of the dominant distal fracture fragment dorsally
and with slight
ventral angulation of the fracture apex, without substantial
interval change.
The ankle mortise appears symmetric. Talar dome is smooth. No
dislocation is
evident.
IMPRESSION:
Re- demonstration of distal tibial and fibular fractures with
minimal
improvement in alignment of the distal tibial fracture. No
dislocation.
Brief Hospital Course:
The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have R distal tibia/fibula fractures and was admitted to the
orthopedic surgery service. The patient was taken to the
operating room on ___ for an open reduction and internal
fixation of the right tibia (R fibula not fixed as no
syndesmotic injury was noted intraoperatively), 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
with ___ 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
TDWB in the right lower extremity, and will be discharged on
Lovenox for DVT prophylaxis. The patient will follow up with Dr.
___ routine. A thorough discussion was had with the
patient regarding the diagnosis and expected post-discharge
course including reasons to call the office or return to the
hospital, and all questions were answered. The patient was also
given written instructions concerning precautionary instructions
and the appropriate follow-up care. The patient expressed
readiness for discharge.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. This patient is not taking any preadmission medications
Discharge Medications:
1. Enoxaparin Sodium 40 mg SC DAILY
Start: Today - ___, First Dose: Next Routine Administration
Time
RX *enoxaparin 40 mg/0.4 mL 40 mg SC once a day Disp #*14
Syringe Refills:*0
2. OxyCODONE (Immediate Release) 5 mg PO Q3H:PRN Pain -
Moderate
RX *oxycodone 5 mg ___ tablet(s) by mouth every three (3) hours
Disp #*50 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Right distal tibia/fibula 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:
- Touch down weight bearing, activity as tolerated.
MEDICATIONS:
- Please take all medications as prescribed by your physicians
at discharge.
- Continue all home medications unless specifically instructed
to stop by your surgeon.
- Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
- Narcotic pain relievers can cause constipation, so you should
drink eight 8oz glasses of water daily and take a stool softener
(colace) to prevent this side effect.
ANTICOAGULATION:
- Please take Lovenox 40mg daily for 2 weeks
WOUND CARE:
- You may shower. No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- No dressing is needed if wound continues to be non-draining.
- Splint must be left on until follow up appointment unless
otherwise instructed
- Do NOT get splint wet
DANGER SIGNS:
Please call your PCP or surgeon's office and/or return to the
emergency department if you experience any of the following:
- Increasing pain that is not controlled with pain medications
- Increasing redness, swelling, drainage, or other concerning
changes in your incision
- Persistent or increasing numbness, tingling, or loss of
sensation
- Fever > 101.4
- Shaking chills
- Chest pain
- Shortness of breath
- Nausea or vomiting with an inability to keep food, liquid,
medications down
- Any other medical concerns
Physical Therapy:
Patient will go home with ___.
Activity: Activity as tolerated
Right lower extremity: Touchdown weight bearing
Encourage turn, cough and deep breathe q2h when awake
Treatments Frequency:
Activity: Activity as tolerated
Right lower extremity: Touchdown weight bearing
Encourage turn, cough and deep breathe q2h when awake
Patient will require physical therapy at home.
Followup Instructions:
___
|
19693707-DS-15
| 19,693,707 | 29,131,730 |
DS
| 15 |
2131-12-23 00:00:00
|
2131-12-25 14:54:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Codeine / anesthetic at dentist- lidocaine
Attending: ___.
Chief Complaint:
Nausea and vomiting with black flakes
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ yo F with history of ___ esophagus,
gastritis and CVA on Plavix who presents to the ___ ED with
acutely worsening nausea and vomiting for 1 day i/s/o 2 weeks of
nausea and vomiting. Yesterday (___) at 7 AM she had her usual
breakfast of petite croissant and cup of coffee. At 10 AM she
had an episode of emesis where she saw "black flakes."
Subsequently, she had ___ episodes of emesis, then slept
through the night. This morning (___) she came to ED for
evaluation. She also reports increasingly worse occasional
vomiting for preceding 2 weeks associated with anorexia and a 10
pound weight loss (was 120 lbs in ___. Her history of
significant emesis goes back about 6 months when she obtained
new bottom dentures, and pt reports vomiting about once/week
until about two weeks ago when it worsened. She attributes these
recent episodes to not being able to chew her food correctly due
to her new dentures. She reports being able to eat soups and
yogurt w/o issue, but struggles with solids including noodles.
She denies LOC, rashes, new joint pain, paresthesias or leg
swelling. She is not on a PPI at home.
Of note the patient has a remote history of vomiting, with EGD
at ___ in ___ that showed gastritis and ___ esophagus.
She takes daily acetaminophen for aches, but no ibuprofen or
aspirin since starting clopidogrel in ___.
Per patient's son, the patient does not eat a lot and is unable
to keep food down. This has been occurring for a couple of
months. No early satiety, but patient can sense when she will
need to throw up after a meal. He was unaware of any blood until
yesterday. The vomit looks like the food she ate. She has had
weight loss, trying to drink Ensure. Family includes 2 sons
___ and his older brother), no HCP documented.
In the ED, initial VS were T 100.3, P 78, BP 125/51, RR 16, O2
100% RA
ED exam notable for:
General - No acute distress
CV - S1, S2, no m/r/g
PULM - CTAB
ABD - Soft, NT, ND
Rectal - Heme negative
MSK - no spinal tenderness or CVAT
Ext - warm, dry, pulses 2+
Labs in ED showed:
Na 141 K 3.7 Cl 102 HCO3 27 BUN 11 Cr 0.9 Glucose 90 AG 16
Ca 9.9 Mg 2.2 P 2.9
AST 20 ALT 10 ALP 37 Tbili 0.6 Alb 4.6
Lactate 1.9
___ 11.3 PTT 30.0 INR 1.0
WBC 13.9* Hgb 13.0 Hct 41.2 Plt 240
N 30%* Band 0% L 63%* M 4%* E 1% B 1%
UA notable for: Protein 30, Ketone 40, Hyaline casts 4
Imaging showed:
___ CXR: No acute intrathoracic process
In the ED, she received:
IV Pantoprazole 40 mg
2L NS IV
TP Bengay Cream 1 Appl
PO Acetaminophen 1000mg
Transfer VS were 98.9 78 126/62 18 100% RA
GI was consulted in the ED and recommended IV PPI.
Decision was made to admit to medicine for further management.
On arrival to the floor, patient reports that she is distressed
by not being able to eat. She denies f/c, vision changes, cough,
COB, chest pain, dysphagia, abdominal pain, diarrhea,
constipation, BRBPR, melena, dysuria, or hematuria.
Past Medical History:
___
CLL
Gastritis
Ischemic stroke, ___
Pericarditis, ___
HTN
Hypothyroid
Palpitations
Migraines
Low back pain ___ lumbar disc disease s/p LESI
Mucocele, ___
Uterine prolapse s/p vaginal hysterectomy, ___
s/p lumpectomy with diagnosis of fibroadenoma ___
s/p Cholecystectomy
s/p b/l cataracts surgery
s/p laser ablation of a right inferolateral pharyngeal wall
Social History:
___
Family History:
There is no family history of strokes. Her sister
died of pancreatic cancer, and her other sister died of CAD.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS - T 98.1 BP 184/57 Lying HR 66 RR 16 O2 97% RA
GENERAL: alert, conversant, NAD
HEENT: AT/NC, EOMI, PERRL w/o RAPD, pupils abnormal shape
bilaterally s/p surgery, anicteric sclera, pink conjunctiva, MMM
NECK: nontender supple neck, no LAD, no JVD
CARDIAC: RRR, normal S1, loud 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, motor strength ___ throughout, CN II-XII intact,
sensation grossly intact
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
DISCHARGE PHYSICAL EXAM:
VS - T 98.2 BP 133/80 HR 84 RR 16 02 97% RA
General: well appearing, NAD, very vibrant personality
HEENT: MMM, EOMI
Neck: no JVD, no LAD
CV: normal S1, loud S2, rrr, no m/r/g
Lungs: CTAB, breathing comfortably
Abdomen: soft, +BS, nontender, nondistended, no HSM appreciated
GU: deferred
Ext: Warm and well perfused, pulses present b/l, no edema
Neuro: grossly normal
Pertinent Results:
ADMISSION LABS:
CBC w/ Diff
___ 12:02PM BLOOD WBC-13.9* RBC-4.54 Hgb-13.0 Hct-41.2
MCV-91 MCH-28.6 MCHC-31.6* RDW-13.9 RDWSD-46.2 Plt ___
___ 12:02PM BLOOD Neuts-30* Bands-0 Lymphs-63* Monos-4*
Eos-1 Baso-1 Atyps-1* ___ Myelos-0 AbsNeut-4.17
AbsLymp-8.90* AbsMono-0.56 AbsEos-0.14 AbsBaso-0.14*
___ 12:02PM BLOOD Hypochr-NORMAL Anisocy-NORMAL
Poiklo-NORMAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL
Coag
___ 12:02PM BLOOD ___ PTT-30.0 ___
Lytes
___ 10:00AM BLOOD Glucose-90 UreaN-11 Creat-0.9 Na-141
K-3.7 Cl-102 HCO3-27 AnGap-16
___ 10:00AM BLOOD Calcium-9.9 Phos-2.9 Mg-2.2
LFTs
___ 10:00AM BLOOD ALT-10 AST-20 AlkPhos-37 TotBili-0.6
___ 10:00AM BLOOD Albumin-4.6
Lactate
___ 10:26AM BLOOD Lactate-1.9
Urinalysis
___ 04:00PM URINE Color-Yellow Appear-Clear Sp ___
___ 04:00PM URINE Blood-NEG Nitrite-NEG Protein-30
Glucose-NEG Ketone-40 Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
___ 04:00PM URINE RBC-3* WBC-3 Bacteri-FEW Yeast-NONE Epi-1
___ 04:00PM URINE CastHy-4*
___ 04:00PM URINE Mucous-FEW
MICRO:
___ Blood Culture: pending
___ Urine Culture: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES),
CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION.
IMAGING:
___ CXR:
No acute intrathoracic process
___ Barium swallow
The esophagus was not dilated. There was no stricture within the
esophagus. There was no esophageal mass. The esophageal mucosa
appear normal. The primary peristaltic wave was abnormal,
suggesting dysmotility. The lower esophageal sphincter opened
and closed normally. A 13 mm barium tablet was administered,
which passed into the stomach without holdup. Limited evaluation
for gastroesophageal reflux or hiatal hernia, due to the
patient's discomfort.
DISCHARGE LABS:
___
___ 06:05AM BLOOD WBC-11.4* RBC-4.28 Hgb-12.3 Hct-38.1
MCV-89 MCH-28.7 MCHC-32.3 RDW-13.9 RDWSD-44.9 Plt ___
Coag
___ 06:05AM BLOOD ___ PTT-28.1 ___
Lytes
___ 06:05AM BLOOD Glucose-87 UreaN-10 Creat-0.7 Na-138
K-4.1 Cl-101 HCO3-27 AnGap-14
___ 06:05AM BLOOD Calcium-9.1 Phos-3.4 Mg-2.0
Brief Hospital Course:
Ms. ___ is a ___ year-old female with a history of ___
esophagus, gastritis and CVA on Plavix who presents to the ___
emergency department with acutely worsening nausea and coffee
ground emesis for 1 day in the setting of several months of
nausea, vomiting, and difficulty chewing because of new, poorly
fitting dentures.
ACTIVE ISSUES:
#Upper GI Bleed:
Patient presented with coffee ground emesis for 1 day. Etiology
is not certain at this time, but differential includes
___ tear, gastritis, or malignancy. The patient
presented hemodynamically stable and without significant anemia.
GI service was consulted. She was started on an IV PPI due to
her history of untreated ___ Esophagus and her hemoglobin
was trended. She maintained stable blood pressures, heart rate,
and hemoglobin without further episodes of bleeding. Her PPI was
switched to oral. She should continue taking omeprazole 40 mg PO
BID until she has outpatient follow-up. She should follow up
with GI for further workup in the outpatient setting as
appropriate.
#Nausea, Vomiting
#Esophageal dysmotility
The patient presents with several months of nausea and vomiting
associated with difficulty chewing and ill-fitting dentures.
Initially there was concern for possible dysphagia for solids
and esophageal obstruction. However, the patient underwent a
barium swallow which demonstrated esophageal dysmotility w/o
mechanical obstruction. The patient had a speech and swallow
evaluation without signs of oropharyngeal dysphagia. She should
follow up with GI in the outpatient setting for further workup
of nausea and vomiting. The risks and benefits of EGD and/or
esophageal manometry should be assessed. It is also possible
that these symptoms come from ill-fitting dentures and the
patient should follow up with dental for denture fitting and/or
implantation. Until her dentures are replaced, she has been told
to remain on a liquid/soft solid diet (4 Ensures and soft solids
as tolerated).
#Leukocytosis
The patient presented with leukocytosis which she has had since
___ with fluctuating hemoglobin values. This is likely related
to her CLL. She had a differential with 63% Lymphocytes. She had
no fevers, CXR normal, UA not suggestive of infection. She had
no tachycardia or tachypnea. There was low suspicion for
infection.
CHRONIC ISSUES:
#Ischemic stroke history: Stable. Home Plavix was initially held
and restarted when the patient was found to be hemodynamically
stable without active bleed.
#Hypertension: Stable. The patient was discharged on her home
antihypertensive regimen.
#Hypothyroidism: Stable. Continued home levothyroxine.
#Menopause: Stable. Continued home Raloxifene
TRANSITIONAL ISSUES:
#Upper GI Bleed: She should continue taking omeprazole 40 mg PO
BID. She should follow up with GI for further workup in the
outpatient setting as appropriate.
#Nausea, Vomiting: She should follow up with GI in the
outpatient setting for further workup of nausea and vomiting.
The risks and benefits of EDG should be assessed. It is also
possible that these symptoms come from ill-fitting dentures and
the patient should follow up with dental for denture fitting
and/or implantation. She should continue on a liquid/soft solid
diet (4 Ensures and soft solids as tolerated).
#CODE: Full (confirmed, with limited trial of life-sustaining
measures) - should be reassessed in the outpatient setting
#EMERGENCY CONTACT HCP: ___ (son), ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atenolol 50 mg PO DAILY
2. amLODIPine 5 mg PO DAILY
3. Lisinopril 40 mg PO DAILY
4. Clopidogrel 75 mg PO DAILY
5. Levothyroxine Sodium 50 mcg PO DAILY
6. raloxifene 60 mg oral DAILY
7. Centrum (multivit-iron-min-folic
acid;<br>multivit-mins-ferrous gluconat) 3,500-18-0.4 unit-mg-mg
oral DAILY
8. Acetaminophen 1000 mg PO BID
Discharge Medications:
1. Pantoprazole 40 mg PO Q12H
RX *pantoprazole 40 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*0
2. Acetaminophen 1000 mg PO BID
3. amLODIPine 5 mg PO DAILY
4. Atenolol 50 mg PO DAILY
5. Centrum (multivit-iron-min-folic
acid;<br>multivit-mins-ferrous gluconat) 3,500-18-0.4 unit-mg-mg
oral DAILY
6. Clopidogrel 75 mg PO DAILY
7. Levothyroxine Sodium 50 mcg PO DAILY
8. Lisinopril 40 mg PO DAILY
9. raloxifene 60 mg oral DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: Esophageal dysmotility, Upper GI Bleed, Nausea and
vomiting, Leukocytosis
Secondary: Hypertension, Hypothyroidism
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were admitted to ___
because you had many episodes of vomiting with some blood in it.
While you were here we kept you on medications to treat your
stomach. We also did an x-ray of your food pipe which was
normal. You had no further bleeding while you were here and your
blood counts were good.
When you leave the hospital, make sure to take all of your
medications as directed. It will also be important to follow up
with your primary doctor, ___, as well as our stomach
doctors (___).
Thank you for allowing us to care for you here,
Your ___ Care Team
Followup Instructions:
___
|
19693734-DS-17
| 19,693,734 | 24,091,874 |
DS
| 17 |
2163-09-07 00:00:00
|
2163-09-07 16:10:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: CARDIOTHORACIC
Allergies:
lisinopril / Iodinated Contrast Media - IV Dye /
Gadolinium-Containing Contrast Media
Attending: ___
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
Cath ___
.
___
1. Coronary artery bypass graft x 4. Total arterial
revascularization.
2. Skeletonized left internal mammary artery sequential
grafting to diagonal and left anterior descending artery.
3. Left radial artery taken off as a T graft off the left
internal mammary artery and anastomosed in a sequential
fashion to the obtuse marginal artery proximally and distally.
4. Endoscopic harvesting of the left radial artery.
History of Present Illness:
Ms. ___ is a ___ with hx
T2DM, HLD, HTN, HCV cirrhosis, and depression who presents with
chest pain.
She reports that she first noted chest pain on ___ or ___
of this week when taking luggage to her car. She describes the
pain as "pressure" located in the ___ her chest that
"spreads to both sides." The pressure lasts for about ___
minutes after stopping activity then slowly dissipates. The pain
is associated with dyspnea on exertion that has been getting
worse over the last several days. The pain also radiates to the
back of her throat. She has never had chest pain before. Today
she was at the grocery store and had symptoms with walking
throughout the store. She drove herself to the emergency room
and
had to park in ___. She needed to stop 3 times between ___
and the ER due to pain and shortness of breath. She also has
noted burping over the last week since the pain started.
She has no history of PE/DVT, malignancy, or recent surgery.
Endorses 10 pound non-intentional weight loss over past ___
months ___ decreased appetite. History of excessive sweating x
___ years.
Past Medical History:
1. Cirrhosis, secondary to hepatitis C:
- Genotype 1
- Liver biopsy (___) with marked portal and moderate periportal
mononuclear cell inflammation with focal bridging (grade ___,
mild steatosis without intracytoplasmic hyalin and stage 4
cirrhosis
- Has been treated twice with clearance and recurrence
- Initiated on interferon/ribavirin/telaprevir 1 week ago
2. Diabetes
3. Anxiety
Social History:
___
Family History:
mom-heart surgery w/valve replacement at age ___ had h/o DM
&
breast CA
dad-prostate CA
sister-seizure disorder, DM, lung and breast cancers
brother-died ___
___ disease and DM
brother-prostate CA
2 ___
Physical Exam:
ADMISSION PHYSICAL EXAM
=======================
VS: 98.6F, HR 88, BP 131/88, RR 17, 94% on RA
GENERAL: NAD
HEENT: AT/NC, anicteric sclera, MMM, poor dentition
NECK: supple, no LAD
CV: RRR, S1/S2, no murmurs, gallops, or rubs
PULM: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
GI: abdomen soft, obese, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: no cyanosis, clubbing, or edema
PULSES: 2+ radial pulses bilaterally
NEURO: Alert, moving all 4 extremities with purpose, face
symmetric
DISCHARGE PHYSICAL EXAM
=======================
97.8
PO 130 / 66
L Lying 81 22 92 Ra
.
General: NAD [x]
Neurological: A/O x3 [x] non-focal [x]
HEENT: PEERL []
Cardiovascular: RRR [x] Irregular [] Murmur [] Rub []
Respiratory: CTA [x]diminished , No resp distress [x]
GI/Abdomen: Bowel sounds present [x] Soft [x] ND [x] NT [x]
Extremities:
Right Upper extremity Warm [x] Edema
Left Upper extremity Warm [x] Edema
Right Lower extremity Warm [x] Edema trace
Left Lower extremity Warm [x] Edema trace
Sternal: CDI [x] no erythema or drainage []
Sternum stable [x] Prevena [x]
Lower extremity: Right [] Left [] CDI []
Upper extremity: Right [] Left [x] CDI [x]
Other:
Pertinent Results:
ADMISSION LABS
==============
___ 09:01PM BLOOD WBC-11.1* RBC-4.15 Hgb-11.7 Hct-36.1
MCV-87 MCH-28.2 MCHC-32.4 RDW-14.6 RDWSD-46.0 Plt ___
___ 09:01PM BLOOD Neuts-63.1 ___ Monos-5.8 Eos-3.9
Baso-0.8 Im ___ AbsNeut-6.98* AbsLymp-2.86 AbsMono-0.64
AbsEos-0.43 AbsBaso-0.09*
___ 09:01PM BLOOD ___ PTT-23.6* ___
___ 09:01PM BLOOD D-Dimer-513*
___ 09:01PM BLOOD Glucose-202* UreaN-21* Creat-1.1 Na-140
K-4.4 Cl-102 HCO3-21* AnGap-17
___ 09:01PM BLOOD CK(CPK)-66
___ 09:01PM BLOOD CK-MB-3
PERTINENT LABS
==============
___ 07:15AM BLOOD %HbA1c-7.8* eAG-177*
___ 09:01PM BLOOD D-Dimer-513*
___ 09:01PM BLOOD cTropnT-0.04*
___ 01:17AM BLOOD CK-MB-3 cTropnT-0.05*
___ 01:17AM BLOOD cTropnT-0.04*
___ 08:45AM BLOOD CK-MB-3 cTropnT-0.04*
___ 11:55PM BLOOD CK-MB-4 cTropnT-0.09*
___ 07:15AM BLOOD CK-MB-5 cTropnT-0.14*
PERTINENT IMAGING
=================
___ Intra-op TEE
Conclusions
PREBYPASS
No atrial septal defect is seen by 2D or color Doppler. Left
ventricular wall thicknesses are normal. The left ventricular
cavity is mildly dilated. There is mild regional left
ventricular systolic dysfunction with hypokinesis of the distal
anterior and anterolateral walls EF 40-45%. The right
ventricular cavity is mildly dilated with normal free wall
contractility. The ascending aorta is mildly dilated. There are
simple atheroma in the descending thoracic aorta. The aortic
valve leaflets (3) are mildly thickened. No aortic regurgitation
is seen. The mitral valve leaflets are mildly thickened.
Physiologic mitral regurgitation is seen (within normal limits).
POSTBYPASS
The LV systolic function has improved post bypass LVEF 55%
RV systolic function remians normal
The MR is now ___ mild-moderate.
The remaining study is unchanged.
.
DISCHARGE LABS
===============
___ 05:57AM BLOOD WBC-9.4 RBC-3.03* Hgb-8.3* Hct-26.5*
MCV-88 MCH-27.4 MCHC-31.3* RDW-14.4 RDWSD-46.0 Plt ___
___ 06:15AM BLOOD WBC-9.4 RBC-2.85* Hgb-7.9* Hct-25.3*
MCV-89 MCH-27.7 MCHC-31.2* RDW-14.5 RDWSD-46.8* Plt ___
___ 02:36AM BLOOD ___ PTT-21.7* ___
___ 01:46PM BLOOD ___ PTT-22.2* ___
___ 05:57AM BLOOD Glucose-85 UreaN-20 Creat-0.9 Na-140
K-4.2 Cl-99 HCO3-26 AnGap-15
___ 06:15AM BLOOD Glucose-126* UreaN-15 Creat-0.9 Na-139
K-4.1 Cl-101 HCO3-25 AnGap-13
___ 02:36AM BLOOD ALT-18 AST-33 LD(LDH)-213 AlkPhos-68
TotBili-0.2
___ 07:07PM BLOOD CK-MB-3 cTropnT-0.13*
___ 05:57AM BLOOD Mg-2.0
___ 07:15AM BLOOD %HbA1c-7.8* eAG-177*
.
Brief Hospital Course:
The patient was brought to the Operating Room on ___ where
the patient underwent CABG x 4 with Dr. ___. Overall the
patient tolerated the procedure well and post-operatively was
transferred to the CVICU in stable condition for recovery and
invasive monitoring.
POD 1 found the patient extubated, alert and oriented and
breathing comfortably. The patient was neurologically intact
and hemodynamically stable. Beta blocker was initiated and the
patient was gently diuresed toward the preoperative weight.
Imdur for radial graft x 6 months. The patient was transferred
to the telemetry floor for further recovery. Chest tubes and
pacing wires were discontinued without complication. The
patient was evaluated by the Physical Therapy service for
assistance with strength and mobility. By the time of discharge
on POD 5 the patient was ambulating freely, the wound was
healing and pain was controlled with oral analgesics. The
patient was discharged to ___ in good condition with
appropriate follow up instructions.
Expected length of stay at rehab is less than 30 days.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. BuPROPion (Sustained Release) 100 mg PO QAM
2. DULoxetine 20 mg PO DAILY
3. Glargine 39 Units Bedtime
4. Losartan Potassium 25 mg PO DAILY
5. MetFORMIN XR (Glucophage XR) ___ mg PO DAILY
6. Pravastatin 40 mg PO QPM
7. Aspirin 81 mg PO DAILY
8. Omeprazole 20 mg PO DAILY
9. LOPERamide 2 mg PO QID:PRN diarrhea
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild/Fever
2. Albuterol Inhaler 4 PUFF IH Q6H
3. Atorvastatin 80 mg PO QPM
4. Docusate Sodium 100 mg PO BID
5. Furosemide 40 mg PO DAILY Duration: 10 Days
6. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
Duration: 6 Months
7. Metoprolol Tartrate 37.5 mg PO Q6H
8. Potassium Chloride 20 mEq PO DAILY Duration: 10 Days
9. TraMADol 50 mg PO Q4H:PRN Pain - Moderate
RX *tramadol 50 mg 1 tablet(s) by mouth every four (4) hours
Disp #*40 Tablet Refills:*0
10. DULoxetine 40 mg PO DAILY
11. Glargine 40 Units Breakfast
Insulin SC Sliding Scale using REG Insulin
12. Aspirin 81 mg PO DAILY
13. BuPROPion (Sustained Release) 100 mg PO QAM
14. MetFORMIN XR (Glucophage XR) ___ mg PO DAILY
Do Not Crush
15. Omeprazole 20 mg PO DAILY
16. HELD- Losartan Potassium 25 mg PO DAILY This medication was
held. Do not restart Losartan Potassium until discussed with PCP
or ___
___ Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSES
=================
CHEST PAIN
NSTEMI
CIRRHOSIS
CAD
.
NSTEMI with acute systolic heart failure this admit
DM2, HTN, dyslipidemia and HCV (has been eradicated now for over
___ years), compensated cirrhosis (reports q6mo liver scans
w/plan to drop to annual scans if ___ scan remained good),
depression, IBS with Diarrhea, 10lb unintentional wt loss/2
months, remote smoking, R hip pain s/p cortisone injection,
unrinary incontinence, neuropathy
Past Surgical History:cholecystectomy, tubal ligation,
tonsillectomy
Discharge Condition:
Alert and oriented x3, non-focal
Ambulating, gait steady
Sternal pain managed with oral analgesics
Sternal Incision - healing well, no erythema or drainage
Edema trace
Discharge Instructions:
Prevena instructions
· The Prevena Wound dressing should be left on for a total
of 7 days post-operatively to receive the full benefit of the
therapy. The date of Day # 7 should be written on a piece of
tape on the canister to ensure that the nurse from the ___ or
___ facility knows when to remove the dressing and inspect the
incision. If the date is not written, please alert your nurse
prior to discharge.
· You may shower, however, please avoid getting the
dressing and suction canister soiled or saturated.
· You will be sent home with a shower bag to hold the
suction canister while bathing.
· If the dressing does become soiled or saturated, turn
the power off and remove the dressing. The entire unit may then
be discarded. Should this happen, please notify your ___ nurse,
so they may make plans to see you the following day to assess
your incision.
· Once the Prevena dressing is removed, you may wash your
incision daily with a plain white bar soap, such as Dove or
___. Do not apply any creams, lotions or powders to your
incision and monitor it daily.
· If you notice any redness, swelling or drainage, please
contact your surgeon's office at ___.
.
Please shower daily -wash incisions gently with mild soap, no
baths or swimming, look at your incisions daily
Please - NO lotion, cream, powder or ointment to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics
Clearance to drive will be discussed at follow up appointment
with surgeon
No lifting more than 10 pounds for 10 weeks
Encourage full shoulder range of motion, unless otherwise
specified
**Please call cardiac surgery office with any questions or
concerns ___. Answering service will contact on call
person during off hours**
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
Followup Instructions:
___
|
19693808-DS-20
| 19,693,808 | 25,155,594 |
DS
| 20 |
2121-02-11 00:00:00
|
2121-02-12 10:29:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Fall
Major Surgical or Invasive Procedure:
Extubation
History of Present Illness:
___ gentleman with HTN, HLD, remote h/o prostate cancer and s/p
AVR for stenosis who presented to OSH w/ acute change in MS. ___
was found to have a GCS of 5 so was intubated prior to being
transferred to ___. Earlier on day of admission, ___ was noted
to have a staring episode while standing and was unresponsive,
wife moved ___ to chair but ___ fell out of chair and struck
his head. Taken to ___ by EMS, found to have GCS 5 with
L gaze deviation. Had seizure activity, given 4mg Ativan and 1gm
keppra before intubation. ___ Head CT and CT Spine
negative. CXR showed infiltrate; received CTX & azithro.
Transferred to ___ ED for further workup.
In the ED, initial vitals: 98.8F, HR 61, BP 153/74, RR16, 97%
Intubation ETCO@ 41.
Past Medical History:
Isolated seizure activity
Remote h/o Prostate Cancer s/p XRT and surgical resection ___
___ ___
HTN
HLD
Aortic Stenosis s/p AVR ___ at ___ not on coumadin
Macular degeneration (wet and dry)
Legally blind
Hearing loss w/ hearing aids
Social History:
___
Family History:
Mother: ___ died of TB
Father: ___ died of MI
Physical Exam:
ADMISSION PHSYICAL
GENERAL: Alert delirious trying to get out of bed
HEENT: Sclera anicteric, MMM, oropharynx clear, Gurgling
NECK: supple, no TTP of C spine
LUNGS: Rhonchi throughout
CV: Regular rate and rhythm, normal S1 S2, soft systolic murmur,
no rubs/gallops
ABD: soft, ___, no rebound tenderness or
guarding
EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
NEURO: AOx1, alert answering some questions with short answers,
moving all extremities, and redirectable if emphasized and
speaking into pt's ear, calling out for his mother
intermittently
DISCHARGE PHYSICAL
VS - 98.4 145/71 59 16 97%
ORTHOSTATICS ___: Suppine: 169/72 HR 70 Sitting: 146/69 HR 79
Standing: 133/68 HR 70. No lightheadedness
GENERAL: NAD, sitting up in bed. Very tan.
HEENT: Sclera anicteric, MMM, oropharynx clear
LUNGS: CTAB, no wheezes/rales/rhonchi
CV: Regular rate and rhythm, normal S1 S2, soft systolic
murmur, no rubs/gallops
ABD: soft, ___, no rebound tenderness or
guarding
EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
NEURO: AOx3, ___ months listed backwards, answering all
questions. Minimal visual acuity (chronic)No facial asymmetry,
strength ___ all extremities.
Pertinent Results:
ADMISSION LABS
___ 06:15PM BLOOD ___
___ Plt ___
___ 06:15PM BLOOD ___
___ Im ___
___
___ 06:15PM BLOOD ___
___
___ 06:15PM BLOOD CK(CPK)-186
___ 03:13PM BLOOD ___ LD(LDH)-279* ___
___
___ 06:15PM BLOOD ___
___ 06:15PM BLOOD ___
___ 03:13PM BLOOD ___
___ 01:29AM BLOOD ___
___ 06:15PM BLOOD ___
___
___ 06:20PM BLOOD ___/ Tidal ___
___ Base XS--6
___ REQ ___ -ASSIST/CON ___
___ 06:30PM BLOOD ___
___ 06:20PM BLOOD O2 ___
___ 06:15PM URINE ___ Sp ___
___ 06:15PM URINE ___
___
MICRO: ___ Blood cx NGTD
IMAGING:
___ CXR
Bilateral perihilar and basilar opacities may be due to
pulmonary edema. Underlying aspiration or infection not
excluded.
___ CT A Head/Neck
IMPRESSION:
1. No acute intracranial abnormality.
2. 4 mm aneurysm involving the anterior communicating artery.
3. Atherosclerotic calcification of intracranial and neck
vasculature without stenosis of bilateral internal carotid
arteries near the bifurcation.
4. Tight stenosis of bilateral vertebral arteries near its
origin.
___ CXR
Endotracheal tube and feeding tube have been removed. There is
unchanged mild cardiomegaly. There are again seen bibasilar
opacities, unchanged. This may be due to atelectasis or
aspiration. No pneumothoraces are seen.
___ MRI - partial, stopped ___ claustrophobia
1. Limited and incomplete MRI of the brain with no contrast
administered secondary to ___ claustrophobia. No acute
infarct or large compressive mass identified on the limited
sequences. A repeat completion MRI can be acquired if
clinically indicated.
2. 4 mm anterior communicating artery aneurysm again seen,
better visualized on the dedicated CTA of the head.
___ ECHO
Mild symmetric left ventricular hypertrophy with preserved
global and regional biventricular systolic function. No frank
left ventricular outflow tract obstruction. ___
bioprosthetic aortic valve replacement. Mild mitral
regurgitation.
EKG: NSR, normal axis, intervals, no ST changes
EEG ___:
IMPRESSION: This is an abnormal routine EEG because of (1)
prominent delta
frequency focal slowing over the left temporal region and
broader left
hemisphere with similar but less prominent slowing over the
right hemisphere at times; (2) a slow, disorganized background;
and (3) excess beta activity throughout the record. These
findings are consistent with focal subcortical dysfunction over
the left hemisphere, as could be seen in a postictal state or
from other etiologies, as well as a ___ diffuse
encephalopathy which is ___. Excessive beta activity
can be consistent with medication effect, as from
benzodiazepines or barbiturates. No epileptiform activity was
seen.
EEG ___: IMPRESSION: This is an abnormal continuous ICU
EEG monitoring study because of excess intermittent focal
slowing on the left, most prominent in the left parasaggital
region, consistent with focal dysfunction. There are no
epileptiform discharges or electrographic seizures.
DISCHARGE LABS:
___ 07:35AM BLOOD ___
___ Plt ___
___ 07:35AM BLOOD ___
___
___ 07:35AM BLOOD ___
Brief Hospital Course:
Mr. ___ is an ___ gentleman with HTN, HLD, remote
h/o prostate cancer and s/p AVR for stenosis who presented to
OSH w/ acute change in MS ___ 5), was intubated and transferred
to ___ MICU for mechanical ventilation. Per wife, ___
looked disoriented at home with left gaze deviation, repetitive
mouth movements but ___ and ___. She sat
him down in chair after which ___ fell and hit his head. Per EMS
report, initial SBPs were in the 240s and was taken to
___. At OSH, ___ remained encephalopathic and was
intubated for protection of his airway, followed by transfer to
___. As ___ regained consciousness, ___ was extubated with
recovery back to his baseline mental status. ___ had EEG
significant for slowing on the left, for which ___ was loaded and
maintained on Keppra. CTA with atherosclerotic disease without
stenosis of the ICAs and notable for 4 mm aneurysm involving the
anterior communicating artery. MRI only partially completed due
to claustrophobia but without acute abonormality. TTE
unremarkable, with EF > 55%.
ACTIVE ISSUES:
#Seizure with ___ state w/ head strike: Initially
presented with AMS, GCS 5 requiring intubation. EMS reports
systolics in the field to the 240s. Rapid resolution of
condition and was extubated less than 24 hours later. CTA not
indicative of stroke. No pathology from head trauma. No
significant metabolic abnormalities. Toxicology screen
unremarkable. AMS began resolving quickly after extubation, per
___ family, to baseline. Did receive Haldol x3 after ___
was extubated for agitation. EEG findings were consistent with
focal subcortical
dysfunction over the left hemisphere consistent with story of
staring episode and seizure episode at ___ was
loaded with Keppra dose and maintained on 500mg bid. Pt was seen
by neurology here throughout the hospitalization, and per their
recommendations, ___ to follow up with PCP and neurology in
setting of new seizure disorder. ___ was also counseled on
importance of continuing his hypertensive medications.
# Pulmonary edema vs Aspiration pneumonitis vs CAP: Initial CXR
significant for bilateral perihilar and basilar opacities may be
due to pulmonary edema vs pneumonia. ___ did not have a fever or
leukocytosis of pneumonia, however, given initial need for
intubation, ___ was covered empirically for community acquired
PNA with CTX and azithromycin. Antibiotics were discontinued
___ lungs sounds ___. Given
hypertensive emergency, likely flash pulmonary edema.
Respiratory status stabilized with unremarkable exam, saturating
well on RA by discharge.
# Anemia: Admission hemoglobin 9.3 which remained stable. MCV
93.
# Hyperkalemia: Resolved. Admission K of 5.5, without peaked T
waves. Potassium values normalized on subsequent labs without
intervention.
Chronic Problems:
# HTN: ___ was continued on metoprolol succinate 50mg qd and
isosorbide mononitrate 30mg daily.
# HLD: ___ was continued on home simvastatin 80mg
# AVR: ___ was continued on Aspirin 81mg.
TRANSITIONAL ISSUES:
- ___ initiated on keppra on ___ for seizure prevention;
please arrange follow up with neurology within the next two
weeks; Final EEG reads can be found in RESULTS section. Notable
for focus of left sided slowing likely implicated in new onset
seizure disorder. ___ should follow up with an epileptologist
(see my d/c letter, and phone call instructions to pt and wife
of last night)
- Creatinine ___: Unclear baseline; outpatient workup for
mild CKD.
- Continue blood pressure control with home medications, with
further uptitration deferred to his PCP
- ___ noted to have a stable anemia Hb ___ during this
admission without signs or symptoms of active bleeding; further
workup deferred to the outpatient setting
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Simvastatin 80 mg PO QPM
2. Aspirin 81 mg PO DAILY
3. Metoprolol Succinate XL 50 mg PO DAILY
4. Isosorbide Dinitrate 10 mg PO TID
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Metoprolol Succinate XL 50 mg PO DAILY
3. Simvastatin 80 mg PO QPM
4. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
5. LeVETiracetam 500 mg PO BID
RX *levetiracetam [Keppra] 500 mg 1 tablet(s) by mouth twice a
day Disp #*30 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
Seizure Disorder
Hypertension
Secondary Diagnoses:
Hyperlipidemia
Bioprosthetic Aortic Valve Replacement
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure to care for you at ___. You were admitted
for a prolonged loss of consciousness and fall that required
intubation with mechanical breathing and monitoring in the
intensive care unit. As your mental status recovered, the tube
was removed and you were stable enough to move to the general
medicine floors. Testing for seizure and stroke were
abbreviated, however, the EEG study showed evidence of possible
seizure activity. We started you on medications to prevent
future seizures and recommend that you follow up with your
neurologist.
It is very important to take all of your medications medications
as prescribed, especially your blood pressure medications:
Metoprolol XL and Isosorbide Mononitrate. It is very important
to take your ___ medication, called levetiracetam.
Please also follow up with your primary care provider ___ 2
weeks. If you experience any weakness, slurred speech,
disorientation, or lightheadness, please seek medical attention.
Wishing you the best of health moving forward,
Your ___ team
Followup Instructions:
___
|
19693808-DS-21
| 19,693,808 | 28,357,314 |
DS
| 21 |
2122-10-03 00:00:00
|
2122-10-29 13:42:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: UROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
bladder perforation, RP urinoma, and hemorrhage
Major Surgical or Invasive Procedure:
NONE during this admission
___: 45 cm right basilic single lumen non-heparin dependent
power PICC placed at bedside.
History of Present Illness:
___ hx chronic anemia, htn, hld, seizure disorder, CKD stage
III, aortic stenosis s/p bioprosthetic AVR, blindness and
prostate cancer and distant open prostatectomy ___ - ___,
XRT, and Lupron complicated by radiation cystitis who presents
as transfer from ___ with bladder perforation by Foley
catheter and hemorrhage. Patient is s/p recent cystoscopy with
bladder biopsy and electrofulguration of minor bladder polyp in
___ after presentation to ED with complaints of abdominal
pain and hematuria from indwelling Foley catheter. Last week,
___, a foley catheter was placed in the ___ clinic for
urinary retention and was notable for hematuria. Patient has
been having active hematuria since that time (x10 days). Patient
presented to ___ ___ with gross hematuria, his Hct was
15 at 12:49. A three-way foley catheter was placed, and
continuous bladder irrigation was initiated, per patient there
were numerous foley placement attempts and replacements at this
time. The patient received 2uPRBC with post-transfusion Hct of
20.5. CT demonstrated fluid and gas in retroperitoneum,
concerning for bladder perforation with retroperitoneal urinoma.
Patient remained hemodynamically stable per report, received 1g
of IV ceftriaxone and was transferred to ___ for ICU
admission. At the time of admission to ___ ED patient was
afebrile and HD stable with HR 94 and BP 144/77. Labs were
notable for Hct 19, Cr 2.0(2.14 at ___, and normal lactate
of 1.3. Patient was started on Vancomycin/Zosyn and CT cystogram
was obtained which demonstrates intraperitoneal bladder rupture
with contrast material seen extending along the left pericolic
gutter with the tip of the Foley catheter extending extraluminal
from bladder wall rupture into the peritoneum. Patient received
1uPRBC at 2:30am for Hct 19 with appropriate response (Hct 23).
His Hct is stable this am at 25 7am. In communication with
Urology, plan is for possible OR for primary closure vs.
percutaneous nephrostomy tubes
Past Medical History:
Prior seizure ___, required intubation for airway protection,
MRI w/ incidental note of 4mm anterior communicating artery
aneurysm)
Remote h/o Prostate Cancer s/p XRT and surgical resection
___
___ c/b radiation cystitis
HTN
HLD
Multifactorial anemia (B12 deficiency & ID)
Aortic Stenosis s/p AVR (bioprosthetic valve - ___ at ___
not on coumadin
Macular degeneration (wet and dry)
Legally blind
Hearing loss w/ hearing aids
Social History:
___
Family History:
Mother: ___ died of TB
Father: ___ died of MI
Physical Exam:
WDWN male, nad, pleasant, cooperative
bilateral hearing aids
legally blind
abdomen soft, NT/ND
Foley in place.
lower extremities w/out e/p/c/d.
Pertinent Results:
___ 09:55AM BLOOD WBC-5.8 RBC-2.66* Hgb-7.7* Hct-22.7*
MCV-85 MCH-28.9 MCHC-33.9 RDW-14.5 RDWSD-44.9 Plt ___
___ 07:00AM BLOOD WBC-4.7 RBC-2.45* Hgb-6.9* Hct-21.0*
MCV-86 MCH-28.2 MCHC-32.9 RDW-14.9 RDWSD-45.8 Plt ___
___ 07:20PM BLOOD WBC-6.2 RBC-2.48* Hgb-7.1* Hct-21.4*
MCV-86 MCH-28.6 MCHC-33.2 RDW-14.9 RDWSD-47.5* Plt ___
___ 07:33AM BLOOD WBC-9.5 RBC-2.86* Hgb-8.6* Hct-25.3*
MCV-89 MCH-30.1 MCHC-34.0 RDW-15.1 RDWSD-48.4* Plt ___
___ 04:40AM BLOOD WBC-10.2* RBC-2.59* Hgb-7.7* Hct-23.2*
MCV-90 MCH-29.7 MCHC-33.2 RDW-14.7 RDWSD-47.8* Plt ___
___ 11:47PM BLOOD WBC-7.8# RBC-2.12*# Hgb-6.4*# Hct-19.1*#
MCV-90 MCH-30.2 MCHC-33.5 RDW-14.2 RDWSD-46.4* Plt ___
___ 11:47PM BLOOD CK(CPK)-1015*
___ 11:47PM BLOOD CK-MB-9 MB Indx-0.9 cTropnT-<0.01
___ 07:20PM BLOOD Calcium-7.6* Mg-2.0
___ 07:33AM BLOOD Calcium-8.1* Phos-4.6* Mg-2.2
___ 04:40AM BLOOD Calcium-7.8* Phos-4.6* Mg-2.1
___ 11:47PM BLOOD Calcium-7.1* Phos-3.6 Mg-1.9
___ 04:56AM BLOOD Lactate-1.4
___ 11:47PM BLOOD Lactate-1.3 K-4.5
___ 04:56AM BLOOD Hgb-8.2* calcHCT-25
___ 11:47PM BLOOD Hgb-6.7* calcHCT-20
___ 11:48PM URINE Color-Red Appear-Cloudy Sp ___
___ 11:48PM URINE Blood-LG Nitrite-POS Protein->300
Glucose-NEG Ketone-40 Bilirub-LG Urobiln-4* pH-5.5 Leuks-LG
___ 11:48PM URINE RBC->182* WBC->182* Bacteri-NONE
Yeast-NONE Epi-0
___ STOOL C. difficile DNA amplification
assay-FINAL INPATIENT
___ URINE URINE CULTURE-FINAL {STAPH AUREUS COAG
+} INPATIENT
___ BLOOD CULTURE Blood Culture, Routine-FINAL
INPATIENT
___ BLOOD CULTURE Blood Culture, Routine-FINAL
INPATIENT
___ BLOOD CULTURE Blood Culture, Routine-FINAL
{STAPH AUREUS COAG +}; Anaerobic Bottle Gram Stain-FINAL
EMERGENCY WARD
___ URINE URINE CULTURE-FINAL {STAPH AUREUS COAG
+} EMERGENCY WARD
___ BLOOD CULTURE Blood Culture, Routine-FINAL
EMERGENCY WARD
Log-In Date/Time: ___ 11:48 pm
URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
STAPH AUREUS COAG +. >100,000 CFU/mL.
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 +
|
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN----------<=0.12 S
NITROFURANTOIN-------- <=16 S
OXACILLIN------------- 0.5 S
TETRACYCLINE---------- <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
___ 11:50 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___:
STAPH AUREUS COAG +. FINAL SENSITIVITIES.
Staphylococcus species may develop resistance during
prolonged
therapy with quinolones. Therefore, isolates that are
initially
susceptible may become resistant within three to four
days after
initiation of therapy. Testing of repeat isolates may
be
warranted.
Consultations with ID are recommended for all blood
cultures
positive for Staphylococcus aureus, yeast or other
fungi.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN----------<=0.12 S
OXACILLIN------------- 0.5 S
TRIMETHOPRIM/SULFA---- <=0.5 S
Anaerobic Bottle Gram Stain (Final ___:
GRAM POSITIVE COCCI IN CLUSTERS.
Reported to and read back by ___ ___ ___
AT 0856).
/___ am URINE Source: Catheter.
**FINAL REPORT ___
URINE CULTURE (Final ___:
STAPH AUREUS COAG +. ~5000 CFU/mL.
SENSITIVITIES PERFORMED ON CULTURE # ___
(___).
Brief Hospital Course:
Mr. ___ is a ___ male with a history of PCa s/p prostatectomy
+ radiation + Lupron, radiation cystitis, chronic anemia, htn,
hld, seizures, hypothyroid, CKD III, legal blindness who had a
recurrent hematuria workup started at ___. He had a
cystoscopy with bladder biopsy and fulguration on ___.
Roughly 10 days prior to admission and was having difficulty
urinating and had a foley placed. He then began having hematuria
about 5 days before admission. When it began clogging his foley,
he presented to ___ for evaluation. He had a CT scan which
was suspicious for a possible bladder perforation given
extension of fluid and some air to the retroperitoneum,
extending up to the left kidney. He additionally had a very low
hematocrit (~15) which prompted transfusion of 2 units of pRBCs
and transfer to ___. On presentation, the patient is
pleasant but confused. He is unable to significantly contribute
to his recent history. Patient with CT cystogram showing
perforation, with tip of foley catheter slightly protruding
through bladder. Contrast is seen up to the level of the kidney,
with some contrast in the left pericolic gutter. Most of the
contrast appears contained, either retroperitoneal or walled
off, but there is certainly contrast around the colon. Mr.
___ foley catheter was repositioned and urine output
monitored. Our colleagues in infectious disease advised on
antibiotics and ruled out valve involvement with regard to his
positive urine and blood cultures. A PICC was placed for long
term IV antibiotics and he and his family elected for discharge
home with infusion therapy vs a rehab. He was subsequently
discharged with bladder injury managed conservatively and a plan
for cystogram in a few weeks followed by possible void trial.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Metoprolol Succinate XL 50 mg PO DAILY
3. Simvastatin 80 mg PO QPM
4. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
5. LeVETiracetam 500 mg PO QPM; 8PM
6. Atorvastatin 80 mg PO QPM
7. Multivitamins W/minerals 1 TAB PO DAILY
8. Acetaminophen 650 mg PO Q8H:PRN Pain - Mild
9. Levothyroxine Sodium 50 mcg PO DAILY
10. LevETIRAcetam 250 mg PO QAM
Discharge Medications:
1. CeFAZolin 2 g IV Q8H
RX *cefazolin in dextrose (iso-os) 2 gram/100 mL 2 g IV three
times a day Disp #*66 Intravenous Bag Refills:*0
2. Senna 8.6 mg PO BID:PRN Constipation
RX *sennosides [Senokot] 8.6 mg one tab by mouth ___ x daily
Disp #*60 Tablet Refills:*0
3. Sodium Chloride 0.9% Flush ___ mL IV DAILY and PRN, line
flush
RX *sodium chloride 0.9 % 0.9 % ___ mL IV TID and PRN Disp
___ Milliliter Milliliter Refills:*0
4. Acetaminophen 650 mg PO Q8H:PRN Pain - Mild
5. Aspirin 81 mg PO DAILY
6. Atorvastatin 80 mg PO QPM
7. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
8. LeVETiracetam 500 mg PO QPM; 8PM
9. LevETIRAcetam 250 mg PO QAM
10. Levothyroxine Sodium 50 mcg PO DAILY
11. Metoprolol Succinate XL 50 mg PO DAILY
12. Multivitamins W/minerals 1 TAB PO DAILY
13. Simvastatin 80 mg PO QPM
14.Outpatient Lab Work
___ WEEKLY LAB RESULTS
ATTN: ___ CLINIC - FAX: ___
WEEKLY: CBC with differential, BUN, Cr
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Acute posthemorrhagic anemia on chronic anemia (requiring blood
transfusion)
bladder perforation (history of postirradiation cystitis)
requiring foley catheter
MSSA bloodstream infection (requiring PICC and ___ IV abx)
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent
Discharge Instructions:
-Please also reference the instructions provided by nursing on
Foley catheter care, hygiene and waste elimination.
-ALWAYS follow-up with your referring provider ___ your PCP
to discuss and review your post-operative course and
medications. Any NEW medications should also be reviewed with
your pharmacist.
-Resume your pre-admission medications except as noted on the
medication reconciliation
-You may take ibuprofen and the prescribed narcotic together for
pain control. FIRST, use Tylenol and Ibuprofen. Add the
prescribed narcotic (examples: Oxycodone, Dilaudid,
Hydromorphone) for break through pain that is >4 on the pain
scale.
-The maximum dose of Tylenol (ACETAMINOPHEN) is 3- 4 grams (from
ALL sources) PER DAY.
-Ibuprofen should always be taken with food. If you develop
stomach pain or note black stool, stop the Ibuprofen. Ibuprofen
works best when taken around the clock.
-For your safety and the safety of others; PLEASE DO NOT drive,
operate dangerous machinery, or consume alcohol while taking
narcotic pain medications.
-Do NOT drive while Foley catheter is in place.
-AVOID lifting/pushing/pulling items heavier than 10 pounds (or
3 kilos; about a gallon of milk) or participate in high
intensity physical activity (which includes intercourse) until
you are cleared by your Urologist in follow-up. Generally about
FOUR weeks. Light household chores are generally ok. Do not
vacuum.
-No DRIVING until you are cleared by your Urologist
-Do not drive or drink alcohol while taking narcotics and do not
operate dangerous machinery
-You may be given prescriptions for a stool softener ___ a
gentle laxative. These are over-the-counter medications that
may be health care spending account reimbursable.
-Colace (docusate sodium) may have been prescribed to avoid
post-surgical constipation or constipation related to use of
narcotic pain medications. Discontinue if loose stool or
diarrhea develops. Colace is a stool-softener, NOT a laxative.
-Senokot (or any gentle laxative) may have been prescribed to
further minimize your risk of constipation.
-You may shower as usual but do not immerse in bath/pool while
foley in place
-Your Foley should be secured to the catheter secure on your
thigh at ALL times until your follow up with the surgeon.
-DO NOT allow anyone that is outside of the urology team remove
your Foley for any reason.
-Wear Large Foley bag for majority of time; the leg bag is only
for short-term when leaving the house, etc.
-___ medical attention for fevers (temp>101.5), worsening pain,
drainage or excessive bleeding from incision, chest pain or
shortness of breath.
Followup Instructions:
___
|
19693863-DS-19
| 19,693,863 | 24,056,853 |
DS
| 19 |
2176-07-23 00:00:00
|
2176-07-24 10:24:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
altered mental status/confusion
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ male with history of RLL G2 moderately
differentiated adenosquamous carcinoma (pT2aN0M0 / Stage IB) s/p
recent right lower lobectomy (discharged ___ from ___,
also CVA (___), CAD, CKD, HTN, p/w AMS per family today. Per
family, has had moments of confusion, and is very emotional
(teary eyed) x ___ days which is drastically diferent from
baseline (AOX3, very active). Wife stated, he has a decrease in
appetite and moderate fluid intake.
After DC from ___ ___, he was doing very well after RLL
lobectomy at home. On ___ he felt tired when going out to
___. Couldn't remember how to get back into building.
Also this afternoon, went out for walk, couldn't figure out how
to open door, didn't know how to find channels on remote. Also
couldn't remember how to open garage. No headache,
fevers/chills, dysuria, neck/back pain, falls, abdominal pain,
CP/SOB. Took advil ___ on ___ and ___ to help sleep but
this was after episode at ___, otherwise no new
medications.
In the ED initial VS were 99 87 157/120 18 98% ra. CXR with no
acute process, UA negative, Cr at baseline, CT head with no
acute process, tox screen negative, TSH pending. Case discussed
with PCP who recommended medicine admission for further workup
of altered mental status. Pt noted to be alert and oriented x 3
in ED and noted to have occasional episodes of confusion but
redirectable.
On the floor, patient is alert, oriented to time, person, place,
in no acute distress, affect is flat but he does not appear
otherwise emotional. He is able to relate history as described
above. ROS positive only for recent poor appetitie and a feeling
of 'fuzziness' in his head.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denied cough, shortness of breath. Denied chest pain
or tightness, palpitations. Denied nausea, vomiting, diarrhea,
constipation or abdominal pain. No recent change in bowel or
bladder habits. No dysuria. Denied arthralgias or myalgias.
Past Medical History:
cerebrovascular accident in ___
coronary and peripheral vascular disease s/p aortobifem and left
renal artery bypass in ___
aortobifemoral bypass graft in ___
left hip surgery for incision and drainage of a septic hip ___
gout
hypertension
hyperlipidemia
Multiple squamous cell lesions excised
Vertigo
CKD
Social History:
___
Family History:
One of 12 children, records unclear. Believes that one brother
and one sister, deceased from lung ca.
Physical Exam:
Admission Physical Exam:
Vitals: 98, 169/85, 83, 18, 99% RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi. Reduced air entry right lung base.
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CN I-XII intact. no asymmetry. pupillary reflexes intact.
Tone, power, reflexes, coordination, sensation intact and equal
in all four extremities. Gait deferred.
Psych: Flat affect, aaox3, no
hallucinations/delusions/psychoses. No pressure of speech/flight
of ideas. pleasant and appropriate.
.
Discharge Physical Exam:
Vitals: Tm 98.4, 138-173/77-87, 75-80, 18, 97% RA ___ pain
I/O ___ 24 hours
General: Alert, oriented, no acute distress, smiling this
morning
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi. Minimal air entry right lung base.
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CN I-XII intact. no asymmetry. pupillary reflexes intact,
EOMI. Tone, strength, reflexes, sensation intact and equal in
all four extremities. Gait deferred.
Psych: Flat affect, aaox3, no
hallucinations/delusions/psychoses. No pressure of speech/flight
of ideas. pleasant and appropriate.
Pertinent Results:
Admission Labs:
___ 08:45PM BLOOD WBC-7.3 RBC-3.12* Hgb-9.8* Hct-29.7*
MCV-95 MCH-31.4 MCHC-33.0 RDW-14.3 Plt ___
___ 08:45PM BLOOD Neuts-57.4 ___ Monos-10.2
Eos-6.4* Baso-0.3
___ 07:25AM BLOOD ___ PTT-33.8 ___
___ 08:45PM BLOOD Glucose-124* UreaN-50* Creat-3.3* Na-140
K-4.1 Cl-105 HCO3-21* AnGap-18
___ 08:45PM BLOOD CK(CPK)-35*
___ 07:25AM BLOOD ALT-11 AST-16 LD(LDH)-202 AlkPhos-100
TotBili-0.3
___ 08:45PM BLOOD CK-MB-3 cTropnT-0.04*
___ 07:25AM BLOOD Albumin-4.3 Calcium-9.1 Phos-4.2 Mg-2.3
___ 08:45PM BLOOD TSH-3.3
___ 07:05AM BLOOD T4-PND
___ 08:45PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 09:06PM BLOOD Lactate-1.9
___ 10:10PM URINE Color-Straw Appear-Clear Sp ___
___ 10:10PM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG
___ 10:10PM URINE RBC-<1 WBC-<1 Bacteri-NONE Yeast-NONE
Epi-0
___ 10:10PM URINE Hours-RANDOM Creat-28 Na-43 K-25 Cl-44
___ 10:10PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG mthdone-NEG
.
.
Discharge Labs:
___ 07:05AM BLOOD WBC-7.0 RBC-3.03* Hgb-9.5* Hct-28.8*
MCV-95 MCH-31.2 MCHC-32.8 RDW-14.3 Plt ___
___ 07:05AM BLOOD UreaN-50* Creat-3.2* Na-140 K-3.7 Cl-107
HCO3-23 AnGap-14
___ CXR: IMPRESSION: Stable right-sided post-surgical
changes and bibasilar atelectasis. No evidence of pneumonia.
.
___ CT HEAD W/O CONTRAST: 1. No evidence of an acute
intracranial abnormality. 2. Stable extensive supratentorial
white matter abnormalities, which are likely sequela of chronic
small vessel ischemic disease. In this setting, mild edema from
small metastases would be easily obscured. MRI would be more
sensitive for detecting intracranial metastases, if clinically
warranted.
.
___ MRI HEAD W/O CONTRAST: 1. Small acute infarct in the
medial left thalamus. 2. No evidence of edema or mass effect on
noncontrast MRI to suggest intracranial metastatic disease.
Please note that the extensive white matter disease, most likely
chronic microvascular ischemic disease in a patient of this age,
may obscure mild edema from small metastatic lesions.
.
Brief Hospital Course:
___ with PMH lung adenoca s/p RLL lobectomy (discharged ___
from ___, also CVA (___), CAD, CKD, HTN, p/w transient AMS
and emotional lability for ___ days.
.
# Acute embolic stroke: Patient presented with a few episodes
separated in space in time of primarily ideational apraxia. On
admission, he was at his baseline and remained at baseline
throughout the admission. Infectious etiologies were excluded.
CT head was unremarkable for acute changes, but MRI showed acute
thalamic infarct which would account for the reported
frontal/executive function changes during these episodes.
Unlikely that these episodes were related to epileptic activity.
Emotional lability may be related to this new infarct but also
to relatively new diagnosis of lung ca. Aspirin was increased to
325mg daily and patient will be set up for cognitive
rehabilitation. Goal blood pressures upon discharge >140
systolic. He will follow up with neurology as an outpatient.
.
.
# Emotional lability: likely acute dysthymia related to cancer
diagnosis. TSH done twice during this hospitalization: 3.3 and
4.5. T4 was normal at 6.8. These findings were related to Dr.
___. The patient's family would like him to be started on
an antidepressant, but given acute stroke held off on starting
anything while he was an inpatient. The patient also seemed to
be hesitant to start an antidepressant and would likely benefit
from further discussion with PCP.
.
.
# ___ on CKD: creatinine now elevated to 3.3 (baseline 2.5-3.0,
but acidemia is worse than prior). Likely secondary to
dehydration given reported poor appetite in the days preceeding
admission. He received IVF and was encouraged to maintain good
fluid and food intake. Creatinine returned to baseline.
.
# Vasculopathy: Discharged on increased aspirin dose 325mg given
new stroke.
.
# Lung adenoca s/p RLL lobectomy: follow up with thoracic
surgery and oncology.
.
# Hypertension: Continued on home nifedipine
.
# Gout: Continued allopurinol and colchicine with renal dosing
(same as home dose).
.
# Pain: Continue standing tylenol, oxycodone for breakthrough
pain. He did not require additional narcotics.
.
# Constipation: Continued home bowel regimen.
.
# Med rec: He was discharged with saline nasal spray for nasal
congestion.
.
Transitional Issues:
- The patient would benefit from sleep study to evaluate for OSA
given his persistent hypertension.
- Cognitive rehabilitation will be available this ___ at the
___. This might be the best
option for this patient. In the interim, there is a program at
___, however this is more targeted to traumatic
brain injury patients and is very goal-driven. It may not serve
his needs as well.
- follow up with neurology
- follow up with PCP for dysthymia
- follow up with thoracic surgery
- follow up with oncology
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO Q6H
2. Allopurinol ___ mg PO DAILY
3. Colchicine 0.6 mg PO EVERY OTHER DAY
4. NIFEdipine CR 90 mg PO DAILY
hold for hr<50, SBP<100
5. Bisacodyl 10 mg PO/PR DAILY:PRN constipation
6. Docusate Sodium 100 mg PO BID
7. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
8. TraMADOL (Ultram) 25 mg PO QID
9. Guaifenesin ER 1200 mg PO Q12H
10. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H
2. Allopurinol ___ mg PO DAILY
3. Bisacodyl 10 mg PO/PR DAILY:PRN constipation
4. Colchicine 0.6 mg PO EVERY OTHER DAY
5. Docusate Sodium 100 mg PO BID
6. Guaifenesin ER 1200 mg PO Q12H
7. NIFEdipine CR 90 mg PO DAILY
8. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
9. TraMADOL (Ultram) 25 mg PO QID
10. Aspirin 325 mg PO DAILY
RX *aspirin 325 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
11. Sodium Chloride Nasal ___ SPRY NU QID:PRN congestion
RX *sodium chloride [Nasal Spray (sodium chloride)] 0.65 % ___
spray nasal four times a day Disp #*1 Bottle Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis: lacunar stroke in thalamus
Secondary diagnosis: lung 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 in the hospital. You were
admitted for evaluation of a few episodes of confusion that you
had at home. You had imaging done which showed a small stroke in
the thalamus, an area of the brain that coordinates information.
This probably explains some of the confusion that you
experienced. There are no problems with your speech or your
motor function. Our Neurologists examined you and recommended
that you increase your aspirin dose to 325mg daily. They will
see you in the stroke clinic in a few weeks (see below). In the
meantime, Dr ___ will work with you to lower your blood
pressure to reduce the risk of future small strokes. You may
also benefit from a sleep study to reduce any obstructive sleep
apnea that might make your blood pressure higher.
Followup Instructions:
___
|
19693863-DS-20
| 19,693,863 | 27,815,192 |
DS
| 20 |
2176-12-08 00:00:00
|
2176-12-09 14:40:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Hemoptysis and dyspnea on exertion
Major Surgical or Invasive Procedure:
Thoracentesis (___)
Bronchoscopy (___)
History of Present Illness:
___ PMHx 6 months s/p RLL lobectomy for ___, 5 months s/p
stroke, anemia, p/w 1 week SOB and 2 days hemoptysis. Hemoptysis
occurs when he coughs, he will bring up ___ tsp of blood. States
that this is more than the hemoptysis he experienced in
___. Also brief epistaxis x 1 day. Denies CP, palpitations,
diaphoresis, N/V, fevers, chills, cough, abd pain, rashes,
numbness, tingling, or weakness. Chest CT ___ for 6 month f/u
showed 1) Growth LUL lung nodule highly concerning for new
primary CA, 2) Widespread RUL, RML ground glass opacities; 3) R
pleural effusion; 4) 2 new R lung nodules highly concerning for
CA. Scheduled for ___ clinic today for f/u of worsening kidney
function w/ Cr >4, ___ clinic tomorrow.
Past Medical History:
- Cerebrovascular accident in ___
- CAD and PVD s/p aortobifemoral and left RA bypass in ___ and
aortobifemoral bypass graft in ___
- Left hip surgery for I&D of a septic hip ___
- Gout
- Hypertension
- Hyperlipidemia
- Multiple squamous cell lesions excised
- Vertigo
- Chronic kidney disease
Social History:
___
Family History:
One of 12 children, records unclear. Believes that one brother
and one sister deceased from lung CA.
Physical Exam:
Admission exam:
Vitals- T 97.6 164/80 86 18 93% RA
General: alert and oriented, no acute distress
HEENT: PERRLA, EOMI, conjunctiva nonicteric, not noted to be
pale
Neck: supple, JVP not elevated, no lymphadenopathy
CV: r/r/r, no m/r/g
Lungs: right mid-lobe mild crackles, left lung
Abdomen: faint midline scar visible, hard
GU: no Foley
Ext: no clubbing, cyanosis or edema
Neuro: CN II-XII intact, ___ strength biceps flexion/extension,
___ strength plantar flexion/extension, sensation grossly
intact, 2+ biceps and brachioradialis reflexes bilaterally
Discharge exam:
Tm/Tc-98.4 BP 160/75 (110-160/52-75) HR 80 (66-80) RR ___
Sat: 96% 5L NC I/O: 1140/1150
General: Sullen elderly man appearing stated age, wearing NC in
NAD, on bed with HOB elevated 25-degrees with 3 pillows.
HEENT: NC/AT, anisocoria R 2.5->2mm/ L 3.5->3mm, MMM, anicteric,
conjunctiva not pale, no LAD, trace blood on tongue surface.
Neck: supple, no carotid bruits, no palpable lymph nodes
CV: nl S1S2, RRR, no M/R/G
Lungs: Non-labored breathing, air movement anteriorly, with
transmitted low-pitched inspiratory/expiratory wheezes from R
lobes. R lobes with crackles. Left fields with expiratory
wheezes. Well healed c/d/i 5-inch scar on right side of back.
Abdomen: nondistended, normoactive bowel sounds, dullness and
hard to palpation on mid-epigastric area (long sternum).
GU: no Foley
Ext: WWP, no clubbing/edema/cyanosis, radial/DP pulses 2+
Skin: seborrheic keratosis on abdomen and back; cherry
hemangiomas on abdomen. No rashes.
Neuro: AAOx3, With exception of decreased L-ear hearing, CN2-12
preserved. Language intact (fluency, comprehension, repetition);
speech intact with normal prosody and speed, some dysarthria
(baseline).
Pertinent Results:
Admission:
___ 01:20PM BLOOD WBC-7.4 RBC-2.75* Hgb-8.6* Hct-26.3*
MCV-96 MCH-31.2 MCHC-32.6 RDW-15.0 Plt ___
___ 01:20PM BLOOD Neuts-66.4 ___ Monos-11.8*
Eos-2.2 Baso-0.4
___ 01:20PM BLOOD ___ PTT-33.6 ___
___ 01:20PM BLOOD Glucose-135* UreaN-75* Creat-4.6* Na-134
K-4.5 Cl-100 HCO3-22 AnGap-17
Discharge:
___ 07:00AM BLOOD WBC-7.1 RBC-3.05* Hgb-9.6* Hct-28.4*
MCV-93 MCH-31.4 MCHC-33.7 RDW-14.2 Plt ___
___ 07:00AM BLOOD ___ PTT-36.2 ___
___ 07:00AM BLOOD Glucose-92 UreaN-94* Creat-4.3* Na-137
K-4.4 Cl-104 HCO3-21* AnGap-16
___ 07:00AM BLOOD Calcium-9.1 Phos-5.2* Mg-2.9*
Microbiolgy:
___ 5:54 pm PLEURAL FLUID
GRAM STAIN (Final ___:
2+ ___ per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
This is a concentrated smear made by cytospin method,
please refer to
hematology for a quantitative white blood cell count..
FLUID CULTURE (Final ___: NO GROWTH.
ANAEROBIC CULTURE (Preliminary): NO GROWTH.
BAL x2:
Time Taken Not Noted Log-In Date/Time: ___ 8:26 am
BRONCHOALVEOLAR LAVAGE RIGHT UPPER LOBE POSTERIOR
SEGMENT.
**FINAL REPORT ___
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
RESPIRATORY CULTURE (Final ___: NO GROWTH, <1000
CFU/ml.
Pleural fluid analysis:
___ 05:54PM PLEURAL WBC-260* RBC-9650* Polys-3* Lymphs-58*
Monos-33* Meso-2* Macro-4*
___ 05:54PM PLEURAL TotProt-3.4 Glucose-100 LD(LDH)-164
Albumin-2.1 Cholest-51
Cytology:
___ BRONCHIAL WASHING, right upper lobe:
ATYPICAL.
Atypical epithelial cells, too few to characterize.
Bronchial epithelial cells and macrophages.
___ BRONCHIAL WASHING, right middle lobe:
NEGATIVE FOR MALIGNANT CELLS.
Bronchial epithelial cells and macrophages.
___ Pleural fluid:
NEGATIVE FOR MALIGNANT CELLS.
Mesothelial cells and many small lymphocytes.
Imaging:
___ CT chest:
IMPRESSION:
1. Increased size and density of the right lung interstitial
and ground-glass opacities, with new involvement of the right
middle lobe. The differential diagnosis is not significantly
changed from prior exam and continues to include pulmonary
infection or pulmonary hemorrhage. Less likely etiologies would
be a diffuse lung adenocarcinoma or drug toxicity. Worsening
asymmetric edema or superimposed edema on the primary
abnormality is also a consideration.
2. Unchanged 15 mm left upper lobe spiculated nodule,
concerning for a second primary cancer.
3. Other smaller nodules are unchanged or more difficult to
evaluate due to surrounding opacification. Continued short-term
followup is recommended.
4. Slight interval increase in the moderate-sized right pleural
effusion.
New trace left pleural effusion.
___ CXR;
IMPRESSION:
1. Similar appearance of widespread ground-glass opacities
involving the
right upper and middle lobe and left lung base which may
represent infection or hemorrhage. Drug toxicity is possible
although unilateral focal involvement makes this unlikely.
2. Roughly 1.6 cm left upper lobe lung nodule as on CT.
3. Small right pleural effusion.
Brief Hospital Course:
___ M PMHx 6 months s/p RLL lobectomy for ___, 5 months s/p
stroke, anemia, p/w 1 week SOB and 2 days hemoptysis.
**ACUTE ISSUES**
# Shortness of breath: Initial ddx included CAP vs. invasive
tumor vs. PE. Patient has been coughing for quite some time and
has had ongoing SOB. CT chest from day prior to admission showed
ground glass opacities and an increasing LUL lesion. He was
treated with 5 days of ceftriaxone and azithromycin without any
improvement. Thoracentesis performed on ___ showed transudative
pleural fluid without any malignant cells. SOB did not improve
after this tap. Bronchoscopy with bronchoalveolar lavage was
performed on ___ and did not find any lesions or areas to
biopsy. Fluid washings returned negative for malignant cells,
although atypical cells were noted in 1 sample. Subsequent
repeat CT chest after these procedures showed worsening of right
lung ground glass opacities and reaccumultation of pleural
fluid. Patient started on oxygen therapy while in hospital and
discharged on home oxygen therapy. Would recommend outpatient
follow-up for growing LUL lesion.
# Hemoptysis: Initially unclear source of bleeding. Bronchoscopy
did not show any active sources of bleeding, only few clots.
Patient was transfused a total of 2 units pRBCs for anemia from
blood loss. Interventional Pulmonology recommended better blood
pressure control for which patient was started on labetalol.
They will follow him as an outpatient.
# Chronic kidney disease: Creatinine up to 4.6, consistent with
___, but increased from baseline. Nephrology was consulted and
did not believe he had any active indication for dialysis,
recommended iron repletion without EPO supplementation given his
history of cancer.
# Anemia: most likely ___ CKD as noted in outpatient notes. Iron
studies and reticulocyte count indicate iron deficiency. Would
recommend iron repletion as an outpatient. Patient transfused
total of 2 units pRBCs during hospitalization with appropriate
bumps in Hct.
# Depression: Patient noted to have h/o depression and often had
a flat affect during this hospitalization. No anti-depressants
were initiated, but would consider starting one as an outpatient
and referring for therapy.
**CHRONIC ISSUES**
# Hypertension: Given patient had active bleeding, attempted to
control BP to SBP < 140. Continued home nifedipine and started
labetolol BID.
# Constipation: Continued home bisacodyl, docusate, and milk of
magnesia.
# Gout: Stable, continued home allopurinol and colchicine.
**TRANSITIONAL ISSUES**
- Patient confirmed DNR/DNI with patient and HCP
- Now on oxygen therapy at home
- Started on labetolol for BP control. Please follow as
outpatient.
- ASA held on discharge given hemoptysis. Consider restarting as
outpatient.
- Follow-up with IP, Thoracic Surgery, and Rad-Onc scheduled.
- Consider depression treatment or therapy
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Allopurinol ___ mg PO DAILY
2. Colchicine 0.6 mg PO EVERY OTHER DAY
3. NIFEdipine CR 90 mg PO DAILY
4. Aspirin 325 mg PO DAILY
5. Milk of Magnesia 30 mL PO Q6H:PRN constipation
6. Levothyroxine Sodium 25 mcg PO DAILY
7. Potassium Chloride 10 mEq PO DAILY
8. Sodium Chloride Nasal ___ SPRY NU QID:PRN congestion
Discharge Medications:
1. Allopurinol ___ mg PO DAILY
2. Colchicine 0.6 mg PO EVERY OTHER DAY
3. Levothyroxine Sodium 25 mcg PO DAILY
4. Milk of Magnesia 30 mL PO Q6H:PRN constipation
5. NIFEdipine CR 90 mg PO DAILY
6. Sodium Chloride Nasal ___ SPRY NU QID:PRN congestion
7. Labetalol 200 mg PO Q 8H
RX *labetalol 200 mg 1 tablet(s) by mouth every eight (8) hours
Disp #*90 Tablet Refills:*0
8. Potassium Chloride 10 mEq PO DAILY
9. Home ___ L via NC continuous pulse dose of portability RA sat 87%, dx
pleural effusion
10. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB
RX *albuterol sulfate 90 mcg 2 puffs INH every six (6) hours
Disp #*1 Inhaler Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary: Bronchial hemorrhage
Secondary: ___
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 a patient at
___. You came to use because
you were coughing up blood. We saw bleeding on your CT scan and
bronchoscopy but we were not able to find a specific source.
Your bleeding appears to have resolved as you have not been
coughing up any more fresh blood. While in the hospital your O2
levels were slightly low and for this reason we will be sending
you home on oxygen therapy.
Please take all of your medications as listed below and be sure
to keep all of your follow-up appointments.
Followup Instructions:
___
|
19693863-DS-21
| 19,693,863 | 20,211,629 |
DS
| 21 |
2178-11-03 00:00:00
|
2178-11-07 11:00:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Labetalol
Attending: ___.
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is an ___ M with pmhx of CAD sp LAD stent, CKD, CVA,
HTN, lung cancer sp rad onc on ___ presenting with one day
of intermittent, substernal chest pain. Patient is unable to
characterize the pain except that it is not stabbing. Denies
radiation and any association with activity; reports that pain
improves with lying flat on his back.
Patient reports mild dyspnea and unproductive cough, without
hemoptysis; both of these symptoms are chronic and unchanged. He
has no fever, chills, ___ swelling or tenderness, no n/v/d. He
also denies any recent recent long car rides.
The ED spoke with patient's PCP dr ___ felt that the
patient was high risk for ACS vs PE. Given his renal disease, a
CTA was unable to be performed. The patient was admitted for a
V/Q scan and further evaluation.
DISPO: In the ED, initial vitals were: T 97.2 P 72 BP 159/81 R
20 O2Sat 98% RA
- Labs were significant for wbc 13.4, H/H 9.7/29.5, Plt 108,
Chem 7 notable for K 5.5 (hemolyzed) repeat 5.3, BUN 86, Cr 5.7,
Tn 0.06, INR 1.0
- CXR showed Small right pleural effusion, not substantially
changed from the previous chest radiograph. Streaky right
basilar opacities likely reflect areas of atelectasis, without
focal consolidation. Unchanged spiculated nodular opacity in the
periphery of the left upper lobe.
- The patient was given aspirin 324 mg and admitted to the
floor.
On arrival to the floor, the patient refuses a physical exam. He
states that his pleuritic chest pain has resolved.
Past Medical History:
- Cerebrovascular accident in ___
- CAD and PVD s/p aortobifemoral and left RA bypass in ___ and
aortobifemoral bypass graft in ___
- Left hip surgery for I&D of a septic hip ___
- Gout
- Hypertension
- Hyperlipidemia
- Multiple squamous cell lesions excised
- Vertigo
- Chronic kidney disease
Social History:
___
Family History:
One of 12 children, records unclear. Believes that one brother
and one sister deceased from lung CA.
Physical Exam:
ADMISSION EXAM:
Vitals: 98.0 176/76 64 18 97% RA
Pt refused physical exam
DISCHARGE EXAM:
VS: 98.4, 64-70, 168-187/83-94, ___, 96-97% on RA
GENERAL: Alert, oriented, no acute distress
HEENT: Sclerae anicteric, MMM, oropharynx clear
NECK: supple, JVP not elevated, no LAD
RESP: CTAB no wheezes, rales, rhonchi
CV: RRR, Nl S1, S2, No MRG
ABD: Soft, NT/ND bowel sounds present, no rebound tenderness or
guarding, no organomegaly
GU: no foley
EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
NEURO: CNs2-12 intact, motor function grossly normal
SKIN: No excoriations or rash.
Pertinent Results:
ADMISSION LABS:
___ 05:00PM BLOOD WBC-13.4*# RBC-2.99* Hgb-9.7* Hct-29.5*
MCV-99* MCH-32.4* MCHC-32.9 RDW-14.9 RDWSD-54.1* Plt ___
___ 05:00PM BLOOD Neuts-68.5 Lymphs-13.6* Monos-15.1*
Eos-1.9 Baso-0.2 Im ___ AbsNeut-9.14* AbsLymp-1.82
AbsMono-2.02* AbsEos-0.26 AbsBaso-0.03
___ 05:00PM BLOOD Hypochr-NORMAL Anisocy-OCCASIONAL
Poiklo-NORMAL Macrocy-OCCASIONAL Microcy-NORMAL Polychr-NORMAL
Ovalocy-OCCASIONAL
___ 05:00PM BLOOD ___ PTT-33.1 ___
___ 05:00PM BLOOD Plt Smr-LOW Plt ___
___ 05:00PM BLOOD Glucose-95 UreaN-86* Creat-5.7* Na-135
K-5.5* Cl-102 HCO3-15* AnGap-24*
___ 05:00PM BLOOD CK-MB-3 proBNP-6801*
___ 05:00PM BLOOD cTropnT-0.06*
___ 05:07PM BLOOD Lactate-1.7 K-5.3*
___ 06:05PM URINE Color-Straw Appear-Clear Sp ___
___ 06:05PM URINE Blood-NEG Nitrite-NEG Protein-100
Glucose-100 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
___ 06:05PM URINE RBC-0 WBC-<1 Bacteri-FEW Yeast-NONE Epi-0
OTHER PERTINENT LABS:
___ 01:30AM BLOOD CK-MB-3 cTropnT-0.06*
MICRO:
Blood cx pending
IMAGING:
V/Q scan ___ : Multiple matched V/Q defects. Low likelihood
of PE.
DISCHARGE LABS:
Patient refused labs on day of discharge.
Brief Hospital Course:
Outpatient Providers: ___ M with hx CAD s/p LAD stent, CKD, CVA,
HTN, and lung cancer s/p XRT in ___ who presents with one day
of intermittent, substernal chest pain.
*ACTIVE ISSUES*
# Chest pain: On presentation, patient was HDS with O2 sat 98%
on RA. EKG showed no ischemic changes. CXR showed small right
pleural effusion, not substantially changed from previous.
Troponins neg x2. There was some concern for PE given patient's
h/o malignancy, but due to patient's CKD, CT-PE couldn't be
performed. Patient was given aspirin 325 mg and admitted to
Medicine for V/Q scan and further evaluation. V/Q scan returned
as low likelihood for PE. Cardiac stress test was discussed;
however, since patient declined HD, it was decided that cardiac
cath would not be feasible and therfore stress testing would not
be indicated. Chest pain resolved without intervention.
*CHRONIC ISSUES*
# CAD: Patient with known CAD, s/p LAD stent. Patient was noted
to not be on a statin, so atorvastatin 40 mg QD was started.
Patient was continued on aspirin 325 mg and metoprolol.
# CKD: Patient with CKD, Cr 5.7 on admission. Home sodium bicarb
was increased from 650 mg BID to ___ mg BID.
# H/o CVA: Patient was continued on home ASA.
# Gout: Patient was continued on home allopurinol and
colchicine.
# HTN: Patient was continued on home metoprolol, lisinopril, and
nifedipine.
*TRANSITIONAL ISSUES*
- Started ASA 81mg daily and atorvastatin 40mg daily
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Allopurinol ___ mg PO DAILY
2. Colchicine 0.6 mg PO EVERY OTHER DAY
3. Vitamin D 50,000 UNIT PO Frequency is Unknown
4. Fluticasone Propionate NASAL 1 SPRY NU DAILY
5. ipratropium bromide 0.06 % nasal QHS
6. Levothyroxine Sodium 25 mcg PO DAILY
7. Lisinopril 2.5 mg PO DAILY
8. Metoprolol Succinate XL 50 mg PO DAILY
9. NIFEdipine CR 90 mg PO DAILY
10. Aspirin 325 mg PO DAILY
11. Cetirizine 10 mg PO DAILY
12. Docusate Sodium Dose is Unknown PO Frequency is Unknown
13. Sodium Bicarbonate 650 mg PO BID
Discharge Medications:
1. Allopurinol ___ mg PO DAILY
2. Aspirin 81 mg PO DAILY
RX *aspirin 81 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
3. Cetirizine 10 mg PO DAILY
4. Colchicine 0.6 mg PO EVERY OTHER DAY
5. Docusate Sodium 100 mg PO BID
6. Fluticasone Propionate NASAL 1 SPRY NU DAILY
7. Levothyroxine Sodium 25 mcg PO DAILY
8. Lisinopril 2.5 mg PO DAILY
9. Metoprolol Succinate XL 50 mg PO DAILY
10. NIFEdipine CR 90 mg PO DAILY
11. Sodium Bicarbonate 650 mg PO BID
12. Atorvastatin 40 mg PO QPM
RX *atorvastatin 40 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
13. ipratropium bromide 0.06 % nasal QHS
14. Vitamin D 50,000 UNIT PO 1X/WEEK (___)
Discharge Disposition:
Home
Discharge Diagnosis:
Chest pain
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure caring for you at ___
___. You presented with chest pain. A scan of your
lungs was performed, which didn't show any evidence of blood
clots. The cause of your chest pain is unclear, but it could be
unstable angina due to your coronary artery disease. Since you
declined dialysis, we would not be able to perform a cardiac
catheterization to further assess your coronary arteries,
therefore, we opted to optimize the medical management of your
coronary artery disease. We started you on atorvastatin to
reduce your risk of heart attack and stroke.
We wish you the best!
Sincerely,
Your ___ Team
Followup Instructions:
___
|
19693868-DS-21
| 19,693,868 | 25,374,349 |
DS
| 21 |
2166-05-26 00:00:00
|
2166-05-26 18:26:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: UROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Right flank pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
HPI: ___ y/o female w/hx of recurrent nephrolithiasis, who
underwent ureteroscopy, laser lithotripsy, stent placement by
Dr. ___ on ___, and presented to the ED on POD 1 for
pain and was found to have entire stent within the bladder. The
stent was removed cystoscopically in the ED. She again,
presented to the ED with nausea and bladder spasm. She has a hx
of ureteral stent intolerance. She denies fevers/chills. She
was admitted for pain control.
Past Medical History:
PMH:
Nephrolithiasis
Tinea Versicolor
PSH:
Ureteroscopy, laser lithotripsy
Stent placement
Medication:
DIAZEPAM - diazepam 5 mg tablet. 1 tablet(s) by mouth every
eight
(8) hours as needed for bladder spasms, stent irritation
HYDROCODONE-ACETAMINOPHEN - hydrocodone-acetaminophen 5 mg-500
mg
tablet. 1 Tablet(s) by mouth every four (4) hours as needed for
pain Do NOT exceed MAX 4g/24hrs of acetaminphen from ALL sources
OXYBUTYNIN CHLORIDE - oxybutynin chloride 5 mg tablet. 1
tablet(s) by mouth every eight (8) hours as needed for bladder
spasms
PHENAZOPYRIDINE - phenazopyridine 100 mg tablet. ONE Tablet(s)
by
mouth three times a day as needed for prn dysuria/pain while
voiding turns urine bright orange
TAMSULOSIN - tamsulosin ER 0.4 mg capsule,extended release 24
hr.
1 capsule(s) by mouth at bedtime
Medications - OTC
DOCUSATE SODIUM - docusate sodium 100 mg capsule. ONE capsule(s)
by mouth twice a day To reduce risk of constipation from
narcotics/anaesthesia
Allergies:
NKDA
Social History:
___
Family History:
Mother with neuromuscular disease. Aunt with mental retardation.
Physical Exam:
AVSS
WdWn very pleasant F in NAD, husband at bedside
___ breathing
Abdomen soft, NTTP, mild R CVAT, none on left
Ext WWP
Pertinent Results:
___ 09:30PM BLOOD WBC-9.9 RBC-3.82* Hgb-12.2 Hct-36.5
MCV-96 MCH-31.9 MCHC-33.4 RDW-11.9 Plt ___
___ 01:45AM BLOOD WBC-8.4 RBC-4.00* Hgb-13.0 Hct-38.7
MCV-97 MCH-32.5* MCHC-33.6 RDW-12.0 Plt ___
___ 09:30PM BLOOD Neuts-69.4 ___ Monos-4.5 Eos-0.4
Baso-0.6
___ 01:45AM BLOOD Neuts-84.4* Lymphs-11.3* Monos-4.0
Eos-0.1 Baso-0.1
___ 06:30AM BLOOD Glucose-86 UreaN-10 Creat-0.7 Na-138
K-3.9 Cl-107 HCO3-28 AnGap-7*
___ 09:30PM BLOOD Glucose-108* UreaN-10 Creat-0.9 Na-141
K-3.7 Cl-104 HCO3-27 AnGap-14
___ 01:45AM BLOOD Glucose-140* UreaN-10 Creat-0.8 Na-138
K-4.3 Cl-104 HCO3-23 AnGap-15
___ 05:15AM URINE Color-DkAmb Appear-SLCLOUDY Sp ___
___ 05:15AM URINE Blood-LG Nitrite-POS Protein-30
Glucose-NEG Ketone-NEG Bilirub-SM Urobiln-2* pH-7.5 Leuks-NEG
___ 05:15AM URINE RBC->182* WBC-5 Bacteri-FEW Yeast-NONE
Epi-<1
Brief Hospital Course:
The patient was admitted to Dr. ___ for pain
control. She was placed NPO in the event her pain was
uncontrolled and she would require a stent placement. She had
some mild nausea that resolved on HD1. She was then started on
regular diet and tolerating oral medications. On HD2, her pain
was much improved on oral meds, tolerating a regular diet,
voiding without difficulty and straining her urine, ambulating.
She was discharged home on HD#2 feeling well. She will f/u with
Dr. ___.
Medications on Admission:
DIAZEPAM - diazepam 5 mg tablet. 1 tablet(s) by mouth every
eight
(8) hours as needed for bladder spasms, stent irritation
HYDROCODONE-ACETAMINOPHEN - hydrocodone-acetaminophen 5 mg-500
mg
tablet. 1 Tablet(s) by mouth every four (4) hours as needed for
pain Do NOT exceed MAX 4g/24hrs of acetaminphen from ALL sources
OXYBUTYNIN CHLORIDE - oxybutynin chloride 5 mg tablet. 1
tablet(s) by mouth every eight (8) hours as needed for bladder
spasms
PHENAZOPYRIDINE - phenazopyridine 100 mg tablet. ONE Tablet(s)
by
mouth three times a day as needed for prn dysuria/pain while
voiding turns urine bright orange
TAMSULOSIN - tamsulosin ER 0.4 mg capsule,extended release 24
hr.
1 capsule(s) by mouth at bedtime
Medications - OTC
DOCUSATE SODIUM - docusate sodium 100 mg capsule. ONE capsule(s)
by mouth twice a day To reduce risk of constipation from
narcotics/anaesthesia
Discharge Medications:
1. Acetaminophen 1000 mg PO Q6H:PRN fever, pain
2. Oxybutynin 5 mg PO TID Prn spasm
RX *oxybutynin chloride 5 mg 1 tablet(s) by mouth every eight
(8) hours Disp #*15 Tablet Refills:*0
3. Phenazopyridine 100 mg PO TID Duration: 3 Days
4. Tamsulosin 0.4 mg PO HS
5. Ibuprofen 600 mg PO Q6H:PRN pain
take with food
RX *ibuprofen 600 mg 1 tablet(s) by mouth every six (6) hours
Disp #*30 Tablet Refills:*0
6. Docusate Sodium 100 mg PO BID
7. Senna 1 TAB PO BID:PRN constipation
RX *sennosides [senna] 8.6 mg 1 tablet by mouth twice a day Disp
#*14 Tablet Refills:*0
8. Hydrocodone-Acetaminophen (5mg-500mg) ___ TAB PO Q6H:PRN pain
Discharge Disposition:
Home
Discharge Diagnosis:
Renal colic after stent removal on ___ s/p right ureteroscopy,
laser lithotripsy
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
-No vigorous physical activity for 2 weeks.
-Expect to see occasional blood in your urine and to experience
urgency and frequecy over the next month.
-You may have already passed your kidney stone, or it may still
be in the process of passing. You may experience some pain
associated with spasm of your ureter. This is normal. Take
Motrin as directed and take the narcotic pain medication as
prescribed if additional pain relief is needed.
-Tylenol should be your first line pain medication, a narcotic
pain medication has been prescribed for breakthough pain >4.
Replace Tylenol with narcotic pain medication. Max daily
Tylenol dose is 4gm, note that narcotic pain medication also
contains Tylenol (acetaminophen)
-Make sure you drink plenty of fluids to help keep yourself
hydrated and facilitate passage of stone fragments.
-You may shower and bathe normally.
-Do not drive or drink alcohol while taking narcotics
-Colace has been prescribed to avoid post surgical constipation
and constipation related to narcotic pain medication,
discontinue if loose stool or diarrhea develops.
-Resume all of your home medications, unless otherwise noted.
Followup Instructions:
___
|
19693912-DS-29
| 19,693,912 | 28,103,782 |
DS
| 29 |
2146-09-06 00:00:00
|
2146-09-12 09:36:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Chlorpromazine / Seroquel / Tape ___ / ibuprofen /
trazodone / NSAIDS (Non-Steroidal Anti-Inflammatory Drug)
Attending: ___.
Chief Complaint:
Bradycardia, confusion
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ with a past medical history of smoldering IgA
myeloma, schizoaffective d/o (bipolar type), hypothyroidism,
insomnia, asthma, GERD, and CKD who is presenting after being
found down at her group home. As per the patient, she stood up
from her bed and reports getting weak in her knees and falling
to the ground; she also reports defecating on the floor. She
denies any chest pain or shortness of breath, no dizziness or
lightheadedness at that time. The people at her home picked her
up off the floor and put her back into bed. EMS was then called
an hour later and she was found to be bradycardic (51) and
hypotensive (83/63). She was paced and given some versed for
sedation; pressure improved to 106 systolic. FSG at the time
was in the 200s.
As per EMS report, the patient was found pale and lethargic in
bed. She woke up on the ground, unsure if there was LOC. She
was able to answer questions, though was confused at times, as
per documentation. The patient also defecated on the floor.
The patient reports that she was feeling like her usual self
prior to this episode. Denies any recent fevers/chills, no
recent changes in her appetite. Denies any abdominal pain.
Otherwise reports feeling well. Does endorse some lower
extremity weakness. Of note, she has a long standing history of
orthostatic hypotension, dizziness, and falls.
In the ED, initial vs were: unable to register rectal
temperature 45 90/56. Her pacing was turned off and there was
no change in her blood pressures. She was responsive to painful
stimuli initially, then found to be AAOx1 (oriented to self
only). She has been confused, unable to provide history.
While in the ED, the patient was given Atroprine 0.5 mg x2, with
little improvement in her heart rate. She was also given
Glucagon 5 mg push (in the setting of concern for beta blocker
toxicity). Levothyroxine 500 mcg also given out of concern for
myxedema coma. A bedside ECHO done in the ED showed bradycardia,
with symmetric wall motion. EKG done in ED with sinus brady,
prolonged QTc 518. The patient was also given Vanc and
Ceftriaxone.
On arrival to the ICU, the patient reported feeling thirsty; she
otherwise reported feeling well.
Past Medical History:
1. Multiple myeloma
2. schizaffective disorder, bipolar type
3. hypthyroidism
4. Insomnia
5. Asthma/Bronchitis
6. GERD
7. Hypercholesterolemia
8. Constipation
9. Memory deficits
10. Chronic lower back pain
11. Stage III CKD
PAST SURGICAL HISTORY
1. Laminectomy (L4-L5)
2. Appendectomy
3. Left knee
Social History:
___
Family History:
Father passed away from tongue cancer. Mother passed away from
"enlarged heart".
Physical Exam:
ADMISSION PHYSICAL EXAM:
General: well appearing, younger than her stated age, NAD, AAOx2
(did not know date)
HEENT: Sclera anicteric, dry mucous membranes, PERRL, EOMI
Neck: supple
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: bradycardic, normal S1 + S2, no murmurs, rubs, gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: + foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: alert and appropriate, slightly slow to respond; CN ___
grossly intact, moving all extremities spontaneously, normal ___
muscle strength
DISCHARGE EXAM:
VS - 98.4 125/71 93 18 95% RA
GEN - Obese, alert, orientedx2.5, no acute distress
HEENT - NCAT, MMM, EOMI, sclera anicteric, OC/OP clear
NECK - supple, no JVD, no LAD
PULM - CTAB, scattered rales/wheezes
CV - RRR, S1/S2, ___ systolic murmur, no 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:
CT Head ___:
IMPRESSION: Mild prominence of ventricles and sulci compatible
with the
patient's age. Otherwise normal study.
Chest X-Ray ___:
IMPRESSION: No pneumonia, edema, or effusion.
ADMISSION LABS
___ 12:37AM BLOOD WBC-11.2*# RBC-3.73* Hgb-11.2* Hct-35.9*
MCV-96 MCH-29.9 MCHC-31.1 RDW-14.3 Plt ___
___ 12:37AM BLOOD Glucose-127* UreaN-22* Creat-1.7* Na-142
K-4.5 Cl-108 HCO3-23 AnGap-16
___ 12:44AM BLOOD Lactate-2.5*
___ 12:37AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 12:37AM BLOOD cTropnT-<0.01
___ 06:28AM BLOOD CK-MB-1 cTropnT-<0.01
DISCHARGE LABS
___ 07:40AM BLOOD WBC-7.5 RBC-3.67* Hgb-10.7* Hct-33.4*
MCV-91 MCH-29.1 MCHC-32.0 RDW-14.4 Plt ___
___ 07:40AM BLOOD Glucose-99 UreaN-14 Creat-1.0 Na-143
K-4.5 Cl-108 HCO3-23 AnGap-17
___ 07:40AM BLOOD Calcium-10.6* Phos-2.4* Mg-1.6
Brief Hospital Course:
Ms. ___ is ___ with history of multiple myeloma,
schizoaffective d/o (bipolar type), hypothyroidism, insomnia,
asthma, GERD, CKD who is presenting after being found down at
her group home, found to be bradycardic and hypotensive.
# Bradycardia: The patient was found to be bradycardic to the
___, and as per report was paced by EMS on the way to the ED.
Unclear etiology, but differential was broad but thought most
likely to be related to atenolol overdose in the setting of mild
renal failure. The patient had a normal TSH. Her bradycardia
slowly improved and she remained HD stable after being
transferred out of the MICU.
# Altered mental status: In addition to hemodynamic
abnormalities, the patient was also confused and minimally
responsive. Her mental status gradually cleared and it was
thought that her presenting altered mental status was due to
cerebral hypoperfursion. Utox and serum tox were both negative.
Infectious work up included a CXR that showed possible
infiltrate. The patient was initially given Augmentin for
coverage but this was subsequently discontinued. Of note, her
home psychiatric meds were initially held, but were restarted
with gradual up-taper to her home dosing.
# Hypothyroidism: The patient has history of hypothyroidism; her
presentation with hypothermia, altered mental status,
bradycardia could have been consistent with myexedema coma. She
was initially given levothyroxine 500 mcg in the ED. Her TSH was
normal and she was restarted on her home dose levothyroxine.
# CKD: The patient has history of CKD. Her CKD may in part be
due to IgA multiple myeloma. Her most recent creatinine prior to
admission was 1.8. Creatinines from the ___ were in
the range of 1.0-1.4. Acute on chronic renal failure may have
limited atenolol clearance. The patient's creatinine nearly
normalized after IVFs.
# Schizoaffective disorder: The patient has a long standing
psych history, with multiple hospitalizations. All of her psych
medications were initially held given her altered mental status
but restarted by discharge.
# Neuropathy: The patient's gabapentin was held initially given
her altered mental status but restarted on discharge
# Insomnia: The patient's Lunesta was also initially held while
in the MICU until her mental status improved.
# Multiple myeloma: Multiple myeloma: Smoldering IgA myeloma
which continues to be stable by both exam and lab tests; her IgA
levels has not changed significantly since diagnosis ( ___.
Her renal function has deteriorated over the years, but
creatinines have been quite fluctuant. BM bx ___: plasma cells
focally and in large clusters occupying ___ of marrow
cellularity. Most recent IgA 1700. Ca+ was high during
admission. Pt advised to stay well hydrated. She will f/u with
Dr. ___ week after dicharge
# H/o bronchitis/asthma: The patient was provided PRN nebulizers
while hospitalized. She was restarted on Advair on ___. She
may resume PRN Combivent and albuterol upon discharge.
Transitional Issues:
********************
- The patient will need TSH checked as an outpatient. She was
given Levothyroxine 500 mcg x1 in the ED out of concern for
myxedema coma; her TSH was noted to be 4.0.
-Pt will need to continue seeing her outpatient mental health
providers for medication titration
-Pt to f/u with her oncologist Dr. ___ continued
management of MM
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Levothyroxine Sodium 50 mcg PO DAILY
2. acidophilus-pectin, citrus *NF* 25 million-100 cell-mg Oral
daily
3. Multivitamins 1 TAB PO DAILY
4. Lorazepam 0.5 mg PO BID
5. Vitamin D 1000 UNIT PO DAILY
6. Docusate Sodium 100 mg PO BID
7. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
8. Ranitidine 150 mg PO HS
9. Clozapine 100 mg PO HS
10. Gabapentin 600 mg PO HS
11. melatonin *NF* 3 mg Oral QHS
12. Pravastatin 20 mg PO DAILY
13. Senna 1 TAB PO HS
14. Lorazepam 0.5 mg PO DAILY:PRN anxiety
15. Benzonatate 100 mg PO TID:PRN cough
16. Acetaminophen 325-650 mg PO Q6H:PRN pain, fever
17. Atenolol 12.5 mg PO DAILY
18. Midodrine 7.5 mg PO DAILY
19. Venlafaxine 225 mg PO DAILY
20. Lidocaine 5% Patch 1 PTCH TD DAILY:PRN pain
12 hours on/12 hours off
21. Omeprazole 20 mg PO DAILY
22. FoLIC Acid 1 mg PO DAILY
23. Vesicare *NF* (solifenacin) 10 mg Oral daily
24. Cyanocobalamin 100 mcg PO DAILY
25. Lunesta *NF* (eszopiclone) 4 mg Oral QHS
26. Mintox *NF* (alum-mag hydroxide-simeth) 200-200-20 mg/5 mL
Oral Q4H:PRN GI upset
27. guaiFENesin *NF* 100 mg/5 mL Oral Q4-6H:PRN cough
28. Loperamide 2 mg PO Q4-6H:PRN diarrhea
29. Lactulose 15 mL PO DAILY:PRN constipation
30. Milk of Magnesia 30 mL PO DAILY:PRN constipation
31. Polyethylene Glycol 17 g PO DAILY:PRN constipation
32. Sodium Chloride Nasal ___ SPRY NU QID:PRN dry nose
33. Cepacol (Menthol) 1 LOZ PO PRN sore throat
34. Albuterol-Ipratropium 1 PUFF IH Q6H:PRN shortness of breath
35. TraMADOL (Ultram) 50 mg PO Q8H:PRN pain
36. ProAir HFA *NF* (albuterol sulfate) 90 mcg/actuation
Inhalation Q4H:PRN SOB
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN pain, fever
2. Clozapine 100 mg PO HS
3. Cyanocobalamin 100 mcg PO DAILY
4. Docusate Sodium 100 mg PO BID
5. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
6. Gabapentin 600 mg PO HS
7. Levothyroxine Sodium 50 mcg PO DAILY
8. Lorazepam 0.5 mg PO BID
9. Lorazepam 0.5 mg PO DAILY:PRN anxiety
10. Multivitamins 1 TAB PO DAILY
11. Omeprazole 20 mg PO DAILY
12. Pravastatin 20 mg PO DAILY
13. Ranitidine 150 mg PO HS
14. Senna 1 TAB PO HS
15. Venlafaxine 225 mg PO DAILY
16. Vitamin D 1000 UNIT PO DAILY
17. acidophilus-pectin, citrus *NF* 25 million-100 cell-mg Oral
daily
18. Albuterol-Ipratropium 1 PUFF IH Q6H:PRN shortness of breath
19. Benzonatate 100 mg PO TID:PRN cough
20. Cepacol (Menthol) 1 LOZ PO PRN sore throat
21. FoLIC Acid 1 mg PO DAILY
22. guaiFENesin *NF* 100 mg/5 mL Oral Q4-6H:PRN cough
23. Lactulose 15 mL PO DAILY:PRN constipation
24. Lidocaine 5% Patch 1 PTCH TD DAILY:PRN pain
12 hours on/12 hours off
25. Loperamide 2 mg PO Q4-6H:PRN diarrhea
26. Lunesta *NF* (eszopiclone) 3 mg Oral QHS
27. melatonin *NF* 3 mg Oral QHS
28. Midodrine 5 mg PO DAILY
29. Milk of Magnesia 30 mL PO DAILY:PRN constipation
30. Mintox *NF* (alum-mag hydroxide-simeth) 200-200-20 mg/5 mL
Oral Q4H:PRN GI upset
31. Polyethylene Glycol 17 g PO DAILY:PRN constipation
32. ProAir HFA *NF* (albuterol sulfate) 90 mcg/actuation
Inhalation Q4H:PRN SOB
33. Sodium Chloride Nasal ___ SPRY NU QID:PRN dry nose
34. TraMADOL (Ultram) 50 mg PO Q8H:PRN pain
35. Vesicare *NF* (solifenacin) 10 mg Oral daily
Discharge Disposition:
Extended Care
Discharge Diagnosis:
Beta blocker induced bradycardia
Schizoaffective disorder
Upper respiratory infection
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure to take care of you at ___
___. You were admitted for a slow heart rate,
confusion and low blood pressure. We believe your slow heart
rate and low blood pressure were due to atenolol. We stopped
this medication and you improved. While in the hospital you
experienced one fever in association with sneezing, cough and
muscle aches. You likely experienced a viral infection which is
improving.
Your calcium was also noted to be high, likely from your
multiple myleoma. Please stay well hydrated so that you are
urinating frequently throughout the day.
Please take your medications as prescribed and follow up with
the appointments listed below.
The following changes were made to your medications:
STOPPED atenolol
Followup Instructions:
___
|
19693912-DS-31
| 19,693,912 | 28,310,427 |
DS
| 31 |
2147-04-11 00:00:00
|
2147-04-11 15:53:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Chlorpromazine / Seroquel / Tape ___ / ibuprofen /
trazodone / NSAIDS (Non-Steroidal Anti-Inflammatory Drug)
Attending: ___.
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Primary Care Physician: ___.
Chief Complaint: respiratory distress
Reason for MICU transfer: respiratory distress
HISTORY OF PRESENT ILLNESS:
___ h/o asthma, smoldering MM, chronic anemia, recent admission
in ___ for PNA who presents from nursing home with SOB and
cough. She has had SOB and a productive cough for the past few
days, denies fevers chills. She says she has felt like this
before but was unable to give further details of when that was.
SOB is a bit worse when laying flat, no CP and no hemoptysis.
She has noticed her legs are a bit more swollen.
In ED vitals were: 98.2 108 170/91 22 89% 10L
Labs notable for: WBC 15 Ht 32, lactate 1.5
CXR showing: LML opcaity concerning for PNA
ABG while on non invsaive: pH 7.36, pCO2 49 pAO2 341
Started on NIV: FiO2:100% PEEP:5 PS:10 and wa satting at 100%
given levoflox, duonebs, MethylPREDNISolone Sodium Succ 125mg
then 1000mg,
On arrival to the MICU she was breathing comfortably on
non-invasive and asked to take it off, when it was removed she
was satting at 97%facemask.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies chest pain, chest pressure, palpitations, or
weakness. Denies nausea, vomiting, diarrhea, constipation,
abdominal pain, or changes in bowel habits. Denies dysuria,
frequency, or urgency. Denies arthralgias or myalgias. Denies
rashes or skin changes.
Past Medical History:
-smoldering IgA multiple myeloma: her IgA
levels has not changed significantly since diagnosis, ___ Her
renal function has deteriorated over the years,
but creatinines have been quite fluctuant. BM bx ___: plasma
cells
focally and in large clusters occupying ___ of marrow
cellularity.
-hypercalcemia with elevated PTH
-hypothyroidism
-gastroesophageal reflux disease
-previous GIB from NSAIDs
-hyperlipidemia
-basal cell carcinoma
-stress urinary incontinence
-stage III chronic kidney disease
- schizaffective disorder, bipolar type: diagnosed in her ___.
h/o of SI/SA.
- Insomnia
- Asthma/Bronchitis
- Constipation
- Memory deficits
- Chronic lower back pain - spinal stenosis s/p laminectomy
- h/o siezures: generalized tonic-clonic seizure x 1 in ___
while on thorazine; abnormal EEG in ___ per OMR: left temporal
slowing with some sharp features consistent with left
hemispheric subcortical dysfunction
-mixed incontinence (Stress>Urge
PAST SURGICAL HISTORY
1. Laminectomy (L4-L5)
2. Appendectomy
3. Left knee
Social History:
___
Family History:
Family History:
Father passed away from tongue cancer. Mother passed away from
"enlarged heart"
Physical Exam:
Admission:
Vitals- 97.7 136/57 77 100% 3L NC
General- Alert, oriented, no acute distress
HEENT- Sclera anicteric, MMM, oropharynx clear
Neck- supple, not able to assess JVP d/t body habitus
CV: distant heart sounds, normal rate, regular rhythm, ___
Systolic murmur at RUSB, no rubs or gallops
Lungs- Coarse crackles halfway up on right lung field,
diminished at base on left, no wheezing, moderate air movement.
Abdomen- soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU- Foley in place
Ext- warm, well perfused, 2+ pulses, 1+ edema right >left lower
extremity to knees
Neuro- CNs2-12 intact, motor function grossly normal
Discharge:
Vitals: 98 61 163/66 18 94% RA
General- Alert, oriented, no acute distress
HEENT- Sclera anicteric, MMM, oropharynx clear
Neck- supple, not able to assess JVP d/t body habitus
CV: distant heart sounds, normal rate, regular rhythm, ___
Systolic murmur at RUSB, no rubs or gallops
Lungs- Crackles in R lung base, otherwise CTAB, no wheezing,
good air movement.
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
Pertinent Results:
Admission
___ 05:30PM BLOOD WBC-15.2*# RBC-3.79* Hgb-10.7* Hct-32.9*
MCV-87 MCH-28.2 MCHC-32.5 RDW-15.3 Plt ___
___ 05:30PM BLOOD Neuts-89.4* Lymphs-5.1* Monos-4.4 Eos-0.8
Baso-0.2
___ 05:30PM BLOOD ___ PTT-33.5 ___
___ 05:30PM BLOOD Glucose-111* UreaN-18 Creat-1.0 Na-142
K-4.2 Cl-103 HCO3-31 AnGap-12
___ 05:30PM BLOOD cTropnT-<0.01
___ 05:30PM BLOOD Calcium-10.1 Phos-2.4* Mg-2.3
___ 06:13PM BLOOD Type-ART Tidal V-100 PEEP-5 pO2-341*
pCO2-49* pH-7.36 calTCO2-29 Base XS-1 Intubat-NOT INTUBA
Vent-SPONTANEOU Comment-BIPAP
CXR ___
IMPRESSION: Subtle nodular opacity at the left lung base is
concerning for pneumonia.
RLE DOPPLER ___
IMPRESSION: No evidence of deep vein thrombosis in the right
lower extremity
Discharge
___ 09:20AM BLOOD WBC-14.6* RBC-3.55* Hgb-10.0* Hct-30.9*
MCV-87 MCH-28.2 MCHC-32.3 RDW-15.0 Plt ___
___ 09:20AM BLOOD Neuts-76.0* ___ Monos-4.8 Eos-0.4
Baso-0.2
___ 09:20AM BLOOD UreaN-20 Creat-0.8 Na-145 K-4.2 Cl-105
HCO3-29 AnGap-15
___ 09:20AM BLOOD Calcium-10.7*
Brief Hospital Course:
___ with h/o IgA myeloma, schizoaffective d/o (bipolar type),
hypothyroidism, asthma, GERD, and CKD, previous admission in ___
for PNA who presents from assisted living in respiratory
distress and PNA.
#Respiratory distress: Pt initially admitted to the MICU with
respiratory distress requiring NIPPV. She was quickly weaned to
NC on arrival to the ICU. Etiology of her respiratory distress
is likely asthma exacberation and pneumonia, with CXR showing
consolidation in LML. She was started on tx for CAP w/
levofloxacin and ceftriaxone. Also given pred for 5 d and
inhalers for asthma exacerbation. Given smoldering MM,
hematology recommended IVIg, though pt preferred to decline. She
was transferred to the floor when respiratory status improved.
Continued on levofloxacin and prednisone (7 and 5 day total
course, respectively). Weaned off O2. Able to ambulate without
O2 req at time of discharge.
#RLE>LLE: Pt is at risk for DVTs bc she is not very mobile at
her assisted living facility. Fortunately, D-dimer was negative
and ___ negative for DVT.
#Leukocytosis: WBC 15 on admission, up to 20 on HD1 in setting
of getting methylpred, last admission for PNA WBC was 22. She is
currently being treated for pneumonia as above and receiving
pred, WBC trended down to 14.
#Hypercalcemia: corrected Ca ___ with elevated PTH 170s
consistent with likely primary hyperpara (from an adenoma). Was
seen by Dr ___ as outpatient and currently continuing workup.
# Multiple Myeloma: this has been stable for years as outlined
in ___. Not on any specific treatment. As above, we discussed
IVIg, however pt declined for the time being and will f/u with
Dr. ___ as outpatient.
# Hypothyroidism: Continuied her home levothyroxine 50 mcg PO
Transitional:
- will finish 7 day course of levaquin (through ___
- will finish 5 day course of prednisone 40mg (through ___
- d/c'd midodrine due to HTN as inpatient, requires ongoing eval
of blood pressure and need for this medication
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Clozapine 100 mg PO HS
2. Cyanocobalamin 100 mcg PO DAILY
3. Docusate Sodium 100 mg PO BID
4. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
5. FoLIC Acid 1 mg PO DAILY
6. Gabapentin 600 mg PO HS
7. Levothyroxine Sodium 50 mcg PO DAILY
8. Lidocaine 5% Patch 1 PTCH TD DAILY
9. Lorazepam 0.5 mg PO HS:PRN sleep/anxiety
10. Midodrine 7.5 mg PO QAM
11. Multivitamins 1 TAB PO DAILY
12. Omeprazole 20 mg PO DAILY
13. Polyethylene Glycol 17 g PO DAILY:PRN constipation
14. Pravastatin 20 mg PO HS
15. Ranitidine 150 mg PO HS
16. Senna 1 TAB PO HS
17. Venlafaxine XR 225 mg PO DAILY
18. Albuterol Inhaler ___ PUFF IH Q4H:PRN wheezing/SOB
19. Ipratropium Bromide MDI 2 PUFF IH QID:PRN SOB
20. Vesicare (solifenacin) 10 mg Oral dai8ly
21. Tiotropium Bromide 1 CAP IH DAILY
22. Cepacol (Menthol) 1 tablet Other QDAY:PRN
23. Benzonatate 100 mg PO TID:PRN cough
24. melatonin 3 mg Oral QHS
25. Lunesta (eszopiclone) 3 mg Oral QHS
26. Acetaminophen 1000 mg PO Q8H:PRN pain, headache
27. TraMADOL (Ultram) 50 mg PO TID pain
Discharge Medications:
1. Levofloxacin 750 mg PO DAILY
Please continue to take for 7 day course (until ___
2. Albuterol Inhaler ___ PUFF IH Q4H:PRN wheezing/SOB
3. Benzonatate 100 mg PO TID:PRN cough
4. Clozapine 100 mg PO HS
5. Cyanocobalamin 100 mcg PO DAILY
6. Docusate Sodium 100 mg PO BID
7. FoLIC Acid 1 mg PO DAILY
8. Levothyroxine Sodium 50 mcg PO DAILY
9. Omeprazole 20 mg PO DAILY
10. Polyethylene Glycol 17 g PO DAILY:PRN constipation
11. Ranitidine 150 mg PO HS
12. Senna 1 TAB PO HS
13. TraMADOL (Ultram) 50 mg PO TID pain
14. Venlafaxine XR 225 mg PO DAILY
15. Cepacol (Menthol) 1 tablet Other QDAY:PRN
16. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
17. Gabapentin 600 mg PO HS
18. Ipratropium Bromide MDI 2 PUFF IH QID:PRN SOB
19. Lidocaine 5% Patch 1 PTCH TD DAILY
20. Lorazepam 0.5 mg PO HS:PRN sleep/anxiety
21. Lunesta (eszopiclone) 3 mg Oral QHS
22. melatonin 3 mg Oral QHS
23. Multivitamins 1 TAB PO DAILY
24. Pravastatin 20 mg PO HS
25. Tiotropium Bromide 1 CAP IH DAILY
26. Vesicare (solifenacin) 10 mg Oral dai8ly
27. PredniSONE 40 mg PO DAILY Duration: 4 Days
Please continue to take for 3 days (until ___
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary diagnosis: Pneumonia
Secondary diagnosis: asthma exacerbation, anemia, smoldering
multiple myeloma
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:
It was a pleasure taking care of you during your admission to
___. As you know, you were
admitted for pneumonia and an asthma exacerbation. You initially
were admitted to the Medical ICU where they treated your
pneumonia with antibiotics and your asthma with steroids. You
improved and were transferred to a standard floor where you
continued to improve. We recommend that you follow-up with your
primary care physician and oncologist.
Followup Instructions:
___
|
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