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19693912-DS-32
| 19,693,912 | 21,784,234 |
DS
| 32 |
2147-04-19 00:00:00
|
2147-04-20 07:15:00
|
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:
L Hip Pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ F with h/o multiple myeloma, asthma/chronic bronchitis,
schizoaffective disorder and recent admission (___) for
PNA who presents with right hip pain and leukocytosis.
Of note, pt was recently admitted from ___ for PNA. She
initially presented with resp distress requiring NIPPV and was
admitted to MICU, quickly weaned to NC on arrival to ICU. CXR
showed consolidation in left middle lobe. Etiology of her sx was
thought ___ PNA and asthma exacerbation. ___ obtained in
setting of ___ edema was negative, D-dimer WNL. She was
treated for CAP with levoquin (7 day course, last day ___
and ceftriaxone. Also received prednisone burst (40mg x5 days,
last day ___ for asthma. Given smoldering MM, hematology
recommended IVIG but pt declined this. She was transferred to
floor when resp status improved and weaned off O2, able to
ambulate without dyspnea or supplemental O2 on discharge. WBC on
discharge was 14.
Pt fell 2 weeks ago prior to her admission for PNA, but did not
note right hip pain and pelvic pain until ___ days ago. Occurs
only when weight bearing. Uses a walker at baseline, denies
changes in her gait. Also endorses R shoulder pain (has chronic
arthritis there, but pain worse after the fall which caused her
to strike the shoulder).
Given the right hip pain, home ___ checked her labs on ___,
and CBC returned with leukocytosis to 23. She was thus directed
to the ED from home by her primary care office for evaluation.
Pt states that her cough and sputum which started prior to last
admission have completely resolved, denies any dyspnea or
wheezing. Denies fevers, chills, SOB, chest pain, abdominal
pain, nausea, vomiting, or urinary symptoms. No weakness,
numbness, paresthesias, or back pain.
- In the ED intial vitals were: 98.4 76 159/84 16 99% ra.
- Labs notable for WBC 19.6, Cr 1.2 (baseline 0.8-1.1), lactate
1.7.
UA bland. CXR showed L lingular opacity, c/w previously dx PNA.
R hip/pelvic x-rays showed no fractures, mild DJD. CT
___ (without contrast) showed no bony or lytic
lesions, but did show diffuse R>L ___ opacities
concerning for infectious vs. inflammatory bronchiolitis.
- Given concern for new/undertreated PNA based on chest CT and
leukocytosis, pt was admitted to medicine.
- Patient was given: Ceftriaxone 1g IV, Azithro 500mg PO, and
then Cefepime 2g IV.
- Vitals on transfer: 98.4 72 144/82 16 100% RA
This AM pt says that R hip has resolved when going to commode. R
shoulder pain persists, but is consistent with prior.
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:
General- Alert, oriented, no acute distress
HEENT- Sclera anicteric, MMM, oropharynx clear
Neck- supple, JVP not elevated, no LAD
Lungs- LLL crackles extending up ___ from base, no wheezes,
rales, ronchi
CV- Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen- soft, obese, non-tender, non-distended, bowel sounds
present, no rebound tenderness or guarding, no organomegaly
GU- no foley
Ext- +mild TTP over lateral right hip and L shoulder, full ROM.
Negative straight leg raise. No hematomas or swelling noted.
Full strength and sensation throughout. Pulses 2+ distally, no
C/C/E.
Neuro- CNs2-12 intact, motor function grossly normal
Discharge exam:
afebrile, VSS
MSK exam- full range of motion of right hip without pain.
ambulatory with walker without pain. some pain on palpation of
gluteus medius muscle on right. no greater trochanter pain.
clear lungs bilaterally
Pertinent Results:
ADMISSION
___ 08:15PM BLOOD WBC-19.6* RBC-3.57* Hgb-10.0* Hct-31.8*
MCV-89 MCH-28.1 MCHC-31.5 RDW-15.1 Plt ___
___ 08:15PM BLOOD Glucose-96 UreaN-22* Creat-1.2* Na-135
K-5.6* Cl-100 HCO3-24 AnGap-17
___ 08:15PM BLOOD Lactate-1.7 K-4.1
DISCHARGE
___ 07:15AM BLOOD WBC-15.5* RBC-3.29* Hgb-9.2* Hct-28.8*
MCV-88 MCH-27.8 MCHC-31.8 RDW-15.1 Plt ___
IMAGING
Imaging:
- CT ___ WO CONTRAST (___):
1. Diffuse right greater than left ___ pulmonary
opacities suggest an infectious or inflammatory bronchiolitis.
2. Large colonic fecal load.
3. No evidence of abscess or lytic bony lesions.
4. Top normal size of the ascending aorta is unchanged since
___.
5. Moderate hiatal hernia.
- R SHOULDER X-RAY (___): Severe glenohumeral joint
arthritis without evidence of fracture or dislocation.
- PA/LAT CXR (___): Hazy lingular opacity persists from
the prior study. There is no pleural effusion or pneumothorax.
The right lung is clear. Cardiac silhouette is top-normal in
size. The aorta is tortuous. IMPRESSION: Lingular opacity
concerning for pneumonia.
- PELVIS AND R HIP X-RAYS (___): Single view of the pelvis
and 2 additional views of the right hip demonstrate no evidence
of fracture dislocation. No lytic or sclerotic lesions. Minor
degenerative changes of both hip joints manifested by osteophyte
formation. Overlying bowel gas pattern is normal. IMPRESSION: No
fracture.
blood cultures and urine cultures showed no growth
Brief Hospital Course:
___ F with h/o multiple myeloma, asthma/chronic bronchitis,
schizoaffective disorder and recent admission (___) for
PNA who presents with right hip pain and leukocytosis with R>L
___ opacifications seen on chest CT.
ACTIVE ISSUES
# LEUKOCYTOSIS: WBC 19.6, up from 14.6 on dischage ___, has
since trended down to 15 after recieving abx
(CTX/Azith/Cefepime) in ED, but a drop across all cell lines
suggests initial value was from some level hemoconcentration. Pt
without cough or other symptoms of pneumonia. No e/o
osteomyelitis or abscess on CT torso (though was done without
contrast). No further abx given on floor.
# BRONCHIOLITIS ON CHEST CT: Chest CT shows L>R ___
opacifications. She c/o mild dry cough which is significantly
improved since recent PNA, minimal sputum production. In
discussion with radiology, this likely represents her chronic
bronchitis and in review of prior CTs, there was some evidence
of this extending back ___ years.
# R HIP PAIN / L SHOULDER PAIN: Hip pain started ___ days ago,
located in R hip with some radiation down posterior thigh but is
now resolved with tylenol. No red flag signs to suggest fracture
and X-ray normal. No osteomyelitis, abscess or fractures seen on
imaging. Likely etiology is muscule strain of gluteus medius as
noted on exam. No signs of knee fracture with referred pain.
Neurologic etiology like sciatica or radiculopathy unlikely
based on exam. L shoulder pain is longstanding without
radiographic evidence of lytic lesions.
# ___: Creatinine elevated to 1.2, baseline 0.8-1.1. Based on
mildly elevated BUN and slightly dry appearance on exam, likely
prerenal insufficiency. Overnight got 2L of fluids, discharge
creatinine normal at 0.8
INACTIVE ISSUES
# SMOLDERING IGA MYELOMA: Pt has chronic renal insufficiency,
anemia and hypercalcemia (but in context of concomitantly
elevated PTH, unclear which is driving this). Last set of IgA
was 1772 in ___. No evidence of lytic lesions to explain joint
pains and pt is able to ambulate with a walker. She has
previously scheduled follow up with Dr. ___ this month.
# ASTHMA: No wheezes on exam, no dyspnea. Continued home
inhalers.
# SCHIZOAFFECTIVE DISORDER. Continued venlafaxine and ativan
# SEIZURE DISORDER: Continued gabapentin
TRANSITIONAL ISSUES
# continued w/u hypercalcemia with endocrinology
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler ___ PUFF IH Q4H:PRN wheezing/dyspnea
2. Benzonatate 100 mg PO TID:PRN cough
3. Clozapine 100 mg PO HS
4. Cyanocobalamin 100 mcg PO DAILY
5. Docusate Sodium 100 mg PO BID
6. FoLIC Acid 1 mg PO DAILY
7. Levothyroxine Sodium 50 mcg PO DAILY
8. Omeprazole 20 mg PO DAILY
9. Polyethylene Glycol 17 g PO DAILY:PRN constipation
10. Ranitidine 150 mg PO HS
11. Senna 1 TAB PO HS
12. TraMADOL (Ultram) 50 mg PO TID
13. Venlafaxine XR 225 mg PO DAILY
14. Cepacol (Menthol) 1 tablet Other daily: PRN sore throat
15. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
16. Gabapentin 600 mg PO HS
17. Ipratropium Bromide MDI 2 PUFF IH QID:PRN dyspnea
18. Lidocaine 5% Patch 1 PTCH TD DAILY
19. Lorazepam 0.5 mg PO HS:PRN anxiety/insomnia
20. Lunesta (eszopiclone) 3 mg oral HS
21. melatonin 3 mg oral HS
22. Multivitamins 1 TAB PO DAILY
23. Pravastatin 20 mg PO DAILY
24. Tiotropium Bromide 1 CAP IH DAILY
25. solifenacin 10 mg oral daily
Discharge Medications:
1. Benzonatate 100 mg PO TID:PRN cough
2. Cepacol (Menthol) 1 tablet Other daily: PRN sore throat
3. Clozapine 100 mg PO HS
4. Docusate Sodium 100 mg PO BID
5. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
6. FoLIC Acid 1 mg PO DAILY
7. Gabapentin 600 mg PO HS
8. Levothyroxine Sodium 50 mcg PO DAILY
9. Lorazepam 0.5 mg PO HS:PRN anxiety/insomnia
10. Multivitamins 1 TAB PO DAILY
11. Omeprazole 20 mg PO DAILY
12. Polyethylene Glycol 17 g PO DAILY:PRN constipation
13. Pravastatin 20 mg PO DAILY
14. Ranitidine 150 mg PO HS
15. Senna 1 TAB PO HS
16. solifenacin 10 mg oral daily
17. Tiotropium Bromide 1 CAP IH DAILY
18. TraMADOL (Ultram) 50 mg PO TID
19. Venlafaxine XR 225 mg PO DAILY
20. Albuterol Inhaler ___ PUFF IH Q4H:PRN wheezing/dyspnea
21. Cyanocobalamin 100 mcg PO DAILY
22. Ipratropium Bromide MDI 2 PUFF IH QID:PRN dyspnea
23. Lidocaine 5% Patch 1 PTCH TD DAILY
24. Lunesta (eszopiclone) 3 mg oral HS
25. melatonin 3 mg oral HS
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Resolving Pneumonia
Chronic Bronchitis
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. ___,
Thank you for choosing us for your care. You were admitted for a
suspicion of recurrent pneumonia based on radiographic evidence.
However, based on your vital signs and exam, this is likely
residual from your prior episode of pneumonia. An elevated ___
count was noted, but this is likely from the prednisone you took
on the last admission.
We did note that your calcium is high, and you should continue
to have this worked up at an endocrinology appointment that we
have scheduled you for below.
We have made no changes to your medications.
Followup Instructions:
___
|
19693912-DS-35
| 19,693,912 | 24,078,857 |
DS
| 35 |
2147-10-11 00:00:00
|
2147-10-12 20:52:00
|
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:
Fatigue and shortness of breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ w/ h/o multiple myeloma, schizoaffective disorder, GERD,
stage III CKD, prior seizure, impaired memory presenting from
living facility after ___ days of decreased energy and PO
intake. Pt reports that she had felt increasingly fatigued and
short of breath over the past few days, and had not been able to
eat or drink well during that time. She also reports new cough
with sputum production and worsened wheezing. Pt was noted to
have two witnessed falls at her living facility without head
strike. In addition, ___ facility would also like pt to be
evaluated by psych for increased anxiety and reported fears of
dying.
In the ED, initial VS were 97.7 84 89/48 18 90% RA. Received
Vancomycin, Cefepime, and Levaquin in the ED after CXR
demonstrated new right mid-to-lower lung consolidation. In
addition, pt received IV fluids. Labs were notable for WBC
20.2, H/H 9.6/31.7, Cr 1.7 from baseline 0.9-1.0, Na 127, normal
UA.
Transfer VS were 97.9 116/58 69 18 100% on 4L. On arrival to
the floor, patient reports that she is feeling better overall,
but reports continued cough and some shortness of breath.
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:
Father passed away from tongue cancer. Mother passed away from
"enlarged heart"
Physical Exam:
ADMISSION PHYSICAL EXAM:
======================
VS - 97.9 116/58 69 18 100% on 4L
General: No apparent distress, lying in bed with nebulizer
HEENT: PERRL, EOMI, MMM, OP clear
Neck: No thyromegaly
CV: S1 S2 RRR no m/r/g
Lungs: Scattered expiratory wheezes, crackles at the bases R>L
Abdomen: Soft, non-tender, non-distended, normoactive BS
GU: deferred
Ext: No edema, clubbing, cyanosis
Neuro: Non-focal
Skin: No rashes
DISCHARGE PHYSICAL EXAM:
=======================
VS - 97.7 148/78 79 18 98% on RA
General: No apparent distress, sleeping and easily aroused this
AM
HEENT: PERRL, EOMI, MMM, OP clear
Neck: No thyromegaly
CV: S1 S2 RRR no m/r/g
Lungs: Improved wheezing, faint crackles at the bases R>L, air
movement improved compared to admission exam
Abdomen: Soft, non-tender, non-distended, normoactive BS
GU: deferred
Ext: No edema, clubbing, cyanosis
Neuro: Non-focal
Skin: No rashes
Pertinent Results:
ADMISSION LABS:
==============
___ 03:10PM BLOOD WBC-20.2*# RBC-3.73* Hgb-9.6* Hct-31.7*
MCV-85 MCH-25.8* MCHC-30.3* RDW-17.1* Plt ___
___ 09:48PM BLOOD WBC-23.0* RBC-3.26* Hgb-8.8* Hct-27.1*
MCV-83 MCH-27.0 MCHC-32.6 RDW-17.3* Plt ___
___ 03:10PM BLOOD Neuts-90.7* Lymphs-3.5* Monos-5.3 Eos-0.3
Baso-0.2
___ 03:10PM BLOOD ___ PTT-34.6 ___
___ 03:10PM BLOOD Glucose-90 UreaN-26* Creat-1.7* Na-127*
K-4.7 Cl-93* HCO3-20* AnGap-19
___ 09:48PM BLOOD Glucose-84 UreaN-27* Creat-1.5* Na-126*
K-4.2 Cl-98 HCO3-20* AnGap-12
___ 03:10PM BLOOD ALT-9 AST-17 AlkPhos-81 TotBili-0.3
___ 03:10PM BLOOD Lipase-21
___ 09:48PM BLOOD Albumin-3.3* Calcium-8.8 Phos-2.3*
Mg-1.1*
___ 03:10PM BLOOD Albumin-3.5
___ 03:10PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 03:20PM BLOOD Lactate-1.5
DISCHARGE LABS:
================
___ 06:30AM BLOOD WBC-14.4* RBC-3.02* Hgb-8.1* Hct-25.4*
MCV-84 MCH-26.7* MCHC-31.8 RDW-17.6* Plt ___
___ 06:30AM BLOOD Glucose-97 UreaN-16 Creat-0.8 Na-142
K-4.4 Cl-113* HCO3-22 AnGap-11
___ 06:30AM BLOOD Calcium-9.2 Phos-2.6* Mg-1.7
MICRO:
=========
___ 5:20 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
IMAGING:
===========
Chest X-Ray AP ___
IMPRESSION: New right mid-to-lower lung consolidation
compatible with pneumonia in the proper clinical setting.
CT Head w/out Contrast ___
IMPRESSION: No evidence of acute intracranial process.
Brief Hospital Course:
___ year old F with schizoaffective disorder, GERD, stage III
CKD, prior seizure, impaired memory presenting from living
facility with HCAP, prerenal ___ and hypovolemic hyponatremia.
ACUTE ISSUES:
==============
# HCAP: Pt presented from living facility after ___ days of
decreased energy and PO intake. Pt was found to have a right
lung infiltrate on chest X-ray and was admitted for HCAP. Pt
was started on Vancomycin and Cefepime and given IV fluids. Pt's
antibiotics were narrowed to Levaquin after pt showed clinical
improvement. After pt showed improvement in PO intake, was
ambulating, and comfortable on room air, she was discharged home
with a 7 day course of Levaquin as outpatient. Pt will be seen
by her PCP at home within 48 hours of discharge.
# Prerenal ___: Pt presented with Cr 1.7 from baseline 0.9-1.0,
which improved to 0.8 with IV fluids and improved PO intake.
# Hypovolemic hyponatremia: Pt presents with hyponatremia to 127
in the setting of decreased PO intake, which Improved to 142
with IV fluids and increased PO intake.
CHRONIC ISSUES:
===============
# Chronic shoulder pain: Continued lidocaine patch and
gabapentin
# Schizoaffective disorder: Continued venlafaxine and clozapine
# Hypothyroidism: Continued home levothyroxine
# GERD: Continued omeprazole and ranitidine
# HL: Continued statin
# Asthma: Continued home inhalers
# MM: Per notes, stable and followed closely by Dr. ___ in
Hem/Onc.
TRANSITIONAL ISSUES:
====================
# Pt will be discharged on 7 day course of Levaquin
# Pt will be seen by PCP ___ 48 hours of discharge
# Recommend checking labs to ensure renal function is stable. If
patient develops pre-renal azotemia again ___ poor PO intake,
will need to decrease frequency of levaquin dosing.
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 wheezing, dyspnea
3. Benzonatate 100 mg PO BID:PRN cough
4. Clozapine 100 mg PO HS
5. Cyanocobalamin 100 mcg PO DAILY
6. Docusate Sodium 100 mg PO BID
7. Fluticasone Propionate NASAL 1 SPRY NU DAILY
8. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
9. FoLIC Acid 1 mg PO DAILY
10. Guaifenesin 10 mL PO Q4H:PRN cough
11. Levothyroxine Sodium 50 mcg PO DAILY
12. Lidocaine 5% Patch 1 PTCH TD QAM
13. Midodrine 5 mg PO DAILY
14. Milk of Magnesia 30 mL PO QHS
15. Omeprazole 20 mg PO DAILY
16. Polyethylene Glycol 17 g PO DAILY:PRN diarrhea
17. Pravastatin 40 mg PO DAILY
18. Ranitidine 150 mg PO HS
19. Senna 8.6 mg PO HS
20. Tiotropium Bromide 1 CAP IH DAILY
21. Venlafaxine XR 225 mg PO DAILY
22. Acidophilus (L.acidoph &
___ acidophilus) 175 mg oral
daily
23. Cepacol (Menthol) 1 tablet Other daily:prn
24. Gabapentin 600 mg PO HS
25. Lactulose 15 mL PO DAILY:PRN constipation
26. Liquid Protein Fortifier (protein hydrolysate,milk) 30 ml
oral daily
27. LOPERamide 2 mg PO Q4-6H:PRN diarrhea
28. Lorazepam 1 mg PO HS
29. melatonin 3 mg oral qhs
30. Mi-Acid (alum-mag hydroxide-simeth;<br>calcium carbonate-mag
hydroxid) 30 ml oral q4h:prn GI upset
31. Multivitamins 1 TAB PO DAILY
32. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain
33. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation
q4h:prn wheezing
34. Prochlorperazine 10 mg PO Q8H:PRN nausea
35. Toviaz (fesoterodine) 8 mg oral daily
36. TraMADOL (Ultram) 50 mg PO TID:PRN pain
37. Vitamin D 1000 UNIT PO DAILY
38. Zeasorb (talc-cellulose-chloroxy-aldiox) 1 appl topical
daily:prn rash
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
2. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheezing, dyspnea
3. Clozapine 100 mg PO HS
4. Cyanocobalamin 100 mcg PO DAILY
5. Docusate Sodium 100 mg PO BID
6. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
7. FoLIC Acid 1 mg PO DAILY
8. Fluticasone Propionate NASAL 1 SPRY NU DAILY
9. Gabapentin 600 mg PO HS
10. Lidocaine 5% Patch 1 PTCH TD QAM
11. Lorazepam 1 mg PO HS
12. Levothyroxine Sodium 50 mcg PO DAILY
13. Midodrine 5 mg PO DAILY
14. Multivitamins 1 TAB PO DAILY
15. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain
16. Pravastatin 40 mg PO DAILY
17. Venlafaxine XR 225 mg PO DAILY
18. Vitamin D 1000 UNIT PO DAILY
19. Levofloxacin 750 mg PO Q24H
RX *levofloxacin [Levaquin] 750 mg 1 tablet(s) by mouth once a
day Disp #*7 Tablet Refills:*0
20. Acidophilus (L.acidoph &
___ acidophilus) 175 mg oral
daily
21. Benzonatate 100 mg PO BID:PRN cough
22. Cepacol (Menthol) 1 tablet Other daily:prn
23. Guaifenesin 10 mL PO Q4H:PRN cough
24. Lactulose 15 mL PO DAILY:PRN constipation
25. Liquid Protein Fortifier (protein hydrolysate,milk) 30 ml
oral daily
26. LOPERamide 2 mg PO Q4-6H:PRN diarrhea
27. melatonin 3 mg oral qhs
28. Mi-Acid (alum-mag hydroxide-simeth;<br>calcium carbonate-mag
hydroxid) 30 ml oral q4h:prn GI upset
29. Milk of Magnesia 30 mL PO QHS
30. Omeprazole 20 mg PO DAILY
31. Polyethylene Glycol 17 g PO DAILY:PRN diarrhea
32. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation
q4h:prn wheezing
33. Prochlorperazine 10 mg PO Q8H:PRN nausea
34. Ranitidine 150 mg PO HS
35. Senna 8.6 mg PO HS
36. Tiotropium Bromide 1 CAP IH DAILY
37. Toviaz (fesoterodine) 8 mg oral daily
38. TraMADOL (Ultram) 50 mg PO TID:PRN pain
39. Zeasorb (talc-cellulose-chloroxy-aldiox) 1 appl topical
daily:prn rash
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS
# Healthcare associated penumonia
# Hypovolemic hyponatremia
# Prerenal acute kidney injury
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mrs. ___,
___ was a pleasure taking care of you during your stay at ___.
You presented with decreased energy and a productive cough.
Chest X-ray showed a right lung pneumonia, and you were started
on antibiotics. In addition, you were given IV fluids and were
eventually able to eat and drink adequately. After you were
able to be weaned off oxygen and walk without problems, you were
discharged home. You will complete a 7 day course of Levaquin
as an outpatient. You will be seen by your PCP ___ 48 hours
of discharge.
*Please eat 3 solid meals per day and drink 2 liters of fluid
per day, if you are unable to do so then call your doctor.
Followup Instructions:
___
|
19693912-DS-38
| 19,693,912 | 24,849,661 |
DS
| 38 |
2149-08-26 00:00:00
|
2149-08-26 16:52:00
|
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:
Depression, acute encephalopathy
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms ___ is a ___ F with hx smoldering myeloma, schizoaffective
disorder, depression, hypothyroidism, CKD, with appointed
guardian residing in nursing facility for ___ yrs who presents
today with worsening depression and is admitted to medicine for
AMS. History is obtained primarily from the ED/psych notes as
the patient is confused and unable to relay much history. Pt
initially went to see her therapist today who referred her to
the ED out of cocern for worsening depression.
In the ED, initial vitals were: 7 98.5 65 130/88 16 100% RA.
While there, she denied SI, HI. Said she has been sleeping all
day and up all night and hasn't eaten in the last few days.
Mentioned to ED nurse that she has multiple myeloma and "I might
as well just die". Says she's been crying all the time and often
for no reason. Has been taking her meds as directed. No
drug/alcohol/tobacco use.
She was monitored in the ED for 2 days and followed by psych,
however given that psych noted a change in her mental status on
re eval today consisting of poor attention, orientation,
difficulty answering questions, disorganized thought process and
near delusional thinking concerning for delirium, psych
recommended admission for medical w/u. Labs were notable for
hct of 30.7, Ca ___ TSH WNL, serum tox negative, urine tox
positive for oxycodone only. UA with small leuks and few
bacteria. CXR showed opacity projecting over the heart on the
lateral radiograph with no correlate seen on the frontal
radiograph, however this was repeated and not visualized on
repeat. Head CT showed no acute process. While in the ED, she
was given GI cocktail, benadryl, gabapentin, bowel reg, statin,
ranitidine, omeprazole, clozapine, haldol, levothyroxine,
fluticasone, omeprazole, duloxetine, midodrine,
tolterodineVitals on transfer were 97.7 76 136/72 18 98% RA .
On the floor, states she in hospital but unable to state BI.
Unable to state why she came in initially but when reminded
states "oh yes, I am confused, mixed up". Endorses depression
and shoulder pain when asked, however will not volunteer any
other symptoms. Pain in shoulder is ___ and chronic. Unable to
state or confirm PCP or any names of family members. Tells me
she is living in the hospital. Seeing "fire dots" "grey dots
floating arround".
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, shortness of breath. Denies chest pain
or tightness, palpitations. Denies nausea, vomiting, diarrhea,
constipation or abdominal pain. No recent change in bowel or
bladder habits. No dysuria. Denies arthralgias or myalgias.
Past Medical History:
(per ED psych note, unable to confirm with pt):
PAST PSYCHIATRIC HISTORY: per Dr. ___ note
Prior Diagnosis: Schizoaffective disorder, diagnosed in ___
Hospitalizations: Numerous, including Deac 4, ___. ___,
___;
last at ___ in ___
Current treaters and treatment: Attends ___
Program
___ psychotherapist at ___ ___
___, relatively new); psychiatrist at ___, Dr.
___ and ECT trials: Numerous antipsychotic trials, now
on
clozapine, lorazepam, duloxetine, Lunesta; previously on other
SSRIs, venlafaxine, klonopin
Prior SI/SA: Multiple priors, including 2 overdoses and 1
hanging
many years ago
Self-injury: denies
Harm to others: denies
Access to weapons: denies
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
-Insomnia
-Asthma/Bronchitis
-Constipation
-Memory deficits
-Chronic lower back pain - spinal stenosis s/p laminectomy
-h/o seizures: 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)
-No history of head injuries.
Social History:
___
Family History:
Father passed away from tongue cancer. Mother passed away from
"enlarged heart"
Physical Exam:
Vitals: 97.3 120/56 70 16 97% RA
General: somnolent but arousable and following commands. Often
falls asleep during interview. Difficulty focusing on questions
asked. No acute distress.
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
CV: ___ SEM, regular rate and rhythm, normal S1 + S2, no rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: obese, soft, non-tender, non-distended, bowel sounds
present, no organomegaly, no rebound or guarding
GU: No foley
Ext: Warm, well perfused, non-pitting ___: aaox1, CNII-XII intact. ___ strength intact in upper and
lower extremities except for R shoulder which is limited by
pain. Brisk upper exrtremity reflexes, diministed in lower
extremities. Unable to state months of year backwards. Falling
asleep during during interview.
Skin: no rashes or lesions
MSK: Tenderness to palpation and movement of R shoulder
Pertinent Results:
___ 07:26PM URINE HOURS-RANDOM
___ 07:26PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG oxycodn-POS mthdone-NEG
___ 07:26PM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 07:26PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5
LEUK-SM
___ 07:26PM URINE RBC-<1 WBC-3 BACTERIA-FEW YEAST-NONE
EPI-2 RENAL EPI-<1
___ 07:26PM URINE HYALINE-4*
___ 07:26PM URINE MUCOUS-RARE
___ 04:51PM GLUCOSE-93 UREA N-22* CREAT-1.1 SODIUM-140
POTASSIUM-5.0 CHLORIDE-103 TOTAL CO2-24 ANION GAP-18
___ 04:51PM estGFR-Using this
___ 04:51PM CALCIUM-11.1* PHOSPHATE-2.7 MAGNESIUM-1.6
___ 04:51PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
___ 04:51PM WBC-6.8 RBC-3.59* HGB-9.7* HCT-32.3* MCV-90
MCH-27.0 MCHC-30.0* RDW-16.1* RDWSD-53.0*
___ 04:51PM NEUTS-54.8 ___ MONOS-10.5 EOS-7.1*
BASOS-0.7 IM ___ AbsNeut-3.69 AbsLymp-1.81 AbsMono-0.71
AbsEos-0.48 AbsBaso-0.05
___ 04:51PM PLT COUNT-250
MICRO: urine cx with mixed bacterial flora
STUDIES:
CT: No acute intracranial process.
EKG: NSR
CXR: ___ No acute cardiopulmonary process. Moderate-sized
hiatus hernia.
___. Opacity projecting over the heart on the lateral radiograph
with no
correlate seen on the frontal radiograph. Recommend follow-up
radiographs
after treatment for pneumonia.
2. Moderate hiatal hernia.
Brief Hospital Course:
___ yo F with MMP presenting with depression, now admitted for
hypoactive encephalopathy attributed to her psychiatric disorder
# Acute encephalopathy/Delerium/schizoaffective d/o: No clear
medical etiology to explain her symptoms. Infectious w/u
negative and head CT reassuring. No known hx of drug use or
evidence of withdrawal. TSH, chem 10 WNL other than calcium
which is mildly, chronically elevated. No LFTs negative. CT
head reassuringly normal. EKG nl. Given hx of seizures, would
consider EEG if no improvement, however no e/o seizure activity
here. Given relatively acute decompensation while in the ED
without clear organic etiology as well as hallucinations,
concern for acute psychiatric decompensation. Polypharmacy also
suspected. Her oxycodone, gabapentin, and lunesta were held.
She was placed on 1:1 with ___. There was no evidence of
infection. Her clozapine and Cymbalta were continued. Low dose
Ativan was trialed which seemed to help. She was transferred to
inpatient psychiatry for ongoing care
# Depression: Followed by psychiatry, kept on 1:1 with ___. Continued medications as above
# Anemia: mild, chronic, stable.
# Hypothyroidism: ___ WNL
-continued levothyroxine
# overactive bladder
-held toviaz given non-formulary, can resume on discharge
# GERD: continued omeprazole, ranitidine
# Asthma: continued fluticasone/salmeterol, albuterol
# Shoulder pain: continued Tylenol, will held oxycodone and
gabapentin given somnolence. Can consider resuming with caution
# HLD: continued statin
# Hypercalcemic hyperparathyroidism: Ca stable, awaiting
surgical eval
# Hypercalcemia/MM: outpt monitoring. Chronically elevated.
Hydrated with short term improvement in the hospital.
Name of health care proxy: ___
Relationship: Lawyer
Phone number: ___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. Guaifenesin 10 mL PO Q4H:PRN cough
2. Cepacol (Sore Throat Lozenge) 1 LOZ PO DAILY:PRN sore throat
3. Polyethylene Glycol 17 g PO DAILY:PRN constipation
4. Lactulose 15 mL PO DAILY:PRN constipation
5. Zeasorb AF (miconazole nitrate) 2 % topical QID:PRN fungal
infx
6. Milk of Magnesia 30 mL PO DAILY:PRN constipation
7. Aluminum-Magnesium Hydrox.-Simethicone 15 mL PO QID:PRN gerd
8. FoLIC Acid 1 mg PO DAILY
9. Levothyroxine Sodium 50 mcg PO DAILY
10. Duloxetine 40 mg PO DAILY
11. Acidophilus (Lactobacillus acidophilus) 1 tab oral DAILY
12. Toviaz (fesoterodine) 8 mg oral DAILY
13. Midodrine 5 mg PO DAILY
14. Cyanocobalamin 500 mcg PO DAILY
15. Alendronate Sodium 70 mg PO QTHUR
16. Vitamin D 1000 UNIT PO DAILY
17. Multivitamins 1 TAB PO DAILY
18. Senna 8.6 mg PO QHS
19. Fluticasone Propionate NASAL 1 SPRY NU DAILY
20. Omeprazole 20 mg PO DAILY
21. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
22. Acetaminophen 1000 mg PO BID
23. Docusate Sodium 100 mg PO BID
24. Sodium Chloride Nasal ___ SPRY NU TID
25. Pravastatin 40 mg PO QPM
26. Clozapine 100 mg PO QHS
27. Ranitidine 150 mg PO QHS
28. Gabapentin 600 mg PO QHS
29. Diphenhist (diphenhydrAMINE HCl) 50 mg oral QHS
30. OxycoDONE (Immediate Release) 2.5 mg PO BID:PRN pain
31. Lunesta (eszopiclone) 1 mg oral QHS:PRN insomnia
32. LOPERamide 2 mg PO QID:PRN diarrhea
33. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation
Q4H:PRN sob
34. Mintox (alum-mag hydroxide-simeth) 200-200-20 mg/5 mL oral
Q4H:PRN GI upset
35. Prochlorperazine 10 mg PO Q8H:PRN n/v
36. Benzonatate 100 mg PO BID:PRN cough
37. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN sob
38. Mi-Acid (alum-mag hydroxide-simeth;<br>calcium carbonate-mag
hydroxid) 700-300 mg oral Q4H:PRN GI upset
Discharge Medications:
1. Acetaminophen 1000 mg PO TID pain
2. Alendronate Sodium 70 mg PO QTHUR
3. Clozapine 100 mg PO QHS
4. Cyanocobalamin 500 mcg PO DAILY
5. Docusate Sodium 100 mg PO BID
6. Duloxetine 40 mg PO DAILY
7. Fluticasone Propionate NASAL 1 SPRY NU DAILY
8. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
9. FoLIC Acid 1 mg PO DAILY
10. Levothyroxine Sodium 50 mcg PO DAILY
11. Multivitamins 1 TAB PO DAILY
12. Omeprazole 20 mg PO DAILY
13. Pravastatin 40 mg PO QPM
14. Senna 8.6 mg PO QHS
15. Sodium Chloride Nasal ___ SPRY NU TID
16. Acidophilus (Lactobacillus acidophilus) 1 tab oral DAILY
17. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN sob
18. Aluminum-Magnesium Hydrox.-Simethicone 15 mL PO QID:PRN gerd
19. Benzonatate 100 mg PO BID:PRN cough
20. Cepacol (Sore Throat Lozenge) 1 LOZ PO DAILY:PRN sore throat
21. Gabapentin 600 mg PO QHS
22. Guaifenesin 10 mL PO Q4H:PRN cough
23. Lactulose 15 mL PO DAILY:PRN constipation
24. LOPERamide 2 mg PO QID:PRN diarrhea
25. Mi-Acid (alum-mag hydroxide-simeth;<br>calcium carbonate-mag
hydroxid) 700-300 mg oral Q4H:PRN GI upset
26. Midodrine 5 mg PO DAILY
27. Milk of Magnesia 30 mL PO DAILY:PRN constipation
28. Mintox (alum-mag hydroxide-simeth) 200-200-20 mg/5 mL oral
Q4H:PRN GI upset
29. Polyethylene Glycol 17 g PO DAILY:PRN constipation
30. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation
Q4H:PRN sob
31. Prochlorperazine 10 mg PO Q8H:PRN n/v
32. Ranitidine 150 mg PO QHS
33. Vitamin D 1000 UNIT PO DAILY
34. Zeasorb AF (miconazole nitrate) 2 % topical QID:PRN fungal
infx
35. Toviaz (fesoterodine) 8 mg oral DAILY
36. Lorazepam 0.5 mg PO BID:PRN agitation
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Depression
Schizoaffective disorder
Hypothyroidism
Hypercalcemia
Multiple Myeloma
Asthma
GERD
R shoulder arthritis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Patient was admitted with hypoactive encephalopathy and
catatonia, likely related to her underlying psychiatric
condition. Medical and metabolic derangments were treated and
excluded. She will now be discharged to the psychiatry service
for ongoing care
Followup Instructions:
___
|
19693912-DS-43
| 19,693,912 | 27,581,083 |
DS
| 43 |
2152-01-25 00:00:00
|
2152-01-25 20:26:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Chlorpromazine / Seroquel / Tape ___ / ibuprofen /
trazodone / NSAIDS ___ Drug)
Attending: ___.
Chief Complaint:
Tremor
Major Surgical or Invasive Procedure:
None
History of Present Illness:
HISTORY OF THE PRESENTING ILLNESS:
___ yo female with a history of chronic UTIs, smoldering IgA
multiple myeloma, CKD, stress incontinence presenting with
complaints of tremor and leg weakness. The patient reports that
she has had bilateral leg weakness and unsteadiness and tremor
___
her lower extremities and her hands for the past month. She also
reports mouth twitching over the last week. She thought they
would go away and that is why she did not present to the ED;
however, over the last few days, they worsened and she wanted to
go to the ED. Four days ago, the patient also states that she
started to have dysuria, bilateral lower abdominal pain, and
urinary frequency. At her assisted living, she was prescribed
macrobid ___ mg BID on ___ by the facility physician, but
she
continued to feel unwell. Her symptoms were primarily weakness
and that she did not notice fevers, chills, chest pain,
shortness
of breath. She describes the weakness ___ her ___ as though her
legs are buckling underneath her as she uses her walker. The ED
reported dyspnea but patient states she never had dyspnea.
Patient has a history of recurrent UTIs and has had urology
evaluation who recommended that she be on suppressive therapy
with trimethoprim 100 mg daily for six months.
___ the ED, initial vitals were:
98.0 105 106/64 22 95% RA
Exam notable for:
+L spine tenderness
unsteady when trying to stand, ___ left hip flexion, otherwise
strength intact, sensation intact, +tremor w/ FTN w/o dysmetria
Labs notable for:
Patient Given:
Magnesium Oxide 400 mg
I L IVF NS
Acetaminophen 1000 mg
IV CefTRIAXone
Vitals on Transfer:
97.7 92 101/52 18 96% RA
On the floor, the patient reports that she feels much better and
that her tremor is completely gone. She has had no shortness of
breath despite chest ___ showing signs of concerning for
pneumonia. Denies cough or chest pain. She does have a history
of
aspiration ___ the setting of oversedation. She has been taking
po. She does not have any belly pain currently and has no
urinary
frequency.
Review of systems:
10 point ROS was performed and positive as above.
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 ___ 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
-Insomnia
-Asthma/Bronchitis
-Constipation
-Memory deficits
-Chronic lower back pain - spinal stenosis s/p laminectomy
-h/o seizures: generalized ___ seizure x 1 ___ ___
while on thorazine; abnormal EEG ___ ___ per OMR: left temporal
slowing with some sharp features consistent with left
hemispheric subcortical dysfunction
-mixed incontinence (Stress>Urge)
-Schizoaffective disorder
-Depression with multiple prior hospitalizations
Social History:
___
Family History:
Father passed away from tongue cancer. Mother passed away from
"enlarged heart".
Physical Exam:
PHYSICAL EXAM AT ADMISSION:
Vital Signs: T 97.9 BP ___ HR ___ RR 20 ___ Ra
General: Alert, oriented, no acute distress
HEENT: Sclerae anicteric, MMM, oropharynx clear, EOMI, PERRL,
neck supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, ___ systolic murmur
heard at the upper sternal borders
Lungs: Clear posteriorly
Abdomen: Soft, obese, ___, +BS, no
organomegaly, no rebound or guarding
GU: No foley. No CVA tenderness
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: ___ intact, ___ strength upper/lower extremities,
grossly normal sensation. No tremor ___ her hands, face, or legs
PHYSICAL EXAM AT ADMISSION:
Vital Signs: per OMR
General: Alert, oriented, no acute distress
HEENT: Sclerae anicteric, MMM, oropharynx clear, EOMI, PERRL,
neck supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, ___ systolic murmur
heard at the upper sternal borders
Lungs: Clear posteriorly
Abdomen: Soft, obese, ___, +BS, no
organomegaly, no rebound or guarding
GU: No foley. No CVA tenderness
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: ___ intact, ___ strength upper/lower extremities,
grossly normal sensation. No tremor ___ her hands, face, or legs
Pertinent Results:
ADMISSION LABS
---------------
___ 11:35AM ___
___
___ 11:35AM ___
___ IM ___
___
___ 11:35AM ___ UREA ___
___ TOTAL ___ ANION ___
___ 11:56AM ___
___ 01:40PM URINE ___
___ 01:40PM URINE ___ WBC->182* ___
___ TRANS ___
___ 01:40PM URINE ___
___
___
IMAGING
--------
___ CT Head w/o contrast
No acute intracranial process.
___ CT ___ w/o contrast
1. No fractures identified.
2. Status post L4 and L5 laminectomies.
3. retrolisthesis of L3 on L4 and entero L4 on L5.
4. Multilevel degenerative changes of the lumbar spine with
spinal canal and neural foraminal narrowing.
___ CXR
Findings concerning for multifocal pneumonia.
MICRO
------
URINE CULTURE (Final ___: NO GROWTH.
MRSA SCREEN (Final ___: No MRSA isolated.
Legionella Urinary Antigen (Final ___:
NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN.
___ 1:34 pm SPUTUM Source: Expectorated.
**FINAL REPORT ___
GRAM STAIN (Final ___:
>25 PMNs and <10 epithelial cells/100X field.
2+ ___ per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS AND SINGLY.
1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S).
RESPIRATORY CULTURE (Final ___:
MODERATE GROWTH Commensal Respiratory Flora.
DISCHARGE LABS
---------------
___ 07:20AM BLOOD ___
___ Plt ___
___ 07:20AM BLOOD ___
___
___ 07:20AM BLOOD ___
Brief Hospital Course:
PATIENT SUMMARY
===============
___ female with a history of chronic UTIs, smoldering IgA
multiple myeloma, CKD, stress incontinence presenting with
complaints of tremor and leg weakness and found to be ___
urosepsis with multifocal PNA now on antibiotics.
ACUTE ISSUES
============
# Urosepsis
# Pyelonephritis: The patient initially presented with fever,
leukocytosis, dysuria, and suprapubic pain. Her UA showed
bacteria and many WBCs consistent with UTI. She has a history of
chronic UTIs on trimethoprim suppressive therapy and has
previously grown out E.coli (resistant to cipro and Bactrim) and
klebsiella (resistant to macrobid). The patient had been
prescribed macrobid on ___ at her assisted living facility but
rapidly improved upon switching to empiric ceftriaxone ___ the
___ ED on ___. Upon presenting to the floor, her exam was
notable for CVA tenderness bilaterally concerning for
pyelonephritis. As the patient's blood and urine culture
resulted ___ no growth, empiric ceftriaxone was continued until
the patient became afebrile and WBC normalized. She was then
transitioned to cefpodoxime 200mg PO BID which she should
continue taking for a 10 day course of antibiotics (___)
for presumed pyelonephritis. Given her history of chronic UTIs,
we also recommend the patient arrange an appointment with
urology as an outpatient to evaluate the etiology of chronic
UTIs and to determine indication for further suppressive
therapy.
# Pneumonia: The patient's ___ CXR was concerning for
multifocal pneumonia. She reported some coughing and shortness
of breath prior to admission, although her lungs remained
relatively clear and her O2 saturation remained normal on room
air. Given fever at admission and leukocytosis, she was
empirically treated for community acquired pneumonia with IV
ceftriaxone and PO azithromycin. She also received albuterol
nebs for her shortness of breath and benzonatate for her cough,
both of which resolved prior to discharge. She subsequently
remained afebrile with a normal WBC count, and ceftriaxone was
transitioned to PO cefpodoxime. She should continue her
azithromycin until ___ and cefpodoxime until ___.
# Tremors
# Lower extremity weakness: The patient initially presented to
the ED with tremors and lower extremity weakness. On arrival to
the floor, however, her tremors were resolved and the remainder
of her neurological exam was normal. It was possible that her
tremors and lower extremity weakness were secondary to her
infection and improved with antibiotic therapy. She was
evaluated by ___ who felt she was functioning well and close to
her baseline at the time of discharge, without further ___ needs.
# Acute on Chronic Renal Failure: The patient's admission Cr was
elevated up to 1.7 from her baseline of 1.3. ___ azotemia
was thought to be the most likely explanation ___ the setting of
sepsis and poor PO intake, and the patient was administered a 1L
fluid chalenge. Cr subsequently improved to 1.3, her baseline.
CHRONIC ISSUES
==============
# Orthostatic Hypotension/Autonomic dysfunction: Continued home
midodrine 5mg daily.
# Schizoaffective Disorder/Anxiety: Continued home clozapine,
mirtazapine, and duloxetine.
# Chronic Normocytic Anemia: Stable and multifactorial, thought
to be due to combination of iron deficiency, kidney disease, and
known smoldering myeloma.
# Hypothyroidism: Continued home levothyroxine.
# Smoldering Myeloma: Patient has longstanding history of IgG
kappa smoldering myeloma with mild chronic renal insufficiency,
followed by Dr. ___ ___ Heme/Onc.
# GERD: Continued home PPI & H2 blocker.
# HLD: Continued home pravastatin.
# Back Pain: Continued home gabapentin, acetaminophen PRN.
# Nutrition: Continued home folic acid, multivitamin, B12.
TRANSITIONAL ISSUES
===================
CONTINUE cefpodoxime 200mg PO BID until ___ for 10 days of
antibiotic therapy (last dose: ___ of ___
CONTINUE azithromycin 250mg PO daily (last dose: ___ AM)
STOP macrobid
HOLD trimethoprim until you meet with your PCP
- ___ with your PCP to discuss this hospitalization
and evaluate possible etiology of chronic UTIs
- patient should have close f/u with urology to discuss need for
further evaluation of the etiology of her chronic UTIs,
including renal u/s.
- please discuss whether patient should be on chronic
supporessive antibiotic therapy for UTI, as she was previously
on trimethoprim (though her prior urine cultures report
resistant organisms to Bactrim); please discuss this after she
completes her antibiotic regimen on ___.
- patient initiated on azithromycin; of note she is on many
other psychiatric medications with QTc prolonging potential.
Please check outpatient EKG at discharge for ongoing monitoring.
FYI QTc on ___ ___
- please ensure ongoing f/u of patient's apparently chronic
anemia as an outpatient
- please ensure patient has f/u CXR to eval for resolution of
PNA ___ weeks after discharge.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Midodrine 5 mg PO DAILY
2. Lactulose 15 mL PO DAILY: PRN constipation
3. Acetaminophen 500 mg PO BID
4. Gabapentin 600 mg PO QHS
5. Mirtazapine 30 mg PO QHS
6. LOPERamide 2 mg PO QID:PRN diarrhea
7. Clozapine 125 mg PO QHS
8. Alendronate Sodium 70 mg PO QTHUR
9. Docusate Sodium 200 mg PO DAILY
10. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - First
Line
11. Senna 8.6 mg PO QHS
12. estradiol 0.01 % (0.1 mg/gram) vaginal DAILY
13. GuaiFENesin 10 mL PO Q4H:PRN cough
14. Ranitidine 150 mg PO QHS
15. Pravastatin 40 mg PO QPM
16. Ferrous Sulfate 325 mg PO TID
17. ___ mg oral TID: PRN
18. Multivitamins 1 TAB PO DAILY
19. Cranberry Concentrate (cranberry ___
acid;<br>cranberry extract) 450 mg oral DAILY
20. Melatin (melatonin) 3 mg oral qHS
21. Omeprazole 20 mg PO DAILY
22. Calcium 500 + D (D3) (calcium ___ D3) ___
___ oral TID
23. DULoxetine 60 mg PO DAILY
24. albuterol sulfate 90 mcg/actuation inhalation PRN
25. Levothyroxine Sodium 50 mcg PO DAILY
26. Cyanocobalamin 500 mcg PO DAILY
27. FoLIC Acid 1 mg PO DAILY
28. Vitamin D ___ UNIT PO DAILY
29. Salonpas (methyl ___ % DAILY DAILY
30. Acidophilus Probiotic ___, citrus) 100
million ___ mg oral DAILY
31. Trimethoprim 100 mg PO Q24H
32. Mintox Maximum Strength (___)
___ mg/5 mL oral PRN
33. Nitrofurantoin Monohyd (MacroBID) 100 mg PO Q12H
Discharge Medications:
1. Azithromycin 250 mg PO DAILY Duration: 1 Dose
final pill to be given AM of ___
RX *azithromycin [Zithromax] 250 mg 1 tablet(s) by mouth daily
Disp #*1 Tablet Refills:*0
2. Cefpodoxime Proxetil 200 mg PO Q12H
please take one dose ___ the evening of ___, then take 1 pill
twice a day. final dose ___ of ___.
RX *cefpodoxime 200 mg 1 tablet(s) by mouth twice a day Disp
#*13 Tablet Refills:*0
3. Acetaminophen 500 mg PO BID
4. Acidophilus Probiotic ___, citrus) 100
million ___ mg oral DAILY
5. albuterol sulfate 90 mcg/actuation inhalation PRN
6. Alendronate Sodium 70 mg PO QTHUR
7. Calcium 500 + D (D3) (calcium ___ D3) ___
___ oral TID
8. Clozapine 125 mg PO QHS
9. Cranberry Concentrate (cranberry ___
acid;<br>cranberry extract) 450 mg oral DAILY
10. Cyanocobalamin 500 mcg PO DAILY
11. ___ mg oral TID: PRN
12. Docusate Sodium 200 mg PO DAILY
13. DULoxetine 60 mg PO DAILY
14. estradiol 0.01 % (0.1 mg/gram) vaginal DAILY
15. Ferrous Sulfate 325 mg PO TID
16. FoLIC Acid 1 mg PO DAILY
17. Gabapentin 600 mg PO QHS
18. GuaiFENesin 10 mL PO Q4H:PRN cough
19. Lactulose 15 mL PO DAILY: PRN constipation
20. Levothyroxine Sodium 50 mcg PO DAILY
21. LOPERamide 2 mg PO QID:PRN diarrhea
22. Melatin (melatonin) 3 mg oral qHS
23. Midodrine 5 mg PO DAILY
24. Mintox Maximum Strength (___)
___ mg/5 mL oral PRN
25. Mirtazapine 30 mg PO QHS
26. Multivitamins 1 TAB PO DAILY
27. Omeprazole 20 mg PO DAILY
28. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - First
Line
29. Pravastatin 40 mg PO QPM
30. Ranitidine 150 mg PO QHS
31. Salonpas (methyl ___ % DAILY DAILY
32. Senna 8.6 mg PO QHS
33. Vitamin D ___ UNIT PO DAILY
34. HELD- Trimethoprim 100 mg PO Q24H This medication was held.
Do not restart Trimethoprim until you have seen your PCP
___:
Home
Discharge Diagnosis:
Urosepsis
Pyelonephritis
Pneumonia
CHRONIC ISSUES
___ on CKD
Lower extremity weakness
Schizoaffective Disorder
Normocytic Anemia
Hypothyroidism
Smoldering Myeloma
GERD
HLD
Back Pain
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were initially admitted to the hospital for tremors and
weakness. During your admission, however, we found signs of two
infections: one ___ your urinary tract and another ___ your lungs.
We treated the urinary tract infection and pneumonia with
antibiotics. We also gave you medications to help with cough and
your breathing.
Now that you are out of the hospital, please complete your
course of antibiotics as instructed. Please also arrange to meet
with your primary care physician regarding this hospitalization.
Finally, please arrange an appointment with your PCP to further
evaluate the cause of your urinary tract infections.
Instructions:
CONTINUE cefpodoxime 200mg PO BID until ___ for a total of 10
days of antibiotic therapy (last dose: evening of ___. Please
make sure you take a dose the evening of ___ when you get home.
CONTINUE azithromycin 250mg PO daily (last dose: ___ AM)
It was a pleasure to be a part of your care!
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
19693912-DS-45
| 19,693,912 | 28,638,378 |
DS
| 45 |
2152-03-28 00:00:00
|
2152-03-29 07:29:00
|
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:
HISTORY OF PRESENTING ILLNESS: Ms. ___ is a ___ year old F w/
schiazoaffective disorder complicated by severe tardive
dyskinesia, CKD, IgA smoldering myeloma, hypothyroidism, and
recurrent UTIs who presents for hypoxia and shortness of breath.
The pt presents today from her rest home with referral from ___
who felt the patient was dyspneic and sounded "wet." She also
was noted to have worsening tremors and difficultly speaking,
which can reportedly happen when she is sick. She was recently
admitted for PNA at ___ and completed a course of abx with
Ceftaz and Vanc. The patient endorsed tongue "wrigging" and lip
pursing. She denied any CP, SOB, ___.
ED Course notable for initial vital signs of afebrile, HR 88, BP
123/70, RR20, and SPO2 98% on RA. Initial exam with clear lungs
bilaterally. Neuro exam notable for decreased strength in UEs
and hip flexors. She appears to be frightened and anxious with
fragmented speech. Psych evaluated and felt no changes in
medication were required at this time and patient was not
experiencing psychiatric decompensation.
Labs significant for:
- WBC 4.2, K 5.8, Cr 1.7 from baseline 1.1, HCO3 19 with AG 17.
- UA with 92 WBCs, few bacteria, lg leuks, 2 epis, and 8 hyaline
casts. Urine culture contaminated.
CT head w/o contrast showed no acute intracranial processes.
Initial CXR showed unchanged streaky left lower lobe
atelectasis.
She was given 1L NS and nitrofurantoin for presumed UTI with
plan to send back to rehab. However, the patient developed
increasing tachypnea and hypoxia requiring non-rebreather. Most
recently, she was breathing at 30 breaths/minute with SpO2 94%
on non-rebreather. She was started on cefepime and azithromycin.
On arrival to the MICU, the pt complained that her head "felt
full of air." Otherwise she denies SOB, dysuria, or pain.
REVIEW OF SYSTEMS:
10-point ROS negative except as noted in HPI.
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
-Insomnia
-Asthma/Bronchitis
-Constipation
-Memory deficits
-Chronic lower back pain - spinal stenosis s/p laminectomy
-h/o seizures: 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)
-Schizoaffective disorder
-Depression with multiple prior hospitalizations
Social History:
___
Family History:
Father passed away from tongue cancer. Mother passed away from
"enlarged heart".
Physical Exam:
======================
ADMISSION PHYSICAL
======================
VITALS: 98.7 157/76 97 25 SaO2 100% 12L NRB
GENERAL: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
NECK: supple, JVP not elevated, no LAD
LUNGS: Bibasilar crackles, no wheezes or rhonchi
CV: Regular rate and rhythm, no m/r/g
ABD: Soft, non-tender, non-distended, bowel sounds present, no
rebound tenderness or guarding, no organomegaly
EXT: Warm, well perfused, bilateral non pitting ___ edema
SKIN: No rashes or bruising
NEURO: AOx3, frequent tremors in extremities
=====================
DISCHARGE PHYSICAL
=====================
VITALS: 24 HR Data (last updated ___ @ 1754)
Temp: 97.8 (Tm 98.4), BP: 126/79 (109-189/72-115), HR: 78
(71-90), RR: 20 (___), O2 sat: 96% (92-98), O2 delivery: ra,
Wt:
221.56 lb/100.5 kg
GENERAL: Obese female in NAD. Heavy breathing while sleeping.
HEENT: Sclera anicteric, MMM. PERRLA. EOMI.
Neck: supple
Cardiac: RRR with normal S1 and S2. II/VI systolic murmur. No
rubs or gallops.
Pulmonary: Occasional wheezing bilaterally.
Abdomen: Normoactive bowel sounds. Soft, nondistended,
nontender.
No guarding or rebound. No masses.
Neuro: Alert and oriented x3. ___ strength throughout. Tardive
dyskinesia.
Skin: Skin type II. Warm, dry. No rashes.
Pertinent Results:
=======================
ADMISSION LABS
=======================
___ 03:20PM BLOOD WBC-8.0 RBC-3.20* Hgb-9.5* Hct-30.7*
MCV-96 MCH-29.7 MCHC-30.9* RDW-14.5 RDWSD-50.4* Plt ___
___ 03:20PM BLOOD Neuts-67.1 Lymphs-14.8* Monos-11.1
Eos-6.1 Baso-0.5 Im ___ AbsNeut-5.36 AbsLymp-1.18*
AbsMono-0.89* AbsEos-0.49 AbsBaso-0.04
___ 04:50PM BLOOD ___ PTT-32.4 ___
___ 03:20PM BLOOD Glucose-84 UreaN-23* Creat-1.7* Na-145
K-5.8* Cl-106 HCO3-26 AnGap-13
___ 03:20PM BLOOD ALT-12 AST-17 AlkPhos-98 TotBili-0.2
___ 04:02AM BLOOD Calcium-8.0* Phos-2.5* Mg-1.5*
==========================
STUDIES/IMAGES/PROCEDURES
==========================
CT Head ___
Slightly motion limited exam. No acute intracranial
abnormalities
demonstrated.
CXR ___
Moderate sized hiatal hernia, unchanged streaky left lower lobe
atelectasis. No signs of pneumonia or edema.
CXR ___. Left lower lung opacity appears stable or minimally worse.
2. Interval development of pulmonary vascular congestion.
3. Platelike left mid lung atelectasis.
TTE with Bubble ___
The left atrial volume index is normal. The right atrium is
mildly enlarged. There is mild symmetric left ventricular
hypertrophy with a normal cavity size. There is normal regional
left ventricular systolic function. Overall left ventricular
systolic function is normal. The visually estimated left
ventricular ejection fraction is 55-60%. Left ventricular
cardiac index is normal (>2.5 L/min/m2). Diastolic function
could not be assessed. The aortic sinus diameter is normal for
gender with normal ascending aorta diameter for gender. The
aortic arch is mildly dilated. The aortic valve is not well
seen. There is no aortic valve stenosis. There is no aortic
regurgitation. The mitral valve leaflets appear structurally
normal with no mitral valve prolapse. There is trivial mitral
regurgitation. The tricuspid valve leaflets appear structurally
normal. There is trivial tricuspid regurgitation. The estimated
pulmonary artery systolic pressure is normal. There is a trivial
pericardial effusion.
1) No echocardiographic evidence seen for cardiac shunting
however image quality is limited.
2) Mild symmetric left ventricular hypertrophy with normal
cavity size and regional/global biventricular systolic function.
EEG:
IMPRESSION: This is an abnormal continuous ICU EEG monitoring
study due to:
1) Occasional multifocal epileptiform discharges, most often
with a left
posterior temporal focus, indicating multifocal areas of
cortical
hyperexcitability;
2) Diffuse slow activity present in the background, which is
suggestive of
mild global encephalopathy that is nonspecific as to etiology.
No electrographic seizures are seen.
========================
MICROBIOLOGY
========================
___ 10:16 am URINE Source: ___. LEAKING SPECIMEN.
**FINAL REPORT ___
Legionella Urinary Antigen (Final ___:
NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN.
(Reference Range-Negative).
Performed by Immunochromogenic assay.
A negative result does not rule out infection due to other
L.
pneumophila serogroups or other Legionella species.
Furthermore, in
infected patients the excretion of antigen in urine may
vary.
___ 5:45 am Rapid Respiratory Viral Screen & Culture
Source: Nasopharyngeal swab.
Respiratory Viral Culture (Pending):
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..
___ 5:56 pm URINE SOURCE: ___.
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
=======================
DISCHARGE LABS
=======================
___ 08:15AM BLOOD WBC-6.6 RBC-2.95* Hgb-8.6* Hct-27.9*
MCV-95 MCH-29.2 MCHC-30.8* RDW-14.8 RDWSD-52.0* Plt ___
___ 07:47AM BLOOD Neuts-61.6 ___ Monos-10.4
Eos-7.5* Baso-0.3 Im ___ AbsNeut-4.10 AbsLymp-1.31
AbsMono-0.69 AbsEos-0.50 AbsBaso-0.02
___ 08:15AM BLOOD Plt ___
___ 08:15AM BLOOD Glucose-89 UreaN-18 Creat-1.2* Na-145
K-5.2 Cl-109* HCO3-23 AnGap-13
___ 08:15AM BLOOD Calcium-8.5 Phos-3.7 Mg-1.8
Brief Hospital Course:
===========================
BRIEF SUMMARY
===========================
___ is a ___ year old women with a medical history
notable for smoldering IgA MM, CKD, recurrent UTIs, seizures,
schizoaffective disorder, depression, and recent PNA who
presents with dyspnea.
# Acute Hypoxemic respiratory failure, resolved
# Leukocytosis, resolved
# Aspiration pneumonitis vs pneumonia
Patient was admitted to the ICU with hypoxic respiratory failure
requiring non breather after an acute hypoxic event occurred in
the emergency department after hours of normal vital signs, the
etiology of which was not entirely clear. Flash edema was
considered, though there was no preceding hypertension and her
EKG was non ischemic. An aspiration event, either from a seizure
or overmedication was also entertained, though there was no
evidence on EEG and many hours had passed in the ED between any
sedatives. TTE was without shunt or significant systolic
dysfunction, no right heart strain or pHTN. Pulmonary embolism
felt less likely given that she was weaned to room air within 24
hours without any PE-directed therapy. Given that her WBC count
acute rose as well to 24, thought was most likely aspiration
pneumonitis vs. pneumonia. Work up notable for transient
leukocytosis and CXR with left lower lobe opacities, similar
location to prior pneumonia. She was started on vancomycin/
ceftazadime and azithromycin for presumed pneumonia. MRSA screen
was negative, so discontinued vancomycin and transitioned to
ceftazidime to cefpoxodime with azithromycin to complete 5 day
course(end ___. She was weaned to low flow NC/RA and
leukocytosis had resolved rapidly and she was transferred to the
floor. Overall picture more consistent with aspiration event,
though infection possible, particularly given CXR. Speech and
swallow was consulted and recommend 1:1 supervision with meals.
#Encephalopathy
H/o schizoaffective disorder c/b tardive dyskinesia and
seizures. Patient intermittently very agitated and also at times
very somnolent requiring sternal rub while in ICU prompting
psychiatric consult. Thought most consistent with delirium or
toxic metabolic encephalopathy. Differential also included
seizures vs medication over-sedation. She had conitnuous video
EEG monitoring which showed no seizure activity but did show
diffuse slowing consitent with encephalopathy which improved.
Given her sedation psyciatry recommended decreasing her home
mirtazapine to 22.5mg QHS.
# ___ (resolved)
Cr 1.7 on admission from recent baseline near 1.0 at last
admission. Possibly pre-renal in setting of poor PO intake.
# Inflammatory UA
Urinanalysis w/ WBC, few bacteria, but patient has been
asymptomatic. Urine culture negative. Will stop treating for
UTI. Patient with hx of recurrent UTIs for which she is on TMP
for ppx.
- Continued Bactrim ppx
CHRONIC ISSUES:
==================
# Schizoaffective Disorder
# Tardive dyskinesia
Evaluated in the ED by psych who did not feel that the pt was
having any form of psychotic episode. The pt has had significant
tremors that are bothersome to her and per the pt, not at her
baseline. Psych evaluated, stressed importance of continuing
clozapine.
- Continued home clozapine, duloxetine, and reduced mirtazipine
# Chronic normocytic anemia
At baseline.
# Smoldering Myeloma
Longstanding history of IgG kappa smoldering myeloma with mild
chronic renal insufficiency, followed by Dr. ___ in
Heme/Onc.
# Orthostatic Hypotension/Autonomic dysfunction:
- Continued home midodrine (Hold for SBP>130)
# Hypothyroidism
- Continued home levothyroxine
# GERD
- Continued home PPI & H2 blocker
# HLD
- Continued home pravastatin
# Back Pain
- Continued home gabapentin, acetaminophen PRN
# Nutrition
- Continued home folic acid multivitamin, B12
TRANSITIONAL ISSUES:
=====================
[] Mirtazapine dose decreased to 22.5mg QHS
[] Please reduce delirium as able by frequent re-orientation,
shades up/lights on during the day, familiar and personal
belonging within reach.
[] Patient should have 1:1 supervision for all meals.
CODE: FULL CODE
Emergency contact: ___ ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Clozapine 125 mg PO QHS
2. Cyanocobalamin 500 mcg PO DAILY
3. Docusate Sodium 200 mg PO DAILY
4. DULoxetine 60 mg PO DAILY
5. FoLIC Acid 1 mg PO DAILY
6. GuaiFENesin 10 mL PO Q4H:PRN cough
7. Lactulose 15 mL PO DAILY: PRN constipation
8. Levothyroxine Sodium 50 mcg PO DAILY
9. Midodrine 5 mg PO DAILY
10. Mirtazapine 30 mg PO QHS
11. Multivitamins 1 TAB PO DAILY
12. Omeprazole 20 mg PO DAILY
13. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - First
Line
14. Pravastatin 40 mg PO QPM
15. Ranitidine 150 mg PO QHS
16. Senna 8.6 mg PO QHS
17. Vitamin D ___ UNIT PO DAILY
18. Acetaminophen 500 mg PO BID
19. Acidophilus Probiotic (acidophilus-pectin, citrus) 100
million cell-10 mg oral DAILY
20. albuterol sulfate 90 mcg/actuation inhalation PRN
21. Alendronate Sodium 70 mg PO QTHUR
22. Calcium 500 + D (D3) (calcium carbonate-vitamin D3) 600-800
mg-units oral TID
23. Cranberry Concentrate (cranberry conc-ascorbic
acid;<br>cranberry extract) 450 mg oral DAILY
24. dextromethorphan-benzocaine ___ mg oral TID: PRN
25. estradiol 0.01 % (0.1 mg/gram) vaginal DAILY
26. Ferrous Sulfate 325 mg PO EVERY OTHER DAY
27. Gabapentin 600 mg PO QHS
28. Melatin (melatonin) 3 mg oral qHS
29. Mintox Maximum Strength (alum-mag hydroxide-simeth)
400-400-40 mg/5 mL oral PRN
30. Trimethoprim 100 mg PO Q24H
31. Salonpas (methyl salicylate-menthol) ___ % DAILY DAILY
32. LOPERamide 2 mg PO QID:PRN diarrhea
Discharge Medications:
1. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation
2. Mirtazapine 22.5 mg PO QHS
3. Acetaminophen 500 mg PO BID
4. Acidophilus Probiotic (acidophilus-pectin, citrus) 100
million cell-10 mg oral DAILY
5. albuterol sulfate 90 mcg/actuation inhalation PRN
6. Alendronate Sodium 70 mg PO QTHUR
7. Calcium 500 + D (D3) (calcium carbonate-vitamin D3) 600-800
mg-units oral TID
8. Clozapine 125 mg PO QHS
9. Cranberry Concentrate (cranberry conc-ascorbic
acid;<br>cranberry extract) 450 mg oral DAILY
10. Cyanocobalamin 500 mcg PO DAILY
11. dextromethorphan-benzocaine ___ mg oral TID: PRN
12. Docusate Sodium 200 mg PO DAILY
13. DULoxetine 60 mg PO DAILY
14. estradiol 0.01 % (0.1 mg/gram) vaginal DAILY
15. Ferrous Sulfate 325 mg PO EVERY OTHER DAY
16. FoLIC Acid 1 mg PO DAILY
17. Gabapentin 600 mg PO QHS
18. GuaiFENesin 10 mL PO Q4H:PRN cough
19. Lactulose 15 mL PO DAILY: PRN constipation
20. Levothyroxine Sodium 50 mcg PO DAILY
21. LOPERamide 2 mg PO QID:PRN diarrhea
22. Melatin (melatonin) 3 mg oral qHS
23. Midodrine 5 mg PO DAILY
24. Mintox Maximum Strength (alum-mag hydroxide-simeth)
400-400-40 mg/5 mL oral PRN
25. Multivitamins 1 TAB PO DAILY
26. Omeprazole 20 mg PO DAILY
27. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - First
Line
28. Pravastatin 40 mg PO QPM
29. Ranitidine 150 mg PO QHS
30. Salonpas (methyl salicylate-menthol) ___ % DAILY DAILY
31. Senna 8.6 mg PO QHS
32. Trimethoprim 100 mg PO Q24H
33. Vitamin D ___ UNIT PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
# Acute Hypoxemic respiratory failure, resolved
# Aspiration pneumonitis
# Toxic metabolic encephalopathy
# ___
Discharge Condition:
Mental Status: Clear and coherent.
Mental Status: Confused - sometimes.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Ms. ___,
You were admitted to the hospital because you were having
shortness of breath and required high amounts of oxygen to help
you breath.
In the hospital, you were taken to the ICU and given oxygen. You
were given antibiotics to treat a possible pneumonia. It is
unclear why you had sudden respiratory failure but this was
thought most likely to be do to an aspiration event. You had
continuous EEG monitoring to montior for seizures which did not
show any seizure acitivity. You were quite sleepy in the
mornings and your night time dose of mirtazapine was lowered.
When you leave the hospital, please follow up with all of your
doctors ___. Please make sure you take all of your
medications.
It was a pleasure caring for you!
Sincerely,
Your ___ Treatment Team
Followup Instructions:
___
|
19693912-DS-46
| 19,693,912 | 20,116,359 |
DS
| 46 |
2152-12-31 00:00:00
|
2152-12-31 20:45:00
|
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:
EGD ___
History of Present Illness:
___ PMH IgA Kappa Smoldering Multiple Myeloma (diagnosed ___,
no anti-myeloma therapy since that time, bm biopsy ___ with
___ plasma cells by immunohistochemistry), mild chronic renal
insufficiency (not clearly related to myeloma), seizures,
schizoaffective disorder, frequent pneumonias (gets routine
IVIG)
admitted from clinic due to acute onset dyspnea
Patient noted that she was in her USOH with exception of acute
onset dyspnea on exertion that she first noticed this morning,
but may be slightly improved. She noted that she is without
cough, fever, chills, chest discomfort. Noted that her breathing
is comfortable/unlabored at rest. Denied increase in leg
swelling, noted that her right leg is chronically larger than
left.
Patient noted that she has also had 3 works of worsening chronic
right shoulder pain. Pain is only present with movement, absent
with rest. Noted that pain occurs with abduction, but shoulder
joint is also tender and she hears clicking. Denied
erythema/fever. Noted that Tylenol no longer helps and has been
taking oxycodone.
In the ED, initial vitals: 98.0 74 128/88 20 98% 2L NC. Of note,
patient weaned to 100% on room air shortly afterward. WBC 4.5,
Hgb 9.7, plt 263, CHEM w/ Cr of 1.4, HCO3 20, K 5.6 (5.4 on
repeat), LFTs wnl, Tprot 7.3, IgG 724, IgA ___, IgM 20, UA
negative for infection, BNP 499, Trop<0.01
Past Medical History:
PAST ONCOLOGIC HISTORY:
Per last outpatient oncology note by Dr ___:
"- ___: Labs demonstrate hemoglobin 10.6, Cr 1.5, with SPEP
showing monoclonal IgA kappa, approximately 1500 mg/dL (best
followed by quantitative IgA level).
- ___: Initial evaluation by Dr. ___. Hemoglobin 11.7,
creatinine 1.7.
- ___: Bone marrow biopsy reveals mildly hypocellular marrow
for age, with maturing trilineage hematopoieis and increased
cytologically-atypical plasma cells consistent with a plasma
cell
dyscrasia (small clusters, <10% of cellularity). Cytogenetics
with normal female karyotype, negative Myeloma FISH panel.
Skeletal survey shows no definitive evidence of a lucent lesion.
This is thought to be most consistent with Smoldering Multiple
Myeloma.
- ___: Dr. ___ not to offer systemic therapy for
Smoldering Myeloma, given her history of peripheral neuropathy
and psychiatric illness and concerns that anti-myeloma therapy
may worsen these issues. Furthermore, the patient herself
expresses her reluctance to begin any treatment for Myeloma.
- ___: Repeat bone marrow biopsy demonstrates hypocellular
marrow for age with persistent involvement by known plasma cell
dyscrasia ___ of marrow cellularity). Cytogenetics with
normal female karyotype.
- ___: Bone marrow biopsy shows a cellular marrow with
unremarkable maturing trilineage hematopoiesis and involvement
by
a kappa-restricted plasma cell dyscrasia ___ by
immunohistochemistry). FISH was positive for gain of 1q,
deletion
13q, and deletion of IgH.
- ___: followed expectantly, without any anti-myeloma
therapy"
PAST MEDICAL HISTORY:
-Smoldering IgA multiple myeloma
-Frequent respiratory infections s/p frequent IVIG
-Hypercalcemia with elevated PTH
-S/p ___
-Hypothyroidism
-GERD
-Previous GIB from NSAIDs
-Hyperlipidemia
-Basal cell carcinoma
-Stress urinary incontinence
-Stage III chronic kidney disease
-Insomnia
-Asthma/Bronchitis
-Constipation
-Memory deficits
-Chronic lower back pain - spinal stenosis s/p laminectomy
-h/o seizures: 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)
-Schizoaffective disorder
-Depression with multiple prior hospitalization
-Dysautonomia/orthostatic hypotension
Social History:
___
Family History:
Father passed away from tongue cancer. Mother passed away from
"enlarged heart".
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: see eflowsheets
GENERAL: sitting in bed, appears comfortable, pleasant, calm
EYES: PERRLA, anicteric
HEENT: OP clear, MMM
NECK: supple, normal ROM
LUNGS: CTA b/l, no wheezes/rales/rhonchi, no dyspnea at rest,
appears to work harder with movement, normal RR, no cough
CV: RRR, normal distal perfusion, no significant peripheral
edema
ABD: soft, NT, ND, obese, normoactive BS
GENITOURINARY: no foley or suprapubic tenderness
EXT: warm, no deformity, has chronic asymmetry in lower legs
R>L
in caliber. Right shoulder asymptomatic at rest but has pain
with
abduction and rotation. Audible clicks heard with ranging joint.
Tenderness to palpation of right shoulder, no palpable effusion
or erythema
SKIN: warm, dry, no rash
NEURO: AOx3, fluent speech
ACCESS: PIV
DISCHARGE PHYSICAL EXAM:
Vitals: 24 HR Data (last updated ___ @ 322)
Temp: 97.6 (Tm 97.8), BP: 126/77 (99-161/61-83), HR: 73
(68-86), RR: 18 (___), O2 sat: 95% (93-98), O2 delivery: RA,
Wt: 218.9 lb/99.29 kg
GENERAL: Lying in bed, alert and interactive, language somewhat
difficult to understand, NAD, breathing comfortably on room air
EYES: PERRL, sclera anicteric
HEENT: OP clear, MMM
NECK: supple, full ROM
LUNGS: CTAB, mild wheezes diffusely
CV: RRR, no m/r/g
ABD: soft, NT, ND, obese, normoactive BS
EXT: extremities WWP, no deformity, has chronic asymmetry in
lower legs R>L in caliber. No calf erythema/swelling. R lateral
aspect of ankle is mildly ttp. No warmth, erythema, or edema.
SKIN: warm, dry, no rash
NEURO: AOx3, mild dysarthria, face symmetric, symmetric and
intermittent tremors in b/l upper extremities
Pertinent Results:
ADMISSION LABS:
===============
___ 10:15AM BLOOD WBC-4.5 RBC-3.37* Hgb-9.7* Hct-31.3*
MCV-93 MCH-28.8 MCHC-31.0* RDW-15.9* RDWSD-54.4* Plt ___
___ 10:15AM BLOOD Neuts-61.9 Lymphs-18.8* Monos-12.6
Eos-5.8 Baso-0.7 Im ___ AbsNeut-2.76 AbsLymp-0.84*
AbsMono-0.56 AbsEos-0.26 AbsBaso-0.03
___ 02:55PM BLOOD ___ PTT-29.8 ___
___ 10:15AM BLOOD UreaN-21* Creat-1.4* Na-141 K-5.6* Cl-105
HCO3-20* AnGap-16
___ 10:15AM BLOOD ALT-10 AST-19 LD(LDH)-133 AlkPhos-82
TotBili-0.2
___ 02:55PM BLOOD proBNP-499
___ 02:55PM BLOOD cTropnT-<0.01
___ 10:15AM BLOOD TotProt-7.6 Albumin-3.3* Globuln-4.3*
Calcium-9.5 Phos-3.3 Mg-1.7
___ 10:15AM BLOOD PEP-ABNORMAL T IgG-724 IgA-___* IgM-20*
RELEVANT LABS:
==============
___ 09:12AM BLOOD ___ pO2-147* pCO2-63* pH-7.27*
calTCO2-30 Base XS-0 Comment-GREEN TOP
___ 11:20AM BLOOD Type-ART pO2-214* pCO2-50* pH-7.35
calTCO2-29 Base XS-1
___ 02:55PM BLOOD cTropnT-<0.01
___ 02:55PM BLOOD proBNP-499
___ 02:30AM BLOOD VitB12-589
___ 01:00PM BLOOD %HbA1c-5.7 eAG-117
___ 01:00PM BLOOD Triglyc-71 HDL-52 CHOL/HD-2.7 LDLcalc-72
___ 01:00PM BLOOD Ammonia-32
___ 01:00PM BLOOD TSH-6.2*
___ 06:03AM BLOOD T4-5.3 T3-84
___ 06:20AM BLOOD FreeKap-107.4* ___ Fr K/L-8.95
___ 10:15AM BLOOD PEP-ABNORMAL T IgG-724 IgA-___* IgM-20*
DISCHARGE LABS:
===============
___ 06:10AM BLOOD WBC-7.2 RBC-3.01* Hgb-8.4* Hct-28.2*
MCV-94 MCH-27.9 MCHC-29.8* RDW-16.3* RDWSD-56.1* Plt ___
___ 06:10AM BLOOD Glucose-82 UreaN-23* Creat-1.1 Na-143
K-5.6* Cl-112* HCO3-23 AnGap-8*
___ 06:10AM BLOOD LD(LDH)-132
___ 06:10AM BLOOD Calcium-9.2 Phos-3.6 Mg-1.8 UricAcd-6.5*
___ 12:07PM BLOOD K-5.0
IMAGING:
========
GLENO-HUMERAL SHOULDER (W/ Y VIEW) RIGHT Study Date of
___ 2:19 ___
No acute fracture or dislocation. Redemonstration of severe
degenerative
changes around the right shoulder.
CXR ___
No acute cardiopulmonary process. Bibasilar atelectasis.
Unchanged moderate cardiomegaly.
V/Q (___) Low likelihood ratio for recent pulmonary embolism.
___ (___)
No evidence of deep venous thrombosis in the right or left lower
extremity
veins.
CTA CHEST (___)
1. Study is limited by respiratory motion and the phase of
contrast. Within these limitations, no central pulmonary
embolus or acute cardiopulmonary abnormality.
2. 9 mm right middle lobe pulmonary nodule, not well assessed
on the prior study from ___, but appears moderately increased
in size. Right hilar lymph nodes measure up to 1.5 cm.
Additional, small pulmonary nodules, measure up to 6 mm not seen
in ___, including a ground-glass, right lower lobe, 6 mm
pulmonary nodule, which could be infectious or inflammatory.
Please see recommendations below.
5. Moderate to large hiatal hernia.
6. Severe degenerative change at the glenohumeral joints.
RECOMMENDATION(S): For incidentally detected single solid
pulmonary nodule bigger than 8mm, a follow-up CT in 3 months or
PET-CT.
___ 1:57 ___ # ___ SKELETAL SURVEY (INCLUD
1. No suspicious lytic lesions are identified.
2. Degenerative changes, as detailed above.
___ 2:26 AM # ___ CTA HEAD AND CTA NECK
1. No acute finding.
2. Stable chronic small vessel ischemic change.
3. Less than 20% focal stenosis at the origin of the left ICA.
4. Otherwise patent intracranial and cervical vasculature.
___ 12:50 ___ # ___ CHEST (PORTABLE AP)
In comparison with the study ___, there is little interval
change.
Cardiac silhouette is within normal limits and there is no
vascular
congestion, pleural effusion, or acute focal pneumonia.
___ 7:18 ___ # ___ MR HEAD W & W/O CONTRAS
1. No evidence of acute infarction, hemorrhage or intracranial
mass.
2. Nonspecific ___ matter changes in the cerebral hemispheres
bilaterally
and in the pons, likely sequela of chronic microangiopathy.
___ 10:42 AM# ___ CHEST (PORTABLE AP)
There is increased opacification at the left lung base partial
obscuring the
costophrenic angle this could represent early pneumonia.
___ 11:08 AM# ___ ANKLE (AP, MORTISE & LA
There is a nondisplaced fracture of the medial malleolus, age
indeterminate. No acute fractures. Degenerative changes
involving the proximal ankle.
STUDIES:
========
___ Transthoracic Echo Report:
Quantitative biplane left ventricular ejection fraction is 63 %
(normal 54-73%).Mild symmetric left ventricular hypertrophy with
normal cavity size and regional/global biventricular systolic
function. Mildly dilated aortic arch. Compared with the prior
TTE (images reviewed) of ___, the findings are similar.
___ EEG :
Preliminary report - no seizure activity noted on study. Diffuse
slowing. No other acute findings.
Brief Hospital Course:
Patient will require < 30 days at rehab facility.
TRANSITIONAL ISSUES:
====================
[ ] Patient sustained fall from knee buckling. I suspect this
may have been ___ to her significant tardive dyskinesia. Had
resultant R ankle sprain. Patient to f/u in ___ clinic
for shoulder, would advise following up on R ankle as well.
[ ] Patient had intermittent hyperkalemia during
hospitalization. Max serum K+ 5.9. Whole blood max 5.2. EKG w/o
any changes and was asymptomatic. Resolves with IVF. Would
recommend BMP during follow up to check lytes, ideally
___.
[ ] Had likely aspiration event ___ leading to PNA. MRSA swab
negative. Respiratory Viral Panel Negative. Continued on
cefepime for 7d course (___) and prednisone 50mg x3d.
[ ] Elevated TSH at 6.2, normal T3, T4. Would consider repeating
thyroid studies and adjusting levothyroxine PRN.
[ ] Has had excessive morning somnolence, would recommend sleep
study to r/o OSA.
[ ] Still seems mildly dysarthric and has facial rigidity, per
neurology consultant: presumably secondary to her clozapine.
Will need psychiatry f/u as an outpatient in ___ weeks. Please
call ___.
[ ] Patient had PFTs done on ___, largely unchanged from prior,
showing mild restrictive pattern. Patient to f/u with
Pulmonology as outpatient.
[ ] She will need a repeat CT scan in 6 months for monitoring of
her pulmonary nodules
[ ] MRI R shoulder shows supraspinatus tear and bicep tendon
tear. Pain controlled with lidocaine patch. Avoided oxycodone
d/t somnolence and AMS. Plan to f/u in ortho clinc in ___ weeks.
[ ] IgG level 558 on ___. Received IVIG x1 during
hospitalization iso of her PNA
BRIEF SUMMARY:
==============
___ PMH IgA Kappa Smoldering Multiple Myeloma (diagnosed ___,
no anti-myeloma therapy since that time, bm biopsy ___ with
___ plasma cells by immunohistochemistry), mild chronic renal
insufficiency (not clearly related to myeloma), seizures,
schizoaffective disorder, frequent pneumonias (gets routine
IVIG) admitted from clinic due to acute onset dyspnea. Extensive
w/u for dyspnea was negative, no PE, no s/sx pulmonary
infection. SOB/Dyspnea spontaneously resolved. It's possible
that - d/t her tardive dyskinesia - pleth tracings had been poor
leading to artifact that appeared to be SpO2 desaturations.
Patient had intermittent episodes of AMS during hospitalization.
Workup for CVA and seizure activity were both negative. She was
briefly, empirically placed on broad spectrum abx. Infectious
workup remained negative.
ACUTE ISSUES:
=============
#Altered Mental Status:
AM of ___ was extremely sleepy, only awaking to sternal rub,
raising concern for altered mental status iso not receiving ppx
trimethoprim for UTI prevention at ___. VBG
with pH 7.27, pCO2 63, ABG with pO2: 214, pCO2: 50, pH: 7.35,
calTCO2: 29. Cultured urine and blood and started empiric
vanc/cefepime to cover for GU infection. Mental status
subsequently resolved and was back to baseline x 3d.
Vanc/cefepime discontinued after 3d course on ___. Patient then
had acute episode of acute onset facial sensory changes,
difficulty speaking, and dysarthria. These symptoms
spontaneously resolved over the course of appx 2 hours. CTA Head
and Neck with no evidence of flow-limiting stenosis or
occlusion. Repeat CXR ___ with little to no interval change. -
VBG, iCal, ammonia, B12, Lipid panel, A1c: unremarkable.
Elevated TSH at 6.2. MRI ___: No evidence of acute infarction,
hemorrhage or intracranial mass. EEG ___: preliminary result
shows diffuse slowing, though no e/o seizure activity. Neurology
was consulted and per their last progress note: "Still seems
mildly dysarthric and has facial rigidity, presumably secondary
to her clozapine. She has been on that for a while and there are
no new pharmacological changes unlikely to be responsible. Also
not other dystonias or features of neuroleptic malignant
syndrome." Plan for outpatient psychiatry follow-up.
#Dyspnea:
Patient presented with acute onset dyspnea. Desatted to 80% with
ambulation, DOE. No e/o pulmonary edema, effusion or pneumonia
on CXR. BNP normal. EKG not consistent with ACS. TTE unchanged
from prior, normal EF. No leukocytosis to suggest infection
despite hx of multiple prior pulmonary infections. Anemia
relatively unchanged from patient's baseline. Treated
empirically with heparin gtt until PE was ruled out. V/Q with
low probability of PE. CTA Chest negative for ___ negative
for DVT. Continued to tx with albuterol nebs PRN. Given AMS,
there was c/f dyspnea ___ aspiration. Speech and swallow
consulted, video swallow showed distal esophageal dysfunction.
GI subsequently consulted, performed EGD ___ which, aside from
hiatal hernia, was wnl, no e/o obstruction or reflux.
Pulmonology had been consulted during the admission. They
performed ambulatory oximetry with no evidence of desaturation.
She has tardive dyskinesia from antipsychotic use and pleth
tracings were very poor, so they suspected this was the etiology
of her prior desaturations. Patient had PFTs done on ___,
largely unchanged from prior, showing mild restrictive pattern.
Patient to f/u with Pulmology as outpatient.
#Shoulder Pain:
Xray negative for fracture, dislocation, or large lytic lesion
though differential remains wide including myelomatous
infiltration, rotator cuff pathology, degenerative changes etc.
MRI shoulder wet read not showing marrow replacement process,
severe degenerative changes of the glenohumeral joint with
multiple intra-articular bodies, circumferential degenerative
changes of the labrum, and complete loss of articular cartilage,
moderate-sized articular sided tear of supraspinatus tendon and
tear of biceps tendon with retraction of the biceps tendon to
glenoid level, markedly attenuated subscapularis tendon without
definite tear identified. Ortho consulted and recommended no
acute intervention, plan to follow up with patient in ___ weeks
after discharge.
CHRONIC ISSUES
#Smoldering MM
Not on any therapy since ___. IgA/IgM roughly stable as
compared to recent baseline. SPEP, light chains stable. Skeletal
survey unremarkable. Bone marrow bx ___, preliminary results do
not show any changes compared to prior BMbx.
#Schizoaffective disorder
#Depression with multiple prior hospitalization
#Seizure history:
Continued Mirtazipine, Melatonin, duloxetine 60 mg daily,
clozapine, gabapentin.
#Hypothyroidism: Continued Synthroid 50 mcg daily. TSH elevated
at 6.2, though T3, T4 wnl. Would recommend repeat TFTs as
transitional issue.
#Dysautonomia/Orthostatic Hypotension: Continued midodrine, held
if SBP > 160
#Anemia: Normocytic, may be related to renal insufficiency.
Chronic, stable, at baseline. Continued ferrous sulfate 325 mg
daily.
#Chronic Renal Insufficiency: Cr on admission was at recent
baseline of 1.4, with K mildly elevated at baseline in low-mid
5's. K normalized and Cr improved to 1.2-->1.1. Cr on discharge
was at baseline of 1.1.
#UTI ppx: Gets frequent UTIs. Per ___ med list, was not
receiving this at facility. Resumed Trimethoprim 100 mg daily
in-house.
#GERD: Moderate to large hiatal hernia seen on CTA chest.
Continued omeprazole + ranitidine. EGD ___ w/o e/o mucosal
changes from reflux.
#Nutrition: Continued folic acid, MVi, vit D
#ASCVD prevention: Continued Pravastatin
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. albuterol sulfate 90 mcg/actuation inhalation Q4H:PRN
2. Albuterol 0.083% Neb Soln 1 NEB IH PRN SOB
3. Clozapine 125 mg PO QHS
4. DULoxetine 60 mg PO DAILY
5. FoLIC Acid 1 mg PO DAILY
6. Gabapentin 600 mg PO QHS
7. Levothyroxine Sodium 50 mcg PO DAILY
8. Midodrine 5 mg PO DAILY
9. Mirtazapine 22.5 mg PO QHS
10. Alendronate Sodium 70 mg PO QTHUR
11. estradiol 0.01 % (0.1 mg/gram) vaginal DAILY
12. Omeprazole 40 mg PO DAILY
13. Pravastatin 40 mg PO QPM
14. Ranitidine 150 mg PO QHS
15. Trimethoprim 100 mg PO Q24H
16. Acidophilus Probiotic (acidophilus-pectin, citrus) 100
million cell-10 mg oral DAILY
17. Vitamin D ___ UNIT PO DAILY
18. Docusate Sodium 200 mg PO DAILY
19. Ferrous Sulfate 325 mg PO DAILY
20. Multivitamins 1 TAB PO DAILY
21. Senna 8.6 mg PO QHS
22. Melatin (melatonin) 3 mg oral qHS
23. Salonpas (methyl salicylate-menthol) ___ % DAILY DAILY
24. Cyanocobalamin 500 mcg PO DAILY
25. cranberry 450 mg oral DAILY
26. Calcium 600 with Vitamin D3 (calcium carbonate-vitamin D3)
600 mg(1,500mg) -400 unit oral TID W/MEALS
27. LOPERamide 2 mg PO BID:PRN Diarrhea
28. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
29. Robafen (guaiFENesin) 100 mg/5 mL oral QID:PRN cough
30. Zeasorb AF (miconazole nitrate) 2 % topical QID:PRN fungal
31. Lidocaine Viscous 2% 5 mL PO QID:PRN pain
32. Benzonatate 100 mg PO BID:PRN cough
33. Cepacol (Sore Throat Lozenge) 1 LOZ PO DAILY:PRN sore throat
34. Polyethylene Glycol 17 g PO QHS:PRN Constipation - Third
Line
35. alum-mag hydroxide-simeth 200-200-20 mg/5 mL oral Q4H:PRN
Discharge Medications:
1. Lidocaine 5% Patch 1 PTCH TD QPM R shoulder
RX *lidocaine [Lidoderm] 5 % Apply to R shoulder QPM Disp #*14
Patch Refills:*0
2. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
3. Acidophilus Probiotic (acidophilus-pectin, citrus) 100
million cell-10 mg oral DAILY
4. Albuterol 0.083% Neb Soln 1 NEB IH PRN SOB
5. albuterol sulfate 90 mcg/actuation inhalation Q4H:PRN
SOB/Wheezing
6. Alendronate Sodium 70 mg PO QTHUR
7. alum-mag hydroxide-simeth 200-200-20 mg/5 mL oral Q4H:PRN
indigestion
8. Benzonatate 100 mg PO BID:PRN cough
9. Calcium 600 with Vitamin D3 (calcium carbonate-vitamin D3)
600 mg(1,500mg) -400 unit oral TID W/MEALS
10. Cepacol (Sore Throat Lozenge) 1 LOZ PO DAILY:PRN sore
throat
11. Clozapine 125 mg PO QHS
12. cranberry 450 mg oral DAILY
13. Cyanocobalamin 500 mcg PO DAILY
14. Docusate Sodium 200 mg PO DAILY
15. DULoxetine 60 mg PO DAILY
16. Estradiol 0.01 % (0.1 mg/gram) vaginal DAILY
17. Ferrous Sulfate 325 mg PO DAILY
18. FoLIC Acid 1 mg PO DAILY
19. Gabapentin 600 mg PO QHS
20. Levothyroxine Sodium 50 mcg PO DAILY
21. Lidocaine Viscous 2% 5 mL PO QID:PRN pain
22. LOPERamide 2 mg PO BID:PRN Diarrhea
23. Melatin (melatonin) 3 mg oral qHS
24. Midodrine 5 mg PO DAILY
25. Mirtazapine 22.5 mg PO QHS
26. Multivitamins 1 TAB PO DAILY
27. Omeprazole 40 mg PO DAILY
28. Polyethylene Glycol 17 g PO QHS:PRN Constipation - Third
Line
29. Pravastatin 40 mg PO QPM
30. Ranitidine 150 mg PO QHS
31. Robafen (guaiFENesin) 100 mg/5 mL oral QID:PRN cough
32. Salonpas (methyl salicylate-menthol) ___ % DAILY DAILY
33. Senna 8.6 mg PO QHS
34. Trimethoprim 100 mg PO Q24H
35. Vitamin D ___ UNIT PO DAILY
36. Zeasorb AF (miconazole nitrate) 2 % topical QID:PRN fungal
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Altered Mental Status
Dyspnea
Pneumonia
Right supraspinatus tear
Right bicep tendon tear
Right ankle sprain
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 because:
===========================
- You had shortness of breath and right shoulder pain.
During your stay:
=================
- An X-ray of your shoulder showed no fracture.
- An MRI of your shoulder showed no myeloma involvement of the
bones, but showed a rotator cuff tear.
- Our orthopedic surgeons evaluated you and recommended that you
follow up with them as an outpatient in ___ weeks.
- A nuclear scan and CT angiogram of your chest showed no blood
clot in the lungs.
- An ultrasound of your lower legs showed no blood clot.
- An ultrasound of your heart showed no changes compared to your
last one. It does not appear your symptoms of shortness of
breath are due to a heart issue.
- Pulmonary function tests were performed on ___. These were
largely unchanged from your prior pulmonary function tests,
showing a mild restrictive pattern.
- You were found to be very sleepy on ___, so you
were started on antibiotics in case this was a sign of
infection. These were discontinued after your mental status
improved and you had no other signs of infection.
- A video swallow study showed some swallowing dysfunction in
your lower esophagus. This was further evaluated with an upper
endoscopy where the gastroenterology doctors looked at your
esophagus with a camera. The endoscopy was normal. There was no
evidence of reflux or obstruction in your esophagus.
- You had another episode of confusion and difficulty speaking
in the early hours of ___. To make sure you
weren't have a stroke, our neurology team evaluated you and you
had imaging done of your head and neck which was normal.
- You had an EEG (monitoring of your brain wave activity) to
check for any seizure activity. There was no evidence of seizure
activity on this study.
- You had a repeat bone marrow biopsy to check on the status of
your smoldering multiple myeloma. This did not show any changes
which is good news.
- You developed a pneumonia later in your stay and completed a
7-day course of antibiotics through your IV which improved your
cough and breathing.
- You had a fall on the morning ___ which resulted in a
mild right ankle sprain. Physical therapy evaluated you
afterward and recommended you were still okay to be discharged
to rehab.
After you leave:
================
- Please continue taking your medications as prescribed. Please
be sure to take your daily prophylactic antibiotic Trimethoprim
that prevents urinary tract infections.
- Please attend any outpatient follow-up appointments you have.
It was a pleasure participating in your care! We wish you the
very best!
Sincerely,
Your ___ HealthCare Team
Followup Instructions:
___
|
19693912-DS-48
| 19,693,912 | 20,677,159 |
DS
| 48 |
2153-03-06 00:00:00
|
2153-03-07 07:22:00
|
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:
confusion
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Patient is a ___ year old female, history of recent pneumonia and
UTI, schizoaffective disorder, IgA Kappa Smoldering Multiple
Myeloma, mild chronic renal insufficiency, seizures, routine
IVIG, s/p parathyroidectomy, who presents with altered mental
status and cough from ___.
Unable to obtain history from patient. She is oriented to
person,
disoriented to place and time.
Past Medical History:
Per last outpatient oncology note by Dr ___:
"- ___: Labs demonstrate hemoglobin 10.6, Cr 1.5, with SPEP
showing monoclonal IgA kappa, approximately 1500 mg/dL (best
followed by quantitative IgA level).
- ___: Initial evaluation by Dr. ___. Hemoglobin 11.7,
creatinine 1.7.
- ___: Bone marrow biopsy reveals mildly hypocellular marrow
for age, with maturing trilineage hematopoieis and increased
cytologically-atypical plasma cells consistent with a plasma
cell
dyscrasia (small clusters, <10% of cellularity). Cytogenetics
with normal female karyotype, negative Myeloma FISH panel.
Skeletal survey shows no definitive evidence of a lucent lesion.
This is thought to be most consistent with Smoldering Multiple
Myeloma.
- ___: Dr. ___ not to offer systemic therapy for
Smoldering Myeloma, given her history of peripheral neuropathy
and psychiatric illness and concerns that anti-myeloma therapy
may worsen these issues. Furthermore, the patient herself
expresses her reluctance to begin any treatment for Myeloma.
- ___: Repeat bone marrow biopsy demonstrates hypocellular
marrow for age with persistent involvement by known plasma cell
dyscrasia ___ of marrow cellularity). Cytogenetics with
normal female karyotype.
- ___: Bone marrow biopsy shows a cellular marrow with
unremarkable maturing trilineage hematopoiesis and involvement
by
a kappa-restricted plasma cell dyscrasia ___ by
immunohistochemistry). FISH was positive for gain of 1q,
deletion
13q, and deletion of IgH.
- ___: followed expectantly, without any anti-myeloma
therapy"
PAST MEDICAL HISTORY:
- Smoldering IgA multiple myeloma
- Frequent respiratory infections s/p frequent IVIG
- Hypercalcemia with elevated PTH
- S/p ___
- Hypothyroidism
- GERD
- Previous GIB from NSAIDs
- Hyperlipidemia
- Basal cell carcinoma
- Stress urinary incontinence
- Stage III chronic kidney disease
- Insomnia
- Asthma/Bronchitis
- Constipation
- Memory deficits
- Chronic lower back pain - spinal stenosis s/p laminectomy
- h/o seizures: 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)
- Schizoaffective disorder
- Depression with multiple prior hospitalization
- Dysautonomia/orthostatic hypotension
Social History:
___
Family History:
Father passed away from tongue cancer. Mother passed away from
"enlarged heart".
Physical Exam:
ADMISSION PHYSICAL
24 HR Data (last updated ___ @ 556)
Temp: 97.8 (Tm 97.8), BP: 93/61, HR: 90, RR: 22, O2 sat:
95%,
O2 delivery: 2LNC, Wt: 186.5 lb/84.6 kg
Patient refused large majority of exam. Became very tearful and
frightened by providers being in the room. Oriented to self but
not to place. Refused to open eyes on exam. Unable to adequately
auscultate due to patient agitation. Moving all extremities.
DISCHARGE PHYSICAL
General: alert, oriented, laying peacefully in bed
HEENT: NG tube in place, oropharynx nonerythematous, non
purulent
Neuro: A&Ox3, moving all extremities
Cardiology: normal S1/S2, no murmurs rubs or gallops
Respiratory: breathing comfortably on room air, anterior lung
fields are CTAB
Abdomen: soft, obese, non distended, non tender to palpation
Pertinent Results:
___ 10:30AM BLOOD WBC-5.1 RBC-3.92 Hgb-11.2 Hct-36.9 MCV-94
MCH-28.6 MCHC-30.4* RDW-17.5* RDWSD-60.5* Plt ___
___ 10:30AM BLOOD Glucose-113* UreaN-16 Creat-1.5* Na-143
K-5.5* Cl-105 HCO3-20* AnGap-18
___ 10:30AM BLOOD Albumin-3.7 Calcium-10.6* Phos-3.8
Mg-1.3*
___ 10:43AM BLOOD Lactate-1.4
___ 10:30AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Tricycl-NEG
___ 05:40AM BLOOD Trep Ab-NEG
___ 09:37AM BLOOD T3-114 Free T4-1.0
___ 10:30AM BLOOD TSH-15*
___ 10:14AM BLOOD VitB12-___* Folate->20
CT Chest w/out Contrast:
1. No evidence of focal consolidation.
2. Small amount of fluid in the right oblique fissure.
3. Unchanged moderate to large hiatal hernia.
CT Head w/out Contrast:
1. No acute intracranial abnormality.
Blood cultures: negative
Urine cultures: negative
CSF;SPINAL FLUID Source: LP 3.
**FINAL REPORT ___
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
This is a concentrated smear made by cytospin method,
please refer to
hematology for a quantitative white blood cell count, if
applicable.
FLUID CULTURE (Final ___: NO GROWTH.
___ 06:08AM BLOOD WBC-6.0 RBC-3.43* Hgb-9.9* Hct-32.8*
MCV-96 MCH-28.9 MCHC-30.2* RDW-16.4* RDWSD-57.5* Plt ___
___ 06:08AM BLOOD Glucose-113* UreaN-26* Creat-1.1 Na-144
K-4.4 Cl-103 HCO3-26 AnGap-15
___ 05:16AM BLOOD ALT-22 AST-33 LD(LDH)-204 AlkPhos-80
TotBili-0.2
___ 06:08AM BLOOD Calcium-9.8 Phos-4.2 Mg-1.9
Brief Hospital Course:
Patient is a ___ year old female with past medical history
notable for schizoaffective disorder, IgA Kappa Smoldering
Multiple Myeloma, mild chronic renal insufficiency, seizures,
routine IVIG, s/p parathyroidectomy who presented with altered
mental status and cough from ___, ultimately
felt to have mixed catatonia and delirium now improved.
TRANSITIONAL ISSUES:
[] Psych medications will require further titration as patient's
mood evolves. Inpatient psychiatry felt confident in regiment of
clozapine and valproate but recommend close follow up with
outpatient psychiatry.
[] Pulmonary Nodules on Chest CT ___: Multiple pulmonary
nodules are re-demonstrated, the largest measuring up to 1 cm in
right middle lobe. This is unchanged in comparison with ___. Outpatient PET-CT is recommended for more complete
evaluation.
[] Repeat TSH/FT4 and titration of levothyroxine as needed.
#Catatonia with Delirium
Patient with altered mental status off of her baseline per
nursing in the ED who know the patient well. She was A&Ox0 and
was non verbal, at times with significant agitation requiring 2
point restraints. Infectious work-up pursued including UA, Chest
CT, cultures and was negative. CT head showed no evidence of
intracranial bleed. Initially thought to be related to ___ but
her AMS persisted despite fluids. Neuro and psych were
consulted, and no neurologic cause has been identified with head
imaging and LP studies bland. EEG with nonspecific generalized
slowing seen with encephalopathy. After discussion with psych,
her presentation is most likely consistent with catatonia with
delirium, and they noted improvement in catatonic symptoms with
IV Ativan though it did worsen her delirium. Upon subsequent
discontinuation of the Ativan, her delirium is now also
improved. Patient is near her baseline on a regimen of
clozapine, valproate, ramelteon (for sleep support).
# Schizoaffective disorder
# Bipolar disorder
# Depression with multiple prior hospitalization
Per above consultation with psychiatry, it was thought that her
home regimen (clozapine, duloxetine, mirtazapine) was
contributing to her altered mental state and thus these three
meds were held with reinitation of a lower dose of clozapine
upon improvement of patient's mental status. Transitional issue
will be if/when to reinitate mirtazapine, duloxetine and
gabapentin and this should be discussed.
#Nutrition: Due to patient's AMS, she was not safe to tolerate
PO intake. After 7 days of no PO nutrition, only maintenance
fluids, an NG tube was placed by ___ and tube feeds were
initiated. As patient's mental status improved, she was followed
by speech and swallow who aided in helping patient return to PO
intake. NG tube was pulled on ___ and patient tolerated Po
intake well. At time of discharge, she was graduated to a soft
solid food diet, which is the patient's baseline.
# Constipation: patient with history of chronic diarrhea but had
recurrent constipation throughout stay (BM on avg every 4 days).
Stopped home loperamide, and placed patient on
Senna/colace/mirlax/biascodyl PRN.
___, resolved: Likely prerenal in the setting of poor PO intake
and reliance on free water flushes. Resolved with IVF and
increased PO intake.
#Fungal infection: Patient with fungal skin infection of
breast/stomach folds. Initiated miconazole.
CHRONIC ISSUES
===============
# Smoldering multiple myeloma
# Anemia
Not on any therapy since ___. Anemia appears at baseline
without signs or symptoms of active bleeding. Continue to
monitor as an outpatient. Continued ferrous sulfate upon
reinitiation of PO intake.
# Hypothyroidism
Patient with a history of hypothyroidism on levo. TSH 15 up from
11 on last admission. T3/T4 studies wnl however her TSH has been
trending upwards. Increased levo to 75 mg ___ however, for
transition to IV will start slow with the IV equivalent to her
home dose of 50 mg. Pt had not been taking PO meds, started IV
levo on ___. Restarted home levo 50 mg PO on ___. Transitional
issue repeat TSH/T4 outpatient.
# GERD
Moderate to large hiatal hernia seen on CTA chest on
recent admission. EGD ___ w/o e/o mucosal changes from reflux.
Continued home omeprazole 40 mg daily upon reinitiation of PO
intake. Discontinued home ranitidine 150mg QHS (no need for both
agents.
# HLD: Continued Pravastatin 40mg QHS upon reinitiation of PO
intake.
# Pulmonary nodules: Multiple pulmonary nodules are
re-demonstrated on chest CT, the largest measuring up to 1 cm in
right middle lobe. This is unchanged in comparison with ___. Outpatient PET-CT is recommended and should be considered
for more complete evaluation.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 1000 mg PO BID
2. Albuterol 0.083% Neb Soln 1 NEB IH PRN SOB
3. Clozapine 125 mg PO QHS
4. Cyanocobalamin 500 mcg PO DAILY
5. Docusate Sodium 200 mg PO DAILY
6. DULoxetine ___ 60 mg PO QHS
7. Ferrous Sulfate 325 mg PO DAILY
8. FoLIC Acid 1 mg PO DAILY
9. Gabapentin 600 mg PO QHS
10. Levothyroxine Sodium 50 mcg PO DAILY
11. Lidocaine 5% Patch 1 PTCH TD QPM R shoulder
12. Mirtazapine 30 mg PO QHS
13. Multivitamins 1 TAB PO DAILY
14. Omeprazole 40 mg PO DAILY
15. Polyethylene Glycol 17 g PO QHS:PRN Constipation - Third
Line
16. Pravastatin 40 mg PO QPM
17. Senna 8.6 mg PO QHS
18. Vitamin D ___ UNIT PO DAILY
19. Fluticasone Propionate 110mcg 2 PUFF IH BID
20. Miconazole Powder 2% 1 Appl TP TID:PRN skin folds
21. Acidophilus Probiotic (acidophilus-pectin, citrus) 100
million cell-10 mg oral DAILY
22. albuterol sulfate 90 mcg/actuation inhalation Q4H:PRN
SOB/Wheezing
23. Alendronate Sodium 70 mg PO QTHUR
24. alum-mag hydroxide-simeth 200-200-20 mg/5 mL oral Q4H:PRN
indigestion
25. Benzonatate 100 mg PO BID:PRN cough
26. Calcium 600 with Vitamin D3 (calcium carbonate-vitamin D3)
600 mg(1,500mg) -400 unit oral TID W/MEALS
27. Cepacol (Sore Throat Lozenge) 1 LOZ PO DAILY:PRN sore throat
28. cranberry 450 mg oral DAILY
29. Estradiol 0.01 % (0.1 mg/gram) vaginal ASDIR
30. Lidocaine Viscous 2% 5 mL PO QID:PRN pain
31. LOPERamide 2 mg PO BID:PRN Diarrhea
32. Melatin (melatonin) 3 mg oral qHS
33. Robafen (guaiFENesin) 100 mg/5 mL oral QID:PRN cough
34. Zeasorb AF (miconazole nitrate) 2 % topical QID:PRN fungal
Discharge Medications:
1. Valproic Acid ___ mg PO Q12H
2. Clozapine 100 mg PO QHS
3. Ferrous Sulfate 325 mg PO EVERY OTHER DAY
Take iron every other day to minimize constipation and to
improve absorption.
4. Acetaminophen 1000 mg PO BID
5. Acidophilus Probiotic (acidophilus-pectin, citrus) 100
million cell-10 mg oral DAILY
6. Albuterol 0.083% Neb Soln 1 NEB IH PRN SOB
7. albuterol sulfate 90 mcg/actuation inhalation Q4H:PRN
SOB/Wheezing
8. Alendronate Sodium 70 mg PO QTHUR
9. alum-mag hydroxide-simeth 200-200-20 mg/5 mL oral Q4H:PRN
indigestion
10. Benzonatate 100 mg PO BID:PRN cough
11. Calcium 600 with Vitamin D3 (calcium carbonate-vitamin D3)
600 mg(1,500mg) -400 unit oral TID W/MEALS
12. Cepacol (Sore Throat Lozenge) 1 LOZ PO DAILY:PRN sore
throat
13. cranberry 450 mg oral DAILY
14. Cyanocobalamin 500 mcg PO DAILY
15. Docusate Sodium 200 mg PO DAILY
16. Estradiol 0.01 % (0.1 mg/gram) vaginal ASDIR
17. Fluticasone Propionate 110mcg 2 PUFF IH BID
18. FoLIC Acid 1 mg PO DAILY
19. Levothyroxine Sodium 50 mcg PO DAILY
20. Lidocaine 5% Patch 1 PTCH TD QPM R shoulder
21. Lidocaine Viscous 2% 5 mL PO QID:PRN pain
22. Melatin (melatonin) 3 mg oral qHS
23. Miconazole Powder 2% 1 Appl TP TID:PRN skin folds
24. Multivitamins 1 TAB PO DAILY
25. Omeprazole 40 mg PO DAILY
26. Polyethylene Glycol 17 g PO QHS:PRN Constipation - Third
Line
27. Pravastatin 40 mg PO QPM
28. Robafen (guaiFENesin) 100 mg/5 mL oral QID:PRN cough
29. Senna 8.6 mg PO QHS
30. Vitamin D ___ UNIT PO DAILY
31. Zeasorb AF (miconazole nitrate) 2 % topical QID:PRN fungal
32. HELD- DULoxetine ___ 60 mg PO QHS This medication was held.
Do not restart DULoxetine ___ ___ see your outpatient
psychiatrist
33. HELD- Gabapentin 600 mg PO QHS This medication was held. Do
not restart Gabapentin until you see your outpatient
psychiatrist
34. HELD- LOPERamide 2 mg PO BID:PRN Diarrhea This medication
was held. Do not restart LOPERamide until you discuss with your
doctors any additional issues with diarrhea
35. HELD- Mirtazapine 30 mg PO QHS This medication was held. Do
not restart Mirtazapine until you discuss with your psychiatrist
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Catatonia with Delirium
Schizoaffective disorder
Bipolar disorder
Depression
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 ___,
It was a pleasure caring for you at ___
___.
WHY WERE YOU IN THE HOSPITAL?
- You were admitted to the hospital for confusion.
WHAT HAPPENED WHEN YOU WERE IN THE HOSPITAL?
- You improved with titration of your psychiatry medications.
- It took a while for you to improve, so you required tube feeds
for a period of time.
WHAT SHOULD YOU DO AFTER YOU LEAVE THE HOSPITAL?
- Continue to take all your medicines as prescribed below.
- Show up to your appointments as listed below.
We wish you the best!
Sincerely,
Your ___ Team
Followup Instructions:
___
|
19693912-DS-49
| 19,693,912 | 21,779,490 |
DS
| 49 |
2153-03-26 00:00:00
|
2153-03-26 16:49:00
|
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:
failure to thrive
Major Surgical or Invasive Procedure:
Colonscopy ___
History of Present Illness:
Ms. ___ is a ___ year-old woman with IgA kappa
Smoldering Multiple Myeloma (diagnosed ___, no anti-myeloma
therapy since that time, most recent bone marrow biopsy on
___ with ___ plasma cells by immunohistochemistry), mild
chronic renal insufficiency (not clearly related to myeloma),
seizures, schizoaffective disorder, frequent pneumonias since
___, and recent admission from ___ to ___ with mixed
catatonia/delirium, who is referred from ___ clinic with
nausea, weakness, and failure to thrive.
She reports nausea and generalized weakness. Patient also
complained of dullness in her head and abdomen. Here in the ED
patient is complaining of generalized weakness and inability to
eat for the past 1 week. Patient states she has decreased
appetite and is unable to eat a whole lot. She has been able to
drink. Denies having any abdominal pain, diarrhea or
constipation, no dysuria. Patient denies having any chest pain,
palpitations, shortness of breath, fevers or cough. Patient also
denies having leg swelling. Patient is ambulatory with a walker
at baseline but states she has been unable to walk for the past
1
week. She is also complaining of poor treatment at current rehab
facility.
In the ED:
- Initial vital signs were notable for: T98.2 HR87 BP129/77 RR20
O2-97% RA
- Exam notable for: Tenderness to palpation in the right upper
quadrant and left upper quadrant. Increased breath
sounds/crackles in the right upper middle lobe of lung.
- Labs were notable for:
Cr 1.3
BNP ___
Mg 1.5
- Studies performed include:
EKG: new diffuse TWI
Chest x-ray: No acute cardiopulmonary abnormality.
Moderate-sized hiatal hernia.
CT abdomen: 1. Large hiatal hernia, increased in size from
___.
2. No acute intra-abdominal or intrapelvic process process.
- Patient was given:
___ 16:05 IVF LR 500 mL
___ 19:02 IV LORazepam .5 mg
- Consults: none
Upon arrival to the floor, she reports that she is thirsty and
hungry but that she wants to go to sleep, declines to provide
further history. She reports that she is frustrated but declines
to elaborate further. When asked why she is in the hospital, she
replies "bad breath." She denies any nausea/vomiting, weakness,
chest pain, shortness of breath, abdominal pain. Subsequently
declines to answer any further questions.
REVIEW OF SYSTEMS: Complete ROS limited as patient declines to
participate.
Past Medical History:
Per last outpatient oncology note by Dr ___:
"- ___: Labs demonstrate hemoglobin 10.6, Cr 1.5, with SPEP
showing monoclonal IgA kappa, approximately 1500 mg/dL (best
followed by quantitative IgA level).
- ___: Initial evaluation by Dr. ___. Hemoglobin 11.7,
creatinine 1.7.
- ___: Bone marrow biopsy reveals mildly hypocellular marrow
for age, with maturing trilineage hematopoieis and increased
cytologically-atypical plasma cells consistent with a plasma
cell dyscrasia (small clusters, <10% of cellularity).
Cytogenetics with normal female karyotype, negative Myeloma FISH
panel. Skeletal survey shows no definitive evidence of a lucent
lesion. This is thought to be most consistent with Smoldering
Multiple Myeloma.
- ___: Dr. ___ not to offer systemic therapy for
Smoldering Myeloma, given her history of peripheral neuropathy
and psychiatric illness and concerns that anti-myeloma therapy
may worsen these issues. Furthermore, the patient herself
expresses her reluctance to begin any treatment for Myeloma.
- ___: Repeat bone marrow biopsy demonstrates hypocellular
marrow for age with persistent involvement by known plasma cell
dyscrasia ___ of marrow cellularity). Cytogenetics with
normal female karyotype.
- ___: Bone marrow biopsy shows a cellular marrow with
unremarkable maturing trilineage hematopoiesis and involvement
by a kappa-restricted plasma cell dyscrasia ___ by
immunohistochemistry). FISH was positive for gain of 1q,
deletion 13q, and deletion of IgH.
- ___: followed expectantly, without any anti-myeloma
therapy"
PAST MEDICAL HISTORY:
- Smoldering IgA multiple myeloma
- Frequent respiratory infections s/p frequent IVIG
- Hypercalcemia with elevated PTH
- S/p ___
- Hypothyroidism
- GERD
- Previous GIB from NSAIDs
- Hyperlipidemia
- Basal cell carcinoma
- Stress urinary incontinence
- Stage III chronic kidney disease
- Insomnia
- Asthma/Bronchitis
- Constipation
- Memory deficits
- Chronic lower back pain - spinal stenosis s/p laminectomy
- h/o seizures: 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)
- Schizoaffective disorder
- Depression with multiple prior hospitalization
- Dysautonomia/orthostatic hypotension
Social History:
___
Family History:
Father passed away from tongue cancer. Mother passed away from
"enlarged heart".
Physical Exam:
ADMISSION PHYSICAL EXAM:
VITALS: 24 HR Data (last updated ___ @ 118) Temp: 98.4 (Tm
98.4), BP: 118/67, HR: 92, RR: 20, O2 sat:
97%, O2 delivery: RA
GENERAL: Alert and interactive. Occasionally writhing around in
bed but denies pain, at other times lying still.
EYES: NCAT. EOMI. Sclera anicteric and without injection.
ENT: MMM. JVD not elevated.
CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No
murmurs/rubs/gallops.
RESP: Clear to auscultation bilaterally. No wheezes, rhonchi or
rales. No increased work of breathing.
ABDOMEN: Normal bowels sounds, non distended, non-tender to deep
palpation in all four quadrants. No organomegaly.
MSK: No clubbing, cyanosis, or edema. Pulses DP/Radial 2+
bilaterally.
SKIN: Warm. Cap refill <2s. No rash.
NEUROLOGIC: A&OX3, face symmetric, moving all extremities w/
purpose. Gait not assessed.
DISCHARGE PHYSICAL EXAM:
VITALS: T 97.8 132/80 77 18 95% RA
GENERAL: Alert and interactive. sitting comfortably in the chair
EYES: NCAT. EOMI. Sclera anicteric and without injection.
ENT: MMM. JVD not elevated.
CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No
murmurs/rubs/gallops.
RESP: Clear to auscultation bilaterally. No wheezes, rhonchi or
rales. No increased work of breathing.
ABDOMEN: Normal bowels sounds, non distended, non-tender to deep
palpation in all four quadrants. No organomegaly.
MSK: No clubbing, cyanosis, or edema. Pulses DP/Radial 2+
bilaterally.
SKIN: Warm. Cap refill <2s. No rash.
NEUROLOGIC: A&OX3, face symmetric, moving all extremities w/
purpose. Gait not assessed.
Pertinent Results:
ADMISSION LABS:
==============
___ 10:25AM BLOOD Neuts-60.8 ___ Monos-10.4 Eos-4.7
Baso-0.5 Im ___ AbsNeut-3.61 AbsLymp-1.39 AbsMono-0.62
AbsEos-0.28 AbsBaso-0.03
___ 10:25AM BLOOD Plt ___
___ 10:25AM BLOOD UreaN-16 Creat-1.4* Na-142 K-4.3 Cl-100
HCO3-22 AnGap-20*
___ 10:25AM BLOOD ALT-29 AST-36 AlkPhos-97 TotBili-0.2
___ 01:30PM BLOOD CK-MB-4 ___ 10:25AM BLOOD Calcium-11.1*
___ 01:30PM BLOOD TSH-7.4*
___ 10:02AM BLOOD Free T4-1.5
___ 07:10AM BLOOD 25VitD-65*
RELEVANT INTERVAL LABS:
========================
___ 09:40AM BLOOD Albumin-3.2* Calcium-9.7 Phos-3.8 Mg-1.9
UricAcd-8.1* Iron-38
___ 09:40AM BLOOD calTIBC-302 Ferritn-55 TRF-232
___ 10:02AM BLOOD Free T4-1.5
___ 07:10AM BLOOD 25VitD-65*
___ 09:40AM BLOOD HBsAg-NEG HBsAb-POS HBcAb-NEG
___ 05:55AM BLOOD CRP-73.0* CEA-2.9
___ 09:40AM BLOOD HIV Ab-NEG
Test Result Reference
Range/Units
QUANTIFERON(R)-TB GOLD PLUS, NEGATIVE NEGATIVE
4T, INCUBATED
Negative test result. M. tuberculosis complex
infection unlikely.
Test Result Reference
Range/Units
NIL 0.16 IU/mL
MITOGEN-NIL 7.85 IU/mL
TB1-NIL 0.17 IU/mL
TB2-NIL 0.04 IU/mL
Test Result Reference
Range/Units
SED RATE BY MODIFIED 106 H < OR = 30 mm/h
___
DISCHARGE LABS:
===============
___ 06:15AM BLOOD WBC-4.7 RBC-3.21* Hgb-9.2* Hct-31.0*
MCV-97 MCH-28.7 MCHC-29.7* RDW-16.5* RDWSD-58.7* Plt ___
___ 06:15AM BLOOD Neuts-46.4 ___ Monos-13.0
Eos-10.5* Baso-0.4 Im ___ AbsNeut-2.17 AbsLymp-1.37
AbsMono-0.61 AbsEos-0.49 AbsBaso-0.02
___ 06:15AM BLOOD ___ PTT-32.1 ___
___ 06:15AM BLOOD Glucose-85 UreaN-16 Creat-0.9 Na-144
K-4.5 Cl-106 HCO3-24 AnGap-14
___ 06:15AM BLOOD ALT-27 AST-29 LD(LDH)-138 AlkPhos-91
TotBili-<0.2
___ 06:15AM BLOOD Calcium-9.3 Phos-3.6 Mg-1.7 UricAcd-6.3*
MULTIPLE MYELOMA LABS:
=====================
___ 10:25AM BLOOD PEP-ABNORMALLY FreeKap-221.3*
___ Fr K/L-14.46* IgG-557* IgA-2385* IgM-24*
IMAGING:
=========
SKELETAL SURVEY: ___
IMPRESSION:
There are no lytic lesions that would be concerning for
progression of multiple myeloma within the limitations of this
study technique.
Severe degenerative changes are demonstrated in midthoracic
vertebral bodies. Severe degenerative changes are demonstrated
at the level of L2-L3 and
anterolisthesis of L5 compared to as 1
Severe degenerative changes are present in the knee, partially
imaged
Severe degenerative changes in both glenohumeral joints
bilaterally with substantial narrowing of the joint space,
sclerosis and osteophyte formation.
TTE: ___
The left atrial volume index is mildly increased. The right
atrial pressure could not be estimated. There is normal left
ventricular wall thickness with a normal cavity size. There is
normal regional and global left ventricular systolic function.
The visually estimated left ventricular ejection fraction is
>=65%. There is a mild (peak 11 mmHg) resting left ventricular
outflow tract gradient with inability to assess for change due
to inability to perform a Valsalva. No ventricular septal defect
is seen. Tissue Doppler suggests an increased left ventricular
filling pressure (PCWP greater than 18 mmHg). Normal right
ventricular cavity size with normal free wall motion. The aortic
sinus diameter is normal for gender. There is a normal
descending aorta diameter. The aortic valve leaflets (3) are
mildly thickened. There is no aortic valve stenosis. There is no
aortic regurgitation. The mitral valve leaflets are mildly
thickened with no mitral valve prolapse. There is trivial mitral
regurgitation. The pulmonic valve leaflets are normal. The
tricuspid valve leaflets appear structurally normal. There is
mild [1+] tricuspid regurgitation. There is mild pulmonary
artery systolic hypertension. There is no pericardial effusion.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
normal biventricular cavity sizes, and regional/global
biventricular systolic function. Increased PCWP. Mild resting
left ventricular outflow tract gradient. Mild tricuspid
regurgitation. Mild pulmonary artery systolic hypertension.
Pharmacology MIBI ___:
NTERPRETATION: This is a ___ year old lady here for the
evaluation of chest pain. The patient was infused with 0.4
mg/5ml regadenoson over 20 seconds, immediately followed by
isotope injection. There were no reported symptoms with the
infusion. There were no significant ST segment changes during
the infusion or recovery. The rhythm was sinus. The heart rate
and blood pressure responses to the infusion and recovery were
appropriate. The regadenoson was reversed with 60 mg/3 ml
caffeine IV. IMPRESSION: No symptoms reported with no
significant ST segment changes during the infusion or recovery
(baseline nonspecific STTW changes). Appropriate hemodynamic
response. Nuclear report sent separately.
PET CT ___:
1. Worsening perihilar nodular consolidations with mild FDG
avidity
are suspicious for infection versus inflammation. 2.
Moderate-sized hiatal
hernia with diffusely increased FDG avidity of the gastric
mucosa, may represent
gastritis. 3. No evidence of active osseous lesions. 4. Focal
FDG uptake in the
sigmoid colon is suspicious for an underlying lesion. Consider
direct
visualization and possible tissue sampling with colonoscopy.
COLONOSCOPY ___:
A single pedunculated nonbleeding appearance found in the
sigmoid colon at 20 to me from the anus. A single piece
polypectomy was performed using a hot snare and sigmoid colon.
Follow-up with complete removed. One Endo Clip was successfully
applied to the polypectomy site. Clip was placed for tissue
apposition and to reduce the risk of bleeding; there was no
active bleeding following polypectomy.
Single sessile 2 mm nonbleeding polyp of benign appearance found
in sigmoid. A single piece polypectomy was performed using cold
forceps. The polyp was completely removed and retrieved.
A single sessile 2 mm found in the ascending colon. A single
piece polypectomy was performed with cold forceps. The polyp
was completely removed and retrieved.
A single sessile 4 mm found. A single piece polypectomy was
performed with cold forceps. The polyp was completely removed
and retrieved
Brief Hospital Course:
====================
PATIENT SUMMARY:
====================
Ms. ___ is a ___ year-old woman with IgA kappa Smoldering
Multiple Myeloma (diagnosed ___, no anti-myeloma therapy
since that time), CKD, seizures, schizoaffective disorder,
admitted for severe malnutrition. Her weight loss was believed
to be multifactorial. Namely, failure to thrive in her recent
rehab setting due to psychosocial factors as well as underlying
infection vs progression of her myeloma. Initially there was
concern that weight loss and uptrending free light chains were
indicative of myeloma progression, but otherwise her disease was
felt to be stable and thus FTT was attributed to aforementioned
issues and decision made not to undergo chemotherapy. During her
failure to thrive workup, she was noted to have a PET avid
signal in sigmoid colon, thus underwent colonoscopy which showed
numerous polyps in the large intestine, the largest of which was
a 1.4 cm polyp of benign appearance and sigmoid colon. These
were all removed and sent for pathology which are pending at the
time of discharge. Her PET scan also showed worsening perihilar
nodular consolidations with mild FDG avidity which are
suspicious for infection versus inflammation so she was started
on Levaquin.
====================
TRANSITIONAL ISSUES:
====================
[ ] Follow-up final pathology from colonoscopy ___
[ ] She will follow-up with her oncologist in 3 weeks to repeat
her myeloma labs.
# CODE: Full, presumed
# CONTACT: Name of health care proxy: ___, Relationship:
Lawyer, Phone number: ___
======================
ACTIVE ISSUES
======================
#Concern for Pneumonia
FDG avid perihilar lesions concerning for infection vs
inflammation. She was started on Levaquin to complete a 7 day
course.
#Severe malnutrition
Admitted from outpatient oncology due to concern that patient
was not thriving at ___ and ___ benefit from placement at an
alternative facility. Suspect psychosocial reasons most likely
the primary factor. Infectious & endocrine workups unrevealing.
Also considered gastroparesis, but good PO intake throughout
admission & no protein loss in urine to suggest amyloidosis.
Multiple admissions w/o identification of cause, leaving
progression of smoldering myeloma as possible explanation. PET
CT however revealed avid lesion of sigmoid colon, per below.
#Sigmoid Colon Lesion
PET CT with avid lesion in sigmoid colon. Given concurrent ___,
c/f malignancy, though CEA wnl. Last c-scope in ___ only
notable for diverticulosis, rec ___ f/up at that point in time.
Colonoscopy on ___ revealed numerous polyps largest of which
was a 1.4 cm benign-appearing polyp in the sigmoid colon 20 cm
from the anus.
# Smoldering IgA multiple myeloma
Free Kappa/Lambda 14.46. Has not been on any anti-myeloma
therapy. ___ BMBx with ___ plasma cells by
immunohistochemistry. Skeletal survey ___ reassuringly
without evidence of lytic lesions. Unclear if recent uptrending
free light chains, intermittent hypercalcemia & anemia
indicative of disease progression, but ultimately felt disease
had been stable for so many years, unlikely to be contributing
to acute failure to thrive per above. Thus, deferred
bortezimib/dex treatment due to risks>benefits. Acyclovir was
also discontinued as there was no immediate plan to undergo
treatment for myeloma.
# Schizoaffective disorder:
# Bipolar disorder:
# Depression with multiple prior hospitalization:
# Seizure history (last seizure ___ years ago):
Intermittent periods of catatonia vs anxiety. Psychiatry
consulted while inpatient and believes her disease to be stable,
though she did have worsening of agitation at night. Duloxetine,
mirtazapine, and gabapentin were held at last admission and
psych recommended to continue to hold. Of note, she required
Lorazepam 0.5 PRN q6h for agitation. PLAN: continue clozapine
100mg PO QHS , consolidated valproic acid ___ PO QHS,
ramelteon QHS
# Dysuria
Treated for 3d with nitrofurantoin d/t likely acute simple
cystitis.
# Normocytic Anemia:
Stable. Baseline ___. Likely secondary to anemia of chronic
disease and iron deficiency anemia. She was continued on ferrous
sulfate, B12, folate.
# ___ on ?CKD:
Cr 1.3 on admission, elevated from baseline of 0.8-0.9. Likely
pre-renal iso poor PO intake. improved with 1000 cc fluids, but
continues to be elevated. lower suspicion that this is related
to disease progression to multiple myeloma given acute
presentation, lack of other CRAB features (hypercalcemia
resolved w/ fluids). Her creatinine discharge was 0.9.
# Hyperphosphatemia:
Possibly in s/o ___ on CKD. Self resolved while in ___.
====================
CHRONIC/STABLE ISSUES:
====================
# Diffuse T wave inversions: Diffuse T wave inversions noted in
I, II, AVL, V3-V6 noted on admission EKG. Initial concern that
nausea was anginal equivalent. Reassured by negative trop upon
admission, TTE ___ w/o wall motion abnormalities, & pharm MIBI
w/ normal perfusion.
# Hypothyroidism: Patient with a history of hypothyroidism on
levo. TSH noted to be uptrending during last admission, though
ultimately home thyroid hormone replacement not uptitrated at
discharge. TSH 7.4, free T4 1.5. We continued home levothyroxine
50mcg as free T4 within normal limits.
# GERD: Moderate to large hiatal hernia seen on CTA chest on
recent admission. EGD ___ w/o e/o mucosal changes from reflux.
We continued omeprazole 40 mg daily
# HLD: Continued Pravastatin 40mg QHS
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Clozapine 100 mg PO QHS
2. Vitamin D ___ UNIT PO DAILY
3. Senna 8.6 mg PO QHS
4. Pravastatin 40 mg PO QPM
5. Polyethylene Glycol 17 g PO QHS:PRN Constipation - Third Line
6. Benzonatate 100 mg PO BID:PRN cough
7. Cepacol (Sore Throat Lozenge) 1 LOZ PO DAILY:PRN sore throat
8. Cyanocobalamin 500 mcg PO DAILY
9. Fluticasone Propionate 110mcg 2 PUFF IH BID
10. FoLIC Acid 1 mg PO DAILY
11. Levothyroxine Sodium 50 mcg PO DAILY
12. Lidocaine 5% Patch 1 PTCH TD QPM R shoulder
13. Acidophilus Probiotic (acidophilus-pectin, citrus) 100
million cell-10 mg oral DAILY
14. Melatin (melatonin) 3 mg oral qHS
15. Multivitamins 1 TAB PO DAILY
16. Omeprazole 40 mg PO DAILY
17. Robafen (guaiFENesin) 100 mg/5 mL oral QID:PRN cough
18. Alendronate Sodium 70 mg PO QTHUR
19. Lidocaine Viscous 2% 5 mL PO QID:PRN pain
20. cranberry 450 mg oral DAILY
21. Calcium 600 with Vitamin D3 (calcium carbonate-vitamin D3)
600 mg(1,500mg) -400 unit oral TID W/MEALS
22. alum-mag hydroxide-simeth 200-200-20 mg/5 mL oral Q4H:PRN
indigestion
23. Docusate Sodium 200 mg PO DAILY
24. albuterol sulfate 90 mcg/actuation inhalation Q4H:PRN
SOB/Wheezing
25. Valproic Acid ___ mg PO Q12H
26. Acetaminophen 1000 mg PO BID
27. Ferrous Sulfate 325 mg PO EVERY OTHER DAY
Discharge Medications:
1. LevoFLOXacin 750 mg PO DAILY Duration: 7 Days
2. Ramelteon 8 mg PO QPM
3. Acetaminophen 1000 mg PO BID
4. Acidophilus Probiotic (acidophilus-pectin, citrus) 100
million cell-10 mg oral DAILY
5. albuterol sulfate 90 mcg/actuation inhalation Q4H:PRN
SOB/Wheezing
6. Alendronate Sodium 70 mg PO QTHUR
7. alum-mag hydroxide-simeth 200-200-20 mg/5 mL oral Q4H:PRN
indigestion
8. Benzonatate 100 mg PO BID:PRN cough
9. Calcium 600 with Vitamin D3 (calcium carbonate-vitamin D3)
600 mg(1,500mg) -400 unit oral TID W/MEALS
10. Cepacol (Sore Throat Lozenge) 1 LOZ PO DAILY:PRN sore
throat
11. Clozapine 100 mg PO QHS
12. cranberry 450 mg oral DAILY
13. Cyanocobalamin 500 mcg PO DAILY
14. Docusate Sodium 200 mg PO DAILY
15. Ferrous Sulfate 325 mg PO EVERY OTHER DAY
16. Fluticasone Propionate 110mcg 2 PUFF IH BID
17. FoLIC Acid 1 mg PO DAILY
18. Levothyroxine Sodium 50 mcg PO DAILY
19. Lidocaine 5% Patch 1 PTCH TD QPM R shoulder
20. Lidocaine Viscous 2% 5 mL PO QID:PRN pain
21. Melatin (melatonin) 3 mg oral qHS
22. Multivitamins 1 TAB PO DAILY
23. Omeprazole 40 mg PO DAILY
24. Polyethylene Glycol 17 g PO QHS:PRN Constipation - Third
Line
25. Pravastatin 40 mg PO QPM
26. Robafen (guaiFENesin) 100 mg/5 mL oral QID:PRN cough
27. Senna 8.6 mg PO QHS
28. Valproic Acid ___ mg PO Q12H
29. Vitamin D ___ UNIT PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSES:
Severe malnutrition
SECONDARY DIAGNOSES:
smoldering multiple myeloma
Acute Kidney Injury on Chronic Kidney Disease
Iron deficiency anemia
Hypercalcemia
Hyperphosphatemia
Schitzoaffective disorder
Bipolar disorder
Depression
Hypothyroidism
Gastroesophageal reflux disease
Hyperlipidemia
History of seizures
Acute simple cystitis
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 ___
___!
WHY WAS I IN THE HOSPITAL?
==========================
- You were admitted because you were nauseous, vomiting, and
losing a lot of weight, so your oncologist recommend you come to
the hospital.
WHAT HAPPENED IN THE HOSPITAL?
==============================
- You were diagnosed with severe malnutrition
- We checked your heart to make sure it is functioning well
- We took pictures of your body to see if there was any reason
you have been feeling nauseous and losing weight
- We used a camera to look inside your colon (colonoscopy) and
took samples of the tissue to evaluate for cancer
- We had the psychiatrists see you and help change some of your
medications to help you sleep better at night
- We started you on antibiotics to treat a lung infection
WHAT SHOULD I DO WHEN I GO HOME?
================================
- Be sure to take all your medications and attend all of your
appointments listed below.
Thank you for allowing us to be involved in your care, we wish
you all the best!
Your ___ Healthcare Team
Followup Instructions:
___
|
19693912-DS-50
| 19,693,912 | 29,741,191 |
DS
| 50 |
2153-04-03 00:00:00
|
2153-04-03 19:23:00
|
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:
depression, suicidal ideation
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old woman with a psychiatric history notable for
schizoaffective disorder on clozapine, multiple psychiatric
admissions, remote prior suicide attempt, and a complicated
medical history that includes smoldering MM, CKD, seizure d/o,
and hypothyroidism who presents from ___ after
patient
endorsed SI.
Notably, patient recently admitted to ___ from ___ to
___ in the setting of FTT. Patient seen by psychiatry during
that admission due to periods of anxiety and depressed mood.
Patient continued on clozapine, Depakote, PRN Ativan.
Intermittently required haloperidol/Ativan I/s/o delirium.
After discharge, she was patient seen by ___ outpatient
psychiatry team on ___, largely stated that she felt well at
that time, denied any anxiety or depression. However, on ___,
patient reported "my insides are black, and if something doesn't
happen you might have a dead body on your hands" and this lead
patient to be brought to ___ ED per her request.
In the ED, reported to the ED physician that she had had not
eaten or drank in three days and was ambivalent about suicidal
ideation ___ I would do it?") Also endorsed poor sleep and
poor concentration.
Past Medical History:
PAST MEDICAL HISTORY:
- Smoldering IgA multiple myeloma
- Frequent respiratory infections s/p frequent IVIG
- Hypercalcemia with elevated PTH
- S/p ___
- Hypothyroidism
- GERD
- Previous GIB from NSAIDs
- Hyperlipidemia
- Basal cell carcinoma
- Stress urinary incontinence
- Stage III chronic kidney disease
- Insomnia
- Asthma/Bronchitis
- Constipation
- Memory deficits
- Chronic lower back pain - spinal stenosis s/p laminectomy
- h/o seizures: 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)
- Schizoaffective disorder
- Depression with multiple prior hospitalization
- Dysautonomia/orthostatic hypotension
Social History:
___
Family History:
-Father passed away from tongue cancer.
-Mother passed away from "enlarged heart".
Physical Exam:
ADMISSION PHYSICAL EXAM:
VITALS: 24 HR Data (last updated ___ @ 1758)
Temp: 97.7 (Tm 97.7), BP: 143/73, HR: 94, RR: 20, O2 sat:
96%, O2 delivery: Ra
GENERAL: lying flat in bed, eyes closed, moaning and not
responding to questions. Left wrist in restrains.
CARDIAC: RRR, no murmurs
RESP: Clear anteriorly
ABDOMEN: soft, NT, ND
EXT: wwp, no edema
NEUROLOGIC: unable to assess, though with facial symmetry and
moving extremities with purpose
DISCHARGE PHYSICAL EXAM:
GENERAL: Obese female. Sitting up in chair
CARDIAC: RRR, no murmurs
RESP: CTAB.
ABDOMEN: soft, NT, ND
EXT: wwp, no edema
NEUROLOGIC: unable to assess, though with facial symmetry and
moving extremities with purpose
Pertinent Results:
ADMISSION LABS:
================
___ 08:50PM BLOOD WBC-6.2 RBC-3.37* Hgb-9.8* Hct-31.6*
MCV-94 MCH-29.1 MCHC-31.0* RDW-16.3* RDWSD-56.1* Plt ___
___ 08:50PM BLOOD Neuts-53.3 ___ Monos-13.8*
Eos-5.4 Baso-0.3 Im ___ AbsNeut-3.28 AbsLymp-1.66
AbsMono-0.85* AbsEos-0.33 AbsBaso-0.02
___ 08:50PM BLOOD Plt ___
___ 08:50PM BLOOD Glucose-126* UreaN-23* Creat-1.5* Na-143
K-4.4 Cl-107 HCO3-21* AnGap-15
___ 08:50PM BLOOD PTH-20
___ 08:50PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Tricycl-NEG
DISCHARGE LABS:
=================
___ 05:40AM BLOOD WBC-5.1 RBC-3.37* Hgb-9.7* Hct-31.6*
MCV-94 MCH-28.8 MCHC-30.7* RDW-16.5* RDWSD-56.2* Plt ___
___ 05:40AM BLOOD Glucose-91 UreaN-13 Creat-0.9 Na-147
K-3.9 Cl-109* HCO3-23 AnGap-15
___ 05:40AM BLOOD Calcium-9.3 Phos-3.0 Mg-1.7
IMAGES:
=======
___
CT of head
FINDINGS:
There is no evidence of fracture, acute territorial
infarction,hemorrhage,edema,or mass effect. There is prominence
of the
ventricles and sulci suggestive of involutional changes. Mild
periventricular
and subcortical ___ matter hypodensities are nonspecific, but
likely
represent sequela of chronic ischemic microvascular disease.
There are mild
atherosclerotic calcifications in the bilateral intracranial
internal carotid
arteries.
Aside from scattered mastoid air cell opacification bilaterally,
the
visualized portion of the paranasal sinuses and middle ear
cavities are clear.
The visualized portion of the orbits are normal.
IMPRESSION:
No acute intracranial process.
___
CXR
FINDINGS:
Portable semi-upright view of the chest provided.
Mild central pulmonary vascular engorgement is seen. There is
atelectasis at
the left lung base and no definite focal consolidation to
suggest pneumonia.
No pleural effusion is demonstrated. Evidence of hiatal hernia
is
re-demonstrated. Cardiac silhouette is mildly enlarged, likely
accentuated by
AP technique.
IMPRESSION:
1. Mild central pulmonary vascular engorgement. Mild
cardiomegaly.
2. Left basilar atelectasis and no definite focal consolidation
to suggest
pneumonia.
MICROBIOLOGY:
==============
___ 9:45 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___: < 10,000 CFU/mL.
Brief Hospital Course:
Patient Summary:
================
___ year old woman with a psychiatric history notable for
schizoaffective disorder on clozapine, multiple psychiatric
admissions, remote prior suicide attempt, and a complicated
medical history that includes smoldering MM, seizure d/o, and
hypothyroidism who presents from ___ after patient
endorsed SI, admitted to the medicine service due to acute
kidney injury, electrolyte abnormalities and refusal of oral
intake. ___ and electrolyte abnormalities improved with IV
fluids. Patient began to eat and ready to be transferred to
inpatient psychiatry facility. She was re-started on her home
medications, including clozapine, valproic acid, and lorazepam
prn. Her mental status improved significantly and she was deemed
appropriate for transfer to ___ at the ___ unit.
Transitional Issues:
====================
[] Patient should follow up with her psychiatrist to manage her
schizoaffective disorder and depression. Recommend adjusting her
medications as necessary.
[] Repeat the CT chest in ___ weeks to ensure resolution of PNA
[] patient was getting lorazepam PRN for agitation and
catatonia- continue to assess the need for this for both
indications
[] Ensure follow-up of colonoscopy biopsies done prior to
admission
[] Patient was receiving trimethoprim at rehab faculty for
unclear reasons, this was held on discharge as she did not have
evidence of acute infection
ACUTE ISSUES:
=============
# Schizoaffective disorder:
# Depressed state:
# Suicidal ideation:
Multiple psychiatric hospitalizations in the past and reports
depressed mood and ambivalence toward suicide. She was recently
discharged ___ for failure to thrive and was co-managed by
psychiatry at that time. Her prior medical hospitalizations have
been complicated by delirium/catatonia. At admission, she was
being uncooperative and was not communicating with the
doctors/nurses. ___ spending time in the therapeutic mileau,
she had marked improvement in her mental status and she was
deemed stable for transfer to ___ to the ___ unit.
Psychiatry put her on ___ and she had a 1:1 sitter. She
was continued on the following medications with good effect:
Clozapine 100 mg QHS, Valproic acid ___ mg Q12H PO, Ramelteon 8
mg QHS if tolerating PO, Lorazepam 0.5 mg PO q4h:PRN agitation
# Refusal of oral intake
# Nutritional status:
Patient was refusing oral intake on admission. Patient began to
tolerate po intake and she showed no signs of refeeding
syndrome. Her electrolytes have been stable, including
Mg/Phos/Calcium. She was also given folic acid/thiamine/MV
banana bag and ensure TID.
# Mild pulmonary vascular congestion:
# Mild cardiomegaly:
She did not appear grossly overloaded on exam. ProBNP was 477
which may have been underestimated in the setting of obesity.
Recent ECHO ___ showed mild LVH, mild TR and mild pHTN; pMIBI
unremarkable. She saturated in the high 90's in room air.
# Recent concern for PNA:
Perihilar nodular pulmonary consolidations concerning for
possible PNA during last hospitalization for which she was
started on levofloxacin 750 mg PO q48h for a 7 day course on
___. Notably, she was discharged on daily levofloxacin (ie not
renally dosed); unclear how she has been taking it. Currently
she
does not appear infected.
RESOVLED ISSUES:
================
# Hypercalcemia (resolved)
Calcium 10.7, albumin 3.0; corrected calcium 11.5. ___ be
secondary to calcium supplementation. PTH 20. That said, this
may also suggest progression of her smoldering myeloma. Ca
improved with IVF and improvement in ___.
# SVT:
6 beat run of SVT on tele. Likely ___ electrolyte abnormalities
iso poor PO intake, mag 1.4, no further episodes
# Acute kidney injury (___)
Cr elevated on arrival to the ED at 1.6. Likely pre-renal iso
poor oral intake as patient is refusing (due to psych
condition).
Patient received 1 L of IVF with subsequent improvement in her
Cr. 1.0.
CHRONIC ISSUES:
===============
# Smoldering myeloma:
Free Kappa/Lambda 14.46. Has not been on any anti-myeloma
therapy. ___ BMBx with ___ plasma cells by
immunohistochemistry. Skeletal survey ___ reassuringly
without
e/o lytic lesions. No osseous lesions on PET CT ___. Free
light chains have been uptrending and unclear if recent
hypercalcemia & anemia indicative of disease progression.
Currently the risks of treatment seem to outweigh any
theoretical
benefit. She will need to follow-up up with outpatient oncology
in 3 weeks
# Chronic lower back pain:
Continued on acetaminophen and lidocaine patch with good
response
# Hypothyroidism:
Continued on home levothyroxine 50 mcg PO
# Anemia, normocytic:
Hb in the 9s, appears at baseline. Likely in part due to
nutritional deficiency/iron deficiency though may also represent
progression of smoldering myeloma.
- Hold home iron, given patent is on MVI
# GERD:
- Home PPI
# Reactive airway disease/frequent bronchitis:
# Sore throat:
Continue Fluticasone Propionate 110mcg 2 PUFF IH BID PRN Duonebs
and held home benzonatate, guaifenesin, cepacollidocaine viscous
# Osteoporosis:
Continue alendronate 70 mg PO ___. Home vitamin D and
calcium were held while NPO
# Vitamin B12 deficiency:
Home cyanocobalamin
# Hyperlipidemia:
home pravastatin
# Constipation:
Home miralax, senna
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO TID
2. Cyanocobalamin 500 mcg PO DAILY
3. Ferrous Sulfate 325 mg PO DAILY
4. FoLIC Acid 1 mg PO DAILY
5. Levothyroxine Sodium 50 mcg PO DAILY
6. Omeprazole 40 mg PO DAILY
7. Pravastatin 40 mg PO QPM
8. Senna 8.6 mg PO QHS
9. LevoFLOXacin 750 mg PO DAILY
10. Ramelteon 8 mg PO QPM
11. Docusate Sodium 200 mg PO DAILY
12. Fluticasone Propionate 110mcg 2 PUFF IH BID:PRN cough wheeze
13. Multivitamins 1 TAB PO DAILY
14. Divalproex (DELayed Release) 125 mg PO BID
15. Gabapentin 600 mg PO QHS
16. LORazepam 0.5 mg IV TID:PRN agitation
17. Midodrine 5 mg PO QAM
18. Ranitidine 150 mg PO QHS
19. Trimethoprim 100 mg PO Q24H
20. Albuterol Inhaler ___ PUFF IH Q6H:PRN sob, wheeze
21. LORazepam 1 mg IV TID
Discharge Disposition:
Extended Care
Discharge Diagnosis:
Final Diagnosis:
Schizoaffective disorder
Depressed state
suicidal ideation
Acute kidney injury
Secondary diagnosis:
Mild pulmonary vascular congestion
Mild cardiomegaly
Hypercalcemia
SVT
Malnutrition
Smoldering myeloma
anemia
Chronic lower back pain
hypothyroidism
GERD
Osteoporosis
Vit b12 deficiency
HLD
Reactive airway disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. ___,
It was a privilege caring for you at ___.
WHY WAS I IN THE HOSPITAL?
- You were in the hospital because you were unresponsive and
having suicidal ideations and not drinking or eating.
- You were also found to have an acute kidney injury due to lack
of oral intake.
WHAT HAPPENED TO ME IN THE HOSPITAL?
- You were given fluids for your acute kidney injury.
- You were placed on ___ and given 1:1 sitter.
- We treated you with your psychiatric medications including
clozapine, valproic acid, and lorazepam as needed.
- You began to eat and your mental status stabilized in the
therapeutic environment.
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
-Please continue to take all of your medications and follow-up
with your appointments as listed below.
We wish you the best!
Sincerely,
Your ___ Team
Followup Instructions:
___
|
19694231-DS-10
| 19,694,231 | 20,810,538 |
DS
| 10 |
2179-12-18 00:00:00
|
2179-12-18 15:00:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Seizure
Major Surgical or Invasive Procedure:
Lumbar Puncture
History of Present Illness:
HPI:
Pt is a ___ yr F w/ hx of HTN and dementia who presented for new
onset weakness and dysarthria. LKW at 0900. While at her ALF, pt
was seen by staff to acutely develop R sided weakness and
slurred
speech. Pt also appeared more confused and seemed to focusing
her
gaze on the L. Out of concern, she was transferred to ___ for
further management.
While in ED, Code Stroke was called w/ CT/CTA/CTP showing no ICH
or LVO to warrant urgent intervention. Thrombolysis was not
pursued due to out of window. Soon after these treatment
decisions made w/ plan for further stroke w/u, pt displayed new
onset twitching in her R face and arm, persistent and not
suppressible. Due to concern for active seizing, given Ativan
2mg
IV x 2 and Keppra 1g IV x 1. Sx resolved after ~10 minutes,
although during this time pt displayed some n/v and airway
difficulties raising concern for aspiration.
Past Medical History:
HYPERTENSION
___ 218
HEARING LOSS
bilateral hearing aides
DEMENTIA
short term memory loss
ALZHEIMER'S DISEASE
HYPOTHYROIDISM
Social History:
___
Family History:
Unknown
Physical Exam:
==============
ADMISSION EXAM
==============
Vitals: T: 98.0 HR: 111 BP: 218/92 RR: 20 SaO2: 96% RA
General: NAD
HEENT: NCAT, no oropharyngeal lesions, neck supple
___: RRR, no M/R/G
Pulmonary: CTAB, no crackles or wheezes
Abdomen: Soft, NT, ND, +BS, no guarding
Extremities: Warm, no edema
Neurologic Examination:
- Mental status: Awake, alert, unable to provide history.
Attentive to examiner with verbal stimuli. Followed few simple
commands such as "squeeze hand" and "stick out tongue".
Responded
intermittently to questions with "I don't know what to do".
Marked dysarthria. Initial evidence of L gaze preference,
improved on follow up exam.
- Cranial Nerves: PERRL 2->1 brisk. BTT on L. EOMI, horizontal
nystagmus present in primary gaze and both lateral gazes. Winces
to noxious applied over V1-V3 b/l. Hearing intact to voice b/l.
Palate elevation symmetric. Tongue midline.
- Motor: Normal bulk and tone. No tremor or asterixis. ___ in
LUE, ___ in LLE, ___ in RLE, and ___ in RUE.
- Reflexes:
[Bic] [Tri] [___] [Quad] [Gastroc]
L 1 1 1 2+ 1
R 1 1 1 2+ 1
Plantar response flexor bilaterally
- Sensory: Grimaced to noxious applied in all extremities b/l
with WD in LEs.
-Coordination/Gait: Deferred
==============
DISCHARGE EXAM
==============
General: Elderly woman lying in bed, happy
HEENT: Normocephalic, atraumatic
Neck: Supple
CV: Regular rate and rhythm
Lungs: breathing comfortably in room air
Abdomen: nondistended
GU: Deferred
Ext: Warm, well perfused, no edema
Skin: Dry, intact, significant flaking of skin on b/l feet
Neuro:
MS- awake, alert, follows simple commands
CN- Pupils 3->2 mm brisk b/l. EOM grossly intact. no facial
droop. no gaze preference.
Sensory/Motor-
RUE: spont, antigravity
LUE: spont, antigravity
RLE: spont, antigravity
LLE: spont, antigravity
Pertinent Results:
====
LABS
====
___ 01:05PM BLOOD WBC-11.7* RBC-4.82 Hgb-14.5 Hct-46.6*
MCV-97 MCH-30.1 MCHC-31.1* RDW-14.1 RDWSD-49.5* Plt ___
___ 12:07AM BLOOD WBC-12.5* RBC-4.35 Hgb-13.1 Hct-41.5
MCV-95 MCH-30.1 MCHC-31.6* RDW-14.0 RDWSD-49.1* Plt ___
___ 12:49AM BLOOD WBC-7.9 RBC-4.41 Hgb-13.3 Hct-43.1 MCV-98
MCH-30.2 MCHC-30.9* RDW-13.6 RDWSD-50.1* Plt ___
___ 12:32AM BLOOD WBC-10.3* RBC-4.76 Hgb-14.4 Hct-46.7*
MCV-98 MCH-30.3 MCHC-30.8* RDW-13.3 RDWSD-48.8* Plt ___
___ 06:11AM BLOOD WBC-9.6 RBC-4.34 Hgb-13.0 Hct-41.6 MCV-96
MCH-30.0 MCHC-31.3* RDW-13.9 RDWSD-49.0* Plt ___
___ 06:52AM BLOOD WBC-9.0 RBC-4.61 Hgb-13.8 Hct-45.1*
MCV-98 MCH-29.9 MCHC-30.6* RDW-14.0 RDWSD-50.5* Plt ___
___ 01:05PM BLOOD ___ PTT-28.2 ___
___ 01:05PM BLOOD UreaN-23*
___ 12:07AM BLOOD Glucose-115* UreaN-18 Creat-0.7 Na-137
K-3.9 Cl-99 HCO3-25 AnGap-13
___ 12:49AM BLOOD Glucose-87 UreaN-11 Creat-0.5 Na-143
K-3.2* Cl-110* HCO3-21* AnGap-12
___ 12:32AM BLOOD Glucose-105* UreaN-10 Creat-0.6 Na-141
K-4.0 Cl-105 HCO3-20* AnGap-16
___ 06:11AM BLOOD Glucose-159* UreaN-19 Creat-1.0 Na-147
K-3.6 Cl-107 HCO3-26 AnGap-14
___ 06:52AM BLOOD Glucose-121* UreaN-15 Creat-0.7 Na-149*
K-3.9 Cl-108 HCO3-29 AnGap-12
___ 01:05PM BLOOD ALT-8 AST-23 AlkPhos-54 TotBili-0.3
___ 06:52AM BLOOD Calcium-9.5 Phos-3.4 Mg-2.3
___ 01:05PM BLOOD %HbA1c-5.4 eAG-108
___ 12:32AM BLOOD Osmolal-288
___ 01:05PM BLOOD TSH-1.8
___ 01:05PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Tricycl-NEG
=======
IMAGING
=======
- ___ MR ___
1. No acute infarct.
2. Small chronic infarct right corona radiata.
3. Moderate chronic small vessel ischemic changes, brain
parenchymal atrophy.
- ___ EEG
IMPRESSION: This is an abnormal continuous ICU EEG monitoring
study because of continuous mild focal slowing, absent posterior
dominant rhythm, and attenuation of faster frequencies over the
left hemisphere, particularly in the left temporal region.
Frequent epileptiform discharges and brief runs of lateralized
periodic discharges are present in the left temporal region.
These findings are indicative of a highly potentially
epileptogenic focal structural lesion in the left temporal
region. No electrographic seizures are present. Compared to the
prior day's recording, there is no significant change.
- ___ EEG
This is an abnormal continuous ICU EEG monitoring study because
of mild focal slowing, absent posterior dominant rhythm, and
mild attenuation of faster frequencies over the left hemisphere,
maximal in the left temporal region. There are occasional
low-voltage epileptiform discharges in the left temporal region.
These findings are indicative of a potentially epileptogenic
focus in the left temporal region. No electrographic seizures
are present. Compared to the prior day's recording, focal
slowing and attenuation have improved, the frequency of left
temporal epileptiform discharges has decreased, and lateralized
periodic discharges are no longer present.
Brief Hospital Course:
___ is a ___ yr F w/ hx of HTN and dementia who presented
for new onset weakness and dysarthria. LKW at 0900. While at her
ALF, pt
was seen by staff to acutely develop R sided weakness and
slurred
speech. Pt also appeared more confused and seemed to focusing
her
gaze on the L. Out of concern, she was transferred to ___ for
further management.
While in ED, Code Stroke was called w/ CT/CTA/CTP showing no ICH
or LVO to warrant urgent intervention. Thrombolysis was not
pursued due to out of window. Soon after these treatment
decisions made w/ plan for further stroke w/u, pt displayed new
onset twitching in her R face and arm, persistent and not
suppressible. Due to concern for active seizing, given Ativan
2mg
IV x 2 and Keppra 1g IV x 1. Sx resolved after ~10 minutes,
although during this time pt displayed some n/v and airway
difficulties raising concern for aspiration.
Infectious causes were ruled-out, and with appropriate AED
therapy with Keppra, she began to improve. There were initially
difficulties with PO intake and level of alertness, but her diet
was gradually upgraded to pureed solids. She was assessed by
physical therapy who felt she could return home but would need a
full-time aide, which her family was able to support.
Family meetings were held including Palliative Care, given Ms.
___ previously stated desire to not be hospitalized nor take
any medications which would prolong her life. Some of these
considerations were made less relevant by her continued
improvement between ___. She and family are in agreement to
continue anti-seizure medication as this would be in line with
her goal of comfort-focused care.
Transition Issues:
[] F/u thyroid ultrasound as outpatient for 22 mm R thyroid
nodule
[] Follow-up with neurology in the next ___ months. Call
___ if not contacted for an appointment within the next
week.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. amLODIPine 10 mg PO DAILY
2. Levothyroxine Sodium 25 mcg PO DAILY
3. Losartan Potassium 25 mg PO DAILY
Discharge Medications:
1. LevETIRAcetam 1000 mg PO BID
RX *levetiracetam 1,000 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*3
2. amLODIPine 10 mg PO DAILY
RX *amlodipine 10 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*3
3. Levothyroxine Sodium 25 mcg PO DAILY
RX *levothyroxine 25 mcg 1 tablet(s) by mouth once a day Disp
#*30 Tablet Refills:*3
4. Losartan Potassium 25 mg PO DAILY
RX *losartan 25 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*3
5.Rolling Walker
DX: unsteady gait
PX: good
___: 13 months
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Seizure with post-ictal ___ palsy
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Patient requires physical assistance for all mobility and cues
for safety precautions with ADLs and transfers. Patient would
benefit from discharge back to ___ with ___ care for mobility
and ADLs as well as home ___ to maximize functional mobility.
Discharge Instructions:
Dear Ms. ___,
You were admitted to ___ Neurology as you presented to ___
Emergency Department were found to have right sided weakness and
slurred speech at ___. CT scan of ___ was obtained
which showed no bleed in the brain. After CT, you were found to
have a seizure (twitching in right face and arm which lasted for
about 10 minutes and resolved with anti-seizure medications (2
mg Ativan and Keppra). You also developed a fever in the
Emergency Department. Therefore workup for infections including
those around the brain was sent and was negative. You improved
significantly over the subsequent days and were ultimately able
to be discharged back to ___ House.
Please take your medications as prescribed and follow up with
your doctors as ___.
We wish you all the best
Your ___ care team
Followup Instructions:
___
|
19694277-DS-8
| 19,694,277 | 29,356,632 |
DS
| 8 |
2179-09-10 00:00:00
|
2179-09-10 08:08:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
rapid respiratory rate
Major Surgical or Invasive Procedure:
Foley placement
History of Present Illness:
___ with dementia, HTN, history of
systolic murmur documented ___, s/p cataracts, incontinence
brought in by family with fever at home, achiness, increase in
respiratory rate, wheezing and cough for the last day. Her
family
also reports that she is fairly mobile with her walker and a
little assistance, typically wanting to go to the ___
but did not wish to go on day of presentation or day before,
saying she was tired. As baseline, she does sometimes not
recognize her family but usually does, she is confused. Family
denies reports of chest pain, diarrhea, vomiting. They did press
on her belly and thought she might have some tenderness.
In the ED, crackles heard at bases, CXR showed pneumonia, and CT
abdomen was done given family report but benign physical exam
and
showed no acute findings. Labs notable for leukocytosis,
elevated
lactate. Vitals on presentation notable for fever 102.5,
tachycardic to 124, 94% RA.
She was given levofloxacin, Tylenol, ___ NS and admitted to
the
medical service.
On the floor, she is tachypneic to the ___, occasionally
speaking
full sentences with granddaughter at bedside.
Review of systems: per HPI, otherwise 10 pt ROS negative
Past Medical History:
Cataract s/p surgery
Heart murmur
H pylori
Osteoarthritis
History of B12 deficiency
Lower extremity edema
Seasonal Allergies
HTN, not on medications
HLD, not on medications
Social History:
___
Family History:
No known family history about parents, both deceased. Children
and grand-children healthy.
Physical Exam:
Admission:
Vital Signs: Tc 99.4 106/49 95 32 94%RA
General: Alert to voice and family, tired-appearing, no acute
distress but obviously tachypneic
HEENT: Sclera anicteric, MM dry, oropharynx clear, EOMI, PERRL,
neck supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, SEM most pronounced
at LUSB
Lungs: bilateral crackles, diminished at L base
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
GU: No foley, otherwise deferred
Ext: Warm, dry, 2+ pulses, no clubbing, cyanosis, trace edema
bilaterally
Neuro: CNII-XII intact, moving all extremities with purpose,
grossly normal sensation, gait deferred.
Discharge
Vitals: 98.4 117/53 P74 R18 95% on RA
General: Alert to voice and family, no acute distress, talking
to
family, not tachypneic, no accessory muscle use
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL,
neck
supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, harsh SEM ___
Lungs: clear, no wheezing, no rhonchi or rales appreciated, good
air movement and inspiratory effort
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
GU: no foley
Ext: Warm, dry, 2+ pulses, no clubbing, cyanosis, trace edema
bilaterally
Neuro: CNII-XII intact, moving all extremities with purpose, she
can raise both upper extremities on her own, she has good grip
strength bilaterally (although requires a lot of coaxing to
comply with exam with the help of her granddaughter
interpreting) and good strength with flexion and extension of
her arms. grossly normal sensation, gait deferred.
Pertinent Results:
Admission Labs:
___ 10:30PM BLOOD WBC-18.1*# RBC-4.03 Hgb-12.0 Hct-36.8
MCV-91 MCH-29.8 MCHC-32.6 RDW-12.7 RDWSD-42.3 Plt ___
___ 08:50AM BLOOD ___
___ 10:30PM BLOOD Glucose-121* UreaN-20 Creat-0.8 Na-137
K-4.4 Cl-102 HCO3-21* AnGap-18
___ 10:30PM BLOOD ALT-16 AST-18 AlkPhos-92 TotBili-0.6
___ 10:30PM BLOOD Lipase-16
___ 10:30PM BLOOD proBNP-61
___ 08:50AM BLOOD Calcium-8.6 Phos-3.2 Mg-1.8
___ 10:30PM BLOOD Albumin-3.9
___ 10:48PM BLOOD Lactate-2.9*
___ 12:16PM BLOOD Lactate-4.0*
___ 08:46AM BLOOD Lactate-2.1*
CXR: New patchy consolidation in the lingula and
right mid lung, concerning for pneumonia.
CT ABD: IMPRESSION:
1. No acute intra-abdominal process.
2. Consolidation in the lingula is consistent with pneumonia.
3. Thickened endometrium. Pelvic ultrasound is recommended to
exclude an
endometrial lesion on a non-urgent basis.
TTE: The left atrium is mildly dilated. Left ventricular wall
thicknesses are normal. The left ventricular cavity size is
normal. Overall left ventricular systolic function is normal
(LVEF = 60%). However, the inferior and posterior walls are
hyopkinetic with focal posterobasal akinesis. The right
ventricular free wall is hypertrophied. Right ventricular
chamber size is normal with depressed free wall contractility.
[Intrinsic right ventricular systolic function is likely more
depressed given the severity of tricuspid regurgitation.] There
are three aortic valve leaflets. The aortic valve leaflets are
moderately thickened. There is severe aortic valve stenosis
(valve area = 0.6 cm2 by continuity equation; 0.9 cm2 by
planimetry). The mitral valve leaflets are mildly thickened. An
eccentric, posteriorly directed jet of Mild to moderate (___)
mitral regurgitation is seen. Due to the eccentric nature of the
regurgitant jet, its severity may be significantly
underestimated (___ effect). The left ventricular inflow
pattern suggests impaired relaxation. 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 may be underestimated due to a very high right
atrial pressure.] There is no pericardial effusion.
Compared with the prior study (images reviewed) of ___
aortic stenosis is now severe. Continuity equation-derived
aortic valve area may be an underestimate due to suboptimal left
ventricular outflow tract visualization hence inaccurate
diameter measurement. Valve area by planimetry is probably more
accurate.
Repeat CXR: Opacification has worsened substantially in the
left lung and the previous mild and evenly distributed pulmonary
edema has cleared from the right lung. Combination of findings
is explained by either resolving edema and new left pneumonia,
or decidedly asymmetric distribution of edema due to persistent
left cubitus positioning. Clinical correlation with clarify
this.
Moderate to severe cardiomegaly and mediastinal venous
engorgement are
unchanged. Pleural effusion is presumed but not large. No
pneumothorax.
___ 01:55PM BLOOD WBC-11.7* RBC-4.17 Hgb-12.2 Hct-38.8
MCV-93 MCH-29.3 MCHC-31.4* RDW-12.8 RDWSD-43.9 Plt ___
___ 01:55PM BLOOD Plt ___
___ 01:55PM BLOOD Glucose-143* UreaN-14 Creat-0.7 Na-135
K-4.0 Cl-103 HCO3-20* AnGap-16
Brief Hospital Course:
Ms. ___ is a ___ year old ___ woman with dementia
(confused at baseline) presenting with elevated RR, cough, fever
found to have severe sepsis due to multifocal pneumonia. While
initially admitted to the floor, she triggered shortly after
arrival with increased tachypnea, tachycardia. ICU evaluated but
family decided against further escalation of care. Improved
significantly since then and now mental status is pretty much
back to baseline.
Her course was complicated by acute diastolic chf exacerbation
after IVF resuscitation, which resolved without intervention.
Bcx ___ +, final growing staph epi, has been off of vanc, now on
continues to improve on levofloxacin monotherapy (completed her
treatment on the day of discharge ___. She also developed
urinary retention (incontinent and needs prompting at baseline),
s/p foley and failed voiding trial and will be discharged with a
foley in place (to follow up with urology that is arranged). her
discharge was delayed a couple days while we awaited a hospital
bed to be delivered to her residence. She will be discharged
home with her family with services. Rest of her hospital course
and plan are outlined below.
# Severe sepsis due to multifocal pneumonia: On levofloxacin,
discontinued vancomycin given staph epi, contaminant most
likely.
UCx negative. Respiratory rate normalized, lactate had improved
and no further fevers, tachycardia. Not requiring IVF since ___,
now
tolerating her usual PO.
- levofloxacin PO 7 day course given severity of infection (last
day of antibiotics ___
-Strep Ag neg
# Acute on chronic diastolic heart failure: Patient with IV
fluid
resuscitation, wheezing on ___. TTE with valvular dz, no
vegetations, does have ___ - no further workup at this time.
Has not required Lasix and continued
to improve. Discussed valvular abnormalities and ___ with
family,
they defer any new medications or treatments.
- no IVF
- encourage albuterol nebs prn wheezing
- f/u CXR in ___ weeks
# Urinary retention: suspect in setting of acute illness, volume
resuscitation, and dementia. At baseline needs prompting to
urinate and with incontinence, ?possible chronic retention as
well. TOV was attempted, able to urinate 300cc but still with
500cc
in bladder. Initially discussed replacing foley, but patient
able
to void more so was monitored throughout the day however given
later recurrent urinary retention requiring intermittent cath,
recommended replacing
foley prior to discharge. she will need follow up with a
urologist as outpatient.
# Cataracts/dry eyes: continue home eye drops
# HTN: not on home medications
# Deconditioning: Family very involved and wishes to take her
home with as much support as possible. Hospital bed prescription
given. ___ following, recommended lift for home use and may need
to await delivery prior to discharge unless further significant
improvement in her mobility.
# Transitional:
-endometrial thickening seen on imaging: endometrial ultrasound
rec'd outpatient
-would recommend ___ week follow up CXR.
-urology follow up in ___ weeks to address foley/urinary
retention
- f/u BCx which are pending at the time of discharge
# CODE: DNR/DNI, no CVL, pressors, no escalation of care
# CONTACT: granddaughter, daughter
-I spoke with her hc proxy ___ on ___ and reviewed the
plan including her need for repeat imaging of her endometrium
and also the need for repeat CXR and urology followup. I
answered all questions.
On the morning of discharge, the granddaughter was with her at
bedside with whom I updated her on the plan after discharge
including pelvic ultrasound. She was concerned that maybe she
wasn't using her L arm as much as her R however on neuro exam, I
could not identify any asymmetry and she was moving both arms
(although favors the L arm when grabbing for things or shaking
hand). Her granddaughter thinks she is left handed as well. We
got word that her hospital bed will be delivered home around 8Am
this morning.
spent >30 minutes seeing patient and organizing discharge.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 500 mg PO Q8H:PRN pain
2. ketotifen fumarate 0.025 % (0.035 %) ophthalmic TID
3. dextran 70-hypromellose 0.1-0.3 % ophthalmic QID
Discharge Medications:
1. Medical Device
1 (One) ___ Bed
___
2. Acetaminophen 500 mg PO Q8H:PRN pain
3. dextran 70-hypromellose 0.1-0.3 % ophthalmic QID
4. ketotifen fumarate 0.025 % (0.035 %) ophthalmic TID
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Severe sepsis with bacterial pneumonia
Urinary retention
Acute on chronic diastolic heart failure
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Ms. ___,
You were admitted to the hospital with severe pneumonia. You
were given antibiotics and fluid and you improved. You finished
your antibiotic course while in the hospital.
You developed urinary retention, but it is unclear how long this
has been going on. Your family discussed your options and
decided to replace the catheter. Please make sure to follow up
with the urologist for this within the next ___ weeks.
Please make sure to follow up with your primary care doctor.
An incidental finding of an abnormal appearing uterus was seen
on a scan. You will need to talk to your primary care doctor
about getting a pelvic ultrasound in the future to evaluate this
further.
Followup Instructions:
___
|
19694291-DS-28
| 19,694,291 | 28,736,581 |
DS
| 28 |
2115-08-17 00:00:00
|
2115-08-17 14:29:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
Rocephin / IV Dye, Iodine Containing Contrast Media / Bee Pollen
/ Phenergan
Attending: ___.
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is ___ year old male s/p L hemicolectomy with
primary anastomosis (___) c/b leak requring ___ with end
colostomy (___). He eventually underwent ___ reversal
with loop ileostomy in ___ of this year wich was taken down
in ___. This was complicated by an abdominal wall abscess
which
has been percutaneously drained at the beginning of ___. The
patient had an outpatient CT done today for followup of his
abdominal wall abscess which was unchanged from the prior one
done on the ___ and shows a collection stable in size
and
characteristics and an appropriately positioned drain. After
undergoing the CT he developed pain on the site of his old
ileostomy, overlying the abscessual cavity, associated with
nausea and vomiting. The patient reports he's been taking pain
medications regularly but hadn't taken any today. He has been
passing gas and had a small loose bowel movement this morning.
He denies fever but does report night sweats. He reports his
drain has been draining approximately 20cc of serosanguinous
fluid per day.
Past Medical History:
-Diverticulitis (sigmoid) with involvement of descending colon
-chronic lumbar back pain
-Depression at the time of his hepatitis B diagnosis
-Left hip bursitis
-chronic insomnia
-Erectile dysfunction, non-organic
-Restless leg syndrome, mild
-Sleep apnea, obstructive (Lost weight, no longer on sleep app)
-Hypertension, controlled
-Gout, chronic
-GERD
-Fibromyalgia (old diagnosis, no recent pain meds)
-Asthma
-Allergic rhinitis, seasonal
-HEPATITIS B, ACUTE -___, spontaneously resolved after being on
liver transplant list at ___
-GLAUCOMA, PRIMARY OPEN-ANGLE
Osteopenia-found after having bone pain and being on chronic
steroids for asthma
-Sc___'s ring-diagnosed about ___ years ago
-Right herpes zoster opthalmicus/keratitis-c/b loss of vision in
R eye (now with tunneled vision, and blurry vision)
-left rotator cuff tears with surgical repair X3 ___,
___, also reports R rotator cuff repairs
-R Carpometacarpal joint athritis s/p surgical repair
-EPS study and radiofrequency ablation for SVT in
s/p TRABECULECTOMY
s/p CATARACT REMOVAL, INSERTION OF LENS: RIGHT EYE
s/p UPPER EGD ___, AND ___
-R knee meniscal removal surgery 2X ___ years ago and ___
___
-reports negative HIV test in ___
-reports negative colonoscopy ___ years ago
Past Surgical History:
-LAR for chronic diverticulitis on ___
-HArtmanns on ___
-Hartmanns takedown with diverting ileostomy on ___
Social History:
___
Family History:
Father: GI ulcer history
Physical Exam:
On admission:
Vitals: 97.4 62 142/91 20 100/RA
GEN: A&O, uncomfortable
HEENT: No scleral icterus, mucus membranes moist
CV: RRR, No M/G/R
PULM: Clear to auscultation b/l, No W/R/R
ABD: Soft, moderately distended, exquisitely tender to palpation
in RLQ around prior ostomy site. Wound appears well healing
with
some fibrinous exudate but no purulece and only mild erythema
surrounding the edges. 5cm area of induration is felt underneath
the wound. Percutaneous drain insertion site is c/d/i. Drain
contains 10cc of serous fluid.
Ext: No ___ edema, ___ warm and well perfused
Pertinent Results:
CT ABD/PELVIS ___:
1. Again, almost complete resolution of anterior wall fluid
collection.
Preliminary Report2. Stable liver cysts.
___ 08:00PM WBC-8.5 RBC-4.94 HGB-14.2 HCT-45.1 MCV-91
MCH-28.7 MCHC-31.4 RDW-15.0
___ 08:00PM NEUTS-76.0* LYMPHS-17.2* MONOS-4.8 EOS-1.6
BASOS-0.4
___ 08:00PM PLT COUNT-242
___ 08:00PM ALBUMIN-4.1
___ 08:00PM GLUCOSE-118* UREA N-17 CREAT-1.2 SODIUM-138
POTASSIUM-5.4* CHLORIDE-102 TOTAL CO2-21* ANION GAP-20
___ 08:00PM GLUCOSE-118* UREA N-17 CREAT-1.2 SODIUM-138
POTASSIUM-5.4* CHLORIDE-102 TOTAL CO2-21* ANION GAP-20
___ 08:11PM LACTATE-1.6 K+-5.2*
Brief Hospital Course:
Mr. ___ was admitted on ___ under the Acute Care
Surgery Service for management of his abdominal pain following
his follow up scheduled CT scan. He was kept NPO overnight and
given IV fluids for hydration. By the morning of ___ his pain
was much improved and he had no further nausea. A large amount
of stool was visible in his right colon on CT scan and so he was
given mineral oil. He subsequently had multiple large bowel
movements and reported feeling much better. His abdomen was
soft, nontender and nondistended. He remained afebrile and
hemodynamically stable. His diet was advanced and he tolerated a
regular diet without nausea/vomiting or abdominal pain. He was
out of bed ambulating independently. His percutaneous drain that
had been placed on prior admission was removed prior to
discharge given that it had very minimal output and almost
complete resolution of the fluid collection had been seen on CT
scan.
In the afternoon of ___ he felt well, was afebrile and
tolerating a regular diet without increased abdominal pain. He
was instructed on appropriate bowel regimen while taking
narcotic pain medications and was discharged home with follow up
scheduled in ___ clinic.
Medications on Admission:
1. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
2. allopurinol ___ mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. fluoxetine 20 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
4. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
5. trazodone 100 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed for insomnia.
6. lorazepam 1 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed for insomnia.
7. prednisolone acetate 1 % Drops, Suspension Sig: One (1) Drop
Ophthalmic DAILY (Daily).
8. polyvinyl alcohol-povidon(PF) 1.4-0.6 % Dropperette Sig: ___
Drops Ophthalmic PRN (as needed) as needed for dry eyes, pt
request.
9. oxycodone 5 mg Tablet Sig: ___ Tablets PO Q3H (every 3
hours) as needed for pain: Do not drive while taking this
medication.
Disp:*30 Tablet(s)* Refills:*0*
10. acyclovir 400 mg Tablet Sig: One (1) Tablet PO Q12H (every
11 hours). Tablet(s)
12. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours) as needed for pain.
Discharge Medications:
1. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
2. allopurinol ___ mg Tablet Sig: One (1) Tablet PO once a day.
3. fluoxetine 20 mg Tablet Sig: One (1) Tablet PO once a day.
4. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
5. Senna Concentrate 8.6 mg Tablet Sig: One (1) Tablet PO twice
a day as needed for constipation.
6. Milk of Magnesia 400 mg/5 mL Suspension Sig: Five (5) mL PO
every six (6) hours as needed for constipation.
7. trazodone 100 mg Tablet Sig: One (1) Tablet PO at bedtime as
needed for insomnia.
8. lorazepam 1 mg Tablet Sig: One (1) Tablet PO at bedtime as
needed for insomnia.
9. oxycodone 5 mg Tablet Sig: One (1) Tablet PO four times a day
as needed for pain.
Disp:*20 Tablet(s)* Refills:*0*
10. acetaminophen 325 mg Tablet Sig: ___ Tablets PO every ___
hours as needed for pain.
11. acyclovir 400 mg Tablet Sig: One (1) Tablet PO every twelve
(12) hours.
12. prednisolone acetate 1 % Drops, Suspension Sig: One (1) drop
Ophthalmic once a day.
13. polyvinyl alcohol-povidon(PF) 1.4-0.6 % Dropperette Sig: ___
drops Ophthalmic PRN as needed for dry eyes.
Discharge Disposition:
Home
Discharge Diagnosis:
Abdominal pain
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted with abdominal pain after having your CT scan
as an outpatient. You were given IV fluids for hydration and
placed on bowel rest. Your CT scan showed some stool in your
colon. Be sure to take over-the-counter stool softners/gentle
laxatives if needed while taking narcotic pain medication as
narcotics can cause constipation. Examples of these medications
include colace, dulcolax, senna, milk of magnesia.
Do not drink alcohol or drive/operate heavy machinery while
taking narcotics as it may cause sedation and impair your
reflexes.
You may resume all other medications you were taking prior to
coming to the hospital.
Please follow up at the appointment scheduled below in ___
clinic. If you have any problems before then feel free to call
the clinic.
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Followup Instructions:
___
|
19694291-DS-29
| 19,694,291 | 29,702,951 |
DS
| 29 |
2115-10-28 00:00:00
|
2115-10-28 21:19:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
Rocephin / IV Dye, Iodine Containing Contrast Media / Phenergan
/ bee sting / Versed / fentanyl
Attending: ___.
Chief Complaint:
Mid abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
The patient is a ___ well known to the ___ service, who had
a sigmoid colectomy for diverticulitis followed by ___
procedure for anastomotic leak, later reversed with placement of
diverting loop ileostomy. His ileostomy was taken down in
___.
In the middle of last night he awoke with acute onset of focal
supraumbilical abdominal pain, worse than any previous episode.
He reports some mild nausea, but no vomiting. He has been having
bowel movements (as recently as the AM of presentation) and has
been passing flatus. The patient has a known ventral hernia and
has had discussions about repair at a later date during recent
clinic visits. He denies fever. The patient recently had his
second of 3 colonoscopic dilations of his rectal anastomosis
with
a third planned for 2 weeks from now.
Past Medical History:
-Diverticulitis (sigmoid) with involvement of descending colon
-chronic lumbar back pain
-Depression at the time of his hepatitis B diagnosis
-Left hip bursitis
-chronic insomnia
-Erectile dysfunction, non-organic
-Restless leg syndrome, mild
-Sleep apnea, obstructive (Lost weight, no longer on sleep app)
-Hypertension, controlled
-Gout, chronic
-GERD
-Fibromyalgia (old diagnosis, no recent pain meds)
-Asthma
-Allergic rhinitis, seasonal
-HEPATITIS B, ACUTE -___, spontaneously resolved after being on
liver transplant list at ___
-GLAUCOMA, PRIMARY OPEN-ANGLE
Osteopenia-found after having bone pain and being on chronic
steroids for asthma
-Schatzki's ring-diagnosed about ___ years ago
-Right herpes zoster opthalmicus/keratitis-c/b loss of vision in
R eye (now with tunneled vision, and blurry vision)
-left rotator cuff tears with surgical repair X3 ___,
___, also reports R rotator cuff repairs
-R Carpometacarpal joint athritis s/p surgical repair
-EPS study and radiofrequency ablation for SVT in
s/p TRABECULECTOMY
s/p CATARACT REMOVAL, INSERTION OF LENS: RIGHT EYE
s/p UPPER EGD ___, AND ___
-R knee meniscal removal surgery 2X ___ years ago and ___
___
-reports negative HIV test in ___
-reports negative colonoscopy ___ years ago
Past Surgical History:
-LAR for chronic diverticulitis on ___
-HArtmanns on ___
-Hartmanns takedown with diverting ileostomy on ___
Social History:
___
Family History:
Father: GI ulcer history
Physical Exam:
On admission:
VS: 97.7 50 114/55 16 98%
Gen: NAD
CV: RRR S1 S2
Lungs: CTA B/L
Abd: soft, ND, palpable midline supraumbilical defect approx 4x6
cm with reducible contents, but acutely tender to palpation.
Abdomen otherwise non-tender. Midline scar and R sided ileostomy
take-down site well-healed.
Pertinent Results:
___ 05:24AM BLOOD WBC-10.9 RBC-4.74 Hgb-13.4* Hct-41.9
MCV-88 MCH-28.3 MCHC-32.0 RDW-14.8 Plt ___
___ 06:49AM BLOOD WBC-10.4# RBC-4.91 Hgb-14.0 Hct-42.9
MCV-88 MCH-28.6 MCHC-32.7 RDW-15.2 Plt ___
___ 05:55AM BLOOD Glucose-95 UreaN-11 Creat-1.2 Na-141
K-4.0 Cl-104 HCO3-30 AnGap-11
___ 05:24AM BLOOD Glucose-118* UreaN-14 Creat-1.2 Na-138
K-4.1 Cl-101 HCO3-28 AnGap-13
___ 06:49AM BLOOD Glucose-102* UreaN-22* Creat-1.3* Na-137
K-4.4 Cl-105 HCO3-24 AnGap-12
___ 06:49AM BLOOD ALT-19 AST-27 AlkPhos-102 TotBili-0.6
___ 06:59AM BLOOD Lactate-1.4
___ CT A/P:
IMPRESSION:
1. Mild dilatation of the ileum with fecalized contents and
transition point
noted at the small bowel anastomosis in the right hemiabdomen
with collapse of
ileal bowel loops distal to the anastamosis. Findings suggest
early or partial
small-bowel obstruction.
2. Ventral hernia containing a loop of small bowel but without
any evidence
of complications.
___ CT A/P:
IMPRESSION:
1. Progression of contrast through the anastomotic site with
resolution of
the previously noted small bowel partial/early obstruction.
2. Ventral hernia containing a single loop of small bowel
without evidence of
incarceration or obstruction.
Brief Hospital Course:
The patient was admitted to the ACS service for evaluation and
treatment of his abdominal pain on ___. He had acute
supraumbilical pain and tenderness in the setting of a known
ventral hernia without evidence of incarceration or obstruction.
He was admitted for serial abdominal exams and pain control. He
was made NPO and started on IVF. His exam continued to improved
over HD#2 with continued pain medication. He had another CT scan
of his abdomen to evaluate for intra-abdominal changes and it
was negative for acute pathology. He was able to tolerate POs
and his pain resolved by HD#3. The patient was discharged home
with pain medications and recommendations for a bowel regimen at
home. He had appointments previously scheduled with his usual
surgeon, Dr. ___ his GI doctor, ___ follow-up
in ___ weeks.
Medications on Admission:
___:
-Centrum 0.4 mg-162 mg-18 mg Tab daily
-EpiPen 0.3 mg/0.3 mL (1:1,000) IM Injector as directed
-Levitra 20 mg PRN
-Restasis 0.05 % Eye gtt, Dropperette in the right eye twice a
day
-Singulair 10 mg daily
-acetaminophen 650 mg Tab q6h PRN pain
-acyclovir 800 mg daily
-allopurinol ___ mg daily
-fluoxetine 20 mg daily
-lorazepam 1 mg qhs:prn
-omeprazole 40 mg
-oxycodone-acetaminophen 5 mg-325 mg Tab ___ times daily PRN
-prednisolone 1 % Eye Drops, 1 Drop Right eye BID, L eye daily
-trazodone 100 mg HS
Discharge Medications:
1. Albuterol Inhaler 1 PUFF IH Q6H:PRN shortness of breath
2. cycloSPORINE *NF* 0.05 % ___ twice a day
* Patient Taking Own Meds *
3. PrednisoLONE Acetate 1% Ophth. Susp. 1 DROP BOTH EYES BID
1 gtt in R eye BID, 1 drop in L eye ___ only
4. Oxycodone-Acetaminophen (5mg-325mg) ___ TAB PO Q4H:PRN Pain
Duration: 2 Weeks
RX *oxycodone-acetaminophen 5 mg-325 mg ___ tablet(s) by mouth
every four (4) hours Disp #*50 Tablet Refills:*0
5. Mineral Oil ___ mL PO DAILY
You should take this medication to keep your stools soft and
help you go to the bathroom. You can take it daily as you need.
RX *mineral oil 1 by mouth once a day Disp #*14 Bottle
Refills:*0
6. Polyethylene Glycol 17 g PO DAILY:PRN Constipation
RX *Miralax 17 gram 1 by mouth once a day Disp #*14 Packet
Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Abdominal pain
Discharge Condition:
Mental status: awake, alert, and oriented appropriately
Ambulatory: independent
Condition: good
Discharge Instructions:
You were admited to the acute care service for abdominal pain at
the site of your non-incarcerated hernia.
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 driving or
operating heavy machinery while taking pain medications.
Followup Instructions:
___
|
19694291-DS-32
| 19,694,291 | 24,578,561 |
DS
| 32 |
2116-04-02 00:00:00
|
2116-04-10 13:35:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
Rocephin / IV Dye, Iodine Containing Contrast Media / Phenergan
/ bee sting / Versed / fentanyl
Attending: ___.
Chief Complaint:
chills, sweats, low grade fever
Major Surgical or Invasive Procedure:
aspiration of left abdominal collection
History of Present Illness:
History of Present Illness:
Mr. ___ is a ___ y/o gentleman s/p ventral hernia repair
with component separation on ___, who was discharged from
the hospital on ___. He was seen in the clinic 2days ago and
was doing well. However, overnight he had some sweats and
chills, as well as low grade temp to 100.9. He reports feeling
generally unwell with decreased appetite. He is passing flatus
and having normal BMs. He denies any chest pain, SOB, or cough.
His activity level is gradually improving, and he has minimal
pain. JP drainsn were removed in the cilnic 2d ago and he has
not had any discharge from his wounds. He has no dysuria.
Past Medical History:
-Diverticulitis (sigmoid) with involvement of descending colon
-chronic lumbar back pain
-Depression at the time of his hepatitis B diagnosis
-Left hip bursitis
-chronic insomnia
-Erectile dysfunction, non-organic
-Restless leg syndrome, mild
-Sleep apnea, obstructive (Lost weight, no longer on sleep app)
-Hypertension, controlled
-Gout, chronic
-GERD
-Fibromyalgia (old diagnosis, no recent pain meds)
-Asthma
-Allergic rhinitis, seasonal
-HEPATITIS B, ACUTE -___, spontaneously resolved after being on
liver transplant list at ___
-GLAUCOMA, PRIMARY OPEN-ANGLE
Osteopenia-found after having bone pain and being on chronic
steroids for asthma
-Schatzki's ring-diagnosed about ___ years ago
-Right herpes zoster opthalmicus/keratitis-c/b loss of vision in
R eye (now with tunneled vision, and blurry vision)
-left rotator cuff tears with surgical repair X3 ___,
___, also reports R rotator cuff repairs
-R Carpometacarpal joint athritis s/p surgical repair
-EPS study and radiofrequency ablation for SVT in
s/p TRABECULECTOMY
s/p CATARACT REMOVAL, INSERTION OF LENS: RIGHT EYE
s/p UPPER EGD ___, AND ___
-R knee meniscal removal surgery 2X ___ years ago and ___
___
-reports negative HIV test in ___
-reports negative colonoscopy ___ years ago
Past Surgical History:
-LAR for chronic diverticulitis on ___
-HArtmanns on ___
-Hartmanns takedown with diverting ileostomy on ___
Social History:
Recently divorced with 3 children. Also is gay. Currently lives
with his mother.
-Smoking/Tobacco: none
-EtOH: none
-Illicits: none
Recently divorced with 3 children. Also is gay. Currently lives
with his mother.
-___: none
-EtOH: none
-Illicits: none
Recently divorced with 3 children. Also is gay. Currently lives
with his mother.
-___: none
-EtOH: none
-Illicits: none
Recently divorced with 3 children. Also is gay. Currently lives
with his mother.
-___: none
-EtOH: none
-Illicits: none
Recently divorced with 3 children. Also is gay. Currently lives
with his mother.
-___: none
-EtOH: none
-Illicits: none
Family History:
Non-contributory.
Physical Exam:
PHYSICAL EXAMINATION upon admission: ___
Temp: 97.7 HR: 94 BP: 131/83 Resp: 18 O(2)Sat: 99 Normal
Constitutional: Comfortable
HEENT: Normocephalic, atraumatic
Chest: Clear to auscultation
Cardiovascular: Regular Rate and Rhythm, Normal first and
second heart sounds
Abdominal: Soft, incision c/d/i, tender but no erythema, no
oozing or purulence
GU/Flank: No costovertebral angle tenderness
Extr/Back: No cyanosis, clubbing or edema
Skin: Warm and dry
Neuro: Speech fluent
Psych: Normal mentation
Pertinent Results:
___ 06:33AM BLOOD WBC-5.7 RBC-3.40* Hgb-9.5* Hct-30.0*
MCV-88 MCH-27.9 MCHC-31.7 RDW-14.2 Plt ___
___ 05:00PM BLOOD WBC-9.5 RBC-4.12* Hgb-11.5* Hct-35.7*
MCV-87 MCH-28.0 MCHC-32.3 RDW-14.4 Plt ___
___ 05:00PM BLOOD Neuts-77.4* Lymphs-15.0* Monos-5.6
Eos-1.5 Baso-0.5
___ 06:33AM BLOOD Plt ___
___ 05:00PM BLOOD Glucose-113* UreaN-14 Creat-1.2 Na-141
K-3.7 Cl-107 HCO3-21* AnGap-17
___ 05:00PM BLOOD ALT-14 AST-14 AlkPhos-90 TotBili-0.6
___ 05:11PM BLOOD Lactate-1.5
___: cat scan of abdomen and pelvis:
IMPRESSION:
1. Fluid and air within the deep anterior abdominal
subcutaneous tissues
abutting the anterior abdominal wall diffusely and subcutaneous
edema
consistent with postsurgical changes; superinfection is not
excluded by
imaging alone.
2. Unchanged femoral head sclerosis consistent with avascular
necrosis.
___: chest x-ray:
There is no evidence of pneumonia
___: ultrasound of gallbladder/liver:
1. No cholecystitis
2. Mild splenomegaly
___ 9:35 pm SWAB Source: abdominal wall hematoma.
GRAM STAIN (Final ___:
3+ ___ per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
WOUND CULTURE (Preliminary):
BETA STREPTOCOCCUS GROUP B. SPARSE GROWTH.
ANAEROBIC CULTURE (Preliminary):
Brief Hospital Course:
The patient was admitted to the acute care service with sweats,
chills, and a low grade fever. Two days prior to admission, he
had a drain removed from his abdomen. Upon admission, he was
made NPO, given intravenous fluids, and underwent imaging. A cat
scan of the abdomen showed a left abdominal fluid collection
which was tapped and sent for culture. The gram stain showed
PMN's and the culture grew beta-strept Group B. The patient was
started on a 10 day course of augmentin. On HD # 3, he reported
right upper quadrant pain with no associated nausea or
vomitting. He underwent an ultrasound of the liver which was
normal. He has resumed a regular diet and his vital signs have
been stable. His white blood cell count has normalized. He was
discharged home on HD # 4 with stable vital signs. A follow-up
appointment was made with the acute care service.
Medications on Admission:
acyclovir 800 mg daily, allopurinol ___ mg daily, cyclosporine
(Restasis) 0.05% 1 drop both eyes BID, prednisolone 1% 1 drop
right eye BID, fluoxetine 40 mg daily, trazodone 100 mg QHS,
lorazepam 1 mg QHS PRN, singulair 10 mg daily, omeprazole 40 mg
daily, levitra 20 mg PRN, MVI, meloxicam PRN arthritis,
prednisone 40 mg daily PRN asthma (took for 4 days pre-op, taper
by 20 mg every 3 days), albuterol 2 puffs PRN SOB/wheeze,
docusate 100 mg daily, metamucil daily
Discharge Medications:
1. Acyclovir 400 mg PO Q12H
2. Amoxicillin-Clavulanic Acid ___ mg PO Q12H
last dose ___
RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tablet(s) by
mouth every twelve (12) hours Disp #*21 Tablet Refills:*0
3. Docusate Sodium 100 mg PO BID
4. Fluoxetine 40 mg PO DAILY
5. Lorazepam 1 mg PO HS:PRN sleep
6. Montelukast Sodium 10 mg PO DAILY
7. Omeprazole 40 mg PO DAILY
8. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
9. PrednisoLONE Acetate 1% Ophth. Susp. 1 DROP RIGHT EYE BID
10. Restasis *NF* (cycloSPORINE) 0.05 % ___ BID Reason for
Ordering: Wish to maintain preadmission medication while
hospitalized, as there is no acceptable substitute drug product
available on formulary.
11. Senna 1 TAB PO BID
12. traZODONE 100 mg PO HS
13. Acetaminophen 650 mg PO Q6H:PRN pain
14. Albuterol Inhaler 2 PUFF IH BID wheezing
Discharge Disposition:
Home
Discharge Diagnosis:
abdominal fluid collection
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
___ were admitted to the hospital with chills, temperature, and
sweats. ___ had a mild elevation in your white blood cell count.
___ underwent a cat scan of the abdomen which showed a small
colleciton of fluid in your abdomen. The fluid collection was
tapped and a small amount of fluid was removed and sent for
culture. ___ reported right upper abdominal pain and underwent
an ultrasound of the abdomen which was normal. ___ are now
preparing for discharge home with the following instructions;
Please call your doctor or return to the emergency room if ___
have any of the following:
* Recurrence of abdominal pain
* ___ experience new chest pain, pressure, squeezing or
tightness.
* New or worsening cough or wheezing.
* If ___ are vomiting and cannot keep in fluids or your
medications.
* ___ 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.
* ___ see blood or dark/black material when ___ vomit or have a
bowel movement.
* ___ have shaking chills, or a fever greater than 101.5 (F)
degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that
concern ___.
* Please resume all regular home medications and take any new
meds
as ordered.
Followup Instructions:
___
|
19694311-DS-10
| 19,694,311 | 27,810,095 |
DS
| 10 |
2146-12-22 00:00:00
|
2146-12-23 22:37:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
metformin / Amaryl
Attending: ___.
Chief Complaint:
Fatigue and melena
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ y/o M with history of GI bleeding secondary to multiple
G/D/J AVMs c/w GAVE, Afib/mechanical MV on Coumadin, ESRD on HD
(TThSat)presenting with melena and fatigue. Pt states his dark
stool started over the past ___ days, similar to prior episodes.
States he came in "earlier" this time. No ___ pain, no CP, no
dyspnea, no additional complaints. Did not take coumadin
tonight.
-In the ED, initial vitals were: T 98 HR 65 BP 120/31 RR 16
SpO2 98% RA
-Exam notable for: Unremarkable
-Labs notable for: INR 1.5, H/H 7.8/26.7 (last H/H was 7.423.9
on ___
-No imaging was performed in the ED
-Patient was not given any medications in ED
-Transfer VS were: T 98.1 HR 67 BP 126/49 RR 18 SpO2 97% RA
Upon arrival to the floor, patient reports ongoing fatigue. He
reports dark brown stools but no actual melena or hematochezia.
He denied any chest pain, dyspnea, fevers, chills, nausea or
vomiting. He remained hemodynamically stable on the floor. He
was started on Pantoprazole IV BID.
Past Medical History:
1. Diabetes mellitus type II
2. Coronary artery disease
3. Congestive heart failure
4. Mitral valve insufficiency: s/p MVR x2
5. Hypertension
6. Hyperlipidemia
7. Chronic kidney disease stage IV (baseline Cr ~3.9)
8. Atrial fibrillation
9. Chronic obstructive pulmonary disease
10. Gout
11. GERD
11. H/o Upper GI bleed ___ duodenal AVMs
12. Anxiety
13. Anemia
14. Small bowel obstruction: s/p ex lap
15. H/o testicular cancer: 1980s, s/p retroperitoneal LN
dissection
Social History:
___
Family History:
Mother - ___
Father - ___ cancer in ___
No children. No siblings.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS T 98.0 BP 144/56 HR 63 RR 18 SpO2 96 RA
General: Alert, oriented, no acute distress
HEENT: Sclerae anicteric, MMM, oropharynx clear, EOMI, PERRL.
Neck: Supple. JVP not elevated. no LAD
CV: RRR. Normal S1+S2, mechanical heart sounds
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
GU: No foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: Moving all extremities with purpose, no facial
assymetry, gait deferred.
DISCHARGE PHYSICAL EXAM:
Vitals: 97.5 109/52 52 18 91 Ra
General: no acute distress
HEENT: Sclerae anicteric, MMM, oropharynx clear, EOMI, PERRL.
Neck: Supple. JVP not elevated. no LAD
CV: RRR. Normal S1+S2, mechanical heart sounds, mild systolic
murmur loudest at apex.
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding, mid-abdominal hernia
noted, reducible on exam with no overlying skin discoloration.
GU: No foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: Moving all extremities with purpose, no facial
assymetry, gait deferred.
Pertinent Results:
============================
ADMISSION/IMPORTANT LABS
============================
___ 10:58PM BLOOD WBC-5.6 RBC-2.64* Hgb-7.8* Hct-26.7*
MCV-101* MCH-29.5 MCHC-29.2* RDW-18.3* RDWSD-68.3* Plt ___
___ 10:58PM BLOOD Neuts-77.6* Lymphs-13.2* Monos-7.1
Eos-1.2 Baso-0.4 Im ___ AbsNeut-4.36 AbsLymp-0.74*
AbsMono-0.40 AbsEos-0.07 AbsBaso-0.02
___ 12:06AM BLOOD ___ PTT-35.4 ___
___ 04:29AM BLOOD Glucose-117* UreaN-42* Creat-6.8*# Na-134
K-4.6 Cl-95* HCO3-25 AnGap-19
___ 04:29AM BLOOD Calcium-9.3 Phos-6.2* Mg-2.2
___ 06:50AM BLOOD VitB12-462
___ 09:20AM BLOOD HBsAg-Negative HBsAb-Negative
HBcAb-Negative
___ 09:20AM BLOOD HCV Ab-Negative
___ 04:30AM BLOOD Lactate-1.2
============================
DISCHARGE LABS
============================
___ 04:29AM BLOOD WBC-5.6# RBC-2.98* Hgb-8.7* Hct-29.1*
MCV-98 MCH-29.2 MCHC-29.9* RDW-16.9* RDWSD-60.8* Plt Ct-89*
___ 04:29AM BLOOD ___ PTT-50.0* ___
___ 04:29AM BLOOD Glucose-117* UreaN-42* Creat-6.8*# Na-134
K-4.6 Cl-95* HCO3-25 AnGap-19
___ 04:29AM BLOOD Calcium-9.3 Phos-6.2* Mg-2.2
============================
IMAGING
============================
ABDOMINAL X-RAY ___: Dilated loop of small bowel within the
left hemiabdomen measuring up to 4 cm
in transverse dimension. Stool and gas project throughout the
___. These
findings may be reflective of an early or partial small bowel
obstruction.
Continued follow-up is recommended.
ABDOMINAL X-RAY ___: Nonspecific bowel gas pattern with
dilated loops of small bowel with multiple
air-fluid levels for which partial small bowel obstruction
cannot be excluded.
ABDOMINAL X-RAY ___:
Interval improvement of small bowel loop distention without
signs of
obstruction.
Brief Hospital Course:
Mr. ___ is a ___ y/o man with history of GI bleeding secondary
to multiple G/D/J AVMs c/w GAVE, Afib/mechanical MV on Coumadin,
ESRD on HD (___) who presented with melena and fatigue that
resolved on admission, but was found to have subtherapeutic INR
and kept in house for bridging with heparin gtt. His course was
complicated by brief hernia pain which resolved. Additionally,
he became supratherapeutic on his INR and was discharged with
plan to monitor daily INR until he reached INR 2.5-3.5.
# Concern for GI Bleed/Chronic Anemia/GAVE/AVMs:
Presented with 2 days black-brown stool and
fatigue/lightheadedness similar to prior GI bleed episodes.
Initially started on IV PPI BID and held metoprolol, lisinopril,
and spironolactone. However, his melena resolved after
admission, and he had hard brown stools while in house. Hgb with
appropriate bump after transfusion on ___. He has known history
of GI bleed secondary to GAVE and AVMs. Most recently, he had a
small bowel enteroscopy with angioectasias in jejenum s/p
thermal therapy. Of note, he stopped taking his octreotide
injections because he felt it did not work for his AVMs. He was
encouraged to re-start it. He received a total of 2 U pRBCs
during the admission and was discharged on his home PO PPI.
# Mechanical Mitral Valve:
INR sub-therapeutic at 1.5 on admission. Therapeutic INR goal
2.5-3.5. Very high risk of thrombotic event with this type of
valve. Patient reports that he takes 2.0 mg - 3.0 mg of Coumadin
at home. He was started on heparin gtt with bridge to warfarin.
He quickly became supratherapeutic to 4.0 on day 4 with daily
dosing of 5mg (day 1), 3mg (day 2) and again 3mg (day 3).
Heparin gtt was stopped after 24 hours of being above 2.5. His
warfarin was held for a day. INR at discharge was 4.1, and he
was discharged on 3mg of warfarin with plan to check INR daily
at ___. AMS with ___ was called and are aware of this
plan. They will follow his INRs as an outpatient. This plan was
discussed with the patient and he agreed.
# Hernia with concern for obstruction:
On ___, patient had hernia pain, firmness, and inability to
reduce. KUB revealed concern for partial bowel obstruction, but
not full obstruction. Surgery was called but before they could
see, the patient's hernia became reducible. He no longer had any
pain. No nausea or vomiting. Repeat KUB prior to discharge was
stable to mildly improved and exam at discharge revealed
reducible and soft hernia without any tenderness. Patient was
given instructions to return if pain recurred, if he was not
passing gas or having bowel movements.
# ESRD on HD (___): Continued TTS dialysis. Continued home
calcitriol, B complex, Nephrocaps, sevelamer.
# Macrocytic anemia:
Hgb 7.3-8.7 MCV range of 99-101 since admission. B12 was normal
on this admission. Etiology unclear.
CHRONIC:
# Thrombocytopenia:
Plt ___ on this admission at his baseline. No acute
infectious process.
# Atrial Fibrillation:
CHADS-2-VAC = 4. High risk of thrombotic event given mechanical
mitral valve discussed above. Warfarin and metoprolol as
above/below.
# sCHF, compensated: Was euvolemic on this admission. Continued
home lasix and spironolactone. Held metoprolol and lisinopril in
setting of GI bleed and restarted once resolved.
# CAD - Continued home ASA, statin. Metoprolol as above.
# Type II DM - Continued home insulin and gabapentin
# GERD - Omeprazole PO BID as above
# Asthma - Continued home albuterol inhaler PRN
# Insomnia - Continued home Clonazepam 1 mg PO QHS:PRN insomnia
===========================
TRANSITIONAL ISSUES
===========================
[ ] Daily INR to be drawn at ___ until 2.5-3.5 (erring on
the side of supratherapeutic INR given high risk valve).
[ ] INR at discharge: 4.1.
[ ] Consider further workup of thrombocytopenia and macrocytic
anemia if not done already.
[ ] Needs hepatitis B vaccine (serologies negative).
DISHARGE Hb 8.7
# CODE: Full code (confirmed)
# CONTACT: ___, ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 40 mg PO QPM
3. Calcitriol 0.5 mcg PO EVERY OTHER DAY
4. ClonazePAM 1 mg PO QHS:PRN insomnia
5. Furosemide 20 mg PO 4X/WEEK (___)
6. Gabapentin 300-600 mg PO TID
7. Lisinopril 5 mg PO DAILY
8. Metoprolol Succinate XL 25 mg PO DAILY
9. Nephrocaps 1 CAP PO DAILY
10. OxyCODONE (Immediate Release) ___ mg PO Q6H:PRN Pain - Mild
11. sevelamer CARBONATE 1600 mg PO TID W/MEALS
12. Spironolactone 12.5 mg PO DAILY
13. Warfarin ___ mg PO DAILY16
14. Ferrex ___ (polysaccharide iron complex) 150 mg iron oral
DAILY
15. melatonin 5 mg oral DAILY
16. Nephro-Vite Rx (vit B cmplx ___ C-biotin) ___
mg-mg-mcg oral DAILY
17. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation
Q4H:PRN
18. SandoSTATIN LAR Depot (octreotide,microspheres) 20 mg
injection Q8H
19. Omeprazole 40 mg PO DAILY
20. Glargine 12 Units Breakfast
Humalog 4 Units Dinner
Discharge Medications:
1. Glargine 12 Units Breakfast
Humalog 4 Units Dinner
2. Warfarin 3 mg PO DAILY16
3. Aspirin 81 mg PO DAILY
4. Atorvastatin 40 mg PO QPM
RX *atorvastatin 40 mg 1 tablet(s) by mouth qpm Disp #*30 Tablet
Refills:*0
5. Calcitriol 0.5 mcg PO EVERY OTHER DAY
6. ClonazePAM 1 mg PO QHS:PRN insomnia
7. Ferrex ___ (polysaccharide iron complex) 150 mg iron oral
DAILY
RX *polysaccharide iron complex [Ferrex ___ 150 mg iron 1
capsule(s) by mouth daily Disp #*30 Capsule Refills:*0
8. Furosemide 20 mg PO 4X/WEEK (___)
9. Gabapentin 300-600 mg PO TID
10. Lisinopril 5 mg PO DAILY
RX *lisinopril 5 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
11. melatonin 5 mg oral DAILY
12. Metoprolol Succinate XL 25 mg PO DAILY
13. Nephro-Vite Rx (vit B cmplx ___ C-biotin) ___
mg-mg-mcg oral DAILY
14. Nephrocaps 1 CAP PO DAILY
15. Omeprazole 40 mg PO DAILY
RX *omeprazole 40 mg 1 capsule(s) by mouth daily Disp #*30
Capsule Refills:*0
16. OxyCODONE (Immediate Release) ___ mg PO Q6H:PRN Pain -
Mild
17. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation
Q4H:PRN
18. SandoSTATIN LAR Depot (octreotide,microspheres) 20 mg
injection Q8H
RX *octreotide,microspheres [Sandostatin LAR Depot] 20 mg 1 inj
every eight (8) hours Disp #*1 Vial Refills:*0
19. sevelamer CARBONATE 1600 mg PO TID W/MEALS
20. Spironolactone 12.5 mg PO DAILY
RX *spironolactone 25 mg 0.5 (One half) tablet(s) by mouth daily
Disp #*30 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
- Melena in the setting of GAVE
Secondary:
- Subtherapeutic INR
- Mechanical mitral valve on anticoagulation
- Atrial fibrillation
- Heart failure with preserved ejection fraction
- ESRD
- T2DM
- GERD
- Coronary artery 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 ___ because you were having dark
stools.
WHILE YOU WERE HERE:
- Your dark stools stopped.
- You had a blood transfusion to help with your blood count.
- Your INR was too low, putting you at risk for a stroke.
Therefore, you were kept in the hospital on the IV blood thinner
(heparin) and given warfarin.
- Your INR then became higher than your goal (2.5-3.5).
WHEN YOU GO HOME:
- Please check your INR EVERY DAY at ___ Care
until your INR goes back between 2.5 and 3.5.
- Your medications may have changed. Please see below for your
medication list.
- Your appointments are below.
It was a pleasure taking care of you.
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
19694378-DS-7
| 19,694,378 | 28,200,675 |
DS
| 7 |
2134-06-18 00:00:00
|
2134-06-18 14:01:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
sulfur dioxide
Attending: ___.
Chief Complaint:
Abdominal Pain
Major Surgical or Invasive Procedure:
EGD ___
History of Present Illness:
Ms. ___ is a very pleasant ___ year old ___ speaking
and partially deaf female s/p ___ Gastric Bypass ___ at ___ who
presents with a chief complaint of epigastric pain. She reports
the pain started two weeks ago as an initial discomfort but has
progressed to a severe, ___ burning pain over the past two
days. The pain is somewhat associated with RUQ pain but does not
bore through to her back. The pain is constant but does increase
with particular movements. There is some associated nausea
without emesis, fever or chills. In the past 48 hours, she has
noticed several black stools without any bright blood. Her bowel
habitus is otherwise normal. She continues to pass flatus and
stools. She is urinating normally. She does not report that she
has much of an appetite secondary to the pain. She denies taking
any NSAIDs at home. She is not an active smoker.
Yesterday, she went to the ED at ___ to address this epigastric
pain but reports she left prior to receiving any medical care
due
to a lengthy waiting time. Dr. ___ her ___ Gastric
Bypass at ___ in ___. She reports she initially lost some
weight
but has since regained some.
Her ROS is positive for lumbar back pain which existed prior to
her current episode of epigastric pain. Her ROS is negative
other
than mentioned above.
Past Medical History:
PMH:
1. Depression
2. Anxiety
3. Bipolar Disorder
4. Morbid Obesity
5. Vitamin B 12 Deficiency
6. Dyspepsia
7. Insomnia
PSH:
1. Laparoscopic Cholecystectomy; unknown date of surgery
2. Laparoscopic ___ Gastric Bypass; ___ with Dr. ___ at ___
3. Hysterectomy; unknown date of surgery
Social History:
___
Family History:
1. Father: passed away from Lung Cancer (smoker)
2. Mother: CAD, h/o MI, DM-Type II, HTN, HLD
3. Brother: h/o Lung Cancer
Physical Exam:
GEN: NAD, well appearing, hard of hearing, ___ speaking
HEENT: NCAT, trachea midline
CV: RRR
RESP: breathing comfortably on room air
GI: abdomen soft and minimally TTP in the epigastrium. No
rebounding, guarding, masses or hernias palpated.
EXT: well perfused
Pertinent Results:
___ 05:45AM BLOOD Hct-36.6
___ 07:19PM BLOOD Hct-36.6
___ 10:27AM BLOOD WBC-6.1 RBC-4.31 Hgb-12.9 Hct-41.2 MCV-96
MCH-29.9 MCHC-31.3* RDW-14.6 RDWSD-50.4* Plt ___
___ 10:27AM BLOOD Neuts-66.0 ___ Monos-9.2 Eos-2.1
Baso-0.8 Im ___ AbsNeut-4.04 AbsLymp-1.30 AbsMono-0.56
AbsEos-0.13 AbsBaso-0.05
___ 10:27AM BLOOD ALT-15 AST-17 AlkPhos-69 TotBili-0.4
___ 10:27AM BLOOD Albumin-4.0
Brief Hospital Course:
Ms. ___ was admitted to ___ on ___ with complaints
of worsening abdominal pain and reports consistent with melena.
Her initial presentation in the ED was most concerning for
gastric ulcers in the face of her previous ___ Gastric Bypass at
___. Her laboratory workup and CT Scan in the ED were
unremarkable relative to her chief complaint. Of note, the CT
Scan picked up two incidental findings that should be assessed
and evaluated as an outpatient; 4 mm right lower lobe nodule and
left adnexal cyst (recommending left pelvic ultrasound.
Ms. ___ pain was controlled overnight and she underwent
an EGD on ___ with GI which demonstrated healthy appearing
gastric and jejunal mucosa with some mild gastritis. The Roux
limb, GJ and JJ junctions were all appropriate appearing. The
patient was urged to follow up with her Primary Care Physician
regarding the management of the incidental findings on CT and
with Dr. ___ at ___ ___.
She was informed that she should not take her Diclofenac or any
other NSAIDs.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Gabapentin 400 mg PO TID
2. LamoTRIgine 100 mg PO BID
3. Zolpidem Tartrate 10 mg PO QHS
4. QUEtiapine Fumarate 50 mg PO BID
5. Venlafaxine XR 150 mg PO DAILY
6. ClonazePAM 0.5 mg PO BID
7. Docusate Sodium 100 mg PO BID:PRN Constipation
8. Omeprazole 20 mg PO DAILY
9. Diclofenac Sodium ___ 50 mg PO BID
Discharge Medications:
1. Omeprazole 40 mg PO BID
RX *omeprazole 40 mg 1 capsule(s) by mouth twice a day Disp #*60
Capsule Refills:*2
2. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain -
Moderate
RX *oxycodone [Oxaydo] 5 mg 1 tablet(s) by mouth every four (4)
hours Disp #*20 Tablet Refills:*0
3. QUEtiapine extended-release 300 mg PO QHS
4. ClonazePAM 0.5 mg PO BID
5. Docusate Sodium 100 mg PO BID:PRN Constipation
6. Gabapentin 400 mg PO TID
7. LamoTRIgine 100 mg PO BID
8. Venlafaxine XR 150 mg PO DAILY
9. Zolpidem Tartrate 10 mg PO QHS
Discharge Disposition:
Home
Discharge Diagnosis:
Abdominal Pain
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 ___ for a short period of time to
monitor and evaluate the cause of your abdominal pain and
suspected GI bleeding. Your symptoms have improved during the
course of your hospital stay and you are ready to return home.
You underwent an EGD (Endoscopy) during your stay which did not
show any evidence of ulcers or any issues with your Roux En Y
Gastric Bypass. Your CAT Scan was reassuring as well.
The CAT Scan did however demonstrate two incidental findings
that you should have evaluated as an outpatient. The first is a
very small, 4 mm pulmonary nodule. Frequently, these nodules are
observed or compared to previous studies. You should discuss
this with your primary medical doctor who likely has access to
your previous scans which may show no changes in your pulmonary
nodule. Your CAT Scan also demonstrated a 4 cm left adnexal mass
in your pelvis that should be evaluated with an ultrasound scan
as an outpatient. Again, please discuss this with your primary
medical provider who can assist you in this process.
Otherwise, you are ready to return home. You may continue your
activity as tolerated and take the oral pain medications that we
will prescribe for your.
You should follow up with your primary care provider as
mentioned and re-establish care with Dr. ___ ___ clinic
at ___.
Good Luck!
Followup Instructions:
___
|
19694420-DS-7
| 19,694,420 | 20,883,977 |
DS
| 7 |
2193-12-09 00:00:00
|
2193-12-09 16:48:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Right leg heaviness
Major Surgical or Invasive Procedure:
NONE
History of Present Illness:
Ms ___ is a ___ year old woman with a history of psoriatic
arthritis who presents to the ED as a transfer from ___
___ with acute onset of right leg weakness.
She was in her usual state of health today and was working as a
___, as she does daily. At approximately 2:45pm as
she was walking from the street to the curb, she felt her right
leg become suddenly "heavy", as if she was unable to move it.
She denies any preceding pain or injury. The weakness was
maximal at onset, and involved the entirety of the leg. The leg
was so weak
that she was unable to support her weight, and essentially
collapsed to the ground, though she was able to lower herself to
the ground via a street sign. She notes that her right arm
seemed strong as she did so. She called to a co-worker for help,
and did not have any difficulty producing the words or with
slurring her words as she did so. Her co-worker got her up and
helped her walk
to her car, though she was only able to bear a slight amount of
weight on the right leg during this time. She sat in her car for
about 15 minutes, and noted only that the leg continued to feel
heavy. She called her grandson to come help her. At around this
time she stepped out of the car, and was able to put some more
weight on the leg, though it still felt weak. Her grandson
brought her to ___.
While there, she had a CT scan of the head that was reportedly
normal. She was given Aspirin and transported to ___. She
notes that while at ___, at approximately 4:30pm,
she stood up to walk to the bathroom and felt that the strength
in her right leg had returned to normal.
At ___, she continues to feel that her strength has returned
to normal. She denies any sensory changes besides a sense of
heaviness in the leg, as well as contralateral leg weakness, arm
weakness, facial droop, slurred speech, confusion, vision
changes. She denies any prior history of similar episodes, or
any episode of weakness, slurred speech, or sensory changes. No
history or back or leg problems, with the exception of arthritis
for which she has undergone bilateral knee replacements.
Past Medical History:
CAD
gout
OSA on CPAP
s/p R nephrectomy
Social History:
___
Family History:
Multiple family members with coronary artery disease, including
a brother who died of an MI at age ___.
Physical Exam:
ADMISSION EXAM:
===============
Vitals: T: 96.8 BP: 170/94 HR: 74 RR: 18 SaO2: 94% RA
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx.
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity.
Pulmonary: Normal work of breathing.
Cardiac: RRR, warm, well-perfused.
Abdomen: Soft, non-distended.
Extremities: No ___ edema.
Skin: No rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented x 3. Able to relate history
without difficulty. Attentive, able to name ___ backward without
difficulty. Language is fluent with intact repetition and
comprehension. Normal prosody. There were no paraphasic errors.
Able to name both high and low frequency objects. Able to read
without difficulty. No dysarthria. Able to follow both midline
and appendicular commands. There was no evidence of apraxia or
neglect.
-Cranial Nerves:
II, III, IV, VI: PERRL 4 to 3mm and brisk. EOMI without
nystagmus. Normal saccades. VFF to confrontation.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii bilaterally.
XII: Tongue protrudes in midline with good excursions. Strength
full with tongue-in-cheek testing.
-Motor: Normal bulk and tone throughout. No pronator drift. No
adventitious movements, such as tremor or asterixis noted.
[___]
L 5 5 5 5 5 5 5- 5 5 5 5 5
R 5 5 5 5 5 5 5- 5 5- 5 5 5
-Sensory: Decreased sensation to pinprick below the mid-shin.
Mild loss of vibratory/position sense in the toes. No extinction
to DSS. Romberg absent.
-Reflexes:
[Bic] [Tri] [___] [Pat] [Ach]
L 2 2 2 1 1
R 2 2 2 1 1
Plantar response was flexor bilaterally.
-Coordination: No intention tremor. Normal finger-tap
bilaterally. No dysmetria on FNF or HKS bilaterally.
-Gait: Good initiation. Narrow-based. Seems to favor the left
leg
slightly.
DISCHARGE EXAM:
===============
Vitals: T 97.5, BP 118/81, HR 76, RR 18, Sa 92% RA
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx.
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity.
Pulmonary: Normal work of breathing.
Cardiac: RRR, warm, well-perfused.
Abdomen: Soft, non-distended.
Extremities: No ___ edema.
Skin: No rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented x 3. Able to relate history
without difficulty. Attentive, able to name ___ backward without
difficulty. Language is fluent with intact repetition and
comprehension.
-Cranial Nerves:
II, III, IV, VI: PERRL 4 to 3mm and brisk. EOMI without
nystagmus. Normal saccades. VFF to confrontation.
V: Facial sensation intact to light touch.
VII: Subtle right facial weakness, facial musculature activates
symmetrically
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii bilaterally.
XII: Tongue protrudes in midline with good excursions. Strength
full with tongue-in-cheek testing.
-Motor: Normal bulk and tone throughout. No pronator drift. No
adventitious movements, such as tremor or asterixis noted.
[___]
L 5 5 5 5 5 5 5 5 5 5 5 5
R 5 5 5 5 5 5 5- 5 5- 5 5 5
-Sensory: Decreased sensation to pinprick below the mid-shin.
Mild loss of vibratory/position sense in the toes. No extinction
to DSS. Romberg absent.
-Reflexes:
[Bic] [Tri] [___] [Pat] [Ach]
L 2 2 2 1 1
R 2 2 2 1 1
Plantar response was flexor bilaterally.
-Coordination: No intention tremor. Normal finger-tap
bilaterally. No dysmetria on FNF or HKS bilaterally.
-Gait: Good initiation. Narrow-based.
Pertinent Results:
ADMISSION LABS:
===============
___ 09:35PM URINE HOURS-RANDOM
___ 09:35PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG oxycodn-NEG mthdone-NEG
___ 09:35PM URINE COLOR-Straw APPEAR-Clear SP ___
___ 09:35PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
___ 07:50PM GLUCOSE-93 UREA N-12 CREAT-0.7 SODIUM-141
POTASSIUM-4.0 CHLORIDE-105 TOTAL CO2-23 ANION GAP-13
___ 07:50PM estGFR-Using this
___ 07:50PM CALCIUM-9.1 PHOSPHATE-3.6 MAGNESIUM-1.9
___ 07:50PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
tricyclic-NEG
___ 07:50PM WBC-8.1 RBC-4.81 HGB-14.6 HCT-42.1 MCV-88
MCH-30.4 MCHC-34.7 RDW-12.9 RDWSD-41.3
___ 07:50PM NEUTS-65.0 ___ MONOS-5.8 EOS-0.6*
BASOS-0.5 IM ___ AbsNeut-5.28 AbsLymp-2.25 AbsMono-0.47
AbsEos-0.05 AbsBaso-0.04
___ 07:50PM PLT COUNT-188
___ 07:50PM ___ PTT-26.2 ___
DISCHARGE LABS:
===============
___ 09:47AM BLOOD WBC-6.2 RBC-4.74 Hgb-14.1 Hct-43.0 MCV-91
MCH-29.7 MCHC-32.8 RDW-13.1 RDWSD-43.6 Plt ___
___ 09:47AM BLOOD Glucose-114* UreaN-10 Creat-0.9 Na-140
K-3.7 Cl-105 HCO3-23 AnGap-12
___ 09:47AM BLOOD Calcium-9.0 Phos-3.7 Mg-1.8 Cholest-193
___ 09:47AM BLOOD %HbA1c-5.5 eAG-111
___ 09:47AM BLOOD Triglyc-100 HDL-55 CHOL/HD-3.5
LDLcalc-118
IMAGING:
========
CTA head/neck ___:
CT HEAD: No acute intracranial hemorrhage or acute vascular
territorial
infarction. Stable focus of right frontal white matter
hypodensity.
CTA HEAD AND NECK: Mild-to-moderate atherosclerotic
calcifications are seen along bilateral carotid bulbs and
bilateral internal carotid siphons. Bilateral vertebral
arteries are patent. The primary vessels of the circle of ___
and their principal intracranial branches are patent without
flow-limiting stenosis, occlusion, or aneurysm greater than 3
mm.
Ill-defined 2.5 x 4.9 x 4.1 cm right thyroid lobe nodule with
punctate
calcifications, recommend nonurgent thyroid ultrasound for
further evaluation.
CXR ___:
No acute cardiopulmonary abnormality.Right superior mediastinal
widening
resulting in leftward tracheal deviation may be due to a thyroid
goiter.
MRI head without contrast ___:
No acute infarct. Chronic right cerebellar infarct. Scattered
periventricular and subcortical white matter T2/FLAIR
hyperintensities, likely sequela of chronic small vessel
disease.
TTE ___:
The left atrial volume index is normal. There is no evidence for
an atrial septal defect by 2D/color Doppler.The estimated right
atrial pressure is ___ mmHg. There is mild symmetric left
ventricular hypertrophy with a
normal cavity size. There is normal regional and global left
ventricular systolic function. No thrombus or mass is seen in
the left ventricle. Overall left ventricular systolic function
is hyperdynamic. Quantitative 3D
volumetric left ventricular ejection fraction is 76 %. Left
ventricular cardiac index is normal (>2.5 L/min/m2). There is a
mid cavitary gradient (peak 11 mmHg) with no change with
Valsalva. No ventricular septal defect is seen. Normal right
ventricular cavity size with normal free wall motion. The aortic
sinus diameter is normal for gender with normal ascending aorta
diameter for gender. The aortic arch diameter is normal. There
is no evidence for an aortic arch coarctation. The aortic valve
leaflets (3) are mildly thickened. No masses or vegetations are
seen on the aortic valve. There is no aortic valve stenosis.
There is no 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 trivial mitral regurgitation. The
tricuspid valve leaflets
appear structurally normal. No mass/vegetation are seen on the
tricuspid valve. There is physiologic tricuspid regurgitation.
The estimated pulmonary artery systolic pressure is normal.
There is a trivial pericardial effusion.
IMPRESSION: No structural cardiac source of embolism (e.g.
atrial septal defect, intracardiac thrombus, or vegetation)
seen. Mild basal septal hypertrophy with normal cavity size and
hyperdynamic regional/global systolic function. Mild mid
cavitary gradient. No valvular pathology
or pathologic flow identified.
Brief Hospital Course:
PATIENT SUMMARY:
================
Mrs. ___ is a ___ year old woman with relatively few vascular
risk factors, except smoking history and hypertension, who
presented to the ED after a transient episode of right leg
weakness, lasting about 45 minutes.
Exam in the hospital notable only for slight weakness in the
right iliopsoas and hamstring, and a gait that somewhat favors
the left leg.
Given the sudden onset of weakness involving the entirety of the
leg which was maximal at onset and resolved over approximately
45 minutes, concern is primarily for a vascular etiology. MRI
did show an area of restricted diffusion at the vertex just
anterior to the primary motor cortex on the left side. Per
discussion with radiology, this may represent artifact rather
than true infarct.
Regardless of TIA or true stroke, workup is the same. She
underwent TTE. This showed: No structural cardiac source of
embolism (e.g. atrial septal defect, intracardiac thrombus, or
vegetation) seen. Mild basal septal hypertrophy with normal
cavity size and hyperdynamic regional/global systolic function.
Mild mid cavitary gradient. No valvular pathology or pathologic
flow identified.
The patient was started on aspirin 81 mg daily as well as
atorvastatin 40 mg daily. LDL was 118. HgBA1c was 5.5%.
The patient was discharged with a Ziopatch cardiac event monitor
to assess for occult atrial fibrillation. She will follow up
with stroke neurology as an outpatient.
TRANSITIONAL ISSUES:
====================
- Consider starting antihypertensive medication as outpatient in
order to further reduce risk of stroke.
- Follow up Ziopatch results as outpatient.
- Ill-defined 2.5 x 4.9 x 4.1 cm right thyroid lobe nodule with
punctate calcifications, recommend nonurgent thyroid ultrasound
for further evaluation.
- Consider further increasing atorvastatin for goal LDL < 70.
AHA/ASA Core Measures for Ischemic Stroke and Transient Ischemic
Attack
=
=
=
=
=
=
=
================================================================
1. Dysphagia screening before any PO intake? (x) Yes, confirmed
done - () Not confirmed () No. If no, reason why:
2. DVT Prophylaxis administered? (x) Yes - () No. If no, why not
(I.e. bleeding risk, hemorrhage, etc.)
3. Antithrombotic therapy administered by end of hospital day 2?
(x) Yes - () No. If not, why not? (I.e. bleeding risk,
hemorrhage, etc.)
4. LDL documented? (x) Yes (LDL = 118) - () No
5. Intensive statin therapy administered? (simvastatin 80mg,
simvastatin 80mg/ezetemibe 10mg, atorvastatin 40mg or 80 mg,
rosuvastatin 20mg or 40mg, for LDL > 70) (x) Yes - () No [if LDL
>70, reason not given:
[ ] Statin medication allergy
[ ] Other reasons documented by physician/advanced practice
nurse/physician ___ (physician/APN/PA) or pharmacist
[ ] LDL-c less than 70 mg/dL
6. Smoking cessation counseling given? () Yes - (x) No [reason
(x) non-smoker - () unable to participate]
7. Stroke education (personal modifiable risk factors, how to
activate EMS for stroke, stroke warning signs and symptoms,
prescribed medications, need for followup) given (verbally or
written)? (x) Yes - () No
8. Assessment for rehabilitation or rehab services considered?
() Yes - (x) No. If no, why not -> Patient at baseline
functional status
9. Discharged on statin therapy? (x) Yes - () No [if LDL >70,
reason not given:
[ ] Statin medication allergy
[ ] Other reasons documented by physician/advanced practice
nurse/physician ___ (physician/APN/PA) or pharmacist
[ ] LDL-c less than 70 mg/dL
10. Discharged on antithrombotic therapy? (x) Yes [Type: (x)
Antiplatelet - () Anticoagulation] - () No
11. Discharged on oral anticoagulation for patients with atrial
fibrillation/flutter? () Yes - (x) No - If no, why not (I.e.
bleeding risk, etc.) (x) N/A
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation
Q4H:PRN
2. PredniSONE 10 mg PO TID
3. LORazepam 0.5 mg PO TID:PRN anxiety
4. Azithromycin 500 mg PO Q24H
5. umeclidinium 62.5 mcg/actuation inhalation DAILY
6. Gabapentin 600 mg PO TID
7. Ibuprofen 400-600 mg PO Q8H:PRN Pain - Mild
Discharge Medications:
1. Aspirin 81 mg PO DAILY
RX *aspirin 81 mg 1 tablet(s) by mouth Daily Disp #*30 Tablet
Refills:*3
2. Atorvastatin 40 mg PO QPM
RX *atorvastatin 40 mg 1 tablet(s) by mouth Daily Disp #*30
Tablet Refills:*3
3. Azithromycin 500 mg PO Q24H
4. Gabapentin 600 mg PO TID
5. Ibuprofen 400-600 mg PO Q8H:PRN Pain - Mild
6. LORazepam 0.5 mg PO TID:PRN anxiety
7. PredniSONE 10 mg PO TID
8. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation
Q4H:PRN
9. umeclidinium 62.5 mcg/actuation inhalation DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Acute ischemic stroke
Hyperlipidemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear ___,
___ were hospitalized due to symptoms of right leg heaviness
resulting from a TIA or ACUTE ISCHEMIC STROKE, a condition where
a blood vessel providing oxygen and nutrients to the brain is
blocked by a clot. The brain is the part of your body that
controls and directs all the other parts of your body, so damage
to the brain from being deprived of its blood supply can result
in a variety of symptoms.
Stroke can have many different causes, so we assessed ___ for
medical conditions that might raise your risk of having stroke.
In order to prevent future strokes, we plan to modify those risk
factors. Your risk factors are:
- High cholesterol
- High blood pressure
We are changing your medications as follows:
- Started aspirin 81 mg daily
- Started atorvastatin 40 mg every night
Please take your other medications as prescribed.
Please follow up with Neurology and your primary care physician
as listed below.
If ___ experience any of the symptoms below, please seek
emergency medical attention by calling Emergency Medical
Services (dialing 911). In particular, since stroke can recur,
please pay attention to the sudden onset and persistence of
these symptoms:
- Sudden partial or complete loss of vision
- Sudden loss of the ability to speak words from your mouth
- Sudden loss of the ability to understand others speaking to
___
- Sudden weakness of one side of the body
- Sudden drooping of one side of the face
- Sudden loss of sensation of one side of the body
Sincerely,
Your ___ Neurology Team
Followup Instructions:
___
|
19694606-DS-12
| 19,694,606 | 23,730,418 |
DS
| 12 |
2157-11-21 00:00:00
|
2157-11-22 19:40:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Syncopal episode
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ y/o woman with PMHx of HTN and HLD, on ASA every other day.
She presented to OSH ED on ___ after a witnessed fall/syncope.
Per records, her fall was witnessed by a bystander as first
leaning towards a wall, then falling from standing height. The
patient does not recall the fall. She reports that she was
walking in the sidewalk outside the mall and felt tired, so she
stopped to rest and leaned on a post. The next thing she
remembers is being in the ED.
She denies feeling lightheaded, chest pain or palpitations
either before or after the fall.
Per report, OSH CT scan with bilateral acute traumatic SHD, thus
patient was transferred to ___ and admitted to the
Neurosurgery Service. Serial head CTs have been stable, and
neurologic exam normal and stable. She has been observed on
telemetry with no events, troponin was negative x1. Cardiology
was consulted to comment on first degree AV delay, and
recommended a TTE.
On ROS, no fever, chills, CP, SOB, abdominal pain, palpitations,
n/v, rash, headache
Past Medical History:
Hypertension, hyperlipidemia, DM
Social History:
___
Family History:
No hx of heart disease. FH of basal cancer.
Physical Exam:
On admission:
O: T:97.4 94 184/80 18 95% RA
Gen: Hard of Hearing. WD/WN, comfortable, NAD.
HEENT: right facial lacs and abrasions with periorbital edema
and
ecchymosis, patient unable to open right eye fully.
Neck: Supple. no midline tenderness
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 4 to 3
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: decreased bulk with normal tone bilaterally. No abnormal
movements, tremors. With the exception of the right triceps
strength is otherwise ___ throughout. No pronator drift
Sensation: Intact to light touch bilaterally.
Toes mute
On discharge:
Vitals: 99.0, 122-136/49-52, 62, 16, 96% RA. ___ 155
General: sleeping comfortably, easily arousable, A&Ox3
HEENT: NC, traumatic ecchymoses on right face, 2 sutures on
right supraorbit, able to open both eyes, EOMI, PERRL, mmm. Neck
nontender to palpation
Lungs: ctab
CV: rrr, normal S1/S2, no murmurs or gallops, no JVD
Abdomen: soft, nontender, nondistended, no CVA tenderness, back
Ext: no peripheral edema
Neuro: A&Ox3, CN II-XII grossly intact
Pertinent Results:
On Admission
___ 04:20PM BLOOD WBC-15.5* RBC-3.80* Hgb-12.8 Hct-36.6
MCV-96 MCH-33.6* MCHC-34.9 RDW-12.9 Plt ___
___ 04:20PM BLOOD Neuts-84.7* Lymphs-10.4* Monos-4.4
Eos-0.4 Baso-0.1
___ 04:20PM BLOOD Glucose-206* UreaN-28* Creat-0.9 Na-136
K-4.1 Cl-98 HCO3-28 AnGap-14
___ 06:15AM BLOOD CK-MB-2 cTropnT-<0.01
___ 06:15AM BLOOD Albumin-3.2* Calcium-8.9 Phos-4.4 Mg-2.0
___ 07:45PM URINE Color-Yellow Appear-Clear Sp ___
___ 07:45PM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-TR Ketone-10 Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG
___ 07:45PM URINE RBC-0 WBC-0 Bacteri-NONE Yeast-NONE Epi-0
On Discharge
___ 06:45AM BLOOD WBC-7.2 RBC-3.21* Hgb-10.6* Hct-31.5*
MCV-98 MCH-33.0* MCHC-33.6 RDW-12.5 Plt ___
___ 06:45AM BLOOD Glucose-159* UreaN-26* Creat-0.8 Na-142
K-3.8 Cl-105 HCO3-29 AnGap-12
IMAGING
___ CT sinus, mandible, maxillofacial without contrast:
No fracture. Soft tissue hematoma and laceration overlying the
right orbit are not significantly changed from the prior CT from
earlier today.
___ CT head without contrast:
No significant change in the appearance of the small bilateral
subarachnoid hemorrhages.
___ CT head
IMPRESSION:
1. No interval change in small bilateral subarachnoid
hemorrhages.
2. No new hemorrhage.
3. Stable soft tissue hematoma overlying the right orbit.
4. Cortical atrophy.
___ Echocardiogram:
Conclusions
The left atrium is normal in size. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity size is
normal. Overall left ventricular systolic function is normal
(LVEF = 70%). Tissue Doppler imaging suggests an increased left
ventricular filling pressure (PCWP>18mmHg). There is no left
ventricular outflow obstruction at rest or with Valsalva. Right
ventricular chamber size and free wall motion are normal. 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. The left ventricular inflow
pattern suggests impaired relaxation. The estimated pulmonary
artery systolic pressure is normal. There is no pericardial
effusion.
Brief Hospital Course:
___ y/o woman with PMHx of HTN and HLD, on ASA who presented
after a witnessed fall/syncope.
# Syncope: ___ y/o woman with PMHx of HTN and HLD, on ASA who
presented after a witnessed fall/syncope and found to have small
b/l SAH. Pt had follow up CTs with stable SAH. No neuro
deficits. ASA held, will restart 7 days from fall. Loaded on
keppra and started on keppra 500mg BID for total 7 days course.
Source of syncope is unclear. The absence of pre-syncope
symptoms such as lightheadedness, nausea, diaphoresis and the
sudden fall was concerning for a cardiac cause of syncope such
as an arrhythmia, outflow obstruction rather than a vasovagal
syncope. However, no abnormailites detected on telemetry and no
AS on ECHO or other major structural defects. Pt has first
degree AV block on EKG, but no progression to ___ block or
bradycardia noted on tele. It is possible that the syncope was
due to orthostatic hypotension given pt felt "tired" from
walking/shopping and was found to be orthostatic during
hospitalization. SBP during hospitalization was in the 100-130
range. Home HCTZ and lisinorpil discontinued given normotension
and orthostatic hypotension. Needs to be re-evaluated as an
outpatient. Small possibility patient had a seizure leading to
syncope. However, there was no witnessed seizure activity by
bystanders. Evaluated by ___ and discharged home with a walker.
TRANSITIONAL ISSUES
[ ] Will need to follow up with neurosurgeon, Dr ___. Pt
instructed to call and make an appt. Will also schedule CT head
during call.
[ ] Discharged on keppra 500mg BID for seizure ppx for total 7
days(last day ___
[ ] Can restart ASA 81mg on ___
[ ] Home HCTZ and lisinorpil discontinued given normotension and
orthostatic hypotension. Needs to be re-evaluated as an
outpatient.
CODE: FULL
Name of health care proxy: ___
Relationship: Son
Phone number: ___
Cell phone: ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Hydrochlorothiazide 25 mg PO DAILY
3. Simvastatin 30 mg PO QPM
4. Lisinopril 10 mg PO DAILY
5. Potassium Chloride 20 mEq PO DAILY
6. sitaGLIPtin 25 mg oral DAILY
Discharge Medications:
1. Simvastatin 30 mg PO QPM
2. LeVETiracetam 500 mg PO BID
RX *levetiracetam [Keppra] 500 mg 1 tablet(s) by mouth twice a
day Disp #*11 Tablet Refills:*0
3. Aspirin 81 mg PO DAILY
RESTART ON ___, DO NOT TAKE BEFORE THAT
4. sitaGLIPtin 25 mg oral DAILY
5. Walker
Name: ___: Rolling Walker
Diagnosis: Impaired Mobility
ICD-9: 789.2
Length of Need: ___ year
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary:
Bilateral traumatic subarachnoid hemorrhage
Syncope with orthostatic hypotension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear ___,
___ was a pleasure caring for you at ___. You were admitted to
the hospital after losing conciousness, falling, and hitting
your head. You were found to have bleeding in your head. You
were followed closely by our neurosurgery team, and the bleeding
stayed stable and there were no further complications. You also
had a cut on the right side of your face. It required a few
stitches to stop the bleeding. You should have the stitches
taken out at your PCP's visit in 1 week. As outlined below, you
will need to follow up with the neurosurgery team as an
outpatient and have follow up head imaging.
The cause of your loss of conciousness and fall is not totally
clear. Some tests showed that you might have been dehydrated,
potential leading to low blood pressure and loss of
conciousness. It is important you are always hydrated well. We
stopped your lisinopril and hydrochlorothiazide due to low blood
pressure.
Please take all medications as prescribed and attend all follow
up appointments.
Sincerely,
Your ___ medical team
Nonsurgical Brain Hemorrhage - Traumatic Brain injury
Take your pain medicine as prescribed.
Exercise should be limited to walking; no lifting, straining,
or excessive bending.
Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Advil, or Ibuprofen
etc.
You may safely resume taking Aspirin 81mg on ___
You have been discharged on Keppra (Levetiracetam) 500mg twice
a day, end date ___
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
New onset of tremors or seizures.
Any confusion, lethargy or change in mental status.
Any numbness, tingling, weakness in your extremities.
Pain or headache that is continually increasing, or not
relieved by pain medication.
New onset of the loss of function, or decrease of function on
one whole side of your body.
Followup Instructions:
___
|
19695104-DS-13
| 19,695,104 | 29,731,572 |
DS
| 13 |
2203-09-09 00:00:00
|
2203-09-10 17:32:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Percocet / Valium
Attending: ___.
Chief Complaint:
Cough and fever
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old male with h/o CAD s/p CABG, ___, HTN, HLD
presenting with cough and fever.
Upon arrival to the floor, patient reports that his cough
started on ___. He reports that he was working with a
friend from ___ who was helping him clean his house, and she
gave him a cough drop. After he took the cough drop he
"immediately felt sick," with coughing, weakness, and muscle
aches. He denied fevers at home, took his temp yesterday and it
was 98.7 F. However he did have chills and sweats. He has had
fits of dry coughing since then, has gotten very little sleep.
He is not producing sputum, not coughing up blood. He denies
abdominal pain, nausea, dysuria, diarrhea. Denies leg swelling.
No changes in his Lasix dose. He has chronic vertigo, no new
headaches or lightheadedness. He is A/Ox3.
On review of the records, he was recently seen by his outpt
providers for ___ tophaceous gout flare and got 5 days of 50 mg
prednisone that was completed on ___.
Past Medical History:
- CAD: ___ CABG (LIMA-LAD, SVG-RCA) c/b inferior MI
___: LCX stenting
___: DES to diag, Plavix x12 months
- Hypertension
- Dyslipidemia
- CKD
- GERD
- Anemia (mild)
- Osteoarthritis
- Lumbar spinal stenosis
- Carpal tunnel surgery
- Anxiety
- Depression
- Tension headaches
- Hard of hearing
- Obesity
- GOUT
Social History:
___
Family History:
Family Hx: Negative for cerebral aneurysm or hemorrhage,
strokes,
migraine or other neurologic problems
Physical Exam:
ADMISSION:
General: Alert, oriented x3, no acute distress
HEENT: Sclerae anicteric, MMM, oropharynx clear although could
not appreciate posterior oropharynx, EOMI, PERRL.
Neck: Supple. JVP not elevated. no LAD
CV: Regular rate and rhythm. Normal S1+S2, no murmurs, rubs,
gallops.
Lungs: diffusely rhonchorous with some end expiratory wheezing
in the upper lung fields.
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
GU: No foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema with significant onchomycosis in the feet
Neuro: CNII-XII intact, ___ strength upper/lower extremities,
grossly normal sensation, gait deferred.
DISCHARGE:
GENERAL: NAD
HEART: RRR, soft S1/S2, II/VI crescendo-decrescendo murmor best
heard at right sternal border, no gallops or rubs
LUNGS: faint crackles heard at right lung base, no wheezing
ABDOMEN: nondistended, +BS, no rebound/guarding, no
hepatosplenomegaly, epigastric fullness consistent with known
lipoma
EXTREMITIES: no cyanosis, trace edema, moving all 4 extremities
with purpose
NEURO: Grossly intact
Pertinent Results:
ADMISSION:
___ 02:42PM BLOOD WBC-15.1*# RBC-3.43* Hgb-10.7* Hct-33.3*
MCV-97 MCH-31.2 MCHC-32.1 RDW-15.5 RDWSD-54.4* Plt ___
___ 02:42PM BLOOD Neuts-83.5* Lymphs-8.9* Monos-5.6 Eos-1.3
Baso-0.2 Im ___ AbsNeut-12.61*# AbsLymp-1.34 AbsMono-0.85*
AbsEos-0.20 AbsBaso-0.03
___ 06:20AM BLOOD ___ PTT-29.5 ___
___ 02:42PM BLOOD Glucose-119* UreaN-34* Creat-1.4* Na-141
K-4.9 Cl-103 HCO3-20* AnGap-23*
___ 06:20AM BLOOD ALT-17 AST-19 LD(LDH)-203 AlkPhos-77
TotBili-0.3
___ 06:20AM BLOOD Albumin-3.7 Calcium-8.2* Phos-4.7* Mg-2.1
Iron-25*
___ 06:20AM BLOOD calTIBC-312 Ferritn-82 TRF-240
___ 06:10AM BLOOD TSH-1.9
___ 03:00PM BLOOD Lactate-2.7*
___ 09:06AM BLOOD Lactate-1.1
DISCHARGE:
___ 06:50AM BLOOD WBC-7.8 RBC-2.98* Hgb-9.4* Hct-29.3*
MCV-98 MCH-31.5 MCHC-32.1 RDW-14.7 RDWSD-52.8* Plt ___
___ 06:50AM BLOOD Glucose-82 UreaN-28* Creat-1.2 Na-141
K-4.4 Cl-102 HCO3-23 AnGap-20
___ 06:50AM BLOOD Calcium-8.6 Phos-3.4 Mg-2.4
STUDIES:
CXR PA/LAT ___:
Retrocardiac opacities on the lateral radiograph may reflect a
lower lobe
pneumonia.
MICRO:
Blood Cultures ___:
1) GRAM + COCCI (returned after discharge)
2) COAGULASE NEGATIVE STAPH
Blood Cxs ___ and ___: NGTD
Brief Hospital Course:
Mr. ___ is an ___ yo M with PMHx CAD s/p CABG, ___,
HTN, HLD presenting with cough and fever concerning for
community acquired pneumonia.
#Community Acquired Pneumonia:
Febrile in the ED and requiring 2L NC, CXR showing retrocardiac
opacities. Flu negative. Treated initially with ceftriaxone and
vancomycin and narrowed to PO levofloxacin following clinical
improvement. Leukocytosis and oxygen requirement resolved.
Treated for a 5 day course of levofloxacin for CAP. Dischraged
with benzonatate and guaifenesin-dextromethorphan for persistent
cough.
#Positive Blood Cultures, likely contaminant:
One of two blood cultures from ___ growing coagulase negative
staph. Initially treated with vancomycin but this was stopped
once culture returned as coag negative. In the context of
clinical improvement, resolving leukocytosis, and no fever, this
was thought to most likely represent contaminant. Subsequent
cultures showing no growth to date. Blood cultures from ___,
___, and ___ pending at discharge and should be followed-up in
clinic. Shortly after discharge, the anaerobic bottle from the
same blood draw on ___ began growing gram positive rods (many
days after culture was drawn), most likely diphtheroids,
supporting the diagnosis of contaminated culture.
# A fib:
The patient was found to be in atrial fibrillation with normal
rates on ___ for several hours. He was placed on metoprolol for
rate control and he subsequently converted spontaneously to
sinus with no further episodes. It is likely this represents
paroxysmal afib. Deferred anticoagulation as there was no
indication for this acutely, however anticoagulation should be
strongly considered in the outpatient setting as the patient has
CHADS2VASC of 4. Discharged on metoprolol XL in place of
atenolol in the setting of renal insufficiency. Discussed the AF
with his outpatient PCP and cardiologist who will consider
anticoagulation after discussion with patient and re-evaluation
in clinic.
#Acute Kidney Injury on CKD stage III:
Cr elevated to 1.6 from baseline 0.9 to 1.1, likely in the
setting of acute infection. Home lasix and lisinopril held until
resolution of creatinine and resumed at home dose prior to
discharge.
# Macrocytic Anemia:
Slightly below baseline ___ from ___, likely with component
from renal disease. Continued iron. Follow-up in clinic.
# CAD: s/p CABG (LIMA-LAD, SVG-RCA) c/b inferior MI, LCX
stenting, DES to diag, Plavix x12 months completed in ___.
Continued ASA, statin and lisinopril.
# HLD: Continued statin
# GERD: Continue pantoprazole
# Anxiety: Continued sertraline
TRANSITIONAL ISSUES:
- Treated with a 5 day course of levofloxacin for CAP (750mg q48
hours through ___.
- Dischraged with benzonatate and guaifenesin-dextromethorphan
for persistent cough.
- Blood cultures from ___, and ___ pending at discharge
and should be followed-up in clinic.
- Discharged on metoprolol XL in place of atenolol in the
setting of renal insufficiency.
- Afib: anticoagulation should be strongly considered in the
outpatient setting as the patient has CHADS2VASC of 4
- Follow-up in clinic for further workup and management of
anemia as appropriate
# CODE: full (presumed)
# CONTACT: ___, daughter and HCP, ___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin EC 81 mg PO DAILY
2. Carbidopa-Levodopa (___) 1 TAB PO TID
3. Furosemide 60 mg PO BID
4. Gabapentin 300-600 mg PO TID
5. Lisinopril 5 mg PO DAILY
6. Multivitamins W/minerals 1 TAB PO DAILY
7. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
8. Sertraline 100 mg PO DAILY
9. Simvastatin 20 mg PO QPM
10. acetaminophen-codeine 300-15 mg ORAL Q6H:PRN pain
11. ubidecarenone-omega 3-vit E ___ mg-mg-unit oral DAILY
12. Vitamin D ___ UNIT PO DAILY
13. Atenolol 25 mg PO BID
14. Pantoprazole 40 mg PO Q24H
15. Ferrous Sulfate 325 mg PO DAILY
16. Polyethylene Glycol 17 g PO DAILY:PRN constipation
17. Fish Oil (Omega 3) 1000 mg PO DAILY
18. coenzyme Q10-vitamin E 100-100 oral DAILY
19. Cyanocobalamin Dose is Unknown PO DAILY
Discharge Medications:
1. Benzonatate 100 mg PO TID
RX *benzonatate 100 mg 1 capsule(s) by mouth three times a day
Disp #*30 Capsule Refills:*0
2. Guaifenesin-Dextromethorphan ___ mL PO Q6H:PRN cough
RX *dextromethorphan-guaifenesin 100 mg-10 mg/5 mL 10 ml by
mouth four times a day Refills:*0
3. Metoprolol Succinate XL 25 mg PO DAILY
RX *metoprolol succinate 25 mg 1 tablet(s) by mouth once a day
Disp #*30 Tablet Refills:*0
4. Cyanocobalamin 1000 mcg PO DAILY
5. acetaminophen-codeine 300-15 mg ORAL Q6H:PRN pain
6. Aspirin EC 81 mg PO DAILY
7. Carbidopa-Levodopa (___) 1 TAB PO TID
8. coenzyme Q10-vitamin E 100-100 oral DAILY
9. Ferrous Sulfate 325 mg PO DAILY
10. Fish Oil (Omega 3) 1000 mg PO DAILY
11. Furosemide 60 mg PO BID
12. Gabapentin 300-600 mg PO TID
13. Lisinopril 5 mg PO DAILY
14. Multivitamins W/minerals 1 TAB PO DAILY
15. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
16. Pantoprazole 40 mg PO Q24H
17. Polyethylene Glycol 17 g PO DAILY:PRN constipation
18. Sertraline 100 mg PO DAILY
19. Simvastatin 20 mg PO QPM
20. ubidecarenone-omega 3-vit E ___ mg-mg-unit oral
DAILY
21. Vitamin D ___ UNIT PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY:
Community Acquired Pneumonia
Atrial Fibrillation
SECONDARY:
Macrocytic Anemia
Coronary Artery Disease
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 caring for you here at ___
___.
WHY YOU WERE HERE:
- You were admitted because you had a very bad cough concerning
for pneumonia
WHILE YOU WERE HERE:
- We treated you for pneumonia with antibiotics
WHEN YOU GO HOME:
- Please continue all your medications as directed
- Please follow-up with your primary care doctor
- Please keep in mind all of the "alarm symptoms" below. If you
experience these, please call your doctor or return to the
emergency department immediately
We wish you the best,
Your ___ Care Team
Followup Instructions:
___
|
19695104-DS-14
| 19,695,104 | 28,013,084 |
DS
| 14 |
2204-11-05 00:00:00
|
2204-11-05 18:01:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Percocet / Valium
Attending: ___.
Chief Complaint:
foot pain
Major Surgical or Invasive Procedure:
I+D x3, bone biopsy
L ___ toe amputation
History of Present Illness:
___ with CAD s/p CABG, CKD, HTN, not diabetic with recurrent
L toe pain. L great toe redness, swelling and pain started about
4 weeks ago. He was seen as an outpatient (___), had wound Cx
showing MSSA, treated with a dose of IV CTX then course of
Cephalexin, after which symptoms resolved and repeat culture one
week later was negative. He was also treated for gout with
colchicine and indomethacin. Cardiologist recently recommended
stopping indomethacin (he was seen for dyspnea). Was seen today
in clinic due to recurrence of symptoms, which started a few
days
ago. Labs and wound Cx taken, and he was sent to the ED for
further workup. No fever, chills; no anorexia. He is currently
reporting no pain in the toe, but does report significant
neuropathy and loss of sensation in the bilateral feet.
In the ED initial VS were 97.8 90 157/67 20 98% RA. Exam was
notable for toe erythema and expression of white chalky material
without tenderness to palpation. Labs notable for WBC 9.8 w/
normal diff, Hgb 11.3, MCV 101, CRP 51.2, BUN/Cr ___.
Podiatry was consulted and on their exam determined that the L
hallux wound was expressing gouty tophi, so a swab was taken,
which showed few extracellular monosodium urate crystals. They
also noted surrounding erythema compatible with cellulitis but
without evidence of abscess. Toe XR was performed and was
without evidence of osteomyelitis. Gram stain showed no
microorganisms; wound culture was sent. He was started on IV
vancomycin and was admitted.
On arrival to the floor, the patient was comfortable and
reported
no toe pain or other complaints.
ROS: A 10-point review of systems was performed and was negative
with the exception of those systems noted in the HPI
Past Medical History:
CAD: ___ CABG (LIMA-LAD, SVG-RCA) c/b inferior MI
___: LCX stenting
___: DES to diag, Plavix x12 months
- Hypertension
- Dyslipidemia
- CKD
- GERD
- Anemia (mild)
- Osteoarthritis
- Lumbar spinal stenosis
- Carpal tunnel surgery
- Anxiety
- Depression
- Tension headaches
- Hard of hearing
- Obesity
- GOUT (has previously been on allopurinol but only briefly, was
told to discontinue this but does not remember why)
Social History:
___
Family History:
Family Hx: Negative for cerebral aneurysm or hemorrhage,
strokes,
migraine or other neurologic problems
Physical Exam:
EXAM
VITALS: 97.8 PO 161 / 84 74 18 95 RA
GENERAL: Alert and in no apparent distress
EYES: Anicteric, pupils equally round
ENT: Ears and nose without visible erythema, masses, or trauma.
Oropharynx without visible lesion, erythema or exudate
CV: Heart regular, no murmur, 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.
GU: No suprapubic fullness or tenderness to palpation
MSK: There is a small to moderate amount of pitting edema
bilaterally, L>R, to the bilateral knees. There is venous
stasis
dermatitis (mild) L>R. The L great toe is surrounded by poorly
demarcated erythema. There is no warmth or tenderness to
palpation. There is a small opening where the I&D was
performed,
there is no expressible fluid. There is crepitance in the
joint.
Sensation to light touch is mildly diminished.
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:
___ 07:48PM BLOOD WBC-9.8 RBC-3.51* Hgb-11.3* Hct-35.3*
MCV-101* MCH-32.2* MCHC-32.0 RDW-14.2 RDWSD-50.7* Plt ___
___ 07:48PM BLOOD Glucose-83 UreaN-27* Creat-1.3* Na-140
K-4.6 Cl-102 HCO3-24 AnGap-14
___ 06:34AM BLOOD ALT-14 AST-14 AlkPhos-85 TotBili-0.5
___ 06:17AM BLOOD CRP-47.9*
___ 07:20PM BLOOD Vanco-19.9
MRI foot:
IMPRESSION:
1. Findings highly suspicious for septic arthritis at the
interphalangeal
joint and osteomyelitis at the base of the distal phalanx and
head of the
proximal phalanx of the great toe. A sinus tract extends to the
skin.
2. No rim enhancing fluid collection seen.
3. Heterogenous enhancement of the soft tissues of the forefoot
may reflect
peripheral vascular disease.
Micro:
___ 6:24 pm SWAB Source: Left hallux wound.
**FINAL REPORT ___
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
WOUND CULTURE (Final ___:
STAPH AUREUS COAG +. SPARSE GROWTH.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN----------<=0.25 S
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- 4 R
OXACILLIN------------- 0.5 S
TETRACYCLINE---------- <=1 S
TRIMETHOPRIM/SULFA---- =>16 R
ANAEROBIC CULTURE (Final ___:
NIAS:
IMPRESSION:
Evidence of bilateral arterial insufficiency with right toe
brachial index of
0.39 and left toe brachial index of 0.46. Calculated left
ankle-brachial
index of 1.08 is likely artificially elevated.
Brief Hospital Course:
___ with CAD s/p CABG, MI s/p DES to Lcx, CKD, HTN, Hx of gout
not currently on allopurinol for unclear reasons, CHF (no TTEs
in our system) and other issues with recent ___ week history of
L toe erythema that has not improved despite treatment for both
gout and MSSA cellulitis now with persistent L toe erythema and
pain, now s/p I+D x3 with podiatry and bone biopsy.
Acute Osteomyelitis and Gout, L ___ Toe with Cellulitis:
PAD s/p PTA L peroneal:
Likely concurrent gout, cellulitis and osteomyelitis, MSSA,
confirmed on cx. He was stabilized on Cefazolin but after
discussion with podiatry, amputation was recommended for
definitive mgt. After several discussions about the
risks/benefits, the patient wished to proceed with the surgery.
His vascular sufficiency was addressed first. Given evidence of
disease on NIAS, angiogram performed and results as noted. He
was s/p PTA with good result and vascular surgery cleared for
surgery/
Regarding his perioperative risk, his outpatient cardiology
records were reviewed in detail, including his h/o CAD, MI,
CABG, and last stress test with reversible ischemia. The
patient does not exercise and is relatively immobile. He can
climb a flight of stairs but this does make him SOB. He has
intermittent stable CP for many years. Overall he appears to be
___ METS. He has no unstable medical or cardiac conditions.
however, he does have h/o CAD and past MI with evidence of MI on
EKG, h/o CHF as well. Thus he has 2 ___ risk factors. His
overall risk would be intermediate for this intermediate risk
procedure. However, given the urgency of the surgery, he
appeared medically optimized and can proceed to OR without
further cardiac eval. This was confirmed with his cardiologist
as well.
He underwent uncomplicated amputation on ___. His final cx
and bx and path were pending. He was initiated on Plavix 75mg
daily x30 days post PTA, day 1 = ___
Atrial fibrillation:
Noted to have paroxysmal atrial fibrillation on prior admission,
started on metoprolol for rate control. Anticoagulation
warranted based on Chads2VASc of 4; however, he is currently
only on Aspirin 325 mg PO QDay
- Discuss anticoagulation with providers as outpatient in
follow-up, as this is warranted unless contraindicated.
- Cont ASA and BB
CAD/CABG:
HTN:
HL:
Stable overall but at risk for perioperative MI. This was
discussed with patient on several occasions in detail and he
understands his risk for MI and accepts them.
- Continued Aspirin EC 325 mg PO perioperatively, and on DC
- Held Lisinopril for now given mild hyperkalemia pending follow
up
- Continued Metoprolol Succinate XL 25 mg PO DAILY and
perioperatively
- Continued Simvastatin 20 mg PO QPM and perioperatively
Chronic CHF Unknown EF (no TTEs in our system)
He was on furosemide BID. Appeared euvolemic on exam. his BID
Lasix was decreased to daily, and held for procedures to be
resumed on DC at 60mg daily
CKD III:
Stable
Parkinsonism:
No chart diagnosis in our system, no rigidity or tremor at
present.
- Continued Carbidopa-Levodopa (___) 1 TAB PO TID
Neuropathy: No diagnosis of diabetes; unclear etiology.
- Continued Gabapentin 300 mg PO TID
GERD:
- Continued Pantoprazole 40 mg PO Q24H
Anxiety/depression:
- Continued Sertraline 100 mg PO DAILY
Chronic cough:
- Continued home Benzonatate 100 mg PO TID
- Continued home Guaifenesin-Dextromethorphan ___ mL PO Q6H:PRN
cough
# Contacts/HCP/Surrogate and Communication: Daughter/HCP ___
___
# Code Status/Advance Care Planning: Re-reviewed and will be
full code for now
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Aspirin EC 325 mg PO DAILY
2. Carbidopa-Levodopa (___) 1 TAB PO TID
3. Ferrous Sulfate 325 mg PO DAILY
4. Furosemide 60 mg PO BID
5. Gabapentin 300-600 mg PO TID
6. Lisinopril 5 mg PO DAILY
7. Multivitamins W/minerals 1 TAB PO DAILY
8. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
9. Pantoprazole 40 mg PO Q24H
10. Sertraline 100 mg PO DAILY
11. Vitamin D ___ UNIT PO DAILY
12. Benzonatate 100 mg PO TID
13. Guaifenesin-Dextromethorphan ___ mL PO Q6H:PRN cough
14. Metoprolol Succinate XL 25 mg PO DAILY
15. coenzyme Q10-vitamin E 100-100 oral DAILY
16. Cyanocobalamin 1000 mcg PO DAILY
17. Fish Oil (Omega 3) 1000 mg PO DAILY
18. Polyethylene Glycol 17 g PO DAILY:PRN constipation
19. ubidecarenone-omega 3-vit E ___ mg-mg-unit oral DAILY
20. Simvastatin 20 mg PO QPM
Discharge Medications:
1. Acetaminophen 1000 mg PO TID:PRN Pain - Moderate
no more than 3 grams per day
RX *acetaminophen 500 mg ___ tablet(s) by mouth three times a
day Disp #*60 Tablet Refills:*0
2. Clopidogrel 75 mg PO DAILY
total 30 days, day 1 in hospital ___
RX *clopidogrel 75 mg 1 tablet(s) by mouth once a day Disp #*29
Tablet Refills:*0
3. Furosemide 60 mg PO DAILY
4. Aspirin EC 325 mg PO DAILY
5. Benzonatate 100 mg PO TID
6. Carbidopa-Levodopa (___) 1 TAB PO TID
7. coenzyme Q10-vitamin E 100-100 oral DAILY
8. Cyanocobalamin 1000 mcg PO DAILY
9. Ferrous Sulfate 325 mg PO DAILY
10. Fish Oil (Omega 3) 1000 mg PO DAILY
11. Gabapentin 300-600 mg PO TID
12. Guaifenesin-Dextromethorphan ___ mL PO Q6H:PRN cough
13. Metoprolol Succinate XL 25 mg PO DAILY
14. Multivitamins W/minerals 1 TAB PO DAILY
15. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
16. Pantoprazole 40 mg PO Q24H
17. Polyethylene Glycol 17 g PO DAILY:PRN constipation
18. Sertraline 100 mg PO DAILY
19. Simvastatin 20 mg PO QPM
20. ubidecarenone-omega 3-vit E ___ mg-mg-unit oral
DAILY
21. Vitamin D ___ UNIT PO DAILY
22. HELD- Lisinopril 5 mg PO DAILY This medication was held. Do
not restart Lisinopril until you follow up with your PCP
23.Rolling Walker
Dx: toe osteomyelitis
Px: Good
___ 13 months
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Acute osteomyelitis and cellulitis, MSSA, L ___ toe
PAD
CAD/CABG
Afib
HTN
Gout
Neuropathy
CKD
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You were admitted for evaluation of a toe/foot infection and
found to have gout as well as a bone infection. For this, you
were evaluated by our podiatry doctors who helped clean out your
wound and performed a bone biopsy. Infection was confirmed in
your toe, and after a vascular procedure and angioplasty,
amputation was performed to remove this infection.
You will be started on Plavix for 30 days after your vascular
procedure. Please take all medication as prescribed and
continue wound care. Some of your medications will be held
until follow up with your doctors. Please follow up with the
podiatry team for ongoing follow up.
Followup Instructions:
___
|
19695231-DS-5
| 19,695,231 | 27,986,780 |
DS
| 5 |
2162-01-07 00:00:00
|
2162-01-07 16:35:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Shoulder pain and hypotension
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is an ___ year old woman with dementia, DM, and HTN
who presented to PCP's office with atruamatic right shoulder
pain and decreased range of motion. She says the pain started
___, but does not know what she was doing when it started and
denies fall or trauma. She was sent into her PCP when her case
worker noticed that she was favoring her right arm.
While in her PCP's office she was found to be hypotensive to
80-90/50-60 (baseline 120-150/60-80). She denies fevers, chills,
nausea, vomiting, chest pain, shortness of breath, dizziness,
lightheadedness, change in urine or stool, redness or swelling
of the shoulder, or rashes.
In the ED, initial vitals were 98.5 82 127/57 18 100% RA. Her
labs were notable for normal CBC, elevated lactate of 3.5,
hyponatremia with Na of 128, hypokalemia to 3.1, low bicarb of
17, and elevated BUN/Cr ratio of ___. A CXR with
interstitial markings with possible pneumonia. She also had an
equivocal urinalysis with 39 WBCs and few bacteria. She was
started on levofloxacin and given 1L NS bolus.
On arrival to the floor, vitals were 98.5 hr 89 sa 02 99% ra bp
147/96. She continued to complain of right shoulder pain with
movement and decreased range of motion. No fevers, chills,
nausea, vomiting, chest pain, shortness of breath,
lightheadedness or dizziness.
Past Medical History:
- Breast cancer
- Hypertension
- Hyperlipidemia
- Dementia
- Anorexia
- DM Type 2
Social History:
___
Family History:
Unknown.
Physical Exam:
Admission:
Vitals: 98.3/98.3 93 129/82 20 96%RA; ___: 191
GEN: Patient appears confused, A&Ox2.
HEENT: MMM.
CV: RRR, no murmurs, rubs, gallops.
PULM: CTAB, no wheezing or crackles.
EXT: Right shoulder very limited active range of motion. Passive
range of motion to 90 degrees abduction before patient complains
of tenderness. Limited internal and external rotation secondary
to pain. No point tenderness to palpation. No step-offs. Left
wrist also swollen and warm. Full range of motion to flexion and
extension. Tenderness with radial rotation. No radial pulses
palpated.
DISCHARGE:
Vitals: 98.4 119/62 95 20 95 ra
Gen: No acute distress, pleasant, quiet, flat affect.
HEENT: NC/AT, EOMI, MMM. Oropharynx clear and without erythema
or exudate
CV: S1, S2, no murmurs, rubs, gallops.
Pulm: CTAB, no wheezing or crackles.
Abd: Soft, non-tender, bowel sounds positive
Extremities: No edema, radial/pedal pulses 2+, no pain in
shoulder full ROM
Neuro: AAO x 1 (person only), motor function grossly normal
Pertinent Results:
Admission:
___ 09:45PM BLOOD WBC-9.8# RBC-3.05* Hgb-9.4*# Hct-28.0*
MCV-92 MCH-30.9 MCHC-33.7 RDW-13.0 Plt ___
___ 09:45PM BLOOD Neuts-75.9* Lymphs-15.9* Monos-7.2
Eos-0.9 Baso-0.1
___ 07:35AM BLOOD ___ PTT-27.1 ___
___ 09:45PM BLOOD Glucose-267* UreaN-30* Creat-1.1 Na-128*
K-3.1* Cl-95* HCO3-18* AnGap-18
___ 07:50AM BLOOD TSH-2.7
___ 09:43PM BLOOD Lactate-3.5*
Discharge:
___ 08:05AM BLOOD WBC-6.1 RBC-3.58* Hgb-11.2* Hct-33.9*
MCV-95 MCH-31.2 MCHC-32.9 RDW-13.1 Plt ___
___ 09:00AM BLOOD Glucose-182* UreaN-17 Creat-0.9 Na-133
K-4.9 Cl-97 HCO3-27 AnGap-14
___ 09:00AM BLOOD Calcium-9.9 Phos-3.4 Mg-1.7
___ 08:05AM BLOOD VitB12-791 Folate-GREATER TH
___ 08:05AM BLOOD TSH-1.9
Studies:
___ GLENO-HUMERAL SHOULDER
Worsening degenerative changes, moderate in severity, including
findings suggestive of chronic rotator cuff pathology. No
evidence of
fracture or dislocation.
___ CHEST (PA & LAT)
1. Asymmetric interstitial abnormality involving the left lung.
Correlation with the prior CT of the abdomen suggests that much
of this appearance is potentially chronic, but acute on chronic
process such as pneumonia cannot be excluded. Correlation with
prior radiographs is recommended if available in Order to help
assess acuity.
2. Air-fluid levels along small and large bowel, non-specific
appearance.
3. Severe degenerative changes involving the right shoulder.
Micro:
___ URINE URINE CULTURE-FINAL: No growth
___ Blood Culture, Routine-PENDING
___ Blood Culture, Routine-PENDING
Brief Hospital Course:
___ with dementia, HTN, presents with atraumatic shoulder pain
and hypotension.
# Dementia: Patient's dementia appears to be significant and pt
has not been evaluated formally in the past. Based on our and
occupational therpay evaluation, pt appears to lack capacity for
medical decision making and requires an alternate decision
maker. However, pt not agitated and was quite pleasant. Her
___ hearing was arranged and her brother was made her
guardian. Per OT she required 24 hour supervision so was dc-ed
to rehab. We started the pt on donepzil and aspriin.
# Right shoulder pain: Resolved. Imaging revealed chronic
changes, possible rotator cuff injury, no fractures. Patient
likely has OA. We held off on MRI or ortho consult given
improvement. Pain well controlled with tylenol.
# Hypotension: Resolved. Likely secondary to hypovolemia from
decrease PO intake. Pt remained normotensive throughout hospital
course and anti-HTN meds were not restarted, except for
lisinopril 5mg daily.
# Hyponatremia: Normalized as of ___. Likely hypovolemic
given low PO intake and improvement with fluids. FeNa was 1.2
but she was on HCTZ, which is now being held.
# Abnormal UA: Urinalysis suggestive of infection; however, Pt
was afebrile without leukocytosis and denied any dysuria but she
is not a reliable historian. Nurses report that she has been
having mixed stool with urine, so may have been contaminated.
However, she was treated with 3 day course of levaquin
# DM: On metformin at home, we continued it in house.
# SOCIAL WORK consulted to evaluate for need for home ___/
guardian
TRANSITIONAL ISSUES:
- pt remained normotensive throughout hospital stay so anti HTN
meds were held. The pt was discharged on 5mg of lisinopril. ___
increase doee and/or restart other meds if pt's BP increases.
- f/up with cognitive neurology arranged for assessment and
neuro testing
Medications on Admission:
Preadmissions medications listed are incomplete and require
futher investigation. Information was obtained from webOMR.
1. Atenolol 100 mg PO DAILY
2. Amlodipine 5 mg PO DAILY
3. Atorvastatin 20 mg PO DAILY
4. Hydrochlorothiazide 25 mg PO DAILY
5. Lisinopril 40 mg PO DAILY
6. MetFORMIN (Glucophage) 500 mg PO BID
7. Ranitidine 150 mg PO BID
8. Risperidone 0.25 mg PO BID
9. Acetaminophen 650 mg PO Q6H:PRN pain
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Atorvastatin 20 mg PO DAILY
3. MetFORMIN (Glucophage) 500 mg PO BID
4. Ranitidine 150 mg PO BID
5. Risperidone 0.25 mg PO BID
6. Aspirin 81 mg PO DAILY
7. Donepezil 5 mg PO HS
8. Lisinopril 5 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Severe Dementia
Osteoarthritis
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were admitted to the hospital because of shoulder pain and
swelling. You were seen by your PCP who also noticed that your
blood pressure was low so he sent you to the emergency room. We
gave you fluids and stopped your blood pressure medications and
your blood pressure improved. You had x-rays of your shoulder
which did not show a fracture. Your shoulder pain improved
overnight, the swelling decreased, and your pain was well
controlled with tylenol.
However, while these issues resolved, it was noted that your
dementia was quite severe and you were not fit for discharge to
home so were arranged to go to rehab.
It was a pleasure taking care of you at the ___ and we wish
you the best.
Followup Instructions:
___
|
19695446-DS-6
| 19,695,446 | 25,484,064 |
DS
| 6 |
2115-06-20 00:00:00
|
2115-06-21 08:19:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
aphasia
Major Surgical or Invasive Procedure:
cvEEG
History of Present Illness:
___ yo female with hypertension, hyperlipidemia, type 2 DM,
possible atrial fibrillation, prior left posterior stroke
(___) and subsequent episodes of aphasia and seizure
on Keppra monotherapy, presenting with several hours of
intermittent aphasia and witnessed GTC at OSH.
Daughter present at bedside and provides history. Patient unable
to provide history.
Per daughter, she talked on the phone to the patient around 7:30
am, at which point she seemed at baseline. Then around 1:30 pm,
she received a voicemail, in which patient was crying and
speaking in half-sentences. Patient has a lot of stress with
needing to move out of her current apartment, so daughter
attributed the half-sentences to her crying and being upset.
Then at 4:00 pm, daughter received a phone call from ___
notifying that her mother had driven herself to the hospital.
Unclear what prompted her to go to the hospital.
Since the daughter has been with her at the OSH and here, she
noted that patient is speaking in "nonsense", although the flow
of the language is normal. At times, she is able to say short
coherent phrases ("my knees are hurting"), but mostly she says
nonsensical words.
At the OSH, patient then reportedly had an episode consistent
with a generalized tonic clonic seizure, which daughter did not
witness. Given 2 mg Ativan IV and transferred here for further
management and EEG monitoring.
With regards to her prior history, daughter reports that patient
presented with a similar episode of aphasia in ___,
which is when she was found to have a left posterior stroke.
Symptoms lasted ___ hours and gradually resolved. At that
time, also had issues with reading and possible right field cut,
which also resolved. No motor symptoms per daughter.
She recovered well from this incident, but in ___,
presented again with aphasia. Work-up was negative and symptoms
resolved, so this was attributed to recrudescence of prior
stroke symptoms.
Presented a third time with aphasia in ___ and then
progressed to have a generalized tonic clonic seizure. She was
started on Keppra, and she has been doing well since.
Past Medical History:
Left posterior stroke, ___
Subsequent epilepsy, ___
? atrial fibrillation - metoprolol is written "for heart rate",
but daughter not sure
___
Hyperlipidemia
Type 2 DM
Reflux and chronic GI issues, remote abdominal surgeries
Knee pain
Social History:
___
Family History:
Father - epilepsy
Physical ___:
ADMISSION
Vitals: T: 97.7 HR: 72 BP: 133/78 RR: 17 SaO2: 99% RA
General: NAD
HEENT: NCAT, no oropharyngeal lesions, neck supple
___: warm and well-perfused
Pulmonary: breathing comfortably in room air
Extremities: Warm, no edema
Neurologic Examination:
- Mental status: Awake, alert. Normal prosody with some intact
short phrases - "I'm cold!", "I'm really hoping that..." but
with
frequent incorrect word usage, word salad. Unable to repeat or
name objects. Understands simple motor commands (open/close your
eyes, grip and release). No dysarthria.
- Cranial Nerves: PERRL 3->2 brisk. Unable to do VF to
confrontation, but appears to respond to visual stimuli in all
fields. EOMI, no nystagmus. No facial movement asymmetry. Palate
elevation symmetric. Tongue midline.
- Motor: Normal bulk and tone. No drift. No tremor or
asterixis.
Difficulty cooperating with confrontational testing in certain
muscle groups, but has ___ strength in bilateral biceps,
triceps,
IP, and gastroc.
- Reflexes: 1+ biceps and patellar. Plantar response flexor
bilaterally
- Sensory: Responds to light touch in all extremities.
- Coordination: Did not understand FNF testing, but no obvious
dysmetria on reaching towards my finger.
DISCHARGE
Vitals: 24 HR Data (last updated ___ @ 802)
Temp: 98.1 (Tm 98.5), BP: 142/80 (125-186/73-99), HR: 66
(55-70), RR: 16 (___), O2 sat: 95% (93-96), O2 delivery: 2L
General: NAD
HEENT: NCAT, no oropharyngeal lesions, neck supple
___: warm and well-perfused
Pulmonary: breathing comfortably in room air
Extremities: Warm, no edema
Neurologic Examination:
- Mental status: Awake, alert. Can say her full name, ___. Naming of both high and low frequency
words intact. Reading and repetition intact. Mild perseveration.
Can do complex commands. No dysarthria.
- Cranial Nerves: PERRL 3->2 brisk. VFF. EOMI, fatiguable end
gaze nystagmus. No facial movement asymmetry. Palate elevation
symmetric. Tongue protrudes midline with good excursions.
- Motor: Normal bulk and tone. No drift. No tremor or
asterixis.
Difficulty cooperating with confrontational testing in certain
muscle groups, but has ___ strength in bilateral delt, biceps,
triceps, IP, quad, TA and gastroc.
- Reflexes: 1+ biceps and patellar. Plantar response flexor
bilaterally
- Sensory: Responds to light touch in all extremities.
- Coordination: FNF intact bilaterally
Pertinent Results:
LABS ON ADMISSION
___ 09:28PM BLOOD WBC-10.3* RBC-4.38 Hgb-13.0 Hct-38.6
MCV-88 MCH-29.7 MCHC-33.7 RDW-14.1 RDWSD-45.1 Plt ___
___ 09:28PM BLOOD ___ PTT-31.1 ___
___ 09:28PM BLOOD Glucose-136* UreaN-9 Creat-0.7 Na-136
K-5.5* Cl-96 HCO3-25 AnGap-15
___ 09:28PM BLOOD ALT-20 AST-33 CK(CPK)-130 AlkPhos-61
TotBili-0.6
___ 09:28PM BLOOD cTropnT-<0.01
___ 09:28PM BLOOD CK-MB-2
___ 09:28PM BLOOD Albumin-4.4 Calcium-8.9 Phos-4.1 Mg-1.2*
___ 09:28PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Tricycl-NEG
___ 09:32PM BLOOD Lactate-2.8*
___ 07:46AM BLOOD Lactate-1.4
LABS ON DISCHARGE
___ 04:15PM BLOOD WBC-8.2 RBC-3.95 Hgb-11.6 Hct-35.0 MCV-89
MCH-29.4 MCHC-33.1 RDW-14.5 RDWSD-46.6* Plt ___
___ 04:15PM BLOOD Glucose-125* UreaN-12 Creat-0.7 Na-140
K-3.4* Cl-103 HCO3-24 AnGap-13
___ 07:44AM BLOOD ALT-15 AST-18 AlkPhos-56 TotBili-0.8
___ 04:15PM BLOOD Calcium-8.2* Phos-3.4 Mg-1.2*
___ 07:46AM BLOOD Lactate-1.4
MRI BRAIN ___
IMPRESSION:
1. Motion limited examination. Postcontrast images are
uninterpretable.
2. No evidence of intracranial hemorrhage or acute or subacute
infarction.
3. Severe encephalomalacia of the posterior, inferior, medial
left temporal lobe. Adjacent FLAIR signal hyperintensity may
reflect gliosis or trace postictal edema.
4. Left cerebellar hemisphere developmental venous anomaly.
Brief Hospital Course:
___ yo female with HTN, HLD, NIDDM Type 2, left posterior stroke
(___) and subsequent episodes of aphasia and seizure
on Keppra monotherapy presented with with several hours of
intermittent aphasia and witnessed GTC at OSH.
#Seizure
Patient has had similar episodes in the past which have been
well controlled on Keppra monotherapy. On exam, patient has no
focal motor findings, but has an receptive aphasia, with poor
comprehension, impaired repetition, and non-sensical speech. MRI
showed her prior left meso-temporal encephalomalacia with FLAIR
hyperintensity, which most likely represents post-ictal changes.
CTA does show some right MCA stenosis; however trial of HOB flat
and IVF bolus and no acute stroke on MRI made hypoperfusion less
likely as etiology for symptoms. She received a 2gm IV loading
dose of keppra and started on EEG which showed left temporal
slowing but no seizures or rhythmic discharges. She remained
aphasic for ~48 hours though improved slowly during that period,
and her language was at baseline by the morning of ___.
According to her daughter, it was likely that she had missed
doses of her medications due to recent stressors involving
illness of her husband and the impending foreclosure of their
home. We increased her Keppra to 1000mg BID, and referred she
and her daughter to utilize pharmacy-filled pill boxes and other
medication adherence techniques.
She was evaluated by ___ and cleared to return home with
services. She will receive services including home ___, OT,
speech therapy, ___, and social worker.
#HTN
#HLD
#H/o prior CVA
Continued home meds: Irbesartan 150 mg QAM, Metoprolol 100 mg
QAM, atorvastatin 80mg daily, Plavix 75mg daily. Increased
Amlodipine to 10 mg QAM with good effect on BP
#Type II DM
Fingersticks and ISS while inpatient. Resume metformin on
discharge
#Depression
Continued home Citalopram 20 mg QAM
#Social
Husband is also chronically ill and is currently in the
hospital. The patient has a fear of not being able to take care
of him anymore, especially since she herself is unwell. SW
getting in touch with elderly services for home support
Transitional Issues:
-F/u with Neurology
-Continue to titrate BP meds
-pill box/alarm
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Metoprolol Succinate XL 100 mg PO DAILY
2. Omeprazole 40 mg PO DAILY
3. amLODIPine 5 mg PO DAILY
4. Citalopram 20 mg PO DAILY
5. irbesartan 150 mg oral DAILY
6. MetFORMIN (Glucophage) 500 mg PO BID
7. LevETIRAcetam 750 mg PO BID
8. Atorvastatin 20 mg PO QPM
9. Clopidogrel 75 mg PO DAILY
Discharge Medications:
1. amLODIPine 10 mg PO DAILY
RX *amlodipine 10 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*2
RX *amlodipine 10 mg 1 tablet(s) by mouth once a day Disp #*14
Tablet Refills:*0
2. LevETIRAcetam 1000 mg PO BID
RX *levetiracetam 1,000 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*2
RX *levetiracetam 1,000 mg 1 tablet(s) by mouth twice a day Disp
#*28 Tablet Refills:*0
3. Atorvastatin 20 mg PO QPM
4. Citalopram 20 mg PO DAILY
5. Clopidogrel 75 mg PO DAILY
6. irbesartan 150 mg oral DAILY
7. MetFORMIN (Glucophage) 500 mg PO BID
8. Metoprolol Succinate XL 100 mg PO DAILY
9. Omeprazole 40 mg PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Seizure
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were admitted to the hospital because you were having
difficulty speaking which was concerning for seizure. Your EEG
did not show a seizure, but you do have an area of your brain
that could act up and cause a seizure. Since you have had a few
of these episodes, we will increase your keppra to 1000mg twice
a day. It is important for you to get a pill box to put your
pills in. This will help you remember to take them. You can also
set a timer or reminder on your phone. We will follow-up with
you in 1 month.
It was a pleasure taking care of you.
Sincerely,
___ Neurology
Followup Instructions:
___
|
19695463-DS-8
| 19,695,463 | 22,291,557 |
DS
| 8 |
2132-06-18 00:00:00
|
2132-06-18 17:39:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / hydrocodone
Attending: ___.
Chief Complaint:
Hemoptysis
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with PMHx significant for HTN and back pain presents with
hemoptysis.
Patient states she has been coughing up blood for about 4 days.
The hemoptysis is small, dime-sized and has occurred only about
once daily. She denies fever, chills but does endorse some
shortness of breath. She presented to her PCP yesterday who
obtained a DDimer that was elevated. A CXR was obtained hazy
opacities, possible groundglass but no definite consolidation.
She was then referred for a CTA chest that showed "Abnormal,
diffuse bilateral heterogeneous opacities throughout the lungs
and can be seen with pulmonary hemorrhage, Wegener's and
multifocal PNA". She was then transferred to ___ for pulmonary
evaluation.
Of note, she is currently being worked up for hematuria and had
plans to see a urologist in a few days. She reportedly presented
to her PCP with dysuria, urgency, and was found to have blood in
her urine. She was treated with bactrim with mostly resolution
of symptoms, but her doctor told her it was not a UTI.
In the ED, initial vitals were: 99 75 145/80 18 96% RA. Labs
significant for Hgb of 9.6, INR 1.2, normal chemistry. Blood
cultures x 2 were obtained. She was given 750 mg of IV
levofloxacin and admitted to the floor.
On the floor, she states before the hemoptysis set in, she
overall has been doing fine. She was admitted to ___ for spine
surgery for arthritis recently which was uncomplicated. She
denied fevers, chills joint pain, eye complaints, night sweats.
No shortness of breath, PND, orthopnea, leg swelling.
Past Medical History:
-cervical spondylitis
-hypertension off therapy
-Right lumbar radiculopathy s/p surgery in ___
-Tubular adenoma of colon
Social History:
___
Family History:
No family history of lung disease.
Physical Exam:
================
ADMISSION EXAM
================
Vitals: 98 145/82 74 18 99% RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric (?mildly injected), MMM, oropharynx
clear, EOMI, PERRL
Neck: Supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: faint crackles at bases bilaterally, otherwise clear
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
GU: No foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, ___ strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred.
================
DISCHARGE EXAM
================
Vitals: 98.2 60 140s/60s 18 99% on RA
General: Pleasant well-appearing older woman, in no distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: Supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, ___ systolic
murmur, rubs, gallops
Lungs: improved crackles at bases, ctab
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
GU: No foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, ___ strength upper/lower extremities,
grossly normal sensation, gait deferred.
Pertinent Results:
==============
ADMISSION LABS
==============
___ 12:40AM BLOOD WBC-11.0 RBC-3.67* Hgb-9.6* Hct-29.3*
MCV-80* MCH-26.0* MCHC-32.6 RDW-15.3 Plt ___
___ 12:40AM BLOOD Neuts-79.6* Lymphs-14.7* Monos-3.3
Eos-1.9 Baso-0.5
___ 12:40AM BLOOD ___ PTT-27.0 ___
___ 12:40AM BLOOD Glucose-81 UreaN-10 Creat-0.6 Na-134
K-4.1 Cl-98 HCO3-31 AnGap-9
___ 12:40AM BLOOD LD(LDH)-206 TotBili-0.4
___ 12:40AM BLOOD cTropnT-<0.01
___ 05:15AM BLOOD Calcium-9.9 Phos-2.9 Mg-1.8
PERTINENT LABS:
___ 05:27AM BLOOD ANCA-NEGATIVE B
___ 05:27AM BLOOD ___ dsDNA-NEGATIVE
___ 05:15AM BLOOD C3-127 C4-19
___ 05:15AM BLOOD ANTI-GBM-Test - NEGATIVE
==============
IMAGING
==============
CT CHEST ___: IMPRESSION: Stable left lower lobe pneumonia or
aspiration. The other improving ground-glass opacities are
either due to resolving pulmonary edema or hemorrhage. Stable
small hiatal hernia.
Anemia.
Stable isolated dilatation of the left pulmonary artery raises
concern for pulmonic stenosis. Consider echocardiographic
correlation.
==============
DISCHARGE LABS
==============
___ 05:15AM BLOOD WBC-5.1 RBC-4.26 Hgb-10.9* Hct-33.8*
MCV-79* MCH-25.6* MCHC-32.2 RDW-15.1 Plt ___
___ 05:15AM BLOOD Glucose-103* UreaN-9 Creat-0.6 Na-137
K-3.6 Cl-102 HCO3-27 AnGap-12
___ 05:15AM BLOOD Calcium-9.8 Phos-4.2 Mg-1.9
___ 05:15AM BLOOD CRP-245.4*
Brief Hospital Course:
___ y/o F with PMHx of HTN presents with hemoptysis, with CT
showing diffuse bilateral ground glass opacities. Clinically,
she appeared very well and had no further episodes of
hemoptysis. Given her CT findings, concern was for possible
vasculitis vs. atypical infection. She was evaluated by the
pulmonary team and broncoscopy was attempted, but could not
obtain an adequate level of sedation for the procedure. A repeat
CT scan was done that showed interval improvement, and
laboratory testing returned negative for ANCA, anti-GBM, and
___. As a result, the most likely diagnosis was an atypical
infection, and given her well appearance, she was discharged
with close outpatient follow-up and return instructions.
=================
ADMISSION ISSUES
=================
#Hemoptysis: Most likely due to atypical pneumonia. Initially,
given her well clinical appearance and the bilateral diffuse
GGOs in setting of recent hematuria, there was concern for
possible vasculitis. Her CRP was highly elevated (to 250). She
was followed by pulmonary and plan was for bronchoscopy, however
this was unable to be performed due to inability to obtain
sufficient sedation. During this time, ___, ANCA, dsDNA,
antiGBM, and complement levels all returned within normal
limits, and repeat UA did not show hematuria. A repeat CT scan
was obtained which showed interval improvement and some areas of
consolidation that seemed more consistent with pneumonia. As a
result, given the higher suspicion for pneumonia rather than a
vasculitis, and her well clinical appearance, she was discharged
with a 7 day course of levofloxacin, with plan for repeat CT in
2 weeks (already scheduled) and f/u with pulmonary in 3 weeks.
#Anemia: Most likely not related to the very minimal hemoptysis.
Iron studies are consistent with mixed iron deficiency and
anemia of chronic inflammation, and retic count is
inappropriately low. No evidence of hemolysis.
#New left bundle branch block: Patient had first degree block
seen on previous EKG in ___. This is likely natural history of
worsening conduction disease. She was chest pain free, and was
ruled out for MI. She was monitored on telemetry with no events.
=================
CHRONIC ISSUES
=================
#Chronic back pain: s/p recent surgery in ___. Continued
pregabalin and oxycodone
=================
TRANSITIONAL ISSUES
=================
-f/u Chest CT on ___ at 11:15am at ___
___, ___ floor above ___. No food 3 hrs before test.
-pulmonary f/u in 3 weeks, which is in the process of being
scheduled
-pt discharged with 7 day course of levofloxacin, (Day 1:
___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. OxycoDONE (Immediate Release) 10 mg PO Q6H:PRN pain
2. Citalopram 20 mg PO DAILY
3. Pregabalin 150 mg PO DAILY
4. Lorazepam 0.5 mg PO BID:PRN anxiety
Discharge Medications:
1. Citalopram 20 mg PO DAILY
2. OxycoDONE (Immediate Release) 10 mg PO Q6H:PRN pain
3. Pregabalin 150 mg PO DAILY
4. Lorazepam 0.5 mg PO BID:PRN anxiety
5. Levofloxacin 750 mg PO DAILY Duration: 7 Days
RX *levofloxacin 750 mg 1 tablet(s) by mouth daily Disp #*6
Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
-hemoptysis
-community-acquired pneumonia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. ___,
You were hospitalized at ___
due to coughing up blood. A CT scan of the chest showed some
abnormal "ground glass" areas. We attempted to perform a
bronchoscopy to find out the cause of the lung changes. However,
we weren't able to make you sleepy enough with the medications,
so the procedure couldn't be done at that time. A repeat CT scan
looked much better. This means that the most likely cause of the
lung changes and coughing up blood was an infection. We will
treat you with a week of antibiotics.
Please come back to the hospital if you start coughing up blood
again, have a fever ___ F, or your breathing gets worse.
Please follow-up with the pulmonary doctors.
We wish you all the best!
-Your ___ Team
Followup Instructions:
___
|
19695954-DS-19
| 19,695,954 | 26,443,941 |
DS
| 19 |
2201-06-15 00:00:00
|
2201-07-19 18:52:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Bactrim / Tetracycline Analogues / Vasotec / Isordil Titradose /
Procardia / Hytrin / Catapres-TTS-1 / Coreg / Neurontin /
Morphine Sulfate
Attending: ___.
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
The patient is a ___ with known severe CAD s/p CABGX4 ___, on
Plavix and baby ASA, CKD, TIA, difficult to control HTN,
hypothyroidism who presents with unstable angina.
.
The patient reports having an episode of mid-sternal/left sided
chest pain occuring while in bed at 10pm. The pain was
non-radiating / localized, described as a pressure sensation.
Patient attributed this first to indigestion. Pain was constant
and increasing in severity so patient took one sublingual
nitroglycerin at 11:20 with relief of pain about 20 minutes
later. She denies associated dizziness, diaphoresis, shortness
of breath, palpitations. Pain recurred when patient went to bed
and was relieved again by nitroglycerin, so patient's husband
called EMS and she was brought to ED. She recieved ASA 325mg
from EMS.
.
In the ED, initial vitals were 02:09 0 98.6 80 ___ 2L
Nasal Cannula. EKG showed SR 75, PR =0.20, compared to previous
tracing from ___ there is a new right axis (limb lead
reversal?), and new ventricular conduction defect with q waves
in V1-V2 and stunted R wave progression across precordium and
morphology in V1 and V6 consistent with LBBB, ST depressions and
TWI in II, III, AVF likely ___ to conduction defect. EKG
changes were concerning for septal infarction of unkown age and
possible limb lead reversal. Troponins were negative x 1 at 2:00
AM (four hours after onset of chest pain). Labs were also
significant for normocytic anemia Hct 33 which is at baseline
and creatinine 1.4 also at baseline. CXR revealed enlarged heart
shadow, vascular congestion and bilateral interstitial pattern
suggseting pulmonary edema, but no focal infitrates, or
effusion.
.
Patient had an episode of shortness of breath while moving in
bed and noted to have desaturation to 86% on ra, up to high 90's
on 2L's. This was transient per patient. In the ED, she was
given @03:27 Nitroglycerin SL 0.4mg SL Tablet, @05:07
HydrALAzine 25 mg Tab 2, @05:07 Labetalol 300mg PO, @05:07
Amlodipine 10mg PO. Vitals on transfer were 98.0, 75, 23,
187/60, 95%2l.
.
On arrival to the floor, patient reports feeling better. She is
chest pain free and denies chest pain, shortness of breath.
.
REVIEW OF SYSTEMS
+ TIA
+ exertional LLE calf pain (walks with walker at baseline,
requires wheelchair for long distances)
On review of systems, she denies hemoptysis, black stools or red
stools, dysuria, hematuria. She denies recent fevers, chills or
rigors. All of the other review of systems were negative.
.
Cardiac review of systems is notable for absence of paroxysmal
nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope
or presyncope.
Past Medical History:
1. CARDIAC RISK FACTORS: -Diabetes,+ Dyslipidemia,+ Hypertension
2. CARDIAC HISTORY:
-Severe hypertension with Left Renal Artery Stenosis (malignant
HTN since ___. [pt reports headaches and tearing with severe
HTN and increased BP when lays down flat in bed, takes
sublingual nitro prn SBP>200]
- Dyslipidemia
-CABG: Coronary artery bypass graft times four and mitral valve
repair on ___
-PERCUTANEOUS CORONARY INTERVENTIONS:LM and three vessel CAD
with DES to ___ RCA in ___
-PACING/ICD:
3. OTHER PAST MEDICAL HISTORY:
-TIA ___ and ___: Thought to be due to embolus from left ICA
s/p left CEA in ___
-Hypothyroidism
-Chronic Kidney Disease (Baseline Cr 1.2-1.3)
-PVD/LLE claudication s/p bypass ___ that subsequently
stenosed; s/p 2 stents to RLE ___
-Obesity
-Gout
-Hiatal hernia
-Uterine fibroids
-Spine scoliosis and DJD
-Benign cartilage tumor, most probably an enchondroma
-Severe spinal stenosis since ___
- diverticulitis
-psoriasis since ___
-crushed left shoulder to smitherines ___
.
Surgrical hx
-Bilateral cataract surgery
-R knee benign tumor resection
-R common iliac and external iliac artery stenting as above
-Left femoral-popliteal bypass
Social History:
___
Family History:
Mother had TIAs and a stroke at age ___. Father died of heart
problem at age ___. No family history of early MI, arrhythmia,
cardiomyopathies, or sudden cardiac death.
Physical Exam:
ADMISSION
VS: 98.1 193/72 70 20 97ra 70.9kg (154lbs on ___
GENERAL: WDWN elderly woman in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL. Conjunctiva were pink, no
pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with JVP noted at angle of mandible. + carotid
bruits bilaterally left>right, but ?radiation of systolic murmur
CARDIAC: RRR, normal S1, S2. ___ systolic murmur loudest at
RUSB, ___ systolic murmur at apex. No thrills, lifts. No S3 or
S4.
LUNGS:Resp were unlabored, no accessory muscle use. + crackles
from bases to one third up bilateral lungs fields, no wheezes or
rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits appreciated.
EXTREMITIES: No c/c. ___ ___ edema ___ up to lower calfs
SKIN: No significant stasis dermatitis changes, ulcers, scars,
or xanthomas. + telangectasias on face and chest
PULSES:
Right: Carotid 2+ DP 1+
Left: Carotid 2+ DP 1+
.
DISCHARGE
VS: 170/50 61 20 96RA 70.5kg
exam otherwise unchanged.
Pertinent Results:
ADMISSION
___ 02:40AM BLOOD WBC-5.6# RBC-3.52* Hgb-10.7* Hct-33.0*
MCV-94 MCH-30.3 MCHC-32.3 RDW-12.8 Plt ___
___ 02:40AM BLOOD Neuts-85.1* Lymphs-6.3* Monos-6.3 Eos-1.7
Baso-0.4
___ 02:40AM BLOOD Glucose-116* UreaN-50* Creat-1.4* Na-135
K-4.4 Cl-99 HCO3-26 AnGap-14
___ 07:45PM BLOOD Calcium-9.4 Phos-3.7 Mg-2.1
.
PERTINENT
___ 02:40AM BLOOD cTropnT-<0.01
___ 07:45AM BLOOD CK-MB-4 cTropnT-0.01
___ 07:45AM BLOOD TSH-0.092*
.
DISCHARGE
___ 06:30AM BLOOD Glucose-71 UreaN-48* Creat-1.3* Na-134
K-4.1 Cl-101 HCO3-26 AnGap-11
___ 06:30AM BLOOD Calcium-8.9 Phos-3.4 Mg-2.0
.
EKG ___ 7:35:06 AM
Sinus rhythm with one ventricular premature beat. Left
bundle-branch block.
Non-specific inferior and lateral ST-T wave changes which may be
due to
intraventricular conduction delay. Q-T interval prolongation.
Compared to the
previous tracing of ___ the ventricular premature beat is
present.
Inferior ST segment depression is less pronounced and the Q-T
interval is
longer. Clinical correlation is suggested.
___
___
.
EKG ___ 2:18:06 AM
Sinus rhythm. Left bundle-branch block. T wave inversions in the
inferior
leads and in the inferior and lateral leads. Compared to the
previous tracing
QRS complex has widened and T wave abnormalities are new
suggesting possible
ischemia. Clinical correlation is suggested.
___
___
.
CXR ___ 4:50 AM
CHEST, AP: Moderate cardiomegaly, central vascular congestion,
and
interstitial pulmonary edema have increased. However, the
moderate left
pleural effusion has nearly resolved. There is minimal left
lower lobe
atelectasis, and no focal consolidation. Changes of CABG with
median
sternotomy wires, mediastinal clips, and mitral valve
replacement. Aorta is
tortuous and calcified. Again noted is a dystrophic humeral head
with
associated joint arthropathy.
IMPRESSION:
1. Congestive heart failure.
2. Minimal left pleural effusion.
Brief Hospital Course:
Ms ___ is a ___ with known severe CAD s/p CABGX4 ___, on
Plavix and baby ASA, CKD, TIA, difficult to control HTN,
hypothyroidism who presented with chest pain, concerning for
unstable angina.
.
ACTIVE MEDICAL PROBLEMS:
# SEVERE HYPERTENSION
Patient presented with chest pain in the setting of SBP of 210,
with reported baseline SBP in 180s. Patient has long history of
difficult to control HTN and is on aggressive BP regimen. BP
elevated despite amlodipine, hydralyzine, labetelol in ED. The
patient's blood pressure was controlled with goal of SBP<180.
She initially required a nitroglycerin drip, however was
eventually transitioned to her home oral regimen. She was
instructed to follow up with her cardiologist upon discharge for
further management.
# CORONARIES: Angina
Angina in this patient with severe CAD (4V CABG ___ and new
LBBB on EKG compared to ___ was initially concerning for acute
coronary syndrome. Cardiac enzymes were cycled and negative. A
heparin gtt was deferred in the setting of significant
hypertension (BP 180-200s). Her BP was controlled w/ goal
pressures < 180. With blood pressure at goal, the patient
remained chest pain free. Review of recent prior EKGs revealed
stable findings. She was ultimately discharged on her home
regimen of Aspirin 81mg daily, Clopidogrel 75mg daily,
benazepril, labetolol, Atorvastatin, and Nitroglycerin
sublingual prn chest pain.
.
# PUMP: Likely Diastolic dysfunction
Echo from ___ showed LVEF 50-60%. A chest xray demonstrated
mildly fluid overloaded which was consistent with crackles on
exam. She was diuresed with IV lasix (80mg) with improvement on
exam. Discharged on home regimen of furosemide 80mg po daily.
.
# HYPOTHYROIDISM
Last TSH in ___ was 0.050. Patient's dose was decreased to
200mcg daily six days a week instead of 7x/week. Repeat TSH was
0.092. She was continued on same dose with instruction to follow
up with her PCP for further management.
.
.
INACTIVE MEDICAL PROBLEMS:
# HYPERLIPIDEMIA
LDL in ___ was 44. She was continued on home statin:
Atorvastatin 40mg daily.
.
# CHRONIC KIDNEY DISEASE
Stage 3 with baseline creatinine of 1.3-1.6. Creatinine
remained at baseline with calculated GFR = 34.
.
# PVD
Patient with LLE claudication s/p bypass ___ that
subsequently stenosed, s/p 2 stents to RLE ___ and s/p Left
CEA in ___ w/ h/o TIA. She was continued on home statin,
Aspirin, and Clopidogrel.
.
# HEADACHES
Continue perphenazine-amitriptyline ___ po BID per home
regimen.
.
# ANEMIA
Likely due to anemia of chronic disease. At baseline. No signs
of active bleeding or resulting HD instability. Continued
Ferrous Sulfate, folic acid, and multivitamin.
Medications on Admission:
-AMLODIPINE [NORVASC] - (Prescribed by Other Provider) - 10 mg
Tablet - 1 Tablet(s) by mouth daily
-ATORVASTATIN [LIPITOR] - 40 mg Tablet - 1 Tablet(s) by mouth
every evening
-BENAZEPRIL [LOTENSIN] - 20 mg Tablet - one Tablet(s) by mouth
twice a day
-BETAMETHASONE DIPROPIONATE - 0.05 % Cream - apply to affected
-area(s) daily as directed **Do not apply on face** [HIGH
POTENCY]
-CLOPIDOGREL [PLAVIX] - 75 mg Tablet - one Tablet(s) by mouth
once
a day
-FUROSEMIDE - - 80 mg Tablet - 1 (One) Tablet(s) by mouth once
a day (QPM)
-HYDRALAZINE - 50 mg Tablet - 2 Tablet(s) by mouth three times a
day
-LABETALOL - 300 mg Tablet - 1 tab po 6 x per day
-LEVOTHYROXINE - 200 mcg Tablet - one Tablet(s) by mouth once a
day - except ___
-NITROGLYCERIN [NITROSTAT] - 0.4 mg Tablet, Sublingual - 1
Tablet(s) sublingually as needed (taken for SBP >200, has used
5x from ___ has not used for CP since ___.
-PERPHENAZINE-AMITRIPTYLINE - 2 mg-10 mg Tablet - 1 Tablet(s) by
mouth twice a day
-POLYETHYLENE GLYCOL 3350 - (Prescribed by Other Provider) - 17
gram/dose Powder - by mouth once a day
Medications - OTC
-ASPIRIN - (OTC) - 81 mg Tablet, Delayed Release (E.C.) - 1
(One)
Tablet(s) by mouth once a day
-DOCUSATE SODIUM - (Prescribed by Other Provider) - 100 mg
Capsule - 1 Capsule(s) by mouth three times a day
-FERROUS SULFATE [IRON] - (Prescribed by Other Provider) - 325
mg
(65 mg iron) Tablet - 1 Tablet(s) by mouth twice a day
-FOLIC ACID - (Prescribed by Other Provider) - 0.8 mg Tablet -
1
Tablet(s) by mouth daily
-MULTIVITAMIN - (Prescribed by Other Provider) - Tablet - 1
Tablet(s) by mouth in AM
-ZINC - (Prescribed by Other Provider; Dosage 220mg) - Dosage
uncertain
- vitamin D 1000iu daily
Discharge Medications:
1. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
Sig: One (1) Tablet, Chewable PO QID (4 times a day) as needed
for heartburn.
Disp:*100 Tablet, Chewable(s)* Refills:*2*
2. amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day.
3. atorvastatin 40 mg Tablet Sig: One (1) Tablet PO at bedtime.
4. benazepril 20 mg Tablet Sig: One (1) Tablet PO twice a day.
5. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. furosemide 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. hydralazine 50 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8
hours).
8. labetalol 300 mg Tablet Sig: One (1) Tablet PO every four (4)
hours.
9. levothyroxine 200 mcg Tablet Sig: One (1) Tablet PO 6x/week
(daily except ___.
10. nitroglycerin 0.4 mg Tablet, Sublingual Sig: as directed
Tablet, Sublingual Sublingual ASDIR (AS DIRECTED) as needed for
chest pain: one tablet every five minutes up to three times. If
pain does not resolve call ___.
11. perphenazine-amitriptyline ___ mg Tablet Sig: One (1)
Tablet PO twice a day.
12. polyethylene glycol 3350 17 gram Powder in Packet Sig: One
(1) Powder in Packet PO DAILY (Daily).
13. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
14. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO three
times a day.
15. ferrous sulfate 325 mg (65 mg iron) Tablet Sig: One (1)
Tablet PO twice a day.
16. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
17. multivitamin Tablet Sig: One (1) Tablet PO DAILY
(Daily).
18. Zinc-220 Oral
19. cholecalciferol (vitamin D3) 1,000 unit Tablet Sig: One (1)
Tablet PO once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Unstable angina, Hypertensive urgency
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 for evaluation of chest pain.
Your tests showed that you did not have a heart attack, but your
blood pressure was very elevated. We gave you IV medication to
control your blood pressure and you improved. We transitioned
you back to your oral blood pressure medications and you
continued to do well. Your chest pain may be related to high
blood pressure. Please use sublingual nitroglycerin as directed
by Dr ___ you have chest pain. Your pain might also be
associated with heartburn. You can also try taking tums when you
have this pain. Please follow up with Dr ___ further
management. It was a pleasure taking care of you.
Medication Changes
START tums
Followup Instructions:
___
|
19695954-DS-22
| 19,695,954 | 21,226,860 |
DS
| 22 |
2202-05-15 00:00:00
|
2202-05-15 18:16:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Bactrim / Tetracycline Analogues / Vasotec / Isordil Titradose /
Procardia / Hytrin / Catapres-TTS-1 / Coreg / Neurontin /
Morphine Sulfate
Attending: ___.
Chief Complaint:
headache, body aches
Major Surgical or Invasive Procedure:
Right neck HD line placement
History of Present Illness:
Ms ___ is ___ female with history of CAD (s/p CABG), CHF,
severe HTN, renal artery stenosis, CKD thought to be secondary
to hypertension, recent hospitalization for CHF exacerbation now
admitted in the setting of acute kidney injury and hyperkalemia.
Patient was recently hospitalized at the end of ___ for
CHF exacerbation. During that admission she was diuresised to
~dry weight of 146lb. At time of discharge, ACEi restarted and
diuretic increased. Since discharge patient noted gradual
worsening of poor appetite, generalized malaise and weakness,
decreased frequency of urination, well as ~5lb weight gain. She
also reports chronic headaches that were worse over the past
week, intensify with laying flat, not associated with changes in
vision or chest pain. Over the ___ days leading up to admission,
she reports loose tarry stools one per day (on iron supplement),
and two episodes of chest "burning" lasting only ___ minutes
each, not associated with headache. On the day prior to
admission pt presented to PCP office for the above complaints
and labs were draw, showing creatinine up to 6.5 from baseline
___, BUN 176 (from ~100), potassium 6.7 and anemia 24.5 from
baseline 28, WBC 12.5. The outpatient provider reached out to
patient via telephone and urged patient to come to ED. Patient
unable to be reached until the following day, at which time she
came as instructed to the ED.
In the ED, initial VS: ___ 122/37 20 100%. Labs notable for
creatinine 7.5, K 7.3, WBC 15.9. EKG with wide QRS and peaked
T-waves, patient received insulin with D50, Bicarb 1 amp, NS 500
cc IV bolus, kayxelate. Renal was consulted and recommended
attempting medical management. VS prior to transfer: 9 48 118/68
16 99% RA.
On arrival to the MICU, vitals were T97.8, HR 50, BP 137/44, RR
15, 99%RA. She was complaining of severe diffuse headache and
diffuse muscle cramping, worst in bilateral thighs. Also
complained of dry mouth, thirst, sore throat. She denied vision
changes, chest pain, palpitations, cough, rhinorrhea, abdominal
pain, dysuria, fevers, chills, N/V/D, hematuria, blood in
stools, rash.
Past Medical History:
-Severe hypertension with Left Renal Artery Stenosis (malignant
HTN since ___. [pt reports headaches and tearing with severe
HTN and increased BP when lays down flat in bed, takes
sublingual nitro prn SBP>200]
- Dyslipidemia
-CABG: Coronary artery bypass graft times four and mitral valve
repair on ___
-PERCUTANEOUS CORONARY INTERVENTIONS:LM and three vessel CAD
with DES to ___ RCA in ___
-TIA ___ and ___: Thought to be due to embolus from left ICA
s/p left CEA in ___
-Hypothyroidism
-Chronic Kidney Disease
-PVD/LLE claudication s/p bypass ___ that subsequently
stenosed; s/p 2 stents to RLE ___
-Obesity
-Gout
-Hiatal hernia
-Uterine fibroids
-Spine scoliosis and DJD
-Benign cartilage tumor, most probably an enchondroma
-Severe spinal stenosis since ___
- diverticulitis
-psoriasis since ___
-crushed left shoulder to smitherines ___
Social History:
___
Family History:
No FMH of kidney problems. Significant FMH of heart disease,
mother had TIAs and a stroke at age ___, father died of heart
problem at age ___.
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: T97.8, HR 50, BP 137/44, RR 15, 99%RA
weight 72.0kg
General: Alert, oriented, mild distress ___ leg pain
HEENT: Sclera anicteric, MM dry, oropharynx clear, EOMI, PERRL
Neck: supple, JVP 9cm, no LAD
CV: Regular and bradycardic, normal S1 + S2, ___ systolic murmur
heard best over RUSB, no rubs, gallops. PMI non-displaced, no
sternal thrills or heaves
Lungs: Poor air movement bilaterally with bibasilar rales, no
increased work of breathing
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: foley in place
Ext: warm, well perfused, 2+ radial pulses, DP and ___ pulses
dopplerable, no clubbing, cyanosis or edema
Neuro: CNII-XII intact, ___ strength upper/lower extremities
limited by pain, grossly normal LT sensation
DISCHARGE PHYSICAL EXAM:PHYSICAL EXAM:
VS: Tm 98.8 T 98.8 BP 138/50 (130-160s/50-70s) P 75 (50-90s)
RR18 (___) POx 99% 2L
Weight: 62.8kg
I/O: 1600/900mL overnight, ___: 1740/2150mL
General: Alert, oriented, and Awake x3, pleasant, cooperative,
appears uncomofortable lying in bed, breathing comfortably on
Nasal cannula.
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP 5-6cm @ 60 degrees, no LAD
CV: Regular and bradycardic, normal S1 + S2, ___ systolic murmur
heard best over RUSB, no rubs, gallops. PMI non-displaced, no
sternal thrills or heaves
Lungs: Mild bibasilar crackles, improved air movement from
yesterday, no wheezes.
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: foley in place
Ext: warm, well perfused, 2+ radial pulses, DP and ___ pulses
dopplerable, no clubbing, cyanosis or 1+ edema
Neuro: CNII-XII intact, ___ strength upper/lower extremities
limited by pain, grossly normal LT sensation
Pertinent Results:
ADMISSION LABS:
___ 11:35AM BLOOD WBC-12.4*# RBC-2.52* Hgb-8.1* Hct-24.5*
MCV-98 MCH-32.3* MCHC-33.1 RDW-14.6 Plt ___
___ 12:30PM BLOOD Neuts-96.5* Lymphs-1.2* Monos-2.1 Eos-0.2
Baso-0
___ 12:30PM BLOOD Hypochr-1+ Anisocy-NORMAL Poiklo-2+
Macrocy-NORMAL Microcy-NORMAL Polychr-OCCASIONAL Ovalocy-1+
Burr-1+
___ 06:51PM BLOOD ___ PTT-34.3 ___
___ 11:35AM BLOOD UreaN-169* Creat-6.5*# Na-127* K-6.7*
Cl-90* HCO3-19* AnGap-25*
___ 05:15PM BLOOD ALT-9 AST-18 LD(LDH)-97 CK(CPK)-25*
TotBili-0.2 DirBili-0.1 IndBili-0.1
___ 11:35AM BLOOD UricAcd-8.7* Cholest-68
___ 12:30PM BLOOD Calcium-9.5 Phos-5.3* Mg-2.5
___ 11:29PM BLOOD calTIBC-203* Ferritn-240* TRF-156*
___ 11:35AM BLOOD Triglyc-135 HDL-22 CHOL/HD-3.1 LDLcalc-19
___ 11:35AM BLOOD %HbA1c-5.6 eAG-114
___ 12:30PM BLOOD Osmolal-333*
___ 11:35AM BLOOD TSH-8.6*
___ 11:35AM BLOOD Free T4-1.2
___ 02:50AM BLOOD Cortsol-50.8*
___ 12:30PM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE
HBcAb-NEGATIVE IgM HBc-NEGATIVE
___ 12:30PM BLOOD HCV Ab-NEGATIVE
___ 11:29PM BLOOD PEP-PND
___ 04:34PM URINE U-PEP-PND Osmolal-330
___ 04:34PM URINE Hours-RANDOM UreaN-342 Creat-141 Na-11
K-68 Cl-<10 TotProt-103 Prot/Cr-0.7*
PERTINENT LABS:
___ 12:39PM BLOOD K-7.3*
___ 02:55PM BLOOD K-6.7*
___ 10:57PM BLOOD ___ pO2-181* pCO2-35 pH-7.49*
calTCO2-27 Base XS-4 Comment-GREEN TOP
___ 11:29PM BLOOD PEP-NO SPECIFI
___ 12:30PM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE
HBcAb-NEGATIVE IgM HBc-NEGATIVE
___ 02:50AM BLOOD Cortsol-50.8*
___ 02:50AM BLOOD Cortsol-50.8*
___ 11:35AM BLOOD Free T4-1.2
___ 11:35AM BLOOD TSH-8.6*
___ 12:30PM BLOOD Osmolal-333*
___ 11:35AM BLOOD Triglyc-135 HDL-22 CHOL/HD-3.1 LDLcalc-19
___ 11:35AM BLOOD %HbA1c-5.6 eAG-114
___ 11:29PM BLOOD calTIBC-203* Ferritn-240* TRF-156*
___ 06:18PM BLOOD Hapto-206*
___ 06:39AM BLOOD Ret Aut-1.2
___ 04:34PM URINE U-PEP-MULTIPLE P IFE-NO MONOCLO
Osmolal-330
___ 04:34PM URINE Hours-RANDOM UreaN-342 Creat-141 Na-11
K-68 Cl-<10 TotProt-103 Prot/Cr-0.7*
MICROBIOLOGY:
BLOOD CULTURES: NEGATIVE
URINE CULTURES: NO GROWTH
MRSA SCREEN: NEGATIVE
PATHOLOGY:
RADIOLOGY:
CXR ___:
IMPRESSION: Findings suggestive of mild pulmonary vascular
congestion.
LEFT THIGH ULTRASOUND ___:
IMPRESSION:
Unremarkable soft tissue ultrasound of the left thigh. No
evidence of abscess
or suspicious soft tissue mass.
RENAL ARTERY U/S ___:
IMPRESSION:
1. No hydronephrosis.
2. The left kidney is mildly atrophic and demonstrates some
cortical thinning.
This could indicate some renal artery stenosis in the left
kidney.
3. Mild ___ noted in the arterial waveforms
bilaterally could be
consistent with renal artery stenosis.
4. Elevated resistive indices bilaterally suggesting chronic
parenchymal
disease.
5. Trace of ascites in the pelvis.
CXR ___:
IMPRESSION:
1. Worsening of the left retrocardiac opacity likely secondary
to increasing
atelectasis and/or effusion.
2. Slight improvement of pulmonary edema.
CT ABDOMEN PELVIS W/O CONTRAST ___:
IMPRESSION:
1. No evidence of retroperitoneal or upper leg hemorrhage to
correlate with
hematocrit drop.
2. Small bilateral pleural effusion, mild ascites and anasarca
with enlarged
heart suggest heart failure. Associated atelectasis.
3. Cholelithiasis.
4. Diverticulosis.
5. Renal stones mentioned on the wet read are probably vascular
calcifications. No definite of renal stone. Severe diffuse
atherosclerotic disease with left femoropopliteal bypass graft.
6. Right femoral chondroid lesion most likely represents an
enchondroma. Lesion is stable from ___ knee radiographs.
CXR ___:
FINDINGS: In comparison with the study of ___, there is some
increased opacification at the left base consistent with volume
loss and pleural effusion. In the appropriate clinical setting,
supervening pneumonia would have to be considered.
Continued enlargement of the cardiac silhouette with some
elevation of
pulmonary venous pressure.
The large-bore central catheter from the right IJ has been
removed.
CXR ___
PA and lateral upright chest radiographs were reviewed in
comparison to
___.
The patient is after median sternotomy and replacement of the
mitral valve
with stable appearance of both. As compared to the prior study,
there is
interval slight improvement in pulmonary edema which is still
present,
substantial. Bilateral pleural effusions are noted, left more
than right. No
change in the fractured left humeral head demonstrated.
No focal consolidation to suggest infectious process
demonstrated. Left
retrocardiac opacity appears to be more pronounced than the rest
of the
findings and thus concerning for coexisting left lower lobe
consolidation.
CXR ___:
Moderate-to-severe cardiomegaly is stable. Moderate pulmonary
edema has
improved. Bibasilar opacities are a combination of component of
edema,
atelectasis, and small effusions. These have improved from
prior study.
There is no pneumothorax. Sternal wires are aligned.
CARDIOLOGY:
EKG ___:
Sinus bradycardia. Left bundle-branch block. Markedly prolonged
QRS intervals
suggest electrolyte abnormality or anti-arrhythmic medication.
Compared to the
previous tracing of ___ the striking difference in axis
likely reflects
incorrect lead placement in previous tracing.
EKG ___:
Sinus rhythm. Left bundle-branch block. Compared to tracing #1
the axis has
changed. Ventricular rate is slower.
ECHO ___:
Conclusions
The left atrium is elongated. There is mild symmetric left
ventricular hypertrophy with normal cavity size. There is mild
regional left ventricular systolic dysfunction with hypokinesis
of the basal to mid septum and inferior wall. Overall left
ventricular systolic function is mildly depressed (LVEF= 45%).
The right ventricular cavity is dilated with borderline normal
free wall function. The aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. Mild to moderate
(___) 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 minimal to mild
valvular mitral stenosis due to MAC. Moderate (2+) mitral
regurgitation is seen. [Due to acoustic shadowing, the severity
of mitral regurgitation may be significantly UNDERestimated.]
The tricuspid valve leaflets are mildly thickened. Moderate to
severe [3+] tricuspid regurgitation is seen. There is moderate
pulmonary artery systolic hypertension. The pulmonic valve
leaflets are thickened. Significant pulmonic regurgitation is
seen. There is no pericardial effusion.
IMPRESSION: Mildly depressed left ventricular function with
regional dysfunction as above. Mild to moderate aortic
regurgitation. At least moderate mitral regurgitation. Moderate
to severe tricuspid regurgitation. Moderate pulmonary
hypertension.
Compared with the prior study (images reviewed) of ___,
the degrees of valvular regurgitation appear greater in the
current study. Relative hypokinesis of the septum as compared
with the lateral wall is appreciated.
DISCHARGE LABS:
___ 08:05AM BLOOD WBC-4.6 RBC-2.88* Hgb-9.2* Hct-26.8*
MCV-93 MCH-32.0 MCHC-34.3 RDW-15.4 Plt ___
___ 08:05AM BLOOD Glucose-78 UreaN-107* Creat-1.7* Na-136
K-3.5 Cl-94* HCO3-31 AnGap-15
___ 08:05AM BLOOD CK(CPK)-15*
___ 09:15PM BLOOD CK-MB-3 cTropnT-0.37*
___ 08:05AM BLOOD Calcium-8.6 Phos-2.7 Mg-2.1
Brief Hospital Course:
Ms ___ is ___ female with history of CHF, severe HTN, renal
artery stenosis recent hospitalization for CHF exacerbation now
admitted in the setting of acute kidney injury and hyperkalemia
requiring emergent hemodialysis .
# Hyperkalemia: Most likely from ACEI restarted and acute kidney
failure, with contribution from slow upper GI bleed. Presented
with myalgias, weakness to PCP, found to have potassium of 6.7,
was called and instructed to present to the ED where repeat K
measurement found to be 7.3. EKG showed peaked T-waves,
prolonged QRS, prolonged PR interval. patient was given insulin
with D50, bicarbonate, NS 500 cc IV bolus, kayxelate and renal
was consulted, patient was admitted to the MICU for further
monitoring. Repeat K was still elevated and patient required
emergent dialysis on the night of admission, with subsequent
potassium levels within normal limits. As ___ resolved and
creatnine returned to baseline, the potassium levels continued
to be normal.
# Acute on chronic kidney injury: Found to have oliguric acute
tubular necrosis on microscopic examination of urine. Likely due
to relative hypotension, as this has happened before when her
blood pressures were well controlled to "normal" range. This is
likely iatrogenic from ACE inhibitor and increase in diuretic
dose as well as possibly blood volume loss from slow GI bleed.
Renal ultrasound showed chronic disease and trace ascites, no
explanation for acute decompensation. Renal was consulted and
patient underwent one session of emergent dialysis for
hyperkalemia on night of admission with subsequent sustained
improvement in creatinine. Investigation for other causes of
renal failure were negative as . SPEP negative. UPEP negative
for monoclonal bands or bence ___. However, creatinine
remained in mid 4's with difficulty maning fluid status
initially, likely secondary to heart failure exacerbation (see
below). Patient was diuresed and creatinine returned to baseline
(1.7) prior to discharge. Sevalmer was discontinued.
# Chronic systolic and diastolic heart failure.(LVEF 45-50%):
Patient was notably volume overloaded, with elevated JVD,
crackles, dyspnea, and ___ edema upon return from endoscopy on
___. She was notably in distress and imaging illustrated
pleural effusion and pulmonary edema on ___. Diuresis with
lasix and metalozone yielded significant improvment in O2
requirement and adequate output. Per last DC summary dry weight
thought to be 69kg. Heart failure service was consulted and felt
diuresis was adequate. ECHO was performed to assess for interval
changes and yielded increased valvular disfunction and relative
hypokinesis of septum/lateral wall as compared to before.
Patient appeared euvolemic ___, and was transitioned to 80mg
of torsemide prior to discharge to maintain euvolemia. Fluid
restriction was maintained at 2L. Patient's admission weight
was 72kg, and discharge weight was noted to be 62.8kg.
# Hyponatremia. Urine sodium and urine osm c/w kidney poor
perfusion. Resolved with diuresis and restoring intravascular
volume. Resolved during hospital course. Patient was maintained
on fluid restriction to 2L.
# Leukocytosis/Fever: Possibly stress response to GI bleed.
Presented with leukocytosis, negative chest xray, blood cultures
and urine cultures. Received one dose of ceftriaxone when
urinalysis showed leukocytes, but this was stopped when cultures
were negative. Gradually resolved without intervention.
# Normocytic anemia: No clear source of bleeding on admission,
hemolysis labs negative. Initial hematocrit drop from 24.5 to
18.7. Did not bump appropriately to 6 units of pRBCs. CT torso
did not show any occult source of bleeding such as
retroperitoneal bleed. She complained of black tarry stools on
the weekend prior to admission and was reportedly guaiac
negative at clinic, did not produced bowel movement until
several days after admission, which was large, dark and tarry
per nursing. Initial rectal exam with brown guaiac positive
stool in rectal vault. Of note patient is on chronic iron
supplementation therapy. Patient was discussed with GI who
decided to perform endoscopy which showed esophagitis, erythema
and friability of fundus, large superficial clean based ulcer in
stomach body, and gastritis. Patient was continued on high dose
IV PPI, and clopidogrel was held in setting of GI bleed.
Patient's hematocrit remained stable for remainder of hospital
course. Patient was continued on PO ferrous sulfate. Repeat EGD
to be porformed on ___ weeks for evaluation of gastric ulcer and
acquisition of biopsies.
# Thrombocytopenia: Down from baseline of 150-200, negative
hemolysis labs, no known heparin exposure at home prior to
presenting with these lab values. Stabilized at 139.
# Hypertension: Adjusted anti-hypertensive regimen for
permissive hypertension to allow for renal perfusion. (SBPs 130s
to 150s).
# Chronic systolic and diastolic heart failure: Presented with
weight gain since recent admission for heart failure. Weight on
arrival here was 72kg, from discharge weight of 68kg. She had
been discharged on PO torsemide, and when she presented to her
PCP with weight gain and increased creatinine, she was changed
back to furosemide. On presentation this admission she had
bibasilar crackles, chest xray showed mild pulmonary edema, so
she received IV furosemide intermittently and discharge weight
was ____.
# CAD s/p CABG, PVD: Continued beta blocker aspirin. Held statin
for myalgias, held ACEI for ___.
# Hypothyroidism: TSH was 8.6 on ___. Free T4 was normal.
Continued levothyroxine.
# Gout: held allopurinol for ___
# Chronic constipation: Coninued senna, miralax. Bisacodyl and
senna were added as iron seems to be contributing to
constipation.
# History of CVA: After discussion with neurologist and
cardiologist, clopidogrel was discontinued and patient was
continued on monotherapy with aspirin.
#Insomnia: Patient was started on trazadone 25mg HS:PRN
#Chronic pain: Patient was treated with oxycodone to 7.5mg q4.
Patient was given diluadid for breakthrough pain.
TRANSITIONAL ISSUES:
- Patient likely requires increased perfusion pressures, target
SBP 130-150s to avoid renal hypoperfusion
- Labetalol dose decreased to TID from 6x/day to allow
permissive hypertension
- statin held for myalgias
- clopidogrel was discontinued in the setting of GI bleed.
- Benazepril was discontinued as likely contributed to renal
injury and hyperkalemia
- Allopurinol, ACEI and PO furosemide held for ___
- Bowel regimen was increased to include senna/bisacodyl for
constipation exacerbated by iron supplementation
- After adequate diuresis, patient was transitioned to 80mg PO
lasix to maintain euvolemia.
- Patient to have daily weights and follow up with PCP if weight
increases more than 1kg.
-Patient was continued on PO ferrous sulfate. Repeat EGD to be
porformed on ___ weeks for evaluation of gastric ulcer and
acquisition of biopsies.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Allopurinol ___ mg PO DAILY
2. Amitriptyline 10 mg PO DAILY
3. Amlodipine 10 mg PO DAILY
4. Aspirin 81 mg PO DAILY
5. Atorvastatin 40 mg PO DAILY
6. Clopidogrel 75 mg PO DAILY
7. Docusate Sodium 100 mg PO BID
8. Ferrous Sulfate 325 mg PO BID
9. FoLIC Acid ___ mcg PO DAILY
10. HydrALAzine 100 mg PO TID
11. Labetalol 300 mg PO 6X/DAY
12. Levothyroxine Sodium 200 mcg PO DAILY
13. Multivitamins 1 TAB PO DAILY
14. Perphenazine 2 mg PO DAILY
15. Polyethylene Glycol 17 g PO DAILY
16. Vitamin D 1000 UNIT PO DAILY
17. Zinc Sulfate 220 mg PO DAILY
18. benazepril *NF* 20 mg ORAL BID
19. Furosemide 80 mg PO DAILY
Discharge Medications:
1. Amitriptyline 10 mg PO DAILY
2. Amlodipine 10 mg PO DAILY
3. Docusate Sodium 100 mg PO BID
4. Ferrous Sulfate 325 mg PO BID
5. FoLIC Acid ___ mcg PO DAILY
6. HydrALAzine 100 mg PO TID
7. Labetalol 300 mg PO 6X/DAY
8. Zinc Sulfate 220 mg PO DAILY
9. Aspirin 81 mg PO DAILY
10. Levothyroxine Sodium 200 mcg PO DAILY
11. Multivitamins 1 TAB PO DAILY
12. Polyethylene Glycol 17 g PO DAILY
13. Vitamin D 1000 UNIT PO DAILY
14. Acetaminophen 325-650 mg PO Q6H:PRN fever, pain
RX *acetaminophen [8 HOUR PAIN RELIEVER] 650 mg 1 tablet(s) by
mouth q8hrs Disp #*30 Tablet Refills:*0
15. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation
RX *bisacodyl 5 mg 2 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
16. Senna 1 TAB PO BID:PRN Constipation
RX *sennosides [senna] 8.6 mg 1 capsule by mouth twice a day
Disp #*60 Capsule Refills:*0
17. Allopurinol ___ mg PO DAILY
18. Atorvastatin 40 mg PO DAILY
19. Perphenazine 2 mg PO DAILY
20. Torsemide 80 mg PO DAILY
RX *torsemide 20 mg 4 tablet(s) by mouth Daily Disp #*120 Tablet
Refills:*0
21. traZODONE 25 mg PO HS:PRN insomnia
RX *trazodone 50 mg 0.5 (One half) tablet(s) by mouth HS Disp
#*30 Tablet Refills:*0
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Hyperkalemia
Acute Renal failure
Upper GI Bleed with ulcer noted in gastric body.
Acute on Chronic DIastolic and Systolic Heart Failure
Hypertension/Renal Artery Stenosis
Thrombocytopenia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Ms. ___:
It was a pleasure taking care of you during your hospitalization
at ___. You had come in because you felt more tired,
experienced a 5lb weight gain, and had total body discomfort.
You potassium levels were found to be very high and your kidney
function was noted to be very poor, and emergent dialysis was
performed after a line was placed in your neck. Your renal
function and potassium began to improve after dialysis. You
were taken to the ICU, and later noted to have bloody stool and
a drop in you blood count. You were given blood products and
supportive care. An endoscopy was performed and a large ulcer
was noted in your stomach. You were continued on medications to
help prevent bleeding. You also experienced problems with your
breathing that was related to your heart failure and
hypertension. We began taking off significant amounts of fluid,
and your breathing improved. We transitioned you to an oral
water pill that will help keep the fluid off your lungs.
We have made the following changes to your medication list:
Please START taking torsemide 80mg daily to keep fluid off your
lungs.
Please START taking trazadone 25mg as needed at night as needed
for insomnia.
Please START taking tylenol as needed for pain.
Please START takng Bisacodyl 10mg daily and Senna twice daily as
needed for constipation.
Please STOP taking Clopidogrel, furosemide, and benazepril.
Please CONTINUE taking the rest of your medications as
prescribed.
Please weigh yourself every morning, call MD if weight goes up
more than 3 lbs.
Please follow up with your appointments as outlined below.
Thank you,
Followup Instructions:
___
|
19696084-DS-15
| 19,696,084 | 29,866,477 |
DS
| 15 |
2182-01-21 00:00:00
|
2182-01-23 23:03:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Chest pressure/shortness of breath
Major Surgical or Invasive Procedure:
___- cardiac catheterization
___- cardiac catheterization
History of Present Illness:
___ with CAD s/p NSTEMI with DES to ___-LAD and POBA of the LCx
in ___, ___, mild-moderate AS (___), HTN, HLD, CKD
and recent NSTEMI which was managed medically who presents with
chest pain. He was changing to watch TV this evening when he had
the sudden onset of ___ chest pressure and felt SOB. He took 1
SL nitro which did not help the pain/dyspnea. He then went to
bed despite continuing to not feel well. His wife called EMS ~2
hours after the onset of his sx because they had not yet
resolved. He was given ASA and 2 sprays of SL nitro by the EMTs
per his report, his chest pressure and dyspnea resolved by the
time he had arrived to ___.
He states that he cannot remember what his symptoms felt like
when he was admitted last month with an NSTEMI and cannot state
if these symptoms feel similar. His NSTEMI was managed medically
last admission after decision was made with pt and family not to
proceed with cath given his age and co-morbidities, especially
his CKD.
He denies anginal symptoms at baseline. Denies orthopnea, PND.
States that his weight has been stable around 184 lately, he
weighs himself daily. Discharge weight at last discharge was
183lbs (83.3kg, per scanned inpatient records). BP in 140-150s
systolic recently which is stable per the patient.
In the ED, initial vitals were 70 132/69 18 99% 3L Nasal
Cannula. Labs notable for trop 0.08 (was 0.5 with last NSTEMI),
BNP 11,000 (no prior), Cr 4.1 (bl 3.5 per records). CXR showed
mild pulmonary vascular congestion and mild pleural effusions.
He received Lasix 20mg IV, urine output to this not documented.
On arrival to the floor, patient states that he has no chest
pain or pressure and his dyspnesa has resolved, although he is
on 3.5L NC which he does not use at home.
Cardiac review of systems is notable for absence of paroxysmal
nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope
or presyncope.
Past Medical History:
1. CARDIAC RISK FACTORS: +Dyslipidemia, +Hypertension
2. CARDIAC HISTORY:
-CAD s/p DES to the LMCA-LAD and POBA of the LCx ___ complex
bifurcation stenting of left main into LAD/LCX ___
-dCHF (EF>60%)
-Mild to moderate AS ___ 1.0cm2)
3. OTHER PAST MEDICAL HISTORY:
-h/o colonic malignancy s/p colostomy
-rectal and anal hemorrhage
-diverticulitis
-gout
-chronic renal insufficiency (baseline Cr 3.5)
-s/p L CEA
-CVD ___
-hearing loss- wears bilat hearing aids
-GERD
-B12 deficiency
-Vitamin D deficiency
Social History:
___
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.
Physical Exam:
Admission:
VS: T 98.3 BP 115/63 HR 72 SpO2 90%/3.5L
GENERAL: WDWN male in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI.
NECK: Supple with JVP of 6-7 cm.
CARDIAC: RRR, normal S1, S2. ___ systolic murmur heard best at
the LUSB.
LUNGS: Mild crackles at the bases bilaterally.
ABDOMEN: Soft, NTND. LLQ ostomy intact.
EXTREMITIES: ___ ___ edema bilaterally, L>R.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas
Discharge:
VS: 98.0 (98.4) 156/72 (102-156/49-72) 55 (55-68) 18 99% RA
I/O: ___
Tele: NSR, rate 60-70s, no alarms
GENERAL: NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI.
NECK: Supple with JVP of 6-7 cm.
CARDIAC: RRR, normal S1, S2. ___ systolic ejection murmur heard
best at the LUSB.
LUNGS: CTAB, slight b/l rales, no wheezes or ronchi
ABDOMEN: Soft, NTND. LLQ ostomy intact with gas, no stool
(recently changed).
EXTREMITIES: 1+ ___ edema bilaterally, L>R.
GROIN: non-tender, no hematoma
Pertinent Results:
Admission:
___ 10:55PM PLT COUNT-200
___ 10:55PM NEUTS-74.3* LYMPHS-15.2* MONOS-4.9 EOS-5.4*
BASOS-0.2
___ 10:55PM WBC-5.5 RBC-3.41* HGB-10.8* HCT-32.3* MCV-95
MCH-31.6 MCHC-33.3 RDW-14.4
___ 10:55PM CK(CPK)-54
___ 10:55PM estGFR-Using this
___ 10:55PM GLUCOSE-206* UREA N-79* CREAT-4.1* SODIUM-142
POTASSIUM-4.9 CHLORIDE-106 TOTAL CO2-19* ANION GAP-22*
___ 11:28PM ___ PTT-24.4* ___
___ 06:00AM CK(CPK)-65
Trops:
___ 10:55PM CK-MB-4 ___
___ 10:55PM cTropnT-0.08*
___ 06:00AM CK-MB-7 cTropnT-0.18*
___ 02:55PM CK-MB-7 cTropnT-0.24
Discharge:
___ 05:58AM BLOOD WBC-4.2 RBC-3.05* Hgb-9.7* Hct-29.1*
MCV-95 MCH-31.7 MCHC-33.2 RDW-14.0 Plt ___
___ 05:58AM BLOOD Glucose-138* UreaN-72* Creat-4.1* Na-141
K-4.4 Cl-108 HCO3-22 AnGap-15
___ 05:58AM BLOOD Calcium-9.4 Phos-4.9* Mg-2.2
___ Radiology CHEST (PA & LAT)
Imaging:FINDINGS: Frontal and lateral views of the chest were
obtained. There are bibasilar opacities most consistent with
atelectasis, although underlying consolidation not excluded in
the appropriate clinical setting. There are trace bilateral
pleural effusions. No evidence of pneumothorax is seen. The
aorta is calcified and tortuous. The cardiac silhouette is top
normal. There is mild pulmonary vascular congestion.
___ Radiology CHEST (PORTABLE AP)
FINDINGS: AP single view of the chest has been obtained with
patient in
sitting semi-upright position. Analysis is performed in direct
comparison with the next preceding AP and lateral chest
examination of ___. The diaphragms are now in
higher position. The pulmonary vasculature shows marked
perivascular haze throughout, compatible with development of
CHF. As there are hazy densities predominantly in the central
pulmonary areas, findings match the clinical impression of
beginning pulmonary edema. There is no pneumothorax detectable
in the apical area on this portable chest examination.
In comparison with the next preceding study obtained one day
earlier, the
patient has now developed severe left-sided CHF. Observed that
the lateral view on the previous examination demonstrated
suspicious calcifications within the aortic valve area and the
aortic root.
___ Cardiovascular C.CATH
COMMENTS:
1. Selective coronary angiography in this right dominant system
demonstrated severe left main and 2 vessel CAD. The LMCA had an
80% in stent restenosis into the LAD as well as compromise of
the LCX.
The remainder of the LAD and LCX had mild luminal
irregularities. The
RCA was not evaluated as unlikely culprit given above findings
to
converse on dye load given stage ___ CKD.
2. Resting hemodynamics revealed elevated biventricular filing
pressures
with LVEDP 32mmHg and RVEDP 12mmHg. Wedge pressure tracings
were
inaccurate and thus not reported. Mild-moderate pulmonary
hypertension
with mean PA 24mmHg and PASP 39mmHg. Cardiac output was
slightly
decreased with CI 2.28 l/min/m2.
3. Moderately severe aortic stenosis with mean gradient 20.26
and
calculated valve area 0.97 cm2.
FINAL DIAGNOSIS:
1. Severe left main and 2 vessel CAD with in-stent restenosis.
2. Elevated biventricular filling pressures.
3. Moderately severe aortic stenosis.
___ Cardiovascular C.CATH
COMMENTS:
1. Severe 90% calcified lesion of Left main into LAD with MLA of
2.7mm2.
2. Severe hazy ostial LCX lesion (90%)
3. Successful bifurcation left main/LAD/LCX stenting with 2
Promus DESs
(3.5 X 16mm and 3.0 X 16mm) with final kissing balloon
inflations.
Reduction in stenoses from 90% to 0%.
4. Succesful placement of ___ angioseal in right CFA
FINAL DIAGNOSIS:
1. Successful complex bifurcation stenting of left main into
LAD/LCX
2. ASA 325mg daily and Plavix 75mg daily
3. Close monitoring post procedure
4. PLEASE SEE OMR NOTES FOR ADDED DETAILS OF CATH REPORT
ECG Study Date of ___ 5:46:14 ___ Sinus rhythm. Voltage
criteria for left ventricular hypertrophy. ST-T wave
abnormalities consistent with left ventricular hypertrophy.
Compared to the previous tracing of ___ no significant
change.
ECG Study Date of ___ 10:27:34 ___ Normal sinus rhythm.
Left ventricular hypertrophy. Biphasic T waves in leads I, aVL,
V4-V6 consistent with left ventricular hypertrophy. Cannot rule
out ischemia consistent with tracing #2.
Brief Hospital Course:
___ with CAD s/p PCI to the LMCA-LAD and POBA of the LCx, dCHF,
mild-moderate AS (___), HTN, HLD, CKD with NSTEMI, now
s/p DES to L main ostium extending into LAD and LCx.
# NSTEMI: Patient presented with chest pressure and dyspnea. The
patient had been recently admitted for NSTEMI and had declined
cardiac cath at that time due to renal failure and opted for
medical management. Troponins on this admission 0.08, 0.23,
0.43. EKG with ST depressions consistent with global ischemia.
After discussion of goals of care, patient opted to proceed with
cardiac cath. Cardiac cath performed ___ showed severe left
main and 2 vessel CAD with in-stent restenosis, no intervention
performed at this time due to risk. Patient evaluted by cardiac
surgery who felt he was not a candidate for bypass given
comorbidities. Results discussed with patient and family
including possible need for dialysis with dye load. Patient seen
and evaluated by renal who discussed risks and benefits of
dialysis. Patient chose to go ahead with cardiac cath which was
performed on ___ with successfull PCI of left main and left
circumflex with DES. Patient tolerated the procedure well.
Medications optimized and patient discharged on atorvastatin,
plavix, aspirin, imdur, nifedipine and carvedilol.
# Acute on chronic diastolic CHF (EF>60%): Patient presented
with dyspnea consistent with flash pulmonary edema, possibly
secondary to aortic stensosis and ischemia. BNP elevated to
11,000 with no prior values for comparison. CXR on arrival with
mild pulmonary edema, however on day two of admission patient
became acutely dyspneic and desaturated. CXR at that time
consistent with acute pulmonary edema. Cardiac cath on ___
with elevated biventricular filling pressures. Patient diuresed
and improved.with only mild pulm edema and this seems less
likely.
Discharged on home dose of Lasix 20 mg daily. Patient not on
ace-inhibitor ___ due to renal failure.
# Moderate AS: Patient has moderate aortic stenosis with mean
gradient on cath of 20.26 and calculated valve area 0.97 cm2.
Symptoms more likely secondary to ischemia and congestive heart
failure than aortic stenosis, although AS contributing.
# CKD: Cr baseline 4.0. Patient was seen and evaluated by
nephrology due to risk of cardiac cath dye causing more renal
failure. The risks and benefits of dialysis were discussed with
the patient and family who chose to proceed with cardiac cath.
There was no urgent indication for dialysis during
hospitalization. He was continued on calcitriol and bicarbonate.
Creatinine on discharge of 4.1, which is very close to
baseline. Patient will follow up with PCP to trend creatinine.
# HTN: Patient continued on home clonidine, nifedipine, and
imdur. Carvedilol increased for better control of morning blood
pressure which was occasional high prior to medication
administration.
Transitional Issues:
- Creatinine to be checked
- Follow up with renal and cardiology
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Allopurinol ___ mg PO DAILY
2. Aspirin 325 mg PO DAILY
3. CloniDINE 0.1 mg PO BID
4. Docusate Sodium 100 mg PO BID
5. NIFEdipine CR 90 mg PO DAILY
6. Ranitidine 150 mg PO DAILY
7. Sertraline 150 mg PO DAILY
8. Sodium Bicarbonate 650 mg PO DAILY
9. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
10. Clopidogrel 75 mg PO DAILY
11. Atorvastatin 80 mg PO DAILY
12. Furosemide 20 mg PO DAILY
13. Psyllium Wafer 1 WAF PO DAILY
14. Senna 1 TAB PO BID:PRN constipation
15. Calcitriol 0.25 mcg PO DAILY
16. carboxymethylcellulose sodium *NF* 0.25 % ___ bid
17. fluorouracil *NF* 5 % Topical asdir
18. Carvedilol 12.5 mg PO BID
Discharge Medications:
1. Allopurinol ___ mg PO DAILY
2. Aspirin 325 mg PO DAILY
3. Atorvastatin 80 mg PO DAILY
4. Calcitriol 0.25 mcg PO DAILY
5. CloniDINE 0.1 mg PO BID
6. Clopidogrel 75 mg PO DAILY
7. Docusate Sodium 100 mg PO BID
8. Psyllium Wafer 1 WAF PO DAILY
9. Ranitidine 150 mg PO DAILY
10. Senna 1 TAB PO BID:PRN constipation
11. Sertraline 150 mg PO DAILY
12. Sodium Bicarbonate 650 mg PO DAILY
13. carboxymethylcellulose sodium *NF* 0.25 % ___ bid
14. fluorouracil *NF* 5 % Topical asdir
15. Furosemide 20 mg PO DAILY
16. Carvedilol 25 mg PO QAM
17. Carvedilol 12.5 mg PO QPM
Take 25mg in the morning and 12.5 mg in the evening.
18. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY
RX *isosorbide mononitrate 60 mg 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*0
19. NIFEdipine CR 90 mg PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary: coronary artery disease, non-st elevation myocardial
infarction, renal failure, diabetes
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
It was a pleasure taking care of you at ___. You were admitted
after a sudden episode of chest pain. You had a cardiac
catheterization that showed a blockage of two of the arteries in
your heart. These were opened with stents. You also were found
to have worsening heart failure due to fluid overload, which we
treated with diuretics.
You should continue to take aspirin and Plavix daily. Do not
stop these medications without talking to your Cardiologist. We
made several other changes to your medications, so please reivew
the attached list carefully.
Please follow-up with your physicians next week as listed below.
Please weigh yourself every morning, call MD if weight goes up
more than 3 lbs.
Followup Instructions:
___
|
19696177-DS-8
| 19,696,177 | 24,913,404 |
DS
| 8 |
2120-05-14 00:00:00
|
2120-06-14 11:43:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Seizure
Major Surgical or Invasive Procedure:
Intubation ___
History of Present Illness:
___ yo female at ___ concert at ___. 1 of 3 brought
in from same concert. Denied drug use. Reportedly tripped and
fell x2 at the concert. No LOC. Questionable head strike. Denied
drug use. EMS called found white powder in bra.
Arrived to ED tachycardic in sinus tach to 180s in ED.
Diaphoretic. Started tonic clonic seizure in ED for ~1 min and
received 2mg ativan x2. Intubated in ED. Friends/patient report
doing ___ at concert. Temperature to 103. HR 180s sinus tach
BP 130/70s. Started on propofol drip. Head CT and CT c-spine
negative. Utox positive for amphetamines. Placed on propfol
70mcg/kg in ED. Toxicology recommending keeping pt normothermic
with external measures, aggressive fluid resuscitation. Repeat
temperature 97. Received 6L of NS in ED.
On arrival to the MICU, T: 97 HR:76 BP: 119/78 100% on vent.
Patient with ice packs and cool to the touch with shivering.
Started on 1L LR on arrival.
Past Medical History:
ADHD, depression
Social History:
___
Family History:
No seizure disorders, noncontributory for current presentation
Physical Exam:
ADMISSION EXAM
General- on propofol, intubated, follows some commands
HEENT- Sclera anicteric, MMM, oropharynx clear
Neck- supple, JVP not elevated, no LAD
Lungs- Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV- normal rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen- soft, non-tender, non-distended, bowel sounds present,
GU- foley
Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro- CNs2-12 intact, motor function grossly normal
DISCHARGE:
VITALS: BP=90/51 PULSE = 84 RR=18 TEMP=99. SPO2 100%RA
General-Alert and oriented x3. NAD
Neck- supple
Lungs- Clear to auscultation bilaterally
CV- normal rate and rhythm
Abdomen- soft, non-tender, non-distended
GU- foley with clear urine
Ext- warm, well perfused, 2+ pulses
Neuro- CNs2-12 intact, motor function grossly normal
Pertinent Results:
ADMISSION
___ 11:30PM BLOOD WBC-13.6* RBC-4.82 Hgb-15.1 Hct-44.0
MCV-91 MCH-31.2 MCHC-34.2 RDW-12.5 Plt ___
___ 11:30PM BLOOD Neuts-76.5* ___ Monos-3.9 Eos-0.8
Baso-0.8
___ 11:30PM BLOOD Glucose-120* UreaN-17 Creat-1.3* Na-141
K-4.6 Cl-101 HCO3-26 AnGap-19
___ 11:30PM BLOOD ALT-18 AST-23 CK(CPK)-100 AlkPhos-57
TotBili-0.4
___ 05:11AM BLOOD CK(CPK)-2654*
___ 11:30PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 03:52AM BLOOD Type-ART Rates-14/ Tidal V-450 FiO2-50
pO2-263* pCO2-43 pH-7.28* calTCO2-21 Base XS--6 -ASSIST/CON
___ 03:52AM BLOOD Lactate-0.8
Chest xray ___
IMPRESSION: No acute cardiopulmonary process. Endotracheal
tube in
appropriate position. Significant distention of air in the
partially imaged
stomach
CT C-SPINE WITHOUT CONTRAST ___
IMPRESSION: No acute fracture or malalignment.
CT HEAD W/O CONTRAST ___
IMPRESSION: No acute intracranial process.
Chest xray(portable) ___
IMPRESSION: AP chest compared to ___ at midnight:
Tip of the endotracheal tube is at the upper margin of the
clavicles, 4 cm
above the carina in standard placement. Stomach has
decompressed since the
earlier examination. Lungs clear. Heart size normal. No
pneumothorax or
appreciable pleural effusion.
Brief Hospital Course:
This is a ___ yo F s/p ingestion consistent with amphetamine
overdose.
# Toxic ingestion - per friends, took ___ form of MDMA at
concert with syncope x2. She had a seizure in the ED.
Toxicology saw patient in ED and stated that ___ can sometimes
be mixed with other sympathomimetic or serotonergic properties
which is likely in this case as seizures are not typical with
the ___ (pure MDMA). Body temperature was rising so concern
was raised for serotonergic syndrome. Patient received
aggressive fluid resuscitation, active external cooling, was
intubated, started with vecuronium 10mg IV initially and heavily
sedated with propofol. Concern also raised for rhabdomyolysis as
initial CK was 2600. CK increased to 4500 by AM after admission.
___ CK pending. Cr was monitored and stable with no elevation
from baseline. In the day after admission temperature fell and
sedation was discontinued. Patient was extubated and improved
clinically over the course of the day prior to transfer from ICU
to medical floor. She was alert and oriented x 3 and in no
distress on transfer. She progressed well on floor with no
neurologic sequelae.
#Elevated CK with ___ : likely as a result of dehydration and
toxic ingestion of illicit substance with sympathomimetic
properties. She was hydrated with IV fluids with CK trending
down, as well as normalization of creatinine. She had adequate
urine output.
#Social work: Social work was consulted due to severity of
intoxication. Patient admitted to occasionally smoking marijuana
with her boyfriend but states
does not drink very much and she was just curious this time. SW
spoke with family who was very supportive. She denies needing
any resources on
drug or alcohol abuse and states she does not plan to do
drugs again.
Medications on Admission:
adderall
Discharge Medications:
Asked to hold Adderall until she follows up with her PCP.
Discharge Disposition:
Home
Discharge Diagnosis:
Toxic ingestion
SEcondary:
ADHD
Discharge Condition:
alert and oriented. NAD. VSS
Ambulatory
Discharge Instructions:
Dear Ms. ___,
you came in after ingestion of a toxic substance with seizures.
You were intubated to protect your breathing and IV fluids were
given to help cleans your blood of breakdown products as a
result of this drug. Your heart rate and rhythm were monitored.
After taking you off the ventilator you have done well. You
stayed on monitor overnight and no worrisome hear rhythms were
seen. Other than some mild body aches and pain which is expected
you are doing well and ready for discharge.
You should see your primary care doctor in ___ week for follow up.
This is very important.
Followup Instructions:
___
|
19696298-DS-10
| 19,696,298 | 21,631,785 |
DS
| 10 |
2129-08-03 00:00:00
|
2129-08-03 21:30:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old male hx of COPD ( not on home O2),CHF ( EF 55%
___, htn, afib ( on Coumadin), and CKD (baseline Cr.
1.5-1.8) presenting with dyspnea. The patient was in his usual
state of health until 1 day prior to admission when he started
to have increasing dyspnea. He states that in the last week he's
had increasing orthopnea needing two pillows instead of one. The
night prior to admission his breathing was getting worse and "
he could not control it". ___ up in a recliner, but was unable
to sleep. Tried his inhaler with minimal relief. He's also
noticed worsening ___ L > R. Given his respiratory distress
he called EMS this morning. When EMS arrived his O2 sat was in
the low ___ so he was placed on CPAP of 10 and given a duo-neb x
1.
Of note he was admitted to ___ in ___ for acute CHF
exacerbation and PNA. He was diursied and discharged at dry
weight of 165 lbs, and treated with 7 day course of CTX and 5
days of azithro for CAP. He had an echo in ___ which
commented on left ventricular inflow pattern suggestive of a
restrictive filling abnormality, with elevated left atrial
pressure concerning for restrictive/infiltrative cardiomyopathy
(?amyloid), He had an SPEP and UPEP sent during his ___
admission which were negative. His weight has beenn slowly
uptrending since discharge to 172, and his torsemide was
decreased from 20 -> 15mg since follow up with his primary
cardiologist.
On arrival to the ED he was placed on NIV with 8 psv / 5 peep/
40% FiO2. Inital vitals were were 93 135/52 32 98% Bipap. His
inital exam notable for bilateral exp wheezes, and rhonic as
well as L > R LLE. He felt that his breathing improved with the
BiPAP and CPap. He was placed on 2L NC satting 97% however he
felt like his breathing was better with the NIVV so this was
restarted.
Labs: CBC without leukocytosis, h/h 13.4/40.5 ( stable),chem
notable for for Cr 1.6 ( baseline) stable from prior, and Phos
4.8,Coags notable for INR of 3.1, lactate 1.2, Trop 0.03 (
baseline), BNP 3701 (was 202 ___ Atrius records). VBG pH 7.33
pCO2 58 pO2 94 HCO3 32.
He had a CXR which showed Minimally worsened pulmonary edema
and bibasilar atelectasis, increased on the left from the
prior exam.
In the ED the working diagnosis was PNA and COPD exacerbation
for which he received 2 combivents, 60 methylpred;
cefepime/vanc/azithro ( recent hospitalization to cover HCAP).
He received 4mg IV zofran for nausea. LENIs were ordered given
___ edema, however he did not get them prior to
transfer
Vitals prior to transfer were 97.8 °F (36.6 °C), Pulse: 95,
RR: 22, BP: 105/49, O2 sat: 98, O2 flow: 40% (bpap), Pain: 0.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough. Denies chest pain, chest pressure,
palpitations, or weakness. Denies nausea, vomiting, diarrhea,
constipation, abdominal pain, or changes in bowel habits. Denies
dysuria, frequency, or urgency. Denies arthralgias or myalgias.
Denies rashes or skin changes.
Past Medical History:
1. CARDIAC RISK FACTORS:- Diabetes, Dyslipidemia,+ Hypertension
2. CARDIAC HISTORY:
- CABG: None
- PERCUTANEOUS CORONARY INTERVENTIONS: None
- PACING/ICD: None
3. OTHER PAST MEDICAL HISTORY:
Sensory hearing loss
HTN
Insomnia
COPD
CHF
Afib
CKD III
Social History:
___
Family History:
Mother had breast cancer
Physical Exam:
ON ICU ADMISSION:
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, dry MM, oropharynx clear
Neck: supple, JVP around 12 cm (to earlobe at 45 deg), no LAD
Lungs: diffuse exp wheezes bilaterally, LLL rales
CV: irregular no murmurs, rubs, gallops
Abdomen: distened, but soft; tympaantic to percussion,
normoactive bowel sounds non-tendder
GU: foley
Ext: warm, well perfused, 2+ pulses, 2+ edema left ankles; 1
right a ankles
Discharge exam:
very hard of hearing, A and O x 3
weight 168 pounds
BP 100s-110s/50s HR ___
JVP ~7 cm
clear lungs bilaterally, no wheezes or crackles
Abdomen slightly distended, soft, non-tender
GU: Foley cath remains in place
Ext: trace bilateral ___ edema
Pertinent Results:
ON ADMISSION:
___ 07:20AM BLOOD WBC-9.2 RBC-4.19* Hgb-13.4* Hct-40.5
MCV-97 MCH-31.9 MCHC-33.0 RDW-13.8 Plt ___
___ 07:20AM BLOOD Glucose-150* UreaN-32* Creat-1.6* Na-143
K-4.1 Cl-104 HCO3-24 AnGap-19
___ 07:20AM BLOOD proBNP-3071*
___ 07:20AM BLOOD Calcium-9.4 Phos-4.8*# Mg-2.4
___ 07:30AM BLOOD ___ pO2-94 pCO2-58* pH-7.33*
calTCO2-32* Base XS-2 Intubat-NOT INTUBA
___ 07:33AM BLOOD Lactate-1.2
Discharge labs:
WBCRBCHgbHctMCVMCHMCHCRDWPlt Ct
___
UreaNCreatNaKClHCO3AnGap
___
trop 0.03 x 3
INR 2.2
u/a:
BloodNitriteProteinGlucoseKetoneBilirubUrobilnpHLeuks
NEGNEGNEGNEGNEGNEGNEG6.5NEG
___ 1:58 pm URINE Source: Catheter.
**FINAL REPORT ___
URINE CULTURE (Final ___:
STAPH AUREUS COAG +. 10,000-100,000 ORGANISMS/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.
GRAM POSITIVE BACTERIA. ~3000/ML.
Alpha hemolytic colonies consistent with alpha
streptococcus or
Lactobacillus sp.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- 0.25 S
NITROFURANTOIN-------- <=16 S
OXACILLIN------------- 1 S
TETRACYCLINE---------- <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
___ 12:05 pm MRSA SCREEN Source: Nasal swab.
**FINAL REPORT ___
MRSA SCREEN (Final ___:
POSITIVE FOR METHICILLIN RESISTANT STAPH AUREUS.
IMAGING:
CXR ___
Mild pulmonary vascular congestion and superimposed left
basilar/retrocardiac opacitites have increased since the prior
which could be due to atelctasis or infection.
ECG:
Atrial flutter with variable block. Intraventricular conduction
delay.
Delayed R wave transition. No diagnostic change from previous
tracing
of ___
Brief Hospital Course:
Mr. ___ is a ___ year old male hx of COPD, dCHF, afib who
presents with hypoxic respiratory failure
# Hypoxic respiratory failure: Likely ___ to acute CHF
exacerbation in the setting of hypoxia, orthopnea, lower
extremity swelling, elevated BNP (was 202 ___ at ___), and
CXR with worsening pulmonary edema. His hypoxia improved prior
to ICU transfer with BiPAP, supporting CHF exacerbation.
Unlikely that he had an acute exacerbation of his COPD, wnr PNA
was unlikely given no leukocytosis, afebrile, and absence of
productive cough. Treated for CHF and COPD as below.
# Acute diastolic CHF ( EF of 55% ): Patient became clinically
volume overloaded with ___ edema, pulmonary edema on CXR. He was
discharged at a dry weight of 165 lbs in ___ while is his
weights in his outpatient records have seemed to slowly up trend
(most recently 173). After speaking with a home visiting nurse,
it seems that the percipitant of his heart failure is likely
non-adherence, as his nurse suspected that he was not always
taking the torsemide. He stated that he arranges his pills every
___ for the upcoming week, and takes them each day. There was
no evidence of ischemia; he does have a reported restrictive
pattern on echo concerning of amyloid so it is possible that is
contributing to diastolic dysfunction. He was diuresed with
improvement in his symptoms prior to transfer to the floor. He
was continued on BID metoprolol tartrate. On transfer to the
floor, torsemide 15 mg was continued daily, and discharge weight
was 168 pounds. In the future, his target dry weight should b3
165-170 pounds, and he and his home ___ were instructed to call
his outpatient providers if his weight rises above 170 pounds.
Did not fluid restrict, as this would be difficult to adhere to
at home. He will follow up with his cardiologist on ___, who
was informed of this hospitalization.
# COPD- This is likely not an acute exacerbation for the reasons
above. Held off on steroids and azithromycin. He received
standing and PRN duo-nebs. Home symbicort held since non
formulary; therapeutic exchange with advair 500/50 IH BID,
restarted Symbicort upon discharge.
# CKD( stage III)- remained stable 1.6-1.9 during his stay while
on torsemide
# Atrial fibrillation/flutter ( CHADS2 3)- INR 3.1 on admission
to the ICU and coumadin held. On arrival to the floor, INR
trended down to 2.2, and restarted home dose. Should have INR
checked on ___.
# Urinary retention- Patient has had urinary retention since
last admission; and failed voiding trial as an outpatient.
Nursing replaced foley and noted the urine to be malodorous.
UA/Ucx was sent and grew MSSA. He was asymptomatic, with a
normal u/a, thus the culture represented colonization and
asymptomatic bacteruria. Voiding trail was attempted about 3
weeks prior to admission, and failed. Consideration was given
to repeat voiding trial, but INR remained supratherapeutic until
day of discharge. Repeat voiding trial should be attempted in
the near future. Flomax continued.
# Glaucoma- cont lantanoprost
DNR/DNI
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. budesonide-formoterol 160-4.5 mcg/actuation inhalation BID
2. Albuterol Inhaler 2 PUFF IH Q ___ H PRN shortnes of breath
3. Torsemide 15 mg PO DAILY
4. Metoprolol Tartrate 12.5 mg PO BID
5. Tamsulosin 0.4 mg PO HS
6. Latanoprost 0.005% Ophth. Soln. 1 DROP LEFT EYE HS
7. Warfarin 3.75 mg PO 1X/WEEK (MO)
8. Warfarin 2.5 mg PO 6X/WEEK (___)
Discharge Medications:
1. Latanoprost 0.005% Ophth. Soln. 1 DROP LEFT EYE HS
2. Metoprolol Tartrate 12.5 mg PO BID
3. Tamsulosin 0.4 mg PO HS
4. Torsemide 15 mg PO DAILY
5. Warfarin 3.75 mg PO 1X/WEEK (MO)
6. Warfarin 2.5 mg PO 6X/WEEK (___)
7. Docusate Sodium 100 mg PO BID
8. Senna 8.6 mg PO BID
9. Albuterol Inhaler 2 PUFF IH Q ___ H PRN shortnes of breath
10. budesonide-formoterol 160-4.5 mcg/actuation inhalation BID
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary diagnosis:
Acute on chronic CHF exacerbation, possibly cardiac amyloid.
Admit weight 175 pounds, discharge weight 168 pounds. Dry
weight appears to be 165-170 pounds. Patient not interested in
aggressive diagnostic work up, which is reasonable. LVEF
preserved on recent TTE, did not repeat TTE during this
hospitalization.
Secondary diagnoses:
COPD
chronic urinary retention with indwelling Foley catheter. Noted
to have MSSA from urine culture, asymptomatic, likely
colonization. Patient recently failed voiding trial in past 3
weeks, would attempt repeat voiding trial in the coming weeks,
as he will be at future risk for developing
cystitis/pyelonephritis.
Discharge Condition:
Mental Status: Clear and coherent, very hard of hearing.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital with difficulty breathing.
This was due to fluid accumulation related to heart failure.
Your breathing improved with torsemide, and your weight on
discharge was 168 pounds. This is a good weight for you. The
more the weight increases, the worse your breathing will become,
so please call your PCP or cardiologist if your weight is more
than 170 pounds.
Please see below for your follow up appointments and
medications.
Followup Instructions:
___
|
19696560-DS-4
| 19,696,560 | 22,726,354 |
DS
| 4 |
2143-10-16 00:00:00
|
2143-10-16 16:03:00
|
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROSURGERY
Allergies:
Codeine / Aspirin / Oxycodone
Attending: ___.
Chief Complaint:
Headache
Major Surgical or Invasive Procedure:
___ ICA pipeline stenting
History of Present Illness:
Mrs. ___ is a ___ year old female with a recent admission to
our service for a newly diagnosed 11mm left sided paraclinoid
ICA aneurysm in the setting of 6 months of worsening headaches.
She was discharged home in late ___ with plans to return for
elective aneurysm coiling in the next few months. She presents
to the ED this morning after waking from sleep with a severe
headache and associated bilateral eye pain and throbbing. She
had severe nausea and vomiting as well. Vitals on arrival were
significant for HR in the ___ range initially with SBP's in
the 150's-160's. She was sent for stat head CT and CTA head and
neck and she was given multiple medications to control her pain
and nausea. The patient states this is one of the worst
headaches she has had and that the headaches come a few times a
week, can last a few hours to the entire day. She does have some
days without any headache. This is one of the most severe
headaches she has ever had but she does suffer from debilitating
headaches on a regular basis.
Past Medical History:
- HTN
- Anxiety
- Fibromuscular dysplasia s/p balloon angioplasty of bilateral
renal aa
- chronic fatigue after testing positive for EBV
- psoriasis
- cholecystectomy ___
- jaw surgery in ___ with jaw realignment
Social History:
___
Family History:
- mom, maternal uncle, and maternal grandmother all had PEs.
These were after surgeries (uncle with abdominal surgery) or
falls (mother with fall) but no one including the patient has
ever been worked up for a hypercoagulable state.
- father passed at ___, smoker, adrenal cancer
- two daughters ___, ___ and healthy
Physical Exam:
Exam:
HR 40's-70's, BP 140's-170's, afebrile, satting 100% on RA
sleepy after ativan but easily arousable
interactive, answering appropriately, AAOx3
pupils reactive 4mm->3mm bilaterally, EOMI, all CN intact, equal
strength and sensation throughout bilateral upper and lower
extremities
EXAM ON DISCHARGE:
AAOx3. Cooperative with exam. Face symmetric, tongue midline. No
drift. Left pupil 6mm, fixed. Right pupil reactive, 3-2mm. CN
III and VI palsy with ptosis and frozen L globe. Right groin
angio site is c/d/i with no hematoma or active bleeding. Full
strength throughout. SILT.
Pertinent Results:
UA negative
trop negative
tox screen negative
Chem ___
Ca 9.4
Mg 2.1
Phos 3.6
CBC 10.6/43.4/290
INR 0.9
PTT 25.6
EKG sinus, no ischemic changes
Noncontrast CT head: no intracranial hemorrhage
CTA head and neck
FINDINGS:
Head CT: There is no evidence of hemorrhage, edema, masses, mass
effect, or infarction. The ventricles and sulci are normal in
caliber and configuration. No fractures are identified.
Head CTA: 11 mm left internal carotid artery aneurysm is
unchanged when compared to prior exam. The anterior cerebral
arteries, middle cerebral arteries, and posterior cerebral
arteries appear normal. There is no evidence of vascular
occlusion. The dural venous sinuses appear patent.
Neck CTA: The carotid and vertebral arteries and their major
branches are patent with no evidence of stenoses. There is
atherosclerotic vascular disease within the aortic arch. The
left
vertebral artery is dominant. There is no evidence of internal
carotid stenosis by NASCET criteria. The lung apices are
unremarkable. There are multiple hypodense thyroid nodules which
are unchanged from prior exam. The submandibular glands and
parotid glands appear normal.
IMPRESSION:
1. Unchanged 11 mm aneurysm of the left supraclinoid internal
carotid artery.
2. No evidence of hemorrhage.
3. No evidence of vascular stenosis or occlusion.
CT HEAD: ___
IMPRESSION:
Status post left internal carotid artery pipeline stent without
evidence of infarction or hemorrhage.
CHEST (PORTABLE AP): ___
No acute cardiopulmonary process.
FEMORAL VASCULAR US RIGHT: ___
IMPRESSION:
Normal right groin ultrasound without evidence of a
pseudoaneurysm.
Brief Hospital Course:
Mrs. ___ was going to be discharge home from the ED, but then
suddenly developed a new CN VI palsy and anisocoria. She was
given 10mg IV of dexamethasone and loaded with ASA and Plavix.
She was then transferred to the ICU for close monitoring. Later
in the afternoon it progressed to a left III nerve palsy. An opt
homology consult was obtained.
On ___ the patient was taken to the angio suite for a pipeline
stenting of the left ICA aneurysm. She continued with heparin
gtt at 500 units/hr until tomorrow 8am. On post operative check
the patient remained stable.
On ___, the heparin drip was turned off. A head CT was obtained
which showed no evidence of infarction or hemorrhage. Her sbp
was liberalized to less than 180.
On ___, the patient remained neurologically and hemodynamically
stable. Her foley was removed and she was ordered for transfer
to the floor.
On ___, the patient's exam remained stable. She had complaints
of nausea and HA. Nausea was managed with compazine, which the
patient had been receiving throughout her hospitalization. She
received Tylenol for her HA. She later had complaints of
dizziness, light-headedness, and SOB. EKG and CXR were done; EKG
revealed sinus bradycardia at rate of 56 bpm, CXR negative for
any acute cardiopulmonary process. She was also noted to be
orthostatic. Gentle IV hydration at 50cc/hour. While the patient
was in the bathroom, she started bleeding from her R groin angio
site. Pressure was held x30 minutes. The patient was kept on
strict flat BR with knee immobilizer in place until 11:30 pm. A
stat CBC was obtained and Hct was noted to be stable.
On ___, the patient remained neurologically and hemodynamically
stable. Her headaches and nausea were controlled with PO
dilaudid and compazine. Right groin angio site was noted to be
clean, dry, and intact with no hematoma or active bleeding. An
ultrasound of her right groin was obtained, which was negative
for pseudoaneurysm, fistula, or hematoma. From a Neurosurgical
standpoint, the patient was deemed safe for discharge to home,
and she was discharged with instructions for follow up.
Medications on Admission:
- HCTZ 25mg daily
- losartan 25mg daily
- Effexor ER 75mg daily
- Ambian 5mg QHS
- ESTRA-NORETH 1.0/0.5MG REG STRENGTH 1 tablet daily
Discharge Medications:
1. Aspirin 325 mg PO DAILY
RX *aspirin 325 mg 1 tablet(s) by mouth once a day Disp #*60
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. Famotidine 20 mg PO BID
RX *famotidine 20 mg 1 tablet(s) by mouth twice a day Disp #*10
Tablet Refills:*0
4. HYDROmorphone (Dilaudid) 2 mg PO Q4H:PRN pain
RX *hydromorphone 2 mg 1 tablet(s) by mouth every four (4) hours
Disp #*20 Tablet Refills:*0
5. Dexamethasone 2 mg PO Q6H Duration: 1 Day
Follow taper instructions
Tapered dose - DOWN
RX *dexamethasone 2 mg Taper tablet(s) by mouth Taper Disp #*16
Tablet Refills:*0
6. Clopidogrel 75 mg PO DAILY
RX *clopidogrel 75 mg 1 tablet(s) by mouth once a day Disp #*60
Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Migraines
ICA aneurysm
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Discharge Instructions
Dr. ___ & Dr. ___
Activity
You may gradually return to your normal activities, but we
recommend you take it easy for the next ___ hours to avoid
bleeding from your groin.
Heavy lifting, running, climbing, or other strenuous exercise
should be avoided for ten (10) days. This is to prevent bleeding
from your groin.
You make take leisurely walks and slowly increase your
activity at your own pace. ___ try to do too much all at once.
Do not go swimming or submerge yourself in water for five (5)
days after your procedure.
You make take a shower.
Medications
Resume your normal medications and begin new medications as
directed.
You may be instructed by your doctor to take one ___ a day
and/or Plavix. If so, do not take any other products that have
aspirin in them. If you are unsure of what products contain
Aspirin, as your pharmacist or call our office.
You may use Acetaminophen (Tylenol) for minor discomfort if
you are not otherwise restricted from taking this medication.
If you take Metformin (Glucophage) you may start it again
three (3) days after your procedure.
Care of the Puncture Site
Keep the site clean with soap and water and dry it carefully.
You may use a band-aid if you wish.
What You ___ Experience:
Mild tenderness and bruising at the puncture site (groin).
Soreness in your arms from the intravenous lines.
Mild to moderate headaches that last several days to a few
weeks.
Fatigue is very normal
Constipation is common. Be sure to drink plenty of fluids and
eat a high-fiber diet. If you are taking narcotics (prescription
pain medications), try an over-the-counter stool softener.
When to Call Your Doctor at ___ for:
Severe pain, swelling, redness or drainage from the puncture
site.
Fever greater than 101.5 degrees Fahrenheit
Constipation
Blood in your stool or urine
Nausea and/or vomiting
Extreme sleepiness and not being able to stay awake
Severe headaches not relieved by pain relievers
Seizures
Any new problems with your vision or ability to speak
Weakness or changes in sensation in your face, arms, or leg
Followup Instructions:
___
|
19696764-DS-19
| 19,696,764 | 24,205,160 |
DS
| 19 |
2155-11-17 00:00:00
|
2155-11-18 13:39:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Fever and fatigue
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ year old woman with no significant past medical
history who presents with two days of weakness and
lightheadedness.
She reports that she woke up on ___ morning feeling some
mild back pain, which went away without treatment. She then
felt well until ___ morning when she woke up at 5:30 am
feeling very lightheaded with body aches. She called an
ambulance and presented to the ED. She was given IVF and sent
home. She felt increasingly worse throughout the day. She
returned to the ED due to increased fatigue and fever. She
reported fever, chills, mild intermittent headache. Denied
stiff neck. No n/v/d/c. No dysuria. No recent sick contacts.
No recent travel. All vaccinations up to date. Flu shot last
fall.
In th ED, initial vitals were 99.9 141 122/66 14 100%/RA. Labs
were unremarkable and HCG negative. UA notable for 22 wbc, few
bact, 2 epi. ED read of EKG: flipped T waves in lateral leads,
no prior for comparison. Received 4L NS, 1Gm Tylenol at ___,
Tamiflu 75mg, Cipro 500mg po for UTI, Toradol at 0230 for aches.
Vitals on transfer 102.7 °F (39.3 °C), Pulse: 117, RR: 18, BP:
119/71, O2Sat: 100. She was admitted for management of
tachycardia and fever.
Past Medical History:
History of swine flu in high school, required antibiotics for
possible bacterial superinfection
Social History:
___
Family History:
Maternal grandfather with HTN, maternal grandmother with gastric
cancer
Physical Exam:
ADMISSION EXAM:
Vitals: T: 102.3 BP: 96/50 P: 121 R: 20 O2:97 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
CV: Regular tachycardic, normal S1 + S2, no m/r/g
Abdomen: soft, NT/ND, bowel sounds present, no rebound
tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, moving all extremities
Skin: no rashes
DISCHARGE EXAM:
Tm 101.9 Tc 98.1 BP: 125/58 P:96 (90s) R: 18 O2:98 RA
General: Alert, oriented, sleepy
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular tachycardic, normal S1 + S2, no m/r/g
Abdomen: soft, NT/ND, bowel sounds present, no rebound
tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, moving all extremities
Skin: no rashes
Pertinent Results:
ADMISSION LABS:
___ 06:18AM BLOOD WBC-11.2* RBC-4.37 Hgb-12.6 Hct-39.2
MCV-90 MCH-28.8 MCHC-32.2 RDW-12.6 Plt ___
___ 06:18AM BLOOD Neuts-82.4* Lymphs-11.9* Monos-4.6
Eos-0.4 Baso-0.7
___ 06:18AM BLOOD Glucose-104* UreaN-11 Creat-0.7 Na-138
K-3.6 Cl-101 HCO3-23 AnGap-18
___ 09:00PM BLOOD ALT-30 AST-21 LD(LDH)-157 AlkPhos-56
TotBili-0.4
___ 09:32PM BLOOD Lactate-1.5
DISCHARGE LABS:
___ 06:20AM BLOOD WBC-6.5 RBC-3.62* Hgb-10.5* Hct-32.1*
MCV-89 MCH-29.1 MCHC-32.8 RDW-12.9 Plt ___
___ 06:20AM BLOOD Glucose-99 UreaN-7 Creat-0.6 Na-139 K-3.5
Cl-106 HCO3-27 AnGap-10
URINE:
___ 10:45PM URINE Color-Straw Appear-Clear Sp ___
___ 10:45PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-10 Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-MOD
___ 10:45PM URINE RBC-1 WBC-22* Bacteri-FEW Yeast-NONE
Epi-2 TransE-<1
___ 10:45PM URINE Mucous-RARE
MICROBIOLOGY:
URINE CULTURE (Final ___:
Culture workup discontinued. Further incubation showed
contamination
with mixed skin/genital flora. Clinical significance of
isolate(s)
uncertain. Interpret with caution.
ESCHERICHIA COLI. >100,000 ORGANISMS/ML..
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
Piperacillin/tazobactam sensitivity testing available
on request.
ESCHERICHIA COLI. 10,000-100,000 ORGANISMS/ML..
PRESUMPTIVE IDENTIFICATION. ___ MORPHOLOGY.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ <=2 S
AMPICILLIN/SULBACTAM-- <=2 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
IMAGING:
CXR: Left lower lobe opacity is concerning for infectious
process. Followup of the patient in four weeks after completion
of antibiotic therapy is recommended for documentation of
resolution. Heart size and mediastinum are unremarkable. Rest
of the lungs are clear. There is no pleural effusion or
pneumothorax.
Brief Hospital Course:
Assessment: Ms. ___ is a ___ year old woman with no significant
past medical history who presented with two days of weakness,
lightheadedness and fever found to have both a UTI and
pneumonia.
# Fever/Pneumonia/UTI -> Ms. ___ presented with two days of
weakness and lightheadedness and was found to have fevers to
102.8 in the ED. Her initial presentation was most consistent
with a viral infection, possibly influenza. Flu swabs were
negative. HIV viral load was negative. CXR suggested a LLL
pneumonia. She was started on levofloxacin for a presumed
community acquired pneumonia. Urinary legionella antigen was
negative. U/A was suggestive of infection and urine culture
ultimately grew pansensitive E. Coli. She never developed any
urinary symptoms or flank pain to suggest pyelonephritis. She
continued to be febrile to over 103 during the first day of her
admission and was treated with IVF and fever reduction with
acetominophen and ibuprofen. Her fevers ultimately began to
subside, although she still spiked fevers to 101.9 on the night
prior to discharge. She was continued on levofloxacin for a 10
day course for both community pneumonia and uncomplicated
urinary tract infection. She was dischaged with instructions
for follow-up at ___ in one week and told to call Dr.
___ at ___ (number provided) if her fevers worsen or do
not improve.
# Tachycardia -> Patient with tachycardia elevated to the 150s.
She remained in sinus rhythm throughout. Tachycardia was likely
in the setting of volume depletion and fever. She was continued
on IVF during the early hospitalization due to insensible losses
due to fever. Her heart rate slowly began to decrease
throughout her stay. She maintained good PO fluid intake.
# Anemia -> After IVF, her hct dropped from 39->31, likely
dilutional. Hct was followed and trended back up throughout the
admission. No evidence of bleeding.
TRANSITION OF CARE:
1. Recommend follow-up CXR in four weeks to assess resolution of
LLL pneumonia
2. Ensure fevers have subsided, on oral antibiotics, and that
course does not need to be extended.
Medications on Admission:
None
Discharge Medications:
1. levofloxacin 750 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily) for 7 days.
Disp:*7 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Pneumonia
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 the hospital because you had a fever. You
had a chest xray which showed an infection in your lung. We
tested your urine and found that you had a urinary tract
infection. You were started on antibiotics to treat your
infection. You were started on a ten day course of
levofloxacin, with three days completed in the hospital and
seven more days of treatment to complete after discharge.
If your symptoms return or you develop a fever, please call
___ and ask for Dr. ___ or return to the
emergency room.
The following changes were made to your medications:
START taking Levofloxacin 750 mg daily for seven days after
discharge
Followup Instructions:
___
|
19696769-DS-7
| 19,696,769 | 23,780,338 |
DS
| 7 |
2121-06-12 00:00:00
|
2121-06-12 17:41:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Cipro / Sulfa (Sulfonamide Antibiotics) / IV Dye, Iodine
Containing Contrast Media / Shellfish
Attending: ___
Chief Complaint:
Dyspnea, congestion
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old male with a past medical history notable for type 2
diabetes, hypertension, hyperlipidemia, h/o TIA, nonischemic
cardiomyopathy with EF 35%, and history of stricturing ileal
Crohn's disease status post ileocecectomy with a side-to-side
anastomosis presenting with cough, shortness of breath and
congestion in the setting of chronic struggle to care for
himself at home.
___ is a poor historian but states that dyspnea started
about 4 days ago with URI symptoms (cough, congestion, runny
nose) after his partner was sick. He feels that his symptoms
have not gotten any better and his cough in particular is worse
than before. The morning of admission he describes a panicked
feeling that "felt like a storm went off in my head and I just
couldn't catch my breath". His partner then called EMS who
brought him to the hospital. He also endorses "3 episodes of
chest pain" that were non-exertional, substernal and occurred on
multiple days in the past week. They resolved with
nitroglycerine SL, but he does not recall how long these
episodes lasted. Reports that the last episode was 2 days ago.
Denies any acute weight gain, increase in ___ edema, abdominal
pain, diarrhea or constipation. Endorses worsening doe but
denies orthopnea.
Per him and his partner, who accompanies him, he is non
compliant with his medications at home and takes things "when he
remembers". He currently is more confused than he is at
baseline. He normally ambulates with walker but his functional
status has also been declining and is currently needing to hold
onto walls, struggling with stairs. Has to get down flight of
stairs currently to use BR or go to the kitchen.
In the ED, initial vitals were:
97.8 109 187/93 24 99% RA
Exam notable for 2+ ___ edema, chronic skin changes.
Labs notable for no leukocytosis no tropinemia, influenza swab
negative , VBG ___, normal lactate
Imaging notable for
___ was given
___ 13:32 PO Azithromycin 500 mg ___
___ 13:32 IH Albuterol 0.083% Neb Soln 1 Neb
___
___ 13:32 IH Ipratropium Bromide Neb 1 Neb ___
___ 16:18 PO PredniSONE 60 mg ___
___ was seen by who recommended ___ who recommended dispo to
rehab
Decision was made to admit for COPD exacerbation although no
wheezing was noted and failure to thrive
Vitals notable for remaining stable on RA throughout
Past Medical History:
DM - ___ is not sure if this is type 1 or type 2, though it
started in childhood he believes that it is a glucose
intolerance
problem
diabetic peripheral neuropathy
HTN
HLD
cardiomyopathy
h/o TIA
Crohn's disease, h/o bowel resection
Asthma
___
Social History:
___
Family History:
Grandfather with stroke in ___. Mother with breast cancer.
Grandmother with colon cancer. Family history of DM
Physical Exam:
ADMISSION PHYSICAL EXAM:
==========================
VS: 98.1 PO, 152/78, 96, 20, 94%RA
Gen: ___ is lying in bed, well appearing, in NAD
HEENT: PERRL, EOMI, sclera non-icteric, MMM without lesion, no
cervical LAD
CV: RRR, normal S1/S2 no S3/S4 or murmurs. JVP ~10mmHg
Pulm: bibasilar crackles without wheezing
Abd: obese but non-tender, unable to appreciate organomegaly,
well healed midline and RLQ scars.
GU: no foley
Ext: Warm, chronic venous stasis changes bilaterally, 1+
pitting edema bilaterally, shallow ulcers bilaterally. Feet with
onychomycosis bilaterally and mild skin breakdown between toes.
Skin: no rash
Neuro: alert and oriented X3 but trouble remembering history
Psych: labile mood
DISCHARGE PHYSICAL EXAM
========================
vs: 97.9PO 164 / 83 83 20 95 RA
Gen: ___ is lying in bed, well appearing, in NAD
HEENT: PERRL, EOMI, sclera non-icteric, MMM without lesion, no
cervical LAD
CV: RRR, normal S1/S2 no S3/S4 or murmurs. JVP ~10mmHg
Pulm: bibasilar crackles without wheezing
Abd: obese but non-tender, unable to appreciate organomegaly,
well healed midline and RLQ scars.
GU: no foley
Ext: Warm, chronic venous stasis changes bilaterally, 1+
pitting edema bilaterally, shallow ulcers bilaterally. Feet with
onychomycosis bilaterally and mild skin breakdown between toes.
Skin: no rash
Neuro: alert and oriented X3 but trouble remembering history
Psych: labile mood
Pertinent Results:
ADMISSION LABS
===============
___ 11:00AM PLT COUNT-185
___ 11:00AM NEUTS-81.2* LYMPHS-10.2* MONOS-6.7 EOS-1.3
BASOS-0.3 IM ___ AbsNeut-4.86 AbsLymp-0.61* AbsMono-0.40
AbsEos-0.08 AbsBaso-0.02
___ 11:00AM WBC-6.0 RBC-4.37* HGB-14.5 HCT-41.0 MCV-94
MCH-33.2* MCHC-35.4 RDW-12.2 RDWSD-42.2
___ 11:00AM cTropnT-<0.01
___ 11:00AM %HbA1c-9.7* eAG-232*
___ 11:00AM GLUCOSE-378* UREA N-13 CREAT-0.8 SODIUM-133
POTASSIUM-3.8 CHLORIDE-99 TOTAL CO2-19* ANION GAP-19
___ 11:34AM LACTATE-1.8
___ 03:00PM proBNP-214
DISCHARGE LABS
==============
___ 06:10AM BLOOD WBC-6.3 RBC-4.11* Hgb-14.0 Hct-39.0*
MCV-95 MCH-34.1* MCHC-35.9 RDW-12.3 RDWSD-42.8 Plt ___
___ 06:10AM BLOOD Glucose-324* UreaN-20 Creat-0.9 Na-134
K-3.9 Cl-101 HCO3-19* AnGap-18
___ 06:21AM BLOOD ___ pO2-65* pCO2-35 pH-7.41
calTCO2-23 Base XS--1 Comment-GREEN TOP
IMAGING
==========
CXR
FINDINGS:
AP upright and lateral views of the chest provided.
Lung volumes are low. There is mild left basal atelectasis. No
convincing
evidence for pneumonia. Cardiomediastinal silhouette is
unchanged. No signs
of congestion or edema. Bony structures are intact.
IMPRESSION:
Mild left basal atelectasis. No convincing evidence for
pneumonia.
Brief Hospital Course:
___ year old male with a past medical history notable for
diabetes, ischemic cardiomyopathy requiring an ICD and history
of stricturing ileal Crohn's disease status post ileocecectomy
with a side-to-side anastomosis presenting with symptoms of URI
in the setting of chronic failure to thrive.
# Cough, Dyspnea: Flu swab negative, CXR w/o evidence of PNA no
hypoxia or significant CO2 retention. No evidence of bacterial
infection. Started on Azithro and pred by ED for presumed COPD
exacerbation but no wheezing on exam so will stop these
therapies. On exam JVP elevated, ___ edema with bibasilar
crackles concerning for mild CHF exacerbation in the setting of
recent URI and medication non-compliance.
# Functional decline: ___ and partner report gradual decline
in functional status and frequent falls at home over months.
Unable to take care of himself at home and is severely limited
by mobility and dyspnea. ___ was placed in rehab.
# AGMA, Hyperglycemia, T2DM: ___ hyperglycemic to >400's in
ED and on floor. Improved once started home lantus and sliding
scale. Metformin and Januvia were held during admission.
CHRONIC ISSUES:
# Non-ischemic HFrEF: ___ with EF 35% per ___ ECHO,
non-ischemic per report has clean coronaries but no h/o cardiac
cath on file. Non compliant with home medications and followed
by Dr. ___. Per last cardiology note: ___
class III. Stage C. ___ Heart Failure score with available
date predicts ___ year survival ___ year ___ - 80% ___ year. With the
addition of ace inhibitors and spironolactone his ___ year
survival could go up to 89%, with ICD 95% ___ years. However, he
didn't tolerate ACE ___ lightheadedness. He was also supposed to
be scheduled for RHC to evaluate pulm cause for ongoing
progressive DOE but ___ states that he doesn't want this
done.
- BNP was not elevated and he was not in a CHF exacerbation.
Restarted on home lasix
# Crohn's disease: ___ h/o bowel resection ___ Crohn's
flair.
___ status he has flairs every ___ months which involve
diarrhea.
#HTN - cont home amlodipine 5 mg, carvedilol, imdur, hydral as
above
#HLD - cont home statin as above
#Asthma/COPD: cont. home inhalers as above
TRANSITIONAL ISSUES
[ ] Pt was intermittently hypertensive to the 160's during
hospitalization, consider uptitrating Coreg as an outpatient.
[ ] ___ may need exploration of an assisted living
environment
[ ] ___ restarted on cholystyramine previously recommended
by GI.
[ ] Consider adding ___ given HFrEF.
# CODE: full code with limiting life sustaining measures
# CONTACT:
Name of health care proxy: ___
Relationship: friend/partner
Phone number: ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. amLODIPine 5 mg PO DAILY
2. Furosemide 40 mg PO DAILY
3. HydrALAZINE 25 mg PO TID
4. Rosuvastatin Calcium 10 mg PO QPM
5. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
6. Montelukast 10 mg PO DAILY
7. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
8. Albuterol Inhaler 1 PUFF IH Q6H:PRN wheezing
9. Fluticasone Propionate NASAL 2 SPRY NU DAILY
10. lantus 70 Units Breakfast
lantus 50 Units Bedtime
novolog 10 Units Breakfast
novolog 10 Units Lunch
novolog 10 Units Dinner
Insulin SC Sliding Scale using novolog Insulin
11. TraZODone 100 mg PO QHS:PRN insomnia
12. MetFORMIN XR (Glucophage XR) 500 mg PO BID
13. Januvia (SITagliptin) 100 mg oral DAILY
14. BuPROPion (Sustained Release) 300 mg PO QAM
15. Silver Sulfadiazine 1% Cream 1 Appl TP BID
16. Coreg CR (carvedilol phosphate) 20 mg oral DAILY
17. olsalazine 500 mg oral BID
Discharge Medications:
1. Cholestyramine 4 gm PO BID
2. Sodium Chloride Nasal ___ SPRY NU QID:PRN Congestion
3. lantus 70 Units Breakfast
lantus 50 Units Bedtime
novolog 10 Units Breakfast
novolog 10 Units Lunch
novolog 10 Units Dinner
Insulin SC Sliding Scale using novolog Insulin
4. Albuterol Inhaler 1 PUFF IH Q6H:PRN wheezing
5. amLODIPine 5 mg PO DAILY
6. BuPROPion (Sustained Release) 300 mg PO QAM
7. Coreg CR (carvedilol phosphate) 20 mg oral DAILY
8. Dipentum (olsalazine) 500 oral BID
9. Fluticasone Propionate NASAL 2 SPRY NU DAILY
10. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
11. Furosemide 40 mg PO DAILY
12. HydrALAZINE 25 mg PO TID
13. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
14. Januvia (SITagliptin) 100 mg oral DAILY
15. MetFORMIN XR (Glucophage XR) 500 mg PO BID
Do Not Crush
16. Montelukast 10 mg PO DAILY
17. olsalazine 500 mg oral BID
18. Rosuvastatin Calcium 10 mg PO QPM
19. Silver Sulfadiazine 1% Cream 1 Appl TP BID
20. TraZODone 100 mg PO QHS:PRN insomnia
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Dyspnea
Secondary diagnosis
AGMA, Hyperglycemia, T2DM
Non-ischemic HFrEF
Functional decline
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Mr. ___,
You were admitted for symptoms of a COPD exacerbation, which
actually was more consistent with an upper respiratory
infection. Also you have been having more difficulty moving
around your home with more frequent falls. You were seen by our
physical therapists, who recommended that you get some rehab to
help make you stronger.
It was a pleasure taking care of you,
Your ___ Care team
Followup Instructions:
___
|
19696769-DS-9
| 19,696,769 | 24,511,833 |
DS
| 9 |
2122-05-15 00:00:00
|
2122-05-15 19:29:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Cipro / Sulfa (Sulfonamide Antibiotics) / IV Dye, Iodine
Containing Contrast Media / Shellfish
Attending: ___.
Chief Complaint:
Abdominal pain, constipation
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___, PhD, PhD is a ___ year old former college ___
who has been retired for the last ___ years who has numerous
medical problems including cardiomyopathy, diabetes,
hypertension, stricturing ileal Crohn's disease status post
ileocecectomy, history of TIA, and a unclear progressive
neurologic decline in the form of cognitive impairment, gait
apraxia, and behavioral issues. He lives alone and called EMS
after he had developed abdominal pain, and was admitted with a
diagnosis of pyelonephritis.
Patient states that he had a "tremendous abdominal pain" that
came on suddenly and called EMS. He has lots of chronic
symptoms, a dry cough for 4 months, urinary incontinence without
dysuria for months. He does not describe any acute symptoms
other than the abdominal pain which has gone away. He also
states that because of his Crohn's disease he get abdominal pain
fairly often. In the ED he was found incontinent of stool.
Patient states that he lives nearby, alone most of the time but
occasionally his friends stay with him ___ and ___ and also
has some people to come for cleaning his apartment and cleaning
him. He describes "a lot of falls" and that he "tries to be
careful" but cannot provide much more detail.
On arrival to the floor, patient reports no acute complaints,
though he is a very poor historian. He says that he is very
tired and would like to go to sleep.
In the ED, initial VS were: 97.3 91 177/128 17 96% RA
Exam notable for: tender to palpation left upper quadrant,
fecal occult blood negative
EKG: sinus, poor r wave progression
Labs showed:
-CBC within limits
-Chem 10 hemolyzed, mildly low bicarbonate
-VBG with respiratory alkalosis, lactate 2.5
-UA with ketones, 12 WBCs, 2 RBCs, negative nitrite, few
bacteria
Imaging showed: no evidence of pyelo, chronic IBD inflammation
Patient received: 500cc NS, ceftriaxone 1g x 1
REVIEW OF SYSTEMS: 10 point ROS reviewed and negative except as
per HPI
Past Medical History:
-Ischemic cardiomyopathy
-Type 2 diabetes
-Stricturing ileal Crohn's disease status post ileocecectomy
with
a side-to-side anastomosis
-Asthma/COPD emphysema
-Hypertension
-Hyperlipidemia
-Peripheral neuropathy
-Seizure disorder (?)
-OSA
-History of TIAs.
-Cognitive impairment, gait instability, visual hallucinations
Social History:
___
Family History:
Grandfather with stroke in ___. Mother with breast cancer.
Grandmother with colon cancer. Family history of DM
Physical Exam:
ADMISSION PHYSICAL EXAM:
==============================
VS: 97.8 ___ 99%RA
Gen: Non toxic appearing, in NAD
HEENT: bruise under left eye
Chest: lungs CTAB
Cardiac: heart sounds are distant, but regular without murmur
Abd: Scars from small bowel resection, appendix surgery. Some
mild discomfort with deep palpation, no rebound or guarding.
Back: Some focal tenderness of the lumbar spinous process. No
CVA tenderness.
GU: wearing an adult diaper
Ext: Chronic venous stasis, some well healed wounds bilaterally.
Warm, no edema.
Neuro: Poor historian, but evidence of his education is clear in
that he occasionally responds in different languages. He asked
why a documentary of ___ was on TV. Was able to recall his
address and HCP phone number.
DISCHARGE PHYSICAL EXAM:
==============================
Vitals: 98.1 148/77 77 18 95 RA
General: Sitting up in bed eating breakfast, no acute distress
HEENT: Bruise resolving under left eye
Neck: No JVD
Lungs: CTAB, no crackles, wheezes
CV: Distant heart sounds, RRR, no murmurs
Abdomen: well healed scars for appendectomy and small bowel
resection. Abd soft, non-tender, bowel sounds present
Ext: Chronic venous stasis L>R, no edema
Neuro: AOx2 (not oriented to date), but able to say days of the
week backwards.
Pertinent Results:
ADMISSION LABS:
====================
___ 05:50PM BLOOD WBC-7.9 RBC-4.66 Hgb-15.8 Hct-43.2 MCV-93
MCH-33.9* MCHC-36.6 RDW-12.5 RDWSD-41.9 Plt ___
___ 05:50PM BLOOD ___ PTT-30.4 ___
___ 05:50PM BLOOD Glucose-227* UreaN-18 Creat-0.8 Na-134*
K-5.6* Cl-98 HCO3-20* AnGap-16
___ 05:50PM BLOOD ALT-25 AST-46* AlkPhos-67 TotBili-0.5
___ 05:50PM BLOOD Lipase-25
___ 05:50PM BLOOD cTropnT-<0.01
___ 05:50PM BLOOD Albumin-4.0 Calcium-9.5 Phos-2.9 Mg-1.9
___ 05:50PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 06:01PM BLOOD ___ pO2-40* pCO2-22* pH-7.55*
calTCO2-20* Base XS-0
___ 06:01PM BLOOD Lactate-2.5* K-3.9
RELEVANT LABS:
====================
___ 05:15AM BLOOD %HbA1c-9.0* eAG-212*
MOST RECENT LABS PRIOR TO DISCHARGE:
======================================
___ 05:15AM BLOOD WBC-6.8 RBC-3.97* Hgb-13.6* Hct-37.5*
MCV-95 MCH-34.3* MCHC-36.3 RDW-12.3 RDWSD-42.5 Plt ___
___ 05:15AM BLOOD Glucose-234* UreaN-15 Creat-0.9 Na-140
K-4.3 Cl-104 HCO3-23 AnGap-13
___ 05:15AM BLOOD ALT-18 AST-18 LD(LDH)-238 AlkPhos-64
TotBili-0.4
___ 05:15AM BLOOD Albumin-3.6 Calcium-8.5 Phos-2.8 Mg-1.9
MICROBIOLOGY:
=================
___ UA (NOTE NORMAL UA ___ 05:50PM URINE Color-Yellow Appear-Hazy* Sp ___
___ 05:50PM URINE Blood-NEG Nitrite-NEG Protein-100*
Glucose-100* Ketone-10* Bilirub-NEG Urobiln-2* pH-6.5 Leuks-MOD*
___ 05:50PM URINE RBC-2 WBC-12* Bacteri-FEW* Yeast-NONE
Epi-1 TransE-<1
___ 05:50PM URINE Mucous-RARE*
IMAGING:
===========
___ CXR PA/LA:
Lungs moderately well expanded. No acute intrathoracic process
___ CT HEAD W/O CONTRAST:
FINDINGS:
The study is moderately limited by motion artifact. A
hypodensity in the
subcortical white matter of the left parietal lobe is again
noted without
interval changes compared to prior CT from ___,
corresponding to the T2/FLAIR hyperintensities seen on prior
MRI. There is no evidence of large territorial
infarction,hemorrhage,edema, or mass. There is prominence of
the ventricles and sulci suggestive of involutional changes,
similar to prior studies. Bilateral periventricular subcortical
white matter hypodensities are nonspecific but most likely
represent sequela of chronic small vessel ischemic changes.
There is no evidence of fracture. The visualized portion of the
paranasal
sinuses, mastoid air cells, and middle ear cavitiesare
essentially clear. The patient is status post bilateral lens
replacement. Otherwise the orbits are unremarkable.
IMPRESSION:
1. No acute intracranial process.
2. No calvarial fractures.
___ CT ABD/PELVIS W/O CONTRAST:
IMPRESSION:
1. No acute process within the abdomen or pelvis. Specifically,
no bowel
obstruction or intraabdominal or intrapelvic abscess.
2. Unchanged chronic inflammatory changes of the distal and
terminal ileum
secondary to known Crohn's disease. Given the limitation of a
noncontrast
study, no evidence of acute Crohn's flare.
3. Cholelithiasis without cholecystitis.
Brief Hospital Course:
SUMMARY:
==============
___ yoM w/ medical history of HFrEF (EF 35%) ___ ischemic
cardiomyopathy, NIDDM, Crohn's disease and progressive
functional decline over the last year who presented with
abdominal pain secondary to constipation, found to have a UA
concerning for a UTI, and worsening gait instability resulting
in frequent falls, visual hallucinations, and urinary/fecal
incontinence. In addition to his significant medical problems,
the patient has limited resources and few options to improve his
safety and quality of life.
ACTIVE PROBLEMS:
==================
#ABDOMINAL PAIN
#CONSTIPATION
Presented with "severe" abdominal pain, relatively benign
abdominal exam. CT A/P showed chronic colitis and large stool
burden. Given colace, senna and miralax with good stool output
and resolution of his abdominal pain. Stool incontinence at home
may be secondary to overflow incontinence. Discharged on
Miralax, Colace, Senna and PRN bisacodyl suppository for no BM
x2-3 days (not need while inpatient).
#COMPLICATED URINARY TRACT INFECTION
UA with mod LEUKS, WBC and few bacteria. Prior UA's (most
recently ___ normal. Per pt and caregiver, incontinence has
been worsening over the past 4 months, as has his balance. Pt
also reported confusion and inattentiveness. Pt's urine culture
with mixed bacterial flora, consistent with skin/genital
contamination. Given persistent confusion as above, pt started
on cefpodoxime 200mg q12h x10 days for an end date through
___.
#GAIT INSTABILITY, FREQUENT FALLS
#VISUAL HALLUCINATIONS
#COGNITIVE DECLINE
#HOME SAFETY
PER CHART REVIEW: Evaluated by neurology ___ during prior
hospital admission. MRI showed only generalized moderate global
atrophy without focal features and chronic small vessel disease.
Given concern for ___ Body ___ syndrome,
he followed up with Dr. ___ neurology in ___. At
that time, pt's visual hallucinations had stopped and thus were
attributed to acute medical illness. The etiology of his gait
instability remained unclear, though extensive medication list
and diabetic neuropathy thought to contribute; pt's HCP also
states severe anxiety and hesitation associated with walking due
to fear of falls. SPECT scan (___) without typical signs of
Alzheimer's or LBD; signs were most consistent with age-advanced
involutional changes. He did not follow up for neuropsych
testing nor did he keep his appointment with Dr. ___
Dr. ___ for further evaluation. During this admission,
the patient and ___ (HCP) note progressive decline in mobility
___ falls over last several months) and intermittent visual
hallucinations (usually cats). ___ is concerned re urinary and
fecal incontinence, as well as the patient's frequent
falls(presented with a black eye). He is tangential at times and
has difficulty focusing, but is not delirious. ___
demonstrated no acute intracranial process. He has worked with
___ and OT who recommended acute rehab at discharge. Of note, ___
(HCP) is his main support system, and he has two other people
who provide services; he does not manage his medications by
himself. He should be re-scheduled for follow up with outpatient
neurology/cognitive neurology for further evaluation.
CHRONIC/STABLE ISSUES:
==========================
#DIABETES MELLITUS, TYPE II
Continued on home regimen with decrease in meal time insulin.
HbA1c 9.0. We increased his metformin 500mg BID to ___ BID for
optimization.
#ISCHEMIC CARDIOMYOPATHY
#HEART FAILURE WITH REDUCED EF
No evidence of CHF on admission. Seems to have been lost to
follow up with ___ cardiology, unclear if RHC/LHC has been
performed elsewhere.
-Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
-Coreg CR (carvedilol phosphate) 20 mg oral DAILY
-Furosemide 40 mg PO DAILY
-HydrALAZINE 25 mg PO TID
-Rosuvastatin Calcium 10 mg PO QPM
#HYPERTENSION
SBP ranged between 120s and 160s, usually correlating to timing
of carvedilol which was given BID (fractionated home dose of
same). Given multiple falls at home in the setting of position
changes, we did not uptitrate his medications due to concern for
orthostasis.
-Coreg CR (carvedilol phosphate) 20 mg oral DAILY
-Furosemide 40 mg PO DAILY
-HydrALAZINE 25 mg PO TID
-Amlodipine 10mg PO DAILY
#COPD
History of obstructive lung disease. No respiratory complaints
while inpatient.
-Fluticasone Propionate NASAL 1 SPRY NU DAILY
-Montelukast 10 mg PO DAILY
-Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
-Albuterol Inhaler 2 PUFF IH Q6H:PRN shortness of breath
-Tiotropium Bromide 1 CAP IH DAILY
#ANXIETY
Stable on home medications. Re-started Venlafaxine.
-Venlafaxine XR 37.5 mg PO DAILY
-BuPROPion XL (Once Daily) 300 mg PO DAILY
-ClonazePAM 0.25 mg PO QHS
#CROHN'S DISEASE
Does not appear to be on any active therapy. CT scan showed
chronic inflammation.
#HISTORY OF OSA
Patient does not have CPAP at home and did not use it while
inpatient.
#BPH
Prostate is very enlarged with calcification on abdominal CT
scan, chronic finding for at least ___ year. Bladder scan with
mild retention but likely chronic (~400cc).
-Tamsulosin 0.4 mg PO QHS
TRANSITIONAL ISSUES:
=======================
#CODE: Full (presumed)
#CONTACT: ___ (friend, HCP) ___
[ ] MEDICATION CHANGES:
- Added: Cefpodoxime (through ___, venlafaxine XR (37.5mg
PO daily)
- Changed: Metformin (500mg PO BID -> 750mg PO BID)
[ ] URINARY TRACT INFECTION:
- Continue cefpodoxime 200mg q12h until ___. Patient should
receive his ___ dose on ___ around 8PM.
[ ] HEART FAILURE:
- Admission weight: 117kg (no scale on floor so we do not have
an accurate discharge weight, but CHF was not a concern during
admission)
- Discharge creatinine: 0.9 on ___
- Consider restarting Lisinopril if no adverse reaction given DM
and CHF (unclear if it fell off the list or was stopped for a
reason)
[ ] CONSTIPATION/ABDOMINAL PAIN:
- Pt discharged on a bowel regimen of miralax and docusate. Can
hold for loose stools/diarrhea, but please provide to encourage
at least one soft bowel movement per day.
[ ] DIABETES MANAGEMENT:
- Uptitrated metformin from 500mg BID -> 750mg PO BID.
- Follow up A1c in ___.
- Consider restarting Lisinopril if no adverse reaction given DM
and CHF (unclear if it fell off the list or was stopped for a
reason)
[ ] COGNITIVE DECLINE:
- Pt should follow up with cognitive neurology as scheduled
given his progressive cognitive decline, gait instability, and
visual hallucinations.
- Neurology can assist with titration of mood medications.
[ ] HOME SAFETY:
- Pt with limited financial and caretaker resources. Please
provide social work assistance while at rehab.
- Please minimize medications that can contribute to sedation or
orthostatic hypotension.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. MetFORMIN XR (Glucophage XR) 500 mg PO BID
2. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
3. Fluticasone Propionate NASAL 1 SPRY NU DAILY
4. amLODIPine 5 mg PO DAILY
5. Glargine 70 Units Breakfast
Glargine 20 Units Dinner
Novolog 20 Units Breakfast
Novolog 20 Units Lunch
Novolog 20 Units Dinner
6. TraMADol 25 mg PO BID
7. Tamsulosin 0.4 mg PO QHS
8. Gabapentin 300 mg PO QHS
9. Coreg CR (carvedilol phosphate) 20 mg oral DAILY
10. ClonazePAM 0.25 mg PO QHS
11. BuPROPion XL (Once Daily) 300 mg PO DAILY
12. Rosuvastatin Calcium 10 mg PO QPM
13. Montelukast 10 mg PO DAILY
14. Venlafaxine XR 37.5 mg PO DAILY
15. Furosemide 40 mg PO DAILY
16. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
17. Albuterol Inhaler 2 PUFF IH Q6H:PRN shortness of breath
18. Tiotropium Bromide 1 CAP IH DAILY
19. HydrALAZINE 25 mg PO TID
Discharge Medications:
1. Cefpodoxime Proxetil 200 mg PO/NG Q12H Duration: 20 Doses
RX *cefpodoxime 200 mg 1 tablet(s) by mouth every 12 hours Disp
#*11 Tablet Refills:*0
2. Docusate Sodium 100 mg PO BID
3. Polyethylene Glycol 17 g PO DAILY
4. Senna 8.6 mg PO DAILY
5. Venlafaxine XR 37.5 mg PO DAILY
6. ClonazePAM 0.25 mg PO QHS:PRN anxiety, insomnia
7. MetFORMIN XR (Glucophage XR) 750 mg PO BID
Do Not Crush
8. Albuterol Inhaler 2 PUFF IH Q6H:PRN shortness of breath
9. amLODIPine 5 mg PO DAILY
10. BuPROPion XL (Once Daily) 300 mg PO DAILY
11. Coreg CR (carvedilol phosphate) 20 mg oral DAILY
12. Fluticasone Propionate NASAL 1 SPRY NU DAILY
13. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
14. Furosemide 40 mg PO DAILY
15. Gabapentin 300 mg PO QHS
16. HydrALAZINE 25 mg PO TID
17. Glargine 70 Units Breakfast
Glargine 20 Units Dinner
Novolog 20 Units Breakfast
Novolog 20 Units Lunch
Novolog 20 Units Dinner
18. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
19. Montelukast 10 mg PO DAILY
20. Rosuvastatin Calcium 10 mg PO QPM
21. Tamsulosin 0.4 mg PO QHS
22. Tiotropium Bromide 1 CAP IH DAILY
23. TraMADol 25 mg PO BID
Discharge Disposition:
Extended Care
Facility:
___
___ and ___)
Discharge Diagnosis:
PRIMARY:
Abdominal pain, constipation
Urinary tract infection
SECONDARY:
Unsteady gait
Cognitive and functional decline
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Mr. ___,
You were admitted to ___
because you were having abdominal pain and had also fallen
recently.
A CT scan of you head was stable. You also had a CT scan of your
abdomen which showed that you were constipated. We gave medicine
to help you go t to the bathroom and you felt better afterward.
You lab tests showed that you had a bladder infection, and we
are treating you with an antibiotic. Please continue this
antibiotic twice daily until ___.
Finally, your family was concerned about your difficulty with
balance and visual hallucinations. You worked with physical and
occupational therapy who recommended that you go to a rehab
center to improve your strength.
We have scheduled you for an appointment with the cognitive
neurology doctors. This appointment is very important, so please
note the date and time below.
It was a pleasure taking part in your care. We wish you all the
best with your health.
Sincerely
Your ___ Care Team
Followup Instructions:
___
|
19696773-DS-12
| 19,696,773 | 27,498,104 |
DS
| 12 |
2178-02-24 00:00:00
|
2178-02-24 19:03:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
gluten
Attending: ___.
Chief Complaint:
Back and L leg pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with hx of celiac dz and one episode of GIB in ___
presents with low back pain.
Pt was in USOH until 2.5 weeks ago, when he developed a "bulge"
in posterior to the L knee. He then developed cramping muscle
pain in the L hamstring area. The pain was ___ and notable,
although not bothersome to pt.
On ___, 5d prior to admission, pt was lifting a heavy
casket and slipped while carying it. He did not fall and does
not report experiencing acute pain. The following morning, 4d
PTA, he developed a pain in his L sacral area, radiating to his
L anterior knee. Pain is cramping/throbbing and occasionally
sharp. It radiates to ipsilateral knee along lateral aspect of
leg. It is relieved with walking (although walking occasionally
makes it worse) and with lying on the R side. He received a
massage at a chi___'s office, without relief. The pain
progressed to ___ PTA and pt presented to an OSH. He was
found to have sx consistent with sciatica and was discharged
with dilaudid. He presented again the following day and was
underwent CT scan (positive for disk bulging). He was discharged
with narcotics but the pain persisted.
In addition, pt reports developing numbness in his L great toe.
He also notes development of decreased urinary stream and some
post-void dribbling. He reports one episode of accidentally
passing stool during an attempt to pass gas. He also endorses
occasional nasal congestion and constipation since onset of sx.
On ROS, he denies fever, chills, n/v, SOB, CP, cough, sore
throat, abd pain, diarrhea, urinary incontinence, stool
incontinence, saddle anesthesia, rashes, weakness, dysuria.
In the ED, initial vitals 98.4 68 141/75 20 97%, pain score 8.
Labs notable for normal chem panel and CBC.
The pt underwent an MRI which showed No evidence of cord signal
abnormality in the thoracic spine. No visualized significant
canal narrowing. Degenerative changes noted in the lower lumbar
spine at the lumbosacral junction.
He received IV dilaudid 4 mg without improvement in his pain.
Currently, pt reports the pain to be an ___ in intensity.
Past Medical History:
Celiac disease
Hyperlipidemia
Obesity
GIB in ___ (likely ugib); gastritis on EGD in ___ internal
hemorrhoids and polyp on CS in ___yst excision
SP sinus surgery
SP R knee arthroscopy
Social History:
___
Family History:
No fam hx of cancer or msk disease
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS - 97.8, 126/84, 88, 18, 95% RA
GENERAL - well-appearing man in NAD, mild discomfort, pacing
room
HEENT - NC/AT, PERRLA, EOMI, injected conjunctiva, MMM, OP clear
NECK - Supple, no thyromegaly, no JVD
LUNGS - CTA bilat, no r/rh/wh, good air movement, resp
unlabored, no accessory muscle use
HEART - PMI non-displaced, RRR, no MRG, nl S1-S2
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials,
DPs). FROM, SLR+ on L.
SKIN - no rashes or lesions
RECTAL - tone present; brown guaiac neg stool, + prostate mildly
enlarged
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
___ throughout, numbness to LT at L great toe, sensation grossly
intact otherwise, DTRs difficult to illicit diffusely, Babinski
downgoing bl, SLR + on LLE. Rectal tone present. No saddle
anesthesia.
DISCHARGE PHYSICAL EXAM:
VS: 98.5, 128/60, R 20, O2 Sat 97% RA
Otherwise, unchanged from above
Pertinent Results:
ADMISSION LABS:
___ 10:00AM BLOOD WBC-8.3 RBC-4.88 Hgb-15.2 Hct-44.0 MCV-90
MCH-31.2 MCHC-34.6 RDW-12.8 Plt ___
___ 10:00AM BLOOD Neuts-72.9* ___ Monos-4.8 Eos-1.0
Baso-0.2
___ 10:00AM BLOOD ESR-9
___ 10:00AM BLOOD Glucose-84 UreaN-14 Creat-0.9 Na-136
K-4.3 Cl-101 HCO3-26 AnGap-13
___ 10:00AM BLOOD Calcium-9.4 Phos-3.2 Mg-2.2
___ 10:00AM BLOOD CRP-3.3
___ 09:55AM URINE Color-Yellow Appear-Clear Sp ___
___ 09:55AM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
DISCHARGE LABS:
___ 05:50AM BLOOD WBC-6.8 RBC-4.55* Hgb-14.2 Hct-40.6
MCV-89 MCH-31.2 MCHC-34.9 RDW-13.0 Plt ___
___ 05:50AM BLOOD Glucose-80 UreaN-18 Creat-0.8 Na-137
K-4.2 Cl-103 HCO3-25 AnGap-13
___ 05:50AM BLOOD Calcium-8.5 Phos-3.7 Mg-2.4
IMAGING:
MRI OF T AND L SPINE WO CONTRAST ___:
FINDINGS:
Thoracic spine: The thoracic vertebral bodies are maintained in
height and alignment. Intervertebral disc spaces are preserved.
The spinal cord is normal in signal and morphology throughout.
Small disk bulge and hypertrophy of the ligamentum flavum seen
at T11-12 without significant canal or foraminal narrowing.
Lumbar spine: There are 5 lumbar-type vertebral bodies which
are maintained in height and alignment. No focal suspicious
marrow lesions identified. There is straightening of the normal
lumbar lordosis. Mild retrolisthesis of L5 on S1 is unchanged
compared to prior exam. Conus terminates at the L1 level and is
normal in signal and morphology.
At L1-L2 through L3-4, there is no significant canal or
foraminal narrowing.
At L4-5, there is a posterior disc bulge with a superimposed
left paracentral protrusion. This causes left-sided
subarticular recess narrowing , crowding and posteriorly
displacing the traversing left L5 nerve root. There is mild
right and minimal left foraminal narrowing.
At L5-S1, there is posterior disc bulge and mild facet joint
hypertrophic
changes. This results in crowding of the bilateral subarticular
recesses, crowding the traversing S1 nerve roots. Mild to
moderate left and mild right foraminal narrowing is seen.
Included paraspinal soft tissues are unremarkable.
IMPRESSION:
No evidence of cord signal abnormality in the thoracic spine.
No visualized significant canal narrowing. Degenerative changes
noted in the lower lumbar spine at the lumbosacral junction as
detailed above.
OSH IMAGING FROM ___:
OSH CT L spine wo contrast ___:
1. No evidence of l spine fx or subluxation.
2. Disc bulges at L4-S1. Mild loss of disc height at all other
levels.
OSH CT AP + Contrast ___:
0.5cm non-calcified RLL nodule (probably benign)
OSH XR of L-spine ___: DJD
OSH L Hip XR ___: No fx or dislocation, no focal osseous
lesion, no abnormalities.
OSH AP pelvis 2-view ___: no abnormalities
Brief Hospital Course:
Mr. ___ is a ___ yoM with PMHx of GIB and celiac disease who was
admitted for management of lower back pain and evaluation.
# Low back pain/Leg pain:
Pain was most consistnet with sciatica. Considering disc bulges
noted on MRI affecting L5, most likely that pt has radiculopathy
in the setting of disk prolapse after heavy lifting of crate one
day prior to symptom onset. Pt had no fevers or leukocytosis to
suggest spinal abscess and no evidence of other pathology on
MRI. He had no objective weakness on exam, no saddle anesthesia,
and had preserved rectal tone. ESR and CRP were low. L toe
numbness was likely ___ radiculopathy and urinary sx were likely
___ opiate use. Patient was treated with NSAIDs,
cyclobenzaprine, lidocaine patch and dilaudid prn. On discharge,
pt was given a prescription for ___ and omeprazole given hx of
gastritis/likely UGIB in the setting of current NSAID use.
# Urinary retension/Weak stream
Pt had bladder scan in ED showing some urinary retention (per
pt) and he reports a change in the consistency of the urinary
stream. Given absence of other objective findings, this is most
likely ___ retension from opiate use. BPH likley contributing.
Pt advised to return immediately if he develops incontinence or
anethesthesia on groin.
TRANSITIONAL ISSUES:
- Please assess pain level and titrate medication regimen as
needed
- Please monitor for evidence of GIB as pt now on NSAIDs for GIB
- Please note, omeprazole was staretd in the setting of NSAID
use. Please reassess indication for omeprazole after resolution
of symptoms.
- Please note, a 0.5cm non-calcified RLL nodule (probably
benign) was noted on the OSH CT scan from ___.
Please consider follow-up imaging at a later time.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Multivitamins 1 TAB PO DAILY
Discharge Medications:
1. Multivitamins 1 TAB PO DAILY
2. Cyclobenzaprine 10 mg PO TID
RX *cyclobenzaprine 10 mg 1 tablet(s) by mouth three time per
day Disp #*30 Tablet Refills:*0
3. Docusate Sodium 100 mg PO BID Constipation
RX *docusate sodium 100 mg 1 tablet(s) by mouth two times per
day Disp #*20 Tablet Refills:*0
4. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN severe
breakthrough pain
RX *hydromorphone 2 mg ___ tablet(s) by mouth every 6 hours Disp
#*30 Tablet Refills:*0
5. Lidocaine 5% Patch 1 PTCH TD DAILY
RX *lidocaine 5 % (700 mg/patch) 1 patch daily Disp #*20 Unit
Refills:*0
6. Omeprazole 40 mg PO DAILY
RX *omeprazole 20 mg 1 tablet(s) by mouth two times per day Disp
#*30 Tablet Refills:*0
7. Polyethylene Glycol 17 g PO DAILY:PRN Constipation
RX *polyethylene glycol 3350 [Miralax] 17 gram 1 packet by mouth
daily Disp #*1 Container Refills:*0
8. Senna 1 TAB PO BID:PRN Constipation
RX *sennosides [senna] 8.6 mg 1 tab by mouth two times per day
Disp #*20 Tablet Refills:*0
9. Naproxen 500 mg PO Q8H:PRN pain
RX *naproxen 500 mg 1 tablet(s) by mouth every 8 hours Disp #*60
Tablet Refills:*0
10. Outpatient Physical Therapy
Please provide outpatient physical therapy for low back strain
and sprain as well as facet joint arthritis.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: Sciatica
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure to participate in your care at ___. You were
admitted for left leg and back pain. You were found to have
symptoms of sciatica (spinal disc bulge). You had some new
urinary symptoms, which were likely caused by your pain
medication. You also had toe numbness, which was likely a
symptoms of sciatica. You underwent an MRI of the spine which
showed no acutely worrisome process. Please continue to take
your pain medication and follow up with your doctor. Please
follow up with physical therapist. Please do not perform any
physically strenuous activities such as heavy lifting until
evaluation by your doctor. We wish you all the best.
Followup Instructions:
___
|
19696926-DS-8
| 19,696,926 | 23,246,261 |
DS
| 8 |
2115-07-25 00:00:00
|
2115-07-25 17:21:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Right flank pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Hospitalist Attending Admission History and Physical
PCP: ___
Location: ___
Address: ___, ___
Phone: ___
___ year-old man with history of CVA, HTN presents with sharp 10
out of 10 pain along his right chest/flank, which at times,
wraps around to the front of his abdomen. This pain started
around 10 days ago after getting into his car after seeing his
PCP. The pain is worse when he sits up from lying down or when
lying down from sitting. He had similar pain on his left side a
few months prior from a muscle strain from moving around heavy
furniture in his home. He denied having fever, chills, nausea,
vomiting, jaundice, diarrhea, constipation, blood in stool,
black tarry stools, dysuria, hematuria, chest pain, shortness of
breath, weight loss, or night sweats.
His family reports that on ___ he presented to the ___
___ and was found to be constipated with possible torsion
of bowel on the CT scan. He was treated there with enemas and
laxatives and has been having bowel movements. Upon discharge
from ___, he continued to have abdominal pain.
ED Course: VS - Tm 100.7, Tc 98.4, HR 66, BP 149/57, RR 22, O2
100% on room air. He received NS 1L, morphine 2mg IV, aspirin
325mg PO.
Review of Systems:
(+) Per HPI and mild lower leg swelling.
(-) Denies visual changes, oral ulcers, bleeding nose or gums,
palpitations, orthopnea, PND, cough, hemoptysis, easy bruising,
skin rash, myalgias, joint pain, back pain, numbness, weakness,
dizziness, vertigo, headache, confusion, or depression. All
other review of systems negative.
Past Medical History:
- Stroke ___ years ago with symptoms of left arm numbness and
slurred speech that resolved in about 3 hours
- Hypertension
Social History:
___
Family History:
Parents both died of heart disease.
Physical Exam:
ADMISSION EXAM:
VS: T 96.2, BP 141/78, HR 86, RR 18, O2 100% on room air
PAIN: 0 out of 10 (after Morphine 2 mg IV)
GEN: NAD
HEENT: EOMI, post-cataract surgery pupils, MMM, no oral lesions
NECK: Supple, no carotid bruits
CHEST: Clear to auscultation. No palpable pain on right chest
wall where patient says he normally has the pain.
CV: RRR, normal S1 and S2, no murmurs
ABD: Soft, nontender, nondistended, bowel sounds present
SKIN: No rashes or other lesions
EXT: 1+ right lower extremity edema
NEURO: Alert, oriented x3, CN ___ intact, sensory intact
throughout, strength ___ BUE/BLE, fluent speech, normal
coordination
PSYCH: Calm, appropriate
DISCHARGE EXAM:
VS: Afebrile
PAIN: None
GEN: NAD
Pertinent Results:
___ BLOOD
WBC-7.3 Hgb-10.7 Hct-33.5 MCV-94 Plt-308
Neuts-66.8 ___ Monos-3.1 Eos-0.9 Baso-0.3
Glu-89 BUN-27 Cr-1.1 Na-140 K-4.6 Cl-104 HCO3-26
Ca-9.3 Ph-3.9 Mg-2.7
ALT-34 AST-41 LDH-183 AlkPhos-120 TotBili-0.5
cTropnT-0.01
Lactate-1.4
___ URINE
Color-Straw Appear-Clear Sp ___ Blood-NEG Nitrite-NEG
Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG
pH-7.5 Leuks-NEG
BLOOD CULTURE ___: PENDING
ECG ___ 10:45AM: Sinus, HR 80, normal axis, ST-depression
V4-V6
CXR PA/LATERAL ___ IMPRESSION:
1. Bibasilar linear opacities most suggestive of subsegmental
atelectasis.
2. Small bilateral pleural effusions.
CT ABDOMEN/PELVIS WITH CONTRAST ___ IMPRESSION:
1. No acute abdominal pathology, especially no gallbladder or
bowel pathology identified to explain the patient's pain.
2. Wedge compression fracture of L2 vertebral body, the acuity
is unknown given the lack of prior imaging studies.
3. Bilateral small pleural effusions.
4. Extensive atherosclerotic disease of the abdominal aorta with
mild aneurysmal dilation of the infrarenal aorta.
RENAL U/S ___ IMPRESSION:
1. Simple right renal cyst
2. Enlarged prostate.
3. Otherwise unremarkable renal ultrasound.
Brief Hospital Course:
___ year-old man presents with on-going right chest/flank pain
for 10 days that may be from muscle strain as it is worse with
positional changes. He did have a fever, but no localizing
evidence of infection. CXR showing atelectasis with small
bilateral pleural effusion. Patient does not have other symptoms
suggesting pneumonia. Perhaps pain from right chest wall is
causing patient to not have full chest excursion. No findings
in CT abdomen can explain this patient's pain. Vitals, labs, and
physical examination reveal a patient who does not have an acute
illness.
PROBLEM LIST:
# Right chest/flank pain: Likely a muscle strain. Pain was
relieved in the ED with morphine. Patient had no further pain
during 24-hour hospitalization. Acetaminophen as needed for
pain. Physical therapy may be helpful as well.
# Hypertension: Continue hydrochlorothiazide
THE FOLLOWING WERE FOUND INCIDENTALLY ON IMAGING:
# Right kidney, simple cyst: Ultrasound revealing a simple renal
cyst
# Atelectasis/pleural effusion possibly from patient not taking
full breaths secondary to right chest/flank pain: Encourage
incentive spirometry
# L2 compression fracture, unknown acuity, asymptomatic, seen
incidentally on imaging
# Prostatic hyperplasia seen incidentally on imaging
# Atherosclerotic disease seen incidentally on imaging
# DVT prophylaxis: Ambulation
# Code status: Full code
Medications on Admission:
- Hydrochlorothiazide 25 mg ___ tablet daily
- Aspirin 81 mg daily
Discharge Medications:
1. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. acetaminophen 325 mg Tablet Sig: ___ Tablets PO every ___
hours as needed for fever or pain.
3. hydrochlorothiazide 25 mg Tablet Sig: 0.5 Tablet PO once a
day.
Discharge Disposition:
Home With Service
Facility:
___
___:
PRIMARY DIAGNOSIS:
- Right chest wall pain, probable muscle strain
SECONDARY DIAGNOSES:
- Hypertension
- Pleural effusion, small
- Atelectasis
- Simple renal cyst, right kidney
- Compression fracture, ___ lumbar vertebrae
- Prostate enlargement
- Atherosclerosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You were admitted for right chest/side pain. A thorough
evaluation was performed with blood tests and radiological
imaging. No specific abnormality was found that would explain
your pain. In any case, your pain resolved in the hospital and
did not recur. Given your history and the results of the
testing, the most likely cause of your pain is related to a
muscle strain. We recommend physical therapy to help you with
the muscle strain and also to improve your mobility.
Over-the-counter pain medications such as Acetaminophen
(Tylenol) may be used as needed for pain.
You were also found to have a small area of uninflated lung
(atelectasis) and small amount of fluid in lung (pleural
effusion) likely from not taking deep breaths because of the
pain. For this you should use the device called Incentive
Spirometer 10 times an hour to help with improving this
condition.
Imaging also revealed a compression fracture of your ___ lumbar
spine as well as a simple kidney cyst in your right kidney.
For all of these conditions, you should follow-up with your
primary care physician.
MEDICATION INSTRUCTIONS:
1. Acetaminophen 325 mg one or two tablets as needed every ___
hours as needed for pain.
2. Continue your regular medications as prescribed by your
doctor.
Followup Instructions:
___
|
19697009-DS-18
| 19,697,009 | 29,501,120 |
DS
| 18 |
2171-04-11 00:00:00
|
2171-04-12 14:43:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
simvastatin / lisinopril / Tegaderm / amlodipine
Attending: ___.
Chief Complaint:
fever, cellulitis in RUE
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms. ___ is a ___ female with ___ vs. small
cell cancer of the right axilla s/p chemoradiation with
resultant
chronic lymphedema and neuropathy as well as ER+/PR-/HER2- stage
IA (T1cN0M0) breast cancer s/p 6 cycles of adjuvant CMF with
plan
to start radiation who presents with fever.
Per review of notes, patient presented to Radiation Oncology
appointment for CT radiation and mapping. She underwent
simulation and afterwards had shaking chills. Vitals were Temp
102.8, HR 109, BP 154/70, RR 18, O2 sat 97% RA. She was very
weak
with unsteady gait and needed 2 people assist to get off CT
table. She was transported to the ED for further evaluation.
Per ED documentation, history obtained from family at bedside as
patient lethargic and slow to respond to questions. She reports
that she currently feels unwell but is unable to elaborate
further. She has a chronic cough which is unchanged. Per
patient's husband swelling is at baseline from chronic
lymphedema
but redness and mass are new, did not notice prior to now.
Past Medical History:
- Extrapulmonary small cell carcinoma versus ___ cell
carcinoma in ___ treated with definitive chemoradiation
- History of multiple squamous and basal cell carcinomas
- Asthma
- Hard of Hearing
- Lymphedema in her right upper extremity and a frozen right
shoulder
- Peripheral Neuropathy from Chemotherapy
- Adenomas
- Achilles Tendinitis
- Hypertension
- Hypercholesterolemia
- Stage III CKD
- Nephritis as a kid and her prior cancer had "aggravated
things"
- Allergic contact dermatitis due to metals
- Ganglion of her hand requiring surgery
- Herpes Zoster
Social History:
___
Family History:
Maternal aunt with ? breast cancer in her ___.
Father had melanoma. Brother had melanoma.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: Temp 98.6, BP 128/58, HR 87, RR 22, O2 sat 96% RA.
GENERAL: Pleasant fatigue-appearing woman, in no distress, lying
in bed comfortably.
HEENT: Anicteric, PERLL, OP clear.
CARDIAC: RRR, no murmurs.
LUNG: Appears in no respiratory distress, clear to auscultation
bilaterally.
ABD: Soft, non-tender, non-distended, positive bowel sounds.
EXT: Warm, well perfused, trace bilateral lower extremity edema.
Right upper extremity erythema, swelling, and warmth. Erythema
extends to include all of right breast and is outlined.
Non-tender mass superior to right breast.
NEURO: A&Ox3, good attention and linear thought. Decreased
strength in right hip potentially limited due to pain. Sensation
to light touch intact. Able to state ___ backwards.
SKIN: Erythema and warmth of RUE and right breast, outlined.
DISCHARGE PHYSICAL EXAM:
VS:
24 HR Data (last updated ___ @ 039)
Temp: 98.2 (Tm 98.4), BP: 136/64 (111-136/64-72), HR: 67
(67-79), RR: 20, O2 sat: 96% (95-98), O2 delivery: RA
GENERAL: Pleasant woman in no distress, lying in bed
comfortably.
HEENT: Anicteric, PERLL, OP clear.
CARDIAC: RRR, no murmurs.
LUNG: Not in respiratory distress, CTAB, no crackles, wheezing,
rhonchi.
ABD: Soft, non-tender, non-distended, positive bowel sounds.
EXT: Warm, well perfused, 1+ b/l ___ edema. Right upper extremity
erythema, swelling, and warmth, but this is decreasing and has
not extended past the demarcated borders. Erythema extends to
include all of right breast and is outlined, but it is also much
decreased. Non-tender mass superior to right breast, has not
increased in size.
NEURO: A&Ox3, good attention and linear thought. Decreased
strength in right hip potentially limited due to pain. Sensation
to light touch intact.
SKIN: Improving rubor and erythema in mid forearm and posterior
R
arm near axilla, no extension of erythema past drawn borders
LABS: Reviewed in OMR.
Pertinent Results:
ADMISSION LABS:
___ 03:52PM BLOOD WBC-1.0* RBC-3.63* Hgb-11.8 Hct-36.7
MCV-101* MCH-32.5* MCHC-32.2 RDW-14.1 RDWSD-50.7* Plt ___
___ 03:52PM BLOOD Neuts-67.6 Lymphs-14.7* Monos-9.8 Eos-6.9
Baso-1.0 AbsNeut-0.69* AbsLymp-0.15* AbsMono-0.10* AbsEos-0.07
AbsBaso-0.01
___ 05:57AM BLOOD Poiklo-1+* Ovalocy-1+* Schisto-1+* RBC
Mor-SLIDE REVI
___ 03:52PM BLOOD ___ PTT-29.5 ___
___ 03:52PM BLOOD Glucose-115* UreaN-19 Creat-1.2* Na-138
K-4.0 Cl-102 HCO3-24 AnGap-12
___ 03:52PM BLOOD ALT-25 AST-53* AlkPhos-111* TotBili-0.6
___ 05:57AM BLOOD Calcium-8.3* Phos-2.9 Mg-1.7
___ 03:52PM BLOOD Albumin-4.2
___ 03:52PM BLOOD Lactate-2.0
DISCHARGE LABS:
___ 06:01AM BLOOD WBC-2.9* RBC-3.46* Hgb-10.8* Hct-34.7
MCV-100* MCH-31.2 MCHC-31.1* RDW-13.9 RDWSD-50.7* Plt ___
___ 06:01AM BLOOD Neuts-33.8* ___ Monos-21.1*
Eos-13.7* Baso-2.5* AbsNeut-0.96* AbsLymp-0.56* AbsMono-0.60
AbsEos-0.39 AbsBaso-0.07
___ 06:01AM BLOOD Glucose-85 UreaN-11 Creat-0.8 Na-144
K-4.3 Cl-108 HCO3-25 AnGap-11
___ 06:01AM BLOOD Calcium-8.7 Phos-2.6* Mg-2.1
IMAGING:
CHEST (PA & LAT) ___ IMPRESSION:
No definite focal consolidation. Hyperinflated lungs.
Heterogeneous, mottled appearance of the right scapula and
possibly the right
midclavicle, not well assessed on this study, but appears
possibly increased
in extent compared to the prior study from ___, given
differences in patient
position. Correlate with history of malignancy.
CT HEAD W/O CONTRAST ___ IMPRESSION:
No acute intracranial process. Please note that MRI is more
sensitive in
detecting small intracranial lesions.
UNILAT UP EXT VEINS US ___ IMPRESSION:
No evidence of deep vein thrombosis in the right upper
extremity.
ECG ___ Sinus tachycardia
Probable left atrial enlargement
small inferior Q waves, likely non pathologic
no previous tracing for comparison
H DIGITAL UNILATERL DX ___ IMPRESSION:
No discrete mass in the area of concern at 12 o'clock.
Note the mammogram images are extremely limited and if
clinically indicated a
repeat mammogram could be obtained when the patient is stable.
UNILAT BREAST US LIMITE ___ IMPRESSION:
No discrete mass in the area of concern at 12 o'clock.
Note the mammogram images are extremely limited and if
clinically indicated a
repeat mammogram could be obtained when the patient is stable.
MICRO:
___ blood cx: NGTD
___ urine: < 10K CFU
___ blood cx: NGTD
___ blood cx: NGTD
MRSA: negative
Brief Hospital Course:
Ms. ___ is a ___ female with ___ vs. small
cell cancer of the right axilla s/p
chemoradiation with resultant chronic lymphedema and neuropathy
as well as ER+/PR-/HER2- stage IA (T1cN0M0) breast cancer s/p 6
cycles of adjuvant CMF with plan to start radiation who presents
with neutropenic fever.
ACUTE ISSUES
==============
# Neutropenic Fever:
# Sepsis secondary to Cellulitis:
Neutropenia is likely in the setting of being at C6D19 when she
was admitted and ANC 690 on admission, up to 4650 on the day of
discharge. Upon gathering additional history it appears that
there was some skin breakdown that occurred on the day prior to
admission after a dermatologic procedure and after time at the
gym. Fortunately, the patient responded well to antibiotics and
will complete a 14 day course of antibiotics.
# Encephalopathy: Likely ___ fever/sepsis as patient reportedly
normal prior to fever. CTH negative for acute intracranial
abnormality. Meningitis/encephalitis considered given
neutropenic
fever, but less likely given obvious source of cellulitis.
Mental
status appears improved on arrival to the floor and she was at
her baseline for the duration of the hospitalization.
# Right Breast Abnormality: Patient noted to have right breast
swelling, ultrasound revealed a non circumscribed,
heterogeneous,
avascular region in the 12 o'clock position of the right breast,
not compatible with abscess. A dedicated breast ultrasound and
mammography was performed with no concerning findings.
# Thrombocytopenia: Lower than baseline, likely ___ recent
chemotherapy. No signs of active bleeding. Coags normal.
# CKD: Cr on admission of 1.2 slightly higher than baseline but
not enough to be considered ___. Returned to baseline.
# Stage IA (T1cN0M0) ER+/PR-/HER2- Left Breast Cancer: She is
s/p
6 cycles adjuvant CMF. Plan for radiation. Her primary team was
communicated with throughout the hospitalization and updated by
email.
# Hypertension
Held her home HCTZ given increased Cr and sepsis as above,
resume upon discharge
# Asthma
Continued home fluticasone
CODE: Full Code (presumed, day team to confirm in AM)
EMERGENCY CONTACT HCP: ___ (husband) ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler ___ PUFF IH Q6H:PRN shortness of
breath/wheezing
2. Fluticasone Propionate 110mcg 2 PUFF IH BID
3. Gabapentin 300 mg PO BID
4. Hydrochlorothiazide 12.5 mg PO DAILY
5. LORazepam 0.5 mg PO Q6H:PRN nausea/vomiting/anxiety/insomnia
6. Prochlorperazine 10 mg PO Q6H:PRN nausea/vomiting
7. Calcium 500 (calcium carbonate) 500 mg calcium (1,250 mg)
oral DAILY
8. Multivitamins 1 TAB PO DAILY
Discharge Medications:
1. Cephalexin 500 mg PO QID Duration: 12 Days
RX *cephalexin 500 mg 1 capsule(s) by mouth four times a day
Disp #*48 Tablet Refills:*0
2. Albuterol Inhaler ___ PUFF IH Q6H:PRN shortness of
breath/wheezing
3. Calcium 500 (calcium carbonate) 500 mg calcium (1,250 mg)
oral DAILY
4. Fluticasone Propionate 110mcg 2 PUFF IH BID
5. Gabapentin 300 mg PO BID
6. Hydrochlorothiazide 12.5 mg PO DAILY
7. LORazepam 0.5 mg PO Q6H:PRN nausea/vomiting/anxiety/insomnia
8. Multivitamins 1 TAB PO DAILY
9. Prochlorperazine 10 mg PO Q6H:PRN nausea/vomiting
Discharge Disposition:
Home
Discharge Diagnosis:
Upper Extremity Cellulitis
Neutropenic Fever
Stage IA (T1cN0M0) ER+/PR-/HER2- Left Breast Cancer
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms ___,
It was a pleasure taking care of you at ___.
Why was I hospitalized?
========================
You were brought to the hospital by your family after you
developed an infection in your arm. Because your immune system
is affected by chemotherapy, the infection made you have a high
fever and become somewhat confused.
What did we do for you while you were here?
==========================================
- You were started on IV antibiotics
- We got a mammogram of the right breast area where there was a
hard, tender area, which did not show anything concerning
- You were transitioned to oral antibiotics to complete the
course at home
What should you do when you leave?
===================================
Please make sure to take all of your medications as directed.
Also make sure to complete the course of antibiotics.
All the best,
Your ___ care team
Followup Instructions:
___
|
19697124-DS-2
| 19,697,124 | 22,500,541 |
DS
| 2 |
2149-10-22 00:00:00
|
2149-10-24 09:46:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Left ___ toe wound
Major Surgical or Invasive Procedure:
___ OR for L ___ toe debridement and wound closure
___ OR for lower extremity angiography
___ OR for L ___ digit open partial amputation
History of Present Illness:
___ yo F with PMH of HTN, HLD, and poorly controlled diabetes not
currently on any therapy who presents with a left second toe
wound. Patient reports first noticing wound ___ late ___.
Denied trauma to the toe, but noticed skin breaks on the
underside of the toe which she attributes to dry skin. Since
that time her toe has gotten increasingly more painful, with
shooting pains up the ankle. She reports that ___ early ___
she removed a scab and the wound drained pus. She also
developed associated left leg swelling and erythema over the
past couple weeks. She reported she sought care at the ED after
her symptoms did not improve and her toe did not heal. She
reports that she cared for the toe with betadine and heating
packs. She denies fever, chills, chest pain, SOB, abdominal
pain, nausea, vomiting, and diarrhea. She denies any baseline
numbness/paresthesias of her lower extremities. Notably, she has
not been to a PCP ___ ___ at which time her HbA1C was 14.5%.
She was on insulin ___ ___ but at this time her only medication
is baby aspirin.
___ the ED, initial vs were: T97.6 HR 64 BP 141/52 RR 18 SaO2
100% RA. ___ the ED, staff noted LLE swelling, and left foot
with swelling, left second toe with color changes to a dark
brown, erythema noted, much scabbing to the toe. Blood cultures
and wound cultures were obtained. Wound culture gram stain
showed 3+ gram positive cocci ___ pairs and clusters. Patient
given 1g vancomycin and 2.25 g Zosyn. Patient seen by podiatry
___ the ED, L ___ toe I&D'd at bedside, revealing copious
prurulent drainage, they plan for left ___ toe amputation
tomorrow.
Labs were remarkable for normal white count (7.8), H/H
10.4/33.1, INR 1.2, A1c 8.5%, BUN/Cr ___, normal U/A. Ankle
and foot films were obtained which showed soft tissue gas and
osseous destruction involving the left second digit and c/f
acute osteomyelitis.
On the floor, vs were: T:98.5 BP:140/66 P:66 R:16 O2:100%. She
was resting comfortably with a bandage over her left toe wound.
Past Medical History:
- Hypertension
- Hyperlipidemia
- Type 2 Diabetes
Social History:
___
Family History:
HTN, DM. No family history of CAD or cancer.
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: T:98.5 BP:140/66 P:66 R:16 O2:100%
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 1+ DP pulses at RLE, ulceration noted
at medial aspect of L ___ digit of foot with packing ___ place,
dopplerable DP pulse ___ ED, 1+ pitting edema of LLE. LLE
slightly warmer around ankle relative to right.
Skin: skin changes with chronic venous stasis noted at BLE
Neuro: CN II-XII grossly intact, moving all extremities,
sensation intact at BLE, able to move all toes bilaterally
DISCHARGE PHYSICAL EXAM:
Vitals: 100.0, 124-171/45-80, 71-86, RR18 98% RA.
General: Laying down, Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: left ___ toe with swelling, mild erythema, no drainage from
surgical site. non-tender, 1+ DP pulses at RLE
Skin: chronic venous stasis
ACCESS: 49cm PICC placed
Pertinent Results:
ADMISSION LABS:
___ 10:30AM BLOOD WBC-7.8 RBC-3.66* Hgb-10.4* Hct-33.1*
MCV-90 MCH-28.5 MCHC-31.5 RDW-13.4 Plt ___
___ 10:30AM BLOOD Neuts-66.1 ___ Monos-5.9 Eos-0.9
Baso-0.7
___ 10:30AM BLOOD ___ PTT-37.9* ___
___ 07:50AM BLOOD ___ PTT-35.0 ___
___ 10:30AM BLOOD Glucose-176* UreaN-28* Creat-1.4* Na-139
K-4.6 Cl-101 HCO3-26 AnGap-17
___ 07:50AM BLOOD ALT-11 AST-15 AlkPhos-55 TotBili-0.5
___ 10:30AM BLOOD Calcium-9.7 Phos-3.6 Mg-2.4
___ 11:02AM BLOOD %HbA1c-8.5* eAG-197*
___ 07:50AM BLOOD Triglyc-132 HDL-32 CHOL/HD-6.2
LDLcalc-139*
___ 02:20PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG
___ 02:20PM URINE Color-Straw Appear-Clear Sp ___
DISCHARGE LABS:
___ 07:50AM BLOOD WBC-5.4 RBC-3.39* Hgb-9.9* Hct-30.1*
MCV-89 MCH-29.1 MCHC-32.8 RDW-14.2 Plt ___
___ 07:50AM BLOOD Glucose-96 UreaN-12 Creat-1.0 Na-138
K-3.4 Cl-102 HCO3-24 AnGap-15
___ 07:50AM BLOOD Calcium-8.8 Phos-2.6* Mg-1.9
___ 06:18AM BLOOD calTIBC-309 Ferritn-301* TRF-238
___ 09:00PM BLOOD Vanco-18.1
MICRO:
___ 10:20 am BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
___ 10:30 am BLOOD CULTURE #2.
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
___ 11:30 am SWAB Source: L ___ digit.
**FINAL REPORT ___
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
3+ ___ per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS AND CLUSTERS.
SMEAR REVIEWED; RESULTS CONFIRMED.
WOUND CULTURE (Final ___:
STAPHYLOCOCCUS, COAGULASE NEGATIVE.
SPARSE GROWTH OF TWO COLONIAL MORPHOLOGIES.
ANAEROBIC CULTURE (Final ___:
ANAEROBIC GRAM POSITIVE ROD(S). SPARSE GROWTH.
UNABLE TO IDENTIFY FURTHER.
___ 2:20 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
___ 1:00 pm TISSUE LEFT ___ TOE PROXIMAL MARGIN.
**FINAL REPORT ___
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS AND SINGLY.
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 BELOW, THEY ARE NOT
PRESENT ___
this culture..
ANAEROBIC CULTURE (Final ___: NO ANAEROBES ISOLATED.
___ 1:00 pm TISSUE LEFT SECOND TOE.
**FINAL REPORT ___
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS AND SINGLY.
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 BELOW, THEY ARE NOT
PRESENT ___
this culture..
ANAEROBIC CULTURE (Final ___: NO ANAEROBES ISOLATED.
BLOOD CULTURES (___): Negative to date as of discharge
___ 10:18 pm Influenza A/B by ___
Source: Nasopharyngeal swab.
**FINAL REPORT ___
DIRECT INFLUENZA A ANTIGEN TEST (Final ___:
Reported to and read back by ___ ___ ___
AT 10:21.
POSITIVE FOR INFLUENZA A VIRAL ANTIGEN.
DIRECT INFLUENZA B ANTIGEN TEST (Final ___:
Negative for Influenza B.
IMAGING/STUDIES:
LEFT FOOT/ANKLE XRAY ___: IMPRESSION: Soft tissue gas and
osseous destruction involving the second digit, at least the
middle and distal phalanges with concern for also involvement of
the distal aspect of the second proximal phalanx, most
consistent with acute osteomyelitis.
LEFT FOOT XRAY ___: FINDINGS: There has been interval
resection of the second ray at the level of the base of the
proximal phalanx. There is a small amount of the base still
present. The overlying soft tissues has also been resected with
some air ___ the residual soft tissue consistent with recent
surgery. No other areas concerning for infection are
visualized. No fracture or dislocation. Small calcaneal spur.
Diffuse soft tissue swelling.
LEFT LOWER EXTREMITY VENOUS DOPPLER ___: IMPRESSION: No
evidence of deep vein thrombosis.
BILATERAL LOWER EXTREMITY ATERIAL DOPPLER ___: Doppler
evaluation was performed of both lower extremity arterial
systems at rest. The right Doppler tracings are triphasic at
the femoral and popliteal levels and monophasic below. The ABI
is falsely elevated. Pulse volume recordings show mild drop off
at the ankle and metatarsal. On the left, Doppler tracings are
triphasic at the femoral and popliteal levels. They is
monophasic below. Ankle-brachial index is falsely elevated.
Pulse volume recordings show mild drop off at the ankle and
metatarsal.
IMPRESSION: On the right, there is mild tibial artery occlusive
disease. On the left, there is mild SFA or popliteal disease as
well as tibial artery occlusive disease.
CXR ___: Cardiac size is normal. Aside from linear
atelectasis ___ the left base, the lungs are clear. There is no
pneumothorax or pleural effusion.
IMPRESSION: No evidence of acute cardiopulmonary abnormalities.
CXR ___: Cardiac size is normal. There are low lung
volumes. Bibasilar atelectases are larger on the right side,
grossly unchanged from prior study. There is no pneumothorax or
pleural effusion. Left PICC tip is ___ the lower SVC.
ECG ___: Baseline artifact. Sinus rhythm at the lower limits
of normal rate. Non-diagnostic Q waves ___ leads I and aVL. Mild
mid-precordial ST segment elevation of uncertain significance.
No previous tracing available for comparison. Clinical
correlation is suggested.
___ ANGIO REPORT ___: we selected the external iliac artery
on the left second-order vessel and performed a runoff of the
left lower extremity. This showed a normal and patent common
femoral,
profunda, and SFA. The popliteal artery was patent and normal.
There was one-vessel runoff through the peroneal artery. The ___
was occluded completely. The AT is proximally patent, but then
occludes after about 2 cm, and has then several islands that are
visible. At the level of the foot, there was very extensive
collateralization and brisk reconstitution of the ___, as well as
the DP.
LEFT SECOND TOE PATHOLOGY REPORT ___: GROSS DESCRIPTION:
The specimen is received fresh labeled with the patient's name,
___, the medical record number, and is
additionally labeled "left second toe". It consists of an
amputated toe that measures 3.5 x 2.5 x 2 cm, The majority of
the toe is involved by gangrenous necrosis with eschar
formation. Representative sections of soft tissue and
underlying bone at the resection margin are submitted
for decalcification ___ cassettes 1A-1B.
Brief Hospital Course:
___ yo F with PMH of HTN, HLD, and poorly controlled diabetes not
on any therapy who presented with a left second toe wound
consistent with acute osteomyelitis.
# Left toe osteomyelitis / cellulitis: Patient had left toe
wound since late ___ with exam concerning for infection.
Imaging of foot was concerning for osteomyelitis. Patient was
started on IV vancomycin and Zosyn. Seen by podiatry who
performed L ___ digit open partial amputation on ___ and
closure on ___. Pathology report of the amputation margin
showed acute osteomyelitis. ID was consulted -recommendation at
this time is for 6 week course of antibiotics. Patient was
discharged on vancomycin 1g BID and ertapenem 1 g daily with
course to be completed on ___. She will be followed by ___.
Patient was also scheduled for follow-up with podiatry for
suture removal and continued monitoring of wound. Activity per
podiatry was weight bearing on heal with surgical shoe.
#Peripheral vascular disease: Vascular performed lower extremity
angiogram on ___ demonstrating ___ occlusion, AT proximally
patent then occludes at level of foot with extensive
collateralization and reconstitution of the ___, as well as the
DP - recommendation was for expectant management with follow-up
w/ Dr ___ revascularization options .
# influenza: Patient with fevers up to 102.6 ___ and ___.
She felt otherwise well except for a cough. Patient did have
sick contacts as her mother had influenza. Flu swab was
positive. CXR was unchanged from prior, likely atalectasis,
but no clear consolidation. Blood cultures were negative to
date as of discharge. Patient started on 5 day course of
tamiflu. Continued on antibiotics as per ID recs (vancomycin
and ertapenem). Discussed fevers with ID who agreed with above
plan, and agreed that fevers were most likely due to influenza
vs other source (i.e. toe wound). Patient was advised on
discharge that should she continue to spike fevers for >48 hours
she should seek medical evaluation.
# Type 2 Diabetes: poorly controlled diabetes. per OMR
notes/labs - A1c ___ ___ was 14.5% improved to 8.4% with NPH
regimen. Patient has not seen PCP ___ ___. No labs since
that time ___ WebOMR. A1c ___ ED during this admission was 8.5%.
Patient was managed on a diabetic diet and with an insulin
sliding scale. Her FSBS remained well controlled while ___
house, rarely going above 200. She was discharged on 500 mg
metformin, and was set up with new PCP at ___ for continued
management of her diabetes.
# HTN: Has h/o hyptertension, was on 5mg lisinopril daily ___
___, was off medication since ___. During admission, BPs were
recorded as high as 180s systolic. Patient was started on 5 mg
lisinopril, however due to continued elevated BPs, regimen was
titrated up to 20mg qd of lisinopril and metoprolol tartrate
12.5 mg BID.
# Anemia: Patient anemic during admission. Unclear etiology,
patient was HDS, asymptomatic. ___ have been ___ to acute
illness and vancomycin. Iron studies all wnl except for
elevated ferritin, elevation likely d/t acute illness.
Recommend outpatient follow-up if patient remains anemic after
antibiotic course has been completed.
# HLD: Patient started on high dose statin - atorvastatin 80mg
daily.
# Mood/depression: Resolved. Patient initially felt down
regarding her diagnosis and hospitalization. Social work saw
patient on ___, noted that patient's main concern has been
mother's well being, assisted patient ___ setting up caretaker
for outpatient services for her mother.
TRANSITIONAL ISSUES:
[ ] ___ and ID follow up -> currently on 1g BID of vancomycin
and 1g daily of Ertapenem with plan for 6 week course (
___. ___ appointment is with Dr. ___ on ___
at 1:30pm at the ___ on ___ (phone
___. She will need weekly CBC w/diff, chem-10, ESR,
CRP, LFTs and vancomycin trough drawn and faxed to the
infectious disease ___ team at ___.
[ ] ___ for daily dressing changes -> wet to dry: betadine,
sterile guaze then clean.
[ ] podiatry follow up for suture removal
[ ] vascular follow up for discussion of revascularization
options
[ ] follow up with PCP for further management of diabetes (A1C
~8.5)
[ ] follow up with PCP for further management of hypertension.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Acetaminophen 650 mg PO Q6H:PRN pain
3. Atorvastatin 80 mg PO DAILY
RX *atorvastatin 80 mg 1 tablet(s) by mouth Daily Disp #*30
Tablet Refills:*0
4. Fexofenadine 60 mg PO BID
RX *fexofenadine [Allegra Allergy] 60 mg 1 tablet(s) by mouth
twice a day Disp #*30 Tablet Refills:*0
5. Guaifenesin-Dextromethorphan ___ mL PO Q6H:PRN cough
RX *dextromethorphan-guaifenesin [Guaifenesin-DM] 100 mg-10 mg/5
mL ___ ML by mouth every six (6) hours Disp ___ Milliliter
Refills:*0
6. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain
RX *oxycodone 5 mg 1 tablet(s) by mouth every six (6) hours Disp
#*10 Tablet Refills:*0
7. Outpatient Lab Work
Weekly CBC+diff, chem-10, AST/ALT/T.bili/Alk phos, ESR/CRP, Vanc
Trough; labs faxed to ___ Attn: Infectious disease ___
team. ICD-9 code: ___ Acute osteomyelitis, ankle and foot
8. MetFORMIN (Glucophage) 500 mg PO DAILY
RX *metformin 500 mg 1 tablet(s) by mouth Daily Disp #*30 Tablet
Refills:*0
9. Vancomycin 1000 mg IV Q 12H
RX *vancomycin 1 gram 1 gram IV every twelve (12) hours Disp
#*74 Gram Refills:*0
10. ertapenem 1 gram injection Daily Duration: 1 Dose
RX *ertapenem [Invanz] 1 gram 1 gram IV Daily Disp #*37 Gram
Refills:*0
11. OSELTAMivir 75 mg PO Q12H Duration: 4 Days
RX *oseltamivir [Tamiflu] 75 mg 1 capsule(s) by mouth every
twelve (12) hours Disp #*8 Capsule Refills:*0
12. Lisinopril 20 mg PO DAILY
RX *lisinopril 20 mg 1 tablet(s) by mouth DAILY Disp #*30 Tablet
Refills:*0
13. Metoprolol Tartrate 12.5 mg PO BID
RX *metoprolol tartrate 25 mg 0.5 (One half) tablet(s) by mouth
twice a day Disp #*15 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Osteomyelitis left second toe
Diabetes
Hypertension
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 a left toe wound which appeared infected. You
underwent a partial amputation of your left second toe and
subsequent closure of the wound. ___ addition, a vascular study
was done to evaluate for peripheral vascular disease. You were
started on medications for your diabetes, high blood pressure
and cholesterol. It was determined you were safe to be
discharged to home with home nursing to assist with wound
dressing changes and administration of IV antibiotics. You have
follow-up with the infectious disease specialists on ___ at
1:30 pm (Dr. ___ ___,
Phone: ___. ___ addition to infectious disease
follow-up, you have follow-up scheduled with podiatry with Dr.
___ per their recommendations you may weight bear on
your left heel while wearing a surgical shoe. You also have
follow-up scheduled with vascular surgery to further evaluate
your vascular disease. You developed fevers on ___, you were tested for the flu, and it was positive. This
was likely the source of your fevers. You were started on
Tamiflu which will reduce the severity and duration of your
symptoms. You have also been set up with a primary care
physician. It is recommended you take your mediations as
prescribed and keep your follow-up appointments to ensure
continued management of your diabetes, hypertension,
hyperlipidemia and left toe wound/bone infection. Should you
develop worsening pain ___ your left foot, swelling, or redness,
or fevers, please seek evaluation at a medical facility or the
nearest emergency department.
Followup Instructions:
___
|
19697164-DS-11
| 19,697,164 | 27,231,248 |
DS
| 11 |
2180-11-19 00:00:00
|
2180-11-20 16:14:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Sensory changes
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ M w a PMHx of HTN, HLD who
presents
to ___ on ___ with one week of bilateral hand and feet
parasthesias.
Mr. ___ reports that he noticed his symptoms upon waking on
___ morning, ___. The day before, he had spent about an
hour in his garden pulling up weeds and he thinks he was stung
on
the right ankle by a yellow jacket. Otherwise, the day was
uneventful and he slept well overnight. On ___ morning Mr.
___ reports that his fingers, though not his palms, felt
"tingly" and "hyper-sensitive." His feet felt "like they were
wrapped in foam," or "like I was walking on air." These symptoms
pesisted and remained stable over the next several days.
At the urging of his husband, he went to his PCP's office on
___ and saw the on-call physician. A TSH, B12, and RPR
checked - all of which have since resulted as normal. He was
told
to simply observe his symptoms and return to clinic if things do
not improve or get worse.
For the rest of the week, he reports feeling mildly "slower"
than
normal. He is quite active and takes many walks with his
husband.
His husband believes that Mr. ___ was having difficulty
keeping up with him. However, for the three nights prior to
presenation, Mr. ___ reports waking up at 3AM with "whole
body soreness and muscle aches" that prevent him from finding a
comfortable position. He did take some Tylenol 1 or 2 night ago,
which he believes helped.
Today, he reports that he believes his symptoms have progressed
ever so slightly over the last week. He does not believe that
the
area involved has increased, but he feels more uncoordinated
with
his legs - notably when going down stairs and driving his car.
He
initially reported some weakness in the legs, but on further
questioning, feels that his is related to his parasthesias and
coordination issues.
Because his symptoms did not improve, he returned to his PCP
___, ___. His PCP was unable to elicit any reflexes and
recommeneded that Mr. ___ go to ___ ED for further
neurological evaluation.
On my interview, Mr. ___ relays the above history and notes
that he aside from some mild fatigue and muscle aches, he has
been feeling generally well. Last night, in fact, he felt well
enough to go to a party and denies having any fatigue at that
time. He denies any recent fevers or illnesses. He denies cough,
rhinorrhea, N/V/D. His neurological ROS is as per the HPI.
Of note, Mr. ___ and his husband did travel to ___ and
___ in ___. They visited a rainfortest in ___.
They returned to ___ in ___.
Past Medical History:
- dysthymic disorder
- HTN
- HLD
Social History:
___
Family History:
- ischemic heart disease
- no family history of seizures, stroke, or autoimmune disease
Physical Exam:
VS T98.6 HR98 BP147/76 RR20 Sat96%RA
GEN - elderly M, pleasant and cooperative, NAD
HEENT - NC/AT, MMM
NECK - full ROM, no meningismus
CV - tachycardic
RESP - normal WOB
ABD - soft, NT, ND
EXTR - warm and well perfused
NEUROLOGICAL EXAMINATION
MS - A&Ox3, able to relay distant and recent medical history;
language is fluent and content demonstrates intact comprehension
and naming; no evidence of apraxia or neglect
CN - VFF to finger counting; PERRLA 3->2mm bilaterally; EOMI
without nystagmus; facial sensation intact to LT, PP, and
temperature; facial motor symmetric at rest and with activation;
hearing intact to voice; no dysarthria; palate elevates
symmetrically; tongue is midline with full ROM; SCMs and traps
are ___ bilaterally
MOTOR - normal bulk and tone throughout, very mild postural
tremor RUE>LUE. No asterixis. No pronator drift. Very mild
weakness throughout (___) with no obvious neurological pattern.
Neck flexors and extensors are full power.
SENSORY -
LT: hyperasthesia over B/L fingers
VIB: absent at L hallux, intact at L medial malleolus; decreased
over R hallux
PROP: says "I don't know" a few times while testing ___ toe B/L
TEMP: gradient of increasing temperature more proximally in all
four extremities
PP: hyperasthetic over B/L fingers and palms; patchy decrease in
PP over BLEs, ?worse distally
OTHER: no agraphesthesia
REFLEXES - 0s throughout, except 1 at L bicep; L toes up, R
equivocal
COORD - no evidence of truncal or appendicular ataxia; no
dysmetria on FNF or bringing his toe to a specific point in
space
bilaterally; minor sway with Romberg but does not step out or
fall
GAIT - careful and slightly wide based, but otherwise normal;
able to tandem gait but mildly unsteady
Discharge exam:
Sensory: intact to pinprick throughout hands and feet, intact
proprioception at toes and fingers, decreased vibration (4s at
feet, 12s on fingers)
Gait: normal based gait, stable
Pertinent Results:
___ 05:30AM BLOOD WBC-5.6 RBC-4.35* Hgb-13.3* Hct-39.3*
MCV-90 MCH-30.6 MCHC-33.8 RDW-13.8 RDWSD-45.1 Plt ___
___ 05:51AM BLOOD Neuts-75.8* Lymphs-14.7* Monos-6.3
Eos-2.7 Baso-0.4
___ 05:51AM BLOOD ___ PTT-28.5 ___
___ 05:30AM BLOOD Plt ___
___ 05:30AM BLOOD Glucose-96 UreaN-14 Creat-0.8 Na-134
K-4.1 Cl-102 HCO3-24 AnGap-12
___ 04:16PM BLOOD CK(CPK)-127
___ 05:51AM BLOOD TotProt-6.2* Calcium-9.4 Phos-3.7 Mg-2.1
___ 05:51AM BLOOD Folate-15.0
___ 05:51AM BLOOD %HbA1c-6.0* eAG-126*
___ 05:51AM BLOOD TSH-1.6
___ 01:20PM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE
___ 04:16PM BLOOD CRP-1.0
___ 03:26PM BLOOD IgA-233
___ 01:20PM BLOOD HIV Ab-NEGATIVE
___ 01:20PM BLOOD HCV Ab-NEGATIVE
MERCURY, BLOOD <4 <=10 mcg/L
LEAD, BLOOD <2 <10 mcg/dL
ESR 2
MR ___
MRI of the cervical spine without and with IV contrast:
Minimal listhesis at C5-6 and C6-7 levels.
Multilevel, multifactorial degenerative changes as described
above.
C2-C3: Prominent facet degenerative changes on the left side,
with mild edema
and moderate left foraminal narrowing.
C5-6: Mild canal and bilateral severe foraminal narrowing with
deformity on
the nerves.
C6-7: Mild right foraminal narrowing.
No obvious focal lesions in the cervical and upper thoracic
cord.
No abnormal enhancement.
EMG:
Abnormal study. Taken together with the patient's clinical
history, the
electrophysiologic findings are suggestive, but not clearly
diagnostic, of a generalized neuropathic process, possibly
consistent with an acute
inflammatory sensorimotor polyneuropathy.
Brief Hospital Course:
Mr ___ presented to the hospital because of tingling in his
hands and feet and decreased reflexes, and he was admitted to
the Neurology service. He had an EMG that demonstrated subtle
abnormalities consistent with Guillain ___ Syndrome, and
therefore, we treated him with four days of IVIg. He had some
improvement in his symptoms during treatment. We also performed
an MRI of his ___ that did not demonstrate any
abnormalities. He had several lab tests sent but these were
negative, and we did not identify the cause of his neuropathy.
His course was complicated by mild increase in his BUN, but this
resolved with aggressive hydration.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Hydrochlorothiazide 25 mg PO DAILY
2. Lisinopril 20 mg PO DAILY
3. Desipramine 25 mg PO DAILY
4. Simvastatin 20 mg PO QPM
5. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Desipramine 25 mg PO DAILY
3. Hydrochlorothiazide 25 mg PO DAILY
4. Lisinopril 20 mg PO DAILY
5. Simvastatin 20 mg PO QPM
Discharge Disposition:
Home
Discharge Diagnosis:
Guillain ___ Syndrome
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr ___,
You were admitted to the hospital because of tingling in the
hands and feet and decreased reflexes. We performed an EMG that
showed subtle abnormalities consistent with Guillain ___
Syndrome, and we gave you a medication to treat this syndrome.
We performed an MRI of your spine, and we sent multiple other
lab tests that did not show any abnormalities that could have
caused these symptoms.
Followup Instructions:
___
|
19697164-DS-12
| 19,697,164 | 26,007,071 |
DS
| 12 |
2181-06-10 00:00:00
|
2181-06-13 08:39:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
worsening parasthesias, malaise/fatigue
Major Surgical or Invasive Procedure:
Lumbar puncture
History of Present Illness:
The patient is a ___ year old ___ man with a history of HTN,
HLD, and s/p prior IVIG treatment for a diagnosis of AIDP, who
presents with worsening parastheias in his arms and legs as well
as fatigue/malaise.
The patient was admitted to ___ Neurology in ___ for
symptoms of "noticing that his palms felt "tingly" and
"hypersensitive" with
his feet feeling like they were "wrapped in foam"" (per prior
note). He was also noted to have severe sensory ataxia during
that time. CSF showed mildly high protein without any WBCs, so
he was treated with IVIG x 5 days with a diagnosis of likely
AIDP. He felt the IVIG improved his symptoms significantly.
Since
then he followed up with Dr. ___ found he was
improving, so he was monitored.
He continued to feel well until the past ___ weeks, when he
noted
gradual onset of similar symptoms of tingling in his fingers and
numbness on the bottom of his feet, similar to prior
presentations. He was evaluated on ___ in the ED by
Neurology, who documented an improvement in his exam from prior,
and arranged follow up for two weeks. However, since then he has
noted that the numbness and tingling have gotten worse, and he
had onset of fatigue/malaise. The numbness and tingling has
spread up from the tips of his fingers up to the base of his
fingers bilaterally, and the numbness in his feet has stayed on
the bottom of his feet but grown more intense. The fatigue is so
severe that he has not been able to go to work since he feels so
bad, which is atypical for him. The fatigue is the reason for
presenting back to the ED today. He has also felt nauseous for
the past few days but has not vomited. On ROS he also endrses
feeling a "mild" numbness on his L cheek. In contrast to his
prior episode, his walking has remained relatively OK during
this
time.
On neurologic review of systems, the patient denies headache,
lightheadedness, or confusion.
Denies difficulty with producing or comprehending speech.
Denies loss of vision, blurred vision, diplopia, vertigo,
tinnitus, hearing difficulty, dysarthria, or dysphagia.
Denies muscle weakness.
+ Sensory changes as described above.
Denies bowel or bladder incontinence or retention.
Denies difficulty with gait.
On general review of systems, the patient denies fevers, rigors,
night sweats, or noticeable weight loss. He does state he feels
"flushed".
Denies chest pain, palpitations, dyspnea, or cough.
Denies nausea, vomiting, diarrhea, constipation, or abdominal
pain.
Denies dysuria.
No muscle aches.
Past Medical History:
- Dysthymic mood d/o
- HTN
- HLD
- Hx of Guillane ___ Syndrome in ___
Social History:
___
Family History:
- ischemic heart disease
- no family history of seizures, stroke, or autoimmune disease
Physical Exam:
On admission:
VS 99.7 108 146/74 14 100% RA
General: NAD, lying in bed comfortably.
Head: NC/AT, no conjunctival icterus, no oropharyngeal lesions
Neck: Supple, no nuchal rigidity, no meningismus
Resp: non-labored. Able to count to 49 in 1 breath
Neurologic Examination:
- Mental Status -
Awake, alert, oriented x 3. Attention to examiner easily
attained
and maintained. Concentration maintained when recalling months
backwards. Recalls a coherent history. Structure of speech
demonstrates fluency with full sentences, intact repetition, and
intact verbal comprehension. Content of speech demonstrates
intact naming (high and low frequency) and no paraphasias.
Normal
prosody. No dysarthria. Verbal registration and recall ___. No
apraxia. No evidence of hemineglect. No left-right agnosia.
- Cranial Nerves -
I. not tested
II. Equal and reactive pupils (2mm to 1mm). Visual acuity fields
were full to finger counting.
III, IV, VI. smooth and full extraocular movements without
diplopia, with ___ beats of far end gaze nystagmus on the L and
___ on the R (likely physiologic).
V. facial sensation was intact to pin and light touch, muscles
of
mastication with full strength
VII. face was symmetric with full strength of facial muscles.
Full strength of eye closure and lip closure on confrontational
testing.
VIII. hearing was intact to finger rub bilaterally.
IX, X. symmetric palate elevation and symmetric tongue
protrusion
with full movement.
XI. SCM and trapezius were of normal strength and volume.
- Motor -
Full strength of neck flexors and extensors.
Muscule bulk and tone were normal. No pronation, no drift.
Delt Bic Tri ECR FExt Fflx IO IP Quad Ham TA Gas ___
L 5 ___ 5 5 4+ 5 5 4+ 5 5 4+ 4
R 5 ___ 5 5 4+ 5 5 5- 5 5 4+ 4
- Sensation -
Decreased pinprick in a length-dependent fashion in the hands
only, 40-50%, from the fingers up to the mid-palms
Decreased cold sensation in the arms up to just above the elbows
bilaterally, and in the legs up to just below the knees
bilaterally
Markedly decreased proprioception with no proprioception in the
R
great toe and only 1 correct at the L great toe. This improves
at
the ankles with one mistake at the R ankle and no mistakes at
the
L ankle.
- DTRs -
Bic Tri ___ Quad Gastroc
L 2 0 1 0 0
R 2 0 1 0 0
Plantar response flexor on the R and extensor on the L.
- Cerebellar -
Mild intention tremor L>R which the patient states is not new.
No dysmetria with finger to nose or heel to shin testing
bilaterally. Good speed and intact cadence with rapid
alternating
movements.
- Gait -
Normal initiation. Slightly wide base. Normal stride length and
decreased arm swing. Difficulty with tandem gait, + sway with
Romberg.
On discharge:
Mental status and cranial nerve exam unchanged. Motor ___
throughout.
Sensory: Decreased pinprick in a length-dependent fashion much
improved in the hands and feet, 80-90%, from the fingers up to
metacarpal area and to mid-shin in bilateral lower extremities.
Still has decrease in proprioception L>R toe but much better
than admission
Reflexes: unchanged from admission
Cerebellar: unchanged from admission
Gait: narrow base, able to do tandem gait, no sway with Romberg
Pertinent Results:
___ 02:45PM BLOOD WBC-7.0 RBC-4.47* Hgb-13.6* Hct-40.5
MCV-91 MCH-30.4 MCHC-33.6 RDW-13.6 RDWSD-45.2 Plt ___
___ 04:58PM BLOOD Neuts-74.5* Lymphs-13.7* Monos-7.6
Eos-2.7 Baso-1.0 Im ___ AbsNeut-9.18* AbsLymp-1.69
AbsMono-0.94* AbsEos-0.33 AbsBaso-0.12*
___ 02:45PM BLOOD Glucose-112* UreaN-15 Creat-0.8 Na-128*
K-3.7 Cl-95* HCO3-24 AnGap-13
___ 02:45PM BLOOD Calcium-8.9 Phos-3.8 Mg-2.1
___ 06:00AM BLOOD VitB12-336
___ 06:00AM BLOOD ANCA-NEGATIVE B
___ 06:00AM BLOOD ___
___ 06:00AM BLOOD CRP-1.2
___ 06:00AM BLOOD PEP-NO SPECIFI IgA-213 IFE-NO MONOCLO
___ 04:58PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
ACE: 17
Copper: 72
___ antibodies: negative
Paraneoplastic antibody evaluatio: negativen
Ro/La: <1
Sed rate: 2
CMV: not detected
EBV: not detected
CSF WBC 2 RBC 4 protein 76 Glc 72
Pending:
Arbovirus antibody IgM
MRI T/L spine:
1. MRI of the thoracic spine. Mild degenerative changes
throughout the
thoracic spine, consistent with Schmorl's nodes at T5, T7 and
T11 levels, and
mild degenerative changes are also visualized from T5/T6 through
T9/T9
intervertebral disc spaces, with no evidence of severe spinal
canal stenosis
or nerve root compression is. The signal intensity throughout
the thoracic
spinal cord is normal with no evidence of focal or diffuse
lesions. There is
no evidence of abnormal enhancement.
2. MRI of the lumbar spine. Multilevel multifactorial
degenerative changes
throughout the lumbar spine, more significant from L3/L4 through
L5/S1 level,
unchanged grade 1 retrolisthesis identified at L5/S1 level.
There is no
evidence of abnormal enhancement.
CT Chest:
No good evidence for intrathoracic malignancy or infection.
With calcified plaque suggesting prior asbestos exposure, 2 3 mm
nodules in
the right Lung should be kept under surveillance with repeat
chest CT in 6
months. No evidence of these a fairly ___ or asbestosis.
Mild coronary atherosclerosis.
CT abdomen/pelvis:
1. No evidence of malignancy within the abdomen or pelvis.
2. Diverticulosis and mild thickening in the sigmoid colon. This
may be from
muscular hypertrophy but please correlate with colonoscopy.
3. Cholelithiasis
4. Bladder diverticula
5. Please see dedicated same day chest CT for complete
intrathoracic findings.
EMG:
Abnormal study. The electrophysiologic findings are consistent
with a mild,
generalized sensorimotor polyneuropathy with demyelinating
features.
The abnormalities do not meet criteria for a more typical
acquired,
demyelinating polyneuropathy as can be seen in acute or chronic
inflammatory
demyelinating polyradiculoneuropathy (i.e. AIDP or CIDP).
However, given the
appropriate clinical context, findings could be supportive of a
sensory
variant of these syndromes. Compared to the study completed on
___,
there has been no significant overall change.
In addition, there is incidental evidence for a mild chronic
left C6
radiculpathy. A median neuropathy at the left wrist, as in
carpal tunnel
syndrome, is also likely present. Finally, an ulnar neuropathy
at the left
elbow cannot be entirely excluded.
Brief Hospital Course:
Mr. ___ is a pleasant ___ man with AIDP s/p IVIg
___ who was admitted ___ for parasthesias in his arms and
legs and general malaise concerning for recurrent AIDP vs CIDP.
Symptoms are similar to his experience ___ when he first
presented with AIDP where he felt tingling in his palms and felt
like he was "walking on cotton." Exam showed full motor strength
but loss of temperature, proprioception, vibration, and pin
prick in the bilateral lower extremities in stocking glove
distribution/L5 distribution and bilateral upper extremities to
the elbow. CSF showed elevated protein. EMG showed a mild
generalized sensorimotor polyneuropathy with demyelinating
features. He was given 5 days of IVIg on which his symptoms
improved. During this time, he was also worked up for other
possible causes of his symptoms such as paraneoplastic syndrome
(___), autoimmune process (IgG, FGFR3, acute sensory
neuronopathy), infectious (VZV), and drug induced (less likely,
was not on chemo previously). This workup was negative
Transitional issues:
1. Repeat CT chest in ___ months to follow up on plaque
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Desipramine 50 mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Hydrochlorothiazide 25 mg PO DAILY
4. Lisinopril 20 mg PO DAILY
5. Simvastatin 20 mg PO QPM
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Desipramine 50 mg PO DAILY
3. Hydrochlorothiazide 25 mg PO DAILY
4. Lisinopril 20 mg PO DAILY
5. Simvastatin 20 mg PO QPM
Discharge Disposition:
Home
Discharge Diagnosis:
GBS
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were admitted to ___ for evaluation of recurrent numbness
in your hands and feet. We did a lumbar puncture which showed
high protein, and sent off for several other studies, which
showed that there was no infection or other clear cause for your
symptoms. We did an MRI of your spine which showed no
explanation either. We spoke with your outpatient neurologist,
Dr. ___ decided that this was likely recurrence of
GBS. Therefore, we treated you with 5 days of IVIG. You have
already started to improve and you should continue to improve
over the next several weeks. You may need to get these infusions
periodically from now on, which is something you can discuss
with Dr. ___ at follow up.
It was a pleasure taking care of you during this hospital stay.
Followup Instructions:
___
|
19697269-DS-11
| 19,697,269 | 25,148,799 |
DS
| 11 |
2166-08-07 00:00:00
|
2166-08-07 09:03:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROSURGERY
Allergies:
methocarbamol / Diclofenac
Attending: ___.
Chief Complaint:
Low Back Pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Patient developed acute back pain after twisting his lower back
quicklyu during a storm. He presented to ___ for evalaution
and was admitted for pain control
Past Medical History:
HLD, chronic back pain, OSA, asthma, prev spinal cord stim
Social History:
___
Family History:
___
Physical Exam:
ON DISCHARGE:
___ R AT, ___ ___ (baseline)
otherwise intact
Pertinent Results:
MRI L-Spine ___:
1. Status post laminectomies with the anterior and posterior
fusion of L4
through S1 in anatomic alignment. The collection within the
laminectomy bed may represent a postsurgical seroma.
Pseudomeningocele may also be considered, given the proximity to
the thecal sac at the L5-S1 level. Superimposed infection cannot
be excluded by imaging, a than if MRI with intravenous contrast
was obtained, but MRI with intravenous contrast could help
assessed the degree to which this collection is liquified.
2. The spinal canal at L4-5 and L5-S1 is well decompressed by
the
laminectomies. Subarticular zones and the left neural foramen at
L5-S1 are suboptimally visualized due to hardware related
artifacts, and persistent narrowing by endplate and facet
osteophytes cannot be excluded.
L-Spine x-ray ___:
Status post fusion across L4-S1 with unchanged alignment and no
hardware
complication.
Brief Hospital Course:
Patient presented to ___ and was evaluated with MRI and X-ray
for acute low back pain. He underwent MRI and X-ray scan which
showed a small likely seroma on MRI and no evidence of hardware
malalignment or disruption on x-ray. He was admitted for pain
control to the floor. He was started on a regimen for pain
control with good effect with goal of remaining on PO therapy.
He was mobilized and his pain mediciation regimen was altered to
correspond with his pain medication needs. He remained stable
overnight into ___ and did require some IV pain medication
doses. His PO regiment was again altered and he was able to
obtain adequate pain control in the afternoon of ___. His
progress was discussed and given transportation issues he will
be discharged to home on ___. He remained stable voernight with
good pain control on ORal agents. He was deemed fit for
discharge to home without serviuces. He was given instructions
for followup, prescriptions for required medications, and all
questions were answered prior to discharge.
Medications on Admission:
effexor, tizanidine, lyrica, amitriptyline, lipitor, valium,
oxycodone
Discharge Medications:
1. Acetaminophen ___ mg PO Q6H:PRN pain
2. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*60 Capsule Refills:*0
3. Gabapentin 300 mg PO TID
RX *gabapentin 300 mg 1 capsule(s) by mouth three times a day
Disp #*90 Capsule Refills:*0
4. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN pain
RX *hydromorphone [Dilaudid] 4 mg ___ tablet(s) by mouth
q4hours Disp #*60 Tablet Refills:*0
5. Pregabalin 150 mg PO TID
6. Tizanidine 6 mg PO TID spasm
Take 1.5 of the 4mg tablets for 6mg total dose
7. Venlafaxine XR 300 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Low back pain
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Do not smoke.
Take your pain medication as instructed; you may find it best
if taken in the morning when you wake-up for morning stiffness,
and before bed for sleeping discomfort.
Increase your intake of fluids and fiber, as pain medicine
(narcotics) can cause constipation. We recommend taking an over
the counter stool softener, such as Docusate (Colace) while
taking narcotic pain medication.
Clearance to drive and return to work will be addressed at
your post-operative office visit.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING:
Pain that is continually increasing or not relieved by pain
medicine.
Any weakness, numbness, tingling in your extremities.
Any signs of infection at the wound site: redness, swelling,
tenderness, and drainage.
Fever greater than or equal to 10.5° F.
Any change in your bowel or bladder habits (such as loss of
bowl or urine control).
Followup Instructions:
___
|
19697457-DS-6
| 19,697,457 | 27,318,772 |
DS
| 6 |
2125-04-15 00:00:00
|
2125-04-14 13:58:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Confusion
Major Surgical or Invasive Procedure:
None
History of Present Illness:
HISTORY OF PRESENT ILLNESS:
===========================
___ female, history of diabetes, prior CVA, presenting
with 2 to 3 weeks of weakness and confusion. Per her family, she
has not been eating and drinking as much as usual for the last 2
to 3 weeks. In addition she has not had a bowel movement for a
1.5 to 2 weeks. She has not been urinating as frequently and has
not urinated since last night. She denies any fevers or chills.
She denies any cough, abdominal pain, n/v/diarrhea, or urinary
symptoms. She denies black or bloody stools. Any chest pain or
shortness of breath.
- In the ED, initial vitals were:
- T 98.6, HR 110, BP 139/92, RR 24, SpO2 98%
- Exam was notable for:
- Constitutional: Comfortable, lethargic.
- Head/eyes: NCAT, PERRLA, EOMI.
- Chest/Resp: CTAB.
- Cardiovascular: RRR, Normal S1/S2.
- Abdomen: Soft, nondistended. Nontender.
- Musc/Extr/Back: ___. No edema.
- Skin: No rash. Warm and dry.
- Labs were notable for:
8.8 141|104| 40
13.9>----<518 ------------<137
29.3 4.7| 19| 1.2
- Ca 9.5, Mg 2.1, P 3.6
- Trop-T < 0.01
- ALT 24, AST 37, AP 111, Lip 12, TBili 0.4, Alb 3.1
- ___ 23.5, PTT 35.0, INR 2.2
- Lactate 1.8
- Studies were notable for:
- CXR Impression:
Relatively rounded region of consolidation in the right mid to
upper lung worrisome for underlying mass. Additional area of
consolidation at the right upper lung could be due to
atelectasis
or infection. CT chest suggested to further characterize.
- CT Head w/out contrast Impression:
1. Suspected mixed density lesion with central hypodensity in
the
left
parietal lobe measuring approximately 3.9 x 2.9 cm with
effacement of the surrounding sulci.
2. Hyperdense lesion in the right parietal periventricular white
matter measuring approximately 2.0 x 1.1 cm may be either
calcific or hemorrhagic.
3. A third mass adjacent to the frontal horn of the right
ventricle measuring 1.1 cm.
4. Right-sided encephalomalacia presumably from previous
infarction.
5. No evidence of acute large territory infarct. MR of the brain
is recommended for further evaluation.
- The patient was given:
- 1L NS
- Phytonadione 5 mg
- FFP
- Neurology were consulted and recommended INR goal <1.5 given
concern for brain bleed. MR brain ___ contrast to define
concern
for mets versus increased stroke burden. Will hold off on
recommending dexamethasone until lesions further characterized
with MRI. Given hemorrhage, would hold off on subq heparin,
antiplatelet, anticoagulation until MR is completed.
On arrival to the floor, patient is confused, oriented to person
only, and accompanied by two daughters. Per daughter, she
noticed
memory loss three weeks ago (did not remember her wedding) as
well as progressive confusion, poor PO intake, and constipation.
She has not had any infectious signs or symptoms. She lives in
___ and daughters are primary caretakers and help with
ADLs.
Past Medical History:
Stroke (about ___ years ago) residual left face/arm/leg weakness
HTN
DM
Social History:
___
Family History:
Sister passed away from cancer, unknown type
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
VITALS: 98.1 PO 169 / 80 91 18 96
GENERAL: confused, follows commands, oriented to person
HEENT: PERRL, EOMI, sclera anicteric, eyes looking slightly
off-center to left, dry MM, missing teeth
NECK: No JVD
CARDIAC: RRR, no murmurs
LUNGS: CTAB, unlabored respirations, no increased work of
breathing, no wheezes, rales, or rhonchi
GI: abdomen soft, non-distended, non-tender to palpation, no
rebound/guarding, normoactive bowel sounds throughout
EXTREMITIES: No lower extremity edema
SKIN: warm, no rashes
NEUROLOGIC: confused, oriented to person, does not remember
daughters in room, left gaze preference, left facial droop
DISCHARGE PHYSICAL EXAM:
========================
Gen: in NAD, elderly woman resting in bed
Resp: Not in resp distress
Card: grossly well perfused
Ext: Warm, well perfused
Pertinent Results:
ADMISSION LABS
___ 02:15PM BLOOD WBC-13.9* RBC-4.09 Hgb-8.8* Hct-29.3*
MCV-72* MCH-21.5* MCHC-30.0* RDW-16.3* RDWSD-41.6 Plt ___
___ 02:15PM BLOOD Neuts-76.0* Lymphs-10.7* Monos-10.2
Eos-1.1 Baso-0.5 Im ___ AbsNeut-10.56* AbsLymp-1.48
AbsMono-1.41* AbsEos-0.15 AbsBaso-0.07
___ 02:16PM BLOOD ___ PTT-35.0 ___
___ 02:15PM BLOOD Glucose-137* UreaN-40* Creat-1.2* Na-141
K-4.7 Cl-104 HCO3-19* AnGap-18
___ 02:15PM BLOOD ALT-24 AST-37 AlkPhos-111* TotBili-0.4
___ 02:15PM BLOOD Albumin-3.1* Calcium-9.5 Phos-3.6 Mg-2.1
___ 02:23PM BLOOD Lactate-1.8
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
___ 3:15 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
DISCHARGE LABS
___ 08:36AM BLOOD Neuts-77.2* Lymphs-10.5* Monos-9.0
Eos-1.2 Baso-0.5 Im ___ AbsNeut-9.87* AbsLymp-1.34
AbsMono-1.15* AbsEos-0.15 AbsBaso-0.06
___ 05:35AM BLOOD Plt ___
___ 05:35AM BLOOD Glucose-147* UreaN-15 Creat-0.7 Na-136
K-4.2 Cl-98 HCO3-25 AnGap-13
___ 05:35AM BLOOD LD(LDH)-567*
___ 05:35AM BLOOD Calcium-9.0 Phos-3.8 Mg-2.2 UricAcd-6.5*
___ 03:15PM URINE Blood-NEG Nitrite-NEG Protein-30*
Glucose-NEG Ketone-10* Bilirub-SM* Urobiln-2* pH-5.5 Leuks-NEG
___ 03:15PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG oxycodn-NEG mthdone-NEG
Brief Hospital Course:
___ female with PMH DM, HTN, prior CVA presenting with
three weeks of confusion d/t metastatic lung cancer (new
diagnosis) to brain to be treated palliatively for comfort, as
per patient wishes.
ACUTE/ACTIVE ISSUES:
====================
# Brain metastases
# History of prior CVA
# New Lung Cancer, unspecified
# Goals of care
Presents with ___ weeks of confusion. CT head showed multiple
lesions concerning for metastases, confirmed on MRI. CXR and CT
shows large
right density concerning for malignancy w potential invasion
into R pulm veins. S/p vitamin K, 2u FFP in ED for coagulopathy.
EEG w epileptiform activity (no seizures as previously
documented). Per neurology/ neuro/oncology started on
dexamethasone 4 mg PO qam for brain metastases (no significant
edema yet) and Keppra 1000 mg twice daily for seizure
prophylaxis (d/t sharp spikes bilateral frontal lobes). Had long
goals of care discussion with family and neuro oncology,
neurology, hematology/oncology, palliative care teams. Pt
clearly stated her wishes to go home and be comfortable, and
family agreed. Provided reassurance to family and recommended
that while we do not have a tissue diagnosis most treatment
options for the possible causes would make her worse before they
make her better. They understood and agreed w home hospice
evaluation.
TRANSITIONAL ISSUES:
[ ] Please continue keppra twice daily and dexamethasone daily
for seizure prophylaxis iso brain mets.
[ ] PCP follow up if desired
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. Atorvastatin 40 mg PO QPM
2. Baclofen 10 mg PO BID
3. Docusate Sodium 100 mg PO DAILY
4. Sertraline 50 mg PO DAILY
5. GlipiZIDE 5 mg PO DAILY
6. Hydrochlorothiazide 12.5 mg PO DAILY
7. amLODIPine 10 mg PO DAILY
8. Clopidogrel 75 mg PO DAILY
9. Lisinopril 40 mg PO QHS
10. Vitamin D ___ UNIT PO DAILY
11. Calcium Carbonate 750 mg PO BID
12. Polyethylene Glycol 17 g PO DAILY
13. Aspirin 81 mg PO DAILY
14. Acetaminophen 650 mg PO Q4H:PRN Pain - Mild/Fever
Discharge Medications:
1. Dexamethasone 4 mg PO DAILY
RX *dexamethasone 4 mg 1 tablet(s) by mouth once daily in the
morning Disp #*30 Tablet Refills:*0
2. LevETIRAcetam 1000 mg PO Q12H
RX *levetiracetam 500 mg/5 mL (5 mL) 10 mL by mouth twice a day
Disp #*120 Packet Refills:*0
3. Morphine Sulfate (Concentrated Oral Solution) 20 mg/mL ___
mg PO Q2H:PRN moderate-severe pain or respiratory distress
RX *morphine concentrate 100 mg/5 mL (20 mg/mL) 0.5 (One half)
ml by mouth Q2:PRN Disp ___ Milliliter Milliliter Refills:*0
4. Ondansetron ODT 4 mg PO Q8H:PRN Nausea/Vomiting - First Line
RX *ondansetron 4 mg 1 tablet(s) by mouth three times daily as
needed for nausea Disp #*10 Tablet Refills:*0
5. Acetaminophen 650 mg PO Q4H:PRN Pain - Mild/Fever
6. Baclofen 10 mg PO BID
7. Polyethylene Glycol 17 g PO DAILY
8. Sertraline 50 mg PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Metastatic lung cancer to brain
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Lethargic but arousable.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Ms. ___,
It was a privilege taking care of you at ___
___.
WHY WAS I ADMITTED TO THE HOSPITAL?
===================================
- Confusion for a few weeks
WHAT HAPPENED WHILE I WAS IN THE HOSPITAL?
==========================================
- Your head and chest were imaged, which showed new cancer in
your chest which has spread to your brain
- You were seen by neurologists and neuro oncologists, who
recommended treatment with steroids and an anti seizure
medication, which you will continue at home
- You also met with palliative care doctors and medical
___. After talking with you, we helped facilitate your
wish of going home by working with a team of medical specialists
called hospice. They will continue to help you be comfortable at
home
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
============================================
- Please let your family and the hospice team know if you are
not comfortable and they can help you with medications
- Please continue to take your Keppra (anti seizure medication)
and deamethasone (steroid to reduce brain swelling)
We wish you all the best!
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
19697615-DS-13
| 19,697,615 | 25,247,548 |
DS
| 13 |
2151-10-16 00:00:00
|
2151-10-16 11:18:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
left sided weakness and speech problems
Major Surgical or Invasive Procedure:
NONE
History of Present Illness:
Mr. ___ is a ___ yo man with no PMH who initially presented to
the ED with symptoms of speech problems with left sided weakness
and numbness. He fell over on ___ because he missed a step
up, and this prompted him to come to the ED. He has been having
dizzy spells for a month, many times a day. He feels off balance
and disoriented, and occassionally the room has been spinning.
Sometimes when he drives he is not able to keep a straight line.
If he stands up quickly, he feels unstable. When walking he
sometimes gets dizzy spells in his head, and this sometimes
occurs when he moves his head. He feels the dizziness more at
work, especially when he is having a stressful night. He had a
fever/cough prior to developing these symptoms. He has had
milder
versions of these symptoms before but not associated with
illness. He feels less dizzy when he is sitting down, resting,
relaxing.
His dizziness is associated with visual symptoms and headache.
Sometimes he gets a flash of darkness affecting his vision. This
is transient, lasting 1 minute or less. It is not tunnel vision
or a shade coming down over one eye. He has trouble describing
exactly how the vision becomes dark.
He also has headache, more frequently now than in the past in
his
life, in his neck and occiput, although it is sometimes frontal.
This is an aching pain which he has 3 times per week. The
headaches are associated with neck tightness. They are not
associated with migranous features.
His wife states that he has not been himself recently because of
these symptoms.
By the time of Neurology evaluation, the patient was not
complaining of speech problems or left sided weakness/numbness.
Additional ROS:
He notices more tearing from his right eye. Had diarrhea 3 days
ago. Has been warm and sweaty recently.
On neuro ROS, the pt denies diplopia, dysarthria, dysphagia,
tinnitus or hearing difficulty. Denies difficulties producing or
comprehending speech. Denies focal weakness, numbness,
parasthesiae. No bowel or bladder incontinence or retention.
Denies difficulty with gait.
On general review of systems, the pt denies night sweats or
recent weight loss or gain. Denies cough, shortness of breath.
Denies chest pain or tightness, palpitations. Denies nausea,
vomiting, constipation or abdominal pain. No recent change in
bladder habits. No dysuria. Denies arthralgias or myalgias.
Denies rash.
Past Medical History:
none
many PCP visits for headache, dizziness, LBP
Social History:
___
Family History:
No dizziness, stroke, seizures
Physical Exam:
T= 97.9F, BP= 160/70, HR= 66, RR= 18, SaO2= 100% on RA
General: Awake, cooperative, NAD.
HEENT: NC/AT
Neck: Supple, no nuchal rigidity
Pulmonary: CTABL
Cardiac: RRR, no murmurs
Abdomen: soft, nontender, nondistended
Extremities: no edema, pulses palpated
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented x 3. Able to relate history,
though has trouble explaining chronicity of symptoms and giving
a
clear picture of what symptoms are most bothersome. 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, but with difficulty
due
to visual acuity. Speech was not dysarthric. Able to follow
both midline and appendicular commands. Mildly inattentive,
able
to name ___ backward but is extremely slow on this task. Pt.
was
able to register 3 objects and recall ___ at 5 minutes. There
was no evidence of apraxia or neglect.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 3 to 2mm, both directly and consentually; brisk
bilaterally. VFF to confrontation. Visual acuity ___
bilaterally, using corrective lenses.
III, IV, VI: EOMI without nystagmus. Normal saccades.
V: Facial sensation diminished to light touch, pinprick in L
face
VII: R face with slower activation and slight nasolabial fold
flattening. Strong eye closure bilaterally, symmetric eyebrow
raise.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and L SCM, R SCM limited by pain in
neck.
XII: Tongue protrudes in midline.
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally. No adventitious movements, such as tremor, noted.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L ___ ___ ___ 5 5 5 5 5
R ___ ___ ___ 5 5 5 5 5
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 3 1
R 2 2 2 3 1
- Plantar response was flexor bilaterally.
- Pectoralis Jerk was absent, and Crossed Adductors are present.
-Sensory: Decreased sensation to light touch in L face/arm/leg.
Decreased sensation to pinprick in L face/leg. Decreased
sensation to cold in L arm/leg. Vibration and proprioception
intact.
-Coordination: No intention tremor, no dysdiadochokinesia noted.
No dysmetria on FNF or HKS bilaterally. Patient passes the
target
on L FNF. Patient performed these tests very slowly despite
instructions otherwise.
-Gait: Broad based, good arm swing, no ataxia. Romberg absent.
Pertinent Results:
___ 11:00PM GLUCOSE-97 UREA N-19 CREAT-1.2 SODIUM-140
POTASSIUM-4.2 CHLORIDE-103 TOTAL CO2-25 ANION GAP-16
___ 11:00PM CALCIUM-8.6 PHOSPHATE-3.2 MAGNESIUM-2.2
___ 11:00PM WBC-7.6 RBC-4.33* HGB-12.7* HCT-36.3* MCV-84
MCH-29.4 MCHC-35.1* RDW-13.6
___ 11:00PM NEUTS-50.3 ___ MONOS-5.0 EOS-5.8*
BASOS-0.5
___ 11:00PM PLT COUNT-214
Brief Hospital Course:
Mr. ___ is a ___ yo man who presents with symptoms of dizziness
and sensory changes on initial exam.
The patient presented with generalized dizziness and
unsteadiness for several weeks. He had a normal neurologic exam
and no abnormalities on MRI or CTA head and neck. There does not
appear to be a neurologic cause for his symptoms. He does
endorse significant stressors, worsening recently, which may be
causing the symptoms.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. This patient is not taking any preadmission medications
Discharge Medications:
none
Discharge Disposition:
Home
Discharge Diagnosis:
dizziness, stress induced
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You came to the hospital because of weeks of dizziness. Because
of a concern for stroke you have an MRI of the brain. This did
not show any stroke or other concerning process. We feel that
the cause of your symptoms is most likely stress from work. You
may consider talking to your primary doctor about strategies to
help lower your stress.
Followup Instructions:
___
|
19697826-DS-7
| 19,697,826 | 21,328,342 |
DS
| 7 |
2188-08-06 00:00:00
|
2188-08-14 23:43:00
|
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, Dyspnea
Major Surgical or Invasive Procedure:
CARDIAC PERFUSION PHARM Scan (___)
CTA Chest
History of Present Illness:
___ yo female with h/o RA and an undifferentiated lung disease
presents with chest pain and dyspnea starting at 10:15 on day of
presentation which has been constant. Patient endorses severe
dyspnea on exertion and some dyspnea at rest. There was some
associated nausea as well. Patient's chest pain was described as
"dull with an edge" substernal radiating to arm, throat and
epigastrium. She has had chest pain on exertion, but never this
severe, or longlasting.
In the ED, initial vitals were: T 98.3, P 66, BP 128/57, RR 18,
O2sat 98% on NC
- Labs notable for: normal BMP, CBC, coags. Trop <0.01 x 2.
- Imaging was notable for: CT showing no PE but anterolateral
rib fracture (from prior). CXR with mild pulm congestion. EKG
without any ischemic changes.
- Patient was given: aspirin, albuterol, ipratroprium, SL nitro
x 2, and Tylenol.
Upon arrival to the floor, patient reports that she is no
longer having chest pain and that her breathing feels much
improved. However, she notes that when she was recently walking
from her bed, she was very dyspneic. She denies fevers/chills.
No recent diarrhea, melena or BRBPR. She notes that after the
duonebs in the ED she felt very tachycardic and there was report
of her hyperventilating after the treatment.
REVIEW OF SYSTEMS:
(+) Per HPI
(-) 10 point ROS reviewed and negative unless stated above in
HPI
Past Medical History:
Rheumatoid arthritis, depression, dyspnea, hypothyroidism
Social History:
___
Family History:
Uncle- RHEUMATOID ARTHRITIS
___ DISEASE, COLON CANCER
Physical Exam:
ADMISSION EXAM:
======================
VITAL SIGNS: T 98.5, BP 133/67, P 70, RR 24, O2sat 97% on RA
GENERAL: Patient appears comfortable, in NAD
HEENT: MMM
NECK: supple, no elevation in JVP
CARDIAC: RRR, no m/r/g, normal s1 and s2
LUNGS: CTAB, though some wheezing audible while speaking to
patient
ABDOMEN: soft, nontender, nondistended
EXTREMITIES: WWP, ___ bilaterally
NEUROLOGIC: A&Ox3, moving all extremities, ___ intact
DISCHARGE EXAM:
======================
VS - Tmax 98.6 Tc 97.7 HR ___ BP ___ RR 20 SzO2
___ on RA
General: Well appearing, pleasant, calm, lying in bed
HEENT: NC/AT, MMM, no cervical lymphadenopathy, EOMI
CV: RRR, no m/r/g
Lungs: CTAB, breathing comfortably
Abdomen: Large vertical abdominal scar, soft, nontender,
nondistended, no HSM appreciated
Ext: warm and well perfused, pulses, trace edema in bilateral
lower extremities
Neuro: grossly normal
Pertinent Results:
ADMISSION LABS:
===============
___ 04:00PM BLOOD ___
___ Plt ___
___ 04:00PM BLOOD ___
___ Im ___
___
___ 04:32PM BLOOD ___ ___
___ 04:00PM BLOOD ___
___
___ 04:00PM BLOOD ___
___ 04:00PM BLOOD cTropnT-<0.01
___ 09:15PM BLOOD cTropnT-<0.01
DISCHARGE LABS:
=================
___ 07:22AM BLOOD ___
___ Plt ___
___ 07:22AM BLOOD ___
___
CXR (___) IMPRESSION: No radiographic evidence for pneumonia or
pneumothorax. Mild pulmonary
vascular congestion.
CTA Chest (___) IMPRESSION:
1. No evidence of pulmonary embolism or aortic abnormality.
2. Acute nondisplaced fracture of the left anterolateral seventh
rib.
___ ___ and ___ IMPRESSION: No anginal type symptoms or
ischemic EKG changes. Normal perfusion, ejection fraction and
wall motion. Normal left ventricular size.
Brief Hospital Course:
___ yo female with h/o RA and an undifferentiated lung disease
who presented with chest pain and dyspnea starting on ___.
# Dyspnea on exertion- Patient's symptoms seem to have an
anxiety component associated with them. However, review of her
history including progressive DOE, borderline DLCO, and mild
PHTN on TTE may indicate some chronic lung disease. Previous
spirometry was normal. Patient also has a history of
seronegative RA, and given seronegativity, it is less likely
that she has pulmonary involvement from her RA. There was no
concern for MTX induced pneumonitis based on patient's symptoms
and imaging. Patient was given Ipratropium Q6H and Flovent BID
and her symptoms improved markedly. Ambulatory SaO2 were 95% on
RA. Cardiac workup was unremarkable as below.
# Chest pain: Episode was atypical and MI was ruled out.
However, given patient's increased risk for CV disease in the
setting of RA and a concerning drop in BP during a previous
exercise stress test, ___ was ordered. Stress test produced no
anginal type symptoms or ischemic EKG changes. Nuclear medicine
results revealed: Normal perfusion, ejection fraction wall
motion, and LV size.
Transitional Issues:
========================
- Cardiac, ENT, Rheumatology, and PCP ___ results were normal, please reassess patient's symptoms
in the outpatient setting
- Cardiology ___ within 2 weeks as possible, pt instructed
to call for a sooner ___
- PCP ___ within 1 week, pt instructed to call for a
sooner appointment than the one scheduled
- Pulmonary Rehabilitation to be scheduled by the patient
Medications on Admission:
1. PredniSONE 3 mg PO DAILY
2. Fluticasone Propionate NASAL 1 SPRY NU BID
3. FoLIC Acid 2 mg PO DAILY
4. Hydroxychloroquine Sulfate 200 mg PO DAILY
5. LamoTRIgine 25 mg PO BID
6. Levothyroxine Sodium 75 mcg PO DAILY
7. Lidocaine 5% Patch ___ PTCH TD DAILY:PRN affected area for
pain control
8. LORazepam 1 mg PO QHS:PRN insomnia
9. Methotrexate 10 mg PO 1X/WEEK (FR)
10. Ranitidine 150 mg PO BID
11. Sertraline 75 mg PO DAILY
12. Simvastatin 40 mg PO QPM
13. Humira Pen (adalimumab) 40 mg/0.8 mL subcutaneous EVERY 2
WEEKS
14. Calcium Citrate + D (calcium ___ D3) ___
___ oral BID
15. ___ Womens Mature (___) 8
mg ___ mcg oral DAILY
16. Acetaminophen ___ mg PO Q6H:PRN Pain - Mild
Discharge Medications:
1. Acetaminophen ___ mg PO Q6H:PRN Pain - Mild
2. Calcium Citrate + D (calcium ___ D3) ___
___ oral BID
3. ___ Womens Mature (___) 8
mg ___ mcg oral DAILY
4. Fluticasone Propionate NASAL 1 SPRY NU BID
5. FoLIC Acid 2 mg PO DAILY
6. Humira Pen (adalimumab) 40 mg/0.8 mL subcutaneous EVERY 2
WEEKS
7. Hydroxychloroquine Sulfate 200 mg PO DAILY
8. LamoTRIgine 25 mg PO BID
9. Levothyroxine Sodium 75 mcg PO DAILY
10. Lidocaine 5% Patch ___ PTCH TD DAILY:PRN affected area for
pain control
11. LORazepam 1 mg PO QHS:PRN insomnia
12. Methotrexate 10 mg PO 1X/WEEK (FR)
13. PredniSONE 3 mg PO DAILY
14. Ranitidine 150 mg PO BID
15. Sertraline 75 mg PO DAILY
16. Simvastatin 40 mg PO QPM
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Dyspnea on exertion
Secondary:
Anxiety,
Rheumatoid arthritis
Hypothyroidism
Depression
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear ___
___ were admitted to ___ on ___.
WHY WAS I HERE?
- ___ were admitted to the hospital for shortness of breath and
chest pain.
WHAT WAS DONE FOR ME?
- ___ received medications to help ___ breath more easily
- ___ had a CT scan of your lungs to look for blood clots, but
no clots were seen
- ___ had a cardiac perfusion scan to evaluate if there are
parts of your heart that are not receiving an adequate amount of
blood. This test was normal.
WHAT SHOULD I DO WHEN I GO HOME?
- ___ should ___ with your primary care doctor within the
next 1 week, cardiologist within the next 2 weeks,
rheumatologist, and ENT doctor.
- ___ should attend pulmonary rehabilitation
It was a pleasure taking care of ___ and we wish ___ good
health.
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
19697979-DS-19
| 19,697,979 | 28,996,753 |
DS
| 19 |
2170-12-20 00:00:00
|
2170-12-20 13:47:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
hypoxia, hypotension
Major Surgical or Invasive Procedure:
Intubation and Mechanical Ventilation
Triple Lumen Catheter Placement
PICC Line Placement
History of Present Illness:
___ year old man with history of CAD/MIs, remote VFib arrest,
Afib on warfarin, seizures, CHF (EF 30%), HTN, transferred here
from ___ for presumed sepsis from pneumonia.
.
The patient was found at his nursing home ___ with
decreased responsiveness, O2 Sat ___ low ___. Initially presented
to ___ and ___ to be febrile to 101.4, normotensive and
improved SaO2 to 100% on NRB. Labs there were notable for Na
150, Cr 1.3 (uncertain baseline), Trop T 0.163/CKMB 3.4, WBC
9.7, INR 4. UA positive for blood and protein, no leuks or
nitrates. Due to difficult access, R femoral TLC was placed
under sterile conditions. He had increasing respiratory distress
___ setting of femoral line placement, thus was intubated.
Pressures dropped to 60's following intubation, so was started
on norepinephrine for hypotension and transferred here. He
received 2L IVF and given Clindamycin and Vancomycin. Also was
noted to have roving eye movements and rhythmic L arm and leg
movements concerning for seizure, so was loaded on
levitiracetam. (Uncertain doses for medications as not ___
reports).
.
On arrival to ___ ED, he was intubated and sedated, not
arousable. VS were T 101, HR 83, BP 142/79, RR 18, 99% on vent
(A/C: Vt 500, PIP 19, PEEP 5, RR 16). His labs were notable for
ABG 7.46/28/167/21, lactate 1.5, TropT 0.16, Na 147, BUN/Cr
___, WBC 7.9, H/H 11.3/36, INR 4.5. CT head was negative for
bleed. CXR notable for R side pneumonia. He was continued on
Fentanyl and Midazolam for sedation, norepinephrine as a
pressor. Given 2L IVF and transferred to ICU. Prior to
transfer, VS T 101.0, 69, 129/85 (on norepinephrine 0.05), 13.
Per report, minimal UOP (70cc ___ ED).
.
On arrival to ICU, patient is intubated and sedated. Does not
awaken to painful stimuli. Review of systems unable to be
obtained.
.
Past Medical History:
CAD/Hx of MIs
Seizures
CVA
Remote Vfib/vtach
Afib on warfarin
RUE DVT
R inguinal hernia repair (___)
CHF, last EF 30% per report
LV thrombus
HTN
EtOH abuse, ___ pint cognac daily. History of withdrawal
seizures
___ Dementia
Frequent falls with hx of head trauma with ICH (___)
Hx PE
Social History:
___
Family History:
unknown
Physical Exam:
On Admission:
Vitals- T: 98.1 BP: 120/82 P: 68 R: 14 O2: 100% on CMV
400/14/5/35%
General: Itubated, sedated. Not responding to painful stimuli
HEENT: Sclera anicteric, dry mucous membranes, oropharynx clear
Neck: supple, no JVD or LAD
Lungs: Lateral basilar crackles, otherwise clear without
wheezes. CV: Regular rhythm, early systolic murmur.
Abdomen: soft, non-distended, bowel sounds present, no
organomegaly
GU: foley draining dark amber urine
Ext: cool, dry. No edema. Pulses not palpable distally
.
On Discharge:
VS: AVSS, afebrile, normotensive, HR 60-70's
Gen: NAD, calm, sleeping but easily arousable
HEENT: anicteric, dry MM
CV: irreg irreg, no murmur appreciated
Lungs: CTAB/L
Abd: soft, NT, ND, NABS
Ext: + RUE edema (improved), no ___ edema
GU: No Foley
Neuro: calm, AAOx0. Responds to voice, but answers all ?'s with
"yes" or "yep"
.
Pertinent Results:
On Admission:
================
___ 12:05PM BLOOD WBC-7.9 RBC-3.67* Hgb-11.3* Hct-36.4*
MCV-99* MCH-30.8 MCHC-31.1 RDW-15.6* Plt ___
___ 12:05PM BLOOD Neuts-89.1* Lymphs-8.3* Monos-2.2 Eos-0.2
Baso-0.2
___ 12:05PM BLOOD ___ PTT-37.1* ___
___ 12:05PM BLOOD Glucose-115* UreaN-30* Creat-1.3* Na-147*
K-3.9 Cl-116* HCO3-22 AnGap-13
___ 12:05PM BLOOD ALT-26 AST-32 AlkPhos-64 TotBili-0.7
___ 12:05PM BLOOD Albumin-2.7* Calcium-7.8* Phos-4.0 Mg-1.8
___ 12:18PM BLOOD Type-ART pO2-167* pCO2-28* pH-7.46*
calTCO2-21 Base XS--1
___ 12:18PM BLOOD Lactate-1.5
.
Cardiac Enzymes:
===================
___ 12:05PM BLOOD cTropnT-0.16*
___ 10:56PM BLOOD cTropnT-0.21*
___ 04:19AM BLOOD cTropnT-0.20*
___ 04:55AM BLOOD cTropnT-0.08*
.
Discharge Labs / Pertinent Labs:
===================================
___ 04:43AM BLOOD WBC-13.2*# RBC-3.54* Hgb-10.6* Hct-34.0*
MCV-96 MCH-30.0 MCHC-31.2 RDW-17.3* Plt ___
___ 04:43AM BLOOD ___ PTT-41.7* ___
___ 04:43AM BLOOD Glucose-83 UreaN-25* Creat-1.0 Na-140
K-3.9 Cl-106 HCO3-23 AnGap-15
___ 08:59AM BLOOD %HbA1c-6.2* eAG-131*
___ 04:55AM BLOOD TSH-3.3
___ 07:56AM BLOOD Valproa-21*
.
Microbiology:
================
___ Blood cultures x 2 - No Growth (FINAL)
___ Urine culture - No Growth (FINAL)
___ Sputum culture
GRAM STAIN (Final ___:
>25 PMNs and <10 epithelial cells/100X field.
1+ (<1 per 1000X FIELD): BUDDING YEAST.
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI.
___ CLUSTERS.
RESPIRATORY CULTURE (Final ___:
SPARSE GROWTH Commensal Respiratory Flora.
LEGIONELLA CULTURE (Preliminary): NO LEGIONELLA ISOLATED.
FUNGAL CULTURE (Preliminary):
YEAST.
.
Imaging/Studies:
===================
___ CXR
IMPRESSION: Increased hazy opacity ___ the right lung and
retrocardiac focal consolidation. Findings are worrisome for
multifocal pneumonia.
.
___ ECG
Atrial fibrillation with moderate ventricular response. Prior
inferior wall myocardial infarction and possible prior anterior
wall myocardial infarction as well. The anterolateral left
ventricular hypertrophy with ST-T wave change. Cannot exclude
active lateral ischemic process with T wave inversion ___ leads
V3-V6 and associated ST segment depression. Followup and
clinical correlation are suggested.
.
___ CT Head
IMPRESSION: No acute intracranial process.
.
___ Echocardiogram
The left atrium is moderately dilated. There is moderate
symmetric left ventricular hypertrophy. The left ventricular
cavity size is normal. There is an inferobasal left ventricular
aneurysm. Overall left ventricular systolic function is severely
depressed with inferior akinesis and moderate/severe hypokinesis
of the remaining segments (LVEF= 25*-30 %). A left ventricular
mass/thrombus cannot be excluded. with moderate global free wall
hypokinesis. The aortic valve leaflets (3) are mildly thickened.
No masses or vegetations are seen on the aortic valve, but
cannot be fully excluded due to suboptimal image quality. There
is no aortic valve stenosis. Mild to moderate (___) aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. An eccentric, anteriorly directed jet of moderate
(2+) mitral regurgitation is seen. The tricuspid valve leaflets
are mildly thickened. There is mild pulmonary artery systolic
hypertension. There is no pericardial effusion.
IMPRESSION: moderate symmetric LVH with regional and global
dysfunction as described above. At least moderate mitral
regurgitation with jets that are directed anteriorly as well as
towards the back wall of the atrium. Mild to moderate aortic
regurgitation. Mild elevation of pulmonary pressures.
.
___ PCXR
IMPRESSION:
Previously severe consolidation ___ the right mid and lower lung
is improving. Lateral view would be helpful to assess the extent
of pleural effusion which could be considerable, as well as the
extent of right lower lobe atelectasis. On the left, there is
some pleural fluid, and mild edema. Heart size is
top-normal, substantially improved since ___. An the cardiac
configuration suggests substantial left atrial enlargement,
although this determination is dubious on a bedside chest
radiograph.
Overall the findings suggest improving cardiovascular status,
and if pneumonia was present earlier, it also has improved.
.
___ RUE US
IMPRESSION:
Nonocclusive thrombus is seen ___ the right proximal brachial
vein. There is an occlusive thrombus ___ the right cephalic
vein.
.
___ PCXR
IMPRESSION:
Previous bibasilar atelectasis ___ moderate pleural effusions
improved between ___ and ___, subsequently stable. The
heart is moderately enlarged. There is a bulge ___ the contour of
the descending thoracic aorta suggesting an aneurysm perhaps of
the arch,, although because of kyphotic positioning, this could
be it and alteration any appearance of the main pulmonary
artery. CT scanning would be definitive, and intravenous
contrast should be employed if the patient can tolerate it.
.
___ EEG
IMPRESSION: This is an abnormal EEG because of diffusely slow
___ Hz polymorphic theta background with abundant intermixed
delta waves. These findings are indicative of a mild to moderate
cerebral dysfunction which is non-specific ___ etiology. There
are no focal findings or epileptiform features.
.
INR TREND:
=============
___ 04:55AM BLOOD ___ PTT-88.4* ___
___ 04:52AM BLOOD ___ PTT-37.8* ___
___ 05:46AM BLOOD ___
___ 06:10AM BLOOD ___
___ 05:26AM BLOOD ___
___ 05:18AM BLOOD ___ PTT-47.8* ___
___ 04:43AM BLOOD ___ PTT-41.7* ___
___ 07:55AM BLOOD ___
___ 06:40AM BLOOD ___
Brief Hospital Course:
___ year old man with history of CAD/MI's, remote VFib arrest,
Afib on warfarin, seizures, chronic CHF (EF 30%), RUE DVT,
transferred here from ___ with sepsis and respiratory
failure from pneumonia.
.
Active Issues
.
# Respiratory failure / # Healthcare-associated PNA vs
aspiration PNA / # septic shock
Presented with hypoxemia, corrected with NRB but intubated for
respiratory distress. CXR initially concerning for right sided
multifocal pneumonia and he was started on vancomycina and
cefepime for a healthcare-associated pneumonia (D1 = ___. He
also had evidence of pulmonary edema ___ conjuntion with elevated
BNP on admission. Echocardiogram showed LEVFR ___ (consistent
with prior echo at ___. This repsonded well to diuresis and
he was weaned to pressure support. He was noted to have apneic
episodes on mininmal pressure support, but maintained
oxygenation and this was felt to be a chronic breathing pattern
for him. He was extubated on HD#4 without complication. He
completed a course of IV antibiotics on ___ for a total of a
full 8 day course. He was evaluated by Speech / Swallow and
cleared for a modified PO diet with pureed solids and
nectar-thick liquids.
.
# Altered mental status
He presented with obtundation, changed from his baseline. Likely
from both infection and hypoxemia from pneumonia. Had
normotension during decreased responsiveness. Also, per OSH
report had activity concerning for seizure activity and loaded
on Keppra. No further activity observed, so Keppra was not
continued. INR was supratherapeutic, but head CT showed no acute
process. EtOH level was negative. His mental status slowly
improved and per SNF his baseline is verbal but not oriented.
His brother came to identify him after admission, but was not
able to give further insight into his baseline mental status.
Head CT obtained ___ setting of supratherapeutic INR was negative
for bleed. EtOH level negative. Awake and responsive today. Per
SNF, baseline is verbal but not oriented. He had an EEG which
did not show any seizure. His current mental status appears to
be at his recent baseline. Per previous hospital reports, he
has a history of many falls ___ the past, with a significant fall
___ ___ with subsequent intracranial hemorrhage. He
also has a history of EtOH abuse, and per previous evaluation,
there is a likely component of ___ syndrome. TSH
was checked and WNL.
.
# Atrial fibrillation
On digoxin and metoprolol as outpatient. Continued on BB only
during hospitalization with excellent rate control. INR was
supratherapeutic on warfarin on admission. Warfarin was held and
restarted when INR at goal. He had paroxysmal atrial
fibrillation on telemetry and no episodes of rapid ventricular
rate. We did not resume his digoxin, but if his HR's are
elevated ___ the future, this can be restarted. INR was 2.9 on
day of discharge.
.
# LV aneurysm with thrombus
Seen on echocardiogram. This was also noted on prior echo at
___. Warfarin was continued as noted above.
.
# RUE DVT
Known RUE DVT, recently diagnosed ___ ___ at ___. He
was anti-coagulated as above.
.
# Acute kidney injury
Creatinine elevated to 1.3 on admission, felt to be prerneal ___
the setting of sepsis. This improved with fluid resuscitation to
his baseline. However, he had recurrent creatinine elevation
from 1 to 1.6 after diuresis, which was felt to be likely from
overdiuresis.
.
# Coronary artery disease / chronic systolic HF
OSH reports a history of MI. Troponin was elevated at OSH and to
0.16 on repeat here, with negative CKMB. EKG with lateral STD
that are unchanged from prior. Appears to have had elevated
trops ___ past, per OSH records. Repeat troponins were stable and
there was no concern for active ACS. He was continued on aspirin
and statin. Metoprolol and nitrate were initially held ___ the
setting of hypotension but was restarted once hypertensive. Has
associated ischemic CHF (EF ___, as described above). He had
previously been on an ACEIi, but this was stopped
.
TRANSITIONAL
.
1. INR check on ___, to determine further Coumadin
dosing
2. re-check his Cr to assess for stable renal function. If
stable, can start ACEi for his systolic heart failure.
3. Monitor his HR. If he develops RVR for his Afib or
suboptimal rate control, can resume his previous digoxin.
4. Continue speech therapy. Consider video swallow study.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Metoprolol Succinate XL 50 mg PO DAILY
2. Digoxin 0.125 mg PO EVERY OTHER DAY
3. lactobacillus acidophilus oral daily
4. melatonin 5 mg oral hs
5. Divalproex Sod. Sprinkles 500 mg PO HS
6. Atorvastatin 80 mg PO HS
7. Senna 8.6 mg PO HS
8. Isosorbide Dinitrate 20 mg PO TID
9. Acetaminophen 650 mg PO BID
10. Vitamin D ___ UNIT PO DAILY
11. ___ MD to order daily dose PO DAILY16
Discharge Medications:
1. Atorvastatin 80 mg PO HS
2. Divalproex Sod. Sprinkles 500 mg PO HS
3. Isosorbide Dinitrate 20 mg PO TID
4. Senna 8.6 mg PO HS
5. Vitamin D ___ UNIT PO DAILY
6. Aspirin 81 mg PO DAILY
7. Metoprolol Succinate XL 50 mg PO DAILY
8. Warfarin 1 mg PO DAILY16 Duration: 2 Days
recommend 1mg daily x 2 days, then check INR on ___ to
determine further dosing
9. melatonin 5 mg oral hs
10. Acetaminophen 650 mg PO BID
11. lactobacillus acidophilus 0 tab ORAL DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary Diagnosis:
Septic shock from aspiration vs healthcare-associated PNA.
.
Secondary Diagnosis:
Seizure disorder
CAD
Ischemic cardiomyopathy / chronic systolic heart failure
LV thrombus
Atrial fibrillation
RUE DVT (chronic)
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Lethargic but arousable.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
You were sent to the hospital with difficulty breathing and
altered mental status. You were found to have a significant
pneumonia with low blood pressure (septic shock), requiring
placement of a breathing tube and use of a breathing machine
temporarily. You responded well to antibiotics and IV blood
pressure support medications (pressors).
.
Please weigh yourself daily. Please call your PCP if you have
weight gain more than 3 lbs.
Followup Instructions:
___
|
19698010-DS-11
| 19,698,010 | 21,994,837 |
DS
| 11 |
2119-11-28 00:00:00
|
2119-12-12 14:21:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Assault/mandibular fracture
Major Surgical or Invasive Procedure:
___:
1. Closed reduction of left subcondylar mandibular fracture with
___ bars
2. Open reduction internal fixation of right parasymphysis
mandibular fracture with interdental fixation
History of Present Illness:
___ year old healthy male who was transferred from OSH with
facial trauma, CT scan at OSH showed open mandibular fracture.
___ surgery evaluated the patient and decided to take him to
the OR today vs tomorrow ___. ACS were consulted for
further evaluation and admission per protocol. Patient could not
recall exact incident, but he believes that he was assaulted
after alcohol intoxication,, and he lost consciousness. He
remembered is that group of strangers was helping him and giving
him a ride to his girlfriend sister's house.Then they called ___
At OSH, where CT Maxface was showed displaced right
parasymphysis and displaced left subcondylar facture. He denies,
fevers, chills, chest pain , COB, headache, abdominal pain,
dizziness, or any neurological symptoms. He does endorse facial
pain L>R.
Past Medical History:
PMH:
None
PSH:
R hand surgery (has a plate )
Social History:
___
Family History:
Non-contributory
Physical Exam:
Admission Physical exam:
VS:
General: NAD
HEENT: AT/NC, left sided pre-auricular swelling that is
tender. not able to bite into MIP, Facial pain L>R
Heart:RRR, no M/R/G
Chest: CTAB
Abdomen: soft, NT/ND, no guarding or rebound
Neuro grossly intact
Neck:supple normal ROM, , no JVD,
EXT: WWP, left elbow abrasion
Discharge Physical Exam:
VS: T: 97.4 Adult Axillary BP: 124/74 R Lying HR: 72 RR: 18 O2:
98% Ra
GEN: A+Ox3, NAD
HEENT: jaws wired shut, lower ___ facial edema consistent with
procedure
CV: RRR
PULM: CTA b/l
ABD: soft, non-distended, non-tender to palpation
EXT: wwp, no edema b/l
Pertinent Results:
IMAGING:
___: Mandible (Panorex) x-ray:
There is an acute oblique fracture through the right mandibular
body. The
fracture is seen to extend to the root ___ tooth number 26
and extends
inferolaterally. Additional fracture seen through the left
mandibular ramus with displacement, better characterized on
prior CT. There is no
temporomandibular joint dislocation. Fractured left maxillary
second molar is better seen on same-day CT scan. No additional
fractures identified.
LABS:
___ 09:40AM GLUCOSE-101* UREA N-8 CREAT-0.9 SODIUM-143
POTASSIUM-5.0 CHLORIDE-101 TOTAL CO2-24 ANION GAP-18
___ 09:40AM WBC-15.8* RBC-4.46* HGB-13.5* HCT-40.9 MCV-92
MCH-30.3 MCHC-33.0 RDW-12.8 RDWSD-43.1
___ 09:40AM NEUTS-85.7* LYMPHS-6.0* MONOS-7.8 EOS-0.0*
BASOS-0.1 IM ___ AbsNeut-13.55* AbsLymp-0.95* AbsMono-1.24*
AbsEos-0.00* AbsBaso-0.02
___ 09:40AM PLT COUNT-282
___ 09:40AM ___ PTT-25.9 ___
Brief Hospital Course:
Mr. ___ is a ___ year old healthy male who was transferred from
OSH with
facial trauma, CT scan at OSH showed displaced right
parasymphysis and
displaced left subcondylar facture. The Oral Maxillofacial
Surgery service (___)evaluated the patient and decided his
injuries warranted operation. The patient was admitted to the
Acute Care Surgery service for further care. An intraoral bridle
wire was under local anesthetics. The patient was started on
cefazolin and peridex mouth washes. He was cleared for full
liquids and was then made NPO at midnight for the OR.
On HD2, the patient was taken to the operating room and
underwent closed reduction of the left subcondylar mandibular
fracture with ___ bars and ORIF of the right
parasymphysis mandibular fracture with interdental fixation.
This procedure went well (reader, please refer to operative note
for further details). After remaining hemodynamically stable in
the PACU, the patient was transferred to the surgical floor.
The patient tolerated a full liquid diet and initially received
IV acetaminophen and IV morphine for pain control. He was
transitioned to oral liquid acetaminophen and oxycodone.
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:
None
Discharge Medications:
1. Acetaminophen (Liquid) 480 mg PO Q6H:PRN Pain - Mild/Fever
RX *acetaminophen 160 mg/5 mL (5 mL) 15 mL(s) by mouth every six
(6) hours Disp #*840 Milliliter Refills:*0
2. Cephalexin 500 mg PO Q6H Duration: 5 Days
RX *cephalexin 250 mg/5 mL 10 mL(s) by mouth every six (6) hours
Disp #*200 Milliliter Refills:*0
3. Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL TID
swish and spit
RX *chlorhexidine gluconate 0.12 % rinse mouth with 15 mL three
times a day Disp #*315 Milliliter Refills:*0
4. Docusate Sodium (Liquid) 100 mg PO BID
Hold for loose stool
RX *docusate sodium 50 mg/5 mL 10 mL(s) by mouth twice a day
Disp ___ Milliliter Refills:*0
5. Nicotine Patch 21 mg/day TD DAILY
RX *nicotine 21 mg/24 hour apply 1 patch to area of upper arm
Daily Disp #*14 Patch Refills:*0
6. OxycoDONE Liquid ___ mg PO Q4H:PRN Pain - Moderate
Reason for PRN duplicate override: Alternating agents for
similar severity
Wean as tolerated. Patient may request partial fill.
RX *oxycodone 5 mg/5 mL ___ mL(s) by mouth every four (4) hours
Disp #*420 Milliliter Refills:*0
7. Polyethylene Glycol 17 g PO DAILY:PRN constipation
RX *polyethylene glycol 3350 17 gram 1 powder(s) by mouth Daily
Disp #*7 Packet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Left subcondylar mandible fracture and right parasymphysis
mandible 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 with jaw fractures due to
facial assault. You were taken to the operating room by the Oral
Maxillofacial Surgeons (___) and you underwent repair of your
jaw fractures, had teeth extracted, and your jaw was wired shut.
Please adhere to a full liquid diet until you are cleared to
advance your diet by the ___ service. You are now ready to be
discharged home to continue your recovery and you will be
contacted by the ___ clinic with a follow-up appointment.
Please note the following discharge instructions:
Please maintain meticulous oral hygiene with twice daily
brushing
and by using the prescribed mouthrinse twice daily. Rinse with
warm salt water after meals.
Please do not smoke while your surgical sites are healing.
Smoking will significantly affect the healing and affect your
sinuses.
Please do not drive while taking narcotic medications as these
medications can slow your reaction time and be sedating. If you
feel you do not need this narcotic medication, then you may take
tylenol only.
No strenuous activity or heavy lifting greater than 10 lbs for
the next 6 weeks.
Please maintain a strict non-chew full liquid diet for 4 weeks
or
until advised otherwise by your surgeon. A diet package will be
provided to you for helpful ideas of liquid meals.
Take your stool softeners daily to prevent constipation. Keep
your stools loose to prevent bearing down or straining.
You have stiches in your mouth. These will dissolve on their own
within ___ weeks.
Call your doctor or go to the nearest ER for the following:
- Fevers > ___
- Increased pain, redness, swelling of the wound
- Drainage, pus from the wound
Contact ___ oral surgery with questions about care of this
patient at any time ___, ask the operator to page the
Oral Surgery resident on call.
Please refer to the provided jaw surgery instruction sheet for
further details regarding post-operative care.
WOUND CARE:
Your wounds need to be kept clean and dry. You may shower, but
you are not to soak your wounds in the bathtub, swimming pool,
or
hot tub for about four weeks. You are to inspect your wounds
daily for signs and symptoms of infection, these include:
increased pain or tenderness on or near the wounds, increased
redness or swelling around the wounds, drainage from the wounds,
reopening of the wounds, or an oral temperature of 101.5 degrees
F or more. If you develop any of these signs of infections
please
return to the emergency room.
CONTINUED CARE:
You may take Tylenol for pain. If you require pain medicine more
frequently than every 6 hours, you may alternate with Motrin
every 6 hours in between so that you are getting a form of pain
medicine every 3 hours. Initially you may need to take pain
medications on a regular basis. Once your pain improves you may
stop taking them based on your symptoms.
Please do not drive while taking narcotic medications as these
medications can slow your reaction time and be sedating
Wired Jaw Care
You may have your jaw wired shut for many reasons, including a
broken jaw or jaw surgery. The wires help hold your jaw in place
while you heal.
HOW TO CARE FOR YOUR WIRED JAW
Keep your mouth clean.
·Rinse your mouth with warm salt water after eating or drinking
anything. To make salt water, mix ½ tsp of salt in one cup of
warm water.
·Brush the front of your teeth with a child-sized, soft
toothbrush after you eat.
·If you need to vomit, bend over and open your lips. Always
rinse out your mouth and brush your teeth after vomiting.
Take care of swelling.
·Follow your health care provider's instructions about how to
help the swelling go down.
·Sit up or prop yourself up with pillows behind your back to
help with swelling.
Take care of pain and discomfort.
·Do not drive or operate heavy machinery while taking pain
medicine.
·Use petroleum jelly on your lips to keep them from drying and
cracking.
·Cover the wire with dental wax if any wires are poking into
your lips or gums.
Follow your health care provider's instructions.
·Follow your health care provider's directions about what you
can and cannot eat.
·Take medicines only as directed by your health care provider.
·Keep all follow-up visits as told by your health care
provider.
This is important.
Only cut wires in an emergency.
·Keep wire cutters with you at all times. Use them only in an
emergency to cut the wires that hold your jaw together.
·Do not cut the wires:
Even if you are tired of having your jaw wired.
Even if you are hungry.
Even if you need to vomit.
·You may cut the wires that hold your jaw together only:
If you have trouble breathing.
If you are choking.
·Do not cut the wires that connect to your back teeth ___
wires). If you must cut the wires in an emergency, cut straight
across the wires that hold your mouth closed. These are the
wires
that are connected to the ___ wires.
SEEK MEDICAL CARE IF:
·You have a fever.
·You feel nauseous or you vomit.
·You feel that one or more wires have broken.
·You have fluid, blood, or pus coming from your mouth or
incisions.
·You are dizzy.
SEEK IMMEDIATE MEDICAL CARE IF:
·You had to cut the wires that hold your jaw together.
·Your pain is severe and is not helped with medicine.
·You faint.
This information is not intended to replace advice given to you
by your health care provider. Make sure you discuss any
questions
you have with your health care provider.
Fractured-Jaw Meal Plan
The purpose of the fractured-jaw meal plan is to provide foods
that can be easily blended and easily swallowed. This plan is
typically used after jaw or mouth surgery, wired jaw surgery, or
dental surgery.
Foods in this plan need to be blended so that they can be sipped
from a straw or given through a syringe. You should try to have
at least three meals and three snacks daily. It is important to
make sure you get enough calories and protein to prevent weight
loss and help your body heal, especially after surgery. You may
wish to include a liquid multivitamin in your plan to ensure
that
you get all the vitamins and minerals you need. Ask your health
care provider for ___ recommendation.
HOW DO I PREPARE MY MEALS?
All foods in this plan must be blended. Avoid nuts, seeds,
skins,
peels, bones, or any foods that cannot be blended to the right
consistency. Make sure to eat a variety of foods from each food
group every day. The following tips can help you as you blend
your food:
·Remove skins, seeds, and peels from food.
·Cook meats and vegetables thoroughly.
·Cut foods into small pieces and mix with a small amount of
liquid in a food processor or blender. Continue to add liquid
until the food becomes thin enough to sip through a straw.
·Adding liquids such as juice, milk, cream, broth, gravy, or
vegetable juice can help add flavor to foods.
·Heat foods after they have been blended to reduce the amount
of
foam created from blending.
·Heat or cool your foods to lukewarm temperatures if your teeth
and mouth are sensitive to extreme temperatures.
WHAT FOODS CAN I EAT?
Make sure to eat a variety of foods from each food group.
Grains
·Hot cereals, such as oatmeal, grits, ground wheat cereals, and
polenta.
·Rice and pasta.
·Couscous.
Vegetables
·All cooked or canned vegetables, without seeds and skins.
·Vegetable juices.
·Cooked potatoes, without skins.
Fruit
·Any cooked or canned fruits, without seeds and skins.
·Fresh, peeled soft fruits, such as bananas and peaches, that
can be blended until smooth.
·All fruit juices, without seeds and skins.
Meat and Other Protein Sources
·Soft-boiled eggs, scrambled eggs, powdered eggs, pasteurized
egg mixtures, and custard.
·Ground meats, such as hamburger, ___, sausage, and
meatloaf.
·Tender, well-cooked meat, poultry, and fish prepared without
bones or skin.
·Soft soy foods (such as tofu).
·Smooth nut butters.
Dairy
·All are allowed.
Beverages
·Coffee (regular or decaffeinated), tea, and mineral water.
Condiments
·All seasonings and condiments that blend well.
WHEN MAY I NEED TO SUPPLEMENT MY MEALS?
If you begin to lose weight on this plan, you may need to
increase the amount of food you are eating or the number of
calories in your food or both. You can increase the number of
calories by adding any of the following foods:
·Protein powder or powdered milk.
·Extra fats, such as margarine (without trans fat), sour cream,
cream cheese, cream, and nut butters, such as peanut butter or
almond butter.
·Sweets, such as honey, ice cream, blackstrap molasses, or
sugar.
This information is not intended to replace advice given to you
by your health care provider. Make sure you discuss any
questions
you have with your health care provider.
If you have any questions about your progress, please call our
office at ___ (dental school) or ___
(hospital). After normal business hours or on weekends, call the
page operator at ___ ___ and have
them
page the on call Oral & Maxillofacial Surgery resident.
Please inform the resident on call that your operation was done
at ___ and provide your ___
Record Number if it is available. If you are already seen by us
at ___ after the surgery and has ___ Record Number,
please inform the resident the most recent visit/surgery.
Followup Instructions:
___
|
19698125-DS-17
| 19,698,125 | 29,089,872 |
DS
| 17 |
2147-03-04 00:00:00
|
2147-03-04 14:30:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
CHIEF COMPLAINT: shortness of breath
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ year old female hx of hypertension, hyperlipidemia depression
and asthma coming in with shortness of breath. The patient
reports several days of progressive dyspnea that started ___
all of sudden. The dyspnea is associated with cough,some sputum
production, but no chest pain. She reports this episode feels
similar to prior admissions at the end of ___. She denies any
fevers, sweats, or chills, no recent travel or sick contacts.
She has been trying her inhalers with out relief. She is
actually scheduled to see her pulmonologist in ___ for repeat
PFTs.
Of note she was admitted to ___ at the end of ___ for
an asthma exacerbation, treated with nebs, azithro, and
steroids. With regards to her pulmonary history she was
diagnosed with asthma and possible hypersensitivity pneumonitis
in ___ records. She follows with Dr.
___ ___.
In the ED, initial vitals: 99.1 85 146/83 24 100%
- Labs notable for: within normal limits
- Imaging notable for: normal CXR
- Pt given: duo-neb x 1 1L NS bolus and 1L NS
- Vitals prior to transfer: 98.0 93 146/98 16 100% RA
Peak flow in ED was 250
On arrival to the floor, pt reports ongoing cough. Wheezing
slighly improved after nebs, but still not able to get deep
breaths without coughing. Her chronic back pain is also worsened
with coughing.
ROS: + cough, shortness of breath, wheezing, back pain ( chronic
from DDD)
No fevers, chills, night sweats, or weight changes. No changes
in vision or hearing, no changes in balance. No cough, no
shortness of breath, no dyspnea on exertion. No chest pain or
palpitations. No nausea or vomiting. No diarrhea or
constipation. No dysuria or hematuria. No hematochezia, no
melena. No numbness or weakness, no focal deficits.
Past Medical History:
HTN
hyperlipidemia
asthma
anxiety
depression
"Summary of asthma/allergy hx"
With regard to her previous history, Ms. ___ was
diagnosed
with asthma in ___ after developing cough, wheezing and
sputum
production shortly after exposure to a wall covered in black
mold
while working in a ___. Her imaging studies at that time
revealed biapical ground-glass opacities with eosinophils,
___ crystals and aspergillus in sputum as well as
elevated IgE at 325 per outside Allergy note. She was treated
for
asthma vs ABPA vs hypersensitivity pneumonitis with steroids and
course of itraconazole in ___. Subsequent skin prick testing
was reportedly negative for aspergillus or cladosporium
sensitivity as well as other common environmental and food
allergens with positive histamine control. PFTs in ___
revealed FEV1 of 69% predicted with significant reversible
component after neb. Repeat chest CT in ___ showed
improvement
of GGOs. Since that time she has been receiving treatment with
Advair, Duonebs and albuterol HFA, followed by a Pulmonologist,
Dr. ___ ___. Most recently she was admitted to
___ from ___ for an asthma exacerbation, at
which time she was treated with steroids, azithromycin and
nebulizers with improvement. With regard to other previous
triggers, pt denies history of known environmental allergens.
She
has had at least one previous sinus infection with evidence of
chronic sinusitis on CT head per Allergy notes.
Social History:
___
Family History:
mother dementia and hx of dvts
father had CAD and died from leukemia
no siblings
Physical Exam:
ADMISSION PHYSICAL EXAM
Vitals: 98.2 125/79 85 22 95%RA
General: sitting in the bed coughing
HEENT: NC/AT, no O/P exudates, maxillary and frontal sinus
tenderness
Neck: supple
Lungs: diffuse coughing with deep breath; with quiet breathing
minimal air movement; unable to appreciated wheezes
CV: nl s1 s2
Abdomen: soft NTND normoactive BS
GU: no foley
Ext: trace edema at the shins
Neuro: AOx 3; mildly anxious
DISCHARGE EXAM
98.3 BP 116-130/68-84 HR 85-100 O2 sat 95-98% RA
Peak flow 350
General: sitting in the bed with neb treatment
HEENT: NC/AT, maxillary sinus tenderness bilaterally
Neck: supple
Lungs: diffuse coughing with deep breaths; but no wheezes CV:
nl s1 s2
Abdomen: soft NTND normoactive BS
GU: no foley
Ext: trace edema at the shins
Neuro: AOx 3; mildly anxious
Pertinent Results:
ADMISSION LABS
___ 02:00PM BLOOD WBC-10.7 RBC-5.20 Hgb-14.8 Hct-43.6
MCV-84 MCH-28.6 MCHC-34.1 RDW-14.8 Plt ___
___ 02:00PM BLOOD Neuts-85.8* Lymphs-8.1* Monos-3.6 Eos-2.0
Baso-0.5
___ 02:00PM BLOOD Glucose-99 UreaN-9 Creat-0.7 Na-137 K-3.5
Cl-103 HCO3-21* AnGap-17
___ 02:00PM BLOOD D-Dimer-3715*
DISCHARGE LABS
___ 09:40AM BLOOD WBC-10.8 RBC-4.97 Hgb-14.2 Hct-42.4
MCV-85 MCH-28.6 MCHC-33.6 RDW-14.9 Plt ___
___ 09:40AM BLOOD Neuts-75.4* ___ Monos-4.3 Eos-1.2
Baso-0.6
REPORTS
CXR ___
IMPRESSION: No acute intrathoracic process.
CTA ___
ReportIMPRESSION: 1. No evidence of pulmonary embolism or aortic
abnormality. 2. No pneumonia or other acute pulmonary
abnormality.
3. Significant dependent atelectasis in the posterior lungs.
ECHO ___
The left atrium is normal in size. The estimated right atrial
pressure is ___ mmHg. Normal left ventricular wall thickness,
cavity size, and regional/global systolic function (biplane LVEF
= 63%). Doppler parameters are most consistent with normal left
ventricular diastolic function. Right ventricular chamber size
and free wall motion are normal. The diameters of aorta at the
sinus, ascending and arch levels are normal. The number of
aortic valve leaflets cannot be determined. There is no aortic
valve stenosis. No aortic regurgitation is seen. The mitral
valve leaflets are structurally normal. There is no mitral valve
prolapse. No mitral regurgitation is seen. The estimated
pulmonary artery systolic pressure is normal. There is an
anterior space which most likely represents a prominent fat pad.
Brief Hospital Course:
ASSESSMENT & PLAN: ___ year old female coming in acute asthma
exacerbation and sinusitis
# Asthma exacerbation/Sinusitis- The patient presented with
several days of cough and dyspnea on admission. Exam was notable
for frontal and maxillary sinus tenderness, bronchospam and
cough on pulmonary exam. She was never hypoxic at rest or with
ambulation maintaining sats in the high ___, with peak flows of
250 down from her baseline of 350. Her symptoms were felt to be
consistent with acute asthma exacerbation. She was initally
started on 40 mg pred, q6H duonebs, q2H prn albuterol nebs, and
guafensin-codeine for cough. Augmentin was started on ___ for
sinuitis with the addition of flonase. CXR did not show focal
infiltrates or pulmonary edema. She also complained of pleurtic
chest pain, and was tachycardic ( see below) with ambulation.
She had a CTA which was negative for PE without evidence of
pulmonary infiltrate. She had minimal improvment in her
symptoms after 48 hrs, thus pulmonary was consulted for
consideration of alternative diagnosis. They recommended
sending total IgE, galactomanan, and ANACA as part of the work
for alternative causes which are pending at discharge , but
agreed that this was most likely an acute asthma exacerbation
likely trigerred by acute sinusitis. They recommend the
addition of singulair, increasing pred to 60 mg until symptoms
improved with a 2 week taper. Neilmed sinus rinuses ( which the
patient already has at home) were also recommended. Peak flows
improved to 400 at the time of discharge. She has follow up with
her outpatient pulmonolgoist Dr. ___ ___ in
early ___.
# tachycardia- The patient was was tachycardic with ambulation
only with heart rates in the 120s. Her EKG showed NSR with rate
of 90 at rest. She has a CTA to evaluate for PE in the setting
of the tachycardia and pleuritic chest pain. CTA did not show
PE. She also had an echo to evaluate for cardiac disease or
evidence of pulmonary hypertension, which was also normal. Her
tachycardia ultimately improved and may have been related to
underlying anxiety.
Chronic stable issues
#Back pain ___ degenerative disk disease- the patient is on
percocet 10 mg TID prn and ibuprofen at home. She was given
tylenol and oxycodone while in house since that dose of percocet
is non-formulary. She was discharged on her home regimen of
percocet and ibuprofen
# depression anxiety- c/w home ativan qhs and zoloft
# HTN- cont home HCTZ
# hyperlipidemia- cont simvastatin
TRANSITONAL ISSUES
-prednisone taper 60 mg x 3 days, 50 mg x 3 days, 40 mg x 3
days, 30 mg x 3 days 20 mg x 3 days and 10 mg x 3 days then stop
( end date ___
-follow up with Dr. ___ ___
-Augmentin end date ___
-IgE, ANCA, and galactomanan pending at discharge
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
2. Sertraline 200 mg PO DAILY
3. Hydrochlorothiazide 25 mg PO DAILY
4. Percocet (oxyCODONE-acetaminophen) ___ mg oral BID prn
5. Ibuprofen 800 mg PO Q8H:PRN pain
6. Pantoprazole 40 mg PO Q24H
7. ProAir HFA (albuterol sulfate) 90 mcg/actuation IH 2 puffs
4x/day
8. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN shortness of
breath
9. Ipratropium Bromide Neb 1 NEB IH Q6H:PRN shortnes of breath
10. Lorazepam 1 mg PO QHS:PRN anxiety
11. Simvastatin 20 mg PO QPM
Discharge Medications:
1. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN shortness of
breath
2. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
3. Hydrochlorothiazide 25 mg PO DAILY
4. Ibuprofen 800 mg PO Q8H:PRN pain
5. Ipratropium Bromide Neb 1 NEB IH Q6H:PRN shortnes of breath
6. Lorazepam 1 mg PO QHS:PRN anxiety
7. Pantoprazole 40 mg PO Q24H
8. Sertraline 200 mg PO DAILY
9. Simvastatin 20 mg PO QPM
10. Amoxicillin-Clavulanic Acid ___ mg PO Q12H
RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tablet(s) by
mouth twice a day Disp #*17 Tablet Refills:*0
11. Fluticasone Propionate NASAL 1 SPRY NU BID
RX *fluticasone 50 mcg/actuation 1 spray IH twice a day Disp #*1
Bottle Refills:*0
12. Guaifenesin-CODEINE Phosphate ___ mL PO Q6H:PRN cough
RX *codeine-guaifenesin 100 mg-10 mg/5 mL ___ mL by mouth every
six (6) hours Refills:*0
13. Montelukast 10 mg PO DAILY
RX *montelukast 10 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
14. Percocet (oxyCODONE-acetaminophen) ___ mg oral TID prn
pain
15. ProAir HFA (albuterol sulfate) 90 mcg/actuation IH 2 puffs
q6H prn shortness of breath
16. PredniSONE 60 mg PO DAILY
60mg 3 days, 50 mg 3 days, 40 mg 3 days, 30 mg 3 days, 20 mg 3
days, 10 mg 3 days
Tapered dose - DOWN
RX *prednisone 10 mg 6 tablet(s) by mouth daily Disp #*63 Tablet
Refills:*0
17. Ipratropium-Albuterol Inhalation Spray 1 INH IH Q6H
Duration: 2 Weeks
RX *ipratropium-albuterol [Combivent Respimat] 20 mcg-100
mcg/actuation 1 puff IH four times a day Disp #*1 Cartridge
Refills:*0
18. Ranitidine 150 mg PO BID
RX *ranitidine HCl 150 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis
1. Acute Sinusitis
2. acute exacerbation of asthma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure participating in your care. You were admitted
to the hospital with shortness of breath and cough which is
likely from an asthma exacerbation. You were also found to have
a sinus infection which was likely the trigger for your asthma
attack. We did a CT of your chest which did not show any
infiltrates or evidence of a blood clot in your lungs as the
cause of your symptoms. Your were seen by our pulmonary doctors
___ lung doctors) who recommended that we treat you with steroids
which should be tapered over the course of two weeks. We also
started you on antibiotics for your sinus infection which you
will take to complete a 10 day course. It is also possible that
your reflux symptoms are worsening your cough so we added
rantidine to your regimen.
Please continue to monitor your peak flows at home. If it is
less than 300 call your pulmonologist to discuss your steroid
dosing.
You should also use Neilmed sinus rinses ( which you have at
home) to help with your sinus congestion.
Please take all medications as prescribed and please keep all
follow up appointments.
Followup Instructions:
___
|
19698306-DS-18
| 19,698,306 | 26,407,863 |
DS
| 18 |
2180-07-05 00:00:00
|
2180-07-08 15:30:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
Shellfish / Imitrex / lisinopril / Lyrica / house dust
Attending: ___.
Chief Complaint:
Sudden onset of chest pain and R face, arm, and leg weakness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Code stroke:
The patient presented with sudden onset of chest pain and R
face,
arm, and leg weakness at 4:30 ___. When she arrived at ___
after
transfer from ___ at 7:15 ___ she was within the stroke window
but ___ from ___ was too old to consider giving TPA, so
NCHCT was repeated. Initial ___ NIHSS was 8 due to bilateral arm
drift, R>L leg drift, and refusal to cooperate with FNF testing.
However, initial Neurology NIHSS was a 3 for R leg>arm drift.
After NCHCT her NIHSS was 1 for R leg drift only (it hovered
just
above the bed). Her R arm at that time did not drift but instead
trembled/shook as she held it up. Other R arm strength testing
at
that time was notable for deltoid weakness only but otherwise
give way weakness in the R arm ___ at maximum without an upper
motor neuron pattern. Her exam was noted to be fluctuating and
often pain or cooperation limited. When we discussed the
possibility of TPA with the patient, she refused. Also, given
the
acute onset chest pain, we were concerned about possible aortic
dissection or MI which could have caused recrudescence of her
old
stroke symptoms, but would NOT be a safe situation in which to
give TPA. Thus, given her improving exam and a possible
dangerous
complication from TPA if she had an aortic dissection, as well
as
the patient's own refusal of TPA unless it was deemed
"absolutely
necessary," TPA was not given.
HPI:
The patient is a ___ year old woman with a history of HTN and
prior stroke affecting the R side in ___, who presents with
sudden onset of Chest Pain and R face, arm, and leg weakness at
4:30 ___.
The patient got off a plane from ___ on ___ and after
the
plane flight was feeling dizzy and noted low energy. Today she
walked with her daughter to the store, and on the way to the
store noted SOB and swelling in her legs. They got food and
brought it back to their shop, where they ate together. While
she
was eating the patient noted sudden onset of chest pain, with
radiation to her R arm, as well as R sided weakness. Her
daughter, who was with her, states that while she was talking to
her mother at 4:30 ___ she witnessed sudden onset of R facial
droop and dysarthria. Several minutes later her mother started
to
complain of R arm and leg weakness as well. She was brought to
___ where ___ was preformed and was negative, labs were
preformed, and she was transferred to ___.
When she arrived at ___ after transfer from ___ at 7:15 ___
she was within the stroke window but ___ from ___ was too
old to consider giving TPA, so NCHCT was repeated. Initial
Neurology NIHSS was a 3 for R leg>arm drift but improved to 1
after NCHCT (see above). Given concern for ongoing chest pain
and
? MI or ? dissection, as well as improving exam and patient
unwillingness to receive TPA, TPA was not given. The patient and
daughter also reported improvement of R facial droop and slurred
speech back to baseline, and the patient noted that her R arm
and
leg were improving in strength.
On neurologic review of systems, the patient denies diplopia,
vision changes, changes in sensation, fevers, chills. Endorses
ongoing chest pain, R arm and leg pain, R arm and leg weakness.
Past Medical History:
- HTN
- Patient reports Stroke in ___, affected the R face/arm/leg
for 3 days before recovering. Reportedly managed at ___
___. Patient was poorly able to tolerate MRI so is not sure
whether it was preformed to confirm the stroke at that time. We
received records from ___. It appears that she was
diagnosed w/ a hypertensive crisis during her admission. She
reports at some point was on ASA and ?Coumadin for several
months before she was taken off both of these for unclear
reasons
- s/p hysterectomy
- h/o L spine disease ? fracture, treated with steroid
injections
only
- recent dental "gum shortening" procedute
- sciatica with R leg weakness and pain
Social History:
___
Family History:
M grandmother with stroke in her ___, M grandfather with stroke
in his ___ or ___, M uncle with stroke in his ___.
Physical Exam:
==============================
Admission Physical Examination
==============================
VS On my exam BP is 120/76 in the R arm, 110/78 in the L arm
General: NAD, lying in bed comfortably.
Head: NC/AT, no conjunctival icterus, no oropharyngeal lesions
Neck: Supple, no nuchal rigidity, no meningismus
CV: RRR
Pulses: palpable bilaterally in the arms, unable to palpate at
the feet but normal cap refill at the toes bilaterally
Neurologic Examination:
- Mental Status -
Awake, alert, speech is fluent, no dysarthria or paraphasic
errors. Able to name stroke card objects except calls a hammock
a
"swing" and a cactus a "catapiller...no, that prickly thing."
Able to state her age and the month. Able to follow 2 step
commands. No visual or sensory neglect.
- Cranial Nerves -
I. not tested
II. Equal and reactive pupils (2mm to 1.5m). Visual fields were
full to finger counting.
III, IV, VI. smooth and full extraocular movements without
diplopia or nystagmus.
V. facial sensation was intact, muscles of mastication with full
strength
VII. face was symmetric with rest and smile, although she tends
to talk out of the R side of her mouth, this appears to be
volitional
VIII. hearing was intact to finger rub bilaterally.
IX, X. symmetric palate elevation and symmetric tongue
protrusion
with full movement.
XI. SCM and trapezius were of normal strength and volume.
- Motor -
Muscule bulk and tone were normal. With pronator drift testing,
L
without drift, the R arm requires assistance to elevate the arm,
but then she is able to keep it at the same level approximately
for 10 seconds but with small tremulous movements up and down.
The L leg drifts down slightly which is correctible with
coaching
from the examiner. The R leg does drift down but can be held
just
barely above the bed ~2 mm for 5 seconds.
Delt Bic Tri ECR Fext Fflx IP Quad Ham TA Gas
L 5 5 ___ 5 5 5 5 5 5
R 4+ 5 ___ 4+ 4- 5 4- 4 5
* R arm and leg strength testing is pain limited. There is give
way weakness in the R arm and leg, reported strength scores
represent maximal effort.
- Sensation -
Intact to light touch throughout without extinction to DSS.
Pinprick is increased on the R arm and leg compared to the L.
Proprioception intact at the great toes.
- DTRs -
Bic Tri ___ Quad Gastroc
L 2 2 2 0 0
R 2 2 2 0 0
Plantar response flexor bilaterally.
- Cerebellar -
No dysmetria with finger to nose testing bilaterally, although
the R side is limited by deltoid weakness and effort.
- Gait -
deferred
=======================
Discharge physical exam
=======================
Awake & alert. Occ. tearful during the interview. ___ --
intact. CN: Ii-XII intact. Normal strength on L. Improved
strength of R UE; + drift; ___ strength of the R deltoid & R
hand grip; ___ otherwise. Strength in the ___ is ___ today.
Sensations intact. DTRs remain difficult to elicit.
Pertinent Results:
====
LABS
====
___ 09:20AM BLOOD WBC-5.3 RBC-4.12 Hgb-12.2 Hct-37.0 MCV-90
MCH-29.6 MCHC-33.0 RDW-12.9 RDWSD-42.2 Plt ___
___ 07:12PM BLOOD WBC-7.0 RBC-4.28 Hgb-12.8 Hct-38.1 MCV-89
MCH-29.9 MCHC-33.6 RDW-12.7 RDWSD-41.3 Plt ___
___ 09:20AM BLOOD Neuts-52.1 ___ Monos-6.4 Eos-1.1
Baso-0.4 Im ___ AbsNeut-2.76 AbsLymp-2.11 AbsMono-0.34
AbsEos-0.06 AbsBaso-0.02
___ 09:20AM BLOOD Plt ___
___ 09:20AM BLOOD ___ PTT-33.9 ___
___ 07:12PM BLOOD ___ PTT-32.9 ___
___ 07:12PM BLOOD Plt ___
___ 09:20AM BLOOD Glucose-90 UreaN-16 Creat-0.7 Na-140
K-3.7 Cl-101 HCO3-28 AnGap-15
___ 07:26PM BLOOD Creat-1.2*
___ 07:12PM BLOOD UreaN-15
___ 09:20AM BLOOD ALT-10 AST-13 LD(LDH)-161 AlkPhos-64
TotBili-0.3
___ 09:20AM BLOOD cTropnT-<0.01
___ 07:12PM BLOOD proBNP-51
___ 07:12PM BLOOD cTropnT-<0.01
___ 09:20AM BLOOD Albumin-4.0 Cholest-223*
___ 10:33PM BLOOD D-Dimer-150
___ 09:20AM BLOOD %HbA1c-5.5 eAG-111
___ 09:20AM BLOOD Triglyc-126 HDL-45 CHOL/HD-5.0
LDLcalc-153*
___ 09:20AM BLOOD TSH-1.3
___ 09:20PM URINE Color-Yellow Appear-Clear Sp ___
___ 09:20PM URINE RBC-13* WBC-1 Bacteri-FEW Yeast-NONE
Epi-4
___ 09:20PM URINE Mucous-RARE
___ 09:20PM URINE bnzodzp-NEG barbitr-POS opiates-NEG
cocaine-NEG amphetm-NEG oxycodn-NEG mthdone-NEG
=======
IMAGING
=======
NCHCT ___:
No acute intracranial abnormalities identified. Note is made of
an empty sella.
NCHCT ___:
No acute intracranial abnormality.
CXR ___:
AP portable upright view of the chest. Lung volumes are low and
overlying
EKG leads are present. There is no focal consolidation,
effusion, or
pneumothorax. The cardiomediastinal silhouette is normal. Imaged
osseous
structures are intact. No acute intrathoracic process
===
ECG
===
Sinus rhythm.
Brief Hospital Course:
___ is a ___ yo woman with medical history of hypertension and
a previous episode she reports as a stroke (however confirmed by
OSH records to be a hypertensive crisis). She presented with a
initial chief complaint of RT chest pain, face, arm, and leg
weakness concerning for a stroke.
Hospital course by system:
NEURO: Patient presented with transient RT face, arm, and leg
weaknes which resolved over the course of 48 hours. Her initial
findings were concerning for an acute ischemic stroke. However,
she refused tPA at the time. She refused an MRI due to
claustrophobia, so was monitored with serial head CTs which did
not show any evidence of acute intracranial process. Stroke risk
factors assessed, and found with LDL 153; Cholesterol 223.
HgbA1c 5.5%. We also reviewed her records from ___. There was no
evidence that she had a prior stroke. Although, we did not think
that she had a new stroke (her exam was confounded by functional
overlay), we have added Aspirin 81mg PO daily to her regimen and
regimen and discuss adding a statin, for which she will consult
her PCP in the following week. She worked with physical therapy
who recommended discharge home with outpatient ___.
CV: She has a known history of hypertension and presented with
chest pain. Serial ECGs were assessed and in sinus rhythm.
Cardiac enzymes were negative. She was monitored on telemetry
with no significant arrhythmias. Pro BNP was assessed and
normal.
===================
Transitional Issues
===================
1. Will need outpatient ___.
2. Will need to discuss starting a statin with her PCP.
3. Would benefit from outpatient open MRI.
AHA/ASA Core Measures for Ischemic Stroke and Transient Ischemic
Attack
1. Dysphagia screening before any PO intake? (X) Yes, confirmed
done - () Not confirmed () No
2. DVT Prophylaxis administered? (X) Yes - () No
3. Antithrombotic therapy administered by end of hospital day 2?
(X) Yes - () No
4. LDL documented? (X) Yes (LDL =153) - () No
5. Intensive statin therapy administered? (simvastatin 80mg,
simvastatin 80mg/ezetemibe 10mg, atorvastatin 40mg or 80 mg,
rosuvastatin 20mg or 40mg, for LDL > 100) () Yes - (X) No [if
LDL >100, reason not given: PATIENT WILL DISCUSS WITH HER PCP]
6. Smoking cessation counseling given? (X) Yes - () No [reason
() non-smoker - () unable to participate]
7. Stroke education (personal modifiable risk factors, how to
activate EMS for stroke, stroke warning signs and symptoms,
prescribed medications, need for followup) given (verbally or
written)? (X) Yes - () No
8. Assessment for rehabilitation or rehab services considered?
(X) Yes - () No
9. Discharged on statin therapy? () Yes - (X) No [if LDL >100,
reason not given: WILL DISCUSS WITH PCP ]
10. Discharged on antithrombotic therapy? (X) Yes [Type: (X)
Antiplatelet - () Anticoagulation] - () No
11. Discharged on oral anticoagulation for patients with atrial
fibrillation/flutter? () Yes - () No - (X) N/A
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Chlorthalidone 25 mg PO DAILY
2. CARtia XT (diltiazem HCl) 240 mg oral DAILY
3. Losartan Potassium 50 mg PO DAILY
Discharge Medications:
1. Chlorthalidone 25 mg PO DAILY
2. Losartan Potassium 50 mg PO DAILY
3. CARtia XT (diltiazem HCl) 240 mg oral DAILY
4. Aspirin 81 mg PO DAILY
RX *aspirin 81 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*3
5. Outpatient Physical Therapy
Discharge Disposition:
Home
Discharge Diagnosis:
Right sided chest pain with face arm and leg weakness.
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 with symptoms of right sided
chest pain, face, and arm weakness concerning for an acute
stroke. However your brain imaging did not show evidence of an
acute stroke. You symptoms improved while in the hospital, you
were seen by physical therapy who recommended outpatient
physical therapy which we have prescribed. We are recommending
an outpatient open MRI if possible.
Stroke can have many different causes, so we assessed you for
medical conditions that might raise your risk of having stroke.
In order to prevent future strokes, we plan to modify those risk
factors. We are changing your medications as follows: adding
Aspirin 81mg oral daily.
Please take your other medications as prescribed.
Please follow up with your primary care physician as listed
below.
If you experience any of the symptoms below, please seek
emergency medical attention by calling Emergency Medical
Services (dialing 911). In particular, since stroke can recur,
please pay attention to the sudden onset and persistence of
these symptoms:
- sudden partial or complete loss of vision
- sudden loss of the ability to speak words from your mouth
- sudden loss of the ability to understand others speaking to
you
- sudden weakness of one side of the body
- sudden drooping of one side of the face
- sudden loss of sensation of one side of the body
Followup Instructions:
___
|
19698737-DS-21
| 19,698,737 | 28,551,965 |
DS
| 21 |
2133-10-15 00:00:00
|
2133-10-19 20:29:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Lisinopril
Attending: ___.
Chief Complaint:
Cough
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ w/ PMHx of Afib on coumadin, anemia, thrombocytopenia,
cardiomyopathy w/ complete heart block s/p ___,
dysphagia/aspiration pneumonia brought in by daughter for
weakness and weightloss. Patient has baseline dysphagia, but
reports increasing difficulty swallowing even thickened liquids
and pureed products. He reports feeling "tired all the time" and
chronic constipation (would like enema when goes to floor) BM
once every 3 days. He reports 35-40lb weight loss in past 6
months with assocatied decreased appetitie. He reports 2 week hx
of productive cough with white sputum. No f/c n/v/ diarrhea. Pt
recently discharged from rehab facility and lives at home alone
with ___ assistance.
In the ED pt's vitals were 99.8, HR66, 116/63, RR22, O2 96% RA.
EKG: ventricular paced at 64bpm. He received 250cc fluid bolus
for clinical dehydration. CXR was performed and is consistent
with aspiration pneumonia, and he was given 2g IV cefepime given
after two sets blood cultures drawn. Urine culture also sent and
are pending. Serum sodium found to be 121 and serum osms is low
at 260, concerning for SIADH. Patient will be admitted to floor
for further management of PNA and hyponatremia.
Currently pt continues to complain of cough and constipation.
Hemodynamically stable.
ROS: per HPI, all other ROS negative
Past Medical History:
1. Atrial fibrillation, on coumadin.
2. Orthostatic hypotension.
3. History of thrombocytopenia.
4. Left lower leg swelling.
5. Dermatitis.
6. Anemia.
7. Myelodysplastic syndrome.
PAST SURGICAL HISTORY:
1. ORIF, right hip ___.
2. Left hand lobar capillary hemangioma excision in ___.
3. Status post pacemaker for complete heart block.
Social History:
___
Family History:
Parents are both deceased. Father - age ___ (complications
from hernia repair); Mother - age ___ (anemia). He has 1 brother
- died at age ___ (complications of diabetes) and one sister -
___, living, diabetes. He has 3 daughters who are well.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS - 97.6 129/78 70 18 94%O2 sat
GENERAL - chronically ill appearing man. NAD,
HEENT - NC/AT, EOMI, right eye with some erythema, sclerae
anicteric, Mucous membranes
NECK - supple, no JVD
LUNGS - decreased breath sounds right lobe at the bases. no
wheezes or rhonic
HEART - PMI non-displaced, RRR, no MRG, nl S1-S2
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)
SKIN - no rashes or lesions
LYMPH - no cervical, axillary, or inguinal LAD
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
___ throughout, sensation grossly intact throughout, DTRs 2+ and
symmetric, cerebellar exam intact, steady gait
DISCHARGE PHYSICAL EXAM:
PHYSICAL EXAM:
VS - 97.3, 116/60, 63, 98%O2 sat on RA
GENERAL - Cachectic elderly man. Alert, interactive.
HEENT - Conjunctive clear, not erythematous, no discharge. MMM,
edentuluous.
LUNGS - CTAB.
HEART - RRR, no MRG, nl S1-S2
ABDOMEN - scaphoid, soft/NT/ND, no rebound/guarding
EXTREMITIES - no c/c/e.
SKIN - venous changes on ___
___ - awake, CNs II-XII grossly intact. No obvious facial
droop, moving all extemities independently.
Pertinent Results:
ADMISSION LABS
==============
___ 02:39PM BLOOD WBC-7.1 RBC-3.84* Hgb-11.8* Hct-36.2*
MCV-94 MCH-30.7 MCHC-32.6 RDW-13.3 Plt ___
___ 02:39PM BLOOD ___ PTT-36.3 ___
___ 07:35AM BLOOD ___ PTT-84.4* ___
___ 02:39PM BLOOD Glucose-105* UreaN-15 Creat-0.5 Na-121*
K-5.3* Cl-87* HCO3-33* AnGap-6*
___ 02:39PM BLOOD ALT-17 AST-23 AlkPhos-62 TotBili-0.2
___ 02:39PM BLOOD Calcium-8.1* Phos-2.6* Mg-1.8 Iron-39*
___ 02:39PM BLOOD calTIBC-165* Ferritn-2904* TRF-127*
___ 07:35AM BLOOD TSH-7.0*
___ 02:51PM BLOOD T4-5.5
RELEVANT LABS
==============
___ 07:35AM BLOOD Glucose-71 UreaN-12 Creat-0.5 Na-122*
K-4.8 Cl-89* HCO3-27 AnGap-11
___ 02:51PM BLOOD Glucose-89 UreaN-13 Creat-0.5 Na-125*
K-4.7 Cl-87* HCO3-32 AnGap-11
___ 09:15AM BLOOD Glucose-85 UreaN-9 Creat-0.6 Na-129*
K-4.5 Cl-92* HCO3-28 AnGap-14
___ 08:25AM BLOOD Glucose-74 UreaN-10 Creat-0.6 Na-132*
K-4.3 Cl-93* HCO3-35* AnGap-8
DISCHARGE LABS
==============
___ 08:10AM BLOOD WBC-5.1 RBC-4.03* Hgb-12.5* Hct-38.1*
MCV-95 MCH-30.9 MCHC-32.7 RDW-13.2 Plt ___
___ 08:10AM BLOOD Plt ___
___ 08:10AM BLOOD Glucose-77 UreaN-11 Creat-0.6 Na-126*
K-4.6 Cl-86* HCO3-36* AnGap-9
___ 08:10AM BLOOD Calcium-8.5 Phos-2.7 Mg-1.9
___ 02:39PM BLOOD calTIBC-165* Ferritn-2904* TRF-127*
IMAGING
==============
CXR PA/LAT ___
IMPRESSION: Interval improvement of left basilar opacity with
interval
development of right basal opacity concerning for pneumonia in
the proper
clinical setting.
MICRO
==============
___ SPUTUM GRAM STAIN-FINAL; RESPIRATORY CULTURE-
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.
RESPIRATORY CULTURE (Final ___:
TEST CANCELLED, PATIENT CREDITED.
___ URINE Legionella Urinary Antigen -FINAL
NEGATIVE
Brief Hospital Course:
___ w/ PMHx of Afib on coumadin, anemia, thrombocytopenia,
cardiomyopathy with complete heart block s/p ___,
dysphagia/aspiration pneumonia presenting with weakness and
found to have pneumonia and hypovolemic hyponatremia.
ACTIVE ISSUES
=============
# Pneumonia- Pt was admitted with 2 weeks productive cough,
found to have pneumonia. Was given cefipime initially, switched
to vanc/zosyn for presumed hospital-acquired pneumonia, received
IVF resuscitation. Sputum culture contaminated with oral flora,
urine legionella returned negative. Pt remained afebrile in
hospital, improving clinically, becoming more alert with
diminished cough. Antibiotic coverage was switched to PO
levofloxacin 750 mg and patient was discharged home with
services to complete a five-day course ending ___.
# Hypovolemic hyponatremia- Pt's sodium was found to be 121 on
admission. Pt has history of hyponatriemia on prior admissions,
baseline in 130s (133 in ___. This acute episode was
judged hypovolemic hyponatremia, likely secondary to infection
w/ decreased po intake. Pt was resuscitated w/ IVF, urine lytes
were trended. Because the time course for the development of
hyponatremia was unclear, pt was corrected slowly, at 0.5
mEq/hour. Pt's sodium rose with IV normal saline to his baseline
in the low 130s, fell again into the high 120s when not
receiving fluids; this fluctuation was judged to be secondary to
patients refusal to eat much hospital food, which he dislikes.
He was also treated with salt tabs, in case SIADH was
contributing some portion of his hyponatremia in the setting of
pneumonia. Pt will have to be encouraged to take po food and
water.
#Afib- Pt is on coumadin, rate controlled on metoprolol. Afib
was not an active issue during this admission. Pt's INR did
become supratherapeutic briefly during his stay, warfarin was
held, then reinstated at a lower dose of 3; he is being
discharged on this dose as he will be taking levofloxacin, which
may elevate his INR. He will need follow up as an outpt with his
PCP to adjust his anticoagulation regimen.
INACTIVE ISSUES
===============
#Subacute chronic weight loss- Pt was noted to be cachectic and
deconditioned, with significant recent weight loss per family.
Diagnosis includes malignancy vs deconditioning. Pt will need
outpatient follow-up to r/o malignancy.
# Anemia- Pt was admitted with Hgb 10.8, which remained stable
over the course of his stay; iron studies pointed to anemia of
chronic disease.
# Constipation- Not an active issue during this admission; pt
stooled regularly during stay.
TRANSITION OF CARE
==================
- At the time of discharge, blood cultures from ___ were
pending and had shown no growth to date
- Pt and family may need assistance from social work at rehab in
discussing and establishing goals of care.
CODE STATUS: Full
daughter ___ ___
___ on Admission:
Preadmissions medications listed are incomplete and require
futher investigation. Information was obtained from webOMR.
1. Metoprolol Succinate XL 25 mg PO DAILY
2. Warfarin 5 mg PO DAILY16
3. Omeprazole 20 mg PO DAILY
4. Sodium Chloride 1 gm PO BID
5. Travatan Z *NF* (travoprost) 0.004 % ___
1 drop in each eye
6. Ensure Enlive *NF* (food supplement,
lactose-free;<br>nut.tx.impaired digest fxn) 1 liquid Oral TID
7. traZODONE 50 mg PO HS
Discharge Medications:
1. Warfarin 4 mg PO DAILY
Hold for INR >3, bleeding, melenotic stools.
2. Ensure Enlive *NF* (food supplement,
lactose-free;<br>nut.tx.impaired digest fxn) 1 liquid Oral TID
3. Metoprolol Succinate XL 25 mg PO DAILY
4. Omeprazole 20 mg PO DAILY
5. Travatan Z *NF* (travoprost) 0.004 % ___
1 drop in each eye
6. Levofloxacin 750 mg PO HS Duration: 3 Days
RX *Levaquin 750 mg 1 Tablet(s) by mouth at bedtime Disp #*3
Tablet Refills:*0
7. Sodium Chloride 1 gm PO TID
RX *sodium chloride 1 gram 1 Tablet(s) by mouth three times
daily Disp #*90 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Pneumonia, likely aspiration.
Hypovolemic hyponatremia, likely ___ poor po intake.
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:
It was a pleasure taking care of you during your recent
admission to ___. As you know, you were admitted with cough
and weakness, and were found to have pneumonia. We gave you IV
fluids, and treated your pneumonia with antibiotics. You will
need to finish your course of antibiotics at home; your last day
is ___. You were also found to have a low sodium level,
which improved with IV fluids. You have been reluctant to eat or
drink much, which may be contributing to this low sodium. Your
sodium has been stable during your visit, but you will need to
follow up with your PCP to monitor it.
START Sodium tablets
START Levofloxacin
Continue your othermedications as you had been taking them
before your hospital stay.
Followup Instructions:
___
|
19698886-DS-15
| 19,698,886 | 24,366,060 |
DS
| 15 |
2127-06-06 00:00:00
|
2127-06-06 15:58:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Shortness of breath, wheezing
Major Surgical or Invasive Procedure:
NONE
History of Present Illness:
___ transmale (FtoM, male pronouns) w/ asthma (w/ history of
intubation ___, HIV since birth (last CD4 ___, with
negative VL, on Epzicom & Prezicobix) & tobacco use who
presented
this afternoon to ___'s office with 2 days of wheezing,
productive cough, SOB. Associated w/ post-tussive emesis,
chills,
diarrhea night sweats & subjective fevers. Some chest pain from
coughing. Denies headache. He had run out of her albuterol
inhaler at home since he ran out of solution due to heavy use.
In PCP office, he had diffuse bilateral rhonchi w/ audible
expiratory wheezing & did not respond to inhalers (PFM post
treatment 250) so he was urged to the ED for further management.
Past Medical History:
-HIV on HAART well controlled CD4 781 and undetectable VL on
___, no hx of OIs
-Depression
-Asthma
-Testosterone injections for hormone therapy
Social History:
___
Family History:
No Fhx of asthma
Physical Exam:
ADMISSION EXAM:
===============
VS: 98.0PO 141 / 98R Sitting 73 20 100 Ra
GEN: Alert, lying in bed, no acute distress
HEENT: Moist MM, anicteric sclerae, no conjunctival pallor.
PERRLA, EOMI.
NECK: Supple without LAD
PULM: full air entry bilaterally, no crackle. diffuse insp and
exp wheezing
HEART: RRR (+)S1/S2 no m/r/g
ABD: Soft, non-distended, non-tender. No rebound/guarding. BS+
EXTREM: Warm, well-perfused, no edema
NEURO: A&ox3, no focal defects
DISCHARGE EXAM:
===============
VS: 98.4 142/95 107 18 99 RA
GEN: Alert, upright in bed, no acute distress
HEENT: Moist MM, anicteric sclerae, no conjunctival pallor.
PERRLA, EOMI.
NECK: Supple without LAD
PULM: Expiratory wheezing diffusely, but good air movement
throughout
HEART: RRR, normal S1/S2 no m/r/g
ABD: Soft, non-distended, non-tender. No rebound/guarding. BS+
EXTREM: Warm, well-perfused, no edema
NEURO: A&ox3, no focal defects
Pertinent Results:
ADMISSION LABS:
===============
___ 08:20PM OTHER BODY FLUID FluAPCR-NEG FluBPCR-NEG
___ 07:23PM ___ PO2-45* PCO2-24* PH-7.53* TOTAL
CO2-21 BASE XS-0
___ 07:18PM GLUCOSE-91 UREA N-8 CREAT-0.8 SODIUM-136
POTASSIUM-5.1 CHLORIDE-98 TOTAL CO2-20* ANION GAP-18
___ 07:18PM estGFR-Using this
___ 07:18PM WBC-6.8 RBC-4.36 HGB-14.9 HCT-42.0 MCV-96
MCH-34.2* MCHC-35.5 RDW-13.7 RDWSD-48.9*
___ 07:18PM NEUTS-73.1* LYMPHS-16.1* MONOS-8.4 EOS-1.3
BASOS-0.4 IM ___ AbsNeut-4.95 AbsLymp-1.09* AbsMono-0.57
AbsEos-0.09 AbsBaso-0.03
___ 07:18PM PLT COUNT-190
___ 07:18PM ___ PTT-26.4 ___
DISCHARGE LABS:
===============
___ 04:22AM BLOOD WBC-9.1 RBC-4.02 Hgb-13.8 Hct-39.2 MCV-98
MCH-34.3* MCHC-35.2 RDW-13.9 RDWSD-50.3* Plt ___
___ 04:22AM BLOOD Plt ___
___ 04:22AM BLOOD Glucose-73 UreaN-15 Creat-1.0 Na-141
K-4.2 Cl-100 HCO3-24 AnGap-17
___ 04:22AM BLOOD Calcium-9.2 Phos-4.9* Mg-2.3
___ 05:38AM BLOOD ___ pO2-187* pCO2-37 pH-7.42
calTCO2-25 Base XS-0
IMAGING:
========
CXR ___
FINDINGS:
The lungs are clear without focal consolidation. A previously
seen right
pleural effusion has resolved. No pleural effusion or
pneumothorax is seen. The cardiac and mediastinal silhouettes
are unremarkable.
IMPRESSION:
No acute cardiopulmonary process.
CXR ___:
IMPRESSION:
Comparison to ___. No relevant change is noted.
The lung volumes are normal. No evidence of overinflation.
Normal size of the cardiac silhouette. No evidence of pneumonia
or other lung parenchymal changes. No pneumomediastinum or
pneumothorax.
Brief Hospital Course:
PATIENT SUMMARY:
================
This is a ___ year old trans-male (F to M, prefers male pronouns)
with PMH asthma (w/2 prior intubations per patient), HIV since
birth (last CD4 ___, with negative VL, on Epzicom &
Prezicobix) & tobacco use who presented to ___'s office with 2
days of wheezing, productive cough, SOB concerning for asthma
exacerbation.
ACUTE ISSUES:
==============
# Asthma Exacerbation
Unclear trigger, most likely viral given myalgias and malaise
though swabs have been negative. No PNA seen on CXR. Flu swab
negative. The patient was briefly treated with IV steroids
(methylprednisolone 60 mg BID) and then transitioned to oral
prednisone 60 mg QD with the plan to taper him off slowly as an
outpatient. He was given standing Duonebs as well as albuterol
rescue inhaler. Azithromycin typically not indicated for asthma
exacerbation but per AZALEA trial, patient given 5 day course
___ - ___.
The patient was started on tiotropium, monteleukast, and
salmeterol prior to discharge. The patient was aslso given
nicotine patches and advised to stop smoking.
STABLE ISSUES:
==============
# HIV
Continued home Epzicom & Prezicobix.
# Mood disorder
Continued home citalopram.
TRANSITIONAL ISSUES:
====================
# Patient started on multiple new asthma medications in house
(salmeterol, tiotropium, and montelukast). Consider
de-escalating in the outpatient setting pending better control
of asthma symptoms.
# Patient was not started on inhaled corticosteroid in house
though he was started on systemic prednisone with taper (see
below). Please consider starting inhaled corticosteroid once
systemic steroids are tapered off.
# Prednisone taper as follows:
___: 60 mg
___: 50 mg
___: 50 mg
___: 50 mg
___: 40 mg
___: 40 mg
___: 40 mg
___: 30 mg
___: 30 mg
___: 30 mg
___: 20 mg
___: 20 mg
___: 20 mg
___: 10 mg
___: 10 mg
___: 10 mg
# Patient has had multiple admissions (including 2 with
intubations) since starting to smoke cigarettes. He needs active
smoking cessation counseling. Please continue to prescribe
nicotine patches as an outpatient.
NEW MEDICATIONS:
- GuaiFENesin ___ mL PO/NG Q4H:PRN Cough
- Ipratropium-Albuterol Neb 1 NEB NEB Q4H:PRN cough/wheeze
- Montelukast 10 mg PO/NG DAILY
- Nicotine Patch 21 mg TD DAILY
- Prednisone taper as above
- Salmeterol Xinafoate Diskus (50 mcg) 1 INH IH Q12H
- Tiotropium Bromide 1 CAP IH DAILY
CHANGED MEDICATIONS: NONE
HELD MEDICATIONS: NONE
CODE STATUS: FULL
CONTACT: Brother - ___ ___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. Citalopram 40 mg PO DAILY
2. Albuterol Inhaler 2 PUFF IH Q4H:PRN wheezing
3. Epzicom (abacavir-lamivudine) 600-300 mg oral DAILY
4. Prezcobix (darunavir-cobicistat) 800-150 mg-mg oral DAILY
5. TraZODone 100 mg PO QHS insomnia
6. Amphetamine-Dextroamphetamine 20 mg PO BID
7. testosterone cypionate 0.25 mg injection 1X/WEEK
Discharge Medications:
1. GuaiFENesin ___ mL PO Q4H:PRN Cough
RX *guaifenesin 100 mg/5 mL ___ mL by mouth q4 Hours Refills:*0
2. Ipratropium-Albuterol Neb 1 NEB NEB Q4H:PRN cough/wheeze
RX *ipratropium-albuterol 0.5 mg-3 mg (2.5 mg base)/3 mL 1 neb
IH q4 Hours Disp #*28 Ampule Refills:*0
3. Montelukast 10 mg PO DAILY
RX *montelukast 10 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
4. Nicotine Patch 21 mg TD DAILY
RX *nicotine 21 mg/24 hour 1 Patch once a day Disp #*30 Patch
Refills:*0
5. PredniSONE 60 mg PO DAILY Duration: 1 Dose
This is dose # 1 of 6 tapered doses
RX *prednisone 20 mg 3 tablet(s) by mouth ONCE Disp #*1 Tablet
Refills:*0
6. PredniSONE 50 mg PO DAILY Duration: 3 Doses
This is dose # 2 of 6 tapered doses
RX *prednisone 50 mg 1 tablet(s) by mouth once a day Disp #*3
Tablet Refills:*0
7. PredniSONE 40 mg PO DAILY Duration: 3 Doses
This is dose # 3 of 6 tapered doses
RX *prednisone 20 mg 2 tablet(s) by mouth once a day Disp #*6
Tablet Refills:*0
8. PredniSONE 30 mg PO DAILY Duration: 3 Doses
This is dose # 4 of 6 tapered doses
RX *prednisone 10 mg 3 tablet(s) by mouth once a day Disp #*9
Tablet Refills:*0
9. PredniSONE 20 mg PO DAILY Duration: 3 Doses
This is dose # 5 of 6 tapered doses
RX *prednisone 20 mg 1 tablet(s) by mouth once a day Disp #*3
Tablet Refills:*0
10. PredniSONE 10 mg PO DAILY Duration: 3 Doses
This is dose # 6 of 6 tapered doses
RX *prednisone 10 mg 1 tablet(s) by mouth once a day Disp #*3
Tablet Refills:*0
11. Salmeterol Xinafoate Diskus (50 mcg) 1 INH IH Q12H
RX *salmeterol [Serevent Diskus] 50 mcg 1 INH IH q12 HOURS Disp
#*5 Disk Refills:*0
12. Tiotropium Bromide 1 CAP IH DAILY
RX *tiotropium bromide [Spiriva Respimat] 2.5 mcg/actuation 1
INH IH once a day Disp #*5 Inhaler Refills:*0
13. Albuterol Inhaler 2 PUFF IH Q4H:PRN wheezing
14. Amphetamine-Dextroamphetamine 20 mg PO BID
15. Citalopram 40 mg PO DAILY
16. Epzicom (abacavir-lamivudine) 600-300 mg oral DAILY
17. Prezcobix (darunavir-cobicistat) 800-150 mg-mg oral DAILY
18. testosterone cypionate 0.25 mg injection 1X/WEEK
19. TraZODone 100 mg PO QHS insomnia
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY:
========
Asthma exacerbation
SECONDARY:
==========
HIV
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 WERE YOU IN THE HOSPITAL?
- You were in the hospital because of trouble breathing. Your
PCP was concerned that you were having an asthma exacerbation so
you were sent to the hospital.
WHAT HAPPENED IN THE HOSPITAL?
- You received steroids to treat your asthma exacerbation.
- You were given antibiotics.
- You were given nebulizers and inhalers to help improve your
breathing.
- You were started on a couple of new medications to better
control your asthma.
WHAT SHOULD YOU DO AFTER LEAVING THE HOSPITAL?
- You should take all of your medications as prescribed.
- You should follow up with your doctors as ___
previously.
- You should notify your doctors ___ that you may be
running out of any medications.
We wish you the best,
Your ___ Care Team
Followup Instructions:
___
|
19699040-DS-5
| 19,699,040 | 28,297,336 |
DS
| 5 |
2128-08-13 00:00:00
|
2128-08-16 08:52:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: OBSTETRICS/GYNECOLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
abdominal pain, nausea and vomiting
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms. ___ is a ___ yo ___ s/p total abdominal hysterectomy,
bilateral
salpingo-oophorectomy, lysis of adhesions for fibroid uterus on
___ who presented to the ED on ___ with two days of
nausea and vomiting. She had not passed flatus or had a bowel
movement since the day prior to presentation. Her pain was rated
as ___, intermittent, without radiaotion, and located in the
epigastric area. It was worse with food. She denied fever,
chills, chest pain, SOB, dysuria, constipation.
Past Medical History:
ObHx:
G3P3
- LTCS x3 (pLTCS for arrest of dilation, rLTCS x2 elective)
GynHx:
- no hx abnormal pap, last at ___ ___ years ago, last
this year at ___ insufficient.
- no history of STIs, PID, endometriosis
- s/p BTL; not sexually active
PMH:
- Asthma, no hospitalizations or intubations, uses albuterol
inhaler only when sick
- Fe deficiency anemia
- h/o acute pancreatitis, ___, following ERCP for choledochal
cyst
- Migraine headaches - no aura, occ nausea if severe
- Intracranial mass, discovered incidentally after CT ___ for
headache, ?meningioma -- per ___ d/w with her PCP ___
___ reviewed images with Radiology, OK to defer MRI unless sxs
worsen.
PSH:
- LTCS x3, one of which c/b wound infection requiring wound
debridement
- ERCP
- LSC cholecystectomy, ___, done in ___
- TAH/BSO, extensive LOA ___
Social History:
___
Family History:
Denies t/e/d
Physical Exam:
On discharge:
Gen: NAD
CV: RRR
Lungs: CTAB
Abd: soft, no r/g, normoactive BS
GU: voiding spontaneously
Ext: non-tender
Pertinent Results:
___ 06:20AM BLOOD WBC-4.4 RBC-3.75* Hgb-11.0* Hct-32.7*
MCV-87 MCH-29.2 MCHC-33.6 RDW-18.5* Plt ___
___ 06:45AM BLOOD WBC-3.2* RBC-3.82* Hgb-11.1* Hct-33.1*
MCV-87 MCH-29.0 MCHC-33.4 RDW-18.4* Plt ___
___ 06:25AM BLOOD WBC-6.1 RBC-3.77* Hgb-10.8* Hct-33.0*
MCV-88 MCH-28.7 MCHC-32.8 RDW-19.3* Plt ___
___ 01:20PM BLOOD WBC-8.9 RBC-4.41 Hgb-12.8 Hct-37.1 MCV-84
MCH-29.0 MCHC-34.4 RDW-18.9* Plt ___
___ 08:43PM BLOOD WBC-10.7 RBC-4.45 Hgb-12.7# Hct-36.9
MCV-83 MCH-28.6 MCHC-34.5 RDW-19.0* Plt ___
___ 06:45AM BLOOD ALT-26 AST-22 LD(LDH)-127 AlkPhos-54
Amylase-47 TotBili-0.4
___ 01:20PM BLOOD ALT-25 AST-24 AlkPhos-65 TotBili-0.6
___ 08:43PM BLOOD ALT-22 AST-26 AlkPhos-70 TotBili-0.4
___ 06:45AM BLOOD Lipase-37
___ 01:20PM BLOOD Lipase-34
___ 08:43PM BLOOD Lipase-29
___ 01:09PM BLOOD Lactate-0.6
___ 01:44PM BLOOD Lactate-1.2
___ 08:49PM BLOOD Lactate-1.0
CT Abdomen/Pelvis ___
IMPRESSION: Small bowel obstruction with transition point in the
anterior
abdominal wall incision. Bowel wall edema and ascites raise the
possibility
of vascular compromise/ischemia.
KUB ___
FINDINGS: Supine and upright views of the abdomen were obtained.
There is
paucity of bowel gas, but a few distended loops of presumably
small bowel are
seen in the upper abdomen with air-fluid levels, raising the
possibility of a
small bowel obstruction. There is a small amount of air in the
rectum. There
is no free air. Cholecystectomy clips are in place. The osseous
structures are
unremarkable.
IMPRESSION: Findings raise possibility of small bowel
obstruction.
KUB ___
Supine and upright abdominal radiographs demonstrate NG tube
with tip in the
stomach body. Unchanged clips noted in the right upper
quadrant. Persistent
multiple air-fluid levels with dilated small bowel measuring 3.5
cm at maximum
diameter. No pneumatosis or free intraperitoneal air.
Visualized lung bases
are clear and osseous structures are unremarkable.
IMPRESSION:
1. Persistent small bowel obstruction.
2. No free intraperitoneal air
Brief Hospital Course:
Ms. ___ was admitted for to the gynecology service on
___ with concern for possible small bowel obstruction.
An NGT was placed for bowel decompression and she was closely
monitored with serial abdominal exams. Her labs showed a normal
WBC, normal LFTs, normal amylase/lipase, and normal lactate
level. The general surgery service was consulted for
recommendations and they agreed with the plan for conservative
management while awaiting return of full bowel function. There
was no indication for acute surgical intervention and low
concern for the possibility of ischemic bowel mentioned in the
imaging impression given her improvement in symptoms with
conservative management and serial normal WBC and lactate
levels. Serial KUB films showed a air fluid levels consistent
with a small bowel obstruction but no evidence of free air. Her
pain was controlled with IV acetaminophen and toradol and a PPI
was started given her epigastric tenderness on exam.
Her distension and pain improved on this regimen and she began
passing flatus.
As her symptoms improved and she began passing flatus, she had
an NGT clamp trial that showed minimal residual. Her NGT was
removed on the evening of ___ and her diet was slowly
advanced. She had episodes of watery diarrhea and a C diff and
stool cultures were sent. Her stool was negative for C diff and
stool cultures were negative, though ova and parasite
examination were still pending at time of discharge. H.Pylori
antibody test was positive. As it was unclear if this
represented acute infection or an evidence of an old infection,
the GI service felt it was reasonable to defer adressing this
work-up as an outpatient. She was seen by nutrition for
education on a low residue diet.
At the time of discharge, her pain was minimal, she was
tolerating a regular diet, passing flatus and BM and voiding.
She was discharged home with outpatient follow-up scheduled.
Medications on Admission:
Albuterol, ibuprofen, percocet, colace
Discharge Medications:
1. Omeprazole 40 mg PO DAILY
RX *omeprazole 40 mg 1 capsule,delayed ___ by
mouth daily Disp #*30 Capsule Refills:*3
Discharge Disposition:
Home
Discharge Diagnosis:
small bowel obstruction
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were admitted to the gynecology service with a small bowel
obstruction after your hysterectomy. You have recovered well and
the team now feels you are safe to discharge home. Please follow
these instructions:
*) Take your medication as prescribed.
*) follow up with your doctors as ___
It is very important that you follow the low residue diet
described to you by the nutritionist.
Followup Instructions:
___
|
19699040-DS-6
| 19,699,040 | 20,421,854 |
DS
| 6 |
2130-03-23 00:00:00
|
2130-03-26 11:30:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
5 days of LLQ pain
Major Surgical or Invasive Procedure:
Ultrasound guided pelvic drainage
History of Present Illness:
___ 2.5mo s/p panniculectomy at outside hospital with sudden
onset lower left quadrant pain 5 days prior to presentation. No
constitutional symptoms consistent with obstruction, no change
in bowel habits. History notable for multiple abdominal
operations including TAH and C-section x3 with history of SBO
conservatively managed in ___. Pt reports current symptoms
different than SBO presentation. Denies fevers, chills,
abdominal distension, nausea or vomiting. Denies any blunt
abdominal trauma. No history of diverticulitis,
liver masses, appendicitis. Remote cholecystectomy.
At time of consultation, patient had stable vital signs with
well healing panniculectomy incisional scar with focal LLQ
tenderness with rebound. Otherwise benign abdominal exam. WBC
9.6. CTAP notable for well circumscribed 7.5x5.5 mesenteric
fluid collection with Hounsfield units 20, low-normal for
hematoma.
CT demonstrated 7.5x5.5cm mesenteric fluid collection
Past Medical History:
ObHx:
G3P3
- LTCS x3 (pLTCS for arrest of dilation, rLTCS x2 elective)
GynHx:
- no hx abnormal pap, last at ___ ___ years ago, last
this year at ___ insufficient.
- no history of STIs, PID, endometriosis
- s/p BTL; not sexually active
PMH:
- Asthma, no hospitalizations or intubations, uses albuterol
inhaler only when sick
- Fe deficiency anemia
- h/o acute pancreatitis, ___, following ERCP for choledochal
cyst
- Migraine headaches - no aura, occ nausea if severe
- Intracranial mass, discovered incidentally after CT ___ for
headache, ?meningioma -- per ___ d/w with her PCP ___
___ reviewed images with Radiology, OK to defer MRI unless sxs
worsen.
PSH:
- LTCS x3, one of which c/b wound infection requiring wound
debridement
- ERCP
- LSC cholecystectomy, ___, done in ___
- TAH/BSO, extensive LOA ___
Social History:
___
Family History:
Denies t/e/d
Physical Exam:
EXAM:
Weight:
VS: T 97.8, HR 86, BP 161/106, RR 18, SaO2 100%rm air
GEN: NAD, A/Ox3
HEENT: EOMI, MMM
CV: regular
PULM: CTAB
BACK: No CVAT
ABD: soft, well-healing lower abdominal and periumbilical
panniculectomy incisional scars. LLQ tenderness with focal
rebound.
EXT: warm, no edema
Pertinent Results:
On admission:
LABS:
13.0 140 / ___ >------< 291 ----------------< 107 AGap=16
36.9 3.___ / 0.6
N:63.2 L:26.9 M:5.4
E:3.7 Bas:0.5
UCG: negative
IMAGING: CTAP [prelim] -
1. No evidence of recurrent small bowel obstruction. Normal
appendix.
2. Interval development of a 7.4 x 4.1 x 5.5 cm
well-circumscribed heterogenous fluid collection within the
mesentery of the left lower abdomen. ___ units verbally
reported as ___, low normal for hematoma. Rim enhancement and
mild adjacent fat stranding concerning for abscess.
Brief Hospital Course:
___ 2.5mo s/p panniculectomy at OSH with sudden onset LLQ pain 5
days prior to presentation. No constitutional symptoms
consistent with obstruction, no change in bowel habits. At time
of consultation, pt AFVSS with well healing panniculectomy
incisional scar with focal LLQ tenderness with rebound.
Otherwise benign abdominal exam. WBC 9.6. CTAP notable for well
circumscribed 7.5x5.5cm mesenteric fluid collection with
___ units 20, low-normal for hematoma. Her large
mesenteric fluid collection was concerning for infected
hematoma, and she was admitted with IV antibiotics and a consult
for interventional radiology drainage under image guidance.
During the ___ procedure on ___, limited grayscale and
color Doppler ultrasound imaging of the left lower quadrant
demonstrated a 7.3 x 4.8 cm loculated fluid collection,
corresponding to the fluid collection seen on CT ___. A
5 ___ catheter was advanced into fluid collection and 80 mL
of clear serous fluid was removed. No drainage catheter was
left in place. A sample was sent for microbiology.
The fluid showed no growth, with no microorganisms seen.
CV: The patient remained stable from a cardiovascular
standpoint; vital signs were routinely monitored.
Pulmonary: The patient remained stable from a pulmonary
standpoint; vital signs were routinely monitored. Good pulmonary
toilet, early ambulation and incentive spirometry were
encouraged throughout hospitalization.
ID: The patient's white blood cell counts 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 ___, IV antibiotics were discontinued, and patient was
advanced from NPO to a regular diet as tolerated.
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:
ALBUTEROL SULFATE - albuterol sulfate HFA 90 mcg/actuation
aerosol inhaler. ___ puffs inhaled every 6 hours as needed
FLUTICASONE-SALMETEROL [ADVAIR DISKUS] - Advair Diskus 250
mcg-50
mcg/dose powder for inhalation. 1 puff inhaled every 12 hours
Please replace your fluticasone inhaler with this medication.
Use
with a spacer.
Medications - OTC
FERROUS SULFATE - ferrous sulfate 325 mg (65 mg iron) tablet. 1
tablet(s) by mouth one to three times a day ___ take less often
if causes stomach upset or constipation
Discharge Medications:
1. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
RX *oxycodone 5 mg 1 tablet(s) by mouth every 4 to 6 hours as
needed for pain Disp #*20 Tablet Refills:*0
2. Docusate Sodium 100 mg PO BID
Hold the medication for any diarrhea
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*20 Capsule Refills:*0
3. Senna 8.6 mg PO BID
Hold for any diarrhea
RX *sennosides [senna] 8.6 mg 1 by mouth twice a day Disp #*20
Capsule Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Serous fluid in the left lower quadrant, most likely a pelvic
seroma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear ___,
You were admitted to ___ and
underwent ultrasound guided drainage of a pelvic fluid
collection. 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.
Followup Instructions:
___
|
19699040-DS-7
| 19,699,040 | 23,786,797 |
DS
| 7 |
2132-08-19 00:00:00
|
2132-08-19 15:10:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Back pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old female with a history of hypertension and asthma who
presents with four days of right flank pain that sometimes
radiates to her right lower abdomen. She reports that it comes
on
without clear precipitant including eating, urinating. She says
that standing and sitting makes the pain worse. Ocassionally
palpating the area makes the pain worse. She has no dysuria,
hematuria, or fever. She denies any trauma to the region.
In the ED, initial VS were:
97.6 63 141/76 14 100% RA
Exam notable for: No abdominal tenderness.
Labs showed:
UA with 4 WBC, RBC 3
Lactate 1.4
Negative UCG
Labs are otherwise normal
Imaging showed:
Renal U.S.
Normal renal ultrasound with no evidence of hydronephrosis or
nephrolithiasis.
CT Abd & Pelvis W/O Contrast
1. No etiology identified for the patient's reported symptoms.
2. A 5.3 cm simple attenuating fluid collection in the upper
left
pelvis is larger than ___, probably a postoperative seroma or
lymphocele.
Patient received:
IV Morphine Sulfate 4 mg
PO Acetaminophen 1000 mg
IVF NS
IVF NS 1000 mL ___ Stopped
IV Ketorolac 15 mg
IV Morphine Sulfate 4 mg ___
NS ___ Started
NS 1000 mL
IV Ondansetron 4 mg
PO OxyCODONE (Immediate Release)
IV Ketorolac 15 mg
PO Ondansetron ODT 4 mg
IVF NS 1000 mL
Transfer VS were:
68 129/71 20 98% RA
On arrival to the floor, patient reports the above story.
Past Medical History:
ObHx:
G3P3
- LTCS x3 (pLTCS for arrest of dilation, rLTCS x2 elective)
GynHx:
- no hx abnormal pap, last at ___ ___ years ago, last
this year at ___ insufficient.
- no history of STIs, PID, endometriosis
- s/p BTL; not sexually active
PMH:
- Asthma, no hospitalizations or intubations, uses albuterol
inhaler only when sick
- Fe deficiency anemia
- h/o acute pancreatitis, ___, following ERCP for choledochal
cyst
- Migraine headaches - no aura, occ nausea if severe
- Intracranial mass, discovered incidentally after CT ___ for
headache, ?meningioma -- per ___ d/w with her PCP ___
___ reviewed images with Radiology, OK to defer MRI unless sxs
worsen.
PSH:
- LTCS x3, one of which c/b wound infection requiring wound
debridement
- ERCP
- LSC cholecystectomy, ___, done in ___
- TAH/BSO, extensive LOA ___
Social History:
___
Family History:
Denies t/e/d
Physical Exam:
ADMISSION
GENERAL: NAD
HEENT: EOMI, anicteric sclera, pink conjunctiva, MMM
NECK: supple
HEART: RRR, S1/S2, no murmurs, gallops, or rubs
LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: nondistended, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
BACK: Mild tenderness to right back
EXTREMITIES: no cyanosis, clubbing, or edema
PULSES: 2+ DP pulses bilaterally
NEURO: A&Ox3, moving all 4 extremities with purpose
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
DISCHARGE
98.3 PO 120 / 80 70 18 97 Ra
GENERAL: NAD
HEENT: EOMI, anicteric sclera, pink conjunctiva, MMM
NECK: supple
HEART: RRR, S1/S2, no murmurs, gallops, or rubs
LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: nondistended, Mild TTP RUQ without ___ sign, no
rebound/guarding, no hepatosplenomegaly
BACK: Mild tenderness to right back
EXTREMITIES: no cyanosis, clubbing, or edema
PULSES: 2+ DP pulses bilaterally
NEURO: A&Ox3, moving all 4 extremities with purpose
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
Pertinent Results:
ADMISSION
==========
___ 10:20AM BLOOD WBC-6.6 RBC-4.41 Hgb-13.4 Hct-38.6 MCV-88
MCH-30.4 MCHC-34.7 RDW-12.6 RDWSD-40.1 Plt ___
___ 10:20AM BLOOD Neuts-59.6 ___ Monos-6.5 Eos-3.8
Baso-0.6 Im ___ AbsNeut-3.95 AbsLymp-1.93 AbsMono-0.43
AbsEos-0.25 AbsBaso-0.04
___ 10:20AM BLOOD Glucose-96 UreaN-12 Creat-0.6 Na-138
K-3.6 Cl-100 HCO3-26 AnGap-12
___ 10:20AM BLOOD ALT-19 AST-16 AlkPhos-72 TotBili-0.5
___ 10:20AM BLOOD Albumin-4.2
DISCAHRGE
==========
___ 08:20AM BLOOD WBC-7.0 RBC-4.35 Hgb-12.9 Hct-38.6 MCV-89
MCH-29.7 MCHC-33.4 RDW-12.4 RDWSD-40.4 Plt ___
___ 08:20AM BLOOD Glucose-105* UreaN-19 Creat-0.7 Na-140
K-4.3 Cl-102 HCO3-27 AnGap-11
___ 08:20AM BLOOD Calcium-9.3 Phos-3.3 Mg-2.3
MICRO
======
___ UCx neg
___ Bcx NGTD
IMAGING
==========
==Renal US==
IMPRESSION:
Normal renal ultrasound with no evidence of hydronephrosis or
nephrolithiasis.
==CT A/P without contrast==
FINDINGS:
LOWER CHEST: Visualized lung fields are within normal limits.
There is no
evidence of pleural or pericardial effusion.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogeneous attenuation
throughout.
There is no evidence of focal lesions within the limitations of
an unenhanced
scan. There is no evidence of intrahepatic or extrahepatic
biliary
dilatation. The gallbladder is surgically absent.
PANCREAS: The pancreas has normal attenuation throughout,
without evidence of focal lesions within the limitations of an
unenhanced scan. There is no pancreatic ductal dilatation.
There is no peripancreatic stranding.
SPLEEN: The spleen shows normal size and attenuation throughout,
without
evidence of focal lesions.
ADRENALS: The right and left adrenal glands are normal in size
and shape.
URINARY: The kidneys are of normal and symmetric size. There is
no evidence of focal renal lesions within the limitations of an
unenhanced scan. There is no hydronephrosis. There is no
nephrolithiasis. There is no perinephric
abnormality.
GASTROINTESTINAL: A 5.3 x 4.3 x 3.8 cm simple attenuating fluid
collection in the upper left pelvis is slightly larger than
___, probably a postoperative seroma or lymphocele (series 601,
image 17; series 2, image 59). The stomach is unremarkable.
Small bowel loops demonstrate normal caliber and wall thickness
throughout. Mild ascending and descending diverticulosis. The
colon and rectum are otherwise within normal limits. The
appendix is normal.
PELVIS: The urinary bladder and distal ureters are unremarkable.
There is no free fluid in the pelvis.
REPRODUCTIVE ORGANS: Patient appears status-post hysterectomy
and bilateral salpingo-oophorectomy.
LYMPH NODES: There is no retroperitoneal or mesenteric
lymphadenopathy. There is no pelvic or inguinal
lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. No
atherosclerotic disease is noted.
BONES: There is no evidence of worrisome osseous lesions or
acute fracture.
SOFT TISSUES: Mild bilateral fat containing inguinal hernias.
Nonspecific fat stranding Ms. ___ fat overlying the
left oblique musculature.
IMPRESSION:
1. No etiology identified for the patient's reported symptoms.
2. 5.3 cm simple attenuating fluid collection in the left pelvis
is slightly
larger than ___, probably a postoperative seroma or lymphocele.
Brief Hospital Course:
___ year old female with a history of hypertension and asthma who
presents with four days of right flank pain that sometimes
radiates to her right lower abdomen with no other symptoms and
renal ultrasound and CT scan with no acute pathology.
ACTIVE ISSUES
-------------
#Right Flank Pain: Unclear etiology of this patient's flank pain
but low suspicion of nephrolithiasis or other kidney pathology.
CT scan showed no abnormalities, no nephrolithiasis, US showed
no nephrolithiasis or signs of hydro or pyelonephritis. UA and
labs all normal. Pain felt most likely to be musculoskeletal in
origin given TTP of right lumbar paraspinal muscles with
associated spasm. Patient received flexeril which did not
provide much pain relief, but then was started on ketorolac q6h
which significantly improved her pain. Patient discharged with
short course of flexeril, advised not to drive while taking this
medicine. Also discharged with 800mg ibuprofen TID for ___dvised to take with food, and to not continue to take
ibuprofen continuously for more than 2 weeks unless instructed
by her PCP.
#Diarrhea
#N/V
#Reduced PO intake
Likely gastroenteritis, low suspicion for acute renal/other
intraabdominal pathology given negative imaging. No gallbladder
(s/p choley). No evidence of pancreatitis. No recent abx or
hospitalizations, so low suspicion for C. dif. Patient had small
amount of diarrhea during admission, but is tolerating good PO
fluid intake and showing no signs of volume depletion.
CHRONIC ISSUES
--------------
HTN: Held amlodipine as BPs normal during admission.
TRANSITIONAL ISSUES
===================
[] Make sure patient is not driving while taking flexeril
[] Simple cyst seen in left pelvic area slightly increased in
size from prior imaging ___, likely nothing to do.
#New meds: Cyclobenzaprine 10 mg PO/NG BID:PRN, Ibuprofen 800 mg
PO Q8H:PRN Pain
Contact: ___ friend ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
2. Albuterol Inhaler ___ PUFF IH Q6H:PRN shortness of breath
3. amLODIPine 5 mg PO DAILY
Discharge Medications:
1. Cyclobenzaprine 10 mg PO BID:PRN Pain/spasm
RX *cyclobenzaprine 10 mg 1 tablet(s) by mouth twice a day Disp
#*10 Tablet Refills:*0
2. Ibuprofen 800 mg PO Q8H:PRN Pain - Moderate
RX *ibuprofen 800 mg 1 tablet(s) by mouth every eight (8) hours
Disp #*21 Tablet Refills:*0
3. Albuterol Inhaler ___ PUFF IH Q6H:PRN shortness of breath
4. amLODIPine 5 mg PO DAILY
5. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
Discharge Disposition:
Home
Discharge Diagnosis:
Primary
=======
Muscular spasm
Muscular strain
Gastroenteritis
Secondary
=========
Asthma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Ms. ___
___ was a pleasure taking care of you at ___
You were admitted to the hospital because you were having back
and abdominal pain and vomiting.
While you were her you had imaging of your abdomen which did not
show any reason for your pain. You were medications to help with
the pain.
-After you leave, you should follow up with your PCP and make
sure to take all your medications as prescribed.
-You will be prescribed a short course of Flexeril to be taken
on an as needed basis. Please do not drive a car or operate any
other heavy machinery if you are taking this medication, as it
can make you very drowsy.
-Please make sure to take your ibuprofen with food to prevent
stomach upset.
We wish you the best!
Your ___ team
Followup Instructions:
___
|
19699040-DS-8
| 19,699,040 | 28,552,124 |
DS
| 8 |
2134-02-10 00:00:00
|
2134-02-14 08:35:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: OBSTETRICS/GYNECOLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
LLQ pain and intermittent nausea with adnexal cystic
structure
Major Surgical or Invasive Procedure:
interventional guided drainage of fluid collection
History of Present Illness:
HPI: Ms. ___ is a ___ G3, P3 who presents to the
emergency room after a 3-day history of left lower quadrant
pain.
She reports intermittent nausea but denies emesis. She denies
any fevers or chills, myalgias, dysuria, constipation or
diarrhea, abnormal vaginal discharge.
In the ED, a CT of the abdomen and pelvis was ordered which
demonstrated a left adnexal cyst that appeared multiloculated
and
enhancing in appearance with adjacent fat stranding. Given
these
findings GYN was consulted to evaluate the patient for
appropriate treatment.
Upon evaluation, the patient reports overall feeling well except
for persistent left lower quadrant pain that is tender to
palpation. She describes pain with movement but denies all
other
symptoms. Of note the patient is status post a total abdominal
hysterectomy bilateral salpingectomy in ___. Patient denies a
history of constipation.
Of note, the patient has had prior pelvic imaging including a
pelvic ultrasound and CT of the abdomen and pelvis in ___ that
demonstrated a similar lobulated cystic structure in the left
adnexa of known unknown etiology. The fluid collection was
thought to possibly be a postoperative seroma or lymphocele.
Review of systems negative except for pertinent positives and
negatives mentioned above.
Past Medical History:
OBHx: G3P3
- LTCS x3 (pLTCS for arrest of dilation, rLTCS x2 elective)
GynHx:
- No longer menstruating s/p TAH-BS in ___
- denies any hx abnormal pap, last Pap in ___ NILM
- denies h/o STIs, PID, endometriosis
PMH:
- Asthma, no hospitalizations or intubations, uses albuterol
inhaler only when sick
- h/o acute pancreatitis, ___, following ERCP for choledochal
cyst
- Migraine headaches - no aura, occ nausea if severe
- Intracranial mass, discovered incidentally after CT ___,
with close follow-up and no deficits
PSH:
- TAH-BS (per op report, extensive lysis of adhesions at the
level of the fascia to the uterus)
- LTCS x3, one of which c/b wound infection requiring wound
debridement
- ERCP
- LSC cholecystectomy, ___, done in ___
___ History:
___
Family History:
FamHx:
No known cancer but not totally aware of her fam hx,
specifically
no known GYN, breast or colon cancer.
Denies h/o blood clots, bleeding disorders, CAD, CVA.
- Mother: osteoporosis, fibroids ?s/p hysterectomy
- Father: diabetes
- ___: healthy
- Daughter with ___ syndrome, artificial valve from
congenital heart defect
- Son has paranoia/psychosis
Physical Exam:
General: NAD
Cardiac: RRR
Resp: CTAB
Abd: soft, nondistended, positive bowel sounds, moderate
tenderness to palpation, no palpable mass
Extrem: nontender to palpation, no palpable edema, no pboots in
place
Pertinent Results:
___ 05:00PM URINE HOURS-RANDOM
___ 05:00PM URINE UCG-NEGATIVE
___ 05:00PM URINE COLOR-Straw APPEAR-Clear SP ___
___ 05:00PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
___ 04:33PM OTHER BODY FLUID CT-NEG NG-NEG
___ 11:18AM ___ COMMENTS-GREEN TOP
___ 11:15AM GLUCOSE-104* UREA N-12 CREAT-0.9 SODIUM-138
POTASSIUM-3.8 CHLORIDE-102 TOTAL CO2-24 ANION GAP-12
___ 11:15AM WBC-10.0 RBC-4.58 HGB-13.7 HCT-40.7 MCV-89
MCH-29.9 MCHC-33.7 RDW-12.6 RDWSD-41.0
___ 11:15AM NEUTS-63.7 ___ MONOS-7.2 EOS-3.3
BASOS-0.2 IM ___ AbsNeut-6.38* AbsLymp-2.52 AbsMono-0.72
AbsEos-0.33 AbsBaso-0.02
___ 11:15AM PLT COUNT-237
___ 10:43AM URINE COLOR-Yellow APPEAR-Hazy* SP ___
___ 10:43AM URINE BLOOD-SM* NITRITE-NEG PROTEIN-30*
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-2* PH-6.0
LEUK-NEG
___ 09:05AM UREA N-14 CREAT-0.6
___ 09:05AM estGFR-Using this
___ 09:05AM CHOLEST-192
___ 09:05AM TRIGLYCER-212* HDL CHOL-48 CHOL/HDL-4.0
LDL(CALC)-102
___ 09:05AM WBC-9.5 RBC-4.49 HGB-13.4 HCT-40.3 MCV-90
MCH-29.8 MCHC-33.3 RDW-12.7 RDWSD-41.6
___ 09:05AM NEUTS-63.6 ___ MONOS-6.4 EOS-4.8
BASOS-0.3 IM ___ AbsNeut-6.04 AbsLymp-2.33 AbsMono-0.61
AbsEos-0.46 AbsBaso-0.03
___ 09:05AM PLT COUNT-269
Brief Hospital Course:
On ___, Ms. ___ was admitted to the gynecology service
after being evaluated in the emergency room, for concern for a
left tubo-ovarian or supra-infected lymphocele. She was treated
presumptively for ___ with IV gentamicin, clindamycin for 24
hours and then transitioned to ceftriaxone IM and PO doxycycline
for ___bdomen pelvis was notable for multiloculated left
adnexal cyst enhancing in appearance w/ adjacent fat stranding;
surrounding descending colon and sigmoid colon is thickened. Her
pelvic ultrasound showed two adjacent hypoechoic structures in
the left adnexa. Her urinalysis and culture were negative, blood
cultures were pending at the time of discharge, gonorrhea,
chlamydia, and treponemal, HIV testing was negative, hepatitis B
and hepatitis C testing was pending.
Patient underwent an ___ guided drainage on ___, which
drained 6cc of bloody fluid, Gram stain was negative, cultures
and cytology pending at the time of discharge.
By ___, she was tolerating a regular diet, voiding
spontaneously, ambulating independently, and pain was controlled
with oral medications. She was then discharged home in stable
condition with outpatient follow-up scheduled.
Medications on Admission:
--------------- --------------- --------------- ---------------
Active Medication list as of ___:
Medications - Prescription
ALBUTEROL SULFATE [VENTOLIN HFA] - Ventolin HFA 90 mcg/actuation
aerosol inhaler. 2 puffs inhaled every six (6) hours as needed
for cough, chest congestion, and shortness of breath
AMLODIPINE - amlodipine 10 mg tablet. 1 tablet(s) by mouth daily
am
FLUTICASONE PROPION-SALMETEROL - fluticasone 232 mcg-salmeterol
14 mcg/actuation breath activated powdr. 2 puffs inhale twice a
day regularly to treat asthma.
Medications - OTC
IBUPROFEN [MOTRIN IB] - Dosage uncertain - (Prescribed by Other
Provider; last used 2 weeks ago)
--------------- --------------- --------------- ---------------
ALL: NKDA
Discharge Medications:
1. Acetaminophen ___ mg PO Q6H:PRN Pain - Mild/Fever
RX *acetaminophen 500 mg ___ tablet(s) by mouth every six (6)
hours Disp #*60 Tablet Refills:*1
2. Doxycycline Hyclate 100 mg PO Q12H Duration: 14 Days
RX *doxycycline hyclate 100 mg 1 tablet(s) by mouth every twelve
(12) hours Disp #*14 Tablet Refills:*0
3. Ibuprofen 600 mg PO Q6H:PRN Pain - Mild
RX *ibuprofen 600 mg 1 tablet(s) by mouth every six (6) hours
Disp #*60 Tablet Refills:*1
4. amLODIPine 10 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
tubo-ovarian abscess
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were admitted to the gynecology service for your abdominal
pain and drainage with treatment for infection. You have
recovered well and the team believes you are ready to be
discharged home. Please call the OB/GYN office with any
questions or concerns, ___. Please follow the
instructions below.
General instructions:
* Take your medications as prescribed.
* Do not drive while taking opioids (e.g. oxycodone,
hydromorphone)
* Take a stool softener such as colace while taking opioids to
prevent constipation.
* Do not combine opioid and sedative medications or alcohol.
* Do not take more than 4000mg acetaminophen (APAP) in 24 hrs.
* No strenuous activity until your post-op appointment.
* You may eat a regular diet.
* You may walk up and down stairs.
Incision care:
* You may shower and allow soapy water to run over incision; no
scrubbing of incision. No tub baths for 6 weeks.
* Leave the steri-strips in place. They will fall off on their
own. If they have not fallen off by 7 days post-op, you may
remove them.
* If you have staples, they will be removed at your follow-up
visit.
Call your doctor for:
* fever > 100.4F
* severe abdominal pain
* difficulty urinating
* vaginal bleeding requiring >1 pad/hr
* abnormal vaginal discharge
* redness or drainage from incision
* nausea/vomiting where you are unable to keep down fluids/food
or your medication
Constipation:
* Drink ___ liters of water every day.
* Incorporate 20 to 35 grams of fiber into your daily diet to
maintain normal bowel function. Examples of high fiber foods
include:
Whole grain breads, Bran cereal, Prune juice, Fresh fruits and
vegetables, Dried fruits such as dried apricots and prunes,
Legumes, Nuts/seeds.
* Take Colace stool softener ___ times daily.
* Use Dulcolax suppository daily as needed.
* Take Miralax laxative powder daily as needed.
* Stop constipation medications if you are having loose stools
or diarrhea.
To reach medical records to get the records from this
hospitalization sent to your doctor at home, call ___.
Followup Instructions:
___
|
19699040-DS-9
| 19,699,040 | 26,123,079 |
DS
| 9 |
2134-06-25 00:00:00
|
2134-06-25 21:59:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: OBSTETRICS/GYNECOLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
left lower quadrant pain
Major Surgical or Invasive Procedure:
Left salpino-oophorectomy
Drainage of pelvic cyst
Laparotomy
History of Present Illness:
Ms. ___ is a ___ s/p TAH-BS in ___ for
symptomatic fibroid uterus with longstanding history of known
left adnexal cyst presenting with left lower quadrant pain.
Patient's cyst was first discovered in ___ on CT showing a
7.4 x 4.1 x 5.5cm well-circumscribed thin-walled fluid
collection
within the mesentery of LLQ at that time. The cyst was thought
to
be a seroma, peritoneal inclusion cyst, or lymphocele. She was
managed conservatively outpatient.
Interval imaging showed the left pelvic fluid collection to be
3.8 x 3.8 x 2.3cm on CT A/P in ___ and 5.3cm on CT A/P in
___. In ___, patient had a PUS describing cyst as 7.5 x
5.5 x 6.9cm lobulated cystic structure in L adnexa.
On ___, she presented to the ED with 3 days of left lower
quadrant pain and intermittent nausea. She was afebrile with
normal vital signs and had WBC 10. She had significant LLQ
tenderness and midline pelvic tenderness on bimanual. PUS
(___) revealed two adjacent hypoechoic cystic structures
measuring 5cm x 3.4cm combined. CT A/P (___) revealed
multiloculated, enhacing L adnexal cyst with fat stranding and
surrounding thickened, inflammed colon. She was admitted to GYN
(___) for suspected ___. She was treated with IV
gent/clinda, IM CTX, and PO doxycycline x 14 days. She had ___
guided drainage of cystic structure for 6cc bloody fluid with
negative gram stain and negative culture. She had negative STI
testing inculding: GC/CT neg, HIV neg, Hep B neg, RPR
nonreactive, Hep C neg.
She had follow up appointment in ___ clinic with Dr. ___ PGY3
on ___, and reported her pain had improved. She was
recommended for repeat pelvic ultrasound in 6 weeks to assess
for
interval changes of adnexal cyst. The patient reported she did
not have this ultrasound performed and did not follow up in ___
clinic because her pain had resolved completely.
Today, she reports that on ___, she experienced ___
pressure-like left lower quadrant pain that occurred
intermittently throughout the day, lasting ~30 mins at a time,
and returning every ~15 minutes. She took 1 dose of 800mg
ibuprofen which did not improve her pain.
Reports that earlier today (___), she woke up at 0615
with ___ sharp burning pain and felt sweaty but not
feverish/ill. This pain was constant and did not respond to
ibuprofen 800mg which she took at 0700, 0830, and 1000 at work.
She had some coffee in the morning, chicken with cabbage at
1230,
however felt nauseous intermittently throughout the morning.
Given pain had persisted, patient presented to ED and arrived
~1400.
In ED, patient reports ___ squeezing LLQ pain upon
presentation
which improved to ___ pain after 4mg Morphine. Pain does not
radiate to pelvis or back and is unchanged with movement. She
last ate few grapes at 1630. She denies fevers/chills,
constipation, diarrhea, SOB, chest pain, dizziness.
Past Medical History:
OBHx: G3P3
- LTCS x3 (pLTCS for arrest of dilation, rLTCS x2 elective)
GynHx:
- No longer menstruating s/p TAH-BS in ___
- denies any hx abnormal pap, last Pap in ___ NILM
- denies h/o STIs, PID, endometriosis
PMH:
- Asthma, no hospitalizations or intubations, uses albuterol
inhaler only when sick
- h/o acute pancreatitis, ___, following ERCP for choledochal
cyst
- Migraine headaches - no aura, occ nausea if severe
- Intracranial mass, discovered incidentally after CT ___,
with close follow-up and no deficits
PSH:
- TAH-BS (per op report, extensive lysis of adhesions at the
level of the fascia to the uterus)
- LTCS x3, one of which c/b wound infection requiring wound
debridement
- ERCP
- LSC cholecystectomy, ___, done in ___
___ History:
___
Family History:
FamHx:
No known cancer but not totally aware of her fam hx,
specifically
no known GYN, breast or colon cancer.
Denies h/o blood clots, bleeding disorders, CAD, CVA.
- Mother: osteoporosis, fibroids ?s/p hysterectomy
- Father: diabetes
- ___: healthy
- Daughter with ___ syndrome, artificial valve from
congenital heart defect
- Son has paranoia/psychosis
Physical Exam:
Exam at Admission
VS: Tmax 98.5, HR 80-94, RR ___, BP 120-140/75-96, O2 sat
95-100% RA, Pain ___
General: patient appears mildly uncomfortable while lying in bed
on left side with legs curled, boyfriend present bedside
CV: RRR
Pulm: LCTAB
Abd: soft, nondistended, nontender in upper quadrants
bilaterally, mildly tender in RLQ, moderately tender in
suprapubic region, significantly tender in LLQ, +rebound
tenderness, no guarding
Pelvis: ~2cm urethral diverticulum vs cyst present immediately
inferior to urethra nontender (patient reports has been present
for "years"), right adnexa and midline pelvis nontender, left
adnexa significantly tender with voluntary guarding, no blood or
discharge on glove (patient declined SSE)
Extr: calves nontender/nonerythematous/no swelling
Exam upon discharge
Pertinent Results:
___ 05:28PM URINE HOURS-RANDOM
___ 05:28PM URINE UCG-NEGATIVE
___ 05:28PM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 05:28PM URINE BLOOD-SM* NITRITE-NEG PROTEIN-TR*
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
___ 05:28PM URINE RBC-1 WBC-1 BACTERIA-FEW* YEAST-NONE
EPI-1
___ 05:28PM URINE MUCOUS-RARE*
___ 03:00PM GLUCOSE-101* UREA N-17 CREAT-0.8 SODIUM-139
POTASSIUM-3.9 CHLORIDE-102 TOTAL CO2-22 ANION GAP-15
___ 03:00PM estGFR-Using this
___ 03:00PM WBC-10.6* RBC-4.57 HGB-13.7 HCT-40.9 MCV-90
MCH-30.0 MCHC-33.5 RDW-12.7 RDWSD-41.6
___ 03:00PM NEUTS-66.4 ___ MONOS-5.6 EOS-1.6
BASOS-0.2 IM ___ AbsNeut-7.05* AbsLymp-2.74 AbsMono-0.59
AbsEos-0.17 AbsBaso-0.02
___ 03:00PM PLT COUNT-292
Brief Hospital Course:
On ___, Ms. ___ was admitted to the gynecology service
after presenting with left lower quadrant pain in the setting of
a known left adenexal cyst. On ___, she underwent a
diagnostic laparoscopy converted to exploratory laparotomy,
extensive enterolysis of adhesion, small bowel resection and
primary anastomosis, and a partial left oophorectomy/cystectomy.
Please see the operative report for full details. Immediately
post-op, her pain was controlled with IV morphine.
On POD1 (___) her pain medication was uptitrated from
oxycodone q4 to q3 in addition to standing Tylenol and
ibuprofen. She was tolerating clears, however not passing flatus
or BMs. She was making adequate urine with foley in place. Her
abd pain was increased.
Over the night she had an episode of emesis with increased abd
distension and pain. Her nausea was unrelieved with IV Zofran.
She had still not passed flatus or a BM. Due to concern for no
return of bowel function and emesis, an NGT was placed with the
colorectal team. She immediately put out 1L of bilious fluid and
her nausea and abd pain improved. She was transitioned to a
dilaudid PCA and IV tylenol.
On POD2 (___) she had an episode of 200cc foul smelling emesis
around her NGT tube. Her NGT was pulled back by CRS with
improvement of nausea. Her total NGT output was 2.5L. Her pain
was well controlled.
On POD3 (___) she had a total output of 400cc of clearer
bilious fluid. Her nausea and pain continued to improve.
On POD4 (___) she had an NGT output of 190cc in the morning and
she denied nausea. She endorsed feeling hungry and was passing
flatus with x2 bowel movements. Her NGT was clamped and had a
four hour residual of 22. Her NGT was d/c'd and was tolerating
clears. She continued to pass gas and have a large BM.
On POD5 (___) she was transitioned to clears. She had an
episode of small emesis in the morning. She continued to have BM
and pass gas. In the afternoon she had a large emesis of 1.1L
and was transitioned back to NPO.
POD6 (___) she was overall improved, continuing to have BM and
passing flatus. Tolerated sips. Repeat KUB showed improving
ileus. She was advanced to full liquid diet on POD7 and by
post-operative day 8, she was tolerating a regular diet,
ambulating independently, and pain was controlled with oral
medications. She was then discharged home in stable condition
with outpatient follow-up scheduled.
Discharge Medications:
1. Acetaminophen ___ mg PO Q6H:PRN Pain - Mild/Fever
RX *acetaminophen 500 mg ___ tablet(s) by mouth every six (6)
hours Disp #*50 Tablet Refills:*0
2. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 tablet by mouth twice day Disp
#*50 Tablet Refills:*0
3. Ibuprofen 600 mg PO Q6H:PRN Pain - Mild
RX *ibuprofen 600 mg 1 tablet by mouth every six (6) hours Disp
#*50 Tablet Refills:*0
4. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain -
Moderate
RX *oxycodone 5 mg 1 tablet by mouth every four (4) hours Disp
#*15 Tablet Refills:*0
5. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN sob, wheezing
6. Albuterol Inhaler ___ PUFF IH Q4H:PRN asthma
7. amLODIPine 10 mg PO DAILY
8. DiphenhydrAMINE 25 mg PO QHS:PRN sleep
9. Fluticasone-Salmeterol Diskus (100/50) 1 INH IH BID
10. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID asthma
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Hemorrhagic cyst
small bowel adhesions
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were admitted to the Gynecology service from the ED for
monitoring of your pelvic pain. Our exams and your imaging were
consistent with enlarging hemorrhagic cyst. We decided to
proceed with surgical management, for which you were taken to
the OR.
During your procedure you required a small bowel resection due
to extensive adhesions. After your surgery you had vomiting due
to an ileus (slowing down of the bowels). You had bowel rest and
were able to tolerate food after some time.
You have recovered well and the team believes you are ready to
be discharged home. Please call the Dr. ___ office at
___ with any questions or concerns. Please follow the
instructions below.
General instructions:
* Take your medications as prescribed.
* Do not drive while taking opioids (e.g. oxycodone,
hydromorphone)
* Take a stool softener such as colace while taking opioids to
prevent constipation.
* Do not combine opioid and sedative medications or alcohol.
* Do not take more than 4000mg acetaminophen (APAP) in 24 hrs.
* No strenuous activity until your post-op appointment.
* No heavy lifting of objects >10 lbs for 6 weeks.
* You may eat a regular diet.
* You may walk up and down stairs.
Incision care:
* You may shower and allow soapy water to run over incision; no
scrubbing of incision. No tub baths for 6 weeks.
Call your doctor for:
* fever > 100.4F
* severe abdominal pain
* difficulty urinating
* vaginal bleeding requiring >1 pad/hr
* abnormal vaginal discharge
* redness or drainage from incision
* nausea/vomiting where you are unable to keep down fluids/food
or your medication
Constipation:
* Drink ___ liters of water every day.
* Incorporate 20 to 35 grams of fiber into your daily diet to
maintain normal bowel function. Examples of high fiber foods
include:
Whole grain breads, Bran cereal, Prune juice, Fresh fruits and
vegetables, Dried fruits such as dried apricots and prunes,
Legumes, Nuts/seeds.
* Take Colace stool softener ___ times daily.
* Use Dulcolax suppository daily as needed.
* Take Miralax laxative powder daily as needed.
* Stop constipation medications if you are having loose stools
or diarrhea.
To reach medical records to get the records from this
hospitalization sent to your doctor at home, call ___.
Followup Instructions:
___
|
19699083-DS-17
| 19,699,083 | 27,902,835 |
DS
| 17 |
2123-02-03 00:00:00
|
2123-02-03 14:25:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ w. hx/o diverticulitis p/w lower abdominal pain found to
have acute uncomplicated diverticulitis on CT abd/pelvis.
She notes that the pain woke her up last night. It was located
mainly in the lower abdomen, colicky, with intermittent sharp
pains. She had no nausea, vomiting, fevers or chills. She has
been passing flatus. She had an episode of diarrhea after the
pain started. She called his PCP to report the symptoms that she
was having and was instructed to go to the ED. In the ED CT
abd/pelvis was obtained which was consistent with acute
uncomplicated diverticulitis.
Of note this is her ___ episode, she had one in ___ requiring
hospital admission and IV antibiotics, then she was treated at
home with PO antibiotics for her ___ episode in ___. She had
a colonoscopy years ago which showed diverticulosis per the
patient's report.
Past Medical History:
liver hemangioma, allergic rhinitis, depression, diverticulitis,
GERD, pancreatic cyst, ovarian cyst, rectocele, asthma
Social History:
___
Family History:
Family History: Mother, ___. Father, melanoma.
Paternal grandfather has throat cancer. Paternal grandmother
had breast cancer, diverticulosis. Brother has diverticulosis.
Physical Exam:
Admission Physical Exam
Vitals:98.8 76 134/70 16 95%RA
GEN: A&O, NAD
HEENT: No scleral icterus, mucus membranes moist
CV: RRR, No M/G/R
PULM: Clear to auscultation b/l, No W/R/R
ABD: Soft, nondistended, lower abdominal tenderness, rebound
tenderness, no guarding, no palpable masses
Ext: No ___ edema, ___ warm and well perfused
Discharge Physical Exam
Vitals: T: 98.7 67 118/75 20 97%RA
GEN: A&O, NAD
HEENT: No scleral icterus, mucus membranes moist
CV: RRR, No M/G/R
PULM: Clear to auscultation b/l, No W/R/R
ABD: Soft, nondistended, nontender, no rebound
tenderness, no guarding, no palpable masses
Ext: No ___ edema, ___ warm and well perfused
Pertinent Results:
___ 07:50PM BLOOD WBC-9.0# RBC-3.90* Hgb-12.5 Hct-37.4
MCV-96 MCH-32.1* MCHC-33.4 RDW-13.3 Plt ___
___ 06:00AM BLOOD WBC-6.3 RBC-3.36* Hgb-10.9* Hct-32.3*
MCV-96 MCH-32.5* MCHC-33.8 RDW-13.6 Plt ___
___ 07:50PM BLOOD Glucose-90 UreaN-12 Creat-0.8 Na-137
K-3.8 Cl-99 HCO3-29 AnGap-13
___ 06:00AM BLOOD Glucose-105* UreaN-5* Creat-0.8 Na-139
K-4.3 Cl-104 HCO3-29 AnGap-10
___ 07:50PM BLOOD ALT-15 AST-19 AlkPhos-40 TotBili-0.5
___ 06:00AM BLOOD Calcium-8.4 Phos-3.1 Mg-2.3
___ 04:18AM BLOOD Lactate-0.9
CT ABD&Pelvis (___)
1. Acute sigmoid diverticulitis. Colonoscopy should be
considered to exclude
malignancy following treatment if clinically appropriate, noting
wall
thickening, although likely inflammatory in etiology.
2. 5.1 cm simple appearing cyst in the left adnexa, could be
paraovarian.
Further evaluation with nonemergent pelvic ultrasound
recommended. Also given
size and patient's age yearly followup recommended.
PELVIS, NON-OBSTETRIC; DUPLEX DOP ABD/PEL LIMITED (___)
1. 6.7 cm left adnexal cyst with two new thin septations and
increase in size
from prior exam on ___ was not fully evaluated on this
exam.
Recommend further evaluation with transvaginal sonographic exam
and
gynecologic consultation.
2. No sonographic evidence of ovarian torsion.
3. Calcified anterior fibroid.
Brief Hospital Course:
Ms. ___ is a ___ admitted to the ___ service on ___ for
acute uncomplicated diverticulitis. She was made NPO, given IV
fluids, and given IV ciprofloxacin and metronidazole. On
___ the patient was put on a clears diet which she
tolerated well. Her abdominal pain had improved but she
continued to have moderate (but improved) rebound tenderness. On
___ she was tolerating a regular low fiber diet. Her
antibioitics were changed to the PO form. On ___ the
patient's pain had resolved. She no longer had any rebound
tenderness. She was tolerating a regular low fiber diet, denies
any pain or any other symptoms, she was passing gas, and
urinating without issue.
The patient received subcutaneous heparin and ___ dyne boots
were used during this stay and she 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 resolved.
The patient received discharge teaching and follow-up
instructions with understanding verbalized and agreement with
the discharge plan.
She was informed to follow up with her gynecologist for finding
of left adnexal cyst with new septations on her pelvic
ultrasound. She is to follow up with the ___ clinic to discuss
future surgical intervention for her recurrent diverticulitis.
Medications on Admission:
Fluticasone Propionate 110mcg 2 PUFF IH BID
Fluticasone Propionate NASAL 2 SPRY NU QHS
Simvastatin 40 mg PO DAILY
LaMOTrigine 150 mg PO DAILY
clonazepam 0.25mg
Gabapentin 300mg
Discharge Medications:
1. MetRONIDAZOLE (FLagyl) 500 mg PO Q8H
RX *metronidazole [Flagyl] 500 mg 1 tablet(s) by mouth three
times a day Disp #*30 Tablet Refills:*0
2. ClonazePAM 0.25 mg PO BID:PRN anxiety
3. Fluticasone Propionate 110mcg 2 PUFF IH BID
4. Fluticasone Propionate NASAL 2 SPRY NU QHS
5. Simvastatin 40 mg PO DAILY
6. LaMOTrigine 150 mg PO DAILY
7. Docusate Sodium 100 mg PO BID
8. Senna 8.6 mg PO BID:PRN constipation
9. Ciprofloxacin HCl 500 mg PO Q12H Duration: 10 Days
RX *ciprofloxacin [Cipro] 500 mg 1 tablet(s) by mouth twice a
day Disp #*20 Tablet Refills:*0
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:
Dear Ms. ___,
You were admitted to ___ under the general surgery service for
diverticulitis. You were given IV antibiotics, IV fluids,
medication for pain, and observed during your hospitalization.
Your pain improved, your vital signs (heart rate, temperature,
blood pressure, respiration and oxygenation) remained stable and
within normal limits. You were able to advance your diet from
clear liquids to regular solid food without issue. There was no
concerns for complications of diverticulitis during your stay.
There was no urgent need for surgery. Please follow up with the
General Surgery Clinic for further discussion about surgical
options for your recurrent 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. Avoid lifting
weights greater than ___ lbs until you follow-up with your
surgeon.
Avoid driving or operating heavy machinery while taking pain
medications.
Followup Instructions:
___
|
19699238-DS-20
| 19,699,238 | 20,032,048 |
DS
| 20 |
2164-08-23 00:00:00
|
2164-08-23 15:40:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Exertional chest pain
Major Surgical or Invasive Procedure:
___ Three Vessel Coronary Artery Bypass Grafting utilizing
left internal mammary artery to left anterior descending with
saphenous vein grafts to diagonal and obtuse marginal.
History of Present Illness:
This is an ___ year old male who presents after positive ETT for
exertional chest pain. Had ETT at ___, after 4 minutes on
treadmill experienced chest pain and shortness of breath. EKG
showed 2 mm STE in aVR, aVL. 2-3 mm STD in II,III, avF, V4-6.
Pain resolved after 10 minutes, given ASA 325. Pt referred to
___. He notes that he first developed substernal chest
pressure lasting ___ minutes with walking on ___. He has
since had two such episodes with exertion, prompting the stress
test. He denies any shortness of breath prior to the stress
test, no fevers, chills, nausea or other symptoms. He was
admitted to medicine for further management. On arrival to the
floor he denied chest pain.
Past Medical History:
- Obstructive Sleep apnea
- CKD III (baseline 1.5)
- Hypertension
- Dyslipidemia
- Squamous cell carcinoma
- Cataracts
- Osteoarthritis
- Spinal Stenosis
- History of Duodenal Ulcer
- History of positive PPD ___
Social History:
___
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: Tc: 97.4 HR: 69 BP: 144/56 RR: 18 98% RA
General: NAD, comfortable, pleasant
HEENT: NCAT, PERRL, EOMI
Neck: supple, no JVD
CV: regular rhythm, no m/r/g. No tenderness on chest palpation
Lungs: CTAB, no w/r/r
Abdomen: soft, NT/ND, BS+
Ext: WWP, no c/c/e, 2+ distal pulses bilaterally
Neuro: moving all extremities grossly
Gait: deferred
Pertinent Results:
Admission Labs:
___ WBC-9.5 RBC-5.07 Hgb-15.5 Hct-42.5 RDW-12.2 Plt ___
___ Neuts-80.5* Lymphs-12.7* Monos-4.6 Eos-1.4 Baso-0.8
___ ___ PTT-31.1 ___
___ Glucose-101* UreaN-29* Creat-1.5* Na-138 K-4.0 Cl-102
HCO3-25 ___ Calcium-8.8 Phos-2.7 Mg-2.0
___ Albumin-3.9
___ ALT-19 AST-23 AlkPhos-54 TotBili-0.7
___ cTropnT-0.02*
___ cTropnT-0.01
___ cTropnT-<0.01
.
Chest x-ray ___:
No acute intrathoracic process.
.
Cardiac Cath ___:
Coronary angiography: right dominant
LMCA: 90% distal LMCA
LAD: 80% ___ LAD
LCX: 30% ___
RCA: 30% ___, 30% mid
.
Intraop TEE ___:
Pre bypass: No atrial septal defect is seen by 2D or color
Doppler. Overall left ventricular systolic function is normal
(LVEF>55%). Right ventricular chamber size and free wall motion
are normal. There are simple atheroma in the ascending aorta.
There are simple atheroma in the aortic arch. There are simple
atheroma in the descending thoracic aorta. There is fusion of
the noncoronary and right coronary cusp.. Mild (1+) aortic
regurgitation is seen. The jet is eccentric .The mitral valve
appears structurally normal with trivial mitral regurgitation.
There is no pericardial effusion.
Post bypass: The patient is s/p CABG x3. The patient is on a
neosynephrine drip LV function is preserved. The EF >55%. The
valvular examination is similar to prebypass, with persistent 1+
Mitral and Aortic regurgitation. No visible dissection flaps
post decannulation are observed.
___ 06:15AM BLOOD WBC-10.6 RBC-3.47* Hgb-10.6* Hct-30.3*
MCV-87 MCH-30.6 MCHC-35.1* RDW-12.9 Plt ___
___ 06:55AM BLOOD ___
___ 06:15AM BLOOD Glucose-120* UreaN-35* Creat-1.3* Na-140
K-4.2 Cl-104 HCO3-26 AnGap-14
Brief Hospital Course:
Mr. ___ is an ___ year old male with 2 month history of
exertional angina with positive ETT on ___. He was
subsequently admitted to ___ where he underwent cardiac
catheterization on ___, which revealed a 90% distal left
main lesion. Urgent surgical revascularization was recommended.
The cardiac surgery was therefore consulted and preoperative
evaluation was performed. Prior to surgery, he remained chest
pain free throughout his time on the cardiology service.
On ___, Dr. ___ three vessel coronary artery
bypass grafting. For surgical details, please see operative
note. Following surgery, he was brought to the CVICU for
invasive monitoring. Within 24 hours, he awoke neurologically
intact and was extubated without incident. He maintained stable
hemodynamics and transferred to the cardiac SDU on postoperative
day one. Low dose beta blockade was resumed and advanced as
tolerated. Renal function remained stable throughout his
hospital stay. Pacing wires and chest tubes were removed without
complication. He continued to make clinical improvements and was
cleared for discharge to ___ Rehab in ___ on
postoperative day #4. All follow up appointments were advised.
Medications on Admission:
Hydrochlorothiazide 12.5 mg PO DAILY
Amlodipine 10 mg PO DAILY
Sertraline 25 mg PO DAILY
Losartan Potassium 100 mg PO DAILY
Discharge Medications:
1. Sertraline 25 mg PO DAILY
2. Acetaminophen 650 mg PO Q4H:PRN pain, Temp >38.5C
3. Aspirin EC 81 mg PO DAILY
4. Atorvastatin 80 mg PO DAILY
5. Metoprolol Tartrate 37.5 mg PO TID
Hold for HR<60, SBP<90
6. Ranitidine 150 mg PO DAILY
7. Furosemide 20 mg PO DAILY Duration: 5 Days
8. Potassium Chloride 20 mEq PO DAILY Duration: 5 Days
Hold for K >
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Coronary Artery Disease s/p CABG
Chronic Kidney Disease
Hypertension
Dyslipidemia
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with oral analgesia
Incisions:
Sternal - healing well, no erythema or drainage
Leg Right/Left - healing well, no erythema or drainage.
Trace Edema
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns ___
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
**Please call cardiac surgery office with any questions or
concerns ___. Answering service will contact on call
person during off hours**
Followup Instructions:
___
|
19699422-DS-6
| 19,699,422 | 28,133,603 |
DS
| 6 |
2186-01-28 00:00:00
|
2186-01-29 14:11:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Chest pain, shortness of breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ yo male w/ PMHx HTN no longer on medication transferred from
OSH with cc of PE. Pt had shoulder surgery to repair a left
rotator cuff injury 2 weeks ago at ___. 2 days ago he
started having SOB, left sided pleuritic chest pain, fatigue,
and nausea. He went to his PCP and had ___ d-dimer > 8k. He was
sent to ED for a CT scan. Initially was hypoxic to 90% per
report but this improved. CT showed bilateral multiple PEs, was
given morphine for shoulder pain and started on a heparin gtt.
As there were no ICU beds available at ___, he was sent
here for further care. He denies recent plane/car flights, no
previous significant clotting history. He states he was active
since his surgery, walking daily. No family history of blood
clots. He had a workup several years ago for anemia during which
he had upper and lower endoscopies that were fairly normal per
his report. The anemia was felt secondary to iron deficiency and
he has been on iron since then. His baseline blood pressure is
around 130/80 he states - it was higher than this in the 150s
the past 2 days so he took lisinopril 10mg each of the past 2
days. He had this leftover from when he was taking it daily for
HTN in the past.
In the ED, initial VS were: 98.5 84 110/54 16 98% RA. He had
labs checked that showed INR of 1.2, trop < 0.01, BNP of 150. He
was continued on the heparin gtt and admitted.
VS on transfer: 98.1 84 107/64 13 95%. He had some left sided
chest pain as well as back pain between his shoulder blades that
worsens with deep breathing.
REVIEW OF SYSTEMS:
(+) per HPI
(-) fever, chills, night sweats, headache, vision changes,
rhinorrhea, congestion, sore throat, nausea, vomiting,
constipation, melena, hematochezia, dysuria, hematuria.
Past Medical History:
- HTN / HL
- Shoulder with multiple injuries s/p arthroscopy: ___
Family History:
Denies clotting/bleeding diathesis, heart disease, cancer.
Physical Exam:
ADMISSION
VS: 98.0 103/60 76 18 97%RA
GENERAL: well appearing
HEENT: NC/AT, PERRL, EOMI, sclerae anicteric, MMM
NECK: supple, obese
LUNGS: CTA bilat, no r/rh/wh, good air movement, resp unlabored,
no accessory muscle use
HEART: RRR, no MRG, nl S1-S2
ABDOMEN: normal bowel sounds, soft, TTP RUQ, non-distended, no
rebound or guarding, no masses
EXTREMITIES: no edema, 2+ pulses radial and dp
NEURO: awake, A&Ox3, CNs II-XII grossly intact, muscle strength
___ throughout, sensation grossly intact throughout, DTRs 2+ and
symmetric
DISCHARGE
VS: 98.2 125/72 72 18 96%RA
GENERAL: well appearing
HEENT: NC/AT, PERRL, EOMI, sclerae anicteric, MMM
NECK: supple, obese
LUNGS: CTA bilat, no r/rh/wh, good air movement, resp unlabored,
no accessory muscle use
HEART: RRR, no MRG, nl S1-S2
ABDOMEN: normal bowel sounds, soft, TTP RUQ, non-distended, no
rebound or guarding, no masses
EXTREMITIES: no edema, 2+ pulses radial and dp
NEURO: awake, A&Ox3, CNs II-XII grossly intact, muscle strength
___ throughout, sensation grossly intact throughout, DTRs 2+ and
symmetric
Pertinent Results:
ADMISSION
___ 12:30AM WBC-11.0 RBC-4.32* HGB-14.2 HCT-40.9 MCV-95
MCH-32.8* MCHC-34.6 RDW-13.1
___ 12:30AM NEUTS-77.2* LYMPHS-16.1* MONOS-4.4 EOS-1.8
BASOS-0.4
___ 12:30AM PLT COUNT-327
___ 12:30AM ___ PTT-122.7* ___
___ 12:30AM proBNP-150
___ 12:30AM cTropnT-<0.01
___ 12:30AM ALT(SGPT)-21 AST(SGOT)-20 ALK PHOS-66 TOT
BILI-0.3
___ 12:30AM GLUCOSE-137* UREA N-16 CREAT-0.8 SODIUM-136
POTASSIUM-4.5 CHLORIDE-102 TOTAL CO2-24 ANION GAP-15
___ 06:35AM ___ PTT-38.4* ___
___ 06:35AM PLT COUNT-314
___ 06:35AM WBC-9.4 RBC-3.93* HGB-12.6* HCT-36.8* MCV-94
MCH-32.0 MCHC-34.2 RDW-12.9
DISCHARGE
___ 07:10AM BLOOD WBC-8.7 RBC-4.31* Hgb-13.7* Hct-40.9
MCV-95 MCH-31.8 MCHC-33.5 RDW-13.0 Plt ___
___ 07:10AM BLOOD Plt ___
___ 07:10AM BLOOD ___ PTT-36.7* ___
___ 07:10AM BLOOD Glucose-109* UreaN-15 Creat-0.9 Na-138
K-4.5 Cl-101 HCO3-27 AnGap-15
___ 07:10AM BLOOD Calcium-8.9 Phos-3.6 Mg-2.2
RIGHT LOWER EXTREMITY US ___: Grayscale, color, and spectral
Doppler evaluation was performed of the right lower extremity
veins. There is normal phasicity of the common femoral veins
bilaterally. There is normal compression and augmentation of
the right common femoral, proximal femoral, mid femoral, distal
femoral, popliteal, posterior tibial, and peroneal veins.
IMPRESSION: No evidence of DVT in the right lower extremity.
EKG ___: Sinus rhythm. Non-specific T wave flattening in lead
aVL. No previous tracing available for comparison.
Rate PR QRS QT/QTc P QRS T
80 ___ ___hest ___: There are multiple pulmonary emboli. The right
lower lobe pulmonary artery is nearly occluded. There are
segmental and subsegmental emboli further peripherally in the
right lower lobe. Emboli straddle the upper lobe and right
middle lobe arteries. There are also multiple emboli on the
left. The main pulmonary artery and central right and left main
pulmonary arteries are patent. Emboli are in the distal main
right pulmonary artery. The left upper lobe is relatively
spared. There is a small embolus in the lingula. There are
multiple left lower lobe emboli. There is dependent atelectasis
bilaterally. There is no apparent infarct. There is no right
pleural effusion. There may be a trivial amount of pleural fluid
on the left adjacent to the subpleural atelectasis. Sections
through the upper abdomen demonstrate small hypodensities in the
liver present in ___, most likely cysts.
Left shoulder surgery (OSH):
1. Left shoulder arthroscopic rotator cuff repair, full
thickness subscapulares and supraspinatus tears.
2. Subacromial decompression.
3. Arthroscopic biceps tenodesis.
4. Distal clavicle excision.
5. Extensive debridement of labral tears.
Brief Hospital Course:
___ y/o male with PMHx HTN/HLD 2 weeks s/p left shoulder
arthroscopic rotator cuff repair who presents with acute PE.
# Acute PE: He developed left sided chest pain exacerbated by
inspiration, and shortness of breath on exertion. He was found
to have new bilateral PEs seen on CT at OSH. He remained
hemodynamically stable during this admission, and did not have
evidence of heart strain on EKG, imaging, or labs. This was
likely provoked in the setting of recent shoulder surgery. He
also had right calf pain, however lower extremity ultrasound did
not show evidence of a DVT. His PESI puts him in the low risk
category (positive only for male and age >___; 1.7-3.5% 30-day
mortality in this group). He has had age appropriate cancer
screening per report. He was treated with lovenox (80 mg SC
q12H) bridge to coumadin (started on 5mg daily). He was
monitored on telemetry without issues. At the time of discharge,
his INR was 1.9, and his ambulatory O2 sat was ___ on RA. He
was instructed to check his INR on ___, and to follow up with
his PCP for further instructions on lovenox and coumadin dosing.
# s/p left shoulder arthroscopy: Stable, no signs of bleeding
into shoulder. No erythema / pain / swelling to suggest left arm
DVT. He had intermittent left hand numbness in an ulnar
distribution, which resolved with replacement of his left arm.
He received pain control with tylenol, and was encouraged to
continue with physical therapy as an outpatient.
TRANSITIONAL ISSUES:
# Mr. ___ was admitted with bilateral pulmonary embolism,
and was found to be in PESI class II (low risk, his risk factors
include male gender and age > ___). He was treated with lovenox
bridge to coumadin. At the time of discharge, his INR was 1.9
after receiving coumadin 5mg for two doses. Please check his INR
on ___ and ___, and discontinue his lovenox as appropriate. He
was discharged with coumadin 5mg. PLEASE ENSURE THAT HE HAS 48
HOURS OVERLAP BETWEEN LOVENOX AND THERAPEUTIC COUMADIN.
# He has chronic lower extremity sensation of cold and tingling
in his toes. His exam during this admission was reassuring
(normal pulses and neurologic exam). Please follow up on his
symptoms.
# He had one episode of left ulnar palsy during this admission,
most likely secondary to positioning of his left arm in his
sling during sleep. He did not have neurologic deficits at the
time of discharge. Please follow up on his left shoulder and
left arm exam.
# Would recommend making sure patient has all age appropriate
cancer screening. ___ consider hypercoagulability workup if he
develops additional PEs or symptoms of DVT in the future.
# Full code
# Contact: Wife ___ ___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. garlic *NF* 1,000 mg Oral daily
2. Fish Oil (Omega 3) 1000 mg PO DAILY
3. Ascorbic Acid ___ mg PO DAILY
4. Zinc Sulfate 220 mg PO DAILY
5. Ferrous Sulfate 325 mg PO DAILY
6. red yeast rice *NF* 600 mg Oral daily
Discharge Medications:
1. Ascorbic Acid ___ mg PO DAILY
2. Ferrous Sulfate 325 mg PO DAILY
3. Fish Oil (Omega 3) 1000 mg PO DAILY
4. garlic *NF* 1,000 mg Oral daily
5. red yeast rice *NF* 600 mg Oral daily
6. Zinc Sulfate 220 mg PO DAILY
7. Acetaminophen 650 mg PO Q6H:PRN pain
8. Enoxaparin Sodium 80 mg SC Q12H
Take until your coumadin (INR) level is therapeutic (between 2
and 3) for 48 hours.
RX *enoxaparin 80 mg/0.8 mL 80 mL every 12 hours Disp #*8
Syringe Refills:*1
9. Warfarin 5 mg PO DAILY16
RX *warfarin 1 mg ___ tablet(s) by mouth daily Disp #*60 Tablet
Refills:*1
RX *warfarin [Coumadin] 2 mg ___ tablet(s) by mouth daily Disp
#*30 Tablet Refills:*1
10. Outpatient Lab Work
ICD-9: 415.1
Please check INR on ___ and ___ or ___, and fax
results to Dr. ___ at ___.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
- Pulmonary embolism
Secondary:
- Left shoulder s/p arthroscopy
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. You were admitted with
chest pain and shortness of breath, and were found to have blood
clots in your lungs (pulmonary embolism). You were treated with
blood thinners (heparin drip, lovenox injections, and oral
coumadin). You should continue to take lovenox (also known as
enoxaparin) injections twice a day until your coumadin level is
therapeutic. You had an ultrasound of your right leg, which did
not show any evidence of blood clots.
Please have your blood checked ___ and ___ or ___, and adjust
your coumadin as appropriate. A script as been provided for your
lab draws. PLEASE CHECK YOUR LABS AT ___.
Followup Instructions:
___
|
19699422-DS-8
| 19,699,422 | 25,740,043 |
DS
| 8 |
2189-08-16 00:00:00
|
2189-08-16 21:05:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
severe neck pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ w/ h/o HTN, HLD, h/o PE who is ___ s/p L CEA for
symptomatic
stenosis presents with increasing neck pain. Patient reports
increased neck discomfort starting with POD 2 with persistent
and
escalating PO narcotic requirement. Presented earlier ___ to
___ and underwent CTA of head and neck. His
pain is constant and exacerbated with movement and has limited
the ROM of his neck. He denies any neurological deficits with
the
exception of diplopia of the left eye. The pain is from the base
of the skull to the middle of his scapula. He denies any
associated symptoms but has resorted to not turning his neck and
not moving his body or changing positions often. There has been
no drainage, erythema, or elevated pain at the operative site on
the left carotid. He denies fevers, child, night sweats any
neurological symptoms or signs at the time.
ROS: negative as per HPI. He denies dizziness, slurred speech,
weakness, drooping eyelids, or headaches. No fevers chills or
night sweats. Pertinent positive includes diplopia vertical in
left eye while reading fine print.
Past Medical History:
PMH: HTN, HLD, GERD, L4-S1 ruptured disks with chronic lower
back
pain, BPH, hearing loss (wears hearing aids).
PSH:
___ L CEA (Dr. ___
rotator cuff surgery in each arm. most recent c/b PE.
Appendectomy as teenager, EGD for GERD. Colonoscopy x2.
Social History:
___
Family History:
Father died from AAA rupture at age ___. Otherwise Non-
contributory.
Physical Exam:
DISCHARGE PHYSICAL EXAM:
=========================
Gen: well appearing male in no acute distress
HEENT: NCAT, EOMI, no diplopia, MMM
NECK: linear surgical incision on left side of neck, healing
well, no surrounding erythema or drainage.
CV: RRR, normal S1, S2, no MRG
LUNGS: CTAB, no crackles, wheezes, rhonchi
ABD: soft, NTND, no palpable masses
Ext: warm and well perfused
Neuro: CN II-XII grossly intact. Motor and sensation intact to
upper and lower extremities
MSK: tenderness to palpation of right paraspinal neck, improved.
ROM still limited by pain but improved, able to rotate neck side
to side with mild increase in pain, able to somewhat flex and
extend neck although limited by pain
Pertinent Results:
ADMISSION LABS:
================
___ 07:58PM GLUCOSE-110* UREA N-18 CREAT-1.0 SODIUM-131*
POTASSIUM-3.9 CHLORIDE-93* TOTAL CO2-28 ANION GAP-14
___ 07:58PM WBC-11.1* RBC-3.94* HGB-12.5* HCT-37.7*
MCV-96 MCH-31.7 MCHC-33.2 RDW-12.4 RDWSD-43.5
___ 07:58PM NEUTS-63.7 ___ MONOS-13.9* EOS-1.2
BASOS-0.2 IM ___ AbsNeut-7.08* AbsLymp-2.26 AbsMono-1.54*
AbsEos-0.13 AbsBaso-0.02
___ 07:58PM ___ PTT-26.8 ___
DISCHARGE LABS:
=================
___ 01:35PM BLOOD WBC-9.1 RBC-3.60* Hgb-11.5* Hct-34.5*
MCV-96 MCH-31.9 MCHC-33.3 RDW-12.5 RDWSD-43.9 Plt ___
___ 07:40AM BLOOD Glucose-95 UreaN-25* Creat-1.0 Na-136
K-4.2 Cl-97 HCO3-27 AnGap-16
___ 07:40AM BLOOD Calcium-9.1 Phos-4.2 Mg-2.0 Cholest-138
___ 07:40AM BLOOD %HbA1c-5.6 eAG-114
___ 07:40AM BLOOD Triglyc-80 HDL-40 CHOL/HD-3.5 LDLcalc-82
___ 07:40AM BLOOD TSH-0.58
___ 07:40AM BLOOD CRP-263.0*
PERTINENT STUDIES:
====================
___ CT NECK from OSH - see OMR for study
___ STROKE PROTOCOL (BRAIN
IMPRESSION:
1. Study is mildly degraded by motion.
2. No acute intracranial abnormality, with no evidence of acute
infarct.
3. Punctate right temporal microhemorrhage vs calcification.
4. Paranasal sinus disease as described.
5. Partially visualized cervical spine demonstrates known
degenerative changes
with at least mild vertebral canal stenosis at C3-4. If
clinically indicated,
cervical spine MRI may be obtained for further evaluation.
___ Cardiovascular ECHO
The left atrium is elongated. 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. Regional left ventricular wall motion is normal. Overall
left ventricular systolic function is normal (LVEF>55%). Right
ventricular chamber size and free wall motion are normal. The
ascending aorta is mildly dilated. The aortic valve leaflets (3)
are mildly thickened but aortic stenosis is not present. 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.
IMPRESSION: Symmetric LVH with normal global and regional
biventricular systolic function. No LV thrombus seen.
Brief Hospital Course:
Mr. ___ is a ___ year-old male with HTN, HLD, h/o PE who
is s/p L CEA for symptomatic stenosis, and presented on POD5
with increasing neck pain likely of muscular etiology w/ low
suspicion of surgical site infection. He also complained of
diplopia.
His neck pain improved after treatment with toradol, tylenol,
and flexeril. Neurology was consulted, and recommended a MRI
brain, which did not reveal any intracranial pathology. It was
determined that his pain was musculoskeletal in etiology. He was
sent home with PO pain medications and should follow up with Dr.
___ at his scheduled appointment.
He also complained of diplopia on admission. This was
intermittent and resolved on its own. He should follow up with
his already established ophthalmologist Dr. ___. He has been
instructed to call the office to schedule an appointment.
Medications on Admission:
1. Aspirin 325 mg PO DAILY
2. Fluticasone Propionate NASAL 2 SPRY NU DAILY
3. Lisinopril 10 mg PO DAILY
4. Acetaminophen 650 mg PO Q6H
5. Atorvastatin 40 mg PO QPM
6. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN pain
7. Ascorbic Acid ___ mg PO DAILY
8. Co Q-10 (coenzyme Q10) 100 mg oral DAILY
9. Ferrous Sulfate 65 mg PO DAILY
10. Fish Oil (Omega 3) 1000 mg PO DAILY
11. garlic 1,000 mg oral DAILY
12. red yeast rice extract (bulk) 600 mg PO BID
13. Vitamin D 1000 UNIT PO DAILY
14. Glucosamine (glucosamine sulfate) 1500 mg oral DAILY
Discharge Medications:
1. Cyclobenzaprine 5 mg PO TID:PRN neck pain
RX *cyclobenzaprine 5 mg 1 tablet(s) by mouth three times a day
Disp #*90 Tablet Refills:*0
2. Docusate Sodium 100 mg PO BID
Please do not take if loose stools
RX *docusate sodium 100 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*3
3. Ibuprofen 600 mg PO Q8H:PRN Pain - Moderate
RX *ibuprofen 600 mg 1 tablet(s) by mouth q8h prn Disp #*90
Tablet Refills:*0
4. Polyethylene Glycol 17 g PO DAILY
Please do not take if loose stools
RX *polyethylene glycol 3350 17 gram 1 packet by mouth daily
Disp #*30 Packet Refills:*3
5. Senna 17.2 mg PO HS
Please do not take if loose stools
RX *sennosides [senna] 8.6 mg ___ tablets by mouth nightly Disp
#*60 Tablet Refills:*3
6. Acetaminophen 650 mg PO Q6H
7. Ascorbic Acid ___ mg PO DAILY
8. Aspirin 325 mg PO DAILY
9. Atorvastatin 40 mg PO QPM
10. Co Q-10 (coenzyme Q10) 100 mg oral DAILY
11. Ferrous Sulfate 65 mg PO DAILY
12. Fish Oil (Omega 3) 1000 mg PO DAILY
13. Fluticasone Propionate NASAL 2 SPRY NU DAILY
14. garlic 1,000 mg oral DAILY
15. Glucosamine (glucosamine sulfate) 1500 mg oral DAILY
16. Lisinopril 10 mg PO DAILY
17. red yeast rice extract (bulk) 600 mg PO BID
18. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Neck pain and cervical muscle spasm
Symptomatic Left Carotid Stenosis s/p Left Carotid
Endarterectomy
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were admitted to ___
because you had neck pain that had started a few days after your
carotid surgery, as well as double vision. While you were here
your neck pain was treated with medications. Your neck pain was
further investigated. You were seen by neurology, and brain
scanning of your head determined that you did not have a stroke.
An ultrasound (Echocardiogram) of your heart was also normal. It
is most likely that your neck pain was due to muscle spasms. You
should continue taking your medications as prescribed as needed
for your pain. You should follow up with Dr. ___ at your
scheduled appointment at his ___ office next week.
For your double vision you should follow up with your
ophthalmologist Dr. ___ as an outpatient. Please call their
office to schedule an appointment so they can follow up with
you.
We wish you the best in your health,
Your ___ care team
Followup Instructions:
___
|
19699436-DS-18
| 19,699,436 | 23,043,942 |
DS
| 18 |
2135-05-10 00:00:00
|
2135-05-12 13:45:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Amoxicillin / Tetracycline / Augmentin / Ampicillin / morphine /
codeine / Levaquin / Cipro / Flagyl / Lasix
Attending: ___.
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms. ___ is a ___ year old female with PMH of HTN, GERD,
recent
RUQ pain with MRI showing hepatic ductal dilatation now s/p ERCP
with placement of plastic stent, who presents with abdominal
pain.
On review of records, patient was hospitalized at ___ from ___ through ___.
At
this time, she was undergoing a work-up for recurrent right
upper
quadrant pain and was found at ___ to have
biliary narrowing and strictures on an MRCP. She was referred
to
___ for ERCP. An ERCP was completed, and a stent was
placed. Brushings were performed. She was able to be
discharged
the following day. Brushings from that procedure showed no
evidence of malignancy.
Since that time, patient has had episodes of abdominal pain
following meals. Initially these were more a discomfort that
would last for a short amount of time. However, the day prior to
presentation she ate a large dinner of mostly fried foods at a
charity event. Shortly after, she developed severe RUQ pain,
radiating to the back, that lasted through the night. It
continued the morning prior to admission, and therefore she
presented to the ED. Associated with chills and hot flashes,
though no known fevers. Also with loose stools and lot of
nausea.
She initially presented to ___, and was transferred to
___ for ERCP evaluation.
In the ED:
Initial vital signs were notable for: T 98.7, HR 72, BP 132/68,
RR 16, 97% RA
Exam notable for: Abd- focal RUQ tenderness, ___ sign
Surgery was consulted for concern for acute cholecystitis. They
felt that presentation was unlikely acute cholecystitis with no
need for acute surgical intervention, and instead had high
suspicion for stent complication. Recommended admission to
medicine and ERCP consult.
Patient was given:
___ 21:13 IV HYDROmorphone (Dilaudid) 1 mg
___ 00:43 IV HYDROmorphone (Dilaudid) 1 mg
___ 00:43 PO Acetaminophen 1000 mg
Vitals on transfer: T 98.1, HR 71, BP 109/62, RR 16, 97% RA
Upon arrival to the floor, patient recounts history as above.
States that her abdominal pain is a bit better, but she has a
fairly severe headache.
Past Medical History:
ADHD
Hyperparathyroidism
Migraines
Sleep apnea
Osteoarthritis
Inguinal hernia repair
Oophrectomy for ruptured cyst
Appendectomy
Social History:
___
Family History:
Relative Status Age Problem Onset Comments
Mother Living ___ HYPERTENSION
HYPERCHOLESTEROLEMIA
ARRHYTHMIA
Father ___ ___ END STAGE RENAL
DISEASE
DIABETES MELLITUS
Daughter Living ___ EPILEPSY following MVA,
___ head
Sister Living ___ HODGKIN'S DISEASE
SYSTEMIC LUPUS
ERYTHEMATOSUS
Physical Exam:
Admission Physical Exam:
========================
VITALS: T 97.7, HR 65, BP 114/72, RR 18, 95% Ra
GENERAL: Alert and in no apparent distress
EYES: Anicteric, pupils equally round
ENT: Ears and nose without visible erythema, masses, or trauma.
Oropharynx without visible lesion, erythema or exudate
CV: Heart regular, no murmur, 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, severely tender to palpation in
RUQ without rebound or guarding. Bowel sounds present. No HSM
GU: No suprapubic fullness or tenderness to palpation
MSK: Neck supple, moves all extremities, strength grossly full
and symmetric bilaterally in all limbs
SKIN: No rashes or ulcerations noted
NEURO: Alert, oriented, face symmetric, gaze conjugate with
EOMI,
speech fluent, moves all limbs, sensation to light touch grossly
intact throughout
PSYCH: pleasant, appropriate affect
Discharge Physical Exam:
========================
VITALS: see Eflowsheets
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 JVD.
RESP: Breathing is non-labored
GI: Abdomen soft, non-distended, mildly tender to palpation in
RUQ without rebound or guarding
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:
===============
___ 06:43AM BLOOD WBC-5.7 RBC-4.00 Hgb-11.5 Hct-35.9 MCV-90
MCH-28.8 MCHC-32.0 RDW-12.2 RDWSD-40.0 Plt ___
___ 06:43AM BLOOD Neuts-57.9 ___ Monos-12.0 Eos-3.2
Baso-1.1* Im ___ AbsNeut-3.30 AbsLymp-1.44 AbsMono-0.68
AbsEos-0.18 AbsBaso-0.06
___ 06:43AM BLOOD ___ PTT-28.7 ___
___ 06:43AM BLOOD Glucose-95 UreaN-12 Creat-0.5 Na-143
K-4.1 Cl-106 HCO3-27 AnGap-10
___ 06:43AM BLOOD ALT-37 AST-31 AlkPhos-112* TotBili-0.7
___ 06:43AM BLOOD Lipase-65*
___ 06:43AM BLOOD Calcium-9.5 Phos-4.1 Mg-2.0
___ 11:38PM BLOOD Lactate-0.8
Imaging:
========
CT Abd/Pelvis:
1. Mild nonspecific gallbladder wall edema. Consider ultrasound
if there is persistent concern for acute cholecystitis.
2. Patient is status post ERCP with biliary stent placement,
which appears to be in appropriate position.
3. Diverticulosis without evidence of acute diverticulitis.
HIDA:
Serial images over the abdomen show homogeneous uptake of tracer
into
the hepatic parenchyma.
At 7 minutes, the gallbladder is visualized with tracer activity
noted in the small bowel at 10 minutes. A right lateral
confirms gall bladder filling.
Discharge Labs:
===============
___ 06:45AM BLOOD WBC-3.7* RBC-4.24 Hgb-12.1 Hct-37.5
MCV-88 MCH-28.5 MCHC-32.3 RDW-11.9 RDWSD-38.2 Plt ___
___ 06:45AM BLOOD Glucose-91 UreaN-5* Creat-0.6 Na-145
K-4.5 Cl-103 HCO3-29 AnGap-13
___ 06:45AM BLOOD ALT-29 AST-23 AlkPhos-119* TotBili-0.4
___ 06:45AM BLOOD Calcium-10.4* Phos-3.3 Mg-2.1
Brief Hospital Course:
Ms. ___ is a ___ year old female with PMH of HTN, GERD,
recent RUQ pain with MRI showing hepatic ductal dilatation now
s/p ERCP with placement of plastic stent, who presented with
acute on chronic RUQ pain.
ACUTE/ACTIVE PROBLEMS:
# Abdominal pain
# Biliary stricture s/p recent stent placement
Presented with abdominal pain following a recent stent placement
over 0.5 cm long biliary stricture. Labs were overall
reassuring, with normal LFTs (apart from mildly elevated
alkaline phosphatase). Lipase was 65.
CT Abd/Pelvis showed non-specific mild gallbladder wall edema.
She received IV ceftriaxone to cover for possible cholecystitis.
She underwent a HIDA scan which was negative for cholecystitis.
Biliary stent was in appropriate position on CT.
She was initially NPO and hydrated with IV fluids. Pain was
managed with prn dilaudid boluses. Diet was later advanced to
clears, which she was tolerating at time of discharge.
She was followed by surgery throughout her hospitalization, who
recommended that she follow up with Dr. ___ as scheduled for
cholecystectomy on ___.
CHRONIC/STABLE PROBLEMS:
# Depression: continued home citalopram
# HLD: continued home rosuvastatin
# HTN: continued home diltiazem
# OA: continued home gabapentin
# GERD: continued home famotidine, omeprazole
> 30 minutes spent on discharge coordination and planning
Transitional Issues:
====================
- discharged on clear liquid, low fat diet until scheduled
cholecystectomy at ___ on ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Ascorbic Acid ___ mg PO DAILY
2. Citalopram 20 mg PO DAILY
3. Diltiazem Extended-Release 240 mg PO DAILY
4. Famotidine 20 mg PO DAILY
5. Gabapentin 400 mg PO BID
6. Multivitamins 1 TAB PO DAILY
7. Omeprazole 40 mg PO DAILY
8. Rosuvastatin Calcium 20 mg PO QPM
Discharge Medications:
1. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain - Severe
Duration: 4 Days
RX *oxycodone 5 mg 1 tablet(s) by mouth every six (6) hours Disp
#*14 Tablet Refills:*0
2. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - First
Line
Reason for PRN duplicate override: Patient is NPO or unable to
tolerate PO
RX *polyethylene glycol 3350 [Miralax] 17 gram/dose 17 g by
mouth once a day Refills:*0
3. Ascorbic Acid ___ mg PO DAILY
4. Citalopram 20 mg PO DAILY
5. Diltiazem Extended-Release 240 mg PO DAILY
6. Famotidine 20 mg PO DAILY
7. Gabapentin 400 mg PO BID
8. Multivitamins 1 TAB PO DAILY
9. Omeprazole 40 mg PO DAILY
10. Rosuvastatin Calcium 20 mg PO QPM
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
RUQ Abdominal pain
biliary stricture s/p stenting
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You came in with abdominal pain. You had a CT scan and a special
gallbladder scan that did not show any sign of gallbladder
infection. The CT scan also showed that the recent stent that
was placed is in a good position. Your labs tests were
reassuring and we did not find any evidence of inflammation of
the liver or pancreas.
You should continue a clear liquid, low fat diet at home. It
will be very important to have your gallbladder surgery on
___ with Dr. ___ at ___.
It was a pleasure taking care of you, and we are happy that
you're feeling better!
Followup Instructions:
___
|
19699515-DS-11
| 19,699,515 | 21,384,083 |
DS
| 11 |
2153-07-01 00:00:00
|
2153-07-01 12:50:00
|
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 15 ft Fall offf ladder
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
___ s/p fall ___ feet off roof at work with unknown loss of
consciousness landing on his left side. He was confused when EMS
arrived, but protecting his airway. He states his left chest
hurts. He denies any head pain or neck pain. No difficulty
moving arms or legs, no neck pain.
Social History:
___
Family History:
Noncontributory
Physical Exam:
Upon presentation to ___:
Temp: 98.8 HR: 90 BP: 118/78 Resp: 22 O(2)Sat: 98
Constitutional: Mild to moderate discomfort
Oropharynx within normal limits
Chest: Clear to auscultation
Cardiovascular: Regular Rate and Rhythm
Abdominal: Soft, Nontender
Neuro: Speech fluent
Psych: Normal mood, Normal mentation
BUE skin clean and intact, no obvious deformity over clavicles
though a ridge is palpable over mid-superior aspect of left
clavicle; mild tenderness to palpation in this singular location
Otherwise. no tenderness, deformity, erythema, edema, induration
or ecchymosis to b/l UEs
Arms and forearm compartments soft
No pain with passive motion
Axillary, Radial, Median, Ulnar SILT
EPL FPL EIP EDC FDP FDI fire
2+ radial pulses
Elbow stable to varus, valgus, rotatory stresses.
No tenderness, deformity, erythema, edema, induration or
ecchymosis
Thighs and leg compartments soft
No pain with passive motion
Saphenous, Sural, Deep peroneal, Superficial peroneal SILT
___ FHS ___ TA Peroneals Fire
1+ ___ and DP pulses
Pertinent Results:
___ 11:34AM GLUCOSE-154* LACTATE-1.9 NA+-138 K+-3.5
CL--105 TCO2-27
___ 11:34AM HGB-15.1 calcHCT-45
___ 11:20AM UREA N-14 CREAT-1.1
___ 11:20AM LIPASE-30
___ 11:20AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
___ 11:20AM WBC-13.2* RBC-4.98 HGB-14.9 HCT-43.2 MCV-87
MCH-29.9 MCHC-34.5 RDW-13.5
___ 11:20AM PLT COUNT-262
___ 11:20AM ___ PTT-25.0 ___
___ 11:20AM ___
CT head:
IMPRESSION: No CT evidence for acute intracranial process.
Small fluid
layering in the maxillary sinuses bilaterally with aeroselized
secretions in the posterior nasopharynx; in the absence of
detected fracture, this may be due to retained secretions.
CT cervical spine:
IMPRESSION:
1. Left first and second rib fractures.
2. Chronic appearing fracture through the spinous process of
T1.
3. Left clavicle fracture seen on scout view only.
4. No CT evidence for acute cervical spine fracture.
CT chest/abd/pelvis:
IMPRESSION:
1. Left small pneumothorax, left lower lobe pulmonary
laceration, and left upper lobe pulmonary contusion with
multiple left-sided rib fractures and adjacent subcutaneous
emphysema.
2. Left clavicle fracture.
3. Submucosal fatty infiltration of the descending colon and
terminal ileal walls, which can be seen with chronic
inflammation.
___ CXR
There is a small left apical pneumothorax. There are low lung
volumes.
Cardiac size is top normal, is accentuated by the low lung
volumes and
projections. Small bilateral pleural effusions have minimally
increased.
Left perihilar and bibasilar opacities, left greater than right
and minimal opacities in the right upper lobe are grossly
unchanged, are consistent with atelectasis on the right base,
contusion in the left perihilar region and laceration and
contusion in the left lower lobe.
___ CXR
There are persistent low lung volumes. There is no
pneumothorax. There is a small left pleural effusion. Cardiac
size is normal. The right lung is grossly clear. The lower
lobe opacity consistent with contusion has improved.
Left upper lobe opacity likely contusion or aspiration is
grossly unchanged.
___ CXR
As compared to the previous radiograph, the slightly displaced
left rib fractures, the displaced left clavicular fracture and
the minimal left apical pneumothorax are unchanged. There also
is unchanged evidence of a small left pleural effusion as well
as of a minimal area of increased opacity at the level of the
right upper lobe. This opacity, however, appears to decrease in
severity.
Unchanged retrocardiac atelectasis, unchanged opacities in the
left apex. Unchanged size of the cardiac silhouette
Brief Hospital Course:
He was admitted to the Acute Care Surgery team for monitoring of
his respiratory status related to his rib fractures. He
initially required supplemental oxygen via nasal cannula due to
intermittent low saturations. Serial exams and daily chest xrays
over the course of 3 days were obtained primarily showing left
pleural effusion and low lung volumes. He was started on
standing nebs and eventually was weaned off of the oxygen.
Orthopedics were consulted for the left clavicle fracture which
was closed treated with a sling and non weight bearing except
for to perfomr ALD's. He will follow up in their clinic in about
2 weeks.
He did have some pain control issues requiring several
adjustments to his pain medications. At time of discharge his
pain is well controlled with oral narcotics and adjunct therapy
using Tylenol and Ultram standing. He was also started on a
bowel regimen.
He was discharged to home with instructions for follow up in ___
clinic, a repeat chest xray will be done on the day of this
appointment for comparison with his previous radiographs.
Medications on Admission:
Denies
Discharge Medications:
1. Docusate Sodium 100 mg PO BID
2. HYDROmorphone (Dilaudid) ___ mg PO Q3H:PRN pain
RX *hydromorphone 2 mg ___ tablet(s) by mouth every ___ hours
Disp #*60 Tablet Refills:*0
3. Acetaminophen 1000 mg PO Q8H
4. TraMADOL (Ultram) 50 mg PO QID
RX *tramadol 50 mg 1 tablet(s) by mouth 4 times a day Disp #*120
Tablet Refills:*1
5. Senna 1 TAB PO BID:PRN constipation
Discharge Disposition:
Home
Discharge Diagnosis:
s/p 15 ft Fall
Injuries:
Left mid-clavicular fracture
Left ___, 11 rib fractures
Small left apical pneumothrax
Left upper lobe pulmonary contusion
Left lower lob pulmonary laceration
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You sustained rib fractures which can cause severe pain and
subsequently cause you to take shallow breaths because of the
pain. You should take your pain medicine as 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.
Do NOT smoke.
Return to the ED right away for any acute shortness of breath,
increased pain or crackling sensation around your rips
(crepitus).
Narcotic pain medication can cause constipation. Therefore you
should take a stool softener twice daily and increase your fluid
and fiber intake if possible.
If your doctor allows, non steriodal ___ drugs are
very effective in controlling pain (i.e. Ibuprofen, Motrin,
Advil, Aleve, Naprosyn) but they have their own set of side
effects so make sure your doctor approves.
Followup Instructions:
___
|
19699649-DS-9
| 19,699,649 | 21,166,960 |
DS
| 9 |
2187-02-03 00:00:00
|
2187-02-03 12:15:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Probable Hantavirus
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old Male referred from ___ for concern for
Hantavirus infection. The patient was on ___ 10 days prior
to admission and was cleaning his daughter's attic and was
cleaning up rat feces and inhaled a significant quantity of
dust. Following this he had laryngitis for 2 days and then
developed dyspnea and reduced exercise tolerance (baseline 45
minutes of formal exercising with trainer twice weekly), along
with myalgias and chills. The patient has tried self-treatment
with albuterol and flovent without relief. The patient notes he
was not wearing a mask during the exposure.
He was seen today at ___ at his PCP's office for a
episodic visit, and noted with transaminitis, fever/chills,
pulmonary infiltrate and hypoxemia there is concern for
hantavirus, so in discussion with the ID consult, he was
transferred to the ___ ED.
Initial vitals in the ___ ED 97.1, 80, 123/82, 16, 94%. Even
though the presumptive diagnosis was hantavirus infection, he
received CAP therapy with ceftriaxone and azithromycin. A Chest
X-ray was performed.
Past Medical History:
History of Back muscle spasms
History of Closed anterior dislocation of humerus, left, initial
encounter
History of Closed Bone Fracture
History of Hematoma
History of acute bronchitis (most likely viral)
History of allergic rhinitis
History of Internal hemorrhoids
History if Neck strain
History of Non-traumatic rupture of Achilles tendon
History of Olecranon bursistis of the left elbow
History of Shoulder dislocation
Achilles rupture s/p surgery c/o Dr. ___ x ___
Colonoscopy c/o Dr. ___ ___
Colonoscopy c/o Dr. ___ ___, next due ___
Social History:
___
Family History:
Sister - ___ tumor of cervix
- Adenocarcinoma
- of the ovary
Maternal Grandmother - ___ obstructive lung disease
Mother - ___
Father - ___ mellitus
Daughter - ___
- ___ Granulomatosis limited to lung
Patient's father had cancer, he is unsure 6 siblings- 2 have
died, ___ child Denies heredofamilial diseases like HTN, heart
disease, premature MI, asthma, stroke, aneursym, ?cholesterol,
thyroid problems, anemia, skin/prostate/colon cancer,
?osteoporosis
Physical Exam:
ROS:
GEN: - fevers, + Chills, - Weight Loss, Decreased Exercise
Tolerance
EYES: - Photophobia, - Visual Changes
HEENT: - Oral/Gum bleeding
CARDIAC: - Chest Pain, - Palpitations, - Edema
GI: - Nausea, - Vomiting, - Diarrhea, - 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
A 10-point review of systems is negative except as above.
PHYSICAL EXAM:
VSS: %
GEN: NAD
Pain: ___
HEENT: sclera anicteric, EOMI, MMM, - OP Lesions, - gum
bleeding
PUL: B/L crackles in all lunch fields
COR: RRR, S1/S2, - MRG
ABD: NT/ND, +BS, - CVAT
EXT: - CCE
NEURO: CAOx3, Non-Focal
Skin: - petechia, - hematomas
Pertinent Results:
___ 05:25PM BLOOD WBC-8.7 RBC-4.77 Hgb-14.4 Hct-44.3 MCV-93
MCH-30.2 MCHC-32.5 RDW-13.0 RDWSD-44.4 Plt ___
___ 05:25PM BLOOD Neuts-66.5 Lymphs-17.6* Monos-13.6*
Eos-1.1 Baso-0.7 Im ___ AbsNeut-5.81 AbsLymp-1.54
AbsMono-1.19* AbsEos-0.10 AbsBaso-0.06
___ 05:25PM BLOOD Glucose-103* UreaN-11 Creat-1.0 Na-141
K-4.2 Cl-99 HCO3-26 AnGap-16
___ 05:25PM BLOOD ALT-75* AST-46* AlkPhos-86 TotBili-0.3
___ 05:25PM BLOOD Albumin-3.9
___ 05:28PM BLOOD Lactate-1.3
___ 6:19 pm BLOOD CULTURE
Blood Culture, Routine (Pending):
CHEST (PA & LAT) Study Date of ___ 6:53 ___
IMPRESSION:
Unchanged multifocal regions of consolidation compatible with
pneumonia in the
proper clinical setting. ___ will be necessary.
Brief Hospital Course:
# Respiratory infection: Concerns for hantavirus low, but
etiology unclear. ID was consulted, and after discussion with ID
and the state lab, we will:
- Send test for pertussis
- Discharge pt home w/ guidance to avoid immunocompromised
children / persons
- Complete 5d course of cefpodox + azithro (last day tx = ___
- Will need to call pt w/ micro results after d/c
[ ] hanta
[ ] lepto
[ ] pertussis
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Fish Oil (Omega 3) 1000 mg PO BID
2. Fluticasone Propionate 110mcg 2 PUFF IH BID
3. Escitalopram Oxalate 10 mg PO DAILY
4. Loratadine 10 mg PO DAILY
5. GuaiFENesin ER 600 mg PO Q12H
6. Multivitamins 1 TAB PO DAILY
7. Pravastatin 80 mg PO QPM
8. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation
Q4H:PRN
9. MethylPHENIDATE (Ritalin) 10 mg PO BID
Discharge Medications:
1. Azithromycin 250 mg PO DAILY Duration: 4 Doses
RX *azithromycin 250 mg 1 tablet(s) by mouth daily Disp #*3
Tablet Refills:*0
2. Cefpodoxime Proxetil 400 mg PO Q12H
RX *cefpodoxime 200 mg 2 tablet(s) by mouth twice a day Disp #*6
Tablet Refills:*0
3. MethylPHENIDATE (Ritalin) 20 mg PO BID
4. Escitalopram Oxalate 10 mg PO DAILY
5. Fish Oil (Omega 3) 1000 mg PO BID
6. Fluticasone Propionate 110mcg 2 PUFF IH BID
7. GuaiFENesin ER 600 mg PO Q12H
8. Loratadine 10 mg PO DAILY
9. Multivitamins 1 TAB PO DAILY
10. Pravastatin 80 mg PO QPM
11. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation
Q4H:PRN
Discharge Disposition:
Home
Discharge Diagnosis:
Pneumonia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were admitted for a respiratory infection. We are still not
sure of the exact cause, but agree that it is safe for you to go
home to complete your antibiotics.
We wish you the best with your health.
___ Medicine
Followup Instructions:
___
|
19700047-DS-19
| 19,700,047 | 20,281,697 |
DS
| 19 |
2175-09-18 00:00:00
|
2175-09-19 12:23:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Percocet / Aspirin
Attending: ___
Chief Complaint:
GI bleed
Major Surgical or Invasive Procedure:
Capsule Swallow
History of Present Illness:
Ms. ___ is a ___ year old woman with chronic GIB s/p multiple
angioectasias, iron deficiency anemia, CAD w DES to 80% RCA
occlusion ___, COPD on 2L home oxygen, R breast CA s/p
lumpectomy & XRT 05, DM2, HTN, and HLD who presents with 3 days
of shortness of breath and with associated light headedness,
nausea, and epigastric pain who was found to have decreased HCT
to 29 from 37.
She was in her USOH until ___ when she developed persistent
SOB. This was associated with light headedness, nausea, and cold
sweats. This symptomatology was c/w prior episodes of low HCT.
However, on ___, she developed epigastric discomfort similar
to her prior anginal equivalent, prompting trip to the ED.
In the ED, initial vs were 97.6 HR 78 BP 102/54 HR 78 RR 20
99%3L. Initial labs were notable for HCT of 29.8 (last 37.5),
WBC 12.8, troponin<0.01. EKG was unremarkable except for 1mm STD
in V4. CXR showed no consolidation or effusion on my read. She
received SL nitro x1 for an additional episode of epigastric
discomfort, and 80IV protonix and transferred to medicine for
further management.
On arrival to the floor, patient is comfortable. She denies
fevers or chills, but notes mild productive cough. Endorses mild
nausea but no abdominal pain. No recent diarrhea or
constipation. She notes one tarry black stool several days ago,
but has had normal BM since.
REVIEW OF SYSTEMS:
Denies fever, chills, night sweats, headache, vision changes,
rhinorrhea, congestion, sore throat, vomiting, diarrhea,
constipation, BRBPR, dysuria, hematuria.
All other 10-system review negative in detail.
Past Medical History:
# Multiple angioectasias: s/p endoscopy x 6 in ___.
# Iron defiency anemia: TTG negative, EGD in ___ at OSH with ?
___ esophagus, duodenitis, colonoscopy negative. Repeat
EGD ___ with mild erosions in antrum and duodenum
# CAD with 80% RCA stenosis, s/p DES in ___
# COPD (diagnosed ___ on home O2
# Congenital pulmonic stenosis
# Chronic low back pain
# R Breast cancer, s/p lumpectomy and XRT ___ with no chemo
# Hypertension
# Hyperlipidemia
# DM2
# Cholecystectomy
# ORIF for right ankle fracture with hardware placement/removal
# Basal cell cancer on face
# Excision of urachal cyst
Social History:
___
Family History:
- colon cancer
- mother MI (died ___)
- father CAD (died ___ from bladder cancer)
Physical Exam:
ON ADMISSION
VS 98.4 124/56 74 18 96% 4L
GEN Alert, oriented, no acute distress
HEENT NCAT MMM EOMI sclera anicteric, OP clear
NECK supple, no JVD, no LAD
PULM Good aeration, CTAB no wheezes, rales, ronchi
CV RRR normal S1/S2, no mrg
ABD soft NT ND normoactive bowel sounds, no r/g
EXT WWP 2+ pulses palpable bilaterally, no c/c/e
NEURO CNs2-12 intact, motor function grossly normal
SKIN no ulcers or lesions
ON DISCHARGE
T-98.0, BP 110/70, P-68, O2 93 on 2LO2
GEN Alert, oriented, no acute distress
HEENT NCAT MMM EOMI sclera anicteric, OP clear
NECK supple, no JVD, no LAD
PULM Good aeration, ronchi at the bases
CV RRR I-II/VI sysolic murmur heard best at LLSB
ABD soft NT ND normoactive bowel sounds, no r/g
EXT WWP 2+ pulses palpable bilaterally, no c/c/e
NEURO CNs2-12 intact, motor function grossly normal
SKIN no ulcers or lesions
Guaiac + in ED
Pertinent Results:
ON ADMISSION
___ 03:37PM GLUCOSE-108* UREA N-19 CREAT-0.8 SODIUM-141
POTASSIUM-3.9 CHLORIDE-105 TOTAL CO2-27 ANION GAP-13
___ 03:37PM LD(LDH)-160 TOT BILI-0.2
___ 03:37PM cTropnT-<0.01
___ 03:37PM calTIBC-437 ___ FERRITIN-15 TRF-336
___ 03:37PM WBC-12.8* RBC-3.57* HGB-9.6* HCT-29.8* MCV-83
MCH-27.0 MCHC-32.4 RDW-17.6*
___ 03:37PM ___ PTT-34.8 ___
ON DISCHARGE
___ 05:45AM BLOOD WBC-8.4 RBC-3.76* Hgb-10.2* Hct-31.9*
MCV-85 MCH-27.2 MCHC-32.1 RDW-17.3* Plt ___
___ 05:45AM BLOOD Glucose-125* UreaN-13 Creat-0.9 Na-142
K-4.0 Cl-105 HCO3-27 AnGap-14
___ 05:45AM BLOOD Mg-2.2
ECG ___
Sinus rhythm. Minor ST-T wave abnormalities. Since the previous
tracing
of ___ ST-T wave abnormalities have probably improved versus
less artifact.
CXR ___
IMPRESSION:
No radiographic evidence for pneumonia. Emphysema. Enlargement
of the main and left pulmonary arteries, unchanged, for which
correlation with
echocardiography, if not previously done, is suggested.
Brief Hospital Course:
Ms. ___ is a ___ year old woman with chronic GIB s/p multiple
angioectasias, iron deficiency anemia, CAD w DES to 80% RCA
occlusion ___, COPD on 2L home oxygen, R breast CA s/p
lumpectomy & XRT 05, DM2, HTN, and HLD who presented with 3 days
of shortness of breath and with associated light headedness,
nausea, and epigastric pain who was found to have decreased HCT
to 29 from 37.
#UGIB with acute blood loss anemia: Patient was guaiac + and
felt to have a recurrent upper AVM bleed given prior EGD and
colonoscopy exams. She received 2U PRBC within first 24 hours of
admission with appropriate response and was placed on protonix
gtt. Afterwards Hct remained above 30 throughout admission and
pt was symptom free. GI was consuled and capsule study was
performed but unfortunately no images were captured. Given
stable CBC, enteroscopy was deferred to outpatient setting. Iron
deficiency was noted on blood work and patient was started on IV
iron therapy which will be continued as an outpatient. Atenolol
and plavix were held throughout admission (see below).
#Epigastric pain: Patient presented with separate epigastric
pain that is known to her as her anginal equivalent. However,
EKG was unremarkable and troponin neg X2. She did not experience
this pain while in house. No events on telemetry.
#CAD
The patient's clopidogrel and atenolol were held during
admission. Is no longer on ASA ___ GI bleed. The patient's
atenolol was restarted on d/c but clopidogrel is held until
Caridology appointment ___. Outpatient Cardiologist Dr.
___ aware.
#COPD
- Continued spiriva, advair, and albuterol. Required baseline
home O2 requirement.
#DM
- HISS while in house. Continued home metformin on discharge.
#HTN
- Holding atenolol as above
#HLD
- Continued rosuvastatin
- Held fenofibrate in house but restarted on d/c.
Transitional Issues
-Patient has Caridology follow-up where Clopidogrel may be
restarted.
-She has been instructed, if she has another GI bleed, to inform
ED attending immediately to contact GI fellow to obtain STAT
capsule study.
-Will follow-up with GI for potential enteroscopy as outpatient.
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from PatientwebOMR.
1. Albuterol Inhaler ___ PUFF IH Q6H:PRN SOB
2. Atenolol 50 mg PO DAILY
3. Clopidogrel 75 mg PO DAILY
4. Tricor *NF* (fenofibrate nanocrystallized) 48 mg Oral daily
5. Fluticasone Propionate NASAL 2 SPRY NU DAILY
6. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
7. Ketoconazole 2% 1 Appl TP BID:PRN Rash
To face as needed for seb derm
8. Lorazepam 0.5 mg PO BID
Hold for oversedation or RR<10
9. MetFORMIN (Glucophage) 500 mg PO QAM
10. MetFORMIN (Glucophage) 1000 mg PO QPM
11. Nitroglycerin SL 0.3 mg SL PRN chest pain
12. Pantoprazole 80 mg PO Q12H
13. Ranitidine 150 mg PO BID
14. Rosuvastatin Calcium 20 mg PO DAILY
15. Sucralfate Dose is Unknown PO QID
16. Tiotropium Bromide 1 CAP IH DAILY
17. traZODONE 225 mg PO HS:PRN insomina
18. Venlafaxine 75 mg PO DAILY
19. Calcarb 600 With Vitamin D *NF* (calcium carbonate-vitamin
D3) 600 mg(1,500mg) -400 unit Oral bid
20. Cyanocobalamin 1000 mcg PO DAILY
Discharge Medications:
1. Albuterol Inhaler ___ PUFF IH Q6H:PRN SOB
2. Cyanocobalamin 1000 mcg PO DAILY
3. Fluticasone Propionate NASAL 2 SPRY NU DAILY
4. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
5. Lorazepam 0.5 mg PO BID
Hold for oversedation or RR<10
6. Nitroglycerin SL 0.3 mg SL PRN chest pain
7. Pantoprazole 80 mg PO Q12H
8. Rosuvastatin Calcium 20 mg PO DAILY
9. Tiotropium Bromide 1 CAP IH DAILY
10. traZODONE 225 mg PO HS:PRN insomina
11. Venlafaxine 75 mg PO DAILY
12. Atenolol 50 mg PO DAILY
13. Calcarb 600 With Vitamin D *NF* (calcium carbonate-vitamin
D3) 600 mg(1,500mg) -400 unit Oral bid
14. Tricor *NF* (fenofibrate nanocrystallized) 48 mg ORAL DAILY
15. Sucralfate 1 gm PO QID
16. Ranitidine 150 mg PO BID
17. MetFORMIN (Glucophage) 1000 mg PO QPM
18. MetFORMIN (Glucophage) 500 mg PO QAM
19. Ketoconazole 2% 1 Appl TP BID:PRN Rash
To face as needed for seb derm
Discharge Disposition:
Home
Discharge Diagnosis:
GI bleed, probably secondary to small bowel AVMs
acute blood loss anemia
SECONDARY DIAGNOSES:
iron deficiency anemia
CAD
DMII
COPD on home O2
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 a GI bleed. Your blood
counts were low. This improved with a transfusion. You were also
started on IV iron therapies that will be continued as an
outpatient.
You will likely have an enteroscopy as on outpatient after
discussion with Dr ___.
If you have a GI bleed in the future, please tell the ED
physician to immediately contact the GI Fellow to have another
capsule study.
We stopped your atenolol and clopidogrel while you were in the
___. Please restart your atenolol. You should hold your
clopidogrel until you see your Cardiologist Dr ___.
Followup Instructions:
___
|
19700047-DS-20
| 19,700,047 | 25,726,942 |
DS
| 20 |
2176-03-08 00:00:00
|
2176-03-09 00:03:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Percocet / Aspirin
Attending: ___.
Chief Complaint:
chest pain, shortness of breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ year old woman with chronic GIB s/p multiple
angioectasias, iron deficiency anemia, CAD w DES to 80% RCA
occlusion ___, COPD on 2L home oxygen, R breast CA s/p
lumpectomy & XRT 05, DM2, HTN, and HLD who presents with 7 days
of shortness of breath and with associated light headedness, and
left sided chest pain nausea, who was found to have decreased
HCT to 25 from 34. She was in her USOH until last week when she
developed persistent SOB in the setting of melena x1. This was
also associated with progressive light headedness.
This symptomatology was c/w prior episodes of low HCT, therefore
she presented for outpatient HCT check, where she was found to
have significant drop. She was initially scheduled for
outpatient transfusion. However, after she developed worsening
chest pressure and lightheadedness at home, she presented to the
ED for further evaluation.
In the ED, initial vs were 97.6 HR 82 BP 117/53 RR 16 95%2L.
EKG was unremarkable per ED. GI was consulted, with
recommendation to admit patient, trasfuse and possibly prep for
capsule study in am.
On ROS, patient endorses constipatien since taking iron pills
last week, otherwise denies fever, chills, night sweats,
headache, vision changes, rhinorrhea, congestion, sore throat,
cough, chest pain, abdominal pain, nausea, vomiting, diarrhea,
dysuria, hematuria.
Past Medical History:
# Multiple angioectasias: s/p endoscopy x 6 in ___.
# Iron defiency anemia: TTG negative, EGD in ___ at OSH with ?
___ esophagus, duodenitis, colonoscopy negative. Repeat
EGD ___ with mild erosions in antrum and duodenum
# CAD with 80% RCA stenosis, s/p DES in ___
# COPD (diagnosed ___ on home O2
# Congenital pulmonic stenosis
# Chronic low back pain
# R Breast cancer, s/p lumpectomy and XRT ___ with no chemo
# Hypertension
# Hyperlipidemia
# DM2
# Cholecystectomy
# ORIF for right ankle fracture with hardware placement/removal
# Basal cell cancer on face
# Excision of urachal cyst
Social History:
___
Family History:
- colon cancer
- mother MI (died ___)
- father CAD (died ___ from bladder cancer)
Physical Exam:
Admission Physical Exam:
VS 97.4 BP 124/60 HR 73 RR 18 O2 98 % on 2L
Patient appears in NAD,
HEENT: COP, MMM, pale conjunctiva
Neck: supple, no LAD
Lung: clear to auscultation
Heart: regular RR, no M/R/G
Abdomen: LLQ tenderness, soft, no guarding, +BS
Extremities: no edema
Skin: no rash
At discharge, conjuntival pallor had resolved. No other
significant change.
Pertinent Results:
___ 05:10PM BLOOD WBC-9.7 RBC-2.89* Hgb-7.7*# Hct-25.3*#
MCV-88 MCH-26.6* MCHC-30.4* RDW-13.9 Plt ___
___ 12:10AM BLOOD WBC-11.0 RBC-2.84* Hgb-7.4* Hct-24.2*
MCV-85 MCH-26.2* MCHC-30.7* RDW-13.7 Plt ___
___ 07:05AM BLOOD WBC-9.3 RBC-3.42* Hgb-9.4*# Hct-29.3*
MCV-86 MCH-27.6 MCHC-32.2 RDW-14.7 Plt ___
___ 05:23PM BLOOD ___ PTT-37.8* ___
___ 05:10PM BLOOD Glucose-108* UreaN-14 Creat-0.7 Na-146*
K-4.2 Cl-111* HCO3-25 AnGap-14
___ 07:05AM BLOOD Calcium-8.6 Phos-4.8*# Mg-1.8
___ 05:10PM BLOOD CK(CPK)-65
___ 05:10PM BLOOD CK-MB-2
___ 05:10PM BLOOD cTropnT-<0.01
___ 12:10AM BLOOD CK(CPK)-62
___ 12:10AM BLOOD CK-MB-2 cTropnT-<0.01
___ 07:05AM BLOOD CK(CPK)-55
___ 07:05AM BLOOD CK-MB-2 cTropnT-<0.01
CT A/P - FINDINGS: The lung bases demonstrate emphysematous
changes particularly in the right lower lobe. In addition
dependent atelectatic changes are seen. There is no significant
pericardial effusion.
ABDOMEN: The liver is hypodense consistent with fatty
infiltration. Patient is status post cholecystectomy. The
portal vein is patent. Spleen is unremarkable. Pancreas,
bilateral adrenals, bilateral kidneys appear unremarkable.
Abdominal aorta is normal in caliber. Atherosclerotic
calcifications are noted throughout its course.
PELVIS: The appendix is visualized in the right lower quadrant
(image 61). A dropped clip is seen in the right lower quadrant.
Small and large bowel demonstrate no evidence of focal wall
thickening or changes of a normal course and caliber. Bladder
and uterus are unremarkable.
No suspicious lytic lesions are seen.
IMPRESSION:
1. No acute intra-abdominal process.
2. Fatty liver.
3. Emphysema.
Brief Hospital Course:
Patient is a ___ yo female with hx of recurrent bleed, CAD, and
COPD, who presents with SOB, and chest pain in the setting of
GIB.
#GIB: Most likely etiology was patient's known AVMs. She was
given 2 units of PRBC's with appropriate bump in her hematocrit
and resolution of her symptoms. Given that her hematocrit had
remained stable in the mid-___ for the past few days, it was
felt that her bleeding had likely resolved. She was seen by the
GI service, who did not feel that there was an indication for
further evaluation during this admission. She was discharged
home with plans for outpatient IV iron infusion on the day after
discharge as well as close PCP ___ for ___ check. She was
started on oral iron and vitamin C prior to discharge.
#LLQ pain: Unlikely diverticulitis given benign exam and no
fever. Seemed most likely musculoskeletal. Will need to
continued to monitor in the outpatient setting to ensure
resolution.
#CAD: Pt presented with left-sided chest pressure radiating into
the arm in the setting of anemia. CE's were negative x 3, ECG
did not show evidence of ischemia. Symptoms resolved with pRBC
administration. While clopidogrel, aspiring, atenolol were
initially held in the setting of GIB, they were restarted at
discharge.
#COPD: Continued spiriva, symbicort, and albuterol. On 2L home
O2.
#DM: Continued home regimen.
#HTN: As above, atenolol initially held but was restarted at
discharge.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Tiotropium Bromide 1 CAP IH DAILY
2. Ketoconazole 2% 1 Appl TP ASDIR
3. Lorazepam 0.5 mg PO BID
4. Atenolol 50 mg PO DAILY
5. MetFORMIN XR (Glucophage XR) 1000 mg PO QAM
Do Not Crush
6. MetFORMIN XR (Glucophage XR) 500 mg PO QPM
Do Not Crush
7. fenofibrate nanocrystallized *NF* 48 mg Oral daily
8. Ranitidine 150 mg PO BID
9. Rosuvastatin Calcium 20 mg PO DAILY
10. Nitroglycerin SL 0.3 mg SL PRN chest pain
11. Clopidogrel 75 mg PO DAILY
12. Sucralfate 1 gm PO QID
13. Pantoprazole 40 mg PO Q12H
14. Calcarb 600 With Vitamin D *NF* (calcium carbonate-vitamin
D3) 600 mg(1,500mg) -400 unit Oral BID
15. Venlafaxine XR 37.5 mg PO DAILY
16. traZODONE 225 mg PO HS:PRN insomnia
17. Cyanocobalamin 1000 mcg PO DAILY
18. Symbicort *NF* (budesonide-formoterol) unknown unknown
Inhalation bid
Discharge Medications:
1. Lorazepam 0.5 mg PO BID
2. Nitroglycerin SL 0.3 mg SL PRN chest pain
3. Pantoprazole 40 mg PO Q12H
4. Ranitidine 150 mg PO BID
5. Rosuvastatin Calcium 20 mg PO DAILY
6. Sucralfate 1 gm PO QID
7. Symbicort *NF* (budesonide-formoterol) 0 unknown INHALATION
BID
8. Tiotropium Bromide 1 CAP IH DAILY
9. traZODONE 225 mg PO HS:PRN insomnia
10. Venlafaxine XR 37.5 mg PO DAILY
11. Ferrous Gluconate 325 mg PO DAILY
RX *ferrous gluconate 325 mg (36 mg iron) 1 tablet(s) by mouth
daily Disp #*30 Tablet Refills:*0
12. Atenolol 50 mg PO DAILY
13. Calcarb 600 With Vitamin D *NF* (calcium carbonate-vitamin
D3) 600 mg(1,500mg) -400 unit Oral BID
14. Clopidogrel 75 mg PO DAILY
15. Cyanocobalamin 1000 mcg PO DAILY
16. fenofibrate nanocrystallized *NF* 48 mg Oral daily
17. Ketoconazole 2% 1 Appl TP ASDIR
18. MetFORMIN XR (Glucophage XR) 1000 mg PO QAM
Do Not Crush
19. MetFORMIN XR (Glucophage XR) 500 mg PO QPM
Do Not Crush
20. Ascorbic Acid ___ mg PO DAILY
RX *ascorbic acid ___ mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
21. Outpatient Lab Work
Please chest hemoglobin and hematocrit. Results should be faxed
to Dr. ___ at ___ ___s to Dr. ___ at
___.
Discharge Disposition:
Home
Discharge Diagnosis:
Iron deficiency anemia
Gastrointestinal bleeding
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 anemia from bleeding in your
gastrointestinal tract. You were given 2 units of blood with
improvement in your blood levels. You were started on oral iron
therapy until your next iron infusion.
Please refer to the list below for any changes to your
medications.
It was a pleasure taking part in your medical care.
Followup Instructions:
___
|
19700168-DS-12
| 19,700,168 | 20,958,916 |
DS
| 12 |
2153-08-20 00:00:00
|
2153-08-21 07:01:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Haldol / Lithium
Attending: ___.
Chief Complaint:
Chief Complaint: Hypotension
Reason for MICU Transfer: Hypotension
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ y/o male with a past medical history of
schizophrenia, CKD (stage 5), h/o hypotension on midodrine who
presented to the ED with hypotension. Pt was at a nephrology
appointment, when his BP was found to be 66/55. He was sent to
___ for further evaluation. The patient's blood pressure runs
in the ___ at baseline and he is on midodrine, however today in
clinic he was found to have blood pressures in the ___ which
is low for him and he was referred to the ED. Patient denies
fevers, chills, cough, shortness of breath, leg swelling,
abdominal pain. Patient has a chronic sacral ulcer however
denies new pain. He is unable to walk on his own and requires
assistance with transfers. The patient denies having had a
stroke in the past and is unable to explain why he cannot walk
on his own.
In the ED, initial vitals were: T 97.7, HR 124, BP 77/61, RR 20,
99% RA.
Labs were notable for a WBC 10.4, Hb 8.7 (baseline 10), PLT 350,
K 6.0, Cr 3.0, lactate 2.2, lipase 178.
Patient received 3L IVF, midodrine 5 mg PO (x2), sodium bicarb
and calcium gluconate 2 g. CXR showed no acute process. BP
improved to the ___. Patient refused UA or UCx. BCx were
obtained. Per discussion with the nurse the bed sores did not
look infected and were examined by the emergency room
physicians.
For his hyperkalemia, patient was given calcium gluconate and
sodium bicarbonate, with improvement in K to 5.4. He reportedly
had no changes on his EKG.
Repeat CBC was 5.6>6.5/21.1<233. Pt refused a rectal exam as
well as blood products, despite knowing that he could suffer
harm if he did not get blood. Of note, patient had a BM in the
ED which was reportedly normal. Patient was transferred to the
MICU for further evaluation.
In the setting of hypotension, pt was started on vancomycin,
presumably for a history of urinary VSE. Of note, pt has a
history of urinary pseudomonas, which was sensitive to only
amikacin.
On transfer, vitals were: 81; 84/63; 19; 99% RA.
On arrival to the MICU, VS were: 98.3; 88; 91/61; 22; 99% RA. Pt
reports that he did not feel unwell today. He notes that he is
incontinent. Otherwise, he denies any recent changes to his
urinary habits, burning with urination, abdominal pain, SOB,
cough, fevers, chest pain, dizziness, fatigue, weakness, n/v, or
diarrhea. Patient was adamant that he wanted to be DNR/DNI. When
discussing the ICU consent form, he reported that he did not
want any of the interventions listed on the sheet, even if they
were life saving.
Past Medical History:
-CKD Stage V thought to be from Lithium toxicity c/b
hyperkalemia (has refused keyexelate per last d/c summary), also
recently worsened by obstructive uropathy, currently with foley
-Nephrogenic DI
-Schizophrenia w/ paranoid psychosis requiring psychiatric
admission at ___, discharged ___ and numerous other inpatient
psychiatric admissions
-Dysautonomia
-HTN
-HLD
-RBBB
-Hypothyroidism
-Venous insufficiency
-Urinary retention
-Secondary hyperparathyroidism
-Anemia of chronic disease
-COPD
-BPH s/p TURP
-?___ disease
Social History:
___
Family History:
Family psychiatric history:
sister with bipolar d/o and polysubstance abuse; mother with
dementia
Physical Exam:
ADMISISON PHYSICAL EXAM:
Vitals: 98.3; 88; 91/61; 22; 99% RA
GENERAL: AOx3, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
NECK: supple, JVP not elevated, no LAD
LUNGS: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs,
gallops
ABD: soft, non-tender, non-distended, bowel sounds present, no
rebound tenderness or guarding, no organomegaly
EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
SKIN: Warm and dry
NEURO: CNII-XII grossly intact
PSYCH: Very tangential with some pressured speech.
DISCHARGE EXAM
==============
VS: 97.9 135/80 (100s-140s/70s-90s) 75 (60s-80s) 18 99% RA
General: WNWD elderly male in NAD
HEENT: anicteric sclera
Neck: supple, no JVD
CV: RRR, no m/r/g
Lungs: NLB on RA, CTAB
Abdomen: soft, NT, ND, NABS
Ext: WWP, no cyanosis or edema, sacral ulcer not assessed,
patient refused
Neuro: A&O, SILT, MAE
Pertinent Results:
ADMISSION LABS:
___ 02:46PM BLOOD WBC-10.4* RBC-2.68* Hgb-8.7* Hct-27.9*
MCV-104* MCH-32.5* MCHC-31.2* RDW-15.8* RDWSD-59.8* Plt ___
___ 02:46PM BLOOD Neuts-51 Bands-0 ___ Monos-7 Eos-2
Baso-0 ___ Myelos-0 AbsNeut-5.30 AbsLymp-4.16*
AbsMono-0.73 AbsEos-0.21 AbsBaso-0.00*
___ 02:46PM BLOOD Hypochr-1+ Anisocy-OCCASIONAL
Poiklo-NORMAL Macrocy-1+ Microcy-NORMAL Polychr-OCCASIONAL
___ 02:46PM BLOOD ___ PTT-29.3 ___
___ 02:46PM BLOOD Glucose-95 UreaN-51* Creat-3.0*# Na-139
K-6.0* Cl-107 HCO3-23 AnGap-15
___ 02:46PM BLOOD ALT-19 AST-21 AlkPhos-102 TotBili-0.4
___ 02:46PM BLOOD Albumin-2.8* Calcium-11.1* Phos-3.6
Mg-1.4*
___ 02:52PM BLOOD Lactate-2.2*
PERTINENT STUDIES:
___ 11:17PM BLOOD WBC-5.6 RBC-2.01* Hgb-6.5*# Hct-21.1*
MCV-105* MCH-32.3* MCHC-30.8* RDW-15.7* RDWSD-58.7* Plt ___
___ 04:28AM BLOOD ___ PTT-24.7* ___
___ 04:28AM BLOOD Glucose-81 UreaN-47* Creat-2.8* Na-141
K-4.9 Cl-109* HCO3-24 AnGap-13
___ 04:28AM BLOOD ALT-17 AST-20 LD(LDH)-203 AlkPhos-80
TotBili-0.2
___ 04:28AM BLOOD calTIBC-199* ___ Ferritn-507*
TRF-153*
___ 01:50AM BLOOD Lactate-0.9
___ 07:45AM BLOOD VitB12-624 Folate-18.6
___ 04:28AM BLOOD TSH-1.3
MICRO:
___ BLOOD CULTURE: NEGATIVE
IMAGING
___ CXR (PORTABLE)
FINDINGS: The lungs are relatively hyperinflated. No focal
consolidation is seen. No large pleural effusion or
pneumothorax is seen. Cardiac and mediastinal silhouettes are
unremarkable.
IMPRESSION: No acute cardiopulmonary process.
DISCHARGE LABS:
___ 09:27AM BLOOD WBC-12.6* RBC-3.22*# Hgb-10.1*#
Hct-32.4*# MCV-101* MCH-31.4 MCHC-31.2* RDW-19.0* RDWSD-69.4*
Plt ___
___ 09:27AM BLOOD Glucose-88 UreaN-61* Creat-3.3* Na-142
K-5.1 Cl-110* HCO3-20* AnGap-17
___ 09:27AM BLOOD Calcium-9.9 Phos-4.1 Mg-1.7
Brief Hospital Course:
Summary
___ with PMHx CKD V ___ lithium toxicity, c/b hyperkalemia),
anemia of chronic disease, Paranoid schizophrenia, dysautonomia,
chronic hypotension on midodrine and hypothyroidism who
presented from ___ clinic with asymptomatic hypotension
found to have acute on chronic anemia, sacral ulcer,
hyperkalemia and elevated lipase.
Patient resistant to most diagnostic or therapeutic
interventions, no active signs of psychosis, however his
personal Neprologist notes that he is not competent to make
medical decisions and his health care proxy (step-brother) was
contacted is aware of his current status.
His hypotension improved with IV fluids and increasing his
midodrine to 10mg TID, no evidence of cariogenic, obstructive,
distributive etiologies. His anemia was significantly worse than
previous baseline, exacerbated by IVF resuscitation. He has
adequate iron stores on a baseline of anemic of chronic disease,
no evidence of hemolysis and an appropriate reticulocytosis. His
stools were guaiac negative. He received 2 units pRBCS which
improved his anemia. Patient has an appointment for EPO infusion
on ___.
His ulcer was evaluated by wound care who felt it was not
infected but made recommendations for proper care and also to
treat a moisture-induced fungal rash.
His hyperkalemia is chronic and was treated with fluids and
calcium gluconate. Patient did not develop any arrhythmias while
in hospital and potassium was improved and stable on discharge.
His elevated lipase was downtrending with no symptoms of
pancreatitis.
# Acute on Chronic Hypotension: Patient's chronic BP appears to
be in the 90's-120's based on previous ___ records. His BP of
66/55 at rehab was likely from hypovolemia and DIB dosing of
midodrine (prescribed TID) given improvement after IVF. His
midodrine was increased to 10mg TID with good response.
# Acute on Chronic Anemia: Presented at Hbg 8.7, below previous
baseline of near 10. Etiology of acute anemia is unclear.
Chronic anemia thought to be due to ACD ___ ESRD. Guaiac
negative BM on floor. Otherwise, there is no obvious source of
bleeding. His acute drop in the ED was likely dilutional given
that all of his cell lines decreased in the setting of IVF
resuscitation. Labs not consistent with hemolysis. Iron studies
consistent with adequate iron stores but ACD. Appropriate
reticulocytosis. Has received 2 units pRBCS, last ___.
Appropriate rise in H/H. Patient has an appointment for EPO
therapy as directed by nephrologist on ___.
# Hyperkalemia: chronic ___ ESRD with a possible contribution
from home metolazone, presented with K of 6.0, w/peaked T-waves
on EKG, treated with fluids and calcium gluconate. Patient did
not develop any arrhythmias while in hospital and potassium was
improved on discharge. Potassium controlled with IV fluid
infusions PRN, improved and stable on discharge.
# Sacral ulcer: patient has full thickness 4.5cm x 1cm sacral
pressure ulcer, evaluated by wound care who felt it was not
infected but made recommendations for proper care and also to
treat a moisture-induced fungal rash.
# Schizophrenia | lack of capacity: disordered thoughts and
reports hearing voices to Psychiatry. Multiple prior psychiatric
admissions and followed closely as an outpatient. Patient
refused a number of treatments despite continued discussions
about the risk of organ damage and death if he does not receive
them. No capacity per Psychiatry evaluation on ___ based on the
inability to articulate, understand or address the risks of
declining treatments. No indication for adjusting medication
regimen at the time. DMH is involved with ___ guardianship
process, ___ accepted patient while this process is
pending.
# Elevated lipase: Patient has history of acute pancreatitis
___ of uncertain etiology. Pt does not currently endorse any
symptoms of pancreatitis. Last lipase on discharge after acute
event was 638. Downtrended while admitted.
# Hypoalbuminemia: Likely reflects poor underlying nutritional
status. We encouraged PO intake while patient is hospitalized.
Nutrition consult added multivitamins with minerals to current
regimen and encouraged biological proteins for wound healing.
# CKD: Baseline Cr ___ since ___. Felt to be secondary to
lithium toxicity and obstructive nephropathy ___ BPH. Cr 3.0 on
admission, improved to 2.8 with IVF resuscitation. Patient has
declined any preparation for advanced renal replacement therapy
and adopted for conservative management per Nephrologist's note.
Complications include anemia with no recent iron studies,
hyperphosphatemia on calcium based binders, secondary
hyperparathyroidism on calcitriol, history of nephrogenic DI
with hypernatremia as well as history of hyperkalemia. Cr within
baseline on discharge. Patient has follow up with nephrologist.
# BPH s/p TURP: Heed home finasteride and tamsulosin while
inpatient given urinary incontinence, hypotension and initial
concerns for hypovolemia and fluid resuscitation. Patient was
incontinent off of medication but did not report abdominal pain.
Resumed medications on discharge as pressures and volume status
improved.
# COPD: Continued home albuterol; fluticasone-vilanterol was
switched to Spiriva, resumed home meds on discharge.
# Hypothyroidism: TSH 1.3 on admission. Continued home
levothyroxine.
# HLD: Continued home atorvastatin.
TRANSITIONAL ISSUES
===================
- patient refused workup and interventions for worsening anemia,
responded to 2 units pRBCs. Recommend close monitoring for
signs/symptoms of bleeding and possible iron therapy,
transfusions, cross sectional imaging, GI workup as patient
allows.
- Patient has appointment for EPO infusion on ___
- patient may need close titration of his midodrine by his
nephrologist and please ensure correct dosing as there was a
discrepancy between prescribed and delivered dose, discharged on
midodrine 10 mg TID
- patient has chronic hyperkalemia which was improved with IV
fluids while admitted. Consider starting low dose furosemide to
help control if systolic blood pressures are consistently > 110,
recommend close monitoring of blood pressure and electrolytes
- CODE: Full code (no capacity to make medical decisions)
- HCP: ___ (step brother) ___
MEDICATIONS CHANGED:
- Midodrine 10mg PO TID (increased)
- added Multivitamins W/minerals 1 TAB PO DAILY
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO Q6H:PRN Pain
2. Aspirin 81 mg PO DAILY
3. fluticasone-vilanterol 100-25 mcg/dose inhalation DAILY
4. Calcitriol 0.25 mcg PO DAILY
5. Loratadine 10 mg PO DAILY
6. Hydrocerin 1 Appl TP DAILY
7. Finasteride 5 mg PO DAILY
8. LOPERamide 6 mg PO BID:PRN Loose stools
9. Levothyroxine Sodium 50 mcg PO DAILY
10. Atorvastatin 40 mg PO QPM
11. Midodrine 5 mg PO BID
12. Omeprazole 40 mg PO DAILY
13. Multivitamins 1 TAB PO DAILY
14. Albuterol Inhaler 2 PUFF IH Q6H:PRN Shortness of breath
15. Sodium Polystyrene Sulfonate 30 gm PO 1X/WEEK (WE)
16. Tamsulosin 0.4 mg PO QHS
17. Tobramycin-Dexamethasone Ophth Susp 1 DROP LEFT EYE BID
18. Ondansetron 4 mg PO Q6H:PRN Nausea
19. LORazepam 1 mg PO QHS
20. Calcium Carbonate 1000 mg PO DAILY
21. Divalproex (EXTended Release) 750 mg PO BID
22. Calcium Carbonate 400 mg PO QID:PRN dyspepsia
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN Pain
2. Albuterol Inhaler 2 PUFF IH Q6H:PRN Shortness of breath
3. Aspirin 81 mg PO DAILY
4. Atorvastatin 40 mg PO QPM
5. Calcitriol 0.25 mcg PO DAILY
6. Calcium Carbonate 1000 mg PO DAILY
7. Divalproex (EXTended Release) 750 mg PO BID
8. Hydrocerin 1 Appl TP DAILY
9. Levothyroxine Sodium 50 mcg PO DAILY
10. LORazepam 1 mg PO QHS
11. Multivitamins 1 TAB PO DAILY
12. Omeprazole 40 mg PO DAILY
13. Calcium Carbonate 400 mg PO QID:PRN dyspepsia
14. Finasteride 5 mg PO DAILY
15. fluticasone-vilanterol 100-25 mcg/dose inhalation DAILY
16. LOPERamide 6 mg PO BID:PRN Loose stools
17. Loratadine 10 mg PO DAILY
18. Ondansetron 4 mg PO Q6H:PRN Nausea
19. Sodium Polystyrene Sulfonate 30 gm PO 1X/WEEK (WE)
20. Tamsulosin 0.4 mg PO QHS
21. Tobramycin-Dexamethasone Ophth Susp 1 DROP LEFT EYE BID
22. Midodrine 10 mg PO TID
23. Multivitamins W/minerals 1 TAB PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
___ Diagnosis:
Primary
# Acute on Chronic Hypotension
# Acute on Chronic Anemia
# Schizophrenia
Secondary
# Chronic kidney disease
# Chronic hyperkalemia
# Malnutrition
# Benign Prostatic Hypertrophy with lower urinary tract
obstruction
# Chronic Obstructive Pulmonary Disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. ___,
You were sent to ___ when your nephrologist found your blood
pressure to be too low. We found that your anemia had worsened
and that your blood pressure medication (midodrine) dose was too
low.
We increased your midodrine dose to 10mg three times per day.
You did not have any bleeding while you were inpatient and
received a blood transfusion for your anemia that improved your
anemia. It is important that you report any bleeding, especially
in your stools to your medical providers.
We also found that your back wound is healing but there was a
fungal rash around it. You are being treated for this wound and
the rash.
You are being sent back to your facility as your blood pressure
improved and your anemia is improved.
We wish you the ___ in health,
Your ___ team
Followup Instructions:
___
|
19700882-DS-13
| 19,700,882 | 27,615,097 |
DS
| 13 |
2193-01-12 00:00:00
|
2193-01-12 12:43:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: CARDIOTHORACIC
Allergies:
Sulfa (Sulfonamide Antibiotics) / ragweed
Attending: ___.
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ s/p tissue AVR with Dr. ___ ___. Post-op course
complicated by seizures. Neurology consulted, Keppra started.
No further seizure activity. Discharged home with nursing care
on POD 7. Returns to day with dyspnea and lower extremity
edema.
Chest X-ray shows new right pleural effusion. He will be
admitted for diuresis.
Past Medical History:
Severe aortic stenosis
first degree AVB
brief atrial fibrillation (during episode of pneumonia ___
lumbar spine stenosis
peripheral neuropathy
s/p appendectomy
s/p carpel tunnel repair
s/p tonsillectomy
Social History:
___
Family History:
Premature coronary artery disease- father and mother both died
of heart failure at age ___ and ___
Physical Exam:
General: NAD, appears younger than stated age
Skin: Dry [x] intact [x] sternotomy c/d/i without erythema or
drainage
HEENT: PERRLA [] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [] diminished at bases
bilaterally
Heart: RRR [x] Irregular [] Murmur [] grade ___
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x] Edema [] 2+
Varicosities: None [] mild
Neuro: Grossly intact [x]
Pulses:
Femoral Right:2+ Left:2+
DP Right:1+ Left:2+
___ Right:1+ Left:1+
Radial Right:2+ Left:2+
Pertinent Results:
Echo ___:
Conclusions
The left atrium is normal in size. The estimated right atrial
pressure is ___ mmHg. There is mild symmetric left ventricular
hypertrophy with normal cavity size and regional/global systolic
function (LVEF>55%). The right ventricular cavity is mildly
dilated with normal free wall contractility. A bioprosthetic
aortic valve prosthesis is present. The aortic valve prosthesis
appears well seated, with normal leaflet/disc motion and
transvalvular gradients. The mitral valve leaflets are mildly
thickened. Mild (1+) mitral regurgitation is seen. Moderate [2+]
tricuspid regurgitation is seen. There is borderline pulmonary
artery systolic hypertension. There is no pericardial effusion.
IMPRESSION: Well seated aortic bioprosthesis with normal
gradients and no aortic regurgitation. Large left pleural
effusion but no pericardial effusion appreciated. Preserved
biventricular systolic function.
___ 05:15AM BLOOD WBC-11.8* RBC-3.87* Hgb-11.5* Hct-35.5*
MCV-92 MCH-29.6 MCHC-32.3 RDW-16.0* Plt ___
___ 05:45AM BLOOD WBC-12.1* RBC-3.60* Hgb-10.8* Hct-33.2*
MCV-92 MCH-30.0 MCHC-32.5 RDW-16.2* Plt ___
___ 05:15AM BLOOD Glucose-83 UreaN-32* Creat-1.5* Na-141
K-4.7 Cl-104 HCO3-28 AnGap-14
___ 05:45AM BLOOD Glucose-88 UreaN-30* Creat-1.5* Na-140
K-4.4 Cl-104 HCO3-28 AnGap-12
___ 06:50AM BLOOD Creat-1.4* Na-140 K-4.8 Cl-105
Chest x-ray ___.
FINDINGS: Following right thoracentesis, a right pleural
effusion has nearly resolved. No visible pneumothorax.
Moderate left pleural effusion with adjacent atelectasis is
unchanged. Cardiomediastinal contours are stable in appearance.
IMPRESSION:
Near resolution of right pleural effusion following
thoracentesis with no
visible pneumothorax.
Brief Hospital Course:
Mr. ___ was admitted for diuresis and to monitor his
Creatinine. He was diuresed with IV lasix with good response.
IP was consulted for thoracentesis of the right sided pleural
effusion. 1470 cc serosanginous fluid was drained with follow up
CXR showed right sided effusion resolved, residual small left
effusion and atelectasis, no pneumothorax. He was discharged
home on HD4 with 1 week of po Lasix. Creatinine was stable
1.4-1.5 at the time of discharge. This should be repeated in
___ days. All follow up appointments were advised.
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from webOMR.
1. LeVETiracetam 250 mg PO BID
2. Metoprolol Tartrate 12.5 mg PO BID
3. TraMADOL (Ultram) 50 mg PO Q4H:PRN pain
4. Aspirin 81 mg PO DAILY
5. Amiodarone 200 mg PO DAILY
6. Vitamin D 400 UNIT PO DAILY
Discharge Medications:
1. Furosemide 20 mg PO DAILY Duration: 7 Days
RX *furosemide 20 mg 1 tablet(s) by mouth daily Disp #*7 Tablet
Refills:*0
Of note, no potassium supplements were given due to K running
4.4-4.8 while on Lasix IV BID
2. Amiodarone 200 mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. LeVETiracetam 250 mg PO BID
5. Metoprolol Tartrate 6.25 mg PO BID
Hold for SBP<95 or HR<55 and notify ___ if held
6. TraMADOL (Ultram) 50 mg PO Q4H:PRN pain
7. Vitamin D 400 UNIT PO DAILY
8. Senna 1 TAB PO BID:PRN constipation
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Pleural effusion
Severe aortic stenosis
first degree AVB
brief atrial fibrillation (during episode of pneumonia ___
lumbar spine stenosis
peripheral neuropathy
Discharge Condition:
Alert and oriented x2, easily re-orientated, nonfocal
Ambulating with assistance
Incisional pain managed with Tylenol
Incisions: Sternal - healing well, no erythema or drainage
1+ lower extremity edema.
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns ___
**Please call cardiac surgery office with any questions or
concerns ___. Answering service will contact on call
person during off hours**
Followup Instructions:
___
|
19700990-DS-4
| 19,700,990 | 25,171,204 |
DS
| 4 |
2158-08-14 00:00:00
|
2158-08-14 19:33:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
eggs
Attending: ___.
Chief Complaint:
LOW BLOOD COUNTS
Major Surgical or Invasive Procedure:
Bone marrow biopsy ___
History of Present Illness:
___ yo woman from ___ P1P1C0 w/ h/o pancytopenia here for
thrombocytopenia. Pt presented for routine PCP visit, workup of
heavy menses, labs showed Platelet count 7,000 on ___, WBC
3.2 and Hgb 9.7.
she was adviced to come to the E.R Labs in the Er. Hg 8.3 WBC
3.6
She reports her only PMH for fibromas.
Menstrual cycle started ___, and she reprots that " periods
are supper heavy" Denies dysnpnea, dizziness, CP.
In the E.R vitals pulse 87 RR 16 bp 93/59 100R%RA
she was given 1 L NS and 40 mg Dexamethanosone.
Past Medical History:
Fibromas
Remove IUD early this year
Social History:
___
Family History:
no hx of bleeding disorders
Physical Exam:
ADMISSION:
General: NAD
VITAL SIGNS: 100/70 T. 98 HR 86 100# RA
HEENT: MMM, no OP lesions, no cervical, supraclavicular, or
axillary adenopathy, no thyromegaly
CV: RR, NL S1S2 no S3S4 MRG
PULM: CTAB
ABD: BS+, soft, NTND, .
LIMBS: No edema, clubbing, tremors, or asterixis; no inguinal
adenopathy
SKIN: No rashes or skin breakdown
NEURO: AOX3 no neurological deficits appreiciated
DISCHARGE:
VS - 98.3 ___ 100%RA
General: Alert and oriented x 3. NAD
HEENT: PERRL, EOMI, MMM
Neck: SUPPLE
CV: RRR
Lungs: CTAB
Abdomen: soft and nontender
Ext: no edema or cyanosis
Pertinent Results:
___ 10:55PM BLOOD WBC-3.6* RBC-2.91* Hgb-8.3* Hct-25.5*
MCV-88 MCH-28.6 MCHC-32.7 RDW-14.8 Plt Ct-6*
___ 10:55PM BLOOD Neuts-63.0 ___ Monos-4.3 Eos-3.4
Baso-0.6
___ 10:30AM BLOOD WBC-2.4* RBC-2.56* Hgb-7.1* Hct-22.5*
MCV-88 MCH-27.9 MCHC-31.7 RDW-15.1 Plt Ct-7*
___ 10:30AM BLOOD Neuts-72.1* ___ Monos-1.6*
Eos-0.9 Baso-0.2
___ 07:00PM BLOOD WBC-4.1# RBC-2.32* Hgb-6.4* Hct-20.6*
MCV-89 MCH-27.6 MCHC-31.2 RDW-14.8 Plt Ct-37*#
___ 08:31AM BLOOD WBC-3.8* RBC-2.70* Hgb-7.8* Hct-24.2*
MCV-90 MCH-28.8 MCHC-32.1 RDW-15.0 Plt Ct-51*
___ 08:31AM BLOOD Glucose-115* UreaN-11 Creat-0.6 Na-143
K-3.8 Cl-114* HCO3-20* AnGap-13
___ 10:30AM BLOOD calTIBC-276 VitB12-708 Folate-GREATER TH
Ferritn-29 TRF-212
___ 10:30AM BLOOD HBsAg-PND HBsAb-PND HBcAb-PND
___ 10:30AM BLOOD PEP-PND
___ 10:55PM BLOOD LtGrnHD-HOLD
___ 10:30AM BLOOD HCV Ab-PND
RENAL U/S ___
IMPRESSION:
1. Hypoechoic lesion within the left upper pole with an
irregular contour. This may reflect calyceal diverticulum or
alternatively a hemorrhagic or proteinaceous cyst. An MR can be
helpful in further characterization.
2. No hydronephrosis or nephrolithiasis identified.
Brief Hospital Course:
___ y/o woman with PMH of uterine fibroids and menorrhagia p/w
pancytopenia.
# Thrombocytopenia: Most likely ITP. She has a hx of mild
thrombocytopenia but was admitted with platelet # of 7,000.
Other than her monorrhiagia no other sources of bleeding. She
received Dexamethasone IV with good response and also required
platelet transfusions. Hem/onc was consulted and she underwent a
bone marrow biopsy just prior to discharge. Due to concerns of
leukemic processes, peripheral blood was also sent for flow
cytometry studies. Both results pending at discharge, as well as
hepatitis serologies. Platelet count is up to 57,000 at
discharge and menstrual flow is slowing down. She will continue
Dexamethasone daily x 2 more days (total of four 40mg doses)
Close follow up with Atrius hematology will be arranged.
#Acute blood loss and Iron deficiency anemia: Her anemia is
mainly due to menorrhagia with a hx of uterine fibroids. Per pt.
has been considering endometrial ablation with her outpt.
gynecologist. Iron studies c/w iron deficiency. She received
1gram dose of IV Dextran to replete her iron stores and also
PRBC transfusions. Hgb from 6.4 to 7.8 upon discharge amd
menstrual bleed subsiding.
#Leukopenia: mild and chronic and likely ___ ethnicity.
# Renal cyst: US was performed for routine ___ cyst.
While no lesion was seen in R upper pole, she was found to have
a lesion in the L upper pole for which MRI is recommended.
TRANSITIONAL ISSUES:
-Follow up with Dr. ___ treatment options re: Fibroids
-Follow up flow cytometry, hepatitis serologies, SPEP, UPEP
-Follow up bone marrow biopsy results (FYI: No core obtained;
aspirate sent off)
-Follow up Renal Ultrasound findings: Hypoechoic lesion within
the left upper pole with an irregular contour which may
represent proteinaceous or hemorrhagic cyst. MRI recommended for
further characterization
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Ferrous Sulfate 650 mg PO DAILY
Discharge Medications:
1. Dexamethasone 40 mg PO DAILY
RX *dexamethasone 4 mg 10 tablet(s) by mouth daily Disp #*20
Tablet Refills:*0
2. DiphenhydrAMINE 25 mg PO DAILY
RX *diphenhydramine HCl [Allergy (diphenhydramine)] 25 mg 1
capsule by mouth daily 30minutes before dexamethasone Disp #*2
Capsule Refills:*0
3. Ferrous Sulfate 650 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Severe Anemia; blood loss and iron deficiency
Severe thrombocytopenia/ITP
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a privilege caring for you here at ___. You came in
because your blood counts were very low. You needed transfusion
of blood and platelets.
You red blood cells were low because of your heavy menses and
because of that you have also been losing Iron. As a result you
also got a dose of iron through the veins to replenish your iron
stores. You need to follow up closely with your gynecologist,
Dr. ___, to treat your uterus fibroids.
You have been given steroids for your platelets which were low
most likely because your body is braeking them down. You are
responding well to these and will need to more doses after you
go home.
Please keep all your doctors' appointments!
We wish you all the best!
Followup Instructions:
___
|
19700990-DS-6
| 19,700,990 | 21,204,649 |
DS
| 6 |
2161-07-13 00:00:00
|
2161-07-13 16:15:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: OBSTETRICS/GYNECOLOGY
Allergies:
eggs / strawberries / lactose
Attending: ___
___ Complaint:
Vaginal bleeding
Major Surgical or Invasive Procedure:
Bilateral uterine artery embolization
History of Present Illness:
___ with hx Fe-deficiency anemia, ITP ___, pancytopenia
(followed by hematology/oncology outpatient), presenting with
vaginal bleeding, abdominal distention, LLQ pain, and Hgb drop
to 7.6 (baseline hgb 8). Pt states that the past two months have
had significantly heavier vaginal bleeding (LMP ___. And then
last week, developed abdominal distention and lower abdominal
pain, with new vaginal bleeding on ___, gotten worse since
then, now passing ~4 fist-sized clots per day. Patient reports
lightheadedness with one presyncopal event with standing from a
seated position but denies fall, head strike, or LOC. Patient
also endorses dark, tarry stools for past few days. No f/c, no
n/v, ROS otherwise negative.
Past Medical History:
Uterine Fibromas
ITP - suspected
Menorrhagia
Anemia of chronic blood loss
Pancytopenia
Herpes Genitalis
Iron deficiency anemia
4 mm lesion in the upper pole of the right kidney under
incidentally identified and under surveillance.
G1P1
Social History:
___
Family History:
no hx of bleeding disorders
Physical Exam:
===========================
Admission Physical Exam
===========================
General appearance: well-appearing woman in discomfort, lying in
bed
HEENT: scleral anicteric, MMM, no JVD, no JP elevation
Cardiovascular: tachycardic, RRR, no murmurs, rubs, or gallops
Lungs: CTAB, no ronchi, rales, or wheezes
Abdomen: minimal bowel sounds, nondistended, nonrigid, no
guarding, tender to palpation diffusely especially @ LLQ
GU: deferred
Rectal deferred
Neuro: Grossly alert and oriented, CNII-XII grossly intact
Pertinent Results:
ADMISSION LABS
___
WBC-3.0* RBC-2.78* Hgb-7.6*# Hct-25.2* MCV-91 MCH-27.3
MCHC-30.2* RDW-15.4 RDWSD-49.1* Plt ___
Neuts-55.6 ___ Monos-10.5 Eos-9.9* Baso-0.0 Im ___
AbsNeut-1.69 AbsLymp-0.72* AbsMono-0.32 AbsEos-0.30
AbsBaso-0.00*
___ PTT-27.5 ___
Glucose-94 UreaN-10 Creat-0.6 Na-138 K-5.6* Cl-104 HCO3-22
AnGap-12
Calcium-7.3* Phos-1.9* Mg-1.6
HCG-<5
K-3.9
OTHER LABS
___ 01:42AM BLOOD WBC-13.7*# RBC-3.30* Hgb-9.5* Hct-28.0*
MCV-85 MCH-28.8 MCHC-33.9 RDW-16.7* RDWSD-51.3* Plt Ct-81*
___ 07:04AM BLOOD WBC-5.5 RBC-2.71* Hgb-7.9* Hct-23.3*
MCV-86 MCH-29.2 MCHC-33.9 RDW-17.2* RDWSD-53.8* Plt Ct-67*
___ 05:44AM BLOOD WBC-5.5 RBC-2.79* Hgb-7.9* Hct-24.4*
MCV-88 MCH-28.3 MCHC-32.4 RDW-16.7* RDWSD-53.8* Plt Ct-81*
___ 08:05PM BLOOD ALT-24 AST-75* AlkPhos-243* TotBili-2.7*
___ 01:52AM BLOOD ALT-18 AST-41* AlkPhos-118* TotBili-1.8*
___ 09:50PM BLOOD TSH-1.6
___ 05:44AM BLOOD Free T4-1.0
___ 08:17PM BLOOD Lactate-2.8*
___ 02:31AM BLOOD Lactate-0.8
MICROBIOLOGY
Urine culture ___: No growth
Blood culture ___ - no growth
Blood culture ___: E Coli
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- 16 I
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- =>16 R
Urine culture ___: E coli
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- 16 I
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---- =>16 R
Blood culture ___: E coli
Tissue culture ___: E coli
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- 16 I
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- =>16 R
Blood culture ___- pending
Blood culture ___ - pending
Mini-BAL ___ - yeast ~4,000 CFU/ml
IMAGING
Ultrasound, pelvis ___: The uterus is anteverted and
measures approximately 21.0 x 10.9 x 13.5 cm. The endometrium is
homogenous and measures 6 mm. Numerous uterine masses are
consistent with fibroids, the largest of which is intramural
located at the body posteriorly and measures 9.1 x 8.5 x 9.6 cm.
The ovaries are not visualized. There is no free fluid.
Uterine Embolization ___: Technically successful right
common femoral artery access bilateral uterine artery particle
embolization to near stasis.
Femoral vascular US ___: No evidence of pseudoaneurysm in
the right groin at the site of recent vascular access.
CT Abd/Pelvis ___: 1. Small right groin hematoma with
minimal blood product tracking along the right iliac vessels.
No large retroperitoneal hematoma. 2. Massively enlarged fibroid
uterus. Multiple foci of air in the fibroids, as expected post
procedure early, likely reflecting early necrosis. 3. Fullness
of the bilateral renal pelvises and ureters, likely secondary to
mass effect by the enlarged uterus.
XR Portable abdomen 101___: No radiographic evidence of
obstruction or ileus.
CTA Chest ___: 1. No evidence of pulmonary embolism or
aortic abnormality.
2. Bilateral moderate-sized pleural effusions right larger than
the left with
passive atelectasis at both lung bases. 3. Scattered areas of
peripheral ground-glass opacities etiologies include infectious
versus inflammatory causes, clinical correlation recommended
with the patient's symptoms.
Echo, surface ___: Normal biventricular cavity sizes with
preserved regional and global biventricular systolic function.
Mild pulmonary hypertension. Left pleural effusion. LVEF >55%
PATHOLOGY:
Utuerus, tubes, and ovaries - ___: pending
Brief Hospital Course:
___ with hx Fe-deficiency anemia, ITP ___, pancytopenia
(followed by hematology/oncology outpatient), presenting with
vaginal bleeding, abdominal distention, and Hgb drop to 7.6
(baseline hgb mid-10s) admitted for concerns for vaginal
bleeding. Her course involved uterine artery emobolization
complicated by GNR septic shock and emergent hysterectomy
requiring ICU stay.
#Vaginal bleeding: patient with hemoglobin drop from 8 (in
___ to 7.6 likely from metromenorrhagia ___ uterine
fibroids. Patient was evaluated by ob-gyn in ED with
recommendation for transfusion of 2 units pRBCs and depo plus
oral provera. However, her bleeding continued, and
interventional radiology evaluated her, and decided to take her
for a bilateral uterine artery embolization on ___, after
which point her bleeding stopped, and her hemoglobin remained
stable. On day 1 post procedure, she developed increasing pain
and a small hematoma at the groin site used for the procedure.
An ultrasound of the area showed no active bleeding, and a CAT
scan showed no retroperitoneal bleed. She was initially
transferred to the floor on ___.
#Septic Shock: On day one after her procedure, the patient
became febrile and hypotensive and was started on Vancomycin and
Zosyn. She returned to the ICU the evening of ___. A right
internal jugular vein central line was placed, and she was
started on Neosinepherine and Vasopressin for blood pressure
support starting ___. She grew gram negative rods on her blood
culture. The source was likely due to the translocation of
bacteria from the necrotic uterine tissue following her uterine
artery embolization. She was initially started on vancomycin and
zosyn for broad spectrum emprirc coverage. Gynecology was
contacted regarding source control and the decision was made to
pursue emergent hysterectomy. She was on 3 pressors during the
case. Following the procedure, she again returned to the ICU
where she was intubated and on pressors stabilization. Her
antibiotics were switched to tobramycin from ___.
Cervical cultures grew gram negative rods. In response to blood
cultures growing E. coli sensitive to ceftriaxone, she was
transitioned to ceftriaxone ad metronidaxole starting ___. She
was eventually weaned off pressors and was extubated on ___.
She returned to the floor on ___ and was transitioned to oral
levaquin and flagyl on ___ to complete a 14 day course
(___). .
#) Narrow Complex Tachycardia: Upon arrival to the floor, her
cardiac rhythm was noted to be narrow complex tachycardia,
thought to be AVNRT, which resolved with carotid massage alone.
She was asymptomatic, but developed a new oxygen requirement of
3 L nasal cannua. A CTA was negative for pulmonary embolus, but
showed bilateral pleural effusions. She was given Lasix 10 mg IV
with adequate diuresis and resolution of her O2 requirement. TSH
and free T4 were normal. Cardiology consult was obtained.
Surface echocardiography showed normal structure and systolic
function. Again, two days later on hospital day 9 she went into
a regular tachyarrythmia (HR 180s) while on tele. She was
symptomatic with lightheadedness and shortness of breath and
desaturated to 80% on room air. Her symptoms and O2 requirement
resolved with metoprolol 5 mg IV, and she was subsequently
started on metoprolol tartrate per cardiology recommendations.
#) Post-op: Her pain was initially controlled with a morphine
PCA. Her diet was advanced slowly with return of the patient's
appetite, and she was transitioned to oral oxycodone, ibuprofen,
and acetaminophen. She ambulated. Her foley was removed and she
voided spontaneously. The JP drain was removed. She underwent
assessment and treatment by physical therapy.
===============
Chronic Issues
#Pancytopenia: patient has been diagnosed with pancytopenia with
unclear etiology and autoimmune thrombocytopenia in the past.
Followed by outpt heme/onc. WBC and Plt levels are at baseline
upon admission, and stabilized after the hysterectomy.
===============
By hospital day 13, she had met all post-op milestones, her
anemia was stable, and her heart rate was well controlled on
metoprolol. She was then discharged in good condition to rehab.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Zinc Sulfate 220 mg PO DAILY
2. Ascorbic Acid ___ mg PO DAILY
3. Ferrous Sulfate 325 mg PO DAILY
4. Vitamin D 1000 UNIT PO DAILY
5. FoLIC Acid 1 mg PO DAILY
6. biotin 1 mg oral DAILY
Discharge Medications:
1. Acetaminophen ___ mg PO Q6H
RX *acetaminophen 500 mg ___ tablet(s) by mouth every 6 hours
Disp #*60 Tablet Refills:*1
2. DiphenhydrAMINE 25 mg PO Q6H:PRN itchiness
RX *diphenhydramine HCl 25 mg 1 tablet(s) by mouth every 6 hours
Disp #*15 Tablet Refills:*0
3. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg ___ tablet(s) by mouth twice daily
Disp #*60 Tablet Refills:*1
4. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN Pain - Moderate
Reason for PRN duplicate override: Alternating agents for
similar severity
RX *hydromorphone 2 mg ___ tablet(s) by mouth every 4 hours Disp
#*20 Tablet Refills:*0
5. Ibuprofen 600 mg PO Q6H
RX *ibuprofen 600 mg 1 tablet(s) by mouth every six hours Disp
#*60 Tablet Refills:*1
6. Levofloxacin 750 mg PO Q24H
RX *levofloxacin 750 mg 1 tablet(s) by mouth every 24 hours Disp
#*7 Tablet Refills:*0
7. Metoprolol Tartrate 25 mg PO BID
RX *metoprolol tartrate 25 mg 1 tablet(s) by mouth every 12
hours Disp #*60 Tablet Refills:*1
8. MetroNIDAZOLE 500 mg PO Q8H
RX *metronidazole 500 mg 1 tablet(s) by mouth every 8 hours Disp
#*21 Tablet Refills:*0
9. Miconazole Nitrate Vag Cream 2% 1 Appl VG QHS vagirnal
irritation, yeast Duration: 7 Days
RX *miconazole nitrate 2 % apply a pea-sized amount to vulva at
night Disp #*1 Tube Refills:*0
10. Ascorbic Acid ___ mg PO DAILY
11. biotin 1 mg oral DAILY
12. Ferrous Sulfate 325 mg PO DAILY
13. FoLIC Acid 1 mg PO DAILY
14. Vitamin D 1000 UNIT PO DAILY
15. Zinc Sulfate 220 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
uterine fibroids, abnormal uterine bleeding, septic shock,
narrow-complex tachycardia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You originally came to the hospital because of heavy vaginal
bleeding. The bleeding did not respond to medications, so you
underwent a procedure to block the blood supply to the uterus.
Unfortunately, you developed a serious infection that spread to
your blood-stream. In order to treat the infection, you had a
hysterectomy to remove your uterus. Afterwards, you stayed in
the intensive care unit (ICU) because you were very sick and you
needed medicine to keep your blood pressures normal. You
received antibiotics to treat the infection as well, and will go
home on antibiotics. Thankfully, this procedure is the
definitive treatment for vaginal bleeding, and your blood counts
have remained stable since.
Once you left the ICU, your heart was in an abnormally fast
rhythm. We evaluated you for some causes of this, including an
echocardiogram (ultrasound of the heart), which were all normal.
However, you went into this rhythm again, so were started on a
medication to prevent your heart from going too fast again
(metoprolol).
You have recovered well on oral pain medications and
antibiotics. The team feels that you are ready to leave the
hospital.
Please follow these instructions:
* Take your medications as prescribed. We recommend you take
non-narcotics (i.e. Tylenol, ibuprofen) regularly for the first
few days post-operatively, and use the narcotic as needed. As
you start to feel better and need less medication, you should
decrease/stop the narcotic first.
* Take a stool softener to prevent constipation. You were
prescribed Colace. If you continue to feel constipated and have
not had a bowel movement within 48hrs of leaving the hospital
you can take a gentle laxative such as milk of magnesium.
* Do not drive while taking narcotics.
* Do not combine narcotic and sedative medications or alcohol.
* Do not take more than 4000mg acetaminophen (tylenol) in 24
hrs.
* No strenuous activity until your post-op appointment.
* Nothing in the vagina (no tampons, no douching, no sex) for 12
weeks.
* No heavy lifting of objects >10 lbs for 6 weeks.
* You may eat a regular diet.
* It is safe to walk up stairs.
.
Incision care:
* You may shower and allow soapy water to run over incision; no
scrubbing of incision. No bath tubs for 6 weeks.
* You should remove your port site dressings ___ days after your
surgery, if they have not already been removed in the hospital.
Leave your steri-strips on. If they are still on after ___
days from surgery, you may remove them.
* If you have staples, they will be removed at your follow-up
visit.
.
To reach medical records to get the records from this
hospitalization sent to your doctor at home, call ___.
Best wishes on your continued recovery,
Your ___ GYN Oncology team
Followup Instructions:
___
|
19701004-DS-4
| 19,701,004 | 26,753,772 |
DS
| 4 |
2161-10-08 00:00:00
|
2161-10-10 10:39:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Syncope
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ yo M with PMH of HTN, HLD, and CKD who presents with syncope.
Patient is in his usual state of health. Last evening he was
having dinner after which he began to feel faint. He walked to
bathroom and began to feel increasingly lightheaded and
nauseous. ___ down on a step stool in kitchen. Per wife's
report, he became ashen, arms started shaking, and he passed
out. His head came to rest on microwave so there was no head
strike. LOC for few seconds per wife. Patient came to, vomited a
few times, was diaphoretic, but quickly regained his bearing.
EMS was called and noted patient to be hypotensive in field.
There was no tongue biting or incontinence. Denies preceding
chest pain, palpitations, and dyspnea. Notably, patient's
god-daughter who lives with him felt unwell earlier this week
with lightheadedness and nausea.
In the ED, intial vitals were: 97.4, 60, 130/65, 16, 100% on
NRB. Labs significant for a negative troponin and a Cr of 1.7
(baseline). EKG remarkable for NSR, normal axis, normal
intervals, Q waves in inferior leads, and no ST changes. CXR
showed elevation of the right hemidiaphragm, unknown chronicity,
and CT head showed no acute intracranial process. Patient given
full-strength ASA and Zofran. After transfer to floor, patient
denies fever/chills, chest pain, dyspnea, abdominal pain,
N/V/D/C, urinary symptoms. This morning, patient is comfortable
and feels ready to go home.
Past Medical History:
- Hypertension
- Hyperlipidemia
- Chronic kidney disease with baseline Cr 1.7-1.8
- Prostate cancer
- Lumbar spinal stenosis s/p multiple injections
- Left inguinal hernia
- Appendectomy
Social History:
___
Family History:
- Mother died of CVA at ___ years
- Father died of "hardening of the arteries" at ___ years
- Brother died of MI at ___ years
- Sister with ___ recently died
Physical Exam:
Vitals: 98.5, 77, 132/88, 20, 95% RA, not orthostatic
General: Well-appearing male in no distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: Supple, JVP not elevated, no LAD
CV: RRR, nl S1/S2, no MRG
Lungs: CTAB, no wheezes/rales/rhonchi
Abdomen: Soft, NTND, bowel sounds present
GU: No Foley
Ext: Warm, well perfused, no cyanosis/clubbing/edema
Neuro: CN II-XII intact, strength and sensation grossly intact,
intention tremor on FTN but HTS and RAM are within normal
limits, gait stable and unremarkable
Pertinent Results:
ADMISSION LABS
___ 08:00PM BLOOD WBC-5.6 RBC-3.93* Hgb-12.1* Hct-37.3*
MCV-95 MCH-30.7 MCHC-32.3 RDW-13.2 Plt ___
___ 08:00PM BLOOD Neuts-65.4 ___ Monos-6.5 Eos-4.2*
Baso-0.5
___ 08:00PM BLOOD Glucose-162* UreaN-36* Creat-1.7* Na-143
K-3.6 Cl-105 HCO3-27 AnGap-15
___ 08:00PM BLOOD ALT-20 AST-28 AlkPhos-61 TotBili-0.3
___ 08:00PM BLOOD Lipase-31
___ 08:00PM BLOOD Albumin-4.2 Calcium-9.9 Phos-4.1 Mg-2.2
PERTINENT LABS
___ 08:00PM BLOOD cTropnT-<0.01
___ 07:05AM BLOOD cTropnT-<0.01
DISCHARGE LABS
___:05AM BLOOD WBC-5.3 RBC-3.94* Hgb-12.2* Hct-36.8*
MCV-94 MCH-30.9 MCHC-33.0 RDW-12.6 Plt ___
___ 07:05AM BLOOD Glucose-84 UreaN-31* Creat-1.6* Na-146*
K-3.8 Cl-109* HCO3-28 AnGap-13
___ 07:05AM BLOOD Calcium-9.6 Phos-3.7 Mg-2.1
IMAGING
CT head (___): No acute intracranial process.
CXR (___): Elevation the right hemidiaphragm, unknown
chronicity. Mild bibasilar atelectasis.
EKG: NSR, NA/NI, Q waves in inferior leads, no ST changes
Brief Hospital Course:
___ yo M with PMH of HTN, HLD, and CKD who presents with syncope.
ACTIVE ISSUES
# Syncope: Patient with preceding lightheadedness and nausea
making episode of vasovagal syncope most likely. Seizure less
likely given absence of tongue biting, incontinence, or
post-ictal state. Cardiac etiology also less likely given that
there was no preceding chest pain, palpitations, or SOB. EKG in
the ED was completely unremarkable. Cardiac biomarkers were
normal and subsequent monitoring on telemetry was unremarkable.
CT head was normal and neurologic exam was entirely within
normal limits. Patient not orthostatic in ED or on floor.
Because of this, it is highly likely that syncope was a
vasovagal episode. Patient was discharged with recommendation to
follow-up with PCP early next week and to call him or come to
the ED should this happen again.
# Nausea and vomiting: ___ be viral in etiology given sick
contacts. Had already improved on admission to the floor. No
fevers or leukocytosis. LFT's and lipase were unremarkable.
Managed with Zofran as needed.
CHRONIC ISSUES
# Hypertension: Patient was reportedly hypotensive in the field
but has been normotensive to slightly hypertensive while in
hospital. Held home blood pressure medications in hospital.
Restarted all with exception of amlodipine on discharge.
Recommended that patient discuss restarting on follow-up with
PCP.
# Hyperlipidemia: Continued home pravastatin.
# Chronic kidney disease: Stage III with baseline Cr of 1.7-1.8.
Held home antihypertensives, including losartan, as above.
Continued his home calcitriol. Renally dosed all medications and
avoided nephrotoxins.
# Lower back pain: Continued home tramadol and Tylenol as
needed.
TRANSITIONAL ISSUES
- Home amlodipine held on discharge. Consider restarting.
- Advised patient to call PCP or go to ED if syncope reoccurs
- Advised patient to drink plenty of fluids
- Patient instructed to schedule follow-up with PCP for early
next week
- Consider physical therapy and/or fall screen as outpatient
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amlodipine 10 mg PO DAILY
2. Atenolol 25 mg PO DAILY
3. Calcitriol 0.25 mcg PO 3X/WEEK (___)
4. Furosemide 20 mg PO DAILY
5. Losartan Potassium 25 mg PO DAILY
6. Pravastatin 80 mg PO HS
7. TraMADOL (Ultram) 50 mg PO Q8H:PRN pain
8. Acetaminophen 1000 mg PO Q8H:PRN pain
9. Aspirin 81 mg PO DAILY
10. Multivitamins 1 TAB PO DAILY
11. Fish Oil (Omega 3) ___ mg PO BID
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H:PRN pain
2. Aspirin 81 mg PO DAILY
3. Calcitriol 0.25 mcg PO 3X/WEEK (___)
4. Multivitamins 1 TAB PO DAILY
5. Pravastatin 80 mg PO HS
6. TraMADOL (Ultram) 50 mg PO Q8H:PRN pain
7. Atenolol 25 mg PO DAILY
8. Fish Oil (Omega 3) ___ mg PO BID
9. Furosemide 20 mg PO DAILY
10. Losartan Potassium 25 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Vasovagal syncope
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 after
passing out at home. We got a CT scan of your head which showed
nothing concerning. We also monitored your heart and found no
evidence of a cardiac problem. Because of this, we are confident
that your passing out was a vasovagal episode. This is fairly
common and it is not at all concerning.
Please take all of your medications as listed below. Please do
not take amlodipine until you follow-up with your PCP. Please
schedule follow-up with your PCP for early next week.
Followup Instructions:
___
|
19701811-DS-13
| 19,701,811 | 26,456,140 |
DS
| 13 |
2117-01-06 00:00:00
|
2117-01-08 10:19:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
Ativan / Percocet
Attending: ___.
Chief Complaint:
L leg pain
Major Surgical or Invasive Procedure:
___ Intramedullary fixation with TFN nail for L femur fracture
History of Present Illness:
___ yo female s/p pivot on L leg with snap and femur fx. Taken to
___, then to ___ for further care.
Past Medical History:
cardiac disease, angioplasty ___ yrs ago
old R and L hip fxs, hardware removed on left
report of "fx" on left femur ___ yr ago but pt remained wbat
gerd
osteoporsis
hypothyroid
Social History:
___
Family History:
nc
Physical Exam:
98.2 60 116/43 16 99%
NAD, AOx3
BUE skin clean and intact
No tenderness, deformity, erythema, edema, induration or
ecchymosis
Arms and forearms are soft
No pain with passive motion
R M U ___
EPL FPL EIP EDC FDP FDI fire
2+ radial pulses
RLE skin clean and intact
No tenderness, deformity, erythema, edema, induration or
ecchymosis
Thighs and legs are soft
No pain with passive motion
Saph Sural DPN SPN MPN LPN ___ FHL ___ TA PP Fire
dp and pt dopplar signals present, pulses not palp
LLE skin clean and intact
2 incisions on lateral aspect of thigh; c/d/i
tender to palpation
Thighs and legs are soft
Saph Sural DPN SPN MPN LPN ___ FHL ___ TA PP Fire
dp and pt dopplar signals present, pulses not palp
Pertinent Results:
___ 07:10PM K+-4.9
___ 06:45PM GLUCOSE-91 UREA N-21* CREAT-0.9 SODIUM-141
POTASSIUM-5.9* CHLORIDE-104 TOTAL CO2-28 ANION GAP-15
___ 06:45PM estGFR-Using this
Brief Hospital Course:
The patient was admitted to the Orthopaedic Trauma Service for
repair of a L TFN. The patient was taken to the OR and
underwent an uncomplicated L TFN. The patient tolerated the
procedure without complications and was transferred to the PACU
in stable condition. Please see operative report for details.
Post operatively pain was controlled with a PCA with a
transition to PO pain meds once tolerating POs. The patient
tolerated diet advancement without difficulty and made steady
progress with ___.
Weight bearing status: WBAT.
The patient received ___ antibiotics as well as
lovenox for DVT prophylaxis. The incision was clean, dry, and
intact without evidence of erythema or drainage; and the
extremity was NVI distally throughout. The patient was
discharged in stable condition with written instructions
concerning precautionary instructions and the appropriate
follow-up care. The patient will be continued on chemical DVT
prophylaxis for 2 weeks post-operatively. All questions were
answered prior to discharge and the patient expressed readiness
for discharge.
Medications on Admission:
menocycline - 60mg BID
alendornate 70mg qweekly
simvastatin 80 qpm
diltiazem 60mg tid
isosorbide dinatrate 20mg tid
atenolol 60mg 1.5 daily
levothyroxin 50mcg daily
chlorthalidone 25mg daily
OTC:
pantoprazole 40 mg/day
Calcium
Vit D3
Pervision
multivit
naproxen 500 mg BID
prilosec 20 mg/day
Discharge Medications:
1. Artificial Tears ___ DROP BOTH EYES PRN dry eyes
2. Aspirin EC 81 mg PO DAILY
3. Calcium Carbonate 500 mg PO TID
4. Diltiazem 60 mg PO TID
5. Docusate Sodium 100 mg PO BID
6. Enoxaparin Sodium 40 mg SC DAILY Duration: 2 Weeks
RX *enoxaparin 40 mg/0.4 mL inject into abdomen at bedtime Disp
#*14 Syringe Refills:*0
7. Hydrocodone-Acetaminophen (5mg-500mg 2 TAB PO Q6H:PRN pain
not to exceed 4mg total acetamenophen/day (8tabs/day)
RX *hydrocodone-acetaminophen 5 mg-500 mg take 2 Capsule(s) by
mouth q6hrs Disp #*60 Capsule Refills:*0
8. Isosorbide Mononitrate 20 mg PO BID
9. Levothyroxine Sodium 50 mcg PO DAILY
10. Metoprolol Succinate XL 25 mg PO DAILY
hold for BP<110, HR<60
11. Milk of Magnesia 30 ml PO BID:PRN Constipation
12. Multivitamins 1 CAP PO DAILY
13. Senna 1 TAB PO BID
14. Simvastatin 40 mg PO DAILY
15. Vitamin D 400 UNIT PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
s/p Intramedullary fixation with TFN nail for L femur fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
******SIGNS OF INFECTION**********
Please return to the emergency department or notify MD if you
should experience severe pain, increased swelling, decreased
sensation, difficulty with movement; fevers >101.5, chills,
redness or drainage at the incision site; chest pain, shortness
of breath or any other concerns.
-Wound Care: You can get the wound wet/take a shower starting
from 3 days post-op. 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 continued to be non-draining.
******WEIGHT-BEARING*******
Weight bearing as tolerated Left Leg
******MEDICATIONS***********
- Resume your pre-hospital medications.
- You have been given medication for your pain control. Please
do not operate heavy machinery or drink alcohol when taking this
medication. As your pain improves please decrease the amount of
pain medication. This medication can cause constipation, so you
should drink ___ glasses of water daily and take a stool
softener (colace) to prevent this side effect.
-Medication refills cannot be written after 12 noon on ___.
*****ANTICOAGULATION******
- Take Lovenox for DVT prophylaxis for 2 weeks post-operatively.
******FOLLOW-UP**********
Please have your staples removed at your rehabilitation facility
at post-operative day 14.
Please follow up with ___ in ___ days
post-operation for evaluation. Call ___ to schedule
appointment upon discharge.
Physical Therapy:
WBAT LLE
Treatments Frequency:
dry to dry; standard care.
Followup Instructions:
___
|
19701995-DS-3
| 19,701,995 | 22,337,733 |
DS
| 3 |
2133-07-17 00:00:00
|
2133-07-17 12:45:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
Iodinated Contrast- Oral and IV Dye
Attending: ___
Chief Complaint:
Vertigo, blurred vision, unsteadiness, and left hearing loss
Major Surgical or Invasive Procedure:
None
History of Present Illness:
The pt is a ___ year old man with history of hypertension,
bladder
cancer s/p resection in ___, hyponatremia, ulcerative colitis,
who presented with acute onset vertigo, blurred vision,
unsteadiness, left hearing loss, and nausea, for which he
received IV tPA and was transferred to ___.
The patient was in his usual state of health earlier this
evening
and was helping his friend install a heater in his boat. He was
seated at the sofa in the boat and upon standing and turning his
head at 17:40, he experienced acute onset of the sensation of
his
head and the world spinning, as well as blurred vision and
hearing loss in the left ear feeling like "muffled hearing". In
addition, he has had constant tinnitus as well as unsteadiness,
and was unable to ambulate further. He states he felt like he
was
"in a fog" but later clarified that he did not experience any
confusion or cognitive deficits. He also experienced an
intermittent right frontal headache and few episodes of nausea.
He was taken to ___ where a tele code stroke was called.
NCHCT was unremarkable, however CTA head/neck revealed multiple
filling defects in the bilateral vertebrobasilar system,
including the entire V2 segment of the right vertebral artery, a
small intracranial portion of the left vertebral artery, and a
small portion of the basilar artery. He was given IV tPA at
20:22, and transferred to ___ via medflight for further
evaluation.
At ___, he reports improvement in most of his symptoms,
including his headache, blurred vision, and vertigo. He can now
see almost clearly out of his right eye and still mildly blurred
from his left eye. However he remains with his hearing loss and
tinnitus in the left ear. He does endorse binocular diplopia in
left gaze only.
Past Medical History:
Hypertension
Bladder cancer
Hyponatremia
Ulcerative colitis
Social History:
___
Family History:
Maternal grandfather and aunt with MI.
Physical Exam:
ADMISSION EXAM
Vitals: temp 97.6 HR 57 BP 129/67 RR 12 spO2 98% RA
General: awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: supple, no nuchal rigidity
Pulmonary: breathing comfortably on room air
Cardiac: RRR, nl
Abdomen: soft, NT/ND
Extremities: warm, well perfused
Skin: no rashes or lesions noted
Neurologic:
-Mental Status: Awake, alert although if not stimulated will at
times drift to sleep, but easily arousable, oriented x3. Able to
relate history although occasionally vague on details.
Attentive,
able to name ___ backward without difficulty. Language is fluent
with intact repetition and comprehension. Normal prosody. There
were no paraphasic errors. Pt was able to name both high and low
frequency objects. Able to read without difficulty. Able to
follow both midline and appendicular commands. There was no
evidence of apraxia or neglect.
-Cranial Nerves:
II, III, IV, VI: PERRL 2 to 1.5mm. There is both vertical and
horizontal misalignment at rest. EOMI with bilateral
direction-changing endgaze nystagmus, though convergence is
limited. Hypometric saccades to left. VFF to confrontation.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Significant difficulty with hearing on left. Hearing
intact
to finger-rub on right and finger snap on left. ___ and ___
tests both negative.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally. No adventitious movements, such as tremor, noted.
No
asterixis noted.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 5 ___ ___ 5 5 5 5 5 5 5
R 5 ___ ___ 5 5 5 5 5 5 5
-Sensory: No deficits to light touch, cold sensation, vibratory
sense throughout. No extinction to DSS.
-DTRs:
Bi Tri ___ Pat Ach
L 2+ 2+ 2+ 1 1
R 2 2 2 1 1
Plantar response was flexor bilaterally.
-Coordination: Mild dysmetria on left FNF and HKS.
-Gait: Pt declined gait exam for fear of falling.
=================================================
DISCHARGE EXAM
-Mental Status: Awake, Alert, Attentive. Speech is not
dysarthric. Language is fluent. Able to follow simple and
complex commands.
-Cranial Nerves:
II, III, IV, VI: PERRL 4 to 3 bilateral. EOMI with endgaze
nystagmus, extinguishable. VFF to confrontation.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally.
Delt Tri WrE IP Ham TA
L ___ ___
R ___ ___
-Sensory: No deficits to light touch,
-Coordination: Mild bilateral intention tremor, subtle dysmetria
on FNF bilaterally (L>R). Subtle slowing/arrhythmia of finger to
crease (L>R). No dysmetria on HKS. No drift. No dysmetria.
-Strength 5
Pertinent Results:
HEMATOLOGY AND CHEMISTRIES
___ 05:43AM BLOOD Na-137
___ 11:41PM BLOOD Glucose-106* UreaN-12 Creat-0.7 Na-135
K-3.6 Cl-97 HCO3-23 AnGap-15
___ 11:41PM BLOOD WBC-5.4 RBC-3.41* Hgb-11.6* Hct-32.7*
MCV-96 MCH-34.0* MCHC-35.5 RDW-13.8 RDWSD-49.1* Plt ___
___ 11:41PM BLOOD ___ PTT-29.4 ___
___ 11:41PM BLOOD Glucose-106* UreaN-12 Creat-0.7 Na-135
K-3.6 Cl-97 HCO3-23 AnGap-15
___ 11:41PM BLOOD Calcium-8.7 Phos-4.0 Mg-1.6
___ 03:42AM BLOOD %HbA1c-5.4 eAG-108
___ 03:42AM BLOOD Triglyc-39 HDL-67 CHOL/HD-3.0 LDLcalc-124
___ 03:42AM BLOOD TSH-2.5
___ 03:42AM BLOOD CRP-1.3
___ 11:53PM BLOOD PROTEIN C ANTIGEN-PND
___ 11:53PM BLOOD ProtSFn-56
___ 11:53PM BLOOD Lupus-NEG
Antithrombin Antigen P 63% [Ref. 80-120]
IMAGING
CT HEAD W/O CONTRAST ___ 11:09 ___
1. No acute hemorrhage.
2. Unchanged linear hypodensity in the left cerebellar
hemisphere. Please
refer to the ___ MRI report for further detail.
MR HEAD & MRA BRAIN W/O CONTRAST; MRA NECK W&W/O CONTRAST
___ 11:45 AM
1. Acute to early subacute infarctions with hemorrhagic
transformation, large in the left cerebellar hemisphere with
superior and inferior involvement, moderate in the inferior
right cerebellar hemisphere, and also involving bilateral
cerebellar tonsils and a small portion of the left superior
vermis.
2. Minimal effacement of the fourth ventricle and mild rightward
displacement of the fourth ventricle, new since the ___
CTs. No supratentorial hydrocephalus.
3. Findings concerning for right vertebral dissection from its
origin through the V2 segment with questionable involvement of
the V3 segment, with occlusion of the proximal V1 segment.
Please note that evaluation for dissection is limited because
the axial T1 weighted fat-suppressed images were obtained after,
rather than before intravenous contrast administration.
4. Flow is seen within bilateral proximal PICAs, basilar artery,
in the left AICA with infundibular origin, in bilateral superior
cerebellar arteries with infundibular origins, and within
bilateral posterior cerebral arteries with fetal type
configuration.
MRI & MRA BRAIN, W/O CONTRAST; MRA NECK W/O CONTRAST ___
1:39 AM
1. Study is mildly degraded by motion.
2. Interval evolution of bilateral cerebellar subacute infarcts
with edema and mass effect and left inferior cerebellar
petechial hemorrhage. Question
minimal interval down a progression of cerebellar tonsils with
grossly
preserved fourth ventricle.
3. Within limits of study, no definite new infarct.
4. Nonvisualization of right V1 and V2 vertebral artery segments
grossly
similar to ___ prior exam, again concerning for
occlusion.
5. Left V4 segment narrowing versus right V4 segment dominance
is again noted, grossly similar to ___ prior exam.
6. There is limited visualization of bilateral V3 and proximal
V4 segments
grossly similar to prior exam. Finding may represent artifact,
steno-occlusive disease is not excluded on the basis of this
examination. If clinically indicated, consider neck CTA for
further evaluation.
7. No ICA stenosis by NASCET criteria.
TTE
Likely patent foramen ovale with premature appearance of
agitated saline in the left heart with maneuvers/cough. Mildly
dilated ascending aorta. Normal biventricular cavity sizes with
preserved regional and global biventricular systolic function.
No valvular pathology or pathologic flow identified.
BILAT LOWER EXT VEINS
Left compressibility or color flow in 1 of the left posterior
tibial veins,
consistent with deep venous thrombosis.
CT CHEST W/CONTRAST
No evidence of metastatic disease in the chest. The imaged base
of neck including the partially visualized thyroid is notable
for a small calcified nodule in the posterior left lobe
measuring 11 mm. A calcified granuloma in the right upper lobe
noted.
CT ABD & PELVIS WITH CONTRAST
1. No acute process in the abdomen or pelvis. No suspicious
mass in the
abdomen or pelvis. Note the current exam does not exclude
bladder lesion.
2. Gas in bladder, please correlate with recent history of
instrumentation.
3. Please see separate report performed on same day for detailed
evaluation of the chest.
Brief Hospital Course:
HOSPITAL COURSE BY PROBLEM
___ w/ history notable for bladder cancer s/p resection, HTN,
and hyponatremia admitted with acute-onset vertigo, hearing
loss, diplopia, and disequilibrium, found to have left > right
cerebellar ischemic infarction with hemorrhagic conversion as
well as right vertebral artery dissection, s/p tPA
administration at ___ prior to transfer. Inpatient
management notable for administration of hypertonic saline to
prevent cerebral edema, which was not noted during monitoring in
the neurosciences ICU or intermediate care unit. Inpatient
evaluation notable for: A1c 5%, LDL 124 (started on atorvastatin
80), and PFO with LLE DVT, prompting initiation of
anticoagulation with apixaban. Evaluation for hypercoagulability
notable for mildly reduced antithrombin III levels, but CT of
the chest, abdomen, and pelvis did not reveal clear evidence of
new or recurrent malignancy. He will need outpatient genetic
testing (Factor 5 Leiden, ___ gene mutation) Physical therapy
evaluation recommended outpatient physical therapy; no
occupational therapy needs noted.
TRANSITIONAL ISSUES:
1. Follow up laboratory evaluation for hypercoagulability.
2. Outpatient neurology follow up
AHA/ASA Core Measures for Ischemic Stroke and Transient Ischemic
Attack
1. Dysphagia screening before any PO intake? () Yes, confirmed
done - (x) Not confirmed () No
2. DVT Prophylaxis administered? (x) Yes - () No
3. Antithrombotic therapy administered by end of hospital day 2?
(x) Yes - () No
4. LDL documented? (x) Yes (LDL = 124) - () No
5. Intensive statin therapy administered? (x) Yes - () No
6. Smoking cessation counseling given? () Yes - (x) No [reason
(x) non-smoker - () unable to participate]
7. Stroke education (personal modifiable risk factors, how to
activate EMS for stroke, stroke warning signs and symptoms,
prescribed medications, need for followup) given (verbally or
written)? (x) Yes - () No
8. Assessment for rehabilitation or rehab services considered?
(x) Yes - () No
9. Discharged on statin therapy? (x) Yes - () No
10. Discharged on antithrombotic therapy? (x) Yes [Type: ()
Antiplatelet - (x) Anticoagulation] - () No
11. Discharged on oral anticoagulation for patients with atrial
fibrillation/flutter? () Yes - () No - (x) N/A
Medications on Admission:
1. Prolensa (bromfenac) 0.07 % ophthalmic DAILY
2. Lisinopril 40 mg PO DAILY
3. ClonazePAM 1 mg PO QHS:PRN sleep/anxiety
4. Fludrocortisone Acetate 0.1 mg PO DAILY
5. Lialda (mesalamine) 1.2 gram oral BID
6. Sodium Chloride 1.5 gm PO DAILY
Discharge Medications:
1. Apixaban 5 mg PO BID
RX *apixaban [Eliquis] 5 mg 1 (One) tablet(s) by mouth twice a
day Disp #*30 Tablet Refills:*0
2. Atorvastatin 80 mg PO QPM
RX *atorvastatin 80 mg 1 (One) tablet(s) by mouth at bedtime
Disp #*30 Tablet Refills:*0
3. ClonazePAM 1 mg PO QHS:PRN sleep/anxiety
4. Fludrocortisone Acetate 0.1 mg PO DAILY
5. Lialda (mesalamine) 1.2 gram oral BID
6. Lisinopril 40 mg PO DAILY
7. Prolensa (bromfenac) 0.07 % ophthalmic DAILY
8. Sodium Chloride 1.5 gm PO DAILY
9. Outpatient Physical Therapy
Evaluate and treat following cerebellar ischemic infarct.
Discharge Disposition:
Home
Discharge Diagnosis:
Bilateral cerebellar ischemic strokes with hemorrhagic
conversion
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were admitted to ___ for
evaluation of sudden-onset dizziness, blurred vision,
unsteadiness, and hearing loss, resulting from an ACUTE ISCHEMIC
STROKE, a condition where a blood vessel providing oxygen and
nutrients to the brain is blocked by a clot. The brain is the
part of your body that controls and directs all the other parts
of your body, so damage to the brain from being deprived of its
blood supply can result in a variety of symptoms. Imaging of
your head showed strokes with some resultant bleeding in your
cerebellum (the part of your brain responsible for
coordination), as well as a torn vessel on the right side of the
back of your neck, called vertebral dissection. You received
tPA, a medication to help dissolve blood clots, when you
arrived, and were monitored in the ICU to look for brain
swelling. You did not experience concerning brain swelling
during your stay.
Stroke can have many different causes, so we assessed you for
medical conditions that might raise your risk of having stroke.
In order to prevent future strokes, we plan to modify those risk
factors. Your risk factors are:
High blood pressure
High Cholesterol
Patent Foramen Ovale (see below)
Blood Clots in Left Leg (see below)
A patent foramen ovale is a connection between the two upper
chambers of your heart, and given the blood clot in your lower
leg, it is possible for a clot to pass from your leg through the
connection within your heart into the brain. For this reason and
to prevent future strokes, you were started on a blood thinning
medication (apixaban) to prevent future strokes. We also checked
to see if you have any underlying predisposition to form blood
clots. Testing, including imaging of your chest and abdomen, so
far did not show a clear predisposition for blood clot
formation, but further testing will be done at your follow-up
visits.
Your medications were changed as follows:
START Apixaban 5 mg twice daily
START Atorvastatin 80 mg at bedtime
If you experience any of the symptoms below, please seek
emergency medical attention by calling Emergency Medical
Services (dialing 911). In particular, since stroke can recur,
please pay attention to the sudden onset and persistence of
these symptoms:
- Sudden partial or complete loss of vision
- Sudden loss of the ability to speak words from your mouth
- Sudden loss of the ability to understand others speaking to
you
- Sudden weakness of one side of the body
- Sudden drooping of one side of the face
- Sudden loss of sensation of one side of the body
It was a pleasure taking care of you at ___.
Sincerely,
Neurology at ___
Followup Instructions:
___
|
19702049-DS-20
| 19,702,049 | 22,288,318 |
DS
| 20 |
2148-09-20 00:00:00
|
2148-09-20 13:20:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
codeine / Vicodin
Attending: ___.
Chief Complaint:
L arm pain x5 days
Major Surgical or Invasive Procedure:
___ I&D
___ Washout in the OR
History of Present Illness:
___ with hx of IVDU (last use 1 month PTA), anxiety, UC on
asacol presenting with progressive LUE pain, erthema, edema, and
drainage x5 days. Reports that on ___ at work, one of
the tire machines kicked back and hit his arm. Was sore
immediately after but no opening. Progressed over the following
days, with increasing pain, began to notice greenish white foul
smelling discharge. No subjective fevers or chills. Initially
went to ___, where initial VS were 97.7, 105,
147/81, 20, 9 RA. Labs notable for WBC 18.7, Hb 10.3, CK 23. BCx
and wound cxs were sent. CT of LUE did not show evidence of deep
collection or gas; pt transferred to ___ for further surgical
evaluation. Prior to transfer, he received zofran 4 mg IV x1,
vancomycin/zosyn, and dilaudid 1 mg IV x2.
In the ___ ED:
18:26 8 100.4 ___ 22 98% RA
Today 21:56 102.3 113 131/85 20 95% RA
Today 21:56 102.3 113 131/85 20 95% RA
Exam remarkable for L arm red from hand to above elbow, skin
tense, warm, tender, radial pulse 2+. 2 cm ulcer forearm,
purulent discharge.
Labs notable for:
WBC 16.0
Hb 9.5
Cr 0.7
LA 0.7
Evaluated by surgery: bedside I&D performed
BCx sent
Ordered for:
dilaudid 1 mg IV x2
1L NS
Zofran 4 mg IV x1
Admitted to medicine for IV antibiotics.
On arrival to the floor, pain is ___. In the ED, dilaudid
"put me to sleep." At home he has been unable to sleep ___ pain.
Denies chest pain, SOB. No other open wounds. Pt reiterates that
pain in LUE began with injury at work. He states that has been
clean for approx 1 month prior to presentation. Reports that he
went to detox at ___ 1 month prior to
presentation, inpatient Behavioral Health Unit, where he was
treated for anxiety for ___ days. He reports that he has not
used heroin since he left detox.
ROS: positive for productive cough x1 week, denies sore throat,
headache, sinus pain, rhinorrhea. Reports his father had similar
URI sxs at home. All else negative.
Past Medical History:
ulcerative colitis - managed by Dr. ___ in ___,
___ Building across the street from ___
___
anxiety
seizures - has had two seizures in the setting of profound
anxiety
knee surgery x 2 - ACL replacement on R knee, and arthroscopic
meniscus surgery on R, believes that he may have small metal
attachment piece
Social History:
___
Family History:
Noncontributory to LUE soft tissue infection
Physical Exam:
Admission Exam
VS 100.4, 113, 139/80, 18, 96% RA
Gen: Pleasant male, intermittently groaning, interactive, NAD
HEENT: PERRL, EOMI, clear oropharynx, no cervical or
supraclavicular adenopathy, no scleral icterus or conjunctival
pallor
CV: RRR, I/VI systolic murmur at apex
Lungs: CTAB, no wheeze or rhonchi
Abd: soft, mildly tenderness to deep palpation throughout, no
rebound or guarding, nondistended, no hepatomegaly, +BS
Ext: Erythema extending just above L elbow, LUE firm, edematous,
with splint in place and ACE wraps over kerlex. Dressing removed
- diffuse erythema and induration of dorsal lateral L forearm,
with punched out ulceration, approx 2 cm in diameter and 1.5 cm
deep, with granulation tissue at base, with clear liquid
collected at base after soak
Neuro: grossly intact
Discharge Exam
VS: 98 54 137/98 18 98% RA
GEN: NAD, resting comfortably in bed
HEENT: EOMI, PERRLA, MMM
CV: RRR nl s1s2 no m/r/g
Resp: CTAB no w/w/r
Abd: soft, NT, ND +BS
Ext: left lower extremity wrapped with kerlex and ACE bandage.
Pertinent Results:
___ 09:49PM COMMENTS-GREEN TOP
___ 09:49PM LACTATE-0.7
___ 09:30PM GLUCOSE-116* UREA N-9 CREAT-0.7 SODIUM-136
POTASSIUM-3.8 CHLORIDE-98 TOTAL CO2-27 ANION GAP-15
___ 09:30PM estGFR-Using this
___ 09:30PM WBC-16.0* RBC-3.89* HGB-9.5* HCT-29.2*
MCV-75* MCH-24.4* MCHC-32.5 RDW-15.5 RDWSD-42.0
___ 09:30PM PLT COUNT-317
CT LUE from ___, read as per surgery c/s note: "non
contrast, no evidence of
gas formation, no deep fluid collection, possible superficial
fluid collection, extensive cellulitis"
EKG: Sinus tachycardia at 108 bpm, normal axis, PR 144, QTc 402,
no TWI or ST segment changes, no priors for comparison
Brief Hospital Course:
___ with hx of IVDU (last use 1 month PTA), anxiety, UC on
asacol presenting with progressive LUE pain, erthema, edema, and
drainage x5 days.
# Skin/soft tissue infection: S/p I&D in ED. BCx and wound cx
sent from ___, and bcx sent in ___ ED. Pt clearly
and consistently states that injury occurred at work, with blunt
injury, and denies IVDU in the last 1 month. Eventually further
history from other parties revealed that he had relapsed
recently and not injured himself at work, making the infection
likely related to IVDU. He was followed closely by the Hand
Surgery service, who performed a washout in the OR on ___
with good effect. Cultures from that grew multiple organisms.
He was treated with ampicillin/sulbactam and vancomycin with
good effect (especially once the vancomycin was therapeutic).
His wound was cared for with multiple daily dressing changes and
his arm was supported with a splint and kept elevated. Culture
results grew mixed bacterial flora
-Discharged on Bactrim and Augmentin for total 10 day course
starting on ___.
-BID dressing changes
-Follow-up in hand clinic in 1 week.
# IVDU and Cocaine use: He denied heroin use for past 1 month,
but we obtained information to the contrary. His urine was
positive for cocaine. Social Work was involved. His HIV test
was negative, as were his hepatitis serologies (he's Hep B
immune). He refused further services for drug rehabilitation.
# Cough: Fever most likely ___ L forearm soft tissue infection,
but pt does endorse productive cough x1 week. No rhonchi or
dullness appreciated on auscultation. CXR was normal.
# Ulcerative colitis: Continued home asacol
# Seizure disorder: Continued home keppra 500 mg BID.
# Anxiety: Continued home zoloft and hydroxyzine
# Stable microcytic anemia: suspect related to acute infection
and phlebotomy.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Mesalamine ___ 800 mg PO TID
2. Gabapentin 600 mg PO QID
3. HydrOXYzine 50 mg PO TID
4. Sertraline 150 mg PO DAILY
5. LeVETiracetam 500 mg PO BID
Discharge Medications:
1. Gabapentin 600 mg PO QID
2. HydrOXYzine 50 mg PO TID
3. LeVETiracetam 500 mg PO BID
4. Mesalamine ___ 800 mg PO TID
5. Sertraline 150 mg PO DAILY
6. Amoxicillin-Clavulanic Acid ___ mg PO Q12H Duration: 4 Days
RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tablet(s) by
mouth twice a day Disp #*8 Tablet Refills:*0
7. Sulfameth/Trimethoprim DS 2 TAB PO BID Duration: 4 Days
RX *sulfamethoxazole-trimethoprim 800 mg-160 mg 2 tablet(s) by
mouth twice a day Disp #*8 Tablet Refills:*0
8. Oxycodone-Acetaminophen (5mg-325mg) ___ TAB PO Q6H:PRN pain
RX *oxycodone-acetaminophen 5 mg-325 mg ___ tablet(s) by mouth
every six (6) hours Disp #*15 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Severe left forearm polymicrobial skin and soft tissue infection
IV drug use
Cocaine use
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted with a severe left forearm infection with an
abscess and cellulitis. You required initial incision and
drainage, and then to be taken to the OR on ___ for a
washout. After this, and with adjustment of your antibiotics,
you began to improve. It's important you receive ongoing care
for your wound so that it heals properly.
Followup Instructions:
___
|
19702121-DS-9
| 19,702,121 | 20,784,931 |
DS
| 9 |
2159-05-11 00:00:00
|
2159-05-12 15:23:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Simvastatin
Attending: ___.
Chief Complaint:
Headache, elevated ESR
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ gentleman with a history significant for
CLL (not on therapy), CAD, DM2 (on insulin), CKD (recent basline
Cr ___, and HTN who presents with headache.
Patient reports worsening frontal headache, soreness on scalp,
no fevers. He reports headache as being a pounding sensation.
Patient denies any pain with mastication. He reports worsening
over the last 3 days. Patient does not report any visual
symptoms. Denies any hx of CVA. Patient reports that he has been
having associated shoulder/hip pain over the last few weeks. Pt.
reports
that he was in his usual state of health until about two weeks
prior when he began to develop pain in his bilateral forearms.
This was followed by heaviness and aching in his bilateral
shoulders and aching of his bilateral knee caps. He became
progressively more fatigued and weak over the subsequent two
weeks. He has been attributing these symptoms to his renal
failure. He denies any morning nausea/vomitting/headache.
Patient was seen in ID and ___ clinic with regards to
systemic symptoms where infectious work up was done and came
back as negative.
In the ED initial vitals were: 98.1 60 154/66 18 96% RA
- Labs were significant for ESR of 46
- Patient was given 100mg prednisone.
Vitals prior to transfer were: 98.1 60 154/66 18 96% RA
On the floor, patient appeared very comfortable and his headache
had resolved. When further questionned, appears that patient had
not received prednisone in the ED. Was given stat dose of
prednisone on floor.
Past Medical History:
1. Coronary artery disease.
2. Right sternoclavicular joint arthritis.
3. Diabetes type 2.
4. Hyperlipidemia.
5. Hypertension.
6. Obesity.
7. Peripheral vascular disease.
8. CLL.
9. Hyperuricemia.
10. He has a history of several vascular stents, status post PCI
in ___ with stenting of LAD.
11. Stenting of right SFA in ___.
12. PCA to RCA in ___.
Social History:
___
Family History:
Father died of a myocardial infarction in ___ at age ___. Mom
died of lung and breast CA at the age of ___. Brothers with
prostate CA.
Physical Exam:
ADMISSION PHYSICAL
Vitals - T:98.2 BP:160/72 HR:88 RR:18 02 sat:97
GENERAL: NAD
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM, good dentition. Scalp tenderness.
NECK: nontender supple neck, no LAD, no JVD
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs
LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: no cyanosis, clubbing or edema, moving all 4
extremities with purpose
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
DISCHARGE PHYSICAL
Vitals - T:98.2/97.5 ___ 58-60 20 97-100%
GENERAL: NAD
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM, good dentition. Tender to palpation to skin overlying right
temporal area, no erythema or edema.
NECK: nontender supple neck, no carotid bruits, no JVD
CARDIAC: Regular rate, normal rhythm, normal 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: warm, well-perfused, no cyanosis, clubbing or edema
NEURO: CN II-XII intact
SKIN: healing scabs on bilateral knees
Pertinent Results:
ADMISSION LABS
___ 09:20PM BLOOD WBC-39.9* RBC-3.85* Hgb-11.3* Hct-33.8*
MCV-88 MCH-29.4 MCHC-33.6 RDW-16.1* Plt ___
___ 09:20PM BLOOD Neuts-20.0* Lymphs-75.8* Monos-1.8*
Eos-2.1 Baso-0.3
___ 09:20PM BLOOD Hypochr-NORMAL Anisocy-NORMAL
Poiklo-NORMAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL
___ 09:20PM BLOOD ___ PTT-29.3 ___
___ 09:20PM BLOOD Glucose-174* UreaN-72* Creat-3.4* Na-140
K-4.2 Cl-106 HCO3-22 AnGap-16
___ 09:20PM BLOOD Calcium-9.3 Phos-4.1 Mg-2.2
___ 09:20PM BLOOD CRP-1.1
___ 10:11PM BLOOD SED RATE-PND
___ 11:10PM URINE Color-Straw Appear-Clear Sp ___
___ 11:10PM URINE Blood-NEG Nitrite-NEG Protein-100
Glucose-TR Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
___ 11:10PM URINE RBC-<1 WBC-<1 Bacteri-FEW Yeast-NONE
Epi-0
___ 11:10PM URINE CastHy-7*
DISCHARGE LABS
___ 06:20AM BLOOD WBC-39.2* RBC-3.93* Hgb-11.3* Hct-34.3*
MCV-87 MCH-28.7 MCHC-32.9 RDW-15.7* Plt ___
___ 06:20AM BLOOD ___ PTT-30.1 ___
___ 06:20AM BLOOD Glucose-194* UreaN-69* Creat-3.2* Na-140
K-4.4 Cl-106 HCO3-24 AnGap-14
___ 06:20AM BLOOD CK(CPK)-75
___ 06:20AM BLOOD Calcium-9.2 Phos-2.9 Mg-2.2
IMAGING
Non-contrast HCT
IMPRESSION:
No acute intracranial process.
CXR
IMPRESSION:
No acute cardiopulmonary process.
Brief Hospital Course:
Mr. ___ is a ___ gentleman with longstanding chronic
renal failure secondary to hypertension and diabetes presenting
with new onset headache with elevated ESR and constitutional
symptoms of fatigue and proximal muscle weakness. He was
diagnosed with likely GCA and PMR. He was started on a course of
high-dose prednisone and discharged with instructions to have a
temporal artery biopsy done as an outpatient by Vascular
Surgery, and to follow-up with Rheumatology within a few days.
#HEADACHE: New onset right-sided headache for the last several
days, in setting of elevated ESR and scalp tenderness was felt
to be most consistent with GCA. The patient denied any vision
changes and jaw claudication. Patient had CT head done in ED
which r/o intracranial process. He was given one dose of 100mg
prednisone and discharged on a 14-day course of prednisone with
close follow-up with Vascular surgery and Rheumatology. A
temporal biopsy was planned to be done shortly in the outpatient
setting. He was counseled about needing to increase his insulin
due to the steroid use, and discharged on humalog sliding scale.
He also was started on a proton pump inhibitor and calcium was
added to his medications as well. He is already on vitamin D and
aspirin.
#MYALGIAS, FATIGUE with PROXIMAL MUSCLE WEAKNESS: The patient
described ongoing smptoms of fatigue, prozimal muscle weakness
and constitutional symptoms for the past two months. The work-up
for this has been unrevealing thus far. Given the patient's
likely diagnosis of GCA, these symptoms were felt to be
concerning for consistent Polymyalgia Rheumatica. His CK was
normal.
#HTN: The patient had SBPs in 150s-160s during his brief
hospitalizztion. Although he had not received his AM
medications, given intensive steroid therapy, he should monitor
his blood pressure for increases and consider changing from
atenolol to labetolol given his already declining kidney
function.
#DM: Patient was continued on his home lantus and given a
sliding scale. He should follow-up with ___ regarding
controlling his sugars while on steroids.
#ESRD: Undergoing evaluation for dialysis vs transplant.
Scheduled to come into clinic on ___ to see transplant team.
This was rescheduled for the patient.
#CLL, indolent: Currently stable. Patient has never required
treatment, was diagnosed ___. Expected possible bump in WBC
with steroid use.
#HLD: Stable. Home statin continued.
TRANSITIONAL ISSUES
- temporal artery biopsy and rheumatology followup for suspected
GCA
- monitor blood pressures and glucose while on steroids and
adjust medications as needed
- If patient is to continue on high-dose steroids, please
consider adding prophylaxis with Bactrim
- Follow-up pending ESR
Of note, when the patient was admitted it was anticipated that
he would require inpatient hospitalization for at least two
midnights given need for biopsy and concern for difficult to
control blood sugars and blood pressures while on steroids.
Given his rapid improvement on steroids and ability to manage
his blood sugars/blood pressures at home, he was discharged
earlier than anticipated.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lisinopril 20 mg PO DAILY
2. Diltiazem Extended-Release 360 mg PO DAILY
3. Atenolol 50 mg PO DAILY
4. Atorvastatin 20 mg PO DAILY
5. liraglutide 0.6 mg/0.1 mL (18 mg/3 mL) subcutaneous daily
6. Glargine 60 Units Breakfast
7. Clopidogrel 75 mg PO DAILY
8. Aspirin 81 mg PO DAILY
9. Fluoxetine 20 mg PO DAILY
10. glimepiride 4 mg oral daily
11. Hydrochlorothiazide 25 mg PO DAILY
12. Vitamin D 1000 UNIT PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Atenolol 50 mg PO DAILY
3. Atorvastatin 20 mg PO DAILY
4. Clopidogrel 75 mg PO DAILY
5. Diltiazem Extended-Release 360 mg PO DAILY
6. Fluoxetine 20 mg PO DAILY
7. Hydrochlorothiazide 25 mg PO DAILY
8. Lisinopril 20 mg PO DAILY
9. Vitamin D 1000 UNIT PO DAILY
10. glimepiride 4 mg ORAL DAILY
11. liraglutide 0.6 mg/0.1 mL (18 mg/3 mL) subcutaneous daily
12. Glargine 60 Units Breakfast
Insulin SC Sliding Scale using HUM Insulin
RX *insulin lispro [Humalog KwikPen] 100 unit/mL 2 units SQ Up
to 8 Units QID per sliding scale Disp #*1 Syringe Refills:*0
13. PredniSONE 60 mg PO DAILY
Tapered dose - DOWN
RX *prednisone 20 mg 3 tablet(s) by mouth Daily Disp #*21 Tablet
Refills:*0
14. Pantoprazole 40 mg PO Q24H
RX *pantoprazole 40 mg 1 tablet(s) by mouth Daily before
breakfast Disp #*30 Tablet Refills:*0
15. Calcium Carbonate 1000 mg PO BID
Discharge Disposition:
Home
Discharge Diagnosis:
Giant Cell Arteritis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you during your hospitalization
at ___. You were admitted for a headache thought to be due to
Giant Cell Arteritis.
You will require a biopsy of one of the arteries near your ear
to formally diagnose this, which will be done next week.
You should monitor your blood pressure closely since steroids
can increase these. If your systolic blood pressure is greater
than 180, you should call your primary care doctor because you
may need your blood pressure medications changed.
We expect that your blood sugars to increase while you're on
steroids. Please check your blood sugars three times a day, and
use the sliding scale of insulin to cover for this.
Please follow-up with your doctors as listed below.
We wish you the best!
-Your ___ Team
Followup Instructions:
___
|
19702250-DS-23
| 19,702,250 | 25,005,973 |
DS
| 23 |
2180-06-20 00:00:00
|
2180-06-20 12:09:00
|
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
Shellfish / Tegaderm Frame Style / Lipitor
Attending: ___.
Chief Complaint:
Incarcerated abdominal hernia
Major Surgical or Invasive Procedure:
___: Open incisional hernia repair with mesh
History of Present Illness:
___ with hx of sigmoid colectomy after perforated
diverticulitis, CAD s/p stent x 1, sinus pause w syncopy s/p
pacer who was sent from primary care office today for concern of
symptomatic incisional hernia. He reports that he'd had 2 days
of
aching/crampy abdominal pain and tenderness at the site of a
prior incision which worsened significantly today. He also noted
the overlying skin becoming red today, and the lump firm and
will
not go back in. He has had multiple bowel movements over the
last
48 hours, some formed, some loose. They are non-painful,
non-bloody. He has never noticed any hernia symptoms before 3
days ago.
.
He denies nausea, vomiting, constipation, hematochezia, melena,
dysuria, fever, chills, unintentional weight loss, night sweats.
.
Colonoscopy last year was unremarkable per patient.
Past Medical History:
PMH: Diverticulitis, CAD s/p stent x 1, sinus pause with syncopy
s/p pacer,
asthma, GERD, OSA (untreated), dyspnea, cough, colonic polyps
PSH: sigmoid colectomy for perforated diverticulitis, bilateral
inguinal hernia repair
Social History:
___
Family History:
No history of GI cancers
Physical Exam:
DISCHARGE PHYSICAL EXAM:
VS: 98.0 140/56 80 20 92%RA
GEN: NAD, resting in bed quietly
HEENT: mucous membranes moist
RESP: slight scattered exp wheeze, no ronchi/rales
CARD: RRR
ABD: soft, non-distended, +BS, appropriately ttp, ventral
incision c/d/I with steri-strips, mild LLQ skin irritation from
abdominal binder with gauze dressing, abdominal binder in place,
diffuse ___ and bilateral lower quadrants resolving
ecchymosis.
EXT: no clubbing, cyanosis, edema
Pertinent Results:
ADMISSION LABS:
==========================
___ 05:50PM BLOOD WBC-8.8 RBC-5.08 Hgb-15.4 Hct-47.3 MCV-93
MCH-30.3 MCHC-32.6 RDW-15.2 RDWSD-52.1* Plt ___
___ 05:50PM BLOOD Neuts-61.3 ___ Monos-10.1 Eos-3.6
Baso-0.9 Im ___ AbsNeut-5.41 AbsLymp-2.08 AbsMono-0.89*
AbsEos-0.32 AbsBaso-0.08
___ 05:50PM BLOOD ___ PTT-33.5 ___
___ 05:50PM BLOOD Glucose-110* UreaN-16 Creat-0.9 Na-139
K-5.1 Cl-101 HCO3-24 AnGap-19
___ 05:50PM BLOOD Albumin-4.5 Calcium-9.9 Phos-3.3 Mg-2.1
___ 05:50PM BLOOD ALT-35 AST-49* AlkPhos-81 TotBili-0.3
___ 05:50PM BLOOD estGFR: >75
.
___ 07:00PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-10 Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
___ 07:00PM URINE Color-Yellow Appear-Clear Sp ___
.
.
MICROBIOLOGY:
==========================
___: URINE CULTURE (Final ___: <10,000
organisms/ml.
.
.
IMAGING:
==========================
___ CXR PA/Lat
FINDINGS:
PA and lateral views of the chest provided. Left chest wall
pacer device is seen again seen with dual leads extending into
the region of the right atrium and right ventricle. Mild left
basal atelectasis noted. Otherwise lungs are clear. No signs
of pneumonia, edema, effusion or pneumothorax.
Cardiomediastinal silhouette appears normal. Bony structures
are intact. No free air below the right hemidiaphragm.
Brief Hospital Course:
The patient presented to the clinic on ___ with
severe abdominal pain at the site of his existing incisional
hernia, which was only partially reducible. Thus, he was
admitted to the ___ and taken to the
operating room where he underwent an incisional hernia repair
with mesh; 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 oral oxycodone,
but changed to a morphine PCA and IV APAP on POD1 due to severe
uncontrolled pain. His pain was subsequently well controlled.
POD2 he was transitioned back to oral medications with good
control.
.
CV: The patient remained stable from a cardiovascular
standpoint; vital signs were routinely monitored.
.
Pulmonary: The patient remained stable from a pulmonary
standpoint; vital signs were routinely monitored. Early
ambulation was encouraged.
.
RESP: Good pulmonary toilet, early ambulation and incentive
spirometry were encouraged throughout hospitalization. He was
started on standing duonebs for the duration of his admission in
place of home symbicort.
.
GI/GU/FEN: The patient was initially kept NPO to await return of
bowel function. The diet was then 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.
.
At the time of discharge, the patient was doing well, afebrile
and hemodynamically stable. The patient was tolerating a diet,
ambulating, voiding without assistance, and pain was well
controlled. The patient received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with the discharge plan.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Finasteride 5 mg PO DAILY
2. Niacin SR 50 mg PO DAILY
3. Metoprolol Succinate XL 25 mg PO DAILY
4. Psyllium Powder 1 PKT PO TID:PRN constipation
5. Ezetimibe 10 mg PO DAILY
6. Fluticasone Propionate NASAL 2 SPRY NU DAILY:PRN allergies
7. Amlodipine 5 mg PO DAILY
8. Fluvastatin Sodium 20 mg oral DAILY
9. Multivitamins 1 TAB PO DAILY
10. budesonide-formoterol 160-4.5 mcg/actuation inhalation BID
11. Pantoprazole 40 mg PO Q12H
12. Hydrochlorothiazide 12.5 mg PO DAILY
13. Cetirizine 10 mg PO DAILY:PRN allergies
14. Aspirin (Buffered) 325 mg PO DAILY
15. Calcitrate-Vitamin D (calcium citrate-vitamin D3) 315-250
mg-unit oral DAILY
16. Albuterol Inhaler 2 PUFF IH Q4H:PRN wheeze/SOB
Discharge Medications:
1. Amlodipine 5 mg PO DAILY
2. Ezetimibe 10 mg PO DAILY
3. Finasteride 5 mg PO DAILY
4. Hydrochlorothiazide 12.5 mg PO DAILY
5. Metoprolol Succinate XL 25 mg PO DAILY
6. Niacin SR 50 mg PO DAILY
7. Pantoprazole 40 mg PO Q12H
8. Aspirin (Buffered) 325 mg PO DAILY
9. budesonide-formoterol 160-4.5 mcg/actuation inhalation BID
10. Calcitrate-Vitamin D (calcium citrate-vitamin D3) 315-250
mg-unit oral DAILY
11. Cetirizine 10 mg PO DAILY:PRN allergies
12. Fluticasone Propionate NASAL 2 SPRY NU DAILY:PRN allergies
13. Fluvastatin Sodium 20 mg ORAL DAILY
14. Multivitamins 1 TAB PO DAILY
15. Psyllium Powder 1 PKT PO TID:PRN constipation
16. Acetaminophen 1000 mg PO Q8H
Do not take more than 4g/day total
17. Docusate Sodium 100 mg PO BID
Don't drive or drink alcohol while taking
18. Senna 8.6 mg PO BID
19. Albuterol Inhaler 2 PUFF IH Q4H:PRN wheeze/SOB
20. HYDROmorphone (Dilaudid) ___ mg PO Q3H:PRN pain
Don't drive or drink alcohol while taking
RX *hydromorphone 2 mg ___ tablet(s) by mouth every 4 hours Disp
#*30 Tablet Refills:*0
21. Polyethylene Glycol 17 g PO DAILY:PRN constipation
Discharge Disposition:
Home
Discharge Diagnosis:
Incarcerated ventral incisional hernia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were admitted to the hospital due to an incarcerated
abdominal hernia which required an operation to repair. You
have recovered in the hospital and are now preparing for
discharge to home with 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 ___ 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. Do not lift more
than 10 lbs for ___ weeks.
Do not drive or drink alcohol while taking narcotic 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.
*The bruising in your abdomen will resolve gradually over the
next few weeks.
We wish you a speedy recovery,
Your ___ Care Team
Followup Instructions:
___
|
19702416-DS-16
| 19,702,416 | 22,048,217 |
DS
| 16 |
2168-08-25 00:00:00
|
2168-08-26 16:04:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
gabapentin / Flagyl
Attending: ___.
Chief Complaint:
hypotension, altered mental status
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. ___ is a ___ w/ ESRD on HD (MWF), HTN, embolic stroke
___, anemia, chronic indwelling foley presents with AMS and
hypotension to the ER from rehab and in ER was found to have a
UTI as well as elevated troponins in the ED. Reportedly,
patient was normotensive on initial nursing rounds this AM at
rehab, then on repeat exam was found to be hypotensive to 60's.
Pt is normally up and walking at baseline, seemed to be more
lethargic. The patient states that he felt well at that time and
denies lightheadedness, palpitations, chest pain, sob at that
time. Does endorse discomfort in the bladder. Son in law is in
room and states that pt has not had recent fevers/chills or
cough. Son in states that he was slightly confused in the ER
but now more or less at baseline. Per family, recently treated
for UTI (was on cipro then macrobid). No report of fever,
chills, n/v, abd pain, diarrhea.
.
Of note, patient was admitted to ___ ___ after a fall. He
was found to have acute ischemic stroke in L occipital lobe.
The etiology of the stroke was thought to be embolic, as he was
in new onset afib. TTE at that time showed EF 70% and a large
pericardial effusion (likely in setting of ESRD).
Anticoagulation with coumadin was not initiated given high fall
risk and pericardial effusion. He was continued on Plavix for
anti-coagulation. Patient was started on Metoprolol 12.5mg PO
bid for rate control.
.
In the ER, patient triggered for bp 89/33, received 2L IV NS and
responded well. Temp was 100.8, blood cultures and u/a
obtained. U/A was c/w UTI. Labs significant for lactate 2.5,
but down to 1.5 after fluids. Hct was 24.8, no prior labs for
comparison. WBC count 8.8, no bands. Trop was 0.22, again, no
baseline, received Asa 324mg PO. EKG showed afib, HR 58, no
STEMI. CT head did not show any hemorrhage or midline shift.
Chest x-ray with ?opacity at left base. Patient recieved a dose
of Vancomycin/Zosyn. A rectal exam was done--guaic positive
light brown stool. Patient was admitted to the floor for ___,
altered mentals status, UTI, hypotension. Prior to transfer to
the floor, vitals were T 98.1 HR 88 RR 13 BP 96/41 O2 100 RA.
.
On the floor, patient feels well. Denies lightheadedness, sob,
chest pain, palpitations. He does not know why he has to be in
the hospital because he feels fine.
.
Review of sytems: as per HPI
.
Past Medical History:
Paroxysmal Afib
Acute ischemic stroke in L occipital lobe, PCA territory
(embolic ___ afib)
TIA ___
Chronic foley for urinary retention
Large pericardial effusion
Hepatitis C
ESRD on HD since ___ (MWF)
BPH
HTN
Anemia (hct
GI bleed
Vitamin D deficiency
Hypothyroidism
Osteoporosis
Gout
Malnutrition
Constipation
GERD
Depression
COPD
Allergic rhinitis
Right inguinal hernia
Idiopathic tremor
Hearing loss
Auditory hallucination
Cataracts b/l
Herpes zoster
OSA
Back pain
Social History:
___
Family History:
nc
Physical Exam:
Physical Exam on Admission:
Vitals: T 98.2 BP 136/64 P 93 R 20 O2 95 RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: bibasilar crackles, 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: foley in place, +hematuria
Skin: Dialysis cath to the R chest wall, old fistulas to the L
arm, mild erythema and tenderness around catheter on chest.
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: oriented to self, can pick out hospital from 3 options,
oriented to month and year, can say days of the week backwards,
CNs2-12 intact, motor function grossly normal, dysmetric in RUE
and RLE
.
Physical Exam on Discharge:
Vitals: T 98.4 Tm 98.1 BP 119-152/55-49 P ___ R 18 O2 96 on 2L
NC
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: mild bibasilar crackles, no wheezes, rales, ronchi
CV: iregular rate and rhythm, normal S1 + S2, ___ systolic
murmur heard best over apex, rubs, gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: foley in place, +hematuria
Skin: Dialysis cath to the R chest wall, old fistulas to the L
arm, mild erythema and tenderness around catheter on chest.
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: oriented to self, can say hospital by name., oriented to
month and year, CNs2-12 intact, motor function grossly normal,
dysmetric in RUE and LUE
Pertinent Results:
Labs on Admission:
___ 10:40AM WBC-8.8 RBC-2.70* HGB-8.0* HCT-24.8* MCV-92
MCH-29.7 MCHC-32.3 RDW-15.0
___ 10:40AM NEUTS-77.7* LYMPHS-15.7* MONOS-4.9 EOS-1.3
BASOS-0.4
___ 10:52AM ___ PTT-26.7 ___
___ 10:45AM LACTATE-2.5* NA+-141 K+-4.4
___ 10:52AM GLUCOSE-152* UREA N-26* CREAT-4.6* SODIUM-140
POTASSIUM-4.6 CHLORIDE-100 TOTAL CO2-30 ANION GAP-15
___ 10:52AM ALT(SGPT)-30 AST(SGOT)-26 ALK PHOS-106 TOT
BILI-0.3
___ 10:52AM LIPASE-21
___ 10:52AM cTropnT-0.22*
___ 11:30AM URINE COLOR-Yellow APPEAR-Cloudy SP ___
___ 11:30AM URINE BLOOD-MOD NITRITE-NEG PROTEIN-100
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-8.0
LEUK-LG
___ 11:30AM URINE RBC->182* WBC->182* BACTERIA-MOD
YEAST-NONE EPI-0
___ 11:30AM URINE AMORPH-MANY
___ 09:05PM CK-MB-3 cTropnT-0.23*
.
Microbiology:
.
Time Taken Not Noted Log-In Date/Time: ___ 3:33 pm
URINE TAKEN FROM ___.
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
.
Blood cultures ___: negative but pending at time of
discharge
.
Urine culture ___:
>100,000 enterococcus
Sensitive: Nitrofurantoin, Vancomycin, ampicillin
Resistant: Levofloxacin
.
Imaging
.
TTE (___):
LV internal ___ normal, no hypertrophy, estimated LVEF
70%, no wall motion abnormalities, mild AS, moderate TR,
pericardioal effusion 2.4cm posteriorly and 1.4cm anteriorly, no
tamponade (new since ___
.
TTE (___):
The left atrium is elongated. There is mild symmetric left
ventricular hypertrophy with normal cavity size and
regional/global systolic function (LVEF>55%). There is no
ventricular septal defect. The right ventricular cavity is
mildly dilated with normal free wall contractility. The
diameters of aorta at the sinus, ascending and arch levels are
normal. The aortic valve leaflets (3) are mildly thickened.
There is mild to moderate aortic valve stenosis (valve area
1.3cm2). The mitral valve leaflets are moderately thickened.
There is no mitral valve prolapse. Mild (1+) mitral
regurgitation is seen. The tricuspid valve leaflets are mildly
thickened. There is mild pulmonary artery systolic hypertension.
There is a small to moderate sized pericardial effusion. The
effusion appears circumferential. There are no echocardiographic
signs of tamponade.
.
CT head:
1. No evidence of acute process.
2. Widespread white matter disease, particularly in the deep
cerebral white matter and especially along the left occipital
cortex suggesting infarct that is probably old versus severe
ischemic change.
3. Patchy ethmoid and mastoid air cell opacification, but not
widespread, probably inflammatory.
4. Vascular calcifications.
.
Chest x-ray:
Moderate left-sided pleural effusion. Cardiomegaly and prominent
central pulmonary vascularity and suspected congestion.
Asymmetric left perihilar opacification with a relatively
straight edge, possibly due to scarring and congestion;
correlation with prior radiographs is suggested as well as
clinical history.
.
EKG: afib, HR 58, no ST changes, low voltage
.
Labs on Discharge:
.
___ 07:00AM BLOOD WBC-7.4 RBC-2.61* Hgb-7.5* Hct-25.1*
MCV-96 MCH-28.9 MCHC-30.1* RDW-15.3 Plt ___
___ 07:00AM BLOOD Glucose-94 UreaN-38* Creat-6.1*# Na-140
K-4.1 Cl-100 HCO3-30 AnGap-14
___ 07:31AM BLOOD cTropnT-0.22*
Brief Hospital Course:
Mr. ___ is a ___ w/ ESRD on HD (MWF), HTN, embolic stroke
___ in setting of new afib, anemia, chronic indwelling foley
who presented with altered mental status and hypotension to the
ER from rehab.
.
# Altered mental status/encephalopathy: Patient was noted to be
somewhat lethargic and confused in rehab on day prior to
admission which was ultimately thought to be secondary to
hypotension. Family reported that the patient was acting not
"quite like himself" but was close to his baseline by time of
arrival on the floor. Differential included infection,
electrolyte abn, medication induced, organic CNS process.
Electrolytes wnl limits, no new meds, CT head with no
hemorrhage/acute process. Patient with indwelling foley catheter
which is a likey nidus for infection which could explain his
mental status changes. U/A was indicative of a UTI and patient
was initially treated with Ceftriaxone/Vancomycin emperically.
Of note, recent ___ culture data for UTI showed enterococcus.
Thought patient had a new UTI vs. an old UTI that was not fully
treated. However, he remained afebrile and final urine culture
showed no growth of bacteria and antibiotics were discontinued.
Most likely, the cause of AMS was transient hypotensive episode.
Once patient was fluid resuscitated in the ER as below, mental
status improved to baseline. Oriented to self, hospital, month,
year, can say days of the week backwards.
.
# Hypotension: Patient was noted to have SBP to ___ at rehab on
morning of admission. In ED, SBP was 89 on arrival and he
received 2L NS. Patient responded well with SBPs in the 130s.
Hypotension was likely in the setting of dehydration, not
concerned for septic shock as patient afebrile, no
leukocytosis,no longer hypotensive.
.
# Bloody bowel movement: Per nursing patient had a "large bloody
bowel movement" on ___. Patient remained hemodynamically stable
and there was no change in his cognition. Hematocrit was
stable. Patient did not have any repeat episodes of bloody bms
or melena. Perhaps this was a hemorrhoidal bleed. Less likely
diverticular vs. angiodysplasia. As no repeat bloody bms and
hct remained stable, no interventions were pursued.
.
# Pericardial effuison: Patient with known pericardial effusion
noted on TTE at ___ ___. Concern for tamponade when renal
fellow heard friction rub on physical exam while the patient was
in hemodialysis. TTE showed minimal pericardial fluid with no
signs of tamponade.
.
# Elevated troponin: Was 0.22 in the ER. Given pt has ESRD on
HD, likely had mild heart strain in setting of poor renal
function. Recent trop at PCP office was 0.18 and ECG today with
no ST changes, so very low concern for ACS. Repeat Trop
0.23-->0.22. No concern for ACS during this admission.
.
# Atrial fibrillation: New onset paroxysmal afib in ___,
opted against anticoagulation with coumadin after diagnosis
given fall risk. Continued Plavix 75mg qd and metoprolol 12.mg
PO bid for rate control.
.
# Chronic anemia: Patient has baseline hct ~27, which remained
approximately at baseline at 25. Hgb was 7.5 on day of
discharge, thus transfused 1 unit pRBCs.
.
# ESRD: On HD MWF. Continued Sevelamer, nephrocaps, epo per
outpatient regimen.
.
# GERD: Continued home ranitidine.
.
# Hypothyroidism: Continued home terazosin.
.
# HLD: Continued home simvastatin.
.
TRANSITIONS OF CARE:
-Full code
-Emergency Contact: ___ ___
Medications on Admission:
Plavix 75mg PO qd
Terazosin 5mg PO qhs
Lipitor 10mg PO qhs
Levothyroxine 88mcg PO qd
Allopurinol ___ PO every 5 days
Ranitidine 150mg PO bid
Simethicone 1 tab tid with meals
Colace 240mg PO qhs prn constipation
Senna 187mg PO qhs prn constipation
Ipratropium bromide neb q4h prn sob
Allegra 180mg PO qd prn itching
Flonase 50mcg/act susp 2 sprays in each nostril prn post nasal
drip
Aranesp (albumin free) 25mcg/ml soln (darbepoetin alfa
polysorbate 25mcg SQ every ___
Renvela 800mg 1 tab tid with meals
Nephrocaps 1mg PO qd
Cyanocobalamin 1000mcg PO qd
Primidone 50mg PO qhs
Nocturnal O2 2L
Metoprolol tartrate 12.5mg PO bid
Discharge Medications:
1. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. terazosin 5 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
3. atorvastatin 10 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
4. levothyroxine 88 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. allopurinol ___ mg Tablet Sig: One (1) Tablet PO every 5
days.
6. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
7. simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO TID (3 times a day).
8. docusate sodium 250 mg Capsule Sig: One (1) Capsule PO at
bedtime as needed for constipation.
9. senna 8.6 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as
needed for constipation.
10. ipratropium bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed for sob/wheezing.
11. Allegra 180 mg Tablet Sig: One (1) Tablet PO once a day as
needed for itching.
12. fluticasone 50 mcg/actuation Spray, Suspension Sig: Two (2)
Spray Nasal DAILY (Daily) as needed for nasal drip.
13. Aranesp (polysorbate) 25 mcg/mL Solution Sig: One (1)
Injection every ___.
14. sevelamer carbonate 800 mg Tablet Sig: One (1) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
15. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
16. cyanocobalamin (vitamin B-12) 500 mcg Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
17. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
18. primidone 50 mg Tablet Sig: One (1) Tablet PO at bedtime.
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Hypotension
Altered mental status
Pericardial effusion
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 with some confusion and low
blood pressure. For the low blood pressure, you were given some
fluids through an IV. You had a CAT scan of your head which did
not show any new changes. You also had a chest x-ray which did
NOT show pneumonia. Initially, we thought your confusion was
secondary to a urinary tract infection and we treated you with
antibiotics. However, the final result of the urine test showed
that you DID NOT have an infection. Most likely, your confusion
was secondary to a low blood pressure. After receiving fluids,
your blood pressure improved and your mental status improved as
well.
.
You also had an ultrasound of your heart which showed that you
still have a small to medium size fluid collection as you did at
___. The fluid collection does not seem to be
enlarging or impacting your heart function.
.
During the hospitalization, you had a dark brown stool which was
concerning for having old blood in it. Your blood counts were
stable which was reassuring. Before discharge, you received a
unit of blood because of your chronic anemia. If you have any
bloody bowel movements you should alert your doctor.
.
We have not made any changes to your medications.
.
On discharge, the doctor at the rehab facility will examine you.
.
It was a pleasure taking care of you, we wish you all the best!
Followup Instructions:
___
|
19702674-DS-22
| 19,702,674 | 25,145,914 |
DS
| 22 |
2152-09-23 00:00:00
|
2152-09-24 17:20:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Aspirin / Methotrexate / codeine
Attending: ___
Chief Complaint:
SOB
Major Surgical or Invasive Procedure:
none
History of Present Illness:
HISTORY OF PRESENT ILLNESS:
___ yo woman with a history of HIV on HAART last CD4 of ___ and a distant history of IV opiate use, alcohol abuse
and heavy smoking, who presents to the ED with cough and SOB.
She reports that she has been feeling unwell for almost two
months now with on and off cough which has been intermittent and
self-resolving. However, this month the cough has been worse and
unrelenting. In fact, over the last ___ weeks she has been
feeling much worse until last week she began feeling terrible.
For the last week her cough has been continuous, keeping her
awake at night and started becoming productive of yellow-green
sputum. She saw her PCP last week, who prescribed her
azithryomicin and sent her home but she did not improve. She
then presented to the ED with similar symptoms and was
discharged home with albuterol. Over the last 2 days her
symptoms have progressed and she is now having sinus congestion
with associated nasal secretions. She then began having fevers,
chills, body aches and extreme fatigue to the point she has
trouble getting around the house. Last week she had a sore
throat but no longer. Her cough has become so severe and more
productive that she was getting short of breath with minimal
exertion so she presented to the ED.
No recent travel or sick contacts.
In the ED, initial vitals were: 101.0 94 173/85 18 100% RA. Exam
weas notable for diffuse wheezes and crackles in the lower lung
fields. CXR showed no PNA and no change from ___ CXR which was
largely unchanged from images dating back to ___. She was
treated with a COPD exacerbaction with nebs, prednisone and
Levofloxacin. Flu Swab returned negative. Initially she was
going to be discharged but with ambulatory sats she desatted to
89% on RA so admitted to medicine.
On the floor, she has a strong, non-productive cough which
limits our communication, she can complete full sentences
without SOB but talking worsens the cough. She has fever,
chills, muscle aches, sinus congestion and cough productive of
yellow sputum.
Review of systems:
(+) Per HPI
(-) Denies night sweats, recent weight loss or gain. Denies
headache, sinus tenderness. Denies chest pain or tightness,
palpitations. Denies nausea, vomiting, diarrhea, constipation or
abdominal pain currently. No recent change in bowel or bladder
habits. No dysuria. Denies arthralgias or myalgias. Otherwise
ROS is negative.
Past Medical History:
HIV on HAART
Uterine fibroids s/p TAH
Obstructive sleep apnea
Latent Tb status post ?lymph node biopsies (negative)
Gastroesophageal reflux
Prior exposure to Hep B and C (but w/ documented negative viral
loads)
Severe rheumatoid arthritis
Social History:
___
Family History:
Her mother died of TB in her ___.
Her father died of liver disease in her ___.
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: Afebrile, aVSS, 95% on 2LNC
Pain Scale: ___
General: Patient appears as if she has a cold, she is coughing
incessantly throughout encounter but it seems dry and she is not
producing sputum. Alert, oriented and in no acute distress, very
pleasant, slightly diaphoretic
HEENT: Sclera anicteric, dry mm, oropharynx clear
Neck: supple, JVP low, no LAD appreciated
Lungs: Reduced breath sounds bilaterally and limited air
movement. There are faint bilateral expiratory wheezing and
prolonged expiratory phase
CV: Regular rate and rhythm, S1 and S2 clear and of good
quality, no murmurs, rubs or gallops appreciated
Abdomen: soft, non-tender, non-distended, normoactive bowel
sounds throughout, no rebound or guarding
Ext: Warm, well perfused, full distal pulses, no clubbing,
cyanosis or edema
Neuro: CN2-12 grossly in tact, motor and sensory function
grossly intact in bilateral UE and ___, symmetric
DISCHARGE PHYSICAL EXAM:
Vitals: 97.8PO 139 / 85R Sitting 81 18 93 RA
General: sitting in bed, speaking in full sentences, in NAD
HEENT: Sclera anicteric, dry mm, oropharynx clear
Neck: supple, JVP low, no LAD appreciated
Lungs: Good air movement with scattered end-expiratory wheezing,
no crackles, rales, rhonchi. No respiratory distress
CV: RRR, no m/r/g
Abdomen: soft, non-tender, non-distended, normoactive bowel
sounds throughout, no rebound or guarding
Ext: Warm, well perfused, full distal pulses, no clubbing,
cyanosis or edema
Neuro: CN's grossly intact, moving all extremities with purpose
Pertinent Results:
Admission Labs:
___ 02:05PM BLOOD WBC-5.7 RBC-4.53 Hgb-12.3 Hct-39.7 MCV-88
MCH-27.2 MCHC-31.0* RDW-13.0 RDWSD-41.4 Plt ___
___ 02:05PM BLOOD Neuts-62.7 ___ Monos-8.0 Eos-0.7*
Baso-0.3 Im ___ AbsNeut-3.59 AbsLymp-1.58 AbsMono-0.46
AbsEos-0.04 AbsBaso-0.02
___ 02:05PM BLOOD Glucose-104* UreaN-6 Creat-0.7 Na-131*
K-4.7 Cl-93* HCO3-26 AnGap-17
___ 02:16PM BLOOD Lactate-1.5
Discharge labs:
___ 05:50AM BLOOD WBC-3.8* RBC-4.57 Hgb-12.5 Hct-38.9
MCV-85 MCH-27.4 MCHC-32.1 RDW-13.7 RDWSD-41.7 Plt ___
___ 05:50AM BLOOD Plt ___
___ 05:50AM BLOOD UreaN-10 Creat-0.6 Na-135 K-4.3 Cl-97
HCO3-28 AnGap-14
Imaging:
CXR ___: Cardiac and mediastinal silhouettes are stable.
Again, there is abnormal lateral and upward retraction and bulge
of the right hilum and adjacent mediastinum as well as rightward
deviation of the trachea. No new focal consolidation is seen.
There is no pleural effusion or pneumothorax. The cardiac
silhouette remains enlarged.
IMPRESSION: No significant interval change from 3 days prior.
Prior CXR ___:
The abnormal lateral bulge of the right hilus and adjacent
mediastinum, and the lateral and cephalad displacement of the
right tracheobronchial region are unchanged since at least
___ when a chest CT showed there was no mass in that
region. Volume loss in the right upper lobe, due in part to
cylindrical bronchiectasis, is responsible for traction on the
right upper lobe bronchus. More secretions in the region of
bronchiectasis would be difficult to detect by conventional
radiographs.
Left lung is clear. There is no pleural abnormality. Heart size
is normal. Right heart border obscured by a large benign
mediastinal fat collection.
Brief Hospital Course:
ASSESSMENT AND PLAN:
___ yo woman with a history of HIV on HAART last CD4 of ___ and a distant history of IV opiate use, alcohol abuse
and heavy smoking, who presents to the ED with cough and SOB.
# Viral Bronchitis
# Acute COPD Exacerbation
The patient does not carry a history of chronic lung disease
though has chronic bronchiectasis changes based on CT and CXR
dating back to ___. She is prescribed an albuterol inhaler but
she denies asthma or COPD and there is no documentation of this
either. Overall her symptoms seem consistent with a viral
syndrome given malaise, low grade fevers, non-specific,
non-localizing symptoms and cough. Given her history of smoking,
bilateral wheezing on exam, cough for nearly 3 months now and
new productive cough with progressive worsening and hypoxemia
she was treated for COPD exacerbation with pred and nebs. She
was also treated with levaquin for bronchitis/CAP as she
recently completed a course of azithromycin without improvement.
She was speaking in full sentences, ambulating well, and exam
was notable for good air movement throughout her lung fields
with mild scattered end-expiratory wheezing.
# Subacute dyspnea on exertion
# OSA
Pt reports worsening dyspnea on exertion for the last several
weeks. Denies other signs of CHF including orthopnea, PND,
weight gain or leg swelling. Appears euvolemic on exam. This
was felt to be possibly related to worsening pulmonary HTN from
untreated OSA as pt reports frequently not using her CPAP at
night due to an ill-fitting and uncomfortable mask. Pt may
benefit from mask-refitting post-discharge.
# HIV
Chronic, well controlled on HAART last CD4 of ___.
Continued Nevirapine 200 mg PO BID and Epzicom
(abacavir-lamivudine) 600-300 mg oral DAILY
Transitional Issues:
[ ] Pt treated for COPD exacerbation given profuse wheezing on
exam. Consider PFT's for further evaluation of RAD and subacute
worsening DOE (see above).
[ ] Pt also reported not using her CPAP d/t ill-fitting mask.
Consider repeat sleep study vs. mask re-fitting.
Billing: greater than 30 minutes spent on discharge counseling
and coordination of care.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Fluticasone Propionate NASAL 2 SPRY NU DAILY
2. Nevirapine 200 mg PO BID
3. Epzicom (abacavir-lamivudine) 600-300 mg oral DAILY
4. Triamcinolone Acetonide 0.1% Cream 1 Appl TP BID:PRN itch
5. etanercept 50 mg/mL (0.98 mL) subcutaneous QWeek
6. estradiol 0.01 % (0.1 mg/gram) vaginal Twice Weekly
7. Pantoprazole 40 mg PO Q12H
8. Albuterol Inhaler ___ PUFF IH Q4H:PRN SOB
9. amLODIPine 2.5 mg PO DAILY
Discharge Medications:
1. Levofloxacin 750 mg PO DAILY Duration: 4 Days
RX *levofloxacin 750 mg 1 tablet(s) by mouth daily Disp #*4
Tablet Refills:*0
2. PredniSONE 40 mg PO DAILY Duration: 4 Days
RX *prednisone 20 mg 2 tablet(s) by mouth every day Disp #*8
Tablet Refills:*0
3. Albuterol Inhaler ___ PUFF IH Q4H:PRN SOB
4. amLODIPine 2.5 mg PO DAILY
5. Epzicom (abacavir-lamivudine) 600-300 mg oral DAILY
6. Estradiol 0.01 % (0.1 mg/gram) vaginal TWICE WEEKLY
7. etanercept 50 mg/mL (0.98 mL) subcutaneous QWeek
8. Fluticasone Propionate NASAL 2 SPRY NU DAILY
9. Nevirapine 200 mg PO BID
10. Pantoprazole 40 mg PO Q12H
11. Triamcinolone Acetonide 0.1% Cream 1 Appl TP BID:PRN itch
Discharge Disposition:
Home
Discharge Diagnosis:
COPD exacerbation
Community Acquired Pneumonia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You came in with shortness of breath. We think that your
worsening shortness of breath in the last few days is due to a
COPD exacerbation from a cold or pneumonia. We are sending you
home with some steroids (prednisone) and an antibiotic
(levofloxacin) to treat the COPD exacerbation and any possible
pneumonia.
It is possible that your more prolonged worsening shortness of
breath over the last few weeks is due to untreated sleep apnea
as you report having an issue with your CPAP mask. Please
discuss with your PCP about whether or not you could get a
different mask or have your mask refitted.
Please return if you have worsening difficulty breathing, chest
pain, fevers/chills (temp>101), or if you have any other
concerns.
It was a pleasure taking care of you at ___ ___
___.
Followup Instructions:
___
|
19702769-DS-7
| 19,702,769 | 26,775,264 |
DS
| 7 |
2114-03-18 00:00:00
|
2114-03-31 07:57:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
s/p fall
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
Mrs. ___ is a ___ ___ woman who was in ___ when she fell down some stairs approximately 1 week ago.
Her family reports the fall was unwitnessed and it is unknown
whether she syncopized prior to the fall. After falling, she
remained unconscious for an unknown amount of time. She was not
seen or treated at a hospital afterwards. Since the fall, she
has
been complaining of a severe headache and increased tearing from
her R eye. She returned to the ___. this morning and was taken
straight to ___ for evaluation.
The patient reports that she has had no other symptoms besides
her headache. Specifically, she denies nausea, vomiting, vision
changes, dizziness, or balance problems.
Past Medical History:
HTN, HLD
Social History:
___
Family History:
Noncontributory
Physical Exam:
In the ED on arrival:
Temp: 97.2 HR: 78 BP: 140/100 Resp: 18 O(2)Sat: 100
Constitutional: Comfortable
HEENT: Pupils equal, round and reactive to light,
Extraocular muscles intact
No c-spine TTP
Chest: R chest wall ecchymoses and TTP
Cardiovascular: Regular Rate and Rhythm
Abdominal: Soft, Nontender
Extr/Back: No T/L/S TTP
Skin: No rash
Neuro: Speech fluent
Psych: Normal mood, Normal mentation
Pertinent Results:
___ Head CT w/out contrast:
1. 1.4 x 1.9 x 0.8 cm hyperdense focus in the left temporal lobe
suggestive of a hemorrhagic contusion with surrounding vasogenic
edema. There is no significant mass effect or herniation.
2. Chronic sinusitis involving the left maxillary sinus.
___ RIB UNILAT, W/ AP CHEST RIGHT:
Displaced fractures of the posterior right third and fourth
ribs,
non-displaced fractures of the right posterior fifth and sixth
ribs, and
minimally displaced fracture of the distal right clavicle.
___ GLENO-HUMERAL SHOULDER (W/ Y VIEW) RIGHT:
Minimally displaced fracture of the lateral right third and
fourth
ribs, non-displaced fractures of the fifth and sixth ribs, and
displaced right distal clavicular shaft fracture.
___ CT c-spine w/out contrast:
1. Non-displaced fracture of the right transverse process of C7,
without
extension to the transverse foramen.
2. Non-displaced fractures of the posterior right first and
second ribs with a slightly comminuted fracture of the posterior
right third rib.
3. No apical pneumothorax.
4. While there is no definite evidence of vascular injury, a
Neck CTA
inclusive of the aortic arch may be obtained, if clinical
suspicion for
vascular injury is high.
___ CTA chest:
1. No evidence of vascular injury
2. Small right upper lobe contusion adjacent to lateral rib fx
but no
pneumothorax. Bibasilar atelectasis and trace effusions (too
small to measure attenuation reliably)
3. Posterior ___ through ___ right rib fractures (near the
costovertebral
junction) of which the ___ appears comminuted as described in
the CT c-spine and the ___ and ___ appear mildly discplaced.
4. Lateral ___ through ___ (and possibly ___ right rib
fractures of which the ___ and ___ appear displaced.
5. Anterolateral right ___ displaced rib fracture.
6. Comminuted right distal clavicular fracture
___ 10:45PM WBC-11.9*# RBC-4.56 HGB-13.3 HCT-40.9 MCV-90
MCH-29.2 MCHC-32.6 RDW-12.8
___ 10:45PM NEUTS-67.4 ___ MONOS-3.3 EOS-1.2
BASOS-0.8
___ 10:45PM PLT COUNT-365
___ 10:45PM GLUCOSE-111* UREA N-19 CREAT-0.7 SODIUM-132*
POTASSIUM-5.3* CHLORIDE-95* TOTAL CO2-26 ANION GAP-16
___ 12:38AM K+-4.3
Brief Hospital Course:
Ms. ___ was admitted on ___ under the Acute Care
Surgery service for monitoring and management of her injuries.
Neurosurgery was consulted for her left temporal contusion who
recommneded antiseizure prophylaxis for 7 days. She was started
on keppra and follow up was scheduled as an outpatient for a
repeat noncontrast head CT in one month with neurosurgery.
Orthopedics was consulted for her distal clavicle fracture who
recommended no operative intervention and a sling to her RUE.
Follow up was scheduled with orthopedics for 2 weeks from
discharge.
A CTA chest was performed on ___ to evaluate for vascular
injury given presence of a first rib fracture. It was negative
for vascular injury but did confirm R posterior ___ rib
fractures ___ and ___ minimally mildly displaced), R lateral
___ rib fractures ___ and ___ displaced), and R anterolateral
___ displaced rib fracture. Pulmonary toileting and incentive
spirometry were encouraged. The pt's oxygen saturation was
monitored routinely with vital signs and her respiratory status
remained uncompromised. She reported minimal pain at the site of
the rib fractuers and her pain was well controlled with standing
PO tylenol and minimal oxycodone use.
Neuro checks were performed q4h and remained stable. Her
cogntive status waxed and waned throughout her admission, and
she continued to have memory and cognitive defecits consistent
with post-concussive symptoms. Occupational therapy evalauted
her cogntive status and recommended outpatient follow up with
cognitive neurology after discharge. This information was
provided for the patient and her family. Education re: safety
was provided to the patient and her family by ___ prior to
discharge, who deemed her safe to be discharged home with home
___ and 24 hour supervision when medically cleared.
On ___ she is neurologically and hemodynamically stable. She
is afebrile and without respiratory compromise. She is
tolerating a regular diet and voiding adequate amounts of urine.
She is being discharged home with 24 hour supervision to be
provided by family and ___ at home. She has follow up scheduled
with neurosurgery, cognitive neurology, orthopedics and ACS.
Medications on Admission:
pravastatin 20 mg daily
lisinopril/HCTZ ___ mg
Discharge Medications:
1. Pravastatin 20 mg PO DAILY
2. Lisinopril 20 mg PO DAILY
3. Hydrochlorothiazide 25 mg PO DAILY
4. Acetaminophen 325-650 mg PO Q6H:PRN pain
5. Docusate Sodium 100 mg PO BID
6. LeVETiracetam 500 mg PO BID
RX *levetiracetam 500 mg 1 Tablet(s) by mouth twice a day Disp
#*10 Tablet Refills:*0
7. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
RX *oxycodone 5 mg ___ Tablet(s) by mouth every four (4) hours
Disp #*30 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
s/p fall
Injuries:
- Left temporal lobe (brain) contusion
- Right clavicle fracture
- Right ___ anterior-lateral rib fracture
- Right 1 - 7 posterior rib fractures
- Right 3 - 6 lateral rib fractures
- C7 transverse process fracture
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 falling down stairs and
sustaining several injuries included multiple broken ribs on the
right side, a head injury, and a broken right collar bone.
You were evaluated by the neurosurgery team for your head injury
who determined the injury to be stable and recommended seizure
prophylaxis for one week. We have started you on a medication
called keppra for this. It is also recommended that you have a
follow up head CT scan in one month and be seen in the
___ clinic. An appointment has been scheduled for you
below.
You were evaluated by the orthopedic surgeons for your collar
bone who recommended a sling and follow up in 2 weeks. An
appointment has been scheduled for you below.
You should also follow up in the Acute Care Surgery service
clinic for a chest xray and to evaluate your rib fractures. An
appointment has been scheduled for you below.
You sustained rib fractures which can cause severe pain and
subsequently cause you to take shallow breaths because of the
pain.
You should take your pain medicine as 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.
Do NOT smoke.
Return to the ED right away for any acute shortness of breath,
increased pain or crackling sensation around your rips
(crepitus).
Take your pain medicine as prescribed.
Exercise should be limited to walking; no lifting, straining, or
excessive bending.
Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (colace)
while taking narcotic pain medication.
Unless directed by your doctor, DO NOT take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, or
Ibuprofen, etc.
If you have been discharged on Keppra (Levetiracetam), you will
not require blood work monitoring.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING:
New onest of tremors or seizures.
Any confusion, lethargy or changes in mental status.
Any numbness, tingling, weakness in your extremities.
Pain or headache that is continually increasing, or not relieved
by pain medication.
New onset of the loss of function, or decrease of function on
one whole side of your body.
Followup Instructions:
___
|
19703655-DS-13
| 19,703,655 | 23,956,658 |
DS
| 13 |
2129-06-05 00:00:00
|
2129-06-05 18:42:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins / Claritin / Amiodarone / coenzyme Q10 / mango
Attending: ___.
Chief Complaint:
"I can't walk"
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with hx. HTN, afib s/p pacemaker and ICD placement on
dabigatran, L hip hemiarthroplasty w/ trochanteric bursitis
presenting with bilateral lower extremity weakness over the past
one to two weeks.
Patient reports pain in his hips/thighs as well as difficulty
walking over the last ___ weeks. Says pain is located in
proximal anterior thighs, worse with bearing weight. Per
daughter's report, the patient has been able to ambulate with a
cane in the past but has had worsening deficit requiring walker
recently. Patient denies any fevers/chills, no back pain, no
recent trauma. Denies any numbness, tingling, urinary problems.
Denies any other symptoms.
In the ED initial vitals were: 98.0 80 131/80 16 100%
- Labs were significant for Na 125, K 5.4, Cl 90, Cr 0.9. trop
x1 was negative, CK normal. Patient was given 1LNS and admitted.
On the floor, patient currently has no complaints. Says his pain
is only when he stands.
Review of Systems:
(+) per HPI
(-) fever, chills, headache, vision changes, sore throat, cough,
shortness of breath, chest pain, abdominal pain, nausea,
vomiting, diarrhea, constipation, BRBPR, melena, hematochezia,
dysuria, hematuria.
Past Medical History:
1. Persistent atrial fibrillation status post AV node ablation
and pacemaker implantation at ___.
2. Prior biventricular pacemaker implantation at ___
___ with subsequent deactivation of the LV lead due to
chest
wall and diaphragmatic capture.
3. Hypertension.
4. Left hip fracture status post hemiarthroplasty in ___ with
resultant trochanteric bursitis.
Social History:
___
Family History:
AFib and Asthma
Physical Exam:
ADMISSION, ___:
PHYSICAL EXAM:
Vitals - 97.1 138/88 hr 71 18 100% RA
GENERAL: awake, alert, oriented x3, NAD
HEENT: EOMI, PERRLA, OMM no lesions
NECK: supple, no JVD
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs
LUNG: CTABL
ABDOMEN: nondistended, +BS, nontender in all quadrants
EXTREMITIES: no cyanosis, clubbing or edema, moving all 4
NEURO: CN II-XII intact, strength ___ in UE and ___ b/l, no pain
to palpation over proximal muscles, mildly positive ___ test
on right
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
DISCHARGE, ___:
Vitals - 97.9 / 126-150/70-80; 75-86; 100% on RA
GENERAL: awake, alert, oriented x3, NAD at rest but in pain with
ROM at hip
CARDIAC: harsh systolic murmur at LLSB, regular rate at 100
LUNG: CTAB
ABDOMEN: nondistended, +BS, nontender in all quadrants
EXTREMITIES: warm, 2+ DP pulses, no edema
NEURO:
- normal mental status
- strength ___ in ___ bilaterally
- DTRs 2+ bilaterally at patellae
- stands w/ assist; favors R. leg (i.e. avoids weight bearing or
flexion)
Pertinent Results:
============================================================
LABS:
133 99 23
-------------< 81 (Discharge, ___
5.1 25 0.9
125 90 20
-------------<103 (On presentation, ___
5.4 25 0.9
5.6 > 13.7 / 42.3 < 133 (Discharge ___
===========================================================
STUDIES:
Bilateral Hip XR (___):
- No fracture
- Diffuse osteopenia
- Mild right hip osteoarthritis on the right
- s/p left hemiarthroplasty w/ noncemented femoral stem in
anatomic alignment; no hardware loosening or evidence of
fracture
- Pelvic girdle is congruent
- Advanced degenerative changes in the lower lumbar spine noted
in the periphery
=
=
=
================================================================
Brief Hospital Course:
___ yo M w/ hx HTN, AFib s/p PPM, L. hemiarthroplasty who
presented with one week of right leg pain limiting ambulation,
found to have right lumbosacral radiculopathy. With pain control
(tramadol 25mg q6h) he was able to transfer independently and
ambulate with a rolling walker. He is being discharged home with
home ___.
Of note, on admission he was hyponatremic (Na 125) and
hyperkalemic (K 5.4) which resolved with 1L IVF and cessation of
home diuretic (spironolactone 25mg BID). On the day of discharge
(___), after 2 days off diuretics, his Na had normalized to 133
and K resolved to 5.1. He was maintained off any
diuretic/anti-hypertensive for the duration of his
hospitalization, and maintained acceptable blood pressures in
the 130-160/80 range. He is being discharged off diuretics.
TRANSITIONAL ISSUES:
#Hyponatremia: resolved with discontinuation of diuretics.
Please check BMP at ___ ___ in on week to ensure
stability.
#HTN/Cessation of diuretic: BPs <160 systolic off any meds. BP
check at PCP ___ to determine if an alternative medication
to spironolactone should be started. Daughter noted a history of
adverse reaction to anti-hypertensives (unclear).
#Right leg pain: while we felt his acute pain was attributable
to sciatica, he also appears to have a chronic, exertional leg
pain which by history is consistent with claudication. Please
consider ABI for further evaluation as needed.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Dabigatran Etexilate 75 mg PO BID
2. Pravastatin 5 mg PO DAILY
3. Spironolactone 25 mg PO BID
4. Magnesium Oxide 400 mg PO DAILY
5. Vitamin D 800 UNIT PO DAILY
6. Calcium Carbonate 500 mg PO BID
7. Cetirizine 10 mg PO DAILY
8. Ocuvite (vit C-vit E-lutein-min-om-3) 150-30-5-150
mg-unit-mg-mg oral once daily
Discharge Medications:
1. Dabigatran Etexilate 75 mg PO BID
2. TraMADOL (Ultram) 25 mg PO QID pain
Take only as need for pain. This medication can make you sleepy.
RX *tramadol 50 mg 0.5 (One half) tablet(s) by mouth every 6
hours Disp #*28 Tablet Refills:*0
3. Calcium Carbonate 500 mg PO BID
4. Cetirizine 10 mg PO DAILY
5. Magnesium Oxide 400 mg PO DAILY
6. Ocuvite (vit C-vit E-lutein-min-om-3) 150-30-5-150
mg-unit-mg-mg oral once daily
7. Pravastatin 5 mg PO DAILY
8. Vitamin D 800 UNIT PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Acute lumbosacral radiculopathy
Discharge Condition:
Mental status: alert and oriented
Ambulatory status: Transfers independently; rolling walker to
ambulate
Discharge Instructions:
Dear Mr. ___,
You were admitted to the hospital with one week of pain in your
right hip and right leg that made it difficult to walk.
After examining you, we determined that the source of your pain
is a pinched nerve in your lower back. This problem is
sometimes called "sciatica" or "radiculopathy". It occurs when
the nerves that go to your legs get pinched as they leave the
spinal cord in the lower back. The pinching is caused by either
arthritis of the back or a bulging disc in the back. The
pinched nerve causes pain in your hip and in your entire leg
when you bend the hip or walk.
The best way to treat sciatica is to use pain medications (which
are often needed only on a temporary basis, until the
inflammation around the nerve resolves) and with physical
therapy. We treated you with a pain medication called tramadol
here in the hospital which you should continue to take at home,
every 6 hours as neededf or pain. Physical therapists will also
come to your home to teach you stretching exercises to help with
the pain.
We did x-rays of your hip to make sure there was no broken bone
in the hip; the x-rays were normal (no fracture).
We also discovered that the blood pressure medication you were
taking, spironolactone, was making you too dehydrated and
causing problems with your electrolyte (for example, low sodium
and high potassium). We STOPPED spironolactone. When you
stopped taking spironolactone, these problems resolved. You
should NOT take any more spironolactone at home. Your doctor
___ check your blood tests the next time you see him to make
sure this problem is still stable. You did not recieve any blood
pressure medications while you were in the hospital, and your
blood pressure remained at an acceptable range (130-160/80).
For a person your age, we aim for a blood pressure goal of less
than 160/90, and anything up to this level is acceptable.
It was a pleasure taking care of you. We wish you all the best.
Sincerely,
Your ___ Team
Followup Instructions:
___
|
19703655-DS-15
| 19,703,655 | 26,042,025 |
DS
| 15 |
2130-03-17 00:00:00
|
2130-03-17 15:31:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
Penicillins / Claritin / Amiodarone / coenzyme Q10
Attending: ___.
Chief Complaint:
Right facial droop and Right sided weakness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ is an ___ old right-handed man with a history of
atrial fibrillation on pradaxa, new onset diastolic heart
failure
and prior infarct who awoke this morning with right facial
droop,
dysarthria, and weakness.
Mr. ___ went to bed last night at his baseline, which is using a
walker to ambulate due to symmetric weakness. He awoke at 1230,
spoke to his wife and his speech was normal; he got up to
urinate
and was able to independently go to the bathroom with his walker
at that time. He then went to sleep and when he awoke this
morning he had prominent dysarthria, right facial droop, and
weakness in his arm and leg. he was unable to walk, even with
his
walker. His blood pressure at home was in the 150s. He presented
to the hospital due to concern for a stroke.
His family reports a history of a "mini stroke," which is
described as the sudden onset of unilateral weakness (don't
remember what side) while driving. They do not believe he has
any
residual deficits. He has never had symptoms as severe as the
current ones. He has ambulated with a walker since a fall and
resultant hip fracture several years ago.
Mr. ___ was recently discharged from ___. He was admitted for
an asthma exacerbation and found to have cardiomegaly and fluid
overload. He had an echocardiogram notable for left ventricular
hypertrophy, mitral and tricuspid regurgitations, and EF of
50-55%. He was discharged to complete a 5-day course of
prednisone and was started on furosemide 10 mg daily with a plan
to follow up with his PCP. His breathing has improved over the
days since his discharge. He is able to lie flat at night.
Neurologic ROS was notable as above. In addition, he denies
amaurosis fugax, headache, blurred vision, diplopia, dysarthria,
dysphagia, lightheadedness, vertigo, tinnitus or hearing
difficulty. Denies difficulties comprehending speech. No bowel
or
bladder incontinence or retention.
General ROS was notable for recent dyspnea which was improving
as
well as constipation with no bowel movement for 2 days, which is
atypical. Otherwise, the pt denies recent fever or chills. No
night sweats or recent weight loss or gain. Denies cough. Denies
chest pain or tightness, palpitations. Denies nausea, vomiting,
diarrhea or abdominal pain. No recent change in bladder habits.
No dysuria. Denies rash.
Past Medical History:
PAST MEDICAL HISTORY:
1. Asthma - per HPI
2. Afib - persistent s/p pacemaker placement and AV node
ablation at ___, on ___, currently sees
cardiologist Dr. ___ 3 months; last echocardiogram
___ ___ dilated, mild symmetric LV hypertrophy with
normal cavity size, LVEF >55%, ascending aorta mildly dilated,
aortic valve leaflets mildly thickened but AS not present, mild
1+ AR, mild 1+ MR with normal valve morphology, findings c/w
hypertensive heart), was due for echocardiogram ___ but
cancelled appointment
3. Hypertension
4. GERD - treated with ranitidine, avoids acidic foods
5. Left hip fracture - s/p hemiarthroplasty in ___ with
resultant trochanteric bursitis, uses a walker to ambulate
6. Cataracts - s/p right cataract surgery in ___
PAST SURGICAL HISTORY:
1. Cholecystectomy complicated by bleeding, approximately ___
years ago
2. Biventricular placement implantation in ___ ___ with subsequent deactivation of the LV lead
due to chest wall and diaphragmatic capture,
3. Right cataract surgery in ___
4. Left hip hemiarthroplasty in ___
Social History:
___
Family History:
- Atrial fibrillation, asthma, allergies
Physical Exam:
ADMISSION PHYSICAL EXAM
97.5 86 153/98 16 99% RA
General: Thin elderly man lying in bed in no apparent distress.
HEENT: NC/AT
Neck: Supple, no carotid bruits appreciated. Jugular venous wave
noted at the angle of the jaw.
Pulmonary: Normal work of breathing with nebulizer in place.
Vesicular breath sounds bilaterally, no wheezes or crackles
appreciated.
Cardiac: S1/S2 appreciated, RRR, Grade ___ murmur loudest over
LLSB with radiation to the axilla. No rubs or gallops.
Abdomen: Thin, soft, nontender, nondistended.
Extremities: Pitting edema in lower extremities bilaterally.
Skin: No rashes or lesions noted.
Neurologic: interview conducted via translator
-Mental Status: Alert, oriented to person, hospital, month (did
not further test). Able to relate history without difficulty.
Language is fluent with intact repetition and comprehension.
Normal prosody. There were no paraphasic errors. Pt. was able
to name both high and low frequency objects. Able to read
without difficulty. Speech was not dysarthric. Able to follow
both midline and appendicular commands. Attentive, able to name
___ backward without difficulty. 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: Pupils reactive, R ___, L ___. Responds reliably to visual
stimuli on the left, unreliably to visual stimuli in the right
hemifield. Blinks to threat on both sides.
III, IV, VI: EOMI without nystagmus. Mild breakdown of smooth
pursuit.
V: Facial sensation intact to light touch, pinprick and
temperature in all distributions.
VII: Profound right facial droop in lower distribution with full
strength of eye closure bilaterally.
VIII: Need to increase volume of voice for communication.
IX, X: Palate elevates symmetrically.
XI: ___ strength in L trapezius, ___ in right.
XII: Tongue protrudes in midline.
-Motor: Increased tone with spastic catch in all extremities, no
consistent asymmetry. No tremor or asterixis. Right proximal
weakness in arm and leg, right hand weakness, superimposed on
bilateral upper motor neuron pattern weakness in lower
extremities.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L ___ ___ 4+ 4+ 5 4+ 4+ 5 4+ 4+
R ___ 5 4+ ___- 5 4+ 4+ 5 4+ 4+
-DTRs:
Bi Tri ___ Pat Ach
L 3 3+ 3 3 2
R 3 3 3 3 1
- Plantar response was extensor bilaterally.
- Pectoralis Jerk was present in LUE, Hoffmans was negative
bilaterally, and Crossed Adductors are present bilaterally.
-Sensory: Decreased sensation to pin and temperature in left
hemi-body (arm, leg, trunk). No extinction to DSS in upper
extremities or in visual modality. Extinction to DSS in RLE.
-Coordination: No dysmetria on FNF or HKS bilaterally out of
proportion to weakness.
-Gait: Not tested
DISCHARGE PHYSICAL EXAM
T 97.8F, 140-160s/40-80, HR 71, RR 20, 99% on RA
General - NAD
Pulm - No respiratory distress, no crackles, b/l decreased
sounds at bases. No rhonchi. No wheeze
Heart - RRR, no murmurs, rubs, gallops
Extremities - 1+ dependent edema
Neuro
Mental status - Alert, following commands well.
Motor -
Deltoid Triceps ECR IP Hamstring TA ___
Left 5- 5- 5 4+ 5- 5 5
Right 4+ 4+ 5 4+ 5- 5 5
No pronator drift.
Reflexes - 3+ in bilateral biceps, brachiaradialis, triceps,
patella. Crossed adductors present. B/l pectoralis jerks
present.
Pertinent Results:
PERTINENT LAB RESULTS
___ 05:04AM BLOOD WBC-7.4 RBC-4.79 Hgb-13.1* Hct-39.4*
MCV-82 MCH-27.3 MCHC-33.2 RDW-15.9* RDWSD-47.3* Plt ___
___ 05:04AM BLOOD ___ PTT-53.9* ___
___ 05:04AM BLOOD Glucose-83 UreaN-22* Creat-0.9 Na-136
K-3.3 Cl-99 HCO3-25 AnGap-15
___ 05:04AM BLOOD ALT-53* AST-34 AlkPhos-63 TotBili-1.3
___ 02:31AM BLOOD cTropnT-<0.01
___ 09:00AM BLOOD cTropnT-<0.01 proBNP-8459*
___ 05:04AM BLOOD %HbA1c-6.1* eAG-128*
___ 05:04AM BLOOD Triglyc-65 HDL-81 CHOL/HD-1.8 LDLcalc-48
LDLmeas-63
___ 05:04AM BLOOD TSH-3.4
___ 05:04AM BLOOD CRP-1.4
___ 09:00AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
IMAGING STUDIES
CTA HEAD AND NECK ___
Preliminary ReportCT HEAD WITHOUT CONTRAST:
Preliminary ReportThere is no evidence of no evidence of
infarction, hemorrhage, edema, or mass.
Preliminary ReportThe ventricles and sulci are normal in size
and configuration.
Preliminary ReportThe visualized portion of the paranasal
sinuses, mastoid air cells, and middle
Preliminary Reportear cavities are clear. The visualized portion
of the orbits are unremarkable.
Preliminary ReportCTA HEAD:
Preliminary ReportThe vessels of the circle of ___ and their
principal intracranial branches
Preliminary Reportappear normal without stenosis, occlusion or
aneurysm formation. The dural
Preliminary Reportvenous sinuses are patent.
Preliminary ReportCTA NECK:
Preliminary ReportThe carotid and vertebral arteries and their
major branches appear normal with
Preliminary Reportno evidence of stenosis or occlusion. There is
no evidence of internal carotid
Preliminary Reportstenosis by NASCET criteria.
Preliminary ReportOTHER:
Preliminary ReportThe visualized portion of the lungs are clear.
The visualized portion of the
Preliminary Reportthyroid gland is within normal limits. There
is no lymphadenopathy by CT size
Preliminary Reportcriteria.
Preliminary ReportIMPRESSION:
Preliminary Report1. Normal head and neck CTA.
..
CHEST XRAY
FINDINGS:
Left-sided pacemaker device is noted with leads terminating in
the regions of
the right atrium, right ventricle, and coronary sinus. Moderate
to severe
cardiomegaly is present. The aorta is diffusely calcified.
There is mild
pulmonary edema with small to moderate size bilateral pleural
effusions.
Associated bibasilar atelectasis is present. No pneumothorax or
focal
consolidation is otherwise present. Clips are seen in the upper
abdomen as
well as surgical anchors within the right humeral head.
IMPRESSION:
Mild pulmonary edema with small to moderate size bilateral
pleural effusions
and bibasilar atelectasis.
..
CT HEAD ___. No evidence of acute hemorrhage, infarct or fractures.
2. A small hypodensity in the right internal capsule likely
represents an old
lacunar infarct.
3. Prominence of ventricles are visualized, suggestive of
involutional
changes, along with evidence of chronic ischemic small vessel
changes.
Brief Hospital Course:
___ is an ___ old man with a history of atrial
fibrillation on pradaxa, newly diagnosed diastolic heart
failure, and prior infarct who presented to the ED with right
facial droop and right hemiparesis predominantly affecting
proximal muscles and hand. These symptoms improved throughout
the admission but were persistent at the time of discharge.
There was also persistent evidence of significant cervical
spondylosis with hyperreflexia and symmetric lower extremity
weakness as well as upper extremity wasting.
His symptoms were most likely secondary to left MCA territory vs
subcortical stroke. Evidence for cortical involvement include
that the face and hand were more affected than the leg. However,
given face, arm and leg were all involved this is difficult to
say for certain. Since we cannot confirm the location of the
stroke with MRI due to the patient's pacemaker, both embolic and
small vessel disease are both on the differential. If the
etiology was embolic this would indicate pradaxa failure. CTA
shows no large vessel cutoff or significant large vessel disease
that could be responsible for artery to artery embolism.
The patient's repeat head CTs were stable during his admission.
His TTE was negative for intracardiac thrombus. Regarding his
risk factors for small vessel disease - they were grossly
unremarkable. His HbA1c-6.1, LDL 48, TSH 3.4, CRP 1.4 and ESR
was 2.
Given the possibility of pradaxa failure, we contacted his
cardiologist who was comfortable with our plan to switch
anticoagulants to apixaban which was dosed at 2.5mg BID given
his age and his weight per pharmacy guidelines.
He was evaluated by speech and swallow and cleared for puree and
thin liq with straw. They did not think the patient was safe to
use his dentures over the weekend due to aspiration risk. These
swallow recommendations will need to be re-evaluated by speech
therapy after discharge at the rehab. At the moment, he should
get his meds whole in puree. The patient was evaluated by both
OT and ___ who were agreeable to rehab placement.
# Diastolic heart failure - On admission, patient had elevated
BNP in 8000 with chest Xray showing mild pulm edema. However, he
had good O2 saturation on RA and did not endorse any shortness
of breath. He was continued on his home dose of 10mg Lasix PO
that was started on discharge from his last admission. He was
continued on his metoprolol succinate 50mg daily. He should
continue to get a cardiac healthy diet with sodium restriction.
If he gets short of breath after discharge, he will need to be
evaluated for heart failure exacerbation.
# Asthma - Not on controller meds at home
- Recently completed 5 days of prednisone. No wheezing during
this admission and no subjective shortness of breath.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Dabigatran Etexilate 75 mg PO BID
2. Pravastatin 5 mg PO QPM
3. Ranitidine 150 mg PO DAILY
4. Baclofen 10 mg PO BID
5. Fexofenadine 60 mg PO BID
6. Vitamin D 1000 UNIT PO DAILY
7. Fluticasone Propionate NASAL 1 SPRY NU BID
8. Albuterol Inhaler 2 PUFF IH Q6H:PRN asthma
9. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation
inhalation BID asthma
10. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600 mg
calcium- 200 unit oral BID
11. Elocon (mometasone) 0.1 % topical BID
12. Salonpas-Hot (capsaicin) 0.025 % topical BID
13. Ocuvite (vit C-vit E-lutein-min-om-3) 150-30-5-150
mg-unit-mg-mg oral DAILY
14. Ipratropium-Albuterol Neb 1 NEB NEB BID
15. Metoprolol Succinate XL 50 mg PO DAILY
Discharge Medications:
1. Albuterol Inhaler 2 PUFF IH Q6H:PRN asthma
2. Metoprolol Succinate XL 50 mg PO DAILY
3. Pravastatin 5 mg PO QPM
4. Ranitidine 150 mg PO DAILY
5. Apixaban 2.5 mg PO BID
6. Ipratropium-Albuterol Neb 1 NEB NEB BID
7. Fluticasone Propionate NASAL 1 SPRY NU BID
8. Ocuvite (vit C-vit E-lutein-min-om-3) 150-30-5-150
mg-unit-mg-mg oral DAILY
9. Salonpas-Hot (capsaicin) 0.025 % topical BID
10. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation
inhalation BID asthma
11. Vitamin D 1000 UNIT PO DAILY
12. Fexofenadine 60 mg PO BID
13. Elocon (mometasone) 0.1 % topical BID
14. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600 mg
calcium- 200 unit oral BID
15. Baclofen 10 mg PO BID
16. Furosemide 10 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
1.) Left sided stroke
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were admitted with a stroke causing right sided weakness. We
were unable to definitively tell whether or not this stroke was
secondary to failure of your pradaxa. Your anticoagulation was
changed to eliquis 2.5mg twice daily after discussion with your
cardiologist. You were continued on your other medications
without changes. You were seen by speech and swallow who felt
that your diet should be modified to prevent aspiration as
below. You were also seen by occupational and physical therapy
who thought that you would be benefit from rehab.
Followup Instructions:
___
|
19703830-DS-10
| 19,703,830 | 23,690,103 |
DS
| 10 |
2147-12-18 00:00:00
|
2147-12-18 10:07:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
diabetic foot ulcer infection
Major Surgical or Invasive Procedure:
___: PROCEDURE: Debridement with open ray amputation 2, 3, 4 of
left foot.
___: PROCEDURE: Debridement of prior amputation site and an
exploration of proximal plantar and dorsal surface of foot.
___: OPERATION:
1. Ultrasound-guided puncture of right common femoral
artery.
2. Contralateral second-order catheterization of left
external iliac artery.
3. Abdominal aortogram.
4. Serial arteriogram of left lower extremity.
5. Perclose closure of right common femoral arteriotomy.
___: PROCEDURE: Left below-knee popliteal to pedal bypass,
debridement left foot.
___: PROCEDURE: Revision transmetatarsal amputation.
History of Present Illness:
___ with DM, HTN, HLD, CVA, osteomyelitis s/p L foot
first digit amputation ___ presenting with left foot pain
and swelling for 3 weeks. Pt was seen by podiatry on ___ who
recommended urgent admission for left ___ digit amputation as
toe was cold and cyanotic. However, pt postphoned being admitted
to hospital for amputation as he needed to "straighten stuff
out" first. He presented to ___ today with increased
toe pain, swelling, and erythema. He reports chills; no
documented fevers. He was given 2mg IV dilaudid and 3g IV
unasyn.
.
He was transferred to ___ ___. In the ___, initial VS: 98.5 95
152/68 18 98%. He was evaluated by podiatry who recommended
medicine admission for continued iv antibiotics and OR for
amputation tomorrow. He received 1g IV vancomycin (unclear if he
also received 4.5g IV zosyn) and 1mg IV dilaudid for pain. ___
was 409 for which he received 25 units lantus and 10units
___ home dose lantus 40 units though pt has not
been taking recently)
.
REVIEW OF SYSTEMS:
Denies headache, rhinorrhea, congestion, sore throat, cough,
shortness of breath, chest pain, abdominal pain, nausea,
vomiting, diarrhea, constipation
Past Medical History:
DM-2
HTN
HLD
CVA (1-day period of L sided paralysis)
MRSA cellulitis of bilat lower extremities
s/p L toe amputation ___
Social History:
___
Family History:
Non-contributory
Physical Exam:
PHYSICAL EXAM:
VS - 98.8 138/70 91 18 97%RA
GENERAL - Overweight male, lethargic but easily arousable,
appears uncomfortable from pain
HEENT - PERRL, EOMI, sclerae anicteric, MMM, OP clear
NECK - Supple, no thyromegaly, no JVD
HEART - PMI non-displaced, RRR, nl S1-S2, no MRG
LUNGS - CTAB, no r/rh/wh, good air movement, resp unlabored, no
accessory muscle use
ABDOMEN - NABS, soft/NT/ND, no masses or HSM
EXTREMITIES - right foot without significant ulcers; left foot
with missing ___ digit, ___ digits cyanotic and necrotic
with purulent drainage at base of ___ digit, malodorous,
diminished sensation of distal foot and toes, diffuse erythema,
swelling, and tenderness to palpation of foot to ankle(DP and ___
pulses dopplerable per podiatry assessment in ___
NEURO - awake, A&Ox3, CNs II-XII grossly intact
Pertinent Results:
___ 07:25AM BLOOD
WBC-8.9 RBC-3.19* Hgb-9.2* Hct-28.5* MCV-89 MCH-28.7 MCHC-32.2
RDW-13.4 Plt ___
___ 04:02AM BLOOD
___ PTT-37.5* ___
___ 07:25AM BLOOD
Glucose-255* UreaN-14 Creat-1.1 Na-139 K-4.7 Cl-103 HCO3-27
AnGap-14
___ 05:31AM
URINE Color-Yellow Appear-Hazy Sp ___
URINE Blood-SM Nitrite-NEG Protein-100 Glucose-300 Ketone-NEG
Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG
URINE RBC-6* WBC-3 Bacteri-FEW Yeast-NONE Epi-<1
___ 8:30 am FOOT CULTURE LEFT FOOT #1.
**FINAL REPORT ___
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES.
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS IN
SHORT CHAINS.
WOUND CULTURE (Final ___:
This culture contains mixed bacterial types (>=3) so an
abbreviated
workup is performed. Any growth of P.aeruginosa, S.aureus and
beta
hemolytic streptococci will be reported.
IF THESE BACTERIA ARE NOT REPORTED BELOW, THEY ARE NOT PRESENT
in this culture..
BETA STREPTOCOCCUS GROUP B. MODERATE GROWTH.
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 .
STAPH AUREUS COAG +
|
CLINDAMYCIN----------- R
ERYTHROMYCIN---------- R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- =>8 R
OXACILLIN------------- =>4 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------ <=0.5 S
ANAEROBIC CULTURE (Final ___:
Mixed bacterial flora-culture screened for B. fragilis, C.
perfringens, and C. septicum. None isolated.
CXR:
FINDINGS: The heart is at the upper limits of normal size,
although with a left ventricular configuration. The mediastinal
and hilar contours are
unremarkable. The lung volumes are low. There is no pleural
effusion or
pneumothorax. The lungs appear clear. Minimal degenerative
changes are noted along the thoracic spine.
IMPRESSION: No evidence of acute disease.
Brief Hospital Course:
___ with DM, HTN, HLD, CVA, osteomyelitis s/p L toe
amputation ___ presenting with right ___ digit pain and
swelling for 3 weeks
.
#Cyanosis/Necrosis Left foot: Pt with cyanosis/necrosis of left
foot ___ digits as well as cellulitis and possibily
osteomyelitis of left foot. Pt with leukocytosis (WBC 20);
however he is afebrile and hemodynamically stable, making
systemic spread of infection less likely. Left foot x-ray
showing gas in soft tissues, likely due to open area of
ulceration; discussed this finding with podiatry. Necrotizing
process unlikely given time course of systems (~3 weeks). S/p
___ Left foot ___ ray amps w/ Podiatry. Podiatry
then consulted Vascular surgery because of lack of bleeding.
Vascular surgery did the following procedures.
___: PROCEDURE:
Debridement of prior amputation site and an
exploration of proximal plantar and dorsal surface of foot.
___: OPERATION:
1. Ultrasound-guided puncture of right common femoral
artery.
2. Contralateral second-order catheterization of left
external iliac artery.
3. Abdominal aortogram.
4. Serial arteriogram of left lower extremity.
5. Perclose closure of right common femoral arteriotomy.
___: PROCEDURE: Left below-knee popliteal to pedal bypass,
debridement left foot.
___: PROCEDURE: Revision transmetatarsal amputation.
Pt stable s/p aforementioned procedures. He is
-nonweight-bearing of left lower extremity s/p TMA.
-pain control
# ID: IV vanc and Cefepime/Flagyl, grew out MRSA and mixed
flora. On DC, pt to continue for an additional two weeks.
.
# Acute kidney injury: Cr mildly elevated to 1.3 (previously
1.0-1.2). Likely due to volume depletion. Will hold lisinopril.
Not oliguric. Fena suggests pre-renal.
-hold lisinopril, started BB
.
# Diabetes: Per last d/c summary in ___, pt was started on
lantus 40units and glipizide for elevated blood sugars. However,
pt states that he has not been taking the insulin at home; has
only been taking metformin. A1c was 13 on last check on
___. Blood sugar elevated to 400s in ___ for which he
received 25 units lantus and 10 units ___
___ was consulted, The put on novolin 70/30 BID with SSI. Pt
to be discharged on insulin.
.
# HTN: SBP in 130s. Will hold ace for now given upcoming surgery
as well as mildly elevated Cr. Lisinopril held. BB started.
.
# Hyperlipidemia: Patient is s/p stroke/TIA in ___.
HLD therapy initiated with lipitor 80 during last admission but
pt has not been taking.
restarted statin
.
# Elevated INR: Pt with elevated INR of 1.4 and low albumin 2.6.
LFTs wnl. Reports previous history of heavy alcohol use, none
currently.
.
# FEN: IVFs / replete lytes prn / cardiac/diabetic diet (
# PPX: heparin SQ, bowel regimen (colace, senna)
# ACCESS: PICC Line
# CODE: Full (confirmed with pt)
# DISPO:
Medications on Admission:
metformin 1000", ASA 325', lisinopril 30'
Discharge Medications:
1. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
Disp:*30 Tablet(s)* Refills:*0*
2. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
4. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*2*
5. hydromorphone 2 mg Tablet Sig: ___ Tablets PO Q4H (every 4
hours) as needed for pain.
Disp:*90 Tablet(s)* Refills:*0*
6. gabapentin 300 mg Capsule Sig: Two (2) Capsule PO TID (3
times a day).
Disp:*180 Capsule(s)* Refills:*2*
7. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
9. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
10. multivitamin Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
11. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours).
Disp:*240 Tablet(s)* Refills:*2*
12. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation .
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
13. Insulin Fixed dose and SS
Insulin SC Fixed Dose Orders
Breakfast Dinner
70 / 30 50 Units 70 / 30 55 Units
Insulin SC Sliding Scale
Breakfast Lunch Dinner Bedtime
Regular
Glucose Insulin Dose
___ mg/dL Proceed with hypoglycemia protocol
71-119 mg/dL 0 Units 0 Units 0 Units 0 Units
120-159 mg/dL 0 Units 0 Units 6 Units 0 Units
160-199 mg/dL 0 Units 0 Units 0 Units 0 Units
200-239 mg/dL 2 Units 2 Units 2 Units 2 Units
240-279 mg/dL 4 Units 4 Units 4 Units 4 Units
280-319 mg/dL 6 Units 6 Units 6 Units 6 Units
320-359 mg/dL 8 Units 8 Units 8 Units 8 Units
360-399 mg/dL 10 Units 10 Units 10 Units 10 Units
> 400 mg/dL 12 Units 12 Units 12 Units 12 Units
14. PICC
Heparin Flush (10 units/ml) 2 mL IV PRN line flush
PICC, heparin dependent: Flush with 10mL Normal Saline followed
by Heparin as above daily and PRN per lumen
15. nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
16. vancomycin in D5W 1 gram/200 mL Piggyback Sig: One (1)
Intravenous Q 12H (Every 12 Hours) for 2 weeks: Please follwo
Vanc trough.
17. cefepime 2 gram Recon Soln Sig: One (1) Recon Soln Injection
Q12H (every 12 hours) for 2 weeks.
18. Flagyl 500 mg Tablet Sig: One (1) Tablet PO three times a
day.
19. heparin (porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day): DC when pt is ambulatory.
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Infected gangrenous left foot
PAD
DM2 (HbA1c 13.0%)
HTN
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
DISCHARGE INSTRUCTIONS FOLLOWING TRANSMETATARSAL AMPUTATION:
This information is designed as a guideline to assist you in a
speedy recovery from your surgery. Please follow these
guidelines unless your physician has specifically instructed you
otherwise. Please call our office nurse if you have any
questions. Dial 911 if you have any medical emergency.
ACTIVITY:
There are restrictions on activity. On the side of your
amputation you are non weight bearing for ___ weeks. You should
keep this amputation site elevated when ever possible.
No driving until cleared by your Surgeon.
PLEASE CALL US IMMEDIATELY FOR ANY OF THE FOLLOWING PROBLEMS:
Redness in or drainage from your leg wound(s).
New pain, numbness or discoloration of your stump site.
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.
Do not drive a car unless cleared by your Surgeon.
Try to keep leg elevated when able.
BATHING/SHOWERING:
You may shower immediately upon coming home. No bathing. A
dressing may cover youre amputation site and this should be
left in place for three (3) days. Remove it after this time and
wash your incision(s) gently with soap and water. You will have
sutures, which are usually removed in 4 weeks. This will be done
by the Surgeon on your ___ appointment.
WOUND CARE:
When the sutures are removed the doctor may or may not place
pieces of tape called steri-strips over the incision. These will
stay on about a week and you may shower with them on. If these
do not fall off after 10 days, you may peel them off with warm
water and soap in the shower.
Avoid taking a tub bath, swimming, or soaking in a hot tub for
four weeks after surgery.
MEDICATIONS:
Unless told otherwise you should resume taking all of the
medications you were taking before surgery. You will be given a
new prescription for pain medication, which can be taken every
three (3) to four (4) hours only if necessary.
Remember that narcotic pain meds can be constipating and you
should increase the fluid and bulk foods in 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.
CAUTIONS:
NO SMOKING! We know you've heard this before, but it really is
an important step to your recovery. Smoking causes narrowing of
your blood vessels which in turn decreases circulation. If you
smoke you will need to stop as soon as possible. Ask your nurse
or doctor for information on smoking cessation.
Avoid pressure to your amputation site.
No strenuous activity for 6 weeks after surgery.
DIET:
There are no special restrictions on your diet postoperatively.
Poor appetite is expected for several weeks and small, frequent
meals may be preferred.
For people with vascular problems we would recommend a
cholesterol lowering diet: Follow a diet low in total fat and
low in saturated fat and in cholesterol to improve lipid profile
in your blood. Additionally, some people see a reduction in
serum cholesterol by reducing dietary cholesterol. Since a
reduction in dietary cholesterol is not harmful, we suggest that
most people reduce dietary fat, saturated fat and cholesterol to
decrease total cholesterol and LDL (Low Density Lipoprotein-the
bad cholesterol). Exercise will increase your HDL (High Density
Lipoprotein-the good cholesterol) and with your doctor's
permission, is typically recommended. You may be self-referred
or get a referral from your doctor.
If you are overweight, you need to think about starting a weight
management program. Your health and its improvement depend on
it. We know that making changes in your lifestyle will not be
easy, and it will require a whole new set of habits and a new
attitude. If interested you can may be self-referred or can get
a referral from your doctor.
If you have diabetes and would like additional guidance, you may
request a referral from your doctor.
___ APPOINTMENT:
Be sure to keep your medical appointments. The key to your
improving health will be to keep a tight reign on any of the
chronic medical conditions that you have. Things like high blood
pressure, diabetes, and high cholesterol are major villains to
the blood vessels. Don't let them go untreated!
Please keep all your scheduled appointments
PLEASE FEEL FREE TO CALL THE OFFICE WITH ANY OTHER CONCERNS OR
QUESTIONS THAT MIGHT ARISE
Followup Instructions:
___
|
19703830-DS-13
| 19,703,830 | 21,384,890 |
DS
| 13 |
2149-03-05 00:00:00
|
2149-03-05 19:09:00
|
Name: ___ Unit ___: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
___ Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Dizziness and headache
Major Surgical or Invasive Procedure:
None
History of Present Illness:
HPI: (history obtained from patient, medical record)
Mr. ___ is a ___ year old man with history of HTN, HLD, DM
II (poorly controlled), s/p L BKA, prior TIA ___ years ago who is
transferred from OSH with left cerebellar infarct on CT with in
the setting of dizziness. On ___, patient was sitting
on the couch and watching TV when he suddenly felt "dizzy." He
denies a room spinning sensation, felt more lightheaded.
Associated with occipital throbbing headache, nausea, 1x episode
vomitting. ___ diplopia/vision changes, incoordination, poor
balance, focal weakness or numbness at that time. He went to
___ where he was admitted for dehydration and treated
with IV fluids. Patient was discharged on ___.
After coming home, symptoms of lightheadedness, nausea, headache
persisted. He also said that he could not walk at home and just
sat in his chair (at baseline with BKA and prosthesis, but
usually mobile). On ___, he decided to return to the ___.
While he was getting out of the car and walking to the hospital,
he felt off balance and fell forward, denies head strike, denies
falling right or left.
Of note, has history of TIA ___ years ago. With that episode,
he had right sided numbness that lasted a few hours. He was
worked up at ___ for this. Per records, this was in
___. He had a head CT angiogram which was negative. An MRI
showed scattered white matter signal changes only. There was ___
evidence for an acute infarct. Carotid ultrasound showed ___
significant disease and an echocardiogram was unremarkable (with
___ evidence for PFO or ASD).
Patient was seen by neurology in OSH ___ today. On exam there,
he reportedly had dysarthria and truncal ataxia. CT showed L
cerebellar infarct with small hemhorragic component, possible
mass effect due to edema, with compressed ___ ventricle. The
neurologist was concerned for herniation, so requested transfer
to ___. On arrival, patient reported HA, lightheadedness and
occasional nausea. States that lightheadedness improves if he
closes his eyes.
On neuro ROS, the pt denies loss of vision, blurred vision,
diplopia, dysarthria, dysphagia, vertigo, tinnitus or hearing
difficulty. Denies difficulties producing or comprehending
speech. Denies focal weakness, numbness, parasthesiae. ___ bowel
or bladder incontinence or retention.
On general review of systems, the pt denies recent fever or
chills. ___ 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. ___ recent change in bowel or bladder habits.
___ dysuria. Denies arthralgias or myalgias. Denies rash.
Past Medical History:
Right foot infection/gangrene
___
HTN
HLD
CVA ___ period of L sided paralysis)
MRSA cellulitis of bilat lower extremities
PSH:
___: Debridement with open ray amputation 2, 3, 4 of
left foot.
___: Debridement of prior amputation site and an
exploration of proximal plantar and dorsal surface of foot.
___: Serial arteriogram of left lower extremity.
___: Left ___ popliteal to pedal bypass,
debridement left foot.
___ transmetatarsal amputation.
___: L toe amputation
Social History:
___
Family History:
___ history of stroke or seizure
Physical Exam:
Physical Exam:
Vitals: T 97.7 BP 134/115 HR 79 RR 15 O2 97 RA
General: Awake, mostly cooperative, disheveled, malodorous
HEENT: NC/AT
Neck: Supple
Pulmonary: CTAB
Cardiac: RRR, ___ murmurs
Abdomen: soft, nontender, nondistended
Extremities: ___ edema, pulses palpated on RLE; BKA on left
Skin: ___ rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented x 3. Able to relate history
without difficulty. Attentive. Language is fluent. Speech is
baseline. There were ___ paraphasic errors. Able to follow both
midline and appendicular commands. There was ___ evidence of
apraxia or neglect.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRLA
III, IV, VI: EOMI without nystagmus. Normal saccades.
V: Facial sensation intact to light touch.
VII: ___ facial droop, facial musculature symmetric.
VIII: Hearing intact to ___ bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal bulk, tone throughout. ___ pronator drift
bilaterally.
___ adventitious movements, such as tremor, noted.
Strength was full in all major muscle groups tested.
-Sensory: Normal LT bilateral UE and ___
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 2 *
R 2 2 2 2 1
* Left BKA
Plantar response was mute on right.
-Coordination: FNF very mild L dymetria. He
does have slight overshooting at times. Improves with effort.
-Gait: Not tested due to poor fit of patient's new left leg
prosthesis.
DISCHARGE EXAM: Unchanged
Pertinent Results:
___ at ___
Hypodensity in the left cerebellar hemisphere consistent with a
cerebellar infarct. There is mass effect upon the fourth
ventricle. Old lacunar infarcts in the right centrum semiovale
and left
thalamus.
CTA head: ___ segment cut offs, patent vasculature.
CTA neck: Irregular, hypoplastic vertebral arteries, worse on
the
right than the left. ___ vessel occlusions.
MRI ___ Evolving left cerebellar hemisphere infarction with
hemorrhage. Extensive white matter changes suggesting chronic
small vessel ischemia. ___ findings to suggest recent infarction
elsewhere.
___ Echo
LEFT ATRIUM: Normal LA and RA cavity sizes.
RIGHT ATRIUM/INTERATRIAL SEPTUM: ___ ASD by 2D or color Doppler.
LEFT VENTRICLE: Mild symmetric LVH with normal cavity size. ___
resting LVOT gradient.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Mildy dilated aortic root. Mildly dilated ascending
aorta.
AORTIC VALVE: Normal aortic valve leaflets (3). ___ AS. ___ AR.
MITRAL VALVE: Normal mitral valve leaflets with trivial MR. ___
MVP.
PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not visualized.
___ PS. Physiologic PR.
GENERAL COMMENTS: Suboptimal image quality - poor echo windows.
Suboptimal image quality - body habitus
___ 07:19AM ___
___
___ 07:19AM PLT ___
___ 05:00AM ___ UREA ___
___ TOTAL ___ ANION ___
___ 05:00AM ___
___ 05:00AM ___ HDL ___
LDL(CALC)-127
Brief Hospital Course:
Mr. ___ is a ___ yo man with HTN, HLD, DM II (poorly
controlled), s/p L BKA, likely TIA ___ years ago transferred from
OSH presented ___ with dizziness and occipital headache found
with left cerebellar infarct at OSH. Transferred from OSH due
to concern for CT which showed possible mass effect on the ___
ventricle. His exam on arrival notable only for mild dysmetria
on left finger to nose, saccadic intrusions on extraocular
movements. CTA head/neck shows irregular vertebrals, but
vasculature is patent. Etiology likely atheroembolic into
region of ___. Evaluation of vascular risk factors shows
obesity, HTN, hyperlipidemia and poorly controlled diabetes.
Symptoms have improved although still with functional gait
impairment due to BKA and cerebellar stroke, physical therapists
recommend further rehab at inpatient facility
# Neuro:
- Distributed stroke information packet and note in the chart
- fasting lipid panel LDL 127 and HbA1c 7.9.
- Home regimen Humulin 70/30 60 U qam, 64U qpm may need to be
uptitrated by PCP
- MRI showed small hemorrhagic component. Will continue aspirin
325mg qd for now.
- TTE was suboptimal in quality but failed to show PFO or large
thrombus to account for his stroke
- PTOT recommending acute rehab based on gait instability, BKA
- Pt passed bedside Speech & Swallow and can eat.
- Precautions: falls and aspiration
# ___:
- ECG
- Telemetry
- Restarted home labetalol 400mg bid, hydralazine 50 TID.
Holding Lisinopril 40mg qd due to creatinine.
- Hydralazine 10 mg IV Q6H PRN SBP > 160
# ENDO:
- HbA1c as above
- Finger sticks QID and Insulin sliding scale with a goal of
normoglycemia
# Renal: Cr 1.4 on arrival, 1.5 today, s/p contrast load. Was
given IVF in the ___ continue po hydration
- trend Cr.
# GI:
- PRN laxatives, zofran as needed
PPX:
- DVT: S/C heparin/pneumoboots
- GI: PRN laxatives
TRANSITIONAL ISSUES
- Please continue aggressive physical therapy
- Uptitrate home statin dose for hyperlipidemia
- Monitor blood glucose daily and follow up with Dr. ___ to
optimize your home insulin dose
- Continue labetolol 400bid and hydralazine 50mg tid for blood
pressure, hold lisinopril in the setting of slightly elevated
creatinine 1.5
AHA/ASA Core Measures for Ischemic Stroke and Transient Ischemic
Attack
1. Dysphagia screening before any PO intake? (x) Yes, confirmed
done - () Not confirmed () ___
2. DVT Prophylaxis administered? (x) Yes - () ___
3. Antithrombotic therapy administered by end of hospital day 2?
() Yes - (x) ___
4. LDL documented? (x) Yes (LDL = as per summary ) - () ___
5. Intensive statin therapy administered? (simvastatin 80mg,
simvastatin 80mg/ezetemibe 10mg, atorvastatin 40mg or 80 mg,
rosuvastatin 20mg or 40mg, for LDL > 100) (x) Yes - () ___ [if
LDL >100, reason not given: ]
6. Smoking cessation counseling given? (x) Yes - () ___ [reason
() ___ - () unable to participate]
7. Stroke education (personal modifiable risk factors, how to
activate EMS for stroke, stroke warning signs and symptoms,
prescribed medications, need for followup) given (verbally or
written)? (x) Yes - () ___
8. Assessment for rehabilitation or rehab services considered?
(x) Yes - () ___
9. Discharged on statin therapy? (x) Yes - () ___ [if LDL >100,
reason not given: ]
10. Discharged on antithrombotic therapy? (x) Yes [Type: ()
Antiplatelet - () Anticoagulation] - () ___
11. Discharged on oral anticoagulation for patients with atrial
fibrillation/flutter? () Yes - () ___ - (x) N/A
Medications on Admission:
Folic acid 1mg PO qd
Humulin 70/30 60 U qam, 64U qpm
Lisinopril 40mg qd
Simvastatin 20mg qd
Aspirin 325mg qd
Labetolol 400mg bid
Hydralazine 50mg bid
Discharge Medications:
1. Aspirin 325 mg PO DAILY
2. Labetalol 400 mg PO BID
3. Simvastatin 20 mg PO DAILY
4. Heparin 5000 UNIT SC TID
5. HydrALAzine 50 mg PO Q8H HTN
6. Ondansetron 4 mg IV Q8H:PRN nausea
7. FoLIC Acid 1 mg PO DAILY
8. Docusate Sodium 100 mg PO BID
9. 70/30 40 Units Breakfast
70/30 40 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
10. Senna 1 TAB PO BID:PRN constipation
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Left cerebellar infarct
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 ___ transferred from your outside
hospital with an acute episode of dizziness and headache. On
imaging studies of your brain you were found to have a stroke
that likely caused your symptoms. You had ___ signs of worsening
mental status. CTA head/neck shows irregular vertebrals, but
vasculature is patent. Etiology likely atheroembolic into
region of ___. Evalution of vascular risk factors showed
elevated lipids,and HbA1c 7.9 consistent with your longstanding
diabetes. Your symptoms improved during our hospitalization but
our physical therapists felt you would benefit from further
rehab. Please take all medications as listed on your discharge
summary and come to the ___ appointments we have
scheduled. Thank you for allowing us to participate in your
care.
Followup Instructions:
___
|
19703968-DS-10
| 19,703,968 | 25,434,138 |
DS
| 10 |
2150-06-06 00:00:00
|
2150-06-06 15:00:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Codeine
Attending: ___.
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms. ___ is a ___ y/o woman with a history of recurrent
diverticulitis, HTN, HLD, DM2, major depression, PTSD presents
with 4 days of ABD pain. Had a GI appointment in the AM, her
gastroenterologist referred her for evaluation of appendicitis
vs colitis. She reports relatively gradual onset of belly pain,
with anorexia, felt warm. She has vomited infrequently and NBNB.
She has had normal stools but noted that she had several
episodes of small string like stool movements in the that
happened in ___. The pain is lower abdominal and per
patient is non-focal to a specific area.
In the ED, initial vitals: 97.5., 103, 123/90, 20, 97% RA
- Exam notable for: mildly uncomfortable, focal RLQ pain/less so
RUQ pain with equivocal ___, mild rebound tenderness and
voluntary guarding and mildly peritoneal signs.
- Labs notable for: WBC nl, UA negative
- Imaging notable for: CT/Abdomen: Sigmoid diverticulitis
without evidence of perforation or abscess formation.
- Pt given: Cipro 400 mgIV, flagyl 500 mgIV, Zofran, Morphine
4mg IV x 2 with no minimal relief then dilaudid 0.5 mg IV with
some relief and 1L of NS.
- Vitals prior to transfer: 97.8, 83, 99/61, 18, 100% RA
On arrival to the floor, pt was walking around in her room and
not complaining of active pain. She endorsed ___ abdominal
pain. She noted that on her drive here she was in a lot pain on
bumpy roads
Past Medical History:
6 spontaneous miscarriages between ___ and ___
HTN
DM2
Hyperlipidemia
Lichen sclerosis
s/p partial vulvectomy
s/p Bartholin gland removal
Exploratory laparoscopy for infertility
PTSD
Major Depressive Disorder
History of Shingles
Recurrent Diverticulitis
Social History:
___
Family History:
Maternal GF had MI at age ___. Mother healthy in her
___. Father in ___ with HTN, CAD but no MI
Physical Exam:
ADMISSION PHYSICAL EXAM
======================
Vitals: 97.7, 115/71, 88, 16, 97%
General: Alert, oriented, no acute distress
HEENT: Sclerae anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: CTAB no wheezes, rales, rhonchi
CV: RRR, Nl S1, S2, No MRG
Abdomen: soft, obese, bowel sounds present, non-distended,
tender to palpation in the lower abdomen diffusely, minimal
rebound tenderness and guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
DISCHARGE PHYSICAL EXAM
=======================
Vitals: Tmax 97.7, 97.5, 100-110/70's, 88, 14, 95% on RA
Exam:
GENERAL - Alert, interactive, well-appearing in NAD
HEART - RRR, nl S1-S2, no MRG
LUNGS - CTAB
ABDOMEN - Obese, normal bowel sounds, non-tympanic, no enlarged
liver or spleen. Voluntary guarding, tender to deep palpation in
the lower abdomen.
EXTREMITIES - WWP, no c/c, no edema, 2+ peripheral pulses
Pertinent Results:
ADMISSION LABS
===============
___ 11:00AM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 11:00AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
___ 09:49AM LACTATE-1.6
___ 09:40AM GLUCOSE-135* UREA N-15 CREAT-0.9 SODIUM-135
POTASSIUM-3.8 CHLORIDE-93* TOTAL CO2-26 ANION GAP-20
___ 09:40AM ALT(SGPT)-16 AST(SGOT)-16 ALK PHOS-86 TOT
BILI-0.7 DIR BILI-<0.2 INDIR BIL-0.7
___ 09:40AM LIPASE-24
___ 09:40AM ALBUMIN-4.9 CALCIUM-10.0 PHOSPHATE-3.8
MAGNESIUM-1.7
___ 09:40AM WBC-7.6 RBC-4.07 HGB-13.5 HCT-40.1 MCV-99*
MCH-33.2* MCHC-33.7 RDW-12.5 RDWSD-45.0
___ 09:40AM NEUTS-62.1 ___ MONOS-9.0 EOS-2.8
BASOS-0.5 IM ___ AbsNeut-4.70 AbsLymp-1.88 AbsMono-0.68
AbsEos-0.21 AbsBaso-0.04
___ 09:40AM PLT COUNT-201
IMAGING
========
___ CT Abdomen/pelvis
Sigmoid diverticulitis without evidence of perforation or
abscess formation.
LABS ON DISCHARGE
===================
___ 08:00AM BLOOD WBC-5.9 RBC-3.44* Hgb-11.6 Hct-34.2
MCV-99* MCH-33.7* MCHC-33.9 RDW-12.3 RDWSD-44.6 Plt ___
___ 08:00AM BLOOD Glucose-104* UreaN-13 Creat-0.9 Na-138
K-3.6 Cl-100 HCO3-25 AnGap-17
Brief Hospital Course:
Ms. ___ is a ___ yo woman ___ re-occurent diverticulitis
presenting with abdominal pain. She was seen day of presentation
in her GI office and given severity of abdominal exam, she was
sent to ED for evaluation for appendicitis vs. complicated
diverticulits. In ED she was afebrile with normal vital signs. A
CT was performed that showed sigmoid diverticulitis without
evidence of perforation or abscess formation. She was given 1 L
NS, IV metronidazole, IV cipro, and IV dilaudid for pain. Of
note, she had no WBC. She was admitted to the medicine service
where IV antibiotics were transitioned to oral. She tolerated a
diet and was discharged on HD2.
=======================
Transitional Issues:
======================
- may consider non-urgent surgical consult as outpatient for
re-occurent diverticulitis
- patient reports history of DM2 though is not on any medicines,
would recommend HgA1c as outpatient
- patient code status is DNR/DNI, would recommended
re-evaluation as outpatient
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Triamterene-HCTZ (37.5/25) 1 CAP PO DAILY
2. Simvastatin 40 mg PO QPM
3. Metoprolol Succinate XL 25 mg PO DAILY
4. varenicline 1 mg oral BID
5. Mirtazapine 30 mg PO QHS
6. Prazosin 1 mg PO DAILY
Discharge Medications:
1. Metoprolol Succinate XL 25 mg PO DAILY
2. Mirtazapine 30 mg PO QHS
3. Prazosin 1 mg PO DAILY
4. Simvastatin 40 mg PO QPM
5. Ciprofloxacin HCl 500 mg PO Q12H
RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth twice a day
Disp #*19 Tablet Refills:*0
6. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*60 Capsule Refills:*0
7. MetroNIDAZOLE 500 mg PO BID
RX *metronidazole 500 mg 1 tablet(s) by mouth twice a day Disp
#*19 Tablet Refills:*0
8. Psyllium Powder 1 PKT PO DAILY:PRN constipation
RX *psyllium husk (aspartame) [Fiber (with aspartame)] 3.4
gram/5.8 gram 1 powder(s) by mouth daily Refills:*0
9. Senna 8.6 mg PO BID
RX *sennosides 8.6 mg 1 tablet by mouth twice a day Disp #*60
Tablet Refills:*0
10. Triamterene-HCTZ (37.5/25) 1 CAP PO DAILY
11. varenicline 1 mg oral BID
Discharge Disposition:
Home
Discharge Diagnosis:
Acute Sigmoid diverticulitis
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 your here at ___.
Why was I here?
- you had abdominal pain
What was done while I was here?
- we got blood work and urine to look for an infection. You did
not have urine or blood infection.
- We got CT of your abdomen that showed diverticulitis,no
perforation or abscess
- We gave you antibiotics, pain medication and fluids
What should I do when I get home?
- Continue taking your by mouth antibiotics ciprofloxacin and
metronidazole both 500 mg twice a day until ___ (total 10
days, you got one dose this morning so can take next dose
tonight).
- Please follow up with your primary doctor and
___.
- We have given you prescriptions for anti-constipation
medicines. This may help to prevent episodes of constipation.
Followup Instructions:
___
|
19704253-DS-22
| 19,704,253 | 23,087,158 |
DS
| 22 |
2111-04-15 00:00:00
|
2111-04-16 08:59:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Abdominal Pain, Nausea, Vomiting, Bloating
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ yr old woman with history of UC s/p colectomy and jpouch and
ileostomy takedown readmitted with continued symptoms on nausea,
abdominal pain, and bloating. She has had several episodes of
these symptoms since her ileostomy takedown ___.
Past Medical History:
PNC:
- ___ ___
- Labs A+/Abs-/RUBNI/RPRNR/HBsAg-/HIV-/GBS unknown
- LR ERA
- FFS wnl
- GLT wnl
- Issues
*) Crohn's disease:no recent flares
*) appendicitis at 24 weeks, with sepsis, bacteremia. Treated
with laproscopic appendectomy, uncomplicated surgery.
Transfusion for anemia.
BMZ given ___, completed.
OBHx:
- G1 current
GynHx:
- remote hx abnl Pap with nl f/u; denies cervical procedures
- denies fibroids, endometriosis, ovarian cysts
- denies STIs, including HSV
PMHx: Crohn's disease, anemia
PSHx: lsc appendectomy
Social History:
Denies Tobacco, alcohol or drug use.
Physical Exam:
Discharge Physical Exam
General: tolerating a regular diet, pain controlled, ambulating,
vitals stable, passing gas, had bowel movement
VSS
Neuro: A&OX3
Cardio/Pulm: no chest pain or shortness of breath.
Abd: well healed surgical incisions, ileostomy takedown site
well healed, abdomen now flat and soft
Pertinent Results:
___ 07:45AM BLOOD WBC-3.6* RBC-3.52* Hgb-9.2* Hct-29.9*
MCV-85 MCH-26.1 MCHC-30.8* RDW-15.3 RDWSD-47.7* Plt ___
___ 06:21AM BLOOD WBC-7.1 RBC-4.56 Hgb-12.0 Hct-39.3 MCV-86
MCH-26.3 MCHC-30.5* RDW-15.6* RDWSD-49.3* Plt ___
___ 06:21AM BLOOD Neuts-73.8* Lymphs-17.2* Monos-6.9
Eos-1.4 Baso-0.4 Im ___ AbsNeut-5.27# AbsLymp-1.23
AbsMono-0.49 AbsEos-0.10 AbsBaso-0.03
___ 07:45AM BLOOD Plt ___
___ 06:21AM BLOOD Plt ___
___ 06:21AM BLOOD ___ PTT-25.1 ___
___ 07:45AM BLOOD Glucose-107* UreaN-9 Creat-0.4 Na-140
K-3.4 Cl-107 HCO3-23 AnGap-13
___ 06:21AM BLOOD Glucose-108* UreaN-11 Creat-0.6 Na-134
K-5.6* Cl-100 HCO3-19* AnGap-21*
___ 06:21AM BLOOD ALT-17 AST-43* AlkPhos-47 TotBili-0.4
___ 07:45AM BLOOD Calcium-8.4 Phos-2.2* Mg-2.1
___ 06:21AM BLOOD Albumin-4.6
___ 09:35AM BLOOD Lactate-0.8 K-3.8
Brief Hospital Course:
On the day of admission Ms ___ was much improved and had
return of bowel function without nasogastric tube placement. She
was hydrated intravenously, however, when she was reliably
taking sufficient liquids, the fluids were discontinued. It was
decided that she likely has some narrowing that is becoming
intermittently obstructed and may warrant surgical exploration
however, she was resolved and we recommended diet changes until
this time. She was discharged home. Dr ___ will contact her
to discuss further management.
Medications on Admission:
nasal b12 500mcg qweek
levonorgestrel-ethinyl estradiol ___ qdail
pre-natal vitamins
Discharge Medications:
Levonorgestrel-ethinyl estrad 0.1-20 mg-mcg oral DAILY
Prenatal Vitamins 1 TAB PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Small Bowel Obstruction
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital for a small bowel
obstruction. You were given bowel rest and intravenous fluids.
Your obstruction has subsequently resolved after conservative
management. You have tolerated a regular diet, are passing gas
and your pain is controlled with pain medications by mouth. You
may return home to finish your recovery. Dr. ___ work
with you to plan surgery to evaluate the cause of your bowel
obstruction and look at a possible area of narrowing. He will
discuss with you over the phone.
If you have any of the following symptoms please call the
office for advice or go to the emergency room if severe:
increasing abdominal distension, increasing abdominal pain,
nausea, vomiting, inability to tolerate food or liquids,
prolonged loose stool, or extended constipation.
Thank you for allowing us to participate in your care! Our hope
is that you will have a quick return to your life and usual
activities.
Good luck!
____________________________________________________________
Followup Instructions:
___
|
19704329-DS-4
| 19,704,329 | 25,228,201 |
DS
| 4 |
2138-09-24 00:00:00
|
2138-11-18 21:14:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
naproxen
Attending: ___.
Chief Complaint:
unrestrained passenger in MVA
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ with history of afib/aflutter on coumadin, CKD who
presented on ___ as a unrestrained driver involved MVA. No LOC
or head trauma noted, no airbag deployment. Found to have liver
laceration, C7-T1 subluxation, subacute R occipital stroke, L5
compression fracture, R ear hematoma and scalp laceration. Was
monitored in the TSICU. Stable hcts, holding coumadin. Neurology
consulting regarding a subacute infarct seen on imaging. No
evidence of acute
intracranial hemorrhage, mass effect, or acute ischemia on
MRA/MRI brain. No evidence of intra-cardiac thrombus on prelim
echo read. Neurosurgery also consulted regarding C7-T1
anterolisthesis. His spinal MRI does not show any ligamentous
injury or spinal cord involvement, and his flexion and extension
films do not show any movement. They have signed off. No
surgical
interventions planned. Also has hyponatremia to 129. Mildly
delerious on exam, but usually AAOx3 and at baseline mental
status
per family. Getting called out to Medicine as part of ___
pathway.
Past Medical History:
afib, HTN, CKD, h/o hyponatremia ___ SIADH, asbestos exposure
(pleural plaques)
Social History:
___
Family History:
family history of colon cancer.
Physical Exam:
ADMISSION EXAM (neurology consult service):
Physical Exam:
Vitals: T:98.3 P:80 R: 16 BP:153/77 SaO2: 100% RA
General: Awake, lying in bed with C collar in place.
HEENT: No skull deformities, MM dry, no lesions noted in
oropharynx. abrasions on his right ear and his right scalp, no
major lacerations
Neck: In hard C collar
Pulmonary: Lungs CTA bilaterally
Cardiac: RRR,S1S2, no M/R/G noted nl.
Abdomen: soft, NT/ND.
Extremities: warm and well perfused
Skin: multiple abrasions.
Neurologic:
-Mental Status: Alert, oriented to self, think he is at ___, says ___ for year and ___ for
date. Also, says it's ___. Able to relate history but
notable for slow processing speed. Attentive, able to name ___
backward without difficulty. Language is fluent with intact
repetition. Normal prosody. There were no paraphasic errors. Pt
was able to name both low frequency objects but not high
frequency objects. Able to read without difficulty. Speech was
not dysarthric. Able to follow simple midline and appendicular
commands but has difficulty with multi step commands. He did
have difficulty identifying the left side of shown picture and
doing FNF in his left lateral visual field.
-Cranial Nerves:
II: PERRL 3 to 2mm and brisk. VF grossly full to finger counting
but patient does say that the left is his bad eye.
III, IV, VI: EOMI without nystagmus. Normal saccades.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
IX, X: Palate elevates symmetrically.
XI: not tested secondary to collar
XII: Tongue protrudes in midline.
-Motor: Decreased bulk throughout, tone increased in lower
extremities. No pronation or drift bilaterally. Tremor at rest,
significantly exacerbated by activity/ intention.
Delt Bic Tri IO IP Quad Ham TA Gastroc
L 5 ___ 5 5 5 5 5
R 5 ___ 5 5 5 5 5
-Sensory: No deficits to light touch throughout. No extinction
to
DSS.
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 1 0
R 2 2 2 1 0
Plantar response was downgoing bilaterally.
-Coordination: Bilateral intention tremor, No dysmetria on FNF
but patient unable to perform FNF in the left visual field.
-Gait: deferred
DISCHARGE EXAM:
98 ___ ___ 18 99-100% on RA
GEN: NAD, A&Ox2-3 (self, "hospital", unable to state BID, and
"the third" of unknown month, year is "14")
HEENT: evidence of trauma with small (<2cm) lac on superior
right aspect of scalp lac, R ear hematoma. View of tympanic
membrane of right ear obstructed by cerumen.
NECK: supple, FROM, no LAD
CV: ___, no m/r/g
LUNG: Trace crackles in b/l bases
ABD: benign, no tenderness to palpation (including deep
palpation of RUQ), no rebound or guarding
EXT: wwp, no c/c/e
NEURO: non focal, EOMI, face symmetric, strength intact b/l.
Able to do days of week backwards at a slightly slowed pace.
** note: later in the day delerious, not oriented to place or
timem, poor attention.
Pertinent Results:
TRANSFER LABS (see ___ discharge for initial presentation
labs):
___ 01:40PM BLOOD WBC-16.3* RBC-3.89* Hgb-12.8* Hct-35.6*
MCV-92 MCH-32.9* MCHC-36.0* RDW-13.3 Plt ___
___ 07:48PM BLOOD Neuts-87.8* Lymphs-5.1* Monos-6.5 Eos-0.4
Baso-0.1
___ 01:40PM BLOOD ___ PTT-25.4 ___
___ 01:40PM BLOOD ___ 07:48PM BLOOD Glucose-107* UreaN-34* Creat-1.3* Na-129*
K-4.4 Cl-93* HCO3-24 AnGap-16
___ 03:33AM BLOOD ALT-31 AST-38 AlkPhos-66 TotBili-1.0
___ 01:40PM BLOOD Lipase-81*
___ 01:40PM BLOOD cTropnT-0.07*
___ 07:48PM BLOOD Calcium-9.0 Phos-3.1 Mg-1.8
___ 03:33AM BLOOD %HbA1c-6.2* eAG-131*
___ 03:33AM BLOOD Triglyc-43 HDL-61 CHOL/HD-2.0 LDLcalc-50
___ 01:40PM BLOOD Osmolal-274*
___ 03:33AM BLOOD TSH-3.1
___ 01:40PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 01:45PM BLOOD Glucose-106* Lactate-1.2 Na-125* K-4.8
Cl-91* calHCO3-23
DISCHARGE LABS:
___ 05:30AM BLOOD WBC-9.1 RBC-3.83* Hgb-12.4* Hct-36.0*
MCV-94 MCH-32.4* MCHC-34.4 RDW-13.7 Plt ___
___ 05:30AM BLOOD ___ PTT-29.1 ___
___ 05:30AM BLOOD Glucose-118* UreaN-32* Creat-1.6* Na-133
K-4.0 Cl-95* HCO3-27 AnGap-15
___ 05:30AM BLOOD ALT-28 AST-36 AlkPhos-59 TotBili-0.5
___ 05:30AM BLOOD Calcium-9.4 Phos-3.4 Mg-1.8
IMAGING/STUDIES:
ECGStudy Date of ___ 1:41:36 ___
Baseline artifact. Atrial flutter. No previous tracing available
for
comparison.
IntervalsAxes
___
___
ECHO ___
Conclusions
The left atrial volume index is severely increased. Due to
suboptimal technical quality, a focal wall motion abnormality
cannot be fully excluded. Overall left ventricular systolic
function is normal (LVEF>55%). Right ventricular chamber size
and free wall motion are normal. The number of aortic valve
leaflets cannot be determined. The aortic valve leaflets are
moderately thickened. The mitral valve leaflets are mildly
thickened. There is no pericardial effusion.
IMPRESSION: Suboptimal image quality. Nomal biventricular
regional/global systolic function. A wall motion abnormality
cannot be fully excluded due to limited image quality. Apex
moves well so apical thrombus very unlikely in setting of normal
ejection fraction. The patient appears to be in atrial flutter,
has biatrial enlargment with left atrium severely enlarged,
there is mitral annular calcification. All these findings
increase the risk of stroke due to atrial fib/flutter. There is
no direct echocardiographic evidence of a cardiac thrombus.
PORTABLE CXR ___
FINDINGS:
Supine portable AP view of the chest. Underlying trauma board is
in place.
Calcified pleural plaques are better visualize on the same day
chest CT. There
is no consolidation, or supine evidence for effusion or
pneumothorax. Heart
size is within normal limits. Mediastinal contour is normal. No
displaced
fractures are seen.
IMPRESSION:
No acute findings.
RIGHT KNEE X rays:
FINDINGS:
AP, oblique, cross-table lateral views of the right knee were
provided. There
is no fracture or dislocation. No joint effusion is seen. There
is minimal
osteoarthritis with tiny marginal spurs. Vascular calcifications
are present.
IMPRESSION:
No fracture or dislocation.
C SPINE FLEXION/EXTENSION
There are severe degenerative changes of cervical spine with
loss of
intervertebral disc height at virtually most levels. At C7-T1,
there is
anterolisthesis measuring 5 mm. This is better appreciated on
the subsequent
MRI of the cervical spine. There are no compression
deformities. The
prevertebral soft tissues are within normal limits.
MR THORACIC, CERVICAL SPINE
IMPRESSION:
1. Multilevel degenerative spondylosis, greatest within the
cervical spine
there is moderate spinal canal narrowing and severe neural
foraminal stenoses,
as described.
2. No evidence of ligamentous injury. Spondylolisthesis of C7 on
T1 is likely
on a degenerative basis.
Probable renal cysts are noted.
MRA NECK/BRAIN/HEAD
IMPRESSION:
1. No evidence of acute intracranial hemorrhage, mass effect, or
acute
ischemia.
2. Brain parenchymal volume loss and presumed sequelae of
chronic small vessel
ischemic disease.
3. No evidence of hemodynamically significant stenosis,
pathologic large
vessel occlusion, or aneurysm within the vasculature of the head
or neck.
Brief Hospital Course:
___ with history of afib/aflutter on coumadin, CKD who
presented on ___ as a unrestrained driver involved MVA found to
have liver laceration, C7-T1 subluxation, subacute R occipital
stroke, L5compression fracture, R ear hematoma and scalp
laceration. Now s/p TSICU stay with stable H/H. Current course
in complicated by hyponatremia of unknown etiology.
ACTIVE ISSUES:
#TSICU COURSE:
Mr. ___ was met in the emergency department at ___ by the
trauma surgery service after his motor vehicle crash on ___
and transfer from ___. He underwent extensive
imaging and was ultimately brought to the intensive care unit
for monitoring. Neurology, Neurosurgery, and Spine were
consulted. His coumadin was held and his hematocrit checked
every 4 hours. His hyponatremia was gently corrected. Overnight,
the patient was hemodynamically stable and his hematocrit was
also stable. The following morning, the patient's cervical
collar was cleared. He was given a regular diet. He got out of
bed to a chair. The patient was transferred to the floor under
the care of the medicine service.
#Hyponatremia: On exam, euvolemic. Urine electrolytes with
UOsms=480, UNa 95, all c/w SIADH. He has a history of SIADH as
an outpatient previously. The etiology of this is unclear. On
___ his Na was 129. He has had a progressive ___ from
___ with Na dropping 139->137->131->129. Could be 2'/2 old
infarct, head trauma from the accident, or ?malignancy in his
kidney or pancreas. Post trauma pain could have also
contributed. He was fluid restricted 2L/d with rise to 133-136.
#R Occipital Stroke: per MRI and MRA imaging this is NOT acute
and not likely to be 2'/2 trauma. It is possible that this
stroke may have caused visual loss leading to his accident. A
TTE was negative for cardiac source of emboli.
#Delirium: Initially had episodes of delirium, believing he was
in a grocery store, etc. This improved after his gabapentin and
oxycodone were held. He had a UA and chest imaging on admission.
Remained afebrile. Given continuing delirium, US resent on
___, with negative nitrites, trace leuks (7 WBC an no bacteria
on micro), cx pending on discharge.
CHRONIC ISSUES:
#AFib: rate controlled with home diltiazem. His coumadin was
initially held due to concern for bleeding after trauma, but
restarted on ___ after discussion with his PCP. He was bridged
with enoxaparin to warfarin and will follow up with her PCP and
cardiologist regarding anticoagulation as an outpatient.
#CKD STage III: Baseline Cr ~1.6. Currently around baseline
====================================
TRANSITIONAL ISSUES:
====================================
# please recheck chem panel ___. If Cr 1.6 or greater, please
discontinue Lovenox. If Na<130, increase fluid restriction to
1.5L per day.
# please recheck INR ___ and titrate warfarin dosing as needed
#SIADH: noted in ___ clinic, chronic and unlikely related to
MVA trauma. Continued evaluation and work up in outpatient
clinic is appropriate. Recommend checking Chem panel within 4
days of discharge and decrease fluid allowance as needed
(currently 2L fluid restriction, could consider 1.5L if sodium
trends down).
#HTN: Initially held Lisinopril 5mh and HCTZ 12.5mg due to
normal BP and liver lac, but with high blood pressures HCTZ was
restarted in addition to ongoing diltiazem for rate control.
His blood pressures were low-normal. Upon further discussion,
lisinopril would be the preferred agent given her CKD, so on
discharge plan is to hold HCTZ and start lisinopril ___.
Giving all anti-hypertensive medications in AM led to morning
borderline-low pressures. Please administer diltiazem in AM and
lisinopril in the evening. Can add back HCTZ as required.
#Stroke: will need formal visual field testing by ophthalmology
as an outpatient. Consider followup with vascular neurology as
outpatient.
#Incidental findings: 2.5cm cyst in left kidney should be
further assessed by ultrasound or MRI nonurgently. And CT
abdomen showed bilobed cystic lesion in the pancreas with mild
dilatation of the pancreatic duct suspicious for IPMN.
Radiology recommended non-urgent MRCP to further assess.
#A flutter/A fib: continue warfarin (goal INR ___. will bridge
with Lovenox given CHADS score of 4, however if Cr increases
plan to allow INR to drift up without ongoing lovenox bridge.
On diltiazem for rate control.
#Delirium: Continues to be intermittently delirious, however is
showing improvement (decreasing frequency of delirium). Likely
related to acute illness (MCV), subacute stroke, and hospital
environment. UA sent due to foley placement during stay, and
was pending at discharge-- results were trace blood, negative
nitrites, 100 protein, neg glucose, trace ketones, negative
bilirub, 2 urobili, pH 5.5, trace leuks, 3 RBC, 7 WBC, no
bacteria/yeast, 9 Hycasts.
Medications on Admission:
1. Terazosin 5 mg PO HS
2. Gabapentin 300 mg PO BID
3. Diltiazem Extended-Release 120 mg PO DAILY
4. Hydrochlorothiazide 12.5 mg PO DAILY
5. Lisinopril 5 mg PO DAILY
6. Alendronate Sodium 70 mg PO QMON
7. Fish Oil (Omega 3) Dose is Unknown PO DAILY
8. calcium carbonate 600 mg (1,500 mg) oral 2 tabs daily
9. ICaps (vitA-B2-C-E-lutein-zeaxant-min) unknown oral 2 tabs
daily
10. Vitamin D 1000 UNIT PO 2X/WEEK (MO,TH)
11. Multivitamins 1 TAB PO DAILY
12. Glucosamine-Chondroitin Complx
(
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C-Mn;<br>glucosamine-chondroit-vit C-Mn) 500-400 mg oral 2 tab
BID
Discharge Medications:
1. Diltiazem Extended-Release 120 mg PO DAILY
Please administer in the morning.
2. Terazosin 5 mg PO HS
3. Acetaminophen 1000 mg PO Q8H:PRN pain
4. Enoxaparin Sodium 60 mg SC BID atrial fibrillation
Start: Today - ___, First Dose: Next Routine Administration
Time
Discontinue when INR >2
5. Senna 8.6 mg PO BID Constipation
6. Warfarin 4 mg PO 5X/WEEK (___) on ___,
___
7. Warfarin 2 mg PO 2X/WEEK (FR,SA) on ___
8. Docusate Sodium 100 mg PO BID:PRN constipation
hold for loose stools.
9. Alendronate Sodium 70 mg PO QMON
10. Calcium Carbonate 600 mg (1,500 mg) ORAL 2 TABS DAILY
11. Fish Oil (Omega 3) 1000 mg PO DAILY
12. Glucosamine-Chondroitin Complx
(
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C-Mn;<br>glucosamine-chondroit-vit C-Mn) 500-400 mg oral 2 tab
BID
13. ICaps (vitA-B2-C-E-lutein-zeaxant-min) 2 tabs ORAL DAILY
14. Multivitamins 1 TAB PO DAILY
15. Vitamin D 1000 UNIT PO 2X/WEEK (MO,TH)
16. Lisinopril 5 mg PO DAILY
Please administer in the evening.
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
MVA trauma
- liver laceration
- C7-T1 subluxation
- L5 compression fracture
Subacute R occipital stroke
___
Discharge Condition:
Mental Status: Confused - sometimes.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Level of Consciousness: Alert and interactive.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you during your hospitalization
at ___. You were admitted to the hospital after a motor
vehicle accident. You injured your neck, your head, and your
liver. None of these injuries requiring surgical intervention.
Your sodium level was a little low which has been a problem for
you in the past. To make sure this doesn't happen again after
you leave the hospital, you should limit your fluid intake to 2
liters per day.
For a couple days, you showed signs of confusion,
disorientation, and poor attention (what we call delerium).
This could have been due to medications you were on, your head
injury in the accident, or your low salt. We stopped your
gabapentin, as this is a medication that can worsen your mental
status.
During the work up of your injuries, you were found to have an
old stroke which may affect your vision; because of this you
should have your visual fields evaluated by an eye doctor. You
should also not drive until you have been cleared by your
primary care doctor and ophthalmologist.
We wish you the best!
Sincerely,
Your ___ team
Followup Instructions:
___
|
19704930-DS-12
| 19,704,930 | 26,521,871 |
DS
| 12 |
2140-08-03 00:00:00
|
2140-08-03 14:47:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
Cardiac Catheterization with DES to midLAD ___
History of Present Illness:
___ year old male with h/o LBBB, BPH, diverticulitis, and OA who
presented with chest pain. He reports that he was feeling well
until this evening when he ate a piece of cake. He describes
"indigestion" starting after the cake that he says was chest
pain across his chest that lasted 30 minutes and resolved with
intake of warm water. Then, as he was getting ready for bed
around 11pm and putting on his nightclothes, he had the onset of
chest pain again that was substernal and stayed in the ___
his chest. Denies accompanying SOB, nausea, or diaphoresis,
although wife says he looked short of breath. Denies radiation
of pain. At baseline, he gets no CP or SOB with exertion, though
on further discussion may have been having exertional chest pain
over the last week. His wife drove him to the fire station,
where EMS was called.
Notably, he was seen by his PCP ___ for abdominal pain felt to
be related to diverticulitis. He was started on Augmentin at
that time. Had CT abdomen that did not show diverticulitis but
PCP wanted him to finish course of antibiotics.
In the ED, he complained of chest pain and ECG showed more
pronounced LBBB changes and ST elevations and code STEMI was
called (actually called by EMS prior to arrival). He was taken
to the cath lab where he was found to have 90% LAD stenosis and
DES was placed in proximal to mid LAD. Had right femoral access,
closed with exoseal. Given 600mg plavix and bivalirudin prior to
procedure.
Currently, he denies chest pain and reports he is feeling well.
Past Medical History:
1. CARDIAC RISK FACTORS: - Diabetes, - Dyslipidemia, -/+
Hypertension (not on meds, states previously well controlled)
2. CARDIAC HISTORY: LBBB
-CABG: None
-PERCUTANEOUS CORONARY INTERVENTIONS: ___ ___ to midLAD
3. OTHER PAST MEDICAL HISTORY:
Left hernia repair
BPH
Diverticulitis
H/o meniscal repair
Colon polyps
Hard of hearing
Social History:
___
Family History:
Father COPD (worked 40+ years in ___), CHF. Mother died of
PNA. Denies other lung, heart, endocrine, hematological diseases
or cancer in family.
Physical Exam:
Admission Exam:
VS: 97.9 123/76 65 18 100%RA
GENERAL: Awake, alert male in NAD.
HEENT: NCAT. Sclera anicteric. EOMI. No xanthalesma.
NECK: Supple with JVP does not appear elevated while laying
flat.
CARDIAC: RRR with distant heart sounds, normal S1, S2. No m/r/g.
LUNGS: Resp unlabored, no accessory muscle use. CTAB, no
crackles, wheezes or rhonchi. Listened only anterior as patient
lying flat post-cath.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation.
EXTREMITIES: No c/c/e. DP pulses palpable bilaterally
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
Discharge Exam:
VS: 98.7, 110/57, 66 (60s), 16, 97%RA
GENERAL: Awake, alert male in NAD, walking around the room.
NECK: Supple with JVP not elevated.
CARDIAC: RRR with distant heart sounds, normal S1, S2. No m/r/g.
LUNGS: Resp unlabored, no accessory muscle use. CTAB, no
crackles, wheezes or rhonchi posteriorly.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation.
EXTREMITIES: No c/c/e. No femoral bruits. Groin dressing C/D/I,
no hematoma or bogginess noted. DP pulses palpable bilaterally.
Warm extremities, sensation intact to light touch and temp
throughout.
Pertinent Results:
Admission Labs:
___ 01:00AM BLOOD WBC-6.3 RBC-5.49 Hgb-17.4 Hct-50.4 MCV-92
MCH-31.7 MCHC-34.5 RDW-13.0 Plt ___
___ 01:00AM BLOOD Neuts-64.1 ___ Monos-6.6 Eos-2.9
Baso-0.6
___ 01:00AM BLOOD ___ PTT-31.6 ___
___ 01:00AM BLOOD Glucose-133* UreaN-23* Creat-1.2 Na-139
K-4.2 Cl-106 HCO3-19* AnGap-18
___ 07:11AM BLOOD CK(CPK)-720*
___ 01:00AM BLOOD cTropnT-0.02*
___ 07:11AM BLOOD Calcium-9.1 Phos-2.3* Mg-2.0
Cardiac enzymes:
(admission)
___ 01:00AM BLOOD cTropnT-0.02*
(s/p cath)
___ 07:11AM BLOOD CK-MB-57* MB Indx-7.9* cTropnT-2.71*
___ 07:11AM BLOOD CK(CPK)-720*
___ 03:10PM BLOOD CK-MB-41* MB Indx-7.5*
___ 03:10PM BLOOD CK(CPK)-545*
___ 04:50PM BLOOD CK-MB-35*
Discharge Labs:
___ 06:10AM BLOOD WBC-7.6 RBC-4.88 Hgb-15.2 Hct-45.3 MCV-93
MCH-31.1 MCHC-33.5 RDW-13.5 Plt ___
___ 06:10AM BLOOD ___ PTT-28.6 ___
___ 06:10AM BLOOD Glucose-90 UreaN-23* Creat-1.2 Na-140
K-4.0 Cl-109* HCO3-22 AnGap-13
___ 06:10AM BLOOD Calcium-8.9 Phos-3.5 Mg-2.0
___ Cardiac Cath (PRELIM): 1) Selective coronary angiography
of this left dominant system demonstrated significant
single-vessel coronary artery disease. The LMCA and large
dominant LCx had no angiographically-apparent flow-limiting
stenoses. The small non-dominant RCA had no
angiographically-apparent flow-limiting stenoses. The LAD had
an 80%
mid-vessel stenosis at the take-off of a moderate-sized diagonal
branch.
2) Limited resting hemodynamics revealed systemic arterial
normotension,
with a central aortic pressure of 119/59 mmHg.
3. Successful PCI to mid-LAD 80% stenosis with a 2.75 x 14 mm
Resolute
DES leaving no residual stenosis.
4. Successful closure of right femoral arteriotomy with an
Exoseal
device.
FINAL DIAGNOSIS:
1. One vessel coronary artery disease.
2. Successful drug-eluting stenting of mid-LAD for primary
treatment of
STEMI with LBBB.
___ Echo: The left atrium is mildly dilated. Left ventricular
wall thicknesses are normal. The left ventricular cavity size is
normal. LV systolic function appears moderatelty-to-severely
depressed (ejection fraction 30 percent) secondary to extensive
severe hypokinesis/akinesis of the interventricular septum,
anterior wall, and apex, with focal apical dyskinesis. No masses
or thrombi are seen in the left ventricle (Optison). Right
ventricular chamber size and free wall motion are normal. The
ascending aorta is mildly dilated. There are focal
calcifications in the aortic arch. The aortic valve leaflets (3)
are mildly thickened but aortic stenosis is not present. Mild
(1+) aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. There is no mitral valve prolapse. Mild (1+)
mitral regurgitation is seen. The tricuspid valve leaflets are
mildly thickened. There is mild pulmonary artery systolic
hypertension. There is no pericardial effusion.
Compared with the findings of the prior report (images
unavailable for review) of ___, extensive left
ventricular wall motion abnormalities are now present.
___ ECG: Sinus rhythm. Left bundle-branch block. Possible
anteroseptal myocardial infarction of indeterminate age.
Compared to the previous tracing of ___, Q waves are now
seen in lead V2. Arm lead reversal is not present on the current
tracing. TRACING #1
Read by: ___.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
70 ___ 67 42 56
___ ECG Sinus rhythm with frequent multifocal ventricular
premature contractions. Left bundle-branch block. Anteroseptal
myocardial infarction, age indeterminate. Compared to tracing
#1, ventricular premature contractions are seen in the current
tracing. TRACING #2
Read by: ___.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
65 0 ___ 0 -81 82
___ ECG:Bradycardia with premature atrial contractions. Left
bundle-branch block. Anteroseptal ST-T wave changes, may be due
to ischemia. Compared to the tracing earlier in the day, there
is no terminal T wave inversion suggesting ischemia. The lateral
ST segment depressions have improved towards normal and no
ventricular premature contractions are present on the current
tracing. TRACING #3
Read by: ___.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
58 ___ 68 47 82
___ CXR The lungs are clear, the cardiomediastinal
silhouette and hila are normal. There is mild vascular
congestion. There is no pleural effusion and no pneumothorax.
IMPRESSION: No acute cardiothoracic process. Mild vascular
congestion.
Brief Hospital Course:
___ year old male with h/o LBBB, BPH, diverticulitis, and OA who
presented with the acute onset of epigastric/chest pain, now s/p
cath with ___ of mid-LAD for 80% stenosis and left
ventricular dyskinesis (EF 30%).
# STEMI: Patient was given plavix load (600mg) and bivalirudin
and quickly brought to the cath lab upon arrival out of concern
for STEMI on ECG (difficult to assess given old LBBB). Cardiac
catheterization showed 80% stenosis of the midLAD, which was
stented with a DES. Chest pain and ECG improved after cardiac
catheterization. Troponin on arrival was 0.02 (no MB), which
elevated to 2.71 several hours after catheterization.
Additionally, MB after catheterization was 57, and trended down
shortly after this. Because of this and questionable history of
a week of exertional pain, it was unclear whether the patient
had experienced a missed MI (with trops trending down, 0.02 on
arrival and elevation in biomarkers due to myocardial injury
during cath) or acute MI that was intervened upon early (with
CEs increased s/p cath due to evolving MI). Echo s/p cath showed
LV dyskinesis, no thrombus, EF 30%. Patient was monitored on
telemetry, started on plavix 75mg daily, ASA 325mg (decreased to
81mg on d/c given other anticoagulant and antiplatelet meds),
metoprolol tartrate 12.5mg BID (switched to succinate 25mg daily
on d/c), lisinopril 5mg (decreased to 2.5mg on d/c given lower
SBPs), atorvastatin 80mg daily. Phyical therapy saw the patient
and recommended home cardiac rehab which was set up, along with
___ and tele monitoring.
# PUMP: Appeared euvolemic on exam without symptoms of CHF,
although CXR shows some evidence of fluid overload. He remained
satting in the high ___ on room air, and denies SOB or DOE
during admission. Echo on ___ showed EF 30% (no prior), with
left ventricular dysfunction. It is unclear whether his
presentation was of a late MI with premanent infarcted tissue,
or of an earily MI with cardiac stunning s/p catheterization and
stenting. He was started on lisinopril 5mg daily, which was
decreased to 2.5mg on discharge given (asymptomatic) systolic
blood pressures in the ___. Additionally, he was started on
metoprolol tartrate 12.5mg BID and converted to succinate 25mg
daily, as well as eplerenone 25mg daily with good effect. Given
his LV dyskinesis (without evidence fo LV thrombus), he was
started on anticoagulation with warfarin 5mg daily, to be
managed by ___ clinic. INR goal ___.
He has follow up with Dr. ___ and
should have a repeat echocardiogram to assess improvement in LV
function.
# Abdominal pain: Patient was admitted on a course of
amoxicillin-pot clavulanate 500 mg-125 mg Tablet BID that was
started on ___ for diverticulitis, however he had subsequent
CT abdomen which was not consistent with this diagnosis.
Etiology unclear however it is possible these symptoms may have
been an atypical anginal equivalent. Antibiotics were
discontinued on admission given no evidence for diverticulitis
or other acute intra-abdominal pathology. Patient denied
abdominal pain during admission. He was started on ranitidine
for GI prophylaxis, as he was started on plavix and ASA this
admission.
# Pancreatic head lesion: Found on recent abdominal CT. Requires
___ year follow up with limited single phase CT of the pancreas to
assess stability.
# BPH: Continued home oxybutynin, terazosin.
Transitional Issues:
#CODE: Full code, confirmed
#EMERGENCY CONTACT: Wife ___ is HCP ___
PCP follow up scheduled. Cardiology follow up scheduled with Dr.
___.
- Cystic lesion in the pancreatic head noted on ___ CT ___.
Follow up limited single phase CT of the pancreas is recommended
in one year to assess stability.
- If blood pressure will tolerate, increase lisinopril to 5mg
daily in the outpatient setting.
- Twice weekly labs for monitoring of INR (to be managed by
___ clinic) and weekly electrolyte and
creatinine monitoring for a month given initiation of lisinopril
and eplerenone.
- Patient requires repeat echocardiogram in about 1 month to
eval for infarcted vs stunned LV myocardium. Reassess need for
warfarin and eplerenone.
- final cardiac catheterization report pending on discharge.
Medications on Admission:
Oxybutynin ER 10mg po qhs
Terazosin 2mg po daily
Glucosamine/Chondroitin 500-400mg po bid
Centrum silver 1 tab po daily
Naproxen 220mg po bid prn pain (does not take)
___ Oil 1000mg po daily
Tylenol prn
Augmentin (amoxicillin-pot clavulanate) 500 mg-125 mg Tablet BID
x10days for possible diverticulitis. Started ___.
Discharge Medications:
1. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
2. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
3. warfarin 2.5 mg Tablet Sig: Two (2) Tablet PO once a day:
Take at the same time every day.
Disp:*60 Tablet(s)* Refills:*0*
4. eplerenone 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
5. glucosamine-chondroitin 500-400 mg Capsule Sig: One (1)
Capsule PO twice a day.
6. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. terazosin 1 mg Capsule Sig: Two (2) Capsule PO HS (at
bedtime).
8. oxybutynin chloride 5 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
9. Outpatient Lab Work
Blood work: Twice weekly INR blood work (first draw on ___
and once weekly Electrolyte blood work (K+, Mg, Phos,
Creatinine; first draw on ___. Please have labs drawn at
___ or fax results to Dr. ___:
___. ICD9 429.9
10. metoprolol succinate 25 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO once a day.
Disp:*30 Tablet Extended Release 24 hr(s)* Refills:*0*
11. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO once a
day.
Disp:*30 Tablet(s)* Refills:*0*
12. lisinopril 2.5 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
13. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnosis: ST Elevation Myocardial Infarction (Heart
Attack), Ejection Fraction 30%
Secondary Diagnosis:
Pancreatic Head lesion
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 a heart attack that
affected the left side of your heart. You had a cardiac
catheterization and a blockage in one of the arteries around
your heart was found and opened up with a ___. You did well
after the procedure and are being discharged on a new medication
regimen that will be very important for you to be compliant
with. Your cardiologist will schedule you for a follow up
echocardiogram to reassess the function of your heart in about 4
weeks.
Please make the following changes to you home medication
regimen:
START Plavix 75mg daily
START Aspirin 81mg daily
START Atorvastatin 80mg daily
START Lisinopril 2.5mg daily
START Metoprolol succinate 25mg daily
START Ranitidine 150mg daily. This medication will protect your
stomach from irritation while on aspirin and plavix.
START Eplerenone 25mg daily. You will need weekly blood work to
monitor your electrolytes during the first month while
initiating this medication.
START Warfarin 5mg daily. You will need to have blood work drawn
twice a week to monitor your INR levels and titrate this
medication dosage to maintain your INR between ___.
STOP Augmentin (you did not have any evidence of diverticulosis
on your CT scan)
There was a cyst in the pancreas found on abdominal imaging that
will require follow up with reimaging ___ year from now. Your
primary care physician should manage this for you.
Followup Instructions:
___
|
19704930-DS-16
| 19,704,930 | 27,341,158 |
DS
| 16 |
2144-05-12 00:00:00
|
2144-05-14 17:54:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
lisinopril
Attending: ___.
Chief Complaint:
BRBPR
Major Surgical or Invasive Procedure:
Angiogram ___
History of Present Illness:
___ yo M with hx of CAD, ischemic cardiomyopathy with history of
lower GI bleeding presumed to be diverticular and multiple
polyps who presents with several episodes of BRBPR. He began
having bloody bowel movements at approximately 5pm on the day of
presentation. He had a previous episode of BRBPR in ___,
thought to be secondary to diverticula, which resolved without
the need for blood transfusion.
In the ED, initial vitals: 98.6 70 120/68 16 98% RA
Labs significant for a H/H of 16.2/40.3, with a decrease to
13.0/39.0 within four hours. BMP WNL with BUN/CR ___.
Platelets 114. LFTs WNL.
CTA significant for active extravasation of contrast into the
transverse colon.
He was taking to ___ for emergent angiogram, at which time vitals
were: 61 118/73 16 96% RA
In the interventional radiology suite, the patient was walking
and was in no acute distress. He denied any dizziness or
lightheadedness. He was answering questions appropriately. He
was following commands.
Mesenteric angiogram was performed of the SMA, transverse colon
arterial supply a-gram ( middle colic, super selective R middle
colic branch, super selective L middle colic branch) without
active extravasation or embolization. R CFA access was closed w
angioseal.
On arrival to the MICU, the patient is alert and in no apparent
distress. He reports three episodes of BRBPR at home and several
in the emergency room. He denies dizziness, lightheadedness,
nausea, vomiting, or abdominal pain. He denies recent illness
including fevers, chills, shortness of breath, chest pain. He
has not had a bowel movement since prior to the ___ procedure.
Past Medical History:
- CAD c/p NSTEMI s/p PCI and DES to mLAD, ___
- Chronic systolic heart failure (EF 40-50%)
- Anterior/septal hypokinesis (previously on warfarin)
- Valvular heart disease (1+ AI, 1+ MR, ___ TR)
- Left bundle branch block
- Diverticulosis
- Colonic polyps
- Recurrent epistaxis
- Hypertension
- Hyperlipidemia
- Benign prostatic hypertrophy
Social History:
___
Family History:
His father died at age ___ of COPD. His mother died at age ___ of
pneumonia and he suspects she may have had heart failure. He
has one-half brother and two daughters. There is no family
history notable for stroke, hypertension, hyperlipidemia,
diabetes, early coronary artery disease, sudden cardiac death.
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: 136/69 70 16 100% RA
GENERAL: Alert, oriented, no acute distress
HEENT: Sclera anicteric, mucus membranes dry, oropharynx clear
NECK: supple, JVP not elevated, no LAD
LUNGS: Clear to auscultation anteriorly, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 S2, systolic murmur
ABD: soft, non-tender, non-distended, bowel sounds present
GU: right femoral site with angioseal, clean/dry/intact without
bruit, right groin hernia present without pain
EXT: Warm, well perfused, 2+ DP pulses bilaterally, no clubbing,
cyanosis or edema
SKIN: warm, well perfused
NEURO: alert, oriented, speech is fluent, follows commands
discharge physical exam
Vitals: BP 115-106/40-50 RR 18 HR ___ RA
General: alert, oriented, no acute distress, wife with patient.
at first lying in bed, when seen later sitting uop; wlking fine
without walker
HEENT: MMM, oropharynx clear,
Neck: supple, JVP not elevated
Lungs: clear to auscultation bilaterally
CV: regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, femoral bandage c/d/i
Ext: warm, well perfused, 2+ pulses DP and ___, no edema.
Neuro: CNs2-12 intact, motor function grossly normal
Pertinent Results:
ADMISSION LABS:
___ 09:00PM WBC-8.3 RBC-5.15 HGB-16.2 HCT-49.3 MCV-96
MCH-31.5 MCHC-32.9 RDW-14.0 RDWSD-49.1*
___ 09:00PM NEUTS-77.8* LYMPHS-11.9* MONOS-8.8 EOS-0.6*
BASOS-0.1 IM ___ AbsNeut-6.48* AbsLymp-0.99* AbsMono-0.73
AbsEos-0.05 AbsBaso-0.01
___ 09:00PM PLT COUNT-136*
___ 09:00PM ___ PTT-31.0 ___
___ 09:00PM ALBUMIN-4.1
___ 09:00PM LIPASE-29
___ 09:00PM ALT(SGPT)-28 AST(SGOT)-34 ALK PHOS-69 TOT
BILI-1.4
___ 09:00PM estGFR-Using this
___ 09:00PM GLUCOSE-110* UREA N-26* CREAT-1.2 SODIUM-138
POTASSIUM-4.2 CHLORIDE-103 TOTAL CO2-24 ANION GAP-15
DISCHARGE LABS:
___ 12:20PM BLOOD WBC-6.2 RBC-3.70* Hgb-11.8* Hct-35.5*
MCV-96 MCH-31.9 MCHC-33.2 RDW-14.2 RDWSD-50.1* Plt ___
___ 05:45AM BLOOD Glucose-90 UreaN-17 Creat-1.1 Na-140
K-3.6 Cl-110* HCO3-20* AnGap-14
STUDIES:
CTA abdomen/pelvis ___:
1. Active extravasation of intravenous contrast into the
transverse colon, likely from diverticulosis.
2. Severe diverticulosis without diverticulitis.
3. Moderate to large right inguinal hernia containing large
bowel, similar the prior exam without evidence of complication.
4. Prostatomegaly.
Mesenteric arteriogram ___: pending
MICRO:
___ 5:39 am MRSA SCREEN Source: Nasal swab.
**FINAL REPORT ___
MRSA SCREEN (Final ___: No MRSA isolated.
Brief Hospital Course:
___ yo M with hx of CAD, ischemic cardiomyopathy with history of
lower GI bleeding presumed to be diverticular and multiple
polyps who presents with several episodes of BRBPR, with CTA
significant for active extravasation in the tranverse colon, now
s/p emergent mesenteric angiogram without active bleed.
ACTIVE ISSUES:
# Hematochezia: Patient with known diverticulosis, prior
diverticular bleed, presenting with BRBPR. He had a large volume
bleed in the ED with a Hb drop from 16 to 13. CTA was positive
for active bleeding in the transverse colon. He was taken to the
___ suite for emergent mesenteric angiogram that did not reveal
an active bleed and thus no intervention was done. He remained
hemodynamically stable during his hospital stay. His blood
counts by discharge were hgb 11.8. He will follow up with GI as
an outpatient on ___.
CHRONIC ISSUES:
# Coronary artery disease/ischemic cardiomyopathy (status post
NSTEMI with DES to mid LAD ___, EF 45-50%): His aspirin,
metoprolol and losartan were held initially given active bleed.
Once his bleeding resolved home metoprolol xl was restarted;
losartan was held for softer BP (sys BP 100-110's on d/c). His
home aspirin and atorvastatin was continued.
# BPH: He was continued on tamsulosin.
TRANSITIONAL ISSUES:
===================================
-Given slightly lower BP on d/c than patient's baseline (sys
100-110's compared to 120's baseline) losartan held on d/c,
please resume on next F/U appoint; d/c Cr. 1.1
-Please recheck CBC at next PCP ___ hgb on d/c 11.8
-Patient to have F/U colonoscopy on ___ with Dr. ___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 20 mg PO DAILY
3. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES HS
4. Metoprolol Succinate XL 25 mg PO DAILY
5. Ranitidine 150 mg PO DAILY
6. Glucosamine-Chondroitin DS
___
2KCl-chondroit) 500-400 mg Oral DAILY
7. Multivitamins 1 TAB PO DAILY
8. Nitroglycerin SL 0.4 mg SL PRN chest pain
9. Losartan Potassium 25 mg PO DAILY
10. Tamsulosin 0.4 mg PO QHS
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 20 mg PO DAILY
3. Latanoprost 0.005% Ophth. Soln. 1 DROP LEFT EYE HS
4. Multivitamins 1 TAB PO DAILY
5. Ranitidine 150 mg PO DAILY
6. Tamsulosin 0.4 mg PO QHS
7. Glucosamine-Chondroitin DS
___
2KCl-chondroit) 500-400 mg Oral DAILY
8. Metoprolol Succinate XL 25 mg PO DAILY
9. Nitroglycerin SL 0.4 mg SL PRN chest pain
Discharge Disposition:
Home
Discharge Diagnosis:
Lower GI bleed
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___, you came to the hospital because you had
blood in your stools. At the hospital, our interventional
radiologists performed an angiography, where they found that
your bleeding had stopped. Due to the volume of blood that you
lost, we stopped your home blood pressure medication losartan.
We ask that you see your primary care provider as bellow for a
repeat blood check in a week and to restart your losartan, and
to see your cardiologist in early ___. You will also have a
colonoscopy on ___ with Dr. ___.
We wish you all the ___!
-Your ___ Care Team
Followup Instructions:
___
|
19704930-DS-20
| 19,704,930 | 20,801,016 |
DS
| 20 |
2147-12-15 00:00:00
|
2147-12-16 10:27:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
lisinopril
Attending: ___
Chief Complaint:
chest pressure
Major Surgical or Invasive Procedure:
Coronary angiography ___
History of Present Illness:
HISTORY OF PRESENT ILLNESS:
Mr. ___ is a ___ yo man with Hx CAD c/b NSTEMI s/p DES to
LAD ___ who presents with new onset dyspnea on exertion
associated with chest pressure. Per the patient this started on
___ while he was on a walk. He quickly became short of breath
and felt lightheaded. When questioned, he endorses a "pressure"
diffusely over his lower chest and abdomen associated with the
shortness of breath, though does not describe this as pain. No
radiation to the back, jaw, or arms. No associated palpitations,
diaphoresis, or nausea. These symptoms lasted for about 30 min
then resolved with rest. He again had a similar episode of
dyspnea on exertion on ___ while on a walk. He presented to
the
ED.
He denies any prior history of dyspnea or similar chest
pressure.
He previously was able to tolerate regular walks without any
shortness of breath. He had an NSTEMI in ___ and recalls chest
pain at that time but this was higher on his chest and not
associated with dyspnea. He denies any orthopnea, PND,
nausea/vomiting, diaphoresis, ___ edema. No fevers/chills,
cough, or sick contacts.
In the ED:
- Initial vital signs were notable for: T 98.5 HR 115 BP 132/78
RR 16 O2 97% RA
- Exam notable for: Comfortable, RRR, lungs CTAB
- Labs were notable for: D-dimer 919, BNP 1159, bicarb 19, Cr
1.3
(baseline 1.0), troponin < 0.01 x 2
- Studies performed include:
EKG - Sinus, LBBB
- Patient was given: ASA 243mg, NS 500cc
- Consults: None
Vitals on transfer: T 98.2 HR 66 BP 133/69 RR 16 O2 97% RA
Upon arrival to the floor, he reports that his dyspnea and chest
pressure have entirely resolved. He notes a history of
hospitalization for GI bleed, no current hematochezia or melena.
REVIEW OF SYSTEMS: Complete ROS obtained and is otherwise
negative.
Past Medical History:
- CAD c/p NSTEMI s/p PCI and DES to mLAD, ___
- Chronic systolic/diastolic heart failure (EF 40-50%)
- Anterior/septal hypokinesis (previously on warfarin)
- Valvular heart disease (1+ AI, 1+ MR, ___ TR)
- Left bundle branch block
- Diverticulosis, recurrent GIB
- Colonic polyps
- Recurrent epistaxis
- HTN, HLD
- Benign prostatic hypertrophy
Social History:
___
Family History:
Father died at age ___ of COPD.
Mother died at age ___ of pneumonia, possible heart failure
Physical Exam:
ADMISSION PHYSICAL EXAM:
VITALS: T 97.7 BP 119/74 HR 123 RR 18 O2 98% Ra
GENERAL: Alert and interactive. In no acute distress.
EYES: NCAT. PERRL, EOMI. Sclera anicteric and without injection.
ENT: MMM. No cervical lymphadenopathy. JVP not elevated.
CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No
murmurs/rubs/gallops.
RESP: Clear to auscultation bilaterally. No wheezes, rhonchi or
rales. No increased work of breathing.
ABDOMEN: Normal bowels sounds, non distended, non-tender to deep
palpation in all four quadrants.
MSK: No spinous process tenderness. No CVA tenderness.
SKIN: Warm. No rash.
NEUROLOGIC: AOx3. CN2-12 intact. ___ strength throughout. Normal
sensation.
DISCHARGE PHYSICAL EXAM:
VITALS: ___ 1118 Temp: 99.1 PO BP: 146/70 L Lying HR: 56
RR:
18 O2 sat: 98% O2 delivery: RA
GENERAL: Alert and interactive. In no acute distress.
EYES: NCAT. PERRL, EOMI. Sclera anicteric and without injection.
ENT: MMM. No cervical lymphadenopathy. JVP not elevated.
CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No
murmurs/rubs/gallops.
RESP: Clear to auscultation bilaterally. No wheezes, rhonchi or
rales. No increased work of breathing.
ABDOMEN: Normal bowels sounds, non distended, non-tender to deep
palpation in all four quadrants.
MSK: No spinous process tenderness. No CVA tenderness.
SKIN: Warm. No rash.
NEUROLOGIC: AOx3. CN2-12 intact. ___ strength throughout. Normal
sensation.
Pertinent Results:
ADMISSION LABS:
===================
___ 04:43PM BLOOD WBC-6.6 RBC-5.81 Hgb-13.1* Hct-42.5
MCV-73* MCH-22.5* MCHC-30.8* RDW-20.5* RDWSD-50.6* Plt ___
___ 04:43PM BLOOD Neuts-76.5* Lymphs-11.4* Monos-10.2
Eos-1.4 Baso-0.2 Im ___ AbsNeut-5.03 AbsLymp-0.75*
AbsMono-0.67 AbsEos-0.09 AbsBaso-0.01
___ 04:43PM BLOOD ___ PTT-29.6 ___
___ 04:43PM BLOOD D-Dimer-919*
___ 04:43PM BLOOD Glucose-112* UreaN-24* Creat-1.3* Na-137
K-5.3 Cl-106 HCO3-19* AnGap-12
___ 04:43PM BLOOD ALT-17 AST-38 AlkPhos-73 TotBili-0.8
TROPS:
___ 12:00PM BLOOD CK-MB-2 cTropnT-<0.01
___ 07:44PM BLOOD cTropnT-<0.01
___ 04:43PM BLOOD cTropnT-<0.01
BNP:
___ 04:43PM BLOOD proBNP-1159*
PERTINENT IMAGING:
===================
CARDIAC CATH
Findings
Mild coronary coronary artery disease.
No visible flow limiting epicardial CAD.
TTE
IMPRESSION:
findings suggest left ventricular electromechanical
dyssynchrony (left bundlebranch block pattern) and multivessel
obstructive coronary artery disease Compared with the prior TTE
(images not available for review) of ___ , the left
ventricular ejection fraction is reduced.
CXR
IMPRESSION:
No acute cardiopulmonary process.
DISCHARGE LABS:
=================
___ 06:53AM BLOOD WBC-6.7 RBC-5.34 Hgb-12.1* Hct-39.5*
MCV-74* MCH-22.7* MCHC-30.6* RDW-20.2* RDWSD-51.4* Plt ___
___ 06:53AM BLOOD ___ PTT-28.5 ___
___ 06:53AM BLOOD Glucose-94 UreaN-18 Creat-1.2 Na-141
K-4.2 Cl-108 HCO3-23 AnGap-10
___ 06:53AM BLOOD Calcium-8.9 Phos-3.5 Mg-2.0
Brief Hospital Course:
TRANSITIONAL ISSUES
===================
[ ] Started on low dose metoprolol 12.5mg BID, had previously
not tolerated in the past, assess for symptoms of intolerance
#CODE: Full (confirmed), expressed that he would want whatever
his wife decided
#CONTACT: ___
Relationship: wife
Phone number: ___
BRIEF HOSPTAL COURSE
====================
___ yo man with Hx HFrEF (EF:45-50) CAD c/b NSTEMI s/p DES to LAD
(___), HFpEF, who presents with new dyspnea on exertion
associated with chest and abdominal pressure w/ neg trops, old
LBBB on EKG and echo with worsening EF and WMA c/f ischemia.
ACUTE ISSUES:
=============
# Dyspnea
# Chest pressure
# CAD c/b NSTEMI s/p PCI and DES to mLAD, ___
Patient presented with dyspnea on exertion associated with chest
pressure, concerning for angina in setting of known history of
CAD. Other possibilities included worsening heart failure (did
have elevated BNP, though no pulmonary edema on CXR and no
history of orthopnea, PND, ___ edema). No fevers, cough,
wheezing, or CXR findings to suggest a pulmonary infection.
D-dimer elevated but PE less likely as tachypnea resolved post
IVF, no hypoxemia, no pleuritic chest pain. TTE was obtained
which showed worsening reduced EF at 35%. Due to this, the
patient underwent coronary angiography. This showed 30% in-stent
restenosis proximal to the prior stent in the LAD, otherwise no
other visualized flow limiting disease. He remained chest pain
free during his admission. Continued ASA 81mg daily and
atorvastatin 20mg daily. He was started on metoprolol tartrate
12.5mg BID (previously had not tolerated due to dizziness) which
he tolerated during this hospitalization.
#EKG with AVNRT
patient has several EKGs with various findings including known
LBBB, AVNRT (transiently), first degree AV block, and atrial
bigeminy
# ___ (resolved)
Presented with Cr elevation to 1.3 from baseline of ___. Most
likely prerenal in setting of decreased fluid intake. Patient
does report not drinking much at home and presented with
tachycardia which improved with fluids. Improved back to
baseline of 1.1 by discharge.
CHRONIC ISSUES:
===============
# BPH
Continued tamsulosin as alfuzosin non-formulary. Will resume
alfuzosin upon discharge.
# Glaucoma
Continued home latanoprost eye drops
# Hypertension
Not on antihypertensives outpatient, BP currently well
controlled.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 20 mg PO DAILY
3. Latanoprost 0.005% Ophth. Soln. 1 DROP LEFT EYE HS
4. Multivitamins 1 TAB PO DAILY
5. Polyethylene Glycol 17 g PO DAILY:PRN constipation
6. Glucosamine-Chondroitin DS
___
2KCl-chondroit) 500-400 mg Oral DAILY
7. Nitroglycerin SL 0.4 mg SL PRN chest pain
8. alfuzosin 10 mg oral BID
9. Fluticasone Propionate NASAL 1 SPRY NU BID
10. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild/Fever
Discharge Medications:
1. Metoprolol Tartrate 12.5 mg PO BID
2. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild/Fever
3. alfuzosin 10 mg oral BID
4. Aspirin 81 mg PO DAILY
5. Atorvastatin 20 mg PO DAILY
6. Fluticasone Propionate NASAL 1 SPRY NU BID
7. Glucosamine-Chondroitin DS
___
2KCl-chondroit) 500-400 mg Oral DAILY
8. Latanoprost 0.005% Ophth. Soln. 1 DROP LEFT EYE HS
9. Multivitamins 1 TAB PO DAILY
10. Nitroglycerin SL 0.4 mg SL PRN chest pain
11. Polyethylene Glycol 17 g PO DAILY:PRN constipation
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis
==================
Angina
Coronary artery disease
Secondary diagnoses
===================
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 was a privilege taking care of you at ___
___.
WHY WAS I ADMITTED TO THE HOSPITAL?
===================================
- You were admitted to the hospital because you were having
chest pain.
WHAT HAPPENED WHILE I WAS IN THE HOSPITAL?
==========================================
- You had a procedure done to look at the vessels of your heart
which did not show any new significant blockages.
- You were started on a medication called metoprolol.
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
============================================
- Contact your doctor if you notice new dizziness or
lightheadedness, this may be related to your new medication.
- Please continue to take all your medications and follow up
with your doctors at your ___ appointments.
We wish you all the ___!
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
19705085-DS-12
| 19,705,085 | 22,175,460 |
DS
| 12 |
2184-03-02 00:00:00
|
2184-03-02 15:44:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Hematemesis
Major Surgical or Invasive Procedure:
Upper Endoscopy
History of Present Illness:
___ PMHx for AVR on Coumadin ( INR 2.9), achalasia c/b esophgeal
perforation s/p repair, ___ myotomy ___ with worsening
dysphagia now s/p laparoscopic ___ myotomy ___ now
presenting with hematemesis as well as CT concerning for
emphysematous gastritis. Patient recently saw Dr. ___
___. At the time, he was doing with complaints of only
worsening reflux symptoms. Patient's PPI dose was increased.
Since then, patient states that he has been experiencing
worsening reflux as well as dysphagia. He was at home yesterday,
and started to experiencing abdominal discomfort. He states that
he ate a hot dog ___ hours prior to the initial onset of
discomfort. He had multiple bouts of black tarry emesis and
ultimately went to ___, where a CT A/P ( non-contrast)
demonstrated pneumatosis around the stomach without evidence of
free air intraperitoneal. Patient's WBC was 27, and he was
subsequently transferred to ___ for further care. Patient
currently denies nausea/vomiting/fever/chills. He does
endorse some epigastric discomfort.
Past Medical History:
AVR ___
Diabetes mellitus
Prostate cancer s/p XRT
Social History:
___
Family History:
Mother - DM
Aunt - DM
Physical Exam:
Vitals:
Temp: 98.7 (Tm 98.9), BP: 150/75 (143-150/63-75), HR: 69
(59-70), RR: 18 (___), O2 sat: 98% (96-99), O2 delivery: Ra
Gen: [x] NAD, [x] AAOx3
CV: [x] RRR, [] murmur
Resp: [x] breaths unlabored, [x] CTAB, [] wheezing, [] rales
Abdomen: [x] soft, [] distended, [] tender, [] rebound/guarding
Ext: [x] warm, [] tender, [] edema
Pertinent Results:
___ 06:44AM BLOOD WBC-7.9 RBC-3.25* Hgb-9.3* Hct-29.0*
MCV-89 MCH-28.6 MCHC-32.1 RDW-13.6 RDWSD-44.6 Plt ___
___ 07:29PM BLOOD WBC-8.4 RBC-3.07* Hgb-8.7* Hct-26.7*
MCV-87 MCH-28.3 MCHC-32.6 RDW-13.5 RDWSD-42.6 Plt ___
___ 02:15AM BLOOD WBC-9.8 RBC-3.16* Hgb-9.1* Hct-28.0*
MCV-89 MCH-28.8 MCHC-32.5 RDW-13.8 RDWSD-44.8 Plt ___
___ 08:49PM BLOOD WBC-11.1* RBC-3.44* Hgb-9.7* Hct-30.4*
MCV-88 MCH-28.2 MCHC-31.9* RDW-14.0 RDWSD-45.1 Plt ___
___ 05:40PM BLOOD WBC-10.2* RBC-3.34* Hgb-9.5* Hct-30.1*
MCV-90 MCH-28.4 MCHC-31.6* RDW-13.9 RDWSD-45.5 Plt ___
___ 02:07AM BLOOD WBC-17.7* RBC-3.93* Hgb-11.2* Hct-35.2*
MCV-90 MCH-28.5 MCHC-31.8* RDW-14.0 RDWSD-46.1 Plt ___
___ 08:22PM BLOOD WBC-18.3* RBC-3.92* Hgb-11.2* Hct-35.3*
MCV-90 MCH-28.6 MCHC-31.7* RDW-14.1 RDWSD-45.9 Plt ___
___ 04:35PM BLOOD WBC-21.5* RBC-4.28* Hgb-12.2* Hct-37.6*
MCV-88 MCH-28.5 MCHC-32.4 RDW-14.0 RDWSD-44.5 Plt ___
___ 06:44AM BLOOD Plt ___
___ 06:44AM BLOOD ___ PTT-35.1 ___
___ 07:29PM BLOOD Plt ___
___ 07:29PM BLOOD ___ PTT-33.1 ___
___ 02:15AM BLOOD Plt ___
___ 02:15AM BLOOD ___ PTT-34.7 ___
___ 08:49PM BLOOD Plt ___
___ 05:40PM BLOOD Plt ___
___ 05:40PM BLOOD ___ PTT-32.5 ___
___ 02:07AM BLOOD Plt ___
___ 08:22PM BLOOD ___ PTT-31.6 ___
___ 04:35PM BLOOD ___ PTT-37.1* ___
___ 06:44AM BLOOD Glucose-73 UreaN-11 Creat-1.0 Na-144
K-4.1 Cl-107 HCO3-25 AnGap-12
___ 07:29PM BLOOD Glucose-192* UreaN-13 Creat-0.9 Na-138
K-3.9 Cl-105 HCO3-24 AnGap-9*
___ 02:15AM BLOOD Glucose-201* UreaN-18 Creat-0.9 Na-140
K-4.2 Cl-107 HCO3-23 AnGap-10
___ 02:07AM BLOOD Glucose-234* UreaN-33* Creat-1.1 Na-141
K-4.8 Cl-107 HCO3-23 AnGap-11
___ 08:22PM BLOOD Glucose-325* UreaN-38* Creat-1.1 Na-140
K-4.8 Cl-104 HCO3-21* AnGap-15
___ 04:35PM BLOOD Glucose-316* UreaN-36* Creat-1.2 Na-141
K-5.3 Cl-102 HCO3-26 AnGap-13
Brief Hospital Course:
Mr. ___ was admitted to the General Surgical Service on
___ for evaluation and treatment of hematemesis. Admission
CT was concerning for concerning for emphysematous gastritis.
Patient was evaluated and monitored in the ICU. He was NPO with
an NGT, lab exams were done. He was also started on IV
antibiotics, Vancomycin, Zosyn, and Fluconazole.
On ___ he had a Upper Gastric Endoscopy study that
demonstrates gastritis, and mucosal friability, but no ulcers.
His hematocrit was closely followed.
Once he was stable and no there was no concern for active
bleeding, his NGT was pulled out and he was advanced to a clear
liquid diet on ___.
On ___ pm he was transferred to the general floor where he
was observed overnight, on ___ he was advanced to a
regular diet which he tolerates without nausea/vomiting, he had
a bowel movement and have been passing flatus.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating diet,
ambulating, voiding without assistance, and pain was well
controlled. The patient was discharged home without services.
The patient received discharge teaching and follow-up
instructions with understanding verbalized and agreement with
the discharge plan.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Simvastatin 20 mg PO QPM
2. GlipiZIDE 5 mg PO BID
3. MetFORMIN XR (Glucophage XR) 500 mg PO DAILY
4. Lisinopril 20 mg PO DAILY
5. Ranitidine 300 mg PO QHS
6. Aspirin 81 mg PO DAILY
7. Warfarin 7 mg PO 5X/WEEK (___)
8. Warfarin 6 mg PO 2X/WEEK (MO,FR)
9. Gabapentin 100 mg PO QHS
10. Omeprazole 40 mg PO DAILY
11. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
Discharge Medications:
1. Sucralfate 1 gm PO QID
RX *sucralfate 1 gram 1 tablet(s) by mouth four times a day Disp
#*60 Tablet Refills:*0
2. Aspirin 81 mg PO DAILY
3. Gabapentin 100 mg PO QHS
4. GlipiZIDE 5 mg PO BID
5. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
6. Lisinopril 20 mg PO DAILY
7. MetFORMIN XR (Glucophage XR) 500 mg PO DAILY
8. Omeprazole 40 mg PO DAILY
9. Ranitidine 300 mg PO QHS
10. Simvastatin 20 mg PO QPM
11. Warfarin 7 mg PO 5X/WEEK (___)
12. Warfarin 6 mg PO 2X/WEEK (MO,FR)
Discharge Disposition:
Home
Discharge Diagnosis:
Hematemesis
Emphasematous gastritis
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
your hematemesis. You are recovering well, and you are stable
now, you are now ready for discharge. Please follow the
instructions below to continue your recovery:
ACTIVITY:
- You may return to your regular activities
- You may climb stairs. You should continue to walk several
times a day.
- You may start some light exercise when you feel comfortable.
Slowly increase your activity back to your baseline as
tolerated.
- Heavy exercise may be started after 6 weeks, but use common
sense and go slowly at first.
- No heavy lifting (10 pounds or more) until cleared by your
surgeon, usually about 6 weeks.
- You may resume sexual activity unless your doctor has told
you otherwise.
- You must not use NSAIDS (non-steroidal anti-inflammatory
drugs) unless approved by your Weight Loss Surgery team.
Examples include, but are not limited to Aleve, Arthrotec,
aspirin, Bufferin, diclofenac, Ecotrin, etodolac, ibuprofen,
Indocin, indomethacin, Feldene, ketorolac, meclofenamate,
meloxicam, Midol, Motrin, nambumetone, Naprosyn, Naproxen,
Nuprin, oxaprozin, Piroxicam, Relafen, Toradol and Voltaren.
These agents may cause bleeding and ulcers in your digestive
system. If you are unclear whether a medication is considered an
NSAID, please ask call your nurse or ask your pharmacist.
If you experience any of the following, please contact your
surgeon:
- Another episode of throwing up blood
- sharp pain or any severe pain that lasts several hours
- chest pain, pressure, squeezing, or tightness
- cough, shortness of breath, wheezing
- pain that is getting worse over time or pain with fever
- shaking chills, fever of more than 101
- a drastic change in nature or quality of your pain
- nausea and vomiting, inability to tolerate fluids, food, or
your medications
- if you are getting dehydrated (dry mouth, rapid heart beat,
feeling dizzy or faint especially while standing)
-any change in your symptoms or any symptoms that concern you
Additional:
*- pain that is getting worse over time, or going to your chest
or back
*- urinary: burning or blood in your urine or the inability to
urinate
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.
Thanks for letting us take care of you!
___ Surgery team
Followup Instructions:
___
|
19705247-DS-8
| 19,705,247 | 23,524,457 |
DS
| 8 |
2126-05-21 00:00:00
|
2126-06-07 11:08:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
Left sided weakness and change in speech
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year-old R-handed M with diet controlled DM, tobacco and
EtOH use, who presents with acute onset L sided weakness.
The patient c/o headache and "fuzzy" feeling in head last night.
He woke up around 3:30am, which is actually normal for him, and
felt initially better. He watched the news, ate breakfast. He
was
playing a word game on his phone, and had trouble coming up with
simple words, but no troubling using hands to manipulate the
screen. Around ___, his headache became worse. He had L arm
pain, then L eye blurry vision. His wife noticed that at 8:30am
he developed left arm and leg weakness. His speech became
mumbling and incomprehensible. The patient remembers her telling
him she was calling 911, but does not remember anything after
this until reaching ___.
In OSH ED, the patient was noted to have L flaccid hemiplegia,
and was thought to have global aphasia due to mumbling speech,
able to say only ___ words. He was somnolent, not following
commands. NIHSS given was 30. NCHCT negative. ___ wnl, BP
150-170s
without treatment. Neurology was consulted there, and made the
decision to give tPA. He received tPA bolus and was medflighted
to ___ while infusion running.
Pt arrived to ___, and ___ varied between physicians, but
was
about ___. The patient's mental status, language and L side
strength was much improved from the reports. tPA was completed.
CT/A/P was done to better identify underlying process, but were
normal.
The patient had one similar episode last fall, with L sided
numbness and weakness, but not with vision or speech changes at
that time. His blood glucose was elevated. He was seen at OSH ED
and symptoms all resolved within 24 hours. He was told this was
a
TIA.
At baseline, he gets headaches only rarely. He takes aspirin
which improves the headaches.
Past Medical History:
DM2, diet controlled, HBa1c last was 10, though 5 is more
typical for him, he blames stress of recent wedding
Social History:
___
Family History:
both parents had stroke, mother had 2 in 24 hours at
age ___, father age ___ (hemorrhagic), mother also had epilepsy,
as
does one uncle.
Physical Exam:
Physical Exam:
Vitals: T:afebrile P:70s R:12 BP:140s-150s/70s SaO2:98%
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted.
Extremities: No C/C/E bilaterally, 2+ radial, DP pulses
bilaterally.
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented x 3. Able to relate history
without difficulty. Attentive, able to name ___ backward
without
difficulty. Language is fluent with intact repetition and
comprehension. Normal prosody. There were no paraphasic
errors.
Pt. was able to name both high and low frequency objects. Able
to read without difficulty. Speech was not dysarthric. Able to
follow both midline and appendicular commands. Pt. was able to
register 3 objects and recall ___ at 5 minutes. There was no
evidence of apraxia or neglect. Had some difficulty with
describing cookie theft picture details, but no particular
pattern of neglect.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 3 to 2mm and brisk. VFF to confrontation (initially
there was concern for L superior quadrant field defect, but not
consistent on repeat exams)
III, IV, VI: EOMI without nystagmus. Normal saccades.
V: Facial sensation intact to light touch, cold and pinprick.
VII: No facial droop, upper and lower facial musculature full
strength and symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline with normal quick lateral
movements.
-Motor: Normal bulk, tone throughout. LUE drifts downward but no
pronation. No adventitious movements, such as tremor, noted. No
asterixis noted.
Initial exam (NIHSS exam) showed LUE antigrav for 10 sec, LLE
antigrav for 5 sec. Had improved after imaging complete.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 5 ___ ___- 4 5 4+ 5 5 5 5
R 5 ___ ___ 5 5 5 5 5 5 5
-Sensory: Initially patient could feel painful stimuli but did
not withdraw on the L. On repeat exam after imaging, patient had
decreased light touch on L face V1 only and LUE, decreased PP
LUE
and LLE. Intact cold sensation, vibratory sense, proprioception
throughout. No extinction to DSS.
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 2 1
R 2 2 2 2 1
Plantar response was mute bilaterally.
-Coordination: No intention tremor, no dysdiadochokinesia noted.
No dysmetria on FNF
-Gait:deferred
Pertinent Results:
Labs on admission:
___ 12:10PM ___ PTT-150* ___
___ 12:10PM PLT COUNT-107*
___ 12:10PM NEUTS-63.1 ___ MONOS-7.0 EOS-1.5
BASOS-0.3
___ 12:10PM WBC-7.0 RBC-4.64 HGB-15.4 HCT-46.3 MCV-100*
MCH-33.1* MCHC-33.1 RDW-12.8
___ 12:10PM CK-MB-1 cTropnT-<0.01
___ 12:10PM UREA N-14
___ 12:19PM estGFR-Using this
___ 12:19PM CREAT-1.7*
___ 12:21PM GLUCOSE-233* NA+-129* K+-4.5 CL--93* TCO2-22
___ 02:39PM %HbA1c-10.7* eAG-260*
___ 03:04PM ETHANOL-NEG
___ 09:38PM ___ PTT-28.5 ___
___ 09:38PM OSMOLAL-291
___ 09:38PM CALCIUM-8.9 PHOSPHATE-4.6* MAGNESIUM-1.9
___ 09:38PM LIPASE-51
___ 09:38PM ALT(SGPT)-21 AST(SGOT)-29 LD(LDH)-257* ALK
PHOS-64 AMYLASE-66 TOT BILI-0.4
___ 09:38PM GLUCOSE-186* UREA N-18 CREAT-0.8 SODIUM-138
POTASSIUM-3.9 CHLORIDE-101 TOTAL CO2-24 ANION GAP-17
___ 10:48PM PLT COUNT-185#
___ 10:48PM WBC-8.1 RBC-3.95* HGB-13.2* HCT-39.1* MCV-99*
MCH-33.4* MCHC-33.8 RDW-12.6
___ 10:56PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-100 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5
LEUK-NEG
___ 10:56PM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 10:56PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
___ 10:56PM URINE HOURS-RANDOM
=
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================================================================
Imaging studies:
CT HEAD/Perfusion/CTA head/neck
___
CT HEAD: There is no evidence of hemorrhage, edema, mass, mass
effect, or
infarction. The ventricles and sulci are normal in size and
configuration. No fracture is identified.
CT PERFUSION: The perfusion maps appear normal with no evidence
of delayed transit time, or reduced blood flow or blood volume.
CTA HEAD AND NECK: The carotid and vertebral arteries and their
major
branches are patent, without evidence of stenosis. There is a
very small
punctate calcification at the left carotid bifurcation. This is
the only
evidence of atherosclerotic disease. The distal cervical
internal carotid
arteries measure 4.5 mm on the left and 4.5 mm on the right.
There is no
evidence of aneurysm formation or other vascular abnormality.
IMPRESSION: Normal study.
MRI-Brain
___
IMPRESSION:
1. There is no evidence of acute intracranial pathology. The
high-resolution images throughout the temporal lobes are
unremarkable and
grossly normal.
2. Unchanged nodular soft tissue lesions likely consistent with
sebaceous
cysts.
MRI- w, w/o contrast
___
IMPRESSION:
1. No evidence of acute infarct, intracranial hemorrhage, or
space-occupying
lesion.
2. Bilateral hippocampi are symmetrical with no focal signal
abnormality.
3. No abnormal leptomeningeal or parenchymal enhancement.
EEG
___
IMPRESSION: This is an normal continuous ICU monitoring study.
No
seizure activity and no interictal epileptiform activity was
identified.
EEG
___
IMPRESSION: This is anbnormal continuous ICU monitoring study.
The
first 90 minutes of the recording had defective electrodes in
the right
side contacts which triggered many of the detection algorithm.
Compared
to the prior day's recording, there were no significant changes.
Brief Hospital Course:
On admission:
___ yo gentleman presenting after witnessed acute onset of
leftsided weakness and difficulty speaking transfered from OSH
s/p iv tPA. On initial assessment at our institution, patient
had only minimal deficits that appeared functional. CT/CTA/CTP
at that time were reassuring.
Nevertheless, given that he had apparently improved
substantially, we decided to complete the full course of ivtPA.
He was admitted to the ICU.
.
ICU course (___):
# Neuro:
post- tPA MRI was without evidence of stroke and his initial EEG
did not show evidence of epileptiform discharges. His deficits
completely resolved and he was transfered to the floor.
However, givent that it is impossible to ever completely rule
out seizure and his stereotyped description of the events could
potentially fit with this diagnosis, and given his history of
repeat head trauma as a boxer, Keppra 1000mg BID was started (to
be increased to 1500mg BID) and he was discharged on this
medication. He was advised not to drive for 6months given the
possibility of seizures. He was also informed about the risks of
taking part in activity that was close to sources of heat (risk
of burns), water (risk of drowning), and heights (risk of fall).
.
Aspirin 81mg was continued as primary stroke prevention given
his risk factors.
.
# Cardiovascular: he did not have any arrhythmias on telemetry.
.
# Endocrine: His TSH was normal, he was maintained on Insulin SS
during admission. His A1C was 10.7, he was advised to discuss
more rigorous blood sugar management with his PCP as an
outpatient. His lipid profile showed: chol 194, Tri 181, HDL 43
Chol/HDL 4.5, LDL 115, he was advised to modify his diet with a
decrease in the intake of fats/cholesterol and to increase his
level of exercise. Consideration will be given to starting a
cholesterol-lowering medication as an outpatient.
.
# Renal: his creatinine remained within normal range.
.
# Infectious disease: there were no signs/symptoms of
infectious etiologies
.
=
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================================================================
Transitional issues:
1. f/u Neurology regarding possibility of seizure and ongoing rx
with Keppra.
2. DM management with PCP
___ on ___:
ASA 81 mg
Discharge Medications:
1. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Keppra 500 mg Tablet Sig: Two (2) Tablet PO twice a day: Take
2 tabs two times daily x 3 days. Then take 2 tabs in the morning
and 3 tabs at night x 3 days. Then take 3 tabs twice daily.
Disp:*180 Tablet(s)* Refills:*0*
5. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Seizure
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
.
Neurological examination reveals no clearly lateralizing signs.
Discharge Instructions:
Dear Mr. ___,
.
You initially presented to ___ with sudden onset
weakness, speech disturbance, and sleepiness. At the time of
the initial evaluation, there was a concern that you could have
had a stroke. The clot-busting medication "tPA" was given. You
were then transferred to the ___ for further evaluation and
care.
.
Immediately performed blood flow studies showed no clear
abnormalities (eg to suggest a stroke). However, as you had
received the blood thinning medication, you spent a night in the
intensive care unit. There were no complications. On the
morning after admission, you felt like your normal self.
.
An MRI of the head showed no evidence of stroke, swelling,
masses, or other clearly contributory lesions. We subsequently
learned you have a family history of seizure in addition to a
personal history of seizure and head trauma with loss of
consciousness. Accordingly, EEG monitoring was done overnight
to evaluate for seizure activity. You had no events while on
the monitoring. While the study showed no seizures, there were
some subtle abnormalities that suggest brain irritability and a
possible predisposition to seize. For this reason, the
anti-seizure medicine keppra (leviteracetam) has been started at
a dose of 1000 mg by mouth twice daily. In three days, the dose
can be changed to 1000 mg in the morning and 1500 mg at night.
After three days on this regimen, the dose can be increased to
the target of 1500 mg by mouth twice daily.
.
As you know, you should avoid driving until you have been
seizure-free for at least six months. As we discussed in
person, you should avoid swimming and bathing independently,
climbing to heights, and other potentially dangerous activities.
Alcohol and sleep deprivation can heighten the chances of
seizures.
.
You demonstrated no signs of alcohol withdrawal throughout the
hospitalization. Because people who drink ample alcohol can
have vitamin deficiencies, multivitamin, thiamine, and folate
supplements were started while you were in the hospital; please
continue these agents after discharge. It will be important to
work with your outpatient providers to slowly decrease and
discontinue alcohol intake.
.
Investigatory studies revealed your blood glucose is not
optimally controlled. Please work with a primary care physician
to improve blood sugar regulation.
.
Please attend at least one follow-up appointment with
neurologist Dr. ___. Please also coordinate a meeting with a
primary care doctor.
.
MEDICATION CHANGES:
- keppra was started
- multivitamin was started
- thiamine was started
- folate was started
Followup Instructions:
___
|
19705426-DS-18
| 19,705,426 | 21,522,363 |
DS
| 18 |
2174-10-31 00:00:00
|
2174-12-01 10:11:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Reglan / Demerol
Attending: ___.
Chief Complaint:
right upper quadrant pain
Major Surgical or Invasive Procedure:
___: ___ drainage
___: ERCP
History of Present Illness:
___ year old female s/p lap converted to open cholecystectomy
___
___ with RUQ pain, found to have a RUQ fluid
collection.
Patient has been admitted to ___ surgery service from
___ after presenting with ephysematous cholecystitis,
she underwent a laparoscopic converted to open cholecystectomy
on
___. patient did well postoperatively and was discharged home
on
7 day course of Ciprofloxacin according to bile cx micro data.
Patient reports that she has been feeling well for 2 days post
discharge then started to have dull pain in the RUQ, nausea and
1
episode of emesis this morning. She presented to ___
where
she was afebrile and hemodynamically stable. CT a/p showed
rim-enhancing fluid collection containing locules of gas in the
gallbladder fossa, measuring 8.3 x 5.6 cm. She was transferred
to
___ for further management. Patient currently reports that she
feels weak and has mild RUQ pain. She denies fevers, chills, SOB
or other associated symptoms.
Past Medical History:
PMH:
Gastroesophageal reflux disease
Ischemic colitis
DM2
Obesity
Hypothyroidism
Fibromyalgia
SVT
PSH:
Right knee arthroplasty ___
Right wrist surgery ___
Reduction mastectomy ___
Hysterectomy ___
Right oophorectomy ___
Social History:
___
Family History:
None.
Physical Exam:
Physical exam: upon admission: ___:
Vitals: 98.1, 75, 114/88, 18, 97% RA
Gen: NAD, A&O x 3
CV: RRR
Pulm: clear breath sounds bilat.,
Abd: soft, nondistended, diffusely tender, with guarding in RUQ,
Ext: warm and well perfused
Pertinent Results:
___ 06:23AM BLOOD WBC-5.7 RBC-3.07* Hgb-9.4* Hct-29.7*
MCV-97 MCH-30.6 MCHC-31.6* RDW-12.8 RDWSD-44.2 Plt ___
___ 01:15AM BLOOD WBC-10.8* RBC-3.12* Hgb-9.6* Hct-29.9*
MCV-96 MCH-30.8 MCHC-32.1 RDW-12.7 RDWSD-43.8 Plt ___
___ 08:25PM BLOOD WBC-4.6 RBC-5.03 Hgb-15.6 Hct-48.4*
MCV-96 MCH-31.0 MCHC-32.2 RDW-13.2 RDWSD-45.7 Plt ___
___ 08:25PM BLOOD Neuts-70.6 Lymphs-17.1* Monos-8.0
Eos-0.0* Baso-0.4 Im ___ AbsNeut-3.27 AbsLymp-0.79*
AbsMono-0.37 AbsEos-0.00* AbsBaso-0.02
___ 06:23AM BLOOD Plt ___
___ 06:23AM BLOOD Glucose-118* UreaN-11 Creat-1.0 Na-142
K-3.4* Cl-103 HCO3-28 AnGap-11
___ 01:15AM BLOOD Glucose-133* UreaN-14 Creat-1.2* Na-139
K-3.4* Cl-100 HCO3-26 AnGap-13
___ 08:25PM BLOOD Glucose-109* UreaN-17 Creat-1.6* Na-140
K-4.1 Cl-98 HCO3-26 AnGap-16
___ 06:23AM BLOOD ALT-82* AST-58* AlkPhos-256* TotBili-0.4
___ 01:15AM BLOOD ALT-156* AST-468* CK(CPK)-34 AlkPhos-358*
TotBili-2.0*
___ 06:23AM BLOOD Lipase-189*
___ 01:15AM BLOOD Lipase-3351*
___ 06:23AM BLOOD Calcium-8.7 Phos-2.7 Mg-2.0
___ 08:35PM BLOOD Lactate-1.7
___: ___ drainage:
Successful US-guided placement of ___ pigtail catheter into
the
subhepatic / gallbladder fossa fluid collection. Samples was
sent for
microbiology evaluation.
___: ERCP:
sphinceterotomy and stent placed, no biliary leak
Brief Hospital Course:
___ female who underwent an open cholecystectomy on ___. The
patient did well postoperatively and was discharged home on a 7
day course of Ciprofloxacin. She presented to an outside
hospital 2 days post discharge with right upper quadrant pain,
weakness, nausea, and emesis. She underwent cat scan imaging
which showed a rim-enhancing fluid collection containing locules
of gas in the gallbladder fossa. The patient was transferred
here for management. Upon admission, the patient was made NPO,
and started on intravenous fluids.
The patient underwent placement of a drain into the gallbladder
fossa with removal of 70cc of bilious fluid. Because there was
concern for a bile leak, the patient underwent an ERCP with a
sphincterotomy and placement of a biliary stent. No bile leak
was identified. The patient did experience vomiting and chest
pain during her recovery. Serial troponins were negative. She
was noted to have a mild elevation in her liver function tests
after the ERCP. These were monitored daily and down-trended.
The patient was discharged home on HD #5. Her vital signs were
stable and she was afebrile. Her white blood cell normalized.
She was tolerating a regular diet and voiding without
difficulty. She had return of bowel function and was
ambulatory. ___ services were contacted for assistance in drain
care. Discharge instructions were reviewed and questions
answered. A follow-up appointment was made in the Acute care
clinic.
Medications on Admission:
Prednisone 5mg QD
Dilaudid 4 mg PRN BID
Metformin 500 mg QD
Levothyroxine 125 mg QD
Trazodone 50mg HS prn
Sertraline 50mg 1 tab QD
Atenolol 50 mg QD
ASA 325 mg QD
Multivitimins
Discharge Medications:
1. Amoxicillin-Clavulanic Acid ___ mg PO Q12H Duration: 2 Days
RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tablet(s) by
mouth every twelve (12) hours Disp #*5 Tablet Refills:*0
2. Acetaminophen 650 mg PO TID
3. Atenolol 50 mg PO DAILY
4. HYDROmorphone (Dilaudid) 4 mg PO BID
5. Levothyroxine Sodium 125 mcg PO DAILY
6. Omeprazole 40 mg PO DAILY
7. PredniSONE 5 mg PO DAILY
8. Sertraline 50 mg PO DAILY
9. TraZODone 50 mg PO QHS:PRN sleep
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
abdominal fluid collection
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You were admitted to the hospital with right upper quadrant
pain. You underwent a cat scan and you were found to have a
fluid collection around the area where the gallbladder was
removed. You had a drain placed to remove the fluid. You blood
work normalized and you are now being discharged with the
following instructions:
You will need to complete 2 days of an antibiotic:
Additional instructions include:
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.
Repeat ERCP in 4 weeks for stent removal, the office will call
you with the date and time. The telephone number is:
___
Followup Instructions:
___
|
19705426-DS-19
| 19,705,426 | 26,634,512 |
DS
| 19 |
2174-11-08 00:00:00
|
2174-11-09 15:41:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Reglan / Demerol
Attending: ___.
Chief Complaint:
diarrhea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ is a ___ year old female on chronic prednisone
who presents with abdominal pain and hematochezia she is ___
weeks SP open chole which was complicated by possible bile leak
and gall bladder fossa fluid collection which was drained by ___
on POD 7 and she underwent ERCP with stent placement on POD 8.
She states she has had persistent pain around her drain site.
She
has developed diarrhea which is she states is as frequent as
___ times a day as of late, she thinks it may be bloody but is
sometimes normal.
Her drain has been putting out about 5 cc a day of serous fluid.
Past Medical History:
PMH:
Gastroesophageal reflux disease
Ischemic colitis
DM2
Obesity
Hypothyroidism
Fibromyalgia
SVT
PSH:
Right knee arthroplasty ___
Right wrist surgery ___
Reduction mastectomy ___
Hysterectomy ___
Right oophorectomy ___
Social History:
___
Family History:
None.
Physical Exam:
Physical Exam at time of discharge:
Physical exam:
Vitals: temp 97.5, BP 135 / 74, HR 70, RR 19, spO2 97 Ra
Gen: NAD, AxOx3
Card: RRR
Pulm: CTAB, no respiratory distress
Abd: Soft, non-tender, non-distended, no rebound or guarding.
Drain has been D/C'd and old drain site with gauze in tact c/d/i
Ext: No edema, warm well-perfused
Pertinent Results:
___ 10:11AM BLOOD WBC-4.9 RBC-3.14* Hgb-9.8* Hct-30.5*
MCV-97 MCH-31.2 MCHC-32.1 RDW-13.3 RDWSD-47.8* Plt ___
___ 10:11AM BLOOD Glucose-176* UreaN-8 Creat-0.8 Na-141
K-3.8 Cl-103 HCO3-25 AnGap-13 Calcium-9.4 Phos-3.1 Mg-1.7
___ 03:00PM BLOOD ALT-59* AST-37 AlkPhos-123* TotBili-0.4
Brief Hospital Course:
___ is a ___ year old female who presented to Emergency
Department on ___ with concerns of abdominal pain and
diarrhea. She is ___ weeks s/p open chole which was complicated
by possible bile leak and gall bladder fossa fluid collection
which was drained by ___ on POD 7 and she underwent ERCP with
stent placement on POD 8. She states she has had persistent
pain around her drain site. She has developed diarrhea which is
she states is as frequent as ___ times a day as of late, she
thinks it may be bloody but is sometimes normal. She was
admitted due to concerns of possible infection and dehydration
secondary to her ongoing diarrhea.
On the floor, her stool was checked for a bacteria called
clostridum difficile which was negative. To treat her diarrhea,
she was started on a medication called Cholestyramine, to help
bind bile acids and decrease diarrhea. After starting this
medication, the patient's diarrhea resolved as she reported more
formed BM and less BM per day. Her ___ drain was also having
minimal output and was therefore pulled during this admission
without any complications. Hydration was encouraged during her
stay and the patient was asymptomatic at time of discharge.
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 was having more
regular BM. The patient was instructed to continue to take
cholestyramine and hydration was encouraged. She should follow
up in the ___ clinic with Dr. ___ to follow up with
Gastroenterology at ___ to undergo biliary stent removal via
ERCP. The patient received discharge follow-up instructions with
understanding verbalized and agreement with the discharge plan.
Medications on Admission:
Prednisone 5mg QD
Dilaudid 4 mg PRN BID
Metformin 500 mg QD
Levothyroxine 125 mg QD
Trazodone 50mg HS prn
Sertraline 50mg 1 tab QD
Atenolol 50 mg QD
ASA 325 mg QD
Multivitimins
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
2. Cholestyramine 4 gm PO BID
RX *cholestyramine (with sugar) 4 gram 1 packet(s) by mouth
twice a day Disp #*60 Packet Refills:*0
3. Atenolol 50 mg PO DAILY
4. HYDROmorphone (Dilaudid) 4 mg PO Q12H:PRN Pain - Moderate
5. Levothyroxine Sodium 125 mcg PO DAILY
6. PredniSONE 5 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Dehydration and diarrhea
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were admitted to the hospital with abdominal pain and loose
stools. Your stool was checked for a bacteria caused clostridum
difficile which was negative. You were started on a medication,
called Cholestyramine, to help bind bile acids and decrease
diarrhea. Your abdominal drain was also removed as it was no
longer needed.
You are now tolerating a regular diet, your pain has improved
and your bowel movements have slowed down. You are ready to be
discharged home. Please follow the discharge instructions
below:
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:
___
|
19705666-DS-3
| 19,705,666 | 24,606,233 |
DS
| 3 |
2186-09-17 00:00:00
|
2186-09-17 12:08:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / amoxicillin
Attending: ___.
Chief Complaint:
LLE weakness
Major Surgical or Invasive Procedure:
-___: T8 corpectomy as well as a partial T9 corpectomy. Fusion
T7 to ___: Multiple thoracic laminotomies. Fusion ___: ___ line placement
History of Present Illness:
___ with PMH significant for IVDU, HCV, and thoracic vertebral
osteomyelitis ___, 2 weeks of inpatient abx and left AMA)
initially presenting as a transfer from ___
___ with complaints of acute weakness of L lower extremity.
Of note, Ms. ___ was recently treated at ___ (___) after a
MVA. At that point, she was found to have non-displaced fracture
of the left 7th rib, patchy opacity of the left lung, and
diffusely abnormal marrow signal at T8 and T9 vertebral bodies,
severe end-plate destruction with wedge compression of T8
vertebral body and post-contrast enhancement of T8 and T9 with
phlegmonous changes anteriorly on MRI. Patient had CT-guided
biopsy on ___. Patient left AMA before she should be treated
for the infection. Patient was not given oral antibiotics.
Multiple drug bottles found in patient's room concerning for
intravenous drug use in house. Plan was to treat with vancomycin
1g q12h for 8 weeks.
She represented to ___ and complained with
increasing lower back discomfort with pain radiating down the
left leg and difficulty walking. Patient was then transferred to
___ for further evaluation.
Patient states that she has had worsening in lower back pain
since the accident and difficulty walking, initially describing
more pronounced in the L leg over the last couple of days.
However, endorsed more diffuse weakness. Unclear if weakness vs
pain limited. No fevers, chills, or night sweats. No visual
changes, headaches. No bowel or bladder problems. Patient
notices no change in sensation with wiping after a bowel
movement. No decrease in sensation in legs.
In the ED, initial vitals were: T 97.9 HR 74 BP 109/49 RR 18
94% RA
Exam notable for :
Midline spinal tenderness to palpation over T8-T10 vertebrae.
No paraspinal muscle tenderness. No fluctuance or abscess. Focal
tenderness over left lower ribs. ___ strength ___ bilaterally
although limited by pain. UE ___ bilaterally. Sensation intact
bilaterally upper and lower extremities. Sensation intact over
abdomen.
CNII-XII intact.
Labs notable for WBC 9, WBC 9.7/21.7< 369, Cr 0.9, lactate 1.1,
neg UA, CRP 32
Imaging notable for CXR without acute cardiopulmonary process
No consults
Patient was given: oxycodone 5 mg po x2, IV vanc x1 g
Decision was made to admit for IV antibiotics, MRI, spine
consult
Vitals prior to transfer:
T 97.4 HR 73 BP 109/72 RR 13 96% RA
On the floor, pt reports feeling "terrible", mostly c/o
bilateral lateral rib pain.
ROS:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain.
Denies headache, sinus tenderness, rhinorrhea or congestion.
Denies cough, shortness of breath. Denies chest pain or
tightness, palpitations. Denies nausea, vomiting, diarrhea,
constipation or abdominal pain. No recent change in bowel or
bladder habits. No dysuria. Denies arthralgias or myalgias.
Past Medical History:
IVDU, heroin
Hepatitis C
MRSA bacteremia
Anxiety
Social History:
___
Family History:
Mother - breast cancer
Physical Exam:
ADMISSION PHYSICAL EXAM:
===========================
Vital Signs: T 99 HR ___ BP 100s/70s 13 96% RA
General: sleepy but arousable and interactive appropriately.
HEENT: Sclera anicteric, dry MM, oropharynx clear, EOMI, PERRL,
neck supple, JVP not elevated, no LAD
CV: RRR, normal S1 + S2, no murmurs, rubs, gallops
Lungs: Clear to auscultation bilaterally in anteriorlateral
lung fields
Abdomen: Soft, TTP in upper quadrants in areas of ribs
bilaterally, otherwise nontender, nondistended
GU: No foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema. No evidence ___ nodes, ___ lesions, splinter
hemorrhage
Neuro: CNII-XII intact, 4+/5 strength upper/lower extremities,
grossly normal sensation although reports LUE numbness on the
dorsal surface of hand C7/C8 distribution
Pertinent Results:
ADMISSION LABS:
===============
___ 09:59PM BLOOD WBC-9.0 RBC-3.91 Hgb-9.7* Hct-31.7*
MCV-81* MCH-24.8* MCHC-30.6* RDW-14.6 RDWSD-43.0 Plt ___
___ 09:59PM BLOOD Neuts-62.5 ___ Monos-6.3 Eos-2.8
Baso-0.2 Im ___ AbsNeut-5.63 AbsLymp-2.52 AbsMono-0.57
AbsEos-0.25 AbsBaso-0.02
___ 09:59PM BLOOD ___ PTT-30.2 ___
___ 09:59PM BLOOD Glucose-84 UreaN-16 Creat-0.9 Na-137
K-3.5 Cl-98 HCO3-26 AnGap-17
___ 09:59PM BLOOD ASA-NEG Acetmnp-NEG Bnzodzp-NEG
Barbitr-NEG Tricycl-POS*
___ 10:54PM BLOOD Lactate-1.1
IMPORTANT LABS:
===============
___ 09:59PM BLOOD CRP-32.0*
___ 06:00AM BLOOD CRP-16.5*
___ 11:41AM BLOOD CRP-15.1*
___ 11:41AM BLOOD HCG-<5
___ 06:00AM BLOOD HIV Ab-Negative
MICRO LABS:
===========
___ 6:00 am IMMUNOLOGY
**FINAL REPORT ___
HCV VIRAL LOAD (Final ___:
86,000 IU/mL.
Performed using Cobas Ampliprep / Cobas Taqman HCV v2.0
Test.
Linear range of quantification: 1.50E+01 IU/mL - 1.00E+08
IU/mL.
Limit of detection: 1.50E+01 IU/mL.
-------------------
___ 9:25 am SWAB SPINE INFECTION.
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
WOUND CULTURE (Final ___:
DOXYCYCLINE AND Daptomycin Sensitivity testing per ___
___
(___).
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.
DOXYCYCLINE = SUSCEPTIBLE sensitivity testing performed
by ___
___.
Daptomycin MIC=0.25 MCG/ML Sensitivity testing
performed by Etest.
STAPH AUREUS COAG +. RARE GROWTH. ___ MORPHOLOGY.
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.
DOXYCYCLINE = SUSCEPTIBLE PERFORMED BY ___.
Daptomycin MIC=0.25MCG/ML PERFORMED BY ETEST.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
| STAPH AUREUS COAG +
| |
CLINDAMYCIN-----------<=0.25 S <=0.25 S
DAPTOMYCIN------------ S S
ERYTHROMYCIN----------<=0.25 S <=0.25 S
GENTAMICIN------------ <=0.5 S <=0.5 S
LEVOFLOXACIN---------- 4 R 4 R
OXACILLIN------------- =>4 R =>4 R
RIFAMPIN-------------- <=0.5 S <=0.5 S
TRIMETHOPRIM/SULFA---- <=0.5 S <=0.5 S
VANCOMYCIN------------ 1 S 1 S
ANAEROBIC CULTURE (Final ___: NO ANAEROBES ISOLATED.
ACID FAST SMEAR (Final ___:
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
ACID FAST CULTURE (Preliminary):
A swab is not the optimal specimen for recovery of
mycobacteria or
filamentous fungi. A negative result should be
interpreted with
caution. Whenever possible tissue biopsy or aspirated
fluid should
be submitted.
.
NO MYCOBACTERIA ISOLATED.
FUNGAL CULTURE (Final ___:
NO FUNGUS ISOLATED.
A swab is not the optimal specimen for recovery of
mycobacteria or
filamentous fungi. A negative result should be
interpreted with
caution. Whenever possible tissue biopsy or aspirated
fluid should
be submitted.
==================
IMPORTANT IMAGING:
==================
MRI c/t/l spine (___): 1. Compared to ___, there has
been increased destruction of the disc and endplates at T8-9
with new T8 loss of height. Increased enhancement of the T8 and
T9 vertebral bodies and the intervening disc suggest interim
progression of discitis/osteomyelitis. Prevertebral phlegmon
from T6-T7 through T11-T12 is essentially unchanged, with a tiny
new fluid pocket at T7 on the right. Small left anterior
epidural phlegmon at T7-T8 appears
decreased in extent. 2. No evidence for new sites of infection
in the thoracic spine. No evidence for infection in the
cervical or lumbar spine.
US L HIP (___): No signs of hematoma or focal collection in
the left thigh.
Pelvis/femur AP/LAT (___): AP pelvis.
Hip joint spaces are preserved. No erosion. No acute fracture.
No
concerning bone lesion. Left femur. No evidence of bone
destruction or periosteal reaction. No acute fracture is seen.
Limited views of the knee demonstrate no evidence of joint
effusion. Small density along the lateral proximal thigh
metaphysis of the tibia may reflect a bone island.
CXR (___): Comparison to ___. Stable minimal left
-sided pleural effusion. Low lung volumes. Moderate
cardiomegaly. Asymmetry of the ribcage caused by scoliosis. No
pneumonia, no pulmonary edema.
L elbow (___): Normal left elbow x-ray examination.
CTA chest (___): 1. No evidence of pulmonary embolism or
aortic abnormality. 2. Moderate loculated left pleural effusion
containing locules of gas suspicious for infection. 3. Extensive
consolidation at the left lung base likely represents
combination of severe lower lobe atelectasis and infection. 4.
Fluid collection in the left lateral chest wall may be
postsurgical,
superinfection not excluded. 5. Several left rib deformities
likely represent old trauma, but given adjacent infection,
osteomyelitis could be considered. 6. Partially visualized
splenic hypodensity could represent hemangioma or infarct.
Splenic US (___): 9 x 4 x 8 mm hyperechoic splenic lesion,
likely representing a hemangioma.
Brief Hospital Course:
TRANSITIONAL ISSUES
======================
- OPAT Orders: Vancomycin 750mg IV q8h, rifampin 300mg PO BID.
Weekly labs including CBC with differential, BUN, Cr, Vancomycin
trough, CRP, ESR; please fax to ATTN: ___ CLINIC - FAX:
___.
- Continune vancomycin for ___ weeks for osteomyelitis per ID
(Day #1: ___, earliest end ___. Will follow up with ID for
further management
- Changed vancomycin dose to 750mg q8, will need vancomycin
trough before second dose on ___
- Started Rifampin 300mg BID on ___ per ID. This may affect
levels of other meds, especially opiates
- New Medications: Vancomycin, Rifampin, Dilaudid, Tizanidine
- Stopped Medications: Clonidine, Baclofen
- Started Rifampin 300mg BID on ___ per ID. This may affect
levels of other meds, especially opiates
- Attempt to wean pain medications and if continued on methadone
at discharge will need to be set up with ___ clinic
- If patient leaves AMA, PICC line must be removed.
- Anemia: Will need continued monitoring of her H/H for anemia
(discharge Hgb and may require transfusions. After course
completed, will need repeat H/H to ensure anemia resolves.
- HCV: viral load 86,000 IU/mL on ___. She should have follow
up with a hematologist to consider genotyping, treatment
- Ulnar neuropathy: Follow-up with neurologist if weakness and
numbness is not improving after ___ months.
- Patient will need a prescription for Narcan prior to discharge
- Patient requesting transfer of ___ clinic from Habit
Opco ___ to Spectrum (intake
___ fax ___. Will need to have
information faxed when pt ready to be discharged
-CODE: full
-CONTACT: ___ (grandmother) ___
===============
ACTIVE ISSUES
===============
#Vertebral Osteomyelitis: On admission ___ she was afebrile
with normal WBC. Earlier this year, patient underwent 2 weeks of
antibiotics in ___ for thoracic vertebral osteomyelitis.
Patient then represented to ___ and had a CT guided biopsy on
___ that showed no growth. She had an MRI on ___ that showed
worsening osteo/discitis at T8 level. She also had a left thigh
US that was negative for hematoma. She had numerous cultures
that did not grow any organisms and she was not started on
antibiotics per infectious disease. She went to the OR on ___,
but due to difficulty with intubation and lung isolation this
was aborted and she instead went back to the OR on ___. Her
procedure (anterior approach) involved single lung ventilation
and resection of the left 7th rib to allow T8 corpectomy as well
as a partial T9 corpectomy; fusion T7 to T9; anterior spacer
placement from T7 to T9; as well as autograft, I&D and
debridement. **Of note, left 7th rib was location of
non-displaced fracture from initial MVA presentation. Samples
from this procedure sent for culture, positive for MRSA. She was
taken back to the OR again on ___ (posterior approach) with
multiple thoracic laminotomies; fusion T4-T11; and autograft.
She was started on vancomycin ___ with plans for a ___ week
course starting ___ (last surgery). She will need weekly ___
trough, CRP, and ESR while on treatment. Otherwise blood
cultures x9 were all negative and TTE was negative for
endocarditis.
#Hospital acquired pneumonia:
#Acute hypoxic respiratory failure:
While recovering from her second procedure, she was noted to
have an increased O2 requirement, increased cough, fever to 103,
tachycardia to 140. A CTPE was negative for embolus but showed a
left sided consolidation and left-sided loculated effusion, and
had evidence concerning for rib osteo as well as splenic infarct
vs. hemangioma. She was the transferred to the ICU for increased
hypoxemic respiratory failure, where her temp was 99 and she was
tachy to the 110s, satting well on 4L O2. IP and ___ were
consulted to drain the located pleural effusion but on repeat
imaging, there was no drainable fluid collection. Cefepime was
added to her vancomycin for concern for hospital acquired
pneumonia and she was treated for an ___nding ___.
She improved after treatment and on remained normoxic on
discharge.
#Anemia: She had 3 red blood cell transfusions for varying
degrees of anemia, thought to be due to anemia of infection. She
will need frequent CBCs
#Pain: Given her history of IVDU, pain control was an issue
throughout her hospital stay especially postoperatively. Chronic
pain service was consulted and recommended ketorolac,
tizanidine, and gabapentin in addition to dilaudid, tylenol, and
methadone.
#Ulnar neuropathy: She has allodynia in left ulnar distribution
reproducible with medial epicondyle palpation. She has decreased
lumbrical strength on left medial digits. This neuropathy is
likely secondary to trauma during recent car accident. She had
an elbow x-ray without signs of fracture or foreign body. OT saw
her and did not recommend splinting. She should follow-up with a
neurologist as an outpatient if her weakness and numbness does
not improve.
#Opiate Use Disorder: She has had multiple admissions for
complications of IVDU. She takes Methadone 73 mg. Her HIV and
b-HCG tests that were negative.
#Hepatitis C: HCV viral load 81,900 IU/mL in ___. 86,000
IU/mL during this hospitalization. She will need follow-up with
a hepatologist.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Gabapentin 300 mg PO TID
2. LORazepam 0.5 mg PO Q12H PRN Anxiety
3. CloNIDine 0.1 mg PO BID
4. Doxepin HCl 100 mg PO HS
5. Methadone 73 mg PO DAILY
6. Baclofen 10 mg PO TID
7. Furosemide 20 mg PO DAILY PRN swelling
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary Diagnosis
Vertebral Osteomyelitis and Discitis
Secondary Diagnoses
Hepatitis C
Opiate use disorder
HAP
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 you had an infection
(MRSA) of your spine. This was treated with two spinal
surgeries, one on ___ in which the infection was cleaned out
and your spine bones were fused (T7-T8), and then another on
___ in which more of your spine bones were fused (T4-T11). You
were treated with antibiotics (vancomycin) and it is absolutely
essential that you continue to receive these antibiotics for a
long period of time ___ weeks). You should follow up with
infectious disease to determine exactly how long you will need
antibiotics. You will also need to wear your TLSO brace when
walking. During your hospitalization you contracted an infection
of your lung which was treated with additional antibiotics,
which have now been stopped. Also during your hospitalization,
you were found to have persistently low blood counts probably
due to the severe infection. This was treated by transfusing
several units of blood but you will need monitoring of this
after you leave the hospital to ensure that your body continues
to make adequate blood counts.
It was a pleasure taking care of you!
-Your ___ Care Team
Followup Instructions:
___
|
19705710-DS-15
| 19,705,710 | 20,593,693 |
DS
| 15 |
2148-05-10 00:00:00
|
2148-05-10 15:12:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
sacral decubitus ulcer
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ who presents for evaluation of sacral decubitus ulcer. He
is a limited historian due to hearing loss and seemingly
baseline dementia, but his primary care physician, ___.
___, was contacted by his home health aide due to
development of sacral decubitus ulcer over the past
approximately 2 weeks, with worsening pain for the past
approximately 2 days. There have been no fevers at home. He was
referred to the ED for further evaluation.
In ED pt endorsed mild pain in his shoulders bilaterally and
back. On discussion with his daughter, she had been unaware of
his ulcer until today, but did note that he had been "moaning in
pain" for the past few days. She has not seen him in 5 months,
but suspects that decline in mental status has been progressive.
Pt hyponatremic, given 500cc bolus.
On arrival to floor pt moaning out in pain.
ROS: +as above, otherwise reviewed and negative
Past Medical History:
Degenerative joint disease, especially of the knees and back
Insomnia
Benign prostatic hypertrophy
Sacral debucitus ulcer
Dementia
Social History:
___
Family History:
unknown
Physical Exam:
Vitals: T:98.8 BP:194/100 P:74 R:16 O2:95%ra
PAIN: unable to quantify
General: looks uncomfortable, crying out in pain
Lungs: clear anteriorly
CV: rrr no m/r/g
Abdomen: bowel sounds present, soft, nt/nd
Ext: pitting edema to mid shins
Skin: stage ___ sacral decubitus ulcer with infected tissue
Neuro: alert, hard of hearing, oriented to person only
(baseline)
Pertinent Results:
___ 06:50PM GLUCOSE-133* UREA N-15 CREAT-0.9 SODIUM-128*
POTASSIUM-4.8 CHLORIDE-90* TOTAL CO2-29 ANION GAP-14
___ 06:59PM LACTATE-1.6
___ 06:50PM CALCIUM-8.7 PHOSPHATE-3.6 MAGNESIUM-1.8
___ 06:50PM WBC-13.1*# RBC-3.51* HGB-11.7* HCT-35.1*
MCV-100* MCH-33.5* MCHC-33.5 RDW-12.5
___ 06:50PM NEUTS-82.6* LYMPHS-8.9* MONOS-5.4 EOS-2.8
BASOS-0.3
___ 06:50PM PLT COUNT-312
CXR Preliminary Report: Bibasilar patchy opacities likely
reflect atelectasis though infection cannot be excluded.
Probable trace bilateral pleural effusions
Brief Hospital Course:
___ who presents for evaluation of sacral decubitus ulcer.
Sacral ulcer and wound: The patient presented with a 3cmx4cm
purulent sacral wound with a 9cm sacral ulcer surrounding it. He
was started on IV antibiotics and a wound care consult was
placed. The wound care consult recommended surgical debridement.
His health care proxy did not feel that it was compatible to do
a surgical procedure for an irreversible process and requested
that the patient be comfort-measures only. Antibiotics were
stopped and hospice was consulted. The patient was discharged
home on hospice.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Clonazepam 0.5 mg PO DAILY anxiety
2. Doxazosin 4 mg PO HS
3. Finasteride 5 mg PO DAILY
4. Fluticasone Propionate NASAL 2 SPRY NU DAILY
5. Omeprazole 20 mg PO DAILY
6. Sarna Lotion 1 Appl TP DAILY
7. Sertraline 50 mg PO DAILY
8. Acetaminophen 650 mg PO Q6H
9. Lisinopril 5 mg PO DAILY
10. ClonazePAM 1 mg PO QHS
11. Naproxen 250 mg PO Q12H:PRN pain
Discharge Medications:
1. Acetaminophen 1000 mg PO TID
RX *acetaminophen [Acetaminophen Extra Strength] 500 mg 2
tablet(s) by mouth three times a day Disp #*180 Tablet
Refills:*0
2. Clonazepam 0.5 mg PO DAILY anxiety
3. ClonazePAM 1 mg PO QHS
4. Doxazosin 4 mg PO HS
5. Finasteride 5 mg PO DAILY
6. Sarna Lotion 1 Appl TP DAILY
7. Sertraline 50 mg PO DAILY
8. Naproxen 250 mg PO Q12H:PRN pain
9. Morphine Sulfate (Concentrated Oral Soln) ___ mg PO Q1H:PRN
pain, dyspnea, restlessness
RX *morphine concentrate 100 mg/5 mL (20 mg/mL) ___ mg by mouth
q1h Disp ___ Milliliter Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Sacral decubitus ulcer
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Bedbound.
Discharge Instructions:
You were admitted with a sacral ulcer ("bedsore"). You were
treated initially with antibiotics and wound care. The
antibiotics were stopped after discussion with your family
confirming that you preferred the focus of the care to be
comfort-oriented, with nothing that would prolong suffering. You
are being discharged with hospice services.
Followup Instructions:
___
|
19705794-DS-20
| 19,705,794 | 25,714,277 |
DS
| 20 |
2133-05-22 00:00:00
|
2133-05-24 23:21:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: OBSTETRICS/GYNECOLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
fever
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ s/p SVD on ___ complicated by chorioamnionitis
presents to the ED with fever. She received an epidural during
labor. She reports that she had been doing well after going home
on PPD2, but started having fevers and chills at home yesterday,
along with joint pain and muscle pain. She reports one episode
of
dysuria that has since resolved. Reports mild headache. She
reports breastfeeding well without breast tenderness or redness,
improved vaginal bleeding, denies vaginal discharge,
nausea/vomiting/diarrhea, denies chest pain/shortness of
breath/cough, denies sick contacts.
During her ED stay, she began complaining of back pain. She
received IV ceftriaxone and vancomycin.
Past Medical History:
denies
Social History:
___
Family History:
non-contributory
Physical Exam:
PHYSICAL EXAM ON ADMISSION
A&O, NAD
Resp: breathing comfortably
Breasts: no erythema, no tenderness
Abd: soft, NT/ND, no rebound or guarding
SSE: Well healing vaginal laceration
Normal vaginal mucosa with pink tinge, no lesions
Normal cervix with pink tinge, no lesions
Os closed
Normal appearing discharge
No active bleeding
BME: Patient reacted with apparent discomfort but denies any
fundal tenderness, denies adnexal tenderness bilaterally
PHYSICAL EXAM ON DISCHARGE
General: NAD, A&O
Lungs: No respiratory distress, normal work of breathing
Abd: soft, nontender, fundus firm at 3cm below umbilicus
Lochia: minimal
Extremities: no calf tenderness
Breast: left breast erythema resolved, no induration, no TTP or
increased warmth or fluctuance. no abnl discharge.
Pertinent Results:
___ 06:56AM LACTATE-0.8 K+-3.6
___ 03:25AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-LG*
___ 03:25AM URINE RBC-1 WBC-2 BACTERIA-FEW* YEAST-NONE
EPI-2
___ 03:25AM URINE MUCOUS-RARE*
___ 01:45AM OTHER BODY FLUID CT-NEG NG-NEG
___ 01:17AM LACTATE-2.3*
___ 01:05AM GLUCOSE-116* UREA N-10 CREAT-0.7 SODIUM-138
POTASSIUM-5.2* CHLORIDE-101 TOTAL CO2-18* ANION GAP-19*
___ 01:05AM ALT(SGPT)-15 AST(SGOT)-38 ALK PHOS-140* TOT
BILI-0.3
___ 01:05AM WBC-21.1*# RBC-3.76* HGB-10.6* HCT-33.5*#
MCV-89 MCH-28.2 MCHC-31.6* RDW-14.9 RDWSD-48.3*
___ 01:05AM NEUTS-91.2* LYMPHS-6.5* MONOS-1.3* EOS-0.0*
BASOS-0.1 IM ___ AbsNeut-19.26*# AbsLymp-1.38 AbsMono-0.27
AbsEos-0.01* AbsBaso-0.03
___ 01:05AM ___ PTT-33.4 ___
___ 01:05AM PLT COUNT-452*#
Brief Hospital Course:
Ms. ___ presented to the ED ___ with fever on PPD12 after a
vaginal delivery complicated by chorioamnionitis. On her initial
exam, she had left breast erythema concerning for mastitis. She
underwent a chest x-ray, and MRI of the cervical and thoracic
spine given concern for epidural abscess, and a pelvic
ultrasound to rule out retained products. All imaging was
negative for acute process. She received a course of vancomycin
and ceftriaxone, and was transition to IV ampicillin,
gentamycin, and clindamycin. She was later transitioned to oral
dicloxacillin for a total 9 day course. While inpatient, she
received a lactation consultation. She was seen by social work
who filed a form 51A after the patient's newborn was not taken
to a pediatrician after the newborn was given honey. The
patient's condition improved, she was persistently afebrile, and
her breast erythema resolved. She was discharged ___ in stable
condition with a prescription for dicloxacillin and follow up
scheduled in the clinic in 1 week.
Medications on Admission:
PNV
Discharge Medications:
1. Acetaminophen ___ mg PO Q6H:PRN Mild Pain
RX *acetaminophen 500 mg ___ capsule(s) by mouth every 6 hours
as needed Disp #*30 Capsule Refills:*0
2. DiCLOXacillin 500 mg PO Q6H Duration: 9 Days
RX *dicloxacillin 500 mg 1 capsule(s) by mouth every 6 hours
Disp #*28 Capsule Refills:*0
3. Ibuprofen 600 mg PO Q6H:PRN Moderate Pain
RX *ibuprofen 600 mg 1 tablet(s) by mouth every 6 hours as
needed Disp #*30 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
mastitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms ___,
You were admitted to the hospital with fevers. You had an MRI,
ultrasound and x-ray, lactation consult, and received
antibiotics. You have recovered well and your medical team now
believes you are ready to go home.
Please refer to your discharge packet and the instructions
below:
Nothing in the vagina for 6 weeks (No sex, douching, tampons)
Do not take more than 4000mg acetaminophen (tylenol) in 24 hrs
Do not take more than 2400mg ibuprofen in 24 hrs
Please call the on-call doctor at ___ if you develop
shortness of breath, dizziness, palpitations, fever of 100.4 or
above, abdominal pain, heavy vaginal bleeding, nausea/vomiting,
depression, or any other concerns.
Followup Instructions:
___
|
19705860-DS-20
| 19,705,860 | 25,552,186 |
DS
| 20 |
2201-05-12 00:00:00
|
2201-05-12 08:59:00
|
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
RUQ pain
Major Surgical or Invasive Procedure:
Laparoscopic cholecystectomy.
History of Present Illness:
___. male p/w acute onset RUQ pain starting at 1am on ___ (3
days ago). Denies fever, nausea, and vomiting. Reports
anorexia since then. Pain has been controlled with Tylenol. He
did present to ___ where RUQ US and CT abdomen
showed sludge in the gallbladder and he was discharged home.
His symptoms persisted, with fever to 101 last night, and he was
referred to the ED by Dr. ___
___ Medical History:
HLD, ADHD
Social History:
___
Family History:
father s/p cholecystectomy
Physical Exam:
ADMISSION EXAM:
T: 97.4 P: 68 BP: 115/67 RR: 16 O2sat: 97% on RA
General: awake, alert, oriented x 3, NAD
HEENT: NCAT, EOMI, anicteric
Heart: RRR
Lungs: normal excursion, no respiratory distress
Back: no vertebral tenderness, no CVA tenderness
Abdomen: soft, RUQ tenderness, ___ sign, ND, ~3 cm
umbilical hernia
Extremities: WWP, no CCE, no tenderness, 2+ B radial pulses
Psychiatric: normal judgment/insight, normal memory, normal
mood/affect
DISCHARGE EXAM:
98.3, 97.8, 52, 131/76, 18, 93RA
Gen: A/Ox3, NAD
CV: bradycardic, sinus, reg, no mrg
Resp: CTAB, no increased WOB
Abd: soft, distended but improved, tympanic but improved,
nontender
Ext: wwp, no edema
Pertinent Results:
ADMISSION LABS:
ADMISSION LABS
___ 05:30PM BLOOD WBC-11.6*# RBC-4.22* Hgb-13.4* Hct-38.6*
MCV-91 MCH-31.7 MCHC-34.7 RDW-12.2 Plt ___
___ 05:30PM BLOOD Neuts-80.9* Lymphs-10.2* Monos-7.5
Eos-1.1 Baso-0.3
___ 05:30PM BLOOD Glucose-102* UreaN-23* Creat-1.0 Na-140
K-4.5 Cl-100 HCO3-33* AnGap-12
___ 05:30PM BLOOD ALT-25 AST-21 AlkPhos-76 TotBili-0.7
___ 05:30PM BLOOD Lipase-13
___ 05:30PM BLOOD Albumin-4.3
___ 08:36PM BLOOD Lactate-1.0
IMAGING:
___ RUQ U/S
Sludge in a mildly distended gallbladder with no other findings
of acute
cholecystitis. Correlate with clinical exam and lab findings.
1.1 cm echogenic focus in the left lobe of the liver may
represent a
hemamgioma in the absence underlying liver disease. In the
presence of
underlying liver disease, followup is recommended.
___ HIDA Scan
No visualization of the gallbladder in the first hour.
Differential
includes chronic or acute cholecystitis. Dr. ___
these findings with the surgical team by telephone at 4:40 at
the time of discovery.
URINE:
___ 04:43PM URINE Color-DkAmb Appear-Clear Sp ___
___ 04:43PM URINE Blood-NEG Nitrite-NEG Protein-100
Glucose-NEG Ketone-10 Bilirub-SM Urobiln-4* pH-6.0 Leuks-NEG
___ 04:43PM URINE RBC-2 WBC-4 Bacteri-FEW Yeast-NONE Epi-0
___ 04:43PM URINE CastHy-2*
___ 04:43PM URINE Mucous-MANY
Urine cx NEGATIVE
Brief Hospital Course:
The patient was admitted to the ___ Service on
___ for evaluation and treatment of abdominal pain.
Admission (abdominal ultra-sound and HIDA) revealed chronic
cholecystitis. The patient was started on preoperative Unasyn
and will continue for 5 days postoperatively. He underwent
laparoscopic cholecystectomy, which went well without
complication (reader referred to the Operative Note for
details). After a brief, uneventful stay in the PACU, the
patient arrived on the floor initially NPO, on IV fluids, and IV
dilaudid for pain control. The patient was hemodynamically
stable but did experience some bradycardia with rates in the
___. EKG was obtained that showed sinus bradycardia and the
patient was asymptomatic.
Pain was well controlled. Diet was progressively advanced as
tolerated to a regular diet. He did begin to have abdominal
distension on POD1 that was consistent with an ileus. He was
regressed to sips for until POD3 when he began to tolerate CLD
without further abdominal pain/distension and he began passing
gas. 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 while in bed.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating CLD with
toast, ambulating, voiding without assistance, and pain was well
controlled. The patient was discharged home without services.
The patient received discharge teaching and follow-up
instructions with understanding verbalized and agreement with
the discharge plan.
Medications on Admission:
simvastatin 40 mg daily, dextroamphetamine-amphetamine ER 25 mg
24hr PRN ADHD, valcyclovir 500 mg daily, aspirin 81 mg daily,
vitamins
Discharge Medications:
1. Amoxicillin-Clavulanic Acid ___ mg PO Q12H
RX *amoxicillin-pot clavulanate [Augmentin] 875 mg-125 mg 1
tablet by mouth every twelve (12) hours Disp #*6 Tablet
Refills:*0
2. Aspirin 81 mg PO DAILY
3. Senna 8.6 mg PO BID
4. Docusate Sodium 100 mg PO BID
5. Acetaminophen ___ mg PO Q6H:PRN pain
Discharge Disposition:
Home
Discharge Diagnosis:
Acute cholecystitis.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
It was a pleasure caring for you during your stay at ___
___. The following is a summary of
discharge instructions.
You are being discharged to home on a clear liquid diet and
should self advance your diet over the next few days as
tolerated. However, if you develop nausea or abdominal
distension or pain, please contact Dr. ___ or for
severe symptoms please go to the emergency room.
MEDICATIONS
1. Please resume all home medications, unless specifically
advised not to take a particular medication. Please take any new
medications as prescribed.
2. You maytake acetaminophen (Tylenol) as directed, but do not
exceed 4000 mg in one day.
3. An over-the-counter stool softener such as Colace (100 mg
twice daily) for constipation as needed.
WOUND CARE
1. Monitor the wounds for signs of infection, including redness
that is spreading or increased drainge from wounds. Please call
Dr. ___ if you experience any of these symptoms.
ACTIVITY
1. You may shower and pat your incisions dry. No swimming or
bathing until your follow-up appointment.
2. No strenuous activity until cleared by ___.
2. Call the office IMMEDIATELY if you have any of the following:
1. Signs of infection: fever with chills, increased redness,
swelling, warmth or tenderness at the surgical site, or unusual
drainage from the incision(s).
2. A large amount of bleeding from the incision(s) or drain(s).
3. Fever greater than 101.5 oF
4. Severe pain NOT relieved by your medication.
Return to the ER if:
* If you are vomiting and cannot keep in fluids or your
medications.
* If you have shaking chills, fever greater than 101.5 (F)
degrees or 38 (C) degrees, increased redness,swelling or
discharge from incision, chest pain, shortness of breath, or
anything else that is troubling you.
* Any serious change in your symptoms, or any new symptoms that
concern you.
Thank you for allowing us to participate in your care.
Followup Instructions:
___
|
19706109-DS-27
| 19,706,109 | 23,198,009 |
DS
| 27 |
2203-04-05 00:00:00
|
2203-04-05 14:07:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Cephalosporins / Ciprofloxacin
Attending: ___.
Chief Complaint:
hypothermia
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Patient is a ___ year old woman with history of astrocytoma s/p
resection with resultant MR, refractory epilepsy, and
panhypopituitarism who presents with temperature ___, and rectal
temperature in ED ___.
.
In the ED, initial vitals were: 95.8 63 130/69 18 97% RA. Labs
notable for WBC 5.2, Hct 39.1, Plt 195, normal chem 7, Ca ___,
ALT 50, AP 146, Tbili, 0.1, Alb: 4.3, AST 48. UA without signs
of infection. Blood cultures sent. Given hydrocortisone 50mg
IV once (cortisol level sent prior to administration). Also
received her ___ home medications administered by her case
manager. CXR not completed prior to transfer. She had a single
convulsive seizing episode during which time she sat up and
became red. Neurology saw patient who thought she was at
baseline (has seizures approximately 1/week). Vitals prior to
transfer: ___: T rectal: 34.1 HR 79, BP 106/72, ___ 96 ___
RA.
.
Upon arrival ICU: patient is alert and speaking in short
sentences, and parents feel that the patient is more clear now
and back to her baseline. No recent medication changes other
than increase in Zonegran during her last hospitalization. She
has had problems getting her progesterone while she was in
___ rehab (___) but she has been on correct
medications since she got back to group home on ___. She did
have an episode of hypothermia in ___, family does not recall
the cause at that time. Pt was doing very well recently, just
out with her parents over the weekends. Of note, patient had
recent dental procedure with prophylactic clarithromycin.
Patient denies cough, diarrhea or dysuria. No known sick
contacts at the group home. Complaining of left arm pain and
abdominal pain. No n/v.
Past Medical History:
1. right parietal astrocytoma age ___, s/p resection and
radiation (so baseline left hemiparesis), complicated by
hydrocephalus s/p VP shunt
2. refractory seizures on multiple AEDs, s/p VNS; mother says
she has little seizures all the time and points out a variety of
manifestations (turns red in the face; brief movements of her
eyes, brief moments of non-responsiveness). Mother says she
swipes the VNS magnet to activate VNS frequently for such
events. Last ?generalized seizure with post-ictal period noted
in OMR chart was sometime in ___, preceeded by sometime in
___. Last VNS update in ___. sleep apnea with obese neck; snores/wakes frequently
(including for nocturia); does not tolerate CPAP.
4. Panhypopituitarism (hypogonadism, adrenal insufficiency,
hypothyroidism); on glucocorticoid and thyroid replacement,
progesterone)
5. Depression
6. Osteoporosis with unclear h/o knee and shoulder pain
7. Meningiomas (Right parietal, growing @2cm; RF=XRT@youth)
8. Developmental Delay / MR
9. s/p Mohs surgery for a recurrent nodular basal cell cancer on
the left occiput; also s/p BCC Tx with Aldara.
10. h/o urinary incontinence and nocturia, chronic
11. h/o VPS in RLV, reportedly removed in ___ (but seen on
current and prior head imaging, with dilated ventricle)
12. s/p cholecystectomy in ___
Social History:
___
Family History:
Adopted
Physical Exam:
Physical Exam on Admission:
T: 95.5 (axillary), HR 90 BP 113/68 RR 19 O2 93% RA
General: Alert, speaking in short but full sentences, no acute
distress
HEENT: PERRL, Sclera anicteric, MMM, oropharynx clear
Neck: obese neck, supple, JVP difficult to appreciate
Lungs: congested upper airway sounds but otherwise clear to
auscultation anteriorly, no wheezes, rales, rhonchi
Chest: palpable VNS on L breast, no overlying erythema, no
fluctuance, no pain with palpation
CV: faint heart sounds, RRR, normal S1 + S2, no m/r/g
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: mild difficulty following commands with neuro exam,
however, eyes conjugate without deviation, PERRL. EOMI on
tracking objects around the room, however, difficulty following
commmands. mild L lower facial asymmetry. tongue protrusion
midline. trapezius weaker on left than right.
On strength exam, LUE and LLE weaker than right, which is her
baseline. LUE contracted, antigravity; can lift LLE off the bed
briefly and wiggle toes bilaterlaly.
Physical Exam on Discharge:
Tmax: 37 °C (98.6 °F)
Tcurrent: 36.5 °C (97.7 °F)
HR: 89 (83 - 114) bpm
BP: 95/77(81) {95/43(53) - 148/92(103)} mmHg
RR: 25 (14 - 29) insp/min
SpO2: 95%
Heart rhythm: SR (Sinus Rhythm)
Wgt (current): 94.9 kg (admission): 95.5 kg
Height: 57 Inch
General: mild, diffuse complaints of tenderness of chest,
abdomen, extremities
Otherwise exam unchanged from admission
Pertinent Results:
ADMISSION LABS:
___ 05:02PM BLOOD WBC-5.2 RBC-4.16* Hgb-13.1 Hct-39.1
MCV-94 MCH-31.6 MCHC-33.5 RDW-14.0 Plt ___
___ 05:02PM BLOOD Neuts-65.3 ___ Monos-5.8 Eos-1.5
Baso-1.0
___ 05:02PM BLOOD ___ PTT-45.1* ___
___ 05:02PM BLOOD Glucose-84 UreaN-17 Creat-0.9 Na-137
K-4.8 Cl-103 HCO3-23 AnGap-16
___ 05:02PM BLOOD ALT-50* AST-48* CK(CPK)-89 AlkPhos-146*
TotBili-0.1
___ 05:02PM BLOOD Lipase-48
___ 05:02PM BLOOD Albumin-4.3 Calcium-10.4* Phos-4.2 Mg-1.8
ENDOCRINE:
___ 05:02PM BLOOD TSH-3.4
___ 05:02PM BLOOD Free T4-1.5
___ 05:02PM BLOOD Cortsol-7.3
TOX SCREEN:
___ 05:02PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 10:35PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG mthdone-NEG
UA:
___ 06:20PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG
MICROBIOLOGY:
BCx ___: pending
UCx ___: final no growth
Studies:
Cardiovascular Report ECG Study Date of ___ 4:30:22 ___
Sinus rhythm. Non-specific T wave inversion in the precordial
leads could be
a normal variant in a female. No significant change compared to
previous
tracings of ___ and ___.
Radiology Report CHEST (PORTABLE AP) Study Date of ___ 7:50
___
IMPRESSION: Extremely limited exam. No definite large
consolidation.
Consider repeat if clinically indicated.
Radiology Report CT HEAD W/O CONTRAST Study Date of ___
1:47 ___
IMPRESSION:
1. No appreciable change in right parietal lobe extra-axial
dense mass, most
compatible with meningioma.
2. Stable moderate dilatation of the lateral ventricles.
Ventricular
catheter terminates in the left frontal horn.
Radiology Report CHEST (PORTABLE AP) Study Date of ___ 2:05
___
FINDINGS: As compared to the previous radiograph, there is no
relevant
change. Normal size of the cardiac silhouette. No pleural
effusions. No
parenchymal opacity suggesting pneumonia. No pneumothorax.
Lab results on Discharge:
___ 05:16AM BLOOD WBC-4.6 RBC-4.23 Hgb-12.6 Hct-39.7 MCV-94
MCH-29.8 MCHC-31.8 RDW-14.1 Plt ___
___ 03:00PM BLOOD Neuts-65.0 ___ Monos-5.2 Eos-0.8
Baso-0.6
___ 05:16AM BLOOD Plt ___
___ 05:16AM BLOOD Glucose-89 UreaN-11 Creat-1.0 Na-141
K-3.8 Cl-111* HCO3-22 AnGap-12
___ 05:16AM BLOOD ALT-48* AST-42* LD(LDH)-164 AlkPhos-138*
TotBili-0.2
___ 05:16AM BLOOD Calcium-9.0 Phos-3.2 Mg-1.8
___ 05:16AM BLOOD Free T4-1.2
___ 05:06AM BLOOD LEVETIRACETAM (KEPPRA)-PND
Brief Hospital Course:
PRIMARY REASON FOR HOSPITALIZATION: Patient is a ___ female
with PMH of astrocytoma s/p resection at ___ months of age with
resultant seizure disorder with VNS, pan-hypopituitarism, and
mental retardation who presents with hypothermia to ___ rectal
in the ED. Patient is otherwise at baseline level of
interactiveness and is asymptomatic. With an overnight ICU stay,
patient's temperature has recovered to ___ rectal. She
experienced increased seizure activity on the day after
admission with several minor seizures and one generalized
tonic-clonic seizure. Her Keppra dose was increased to 100mg PO
BID and she was discharged to follow-up without further
increased seizure activity.
ACUTE CARE
1. Hypothermia: Patient presented from group home with
temperature found to be ___ rectal on initial presentation.
Potential considered etiologies of patient's hypothermia
included hypothyroidism, hypoadrenalism, hypopituitarism,
hypothalamic dysfunction related to seizure, drug-induced, or
inactivity. Her degree of hypothermia was mild without
electrolyte or EKG abnormalities. Lipase was normal, pointing
away from pancreatitis. Infectious cause was considered but WBC
count was normal and patient was normotensive with normal
lactate making sepsis less likely an etiology. Patient's glucose
was normal on admission (108), which ruled out hypoglycemia.
Anxiolytics could cause hypothermia, but less likely as patient
has been on ativan for a long time without frequent episodes of
hypothermia. Patient was treated with bair hugger with
improvement in her temperature, and eventually weaned off bair
hugger with maintained temperature. Endocrine work up was done
and showed normal TSH and free T4. Cortisol was also within
normal limits ___ random draw) but patient was started on
overnight stress dose hydrocortisone for empiric coverage of
hypoadrenalism with taper following thereafter. Endocrinology
felt that her steroids could be tapered down from the stress
dosing given no obvious infectious source and rapid resolution
of her hypothermia with active rewarming. Exact nature of
hypothermia may be multifactorial and has resolved without
obvious precipitating factors. She will be followed by PCP and
neurology.
2. Seizure Disorder: Patient has a long history of rather
refractory seizure disorder leading to multiple AED's and VNS
implantation. She reportedly has multiple small seizure episodes
weekly requring activation of the VNS. Patient possibly has
hypothermia related to hypothalamic involvement with a seizure.
Patient was continued on home antiepileptic therapies including
VNS, lamotrigine, levitiracetam, high dose progesterone, and
Zonergan. Patient had a witnessed, short lasting seizure in ED,
and another one in the ICU. We titrated Keppra to 1000 PO BID
given a witnessed grand mal seizure on ___. An infectious
source was considered as a precipitant, but no source was
identified by discharge and she had no elevated white count or
other sign or symptom of infection. She was discharged on the
increased keppra dose and neurology follow-up.
CHRONIC CARE:
1. Secondary Hypothyroidism: Patient has long-standing
hypothyroidism and this presentation with hypothermia was
unlikely an exacerbation of that underlying condition. TSH and
free T4 were checked and were within normal limits. Her
synthroid was continued.
2. Secondary Hypoadrenalism: Patient is on maintenance dose of
hydrocortisone at home, but it was initially unclear if her
hypothermia represented acute adrenal insufficiency. This is
unlikely given absence of electrolyte abnormalities and
normotension but patient was treated empirically with stress
dose steroids for a day given her hypothermia and concern for
hypoadrenalism. Endocrine was consulted and felt hypoadrenism is
unlikely. Her steroids were tapered down to home dosing per
Endocrine's recommendations.
3. Hypopituitarism: Patient has resultant hypopituitarism from
her childhood resection of astrocytoma. Her hormonal
insufficiencies were treated as above. In addition, patient is
on progesterone 100mg PO TID for seizure prophylaxis and her
home medication was brought in by group home as the exact
formulation was not available in the hospital.
4. Intellectual Disability: Patient has had significant
intellectual disability resulting from parietal astrocytoma
resection and long course of seizure disorder. She lives at a
group home and is completely dependent in her activities of
daily living. Updates were given to her caregiver and her
parents.
TRANSITIONS IN CARE:
1. CODE STATUS: DNR/DNI (discussed with parents/HCP)
2. Communication: Patient, parents, group home
3. Medication Changes:
These CHANGES were made to your medications:
INCREASE Keppra to 1000 mg twice daily by mouth
4. Follow-up:
Department: ___ POST DISCHARGE CLINIC ___
When: ___ at 11:10 AM
With: ___ Best Parking: ___
NOTE: This appointment is with a member of Dr/NPs team as part
of your transition from the hospital back to your primary care
provider. After this visit, you will see your regular primary
care provider
___: NEUROLOGY
When: ___ at 10:00 AM
With: ___
Building: ___
Campus: ___ Best Parking: ___
Department: DERMATOLOGY
When: ___ at 11:15 AM
With: ___
Building: ___
Campus: ___ Best Parking: ___
Department: NEUROLOGY
When: ___ at 1 ___
With: ___
Building: ___
Campus: ___ Best Parking: ___
5. OUTSTANDING CLINICAL ISSUES:
[ ] follow up on pending blood cultures
[ ] Keppra level sent on the morning of discharge per neurology
recommendations
Medications on Admission:
Multivitamin 8 am
Cortef 15mg qam, 5mg 4pm
Synthroid ___ qam
Lamictal 400mg qam 300mg qpm
Tylenol ___ BID standing for headaches
Progesterone 100mg TID (8am, 4pm, 8pm)
Keppra 750mg qam, 500mg qpm
Tums 1000mg BID
Ativan 0.5mg 8pm
Zonergan 300mg 8pm
Metamucil 1pkg qd
z-asorb BID to abdominal folds
ativan 0.5 mg prn seizure >15 mins or clusters of >3 seizures
magnesium hydroxide 400 mg/5 mL daily as needed for constipation
Robitussin-DM ___ mg/5 mL Syrup, One teaspoon by mouth every
six hours as needed for cough
Discharge Medications:
1. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. levothyroxine 112 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. acetaminophen 325 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
4. progesterone micronized 100 mg Capsule Sig: One (1) Capsule
PO TID (3 times a day): at 8 AM, 4 ___ and 8 ___.
5. Lamictal 150 mg Tablet Sig: Two (2) Tablet PO twice a day.
6. Lamictal 100 mg Tablet Sig: One (1) Tablet PO in morning: in
addition to 300 mg, for total of 400 mg daily in AM.
7. zonisamide 100 mg Capsule Sig: Three (3) Capsule PO at 8 ___.
8. Keppra 1,000 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*0*
9. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q 8PM ().
10. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
Sig: Two (2) Tablet, Chewable PO BID (2 times a day).
11. psyllium 1.7 g Wafer Sig: One (1) Wafer PO DAILY (Daily).
12. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical BID
(2 times a day): apply to abdominal folds.
13. hydrocortisone 5 mg Tablet Sig: Three (3) Tablet PO qAM.
14. hydrocortisone 5 mg Tablet Sig: One (1) Tablet PO qPM:
Please give at 4PM.
15. Milk of Magnesia 400 mg/5 mL Suspension Sig: One (1)
teaspoon PO once a day as needed for constipation.
16. Robitussin-Cough-Chest-Cong ___ mg/5 mL Syrup Sig: One
(1) teaspoon PO every six (6) hours as needed for cough.
17. Ativan 0.5 mg Tablet Sig: One (1) Tablet PO every 5 mins as
needed for seizures >15 mins or clusters of seizures >3.
18. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO once a day:
Please administer once daily at 8pm.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnoses: hypothermia, refractory partial epilepsy,
panhypopituitarism
Secondary Diagnosis: astrocytoma s/p resection and radiation
therapy, meningiomas
Discharge Condition:
Mental Status: Patient with baseline intellectual disability
secondary to medical conditions, dependent for all ADLs. Verbal
at baseline.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure to take care of you at ___
___. You were admitted to the hospital because your
temperature was low, and you were warmed with hot air blanket.
You were given higher dose of steroids and work up for infection
was done and did not show any obvious source.
While you were in the hospital, you had several seizures, likely
related to your missing doses of medications while we were
waiting for them to come in from your group home. Your Keppra
was increased and you did not have any more seizures.
Please follow up with Dr. ___ Dr. ___ as scheduled.
These CHANGES were made to your medications:
INCREASE Keppra to 1000 mg twice daily by mouth
Followup Instructions:
___
|
19706109-DS-29
| 19,706,109 | 26,979,329 |
DS
| 29 |
2203-05-31 00:00:00
|
2203-05-31 16:02:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
Penicillins / Cephalosporins / Ciprofloxacin
Attending: ___.
Chief Complaint:
somnolence and non-responsiveness at group home
Patient's Chief Complaint: none (how do you feel? "good")
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ is a ___ woman with a refractory seizure
disorder (on 3 AEDs and w/VNS; followed by Dr. ___ in clinic here at ___ following resective and
radiation therapy for astrocytoma in infancy. Also multiple
meningiomas, MR/ID and pan-hypopituitarism with chronic
hypothermia, obesity with OSA (no CPAP). Also recurrent urinary
incontinence and UTIs. She was most recently seen her for
hypothermia two weeks ago (etiology not discovered), and stayed
in our EMU for break-through seizures a little over one month
ago
(LTG and ZON were increased slightly prior to discharge, as
below). Her mother, present for this exam, says that she has
been
more hypothermic again in the past ___ weeks, of uncertain
etiology. She was just treated with 3d Bactrim by her PCP for
presumed UTI (see OMR note from ___. PEr her monther, she
has
not convulsed since ___ (see last set of notes in OMR), but
today at the group home she was noted to be far more somnolent
than usual. They had difficulty getting her out of bed and noted
decreased responsiveness, with one or more episodes of staring
and possibly eyes deviated upward. One such episode was in the
ED
around 1pm, per her mother, and nothing since that time besides
lethargy. No new focal deficits or change in speech language
vision, motor function, etc. IN fact, she has been doing well
with ___ and has her best hand function yet. She is apparently
restricted to her wheelchair recently (SINCE ___, whereas she
had been walking with a walker at one point in the past (reasons
for the change unclear to me at present). Her baseline seizure
frequency until recently had been around five non-convulsive
episodes per month per her group home. She has not, per her
mother, had any medication changes since the slight increases in
LTG and ZON on d/c in early ___. She followed up in ___
in clinic, and blood levels looked ok (see below; LTG was
perhaps
on the low side for her historically).
She was referred to our ED by ___. ___, for evaluation for
medical and/or neurologic causes of her somnolence and ?seizures
today, and we were consulted on arrival.
Past Medical History:
1.) Right parietal astrocytoma- age ___, s/p resection and
radiation (so baseline left hemiparesis), complicated by
hydrocephalus s/p VP shunt
2.) Refractory seizures on multiple AEDs, s/p VNS; about 5
times per month with a variety of manifestations (turns red in
the face; brief movements of her eyes, brief moments of
non-responsiveness). Swiping the VNS magnet to activate VNS.
Last generalized seizure with post-ictal period noted in OMR
chart was sometime in ___, preceeded by sometime in ___.
Last VNS update in ___ Sleep apnea with obese neck; snores/wakes frequently
(including for nocturia); does not tolerate CPAP.
4.) Panhypopituitarism (hypogonadism, adrenal insufficiency,
hypothyroidism); on glucocorticoid and thyroid replacement,
progesterone)
5.) Osteoporosis with unclear h/o knee and shoulder pain
6.) Meningiomas (Right parietal, growing @2cm; RF=XRT@youth)
7.) Developmental Delay / MR following astrocytoma resection
8.) s/p Mohs surgery for a recurrent nodular basal cell cancer
on the left occiput; also s/p BCC Tx with Aldara.
9.) h/o urinary incontinence and nocturia, chronic
10.) h/o VPS in RLV, reportedly removed in ___ (but seen on
current and prior head imaging, with dilated ventricle)
11.) s/p cholecystectomy in ___
Social History:
___
Family History:
Adopted. Unknown family history.
Physical Exam:
At admission:
Vital signs: 95.4F 66 106/?36 16 99%RA
General: Awake, cooperative, NAD.
HEENT: Macrocephalic. Old scars on scalp and Left of philtrum.
Thinned hair. Anicteric. Mucous membranes are moist. No lesions
in oropharynx.
Neck: Supple. Obese. Pt c/o pain on the left and in left
shoulder
with passive ROM. Pt c/o pain in back and top of head (mother
said this is not new). No carotid bruits. No gross
lymphadenopathy appreciated.
Pulmonary: Lungs CTA at the bases on inspiration, with overlying
upper airway/grunting sounds with effortful exhalation.
Non-labored.
Cardiac: RRR, distant HS.
Abdomen: Obese. Soft, non-tender, and non-distended.
Extremities: Well-perfused, slightly cool. pt c/o cold when
extremities are exposed from under covers. no clubbing,
cyanosis,
or frank edema. Intact distal pulses.
Skin: no gross rashes or lesions noted.
*****************
Neurologic examination:
Mental Status:
Oriented to name, "hospital," and ___ Does not know year
or month/date. Mother says this is her baseline. Not a reliable
historian (also b/l). Mildly lethargic. Reliably follows simple
commands. Grossly attentive. Speech is dysarthric (mother says
this is her b/l), and becomes hoarse at one time (mother says
this is ___ VNS firing). Language is fluent with intact
repetition and gross comprehension. Childlike prosody/affect. No
paraphasic errors.
-Cranial Nerves:
II III IV VI: PERRL 3->2. Cannot see/blink to threat from the
LEft side (chronic). Tracks normally on the Right. Right
exotropia.
V: Facial sensation grossly intact to LT/pin
VII: Left lower facial droop (does not elevate w/smile). No
ptosis or upper-facial weakness apparent.
VIII: Cannot hear anything on R; intact to finger-rub on L.
IX, X: Mallampati IV airway; palate appears to elevate midline,
but difficult view.
XI: R trap full; Left trap paretic.
XII: Tongue protrudes midline.
-Motor:
Can lift all extremities anti-gravity, but she is impersistent
and has give-way weakness, limiting the relevance of formal
power
assessment. Both arms are spastic at the elbow. Left arm/hand is
contracted (with cortical-hand-type weakness Left>right), but
she
can open and close the hand/fingers (mother said this is a
recent
improvement). No gross asterixis or tremor.
-Sensory:
Patient says she can feel LT/pin in all four proximal and distal
extremities. JPS grossly intact at the ankles. Cognitive
abilities and lethargy limit more detailed testing at this time.
Can discriminate left versus right in hands and feet;
consistently extinguishes to DSS (extinguishes on the left).
-Reflexes (left; right):
Reflexes:
Biceps (++;++) brisker on the Left
Triceps (++;+) brisk on Left
Brachioradialis (++;++) brisk on Left
Quadriceps / patellar (++;++)
- brisk bilaterally, possibly more on the Left
Gastroc-soleus / achilles (++;++++)
- several beats of clonus in LEFT ankle
Plantar response was briskly-UP on the LEFT; down on the right.
-Coordination:
Finger-nose-finger testing with mild ataxia on the Right, and
severe ataxia on the LEft. Heel-knee-shin testing with no gross
dysmetria, but poor task adherence. No truncal titubation on
sitting up.
-Gait: unable (pt bed and wheelchair-bound currently per mother)
At discharge:
At baseline.
chronic cognitive limitations, L > R spastic UEs and LEs,
chronic non-ambulatory
Pertinent Results:
___ 03:00PM BLOOD WBC-5.1 RBC-4.41 Hgb-13.5 Hct-42.2 MCV-96
MCH-30.5 MCHC-31.9 RDW-14.8 Plt ___
___ 03:00PM BLOOD Neuts-61.1 ___ Monos-4.4 Eos-1.5
Baso-0.5
___ 04:15AM BLOOD WBC-4.8 RBC-4.19* Hgb-12.9 Hct-40.0
MCV-96 MCH-30.7 MCHC-32.2 RDW-14.8 Plt ___
___ 04:40AM BLOOD WBC-10.1# RBC-4.43 Hgb-13.6 Hct-41.8
MCV-94 MCH-30.7 MCHC-32.5 RDW-14.6 Plt ___
___ 03:00PM BLOOD Glucose-93 UreaN-19 Creat-1.2* Na-136
K-4.7 Cl-102 HCO3-25 AnGap-14
___ 03:00PM BLOOD ALT-30 AST-30 AlkPhos-168* TotBili-0.2
___ 03:00PM BLOOD Albumin-4.6
___ 04:15AM BLOOD Albumin-4.2 Calcium-9.8 Phos-3.6 Mg-2.1
___ 03:00PM BLOOD TSH-3.2
___ 04:15AM BLOOD TSH-3.9
___ 04:15AM BLOOD Free T4-1.4
___ 04:15AM BLOOD Cortsol-2.3
___ 03:12PM BLOOD Lactate-1.0
___ 03:30PM URINE Color-Straw Appear-Hazy Sp ___
___ 03:30PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG
___ 3:30 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
___ Blood culture - No growth.
___ Blood cultures x3 - no growth to date
___ CXR 2 view:
FINDINGS: Single AP portable view of the chest was compared to
previous exam from ___. Based on a limited portable
exam, the lungs are grossly clear of large confluent
consolidation or effusion. Cardiomediastinal silhouette is
stable. Radiopaque linear structure seen projecting over the
left upper quadrant is compatible with a vagal nerve stimulator.
Surgical clips seen in the right upper quadrant.
IMPRESSION: Unremarkable limited portable chest x-ray.
___:
FINDINGS: As compared to the previous radiograph, the lung
volumes continue to be very low. There is a subsequent crowding
of vascular and interstitial structures at the lung bases.
Borderline size of the cardiac silhouette. No overt pulmonary
edema. No pneumonia. No larger pleural effusions.
___:
There are low inspiratory volumes, accentuating the
cardiomediastinal
silhouette. No CHF or effusion is identified. The lateral
view is blurred due to respiratory motion. Allowing for this, I
doubt focal infiltrate. Slight crowding of vascular and
interstitial markings at both bases appears unchanged compared
with ___.
Note is made of a battery pack overlying the left chest,
oriented transverse to the anterior chest wall, with an
electronic lead extending cephalad. Two tiny radiopacities
overlie soft tissues at the lower left neck.
IMPRESSION:
1) Bibasilar atelectasis; no definite infiltrate.
2) Battery pack perpendicular to the anterior chest wall.
EEG:
___:
IMPRESSION: This is an abnormal video EEG due to the presence of
high
amplitude slow and disorganized activity predominantly over the
right
hemisphere in the delta frequency range and high voltage theta
frequency
slowing over the left hemisphere, indicative of a moderate to
severe
encephalopathy and bihemispheric dysfunction. Independent spike
and wave
discharges were seen most frequently in the left temporal or
frontotemporal region, and less frequently over the right
frontal and
parietal regions. These multifocal epileptiform discharges are
indicative of independent areas of potential epileptogenesis. No
clear
electrographic seizures were seen.
___:
IMPRESSION: This is an abnormal video EEG monitoring session
which
captured 4 electrographic seizures, of which one seizure was
associated
with an accompanying video but no clear clinical features of
seizures
were seen. Electrographically, 2 seizures appeared to be a tonic
seizure
arising from the right hemisphere while the other two were
generalized
tonic seizures. The background showed high amplitude slow and
disorganized activity bilaterally and multifocal epileptiform
discharges
seen in the left frontal temporal, more than right central and
parietal
regions. These multifocal epileptiform discharges indicate
independent
areas of potential epileptogenesis. Breach artifact due to
overlying
skull defect was seen over the right hemisphere with subcortical
dysfunction diffusely over the left hemisphere. The slow and
disorganized background seen is indicative of a moderate to
severe
encephalopathy.
___:
IMPRESSION: This is an abnormal video EEG monitoring session
which
captured 15 electrographic and clinical seizures, most of which
had a
left hemispheric onset, and a few had a generalized onset or
right
hemispheric onset. Clinically, these seizures were characterized
by
slight right head deviation, right gaze deviation, neck flexion
and were
frequently associated with rapid shallow breathing and body
stiffening
with minimal body jerks. The background showed high amplitude
slow and
disorganized activity predominantly over the right hemisphere
and
multifocal epileptiform discharges seen in the left frontal
temporal,
more than right central and parietal regions. These multifocal
epileptiform discharges indicate independent areas of potential
epileptogenesis. Breach artifact due to overlying skull defect
was seen
over the right hemisphere with subcortical dysfunction diffusely
over
the left hemisphere. The slow and disorganized background is
indicative
of a moderate to severe encephalopathy. Compared to the previous
day
this study represents a worsening due to the increase in the
number of
electrographic seizures.
___:
IMPRESSION: This is an abnormal video EEG monitoring session
which
captured 3 electrographic seizures, with left hemispheric onset,
right
hemispheric onset and a generalized onset pattern. The
electrographic
features were consistent with tonic seizures although one of
them
occurred during sleep did not have a clinical correlate. During
the
clinical seizure with a left hemispheric onset, the patient had
facial
contraction, left arm abduction and left arm posturing with
myoclonic
jerking. The seizure with a generalized onset correlated
clinically with
unresponsiveness. The background showed high amplitude slow and
disorganized activity predominantly over the right hemisphere
and
multifocal epileptiform discharges seen in the left frontal
temporal,
more than right central and parietal regions. These multifocal
epileptiform discharges are indicative of independent areas of
potential
epileptogenesis. Breach artifact due to overlying skull defect
was seen
over the right hemisphere with subcortical dysfunction diffusely
over
the left hemisphere. The slow and disorganized background is
indicative
of a moderate to severe encephalopathy which is etiologically
non-specific. Compared to the previous day this study represents
an
improvement given the decrease in the number of electrographic
seizures.
___:
IMPRESSION: This is an abnormal video EEG monitoring session
which
captured five electrographic seizures consistent with tonic
seizures
electrographically, with either left hemispheric onset, right
hemispheric onset, or generalized onset. Three of these seizures
had
clinical correlate of unresponsiveness, right head tilt, heavy
breathing and subtle myoclonic jerks of the left shoulder/arm.
The background continued to show high amplitude slow and
disorganized
activity predominantly over the right hemisphere and multifocal
epileptiform discharges seen in the left frontal temporal and
left
frontotemporal region, more than right central and parietal
regions.
These multifocal epileptiform discharges are indicative of
independent
areas of potential epileptogenesis. Breach artifact due to
overlying
skull defect was seen over the right hemisphere with subcortical
dysfunction diffusely over the left hemisphere. The slow and
disorganized background is indicative of a moderate to severe
encephalopathy which is etiologically non-specific. Compared to
the
previous day, this study represents a slight worsening due to
the slight
increase in number of electrographic seizures.
___:
IMPRESSION: This 24 hour EEG telemetry captured five
electrographic
seizures associated with a generalized electrodecremental
response.
These are associated with two distinct clinical semiologies: in
wakefulness, the patient has behavioral arrest with leftward
head
deviation, and in sleep, she has an ictal cry with left hand/arm
automatisms.
___:
IMPRESSION: This is an abnormal video-EEG monitoring session
because of
two electrographic and clinical seizures as described earlier
under
pushbutton activations. In addition, there were frequent
multifocal left
hemispheric epileptiform discharges mainly seen in the left
temporal
region and occasional epileptiform discharges in the right
temporal and
centroparietal regions indicative of active underlying
epileptogenic
foci. Furthermore, background was diffusely slow with slower
activity
over the right hemisphere indicative of a diffuse encephalopathy
with
more severe dysfunction of the right hemisphere. Also background
amplitude was markedly higher over the right hemisphere likely
representing breach artifact.
___: pending
___: pending
Bilateral lower dopplers:
FINDINGS: Grayscale, color, and spectral Doppler evaluation was
performed of the bilateral lower extremity veins. There is
normal phasicity of the common femoral veins bilaterally. There
is normal compression and augmentation of the common femoral,
proximal femoral, mid femoral, popliteal, posterior tibial, and
peroneal veins bilaterally. The left distal femoral vein is not
well visualized, but has normal color flow and augmentation.
The right distal femoral vein compresses and augments normal.
IMPRESSION: No evidence of DVT in either right or left lower
extremity.
Brief Hospital Course:
___ woman with complex neurologic history, including refractory
seizure history on 3 AEDs with VNS followed by Dr. ___
___ in Epilepsy clinic, as well as
pan-hypopituitarism followed by ___ clinic who was
admitted for concern of worsening hypothermia and possible
somnolence (reports variable). In the ED her temperature was 91
and her examination was near her baseline. She was tachypneic
with an occasional cough. Despite no findings on CXR, we treated
her for community acquired pneumonia as her temperature
increased to Tm 100.5. While treating this we placed her on
stress-level steroids that were subsequently tapered off.
Overall her fever curve improved during her stay. We stopped the
antibiotics after 5 days of treatment as it appeared more likely
that this was a viral bronchitis rather than a bacterial
infection.
#Neuro: Epilepsy - cont to have freq tonic seizures including at
least 2 GTCs that lasted 2 minutes or less with a typical
post-ictal state. Throughout her stay she was maintained on EEG
and overall this remained close to her baseline.
-during her stay we increased levetiracetam to 1g po bid and
continued other home AEDs (LTG 400/350, ZON 350qhs, lorazepam
0.5mg po qPM)
-she did not require any additional lorazepam during her stay
-physical therapy evaluated the patient and suggested acute
rehab for general deconditioning during hospital stay to help
with transfers and mobility at group home
#Endocrine: hypo-pituitary with hypothermia exacerbation
followed by hyperthermia - thought to be related to viral
bronchitis. Received stress dose steroids while she was
antibiotic therapy
-Endocrine was consulted and guided steroid theray
-increased home hydrocortisone to ___ and plan continue
indefinitely on this dose.
-TSH and cortisol wnl
-home pituitary-hormone replacement med regimen:levothyroxine
112, hydrocortisone ___, progestin 100 tid.
-per endocrine, they do not think baseline hypothermia is
related to pan hypopit since this would be thyroid mediated and
thyroid function tests show adequate replacement
Future instructions for rehab and later group home:
- Given Ms. ___ size, please have 2 people assist when
using the Hoya list to transfer the patient safely.
- Please use 1 consistent location on the body to measure body
temperature (preferably oral). By using 1 consistent location we
will be better able to identify trends and fluctuations.
- Given Ms. ___ panhypopituitarism, her body temperature
fluctuates and typically runs on the the lower side. Please
consider temperatures outside of the range of 94-99.9 to be
abnormal, recheck in 1 hour, and have Ms. ___ checked for
infection.
Medications on Admission:
(discharge med list from recent admission ** LTG was
increased, ___ dose only, from 400/300 to 400/350; ZON was
increased from 300 to 350qhs):
1. Zonegran 350mg qhs
2. Lamotrigine 400/350mg daily
3. Levetiracitam 750mg bid
4. lorazepam 0.5mg qPM
5. hydrocortisone ___
6. levothyroxine 112mcg daily
7. progesterone micronized 100mg tid
8. vitamin D3 400U daily
9. CaCO3 500mg bid
10. heparin sc 5000U tid
11. acetaminophen 650mg q6h:PRN for pain/fever
12. senna, colace, PRN milk-of-mag
13. MVI
Discharge Medications:
1. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) ml
Injection TID (3 times a day).
2. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
3. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO DAILY (Daily) as needed for constipation.
4. levothyroxine 112 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
7. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. progesterone micronized 100 mg Capsule Sig: One (1) Capsule
PO tid ().
9. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
Sig: Two (2) Tablet, Chewable PO BID (2 times a day).
10. cholecalciferol (vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
11. zonisamide 100 mg Capsule Sig: 3.5 Capsules PO QHS (once a
day (at bedtime)).
12. psyllium 1.7 g Wafer Sig: One (1) Wafer PO DAILY (Daily).
13. hydrocortisone 5 mg Tablet Sig: Two (2) Tablet PO QPM (once
a day (in the evening)).
14. hydrocortisone 5 mg Tablet Sig: Three (3) Tablet PO QAM
(once a day (in the morning)).
15. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day) as needed for moist erythematous skin rash.
16. levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
17. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO QPM (once a
day (in the evening)).
18. lamotrigine 100 mg Tablet Sig: Four (4) Tablet PO QAM (once
a day (in the morning)): brand name only.
19. lamotrigine 100 mg Tablet Sig: 3.5 Tablets PO QPM (once a
day (in the evening)): brand name only.
20. lorazepam 2 mg/mL Syringe Sig: ___ mg Injection Q4H (every 4
hours) as needed for seizure > 5min or cluster >3/hr.
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
seizures
pan-hypopituitarism
bronchitis
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Neuro: chronic cognitive limitations, L > R spastic UEs and LEs,
non-ambulatory at baseline
Discharge Instructions:
Dear ___,
You were admitted to the hospital for evaluation of low
temperatures (91 deg F). After being admitted, your temperature
then went up, with a max temp of 100.5 F. During your stay you
have had a cough with an increased breathing rate. We treated
you with 5 days of antibiotics (doxycycline) for pneumonia,
although the chest Xray did not show any clear pneumonia. We
think more likely you had a viral bronchitis that is slowly
improving. Your temperature curve has been improving. During the
antibiotics we gave you stress-dose steroids due to your
pan-hypopituitarism and subsequently tapered down to
hydrocortisone po 15mg qAM and 10mg q1400. Please continue on
this dose unless further instructed by your endocrinologist.
In regard to future, given your temperature tends to run low and
varies quite a bit, if you have any temperature outside of the
range of 94-99.9, please have it re-checked in 1 hour and ask
your doctor to check your urine and lungs for infection and
consider antibiotics if necessary.
Regarding your seizure disorder, we increased your Keppra to 1g
po bid. During your stay you had a few more seizures than usual
but overall are close to your baseline of ___ seizures per day.
Please call Dr. ___ if you are concerned for more
frequent seizures.
Followup Instructions:
___
|
19706109-DS-31
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DS
| 31 |
2203-09-22 00:00:00
|
2203-09-22 11:02:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
Penicillins / Cephalosporins / Ciprofloxacin
Attending: ___.
Chief Complaint:
Shortness of Breath, Lower Extremity Swelling, Events concerning
for increased seizure frequency.
Major Surgical or Invasive Procedure:
None
History of Present Illness:
The pt is a ___ yo F with hx of refractory seizure disorder (on 3
AEDs and w/VNS; followed by Dr. ___
following resective and radiation therapy for astrocytoma in
infancy, multiple meningiomas, MR/ID and pan-hypopituitarism
with chronic hypothermia, obesity with OSA (no CPAP) who
presents with progressive weight gain, shortness of breath and
bipedal edema concerning for CHF.
Her parents and case manager report that she has had progressive
sdyspnea on exertion for the last month, particularly when
transferring from her wheelchair. Over the last few weeks they
have also noticed a weight gain of 6lbs, and increased lower
extremity edema (left>right). She has not been transferring as
well as she usually does and also has had some difficulty with
weight bearing on the L leg. Her parents report one fall while
she was at rehab in ___ when she was in the bathroom. She did
not sustain any known injuries at that time and has had no
further falls since then. They also report a brief episode of
confusion on ___, when she seemed to space out for a few
seconds while getting out of the car. Otherwise she has had no
activity concerning for seizure.
She has had dyspnea symptoms and seen cardiology in the past
with the question of cardiomegaly raised by a suboptimal chest
x-ray, but reportedly had a normal echo back in ___. She last
saw Dr. ___ in clinic on ___, at which point no medication
changes were made. She was referred to ___ for ___
given her decreased mobility since her last hospitalization.
In the ED her vitals were wnl. CXR showed no evidence of volume
overload, and US of the L leg showed no DVT. EKG was wnl and BNP
was 73. D dimer was also negative. An XR of her L ankle showed a
likely non-displaced distal tibial fracture (likely several
weeks old). She was started on vancomycin due to concerns for
cellulitis given swelling and erythema over her L leg.
ROS currently unable to be obtained from pt but per caregivers
she has had no fevers/chills at home, no infectious symptoms,
nausea/vomiting, changes in bladder/bowel habits. No new
neurologic complaints.
Past Medical History:
1.) Right parietal astrocytoma- age ___, s/p resection and
radiation (so baseline left hemiparesis), complicated by
hydrocephalus s/p VP shunt
2.) Refractory seizures on multiple AEDs, s/p VNS; about 5
times per month with a variety of manifestations (turns red in
the face; brief movements of her eyes, brief moments of
non-responsiveness). Swiping the VNS magnet to activate VNS.
Last generalized seizure with post-ictal period noted in OMR
chart was sometime in ___, preceeded by sometime in ___.
Last VNS update in ___ Sleep apnea with obese neck; snores/wakes frequently
(including for nocturia); does not tolerate CPAP.
4.) Panhypopituitarism (hypogonadism, adrenal insufficiency,
hypothyroidism); on glucocorticoid and thyroid replacement,
progesterone)
5.) Osteoporosis with unclear h/o knee and shoulder pain
6.) Meningiomas (Right parietal, growing @2cm; RF=XRT@youth)
7.) Developmental Delay / MR following astrocytoma resection
8.) s/p Mohs surgery for a recurrent nodular basal cell cancer
on the left occiput; also s/p BCC Tx with Aldara.
9.) h/o urinary incontinence and nocturia, chronic
10.) h/o VPS in RLV, reportedly removed in ___ (but seen on
current and prior head imaging, with dilated ventricle)
11.) s/p cholecystectomy in ___
Social History:
___
Family History:
Adopted. Unknown family history.
Physical Exam:
ADMISSION PHYSICAL EXAMINATION:
Vitals: 96.2 67 99/63 16 97%
General: Sleeping, arouses to voice, NAD
HEENT: NC/AT, no scleral icterus noted, MMM
Neck: Supple
Pulmonary: Lungs CTAB, +transmitted upper airway noises b/l
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND
Extremities:
Skin: mild erythema over LLE
Neurologic:
-Mental Status: Sleeping, arouses to voice, able to state name,
falls back to sleep frequently and not currently very
cooperative
with exam. Able to follow simple commands.
-Cranial Nerves:
PERRL 3 to 2mm and brisk. EOMI without nystagmus, R esotropia.
Facial sensation intact to light touch. No facial droop, facial
musculature symmetric.
-Motor: Increased tone in LUE with contracture of L hand. No
adventitious movements. Moving all extremities spontaneously
anti-gravity.
-Sensory: Responds to light touch throughout
-DTRs:
2+ throughout on R, 3+ on L. L toe upgoing, R toe down.
-Coordination: Did not cooperate
-Gait: Deferred
DISCHARGE EXAMINATION: Unchanged from previous with Temp 97.6F
which had decreased from earlier febrile episodes. Patient was
interactive, alert, oriented to person, place, and time, had
identical neurologic examination with motor findings of ___
strength throughout although limited evaluation of the left
lower extremity as the patient has Aircast placed. When cast
removed, the site shows no erythema, increased warmth, or edema.
Pertinent Results:
___ 04:15AM GLUCOSE-65* UREA N-16 CREAT-1.1 SODIUM-143
POTASSIUM-4.0 CHLORIDE-108 TOTAL CO2-26 ANION GAP-13
___ 04:15AM CALCIUM-9.5 PHOSPHATE-4.2 MAGNESIUM-2.3
___ 04:15AM WBC-5.6 RBC-3.91* HGB-12.4 HCT-36.4 MCV-93
MCH-31.7 MCHC-34.1 RDW-14.4
___ 04:15AM PLT COUNT-237
___ 04:15AM PLT COUNT-237
___ 12:00AM URINE COLOR-Yellow APPEAR-Hazy SP ___
___ 12:00AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
___ 10:42PM D-DIMER-298
___ 10:10PM URINE HOURS-RANDOM
___ 10:10PM URINE HOURS-RANDOM
___ 09:30PM GLUCOSE-86 UREA N-18 CREAT-1.0 SODIUM-138
POTASSIUM-4.1 CHLORIDE-105 TOTAL CO2-25 ANION GAP-12
___ 09:30PM estGFR-Using this
___ 09:30PM proBNP-73
___ 09:30PM WBC-6.0 RBC-4.16* HGB-13.3 HCT-38.6 MCV-93
MCH-32.0 MCHC-34.5 RDW-14.5
___ 09:30PM WBC-5.9 RBC-4.16* HGB-13.4 HCT-38.5 MCV-93
MCH-32.2* MCHC-34.8 RDW-14.5
___ 09:30PM NEUTS-60.5 ___ MONOS-4.2 EOS-3.3
BASOS-0.8
___ 09:30PM NEUTS-60.6 ___ MONOS-5.3 EOS-3.8
BASOS-1.2
___ 09:30PM PLT COUNT-274
___ 09:30PM PLT COUNT-260
___ 09:30PM ___ PTT-36.3 ___
CT HEAD W/O CONTRAST (___) IMPRESSION:
1. No significant change in size of multiple dural-based
lesions.
2. Dilation of the lateral ventricles, right greater than left.
On some
images, the size of the ventricles appears slightly increased
compared to the most recent CT head of ___. This
most likely represents plane of scanning and slice selection
rather than true increase in ventricular size, however,
correlate with clinical findings.
3. Right frontal approach ventricular catheter tip terminates
in the left frontal horn in unchanged position compared to the
prior examination.
4. No acute intracranial hemorrhage, shift of normally midline
structures or large acute major vascular territory infarction.
CTA TORSO IMPRESSION:
1. Technically limited study with suboptimal opacification of
the pulmonary arteries. No central or segmental pulmonary
embolus.
EEG IMPRESSION: This is an abnormal video EEG telemetry study
due to the frequent multifocal epileptiform discharges seen
throughout the study and this suggests multiple areas of
potential epileptogenesis. Background rhythms were diffusely
slow and the slowing was more prominent on the right.
Brief Hospital Course:
# NEUROLOGY:
The patient was observed on long term EEG monitoring which
revealed no significant changes - at baseline the patient has
epileptiform discharges and abnormal background. Push button
events which were characterized by a scream out and tonic
posturing with both arms into the air with resolution within a
minute. The parents have also been swiping the vagal nerve
magnet to ablate the seizures which has in general lead to
resolution in minutes status post swipe. Repeat CT imaging of
the head revealed no significant changes.
# ORTHOPEDIC:
Because of concern for your left lower extremity fracture, we
consulted our orthopedic surgeons to determine if further
intervention was appropriate, and to determine weight bearing
status for ambulation. They recommended continuing conservative
management through the use of an aircast which has been
provided. Her parents have been trained in the used this
device.
# PULMONARY:
Because of increased respiratory rate, the patient was evaluated
for pulmonary process or embolus. CTA was performed with
revealed no significant perfusion deficit, or intrathoracic
process.
# INFECTIOUS DISEASE:
Concern was also raised for your left lower extremity swelling
to possibly be a skin infection known as cellulitis. We began a
course of antibiotic therapy first with Vancomycin and then with
Clindamycin, Meropenem, and finally Bactrim. At the time of
discharge the patient had no signs of infection.
Medications on Admission:
- Lamictal 400 mg daily 8am/350 mg at 8pm
- Keppra 1000 mg BID (8am, 8pm)
- Zonisamide 350 mg daily at 8pm
- Ativan 0.5 mg Q HS
- Synthroid ___ mcg daily
- Cortef 15 mg qAM (8am), 10 mg qPM (4pm)
- Progesterone 100 mg TID
- Tums
- Metamucil, senna, colace
- Vitamin C, D, MVI
- Tylenol prn
Discharge Medications:
1. LaMICtal *NF* (lamoTRIgine) 400 Mg Oral QAM
* Patient Taking Own Meds *
2. LaMOTrigine *NF* (lamoTRIgine) 350 Mg ORAL QPM
* Patient Taking Own Meds *
3. LeVETiracetam 1000 mg PO BID
4. zonisamide *NF* 350 Mg Oral QHS
* Patient Taking Own Meds *
5. Lorazepam 0.5 mg PO HS
6. Levothyroxine Sodium 125 mcg PO DAILY
7. Hydrocortisone 15 mg PO QAM
8. Hydrocortisone 5 mg PO DAILY16
9. progesterone micronized *NF* 100 mg Oral TID
Takes at 8a, 4p, 8p * Patient Taking Own Meds *
10. Calcium Carbonate 1000 mg PO BID
11. Milk of Magnesia 30 mL PO DAILY:PRN constipation
12. Multivitamins 1 TAB PO DAILY
13. Vitamin D 400 UNIT PO DAILY
14. Acetaminophen 325-650 mg PO Q6H:PRN pain or fever
15. Psyllium Wafer 1 WAF PO DAILY
16. Guaifenesin-Dextromethorphan 5 mL PO Q6H:PRN cough
17. Hydrocortisone 5 mg PO DAILY16
18. LaMOTrigine *NF* (lamoTRIgine) 350 Mg ORAL QPM
* Patient Taking Own Meds *
19. Ibuprofen 400 mg PO BID:PRN headache
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Lower Extremity Swelling
Discharge Condition:
Mental Status: Clear and coherent, with some cognitive deficit
at baseline
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane) - given recent injury to lower extremity
Discharge Instructions:
You were evaluated at ___ for
your complaint of increased shortness of breath and lower
extremity swelling. Because both of these symptoms can be
associated with certain dysfunctions of the heart, we obtained
an echocardiogram and blood tests which can reveal decreased
activity of the heart muscle. Both of these tests revealed no
abnormalities concerning for any dysfunction of the heart. We
also reevaluated you with EEG monitoring for any changes
concerning for epilepsy; however, we did not see any specific
changes which were concerning for new seizure activity on the
monitoring performed.
Because of concern for your left lower extremity fracture, we
consulted our orthopedic surgeons to determine if further
intervention was appropriate, and to determine weight bearing
status for ambulation. They recommended continuing supportive
therapy with the aircast provided. Please adjust the aircast by
first releasing the air from the two sides of the cast with the
pump. When inflating or replacing the cast in the morning,
please administer four (4) pumps in each site on both sides of
the cast.
Concern was also raised for your left lower extremity swelling
to possibly be a skin infection known as cellulitis. We began a
course of antibiotic therapy first with Vancomycin and then with
Clindamycin, Meropenem, and finally Bactrim. After this course
of management, your symptoms improved and no signs of infection
were evident.
Please continue with your medical regimen as prescribed, and
follow up with your appointments as scheduled. If any issues
with your aircast arise, please contact ___ at ___.
Followup Instructions:
___
|
19706109-DS-32
| 19,706,109 | 29,229,063 |
DS
| 32 |
2203-12-15 00:00:00
|
2203-12-15 20:31:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Cephalosporins / Ciprofloxacin
Attending: ___
Chief Complaint:
Cough
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is a ___ yo F with complicated PMH including childhood
astrocytoma s/p resection and radiation, multiple menginomas,
pan-hypopituitarism, refractory seizure disorder and mental
retardation who presents with cough for 3 days and concern for
early pneumonia. Patient is accompanied by her mother, who the
history was obtained from. Patient had non-productive cough
associated with sinus congestion and rhinorrhea for 3 days.
Breathing is now labored. Afebrile, temperatures 96-97. Patient
has also been more fatigued during the same period. She has been
hospitalized multiple times for infections, during which times
she is more hypothermic. She has been hospitalized about 8 this
since Janurary. She was last in the ICU due to hypothermia in
___.
The patient presented to outpatient clinic today and they spoke
with her neurologist who recommended that the patient be
admitted due to concern for aspiration pneumonia and that the
patient should receive stress-dose steroids, as she is on
chronic hydrocortisone due to her pan-hypopituitarism.
In the ED, initial VS were: 97.4 76 122/72 18 97% RA. The
patient was given 100 mg hydrocortisone, meropenem, and
azithromycin. The patient had a CXR that showed low lung
volumes, but no clear consolidation. UA was negative. BCx were
sent. The patient was admitted to the floor due to concern of
early infection/sepsis.
On arrival to the floor, the patient has no acute complaints and
history is obtained from her mother.
REVIEW OF SYSTEMS:
(+) HPI
(-) fever, chills, night sweats, headache, vision changes,
shortness of breath, chest pain, abdominal pain, nausea,
vomiting, diarrhea, constipation, BRBPR, melena, hematochezia,
dysuria, hematuria.
Past Medical History:
1.) Right parietal astrocytoma- age ___ yrs, s/p resection and
radiation (so baseline left hemiparesis), complicated by
hydrocephalus s/p VP shunt
2.) Refractory seizures on multiple AEDs, s/p VNS; about 5
times per month with a variety of manifestations (turns red in
the face; brief movements of her eyes, brief moments of
non-responsiveness). Swiping the VNS magnet to activate VNS.
Last generalized seizure with post-ictal period noted in OMR
chart was sometime in ___, preceeded by sometime in ___.
Last VNS update in ___ Sleep apnea with obese neck; snores/wakes frequently
(including for nocturia); does not tolerate CPAP.
4.) Panhypopituitarism (hypogonadism, adrenal insufficiency,
hypothyroidism); on glucocorticoid and thyroid replacement,
progesterone)
5.) Osteoporosis with unclear h/o knee and shoulder pain
6.) Meningiomas (Right parietal, growing @2cm; RF=XRT@youth)
7.) Developmental Delay / MR following astrocytoma resection
8.) s/p Mohs surgery for a recurrent nodular basal cell cancer
on the left occiput; also s/p BCC Tx with Aldara.
9.) h/o urinary incontinence and nocturia, chronic
10.) h/o VPS in RLV, reportedly removed in ___ (but seen on
current and prior head imaging, with dilated ventricle)
11.) s/p cholecystectomy in ___
Social History:
___
Family History:
Adopted. Unknown family history.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS - Temp 97.2F, BP 116/68, HR 83, R 20, O2-sat 93% RA
GENERAL - Cushingoid features, legally blind, arousable to voice
HEENT - PERRLA, MMM, no LAD
NECK - supple, obese
LUNGS - scattered rhonchi and wheezes listened anteriorlly, good
breath sounds bilaterally
HEART - distant heart sounds, RRR, no MRG, nl S1-S2
ABDOMEN - NABS, NT, obese, no rebound/guarding
EXTREMITIES - WWP, no c/c/e, wearing foot brace on left foot
SKIN - no rashes or lesions
NEURO - awake, nonfocal, following commands
Pertinent Results:
___ 06:15PM BLOOD WBC-3.7*# RBC-4.35 Hgb-13.6 Hct-39.9
MCV-92 MCH-31.2 MCHC-34.0 RDW-14.0 Plt ___
___ 06:15PM BLOOD Neuts-38.6* Lymphs-49.3* Monos-7.5
Eos-3.8 Baso-0.9
___ 06:15PM BLOOD Plt ___
___ 06:15PM BLOOD Glucose-79 UreaN-17 Creat-1.0 Na-138
K-5.1 Cl-106 HCO3-20* AnGap-17
___ 06:27PM BLOOD ___ pO2-83* pCO2-32* pH-7.41
calTCO2-21 Base XS--2
___ 06:27PM BLOOD Lactate-1.2 K-4.9
.
On discharge:
___ 07:15AM BLOOD WBC-4.8 RBC-4.24 Hgb-12.9 Hct-38.2 MCV-90
MCH-30.4 MCHC-33.8 RDW-14.0 Plt ___
___ 07:15AM BLOOD Neuts-37* Bands-0 Lymphs-53* Monos-9
Eos-1 Baso-0 ___ Myelos-0
___ 07:15AM BLOOD Glucose-84 UreaN-13 Creat-1.1 Na-142
K-3.7 Cl-108 HCO3-23 AnGap-15
___ 07:15AM BLOOD ALT-13 AST-19 AlkPhos-112* TotBili-0.2
___ 07:15AM BLOOD Calcium-9.0 Phos-3.0 Mg-2.2
.
U/A: unremarkable
CXR: unremarkable
Brief Hospital Course:
Hospitalization Statement:
___ yo F with complicated PMH including mental retardation,
seizure disorder, and pan-hypopituitarism who presented with
cough and fatigue. She was observed for 2 days out of concern
for history of mild infections progressing to sepsis but
remained well-appearing and felt better prior to discharge.
Symptoms were thought to be secondary to viral URI.
# Cough/Fatigue: Patient presented with URI symptoms including
non-productive cough, sinus congestion and rhinorrhea. Given
relative leukopenia and lymphocytosis, infection was thought to
be viral in nature. She was initially started on meropenem and
azithromycin in the ER (given allergies) but this was stopped
the next morning. CXR, U/A were negative. Lung exam was benign.
WBC improved (though lymphocyte predominance persisted) and the
patient remained non-toxic appearing. Her usual home
hydrocortisone was doubled for 3 days and she is to resume her
usual hydrocortisone dosing (15 mg qAM and 5 mg q4PM) on ___.
Blood and urine cultures were negative.
.
# Pan-hypopituitarism: The patient is on hydrocortisone at home.
The patient's neurologist recommended increasing the dose in the
setting of possible infection. The patient received 100mg
hydrocortisone in ED. Home dose of hydrocortison 15mg QAM and
5mg QPM. Dose was increased to 30mg QAM, 10mg QPM for 3 days.
Home dose to be resumed on ___.
# Seizure history: We continued keppra, lamictal, and zonegran
with no changes in dosing. No changes were made to the vagal
nerve stimulator. She was scheduled to follow-up with the
epilepsy RN.
# Hypothyroidism: Continued home dose of synthroid.
Transitional Issues:
- please verify whether patient needs to be on standing
ibuprofen - inpatient team was not able to determine whether
this should remain a long-term medication given GI/renal risks
- f/u was scheduled in ___ clinic and with the
epilepsy RN
- patient was discharged to continue 1 additional day of double
dose hydrocortisone and is then to resume her usual home regimen
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Hydrocortisone 15 mg PO QAM
2. Hydrocortisone 5 mg PO DAILY16
3. LeVETiracetam 1000 mg PO BID
Keppra, No subsitution
4. Lorazepam 0.5 mg PO HS
5. LaMOTrigine 400 mg PO BID
Lamictal, No subsitution
6. Milk of Magnesia 30 mL PO PRN constipation
7. Multivitamins 1 TAB PO DAILY
8. Guaifenesin ___ mL PO PRN cough
9. Levothyroxine Sodium 125 mcg PO DAILY
No Subsitution
10. Calcium Carbonate 1000 mg PO BID
11. Zonisamide 300 mg PO QHS
12. Zonisamide 50 mg PO Q8PM
13. Vitamin D 400 UNIT PO DAILY
14. Ibuprofen 400 mg PO BID
15. Mupirocin Cream 2% 1 Appl TP BID rash
16. progesterone micronized *NF* 100 mg Oral TID
Takes at 8a, 4p, 8p * Patient Taking Own Meds *
17. Acetaminophen 325-650 mg PO Q6H:PRN pain or fever
18. Psyllium Wafer 1 WAF PO DAILY
Discharge Medications:
1. Acetaminophen 325 mg PO Q4H:PRN pain or fever
1 tablet by mouth every 4 hours between 8 am and 4 pm, 2 tabs
every 4 hours after 8 pm as needed for headaches or generalized
pain
2. KePPRA 1000 mg PO BID
Keppra, No subsitution
Take 2, 500 mg tablets twice per day.
3. Levothyroxine Sodium 125 mcg PO DAILY
Synthroid No Subsitution
4. Lorazepam 0.5 mg PO HS
5. Vitamin D 400 UNIT PO DAILY
6. Benzonatate 100 mg PO BID Duration: 2 Days
RX *benzonatate 100 mg 1 capsule(s) by mouth two times per day
Disp #*4 Capsule Refills:*0
7. Guaifenesin ___ mL PO PRN cough
8. Ibuprofen 400 mg PO BID
9. Mupirocin Cream 2% 1 Appl TP BID rash
10. Zonegran 300 mg PO QHS
Take 3, 100 mg capules in the evening
11. Zonisamide 50 mg PO Q8PM
Take 2, 25 mg tablets by mouth daily at 8 pm
12. Psyllium Wafer 2 WAF PO DAILY
Take 2 wafers with 8 ounces of water every day as needed for
constipation
13. Prometrium *NF* (progesterone micronized) 100 mg Oral TID
14. Milk of Magnesia 30 mL PO HS:PRN constipation
Take 30 ml by mouth at bedtime as needed for constipation; take
if no bowel movement for more than 48 hours
15. Multivitamins 2 TAB PO DAILY
16. Calcium Carbonate 1000 mg PO BID
Take 2, 500 mg tablets twice per day
17. Hydrocortisone 30 mg PO QAM
Take 3, 10 mg tablets on the morning of ___ (30 mg). On ___,
resume the usual home dose (15 mg (or 1.5 tablets) in the
morning and 5 mg (1 tablet) at 4 ___
18. Lamictal 400 mg PO BID
Lamictal, No subsitution
Take 4, 100 mg tablets twice per day (400 mg BID)
19. Hydrocortisone 10 mg PO QPM
Take 1 tablet (10 mg) at 4 ___ on ___ and then resume the normal
home dose (0.5 tablets or 5 mg daily at 4 ___
RX *hydrocortisone 10 mg ___ tablet(s) by mouth twice per day
Disp #*4 Tablet Refills:*0
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Upper respiratory infection
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:
Ms. ___,
It was a pleasure to participate in your care at the ___
___. You were admitted with a cough, nasal
congestion and runny nose. This was likely a viral upper
respiratory infection. Due to your previous severe respiratory
infections, we observed you overnight. Your temperature and
respiration remained stable.
Please follow up with your physicians as noted below and
continue to take all of your medications as prescribed.
MEDICATION CHANGES:
STARTED Benzonatate 100mg twice per day for 2 days (last day is
___ this is a cough suppressant
CHANGED Hydrocortisone from 15mg to 30mg in the morning (only
for 1 day - on ___.
CHANGED Hydrocortisone from 5mg to 10mg at 4 ___ (only for 1 day
- on ___.
Please resume your usual dose of Hydrocortisone 15mg every
morning and 5mg at 4 ___ on ___.
WE MADE NO CHANGES TO THE SEIZURE MEDICATIONS. PLEASE CONTINUE
HER CURRENT REGIMEN.
Followup Instructions:
___
|
19706155-DS-3
| 19,706,155 | 29,186,098 |
DS
| 3 |
2196-03-12 00:00:00
|
2196-03-12 11:52:00
|
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
incisional drainage
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old female s/p ___ L4-L5 microdiskectomy,
laminectomy, hemifacetectomy on right. Presented to clinic with
continued incisional drainage. Patient was transferred to the ED
so the incision could be oversewn. Patient does not report any
other complaints besides drainage from the incision
Past Medical History:
dyslipidemia, HTN, OSA, DM type 2, reflux, thyroid disease,
reflux, c section, sinus surgery, kidney stones.
Social History:
___
Family History:
Positive for psoriasis, diabetes and renal
problems.
Physical Exam:
O: T: 98.4 BP: 113/76 HR:97 R 18 O2Sats 100%
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: PERRL
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Motor:
D B T WE WF IP Q H AT ___ G
R 5 5 5 5 5 5 5 5 5 5 5
L 5 5 5 5 5 5 5 5 5 5 5
Sensation: Intact to light touch, proprioception, pinprick and
vibration bilaterally.
Proprioception intact
Toes downgoing bilaterally
On Discharge: intact neurologically, incision without drainage
Pertinent Results:
MRI Lumbar spine ___:
1. Status post L4-L5 laminectomy. There is a non-enhancing
fluid collection extending from the laminectomy site into the
paraspinal soft tissues. There is no frank communication of the
collection with the thecal sac, but the collection has a
geometric shape and "points" to the dura; this may represent a
persistent CSF leak. The patient is reportedly status post
over-sewing in the ED just prior to the scan. Heterogeniety of
and foci of hypointensity with in the collection likely
represent the combination of air, DuraSeal and
blood products.
2. No finding specific for infection, either of this colleciton
or elsewhere.
3. Disc bulge with superimposed broad-based left paracentral
protrusion at
L4-5, with the collection above, causes significant residual
spinal canal
narrowing.
Brief Hospital Course:
Ms. ___ was admitted to the neurosurgery service for
continued drainage from the recent lamiectomy site concerning
for CSF leak. On ___ she went to the OR for a wound oversewing
of the incision. Afterwards MRI showed post surgical changes,
with some epidural enhancement. No CSF leakage in the AM on
___. Patient kept NPO in case she develops leakage later in the
day, if ___ would take her back to the OR for
exploratory surgery. She remained stable without leakage. Plan
was again made to observe her inscision overnight for any signs
of leakage and perform an operative intervention if required.
She remained stable overnight into 4.___ without leakage and was
deemed fit for discharge to home without services. She was given
prescriptions for required medications, instructions for
followup, and all questions were answered prior to discharge.
Medications on Admission:
1. Detemir 25 Units Bedtime
2. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB
3. Cyclobenzaprine 10 mg PO TID:PRN back spasm
4. Fluoxetine 20 mg PO DAILY
5. GlipiZIDE 10 mg PO DAILY
6. Levothyroxine Sodium 175 mcg PO DAILY
7. Lisinopril 5 mg PO DAILY
8. MetFORMIN (Glucophage) 500 mg PO QAM
9. MetFORMIN (Glucophage) 1000 mg PO QPM
10. Omeprazole 20 mg PO DAILY
11. Oxycodone-Acetaminophen (5mg-325mg) 1 TAB PO Q6H:PRN pain
12. Bisacodyl 10 mg PO/PR DAILY:PRN constipation
RX *bisacodyl 5 mg 2 tablet,delayed release (___) by mouth
daily Disp #*14 Tablet Refills:*0
13. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 tablet(s) by mouth twice a day Disp
#*28 Capsule Refills:*0
14. Atorvastatin 40 mg PO DAILY
15. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*40 Tablet Refills:*0
16. Senna 8.6 mg PO QHS
RX *sennosides [senna] 8.6 mg 1 tab by mouth HS Disp #*14 Tablet
Refills:*0
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN fever/pain
2. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB
3. Atorvastatin 40 mg PO DAILY
4. Docusate Sodium 100 mg PO BID
5. Fluoxetine 20 mg PO DAILY
6. Detemir 25 Units Bedtime
7. Levothyroxine Sodium 175 mcg PO DAILY
8. Lisinopril 5 mg PO DAILY
9. Omeprazole 20 mg PO DAILY
10. Cephalexin 500 mg PO Q6H Duration: 5 Days
RX *cephalexin 500 mg 1 capsule(s) by mouth q6hours Disp #*20
Capsule Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Incisional Drainage
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Do not smoke.
Keep your wound(s) clean and dry / No tub baths or pool
swimming for two weeks from your date of surgery.
No pulling up, lifting more than 10 lbs., or excessive bending
or twisting.
Limit your use of stairs to ___ times per day.
Have a friend or family member check your incision daily for
signs of infection.
Take your pain medication as instructed; you may find it best
if taken in the morning when you wake-up for morning stiffness,
and before bed for sleeping discomfort.
Do not take any anti-inflammatory medications such as Motrin,
Advil, Aspirin, and Ibuprofen etc. unless directed by your
doctor.
Increase your intake of fluids and fiber, as pain medicine
(narcotics) can cause constipation. We recommend taking an over
the counter stool softener, such as Docusate (Colace) while
taking narcotic pain medication.
Clearance to drive and return to work will be addressed at
your post-operative office visit.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING:
Pain that is continually increasing or not relieved by pain
medicine.
Any weakness, numbness, tingling in your extremities.
Any signs of infection at the wound site: redness, swelling,
tenderness, and drainage.
Fever greater than or equal to 101° F.
Any change in your bowel or bladder habits (such as loss of
bowl or urine control).
Followup Instructions:
___
|
19706224-DS-9
| 19,706,224 | 27,684,788 |
DS
| 9 |
2135-07-29 00:00:00
|
2135-08-05 07:27:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
Lamictal
Attending: ___
Chief Complaint:
paresthesias
Major Surgical or Invasive Procedure:
lumbar puncture
History of Present Illness:
The patient is a ___ woman with past medical history
significant for depression and anxiety/panic attacks who
presents
for further evaluation of paresthesias.
Briefly, 2 weeks ago patient had a URI symptoms and viral
conjunctivitis. On ___ she woke up at 3 AM and noticed she
felt wobbly, she attributed to not being fully awake and went
back to bed. The following morning she noticed paresthesias,
which she describes as pins and needles feeling in both feet as
well as her hands. The following day the parasthesias had
progressed to mid thigh b/l. She went to see her PCP on ___
who told her to just monitor the symptoms. On ___ she felt
like the symptoms worsened and now the paresthesias did not only
involve her hands but also traveled up to mid forearm
bilaterally. She also felt more unsteady walking, but denies
weakness states it just feels funny. Yesterday she had a fall,
no head strike. She called her PCP who recommended to come to
the ED for further evaluation. She denies any recent stressors.
This never happened to her before. No back pain, no recent
trauma. No changes in vision.
ROS:
10 point review of system was reviewed, as in HPI
Past Medical History:
ACNE
ANXIETY
TINEA CORPORIS
H/O DEPRESSION
Social History:
Marital status: Significant Other
Children: No
Lives with: Parents
Lives in: House
Work: ___
Multiple partners: ___
___ activity: Present
Sexual orientation: Male
Sexual Abuse: Denies
Domestic violence: Denies
Contraception: OCPs
Tobacco use: Never smoker
Alcohol use: Denies
Recreational drugs Denies
(marijuana, heroin,
crack pills or
other):
Depression: Patient already being treated for depression
Exercise: Activities: running ___
Diet: mod fat
Seat belt/vehicle Always
restraint use:
Comments: Hobbies: photos, writing ___: mod
Family History:
Relative Status Age Problem Onset Comments
Mother Living ___ HEALTHY
Father Living ___ HEALTHY
Brother Living ___ HEALTHY
MGF Deceased DIABETES TYPE II
Comments: paternal great grandmother had breast cancer No fhx of
colon cancer
Physical Exam:
Admission Physical Exam:
- General: Awake, cooperative, NAD.
- HEENT: NC/AT
- Neck: Supple
- Pulmonary: no increased WOB
- Cardiac: well perfused
- Abdomen: soft, nontender, nondistended
- Extremities: no edema, pulses palpated
- Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented x 3. Able to relate history
without difficulty. Attentive, able to name ___ backward without
difficulty. Language is fluent with intact repetition and
comprehension. Normal prosody. There were no paraphasic errors.
Pt was able to name both high and low frequency objects. Able
to
read without difficulty. Speech was not dysarthric. Able to
follow both midline and appendicular commands. There was no
evidence of apraxia or neglect.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 3 to 2mm and brisk. VFF to confrontation. No red
desaturation or RAPD
III, IV, VI: EOMI without nystagmus.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally.
No adventitious movements, such as tremor, noted. No asterixis
noted.
Delt Bic Tri WrE FFl FE IP Quad Ham TA ___
L 5 ___ ___ 5 5 5 5 5 5
R 5 ___ ___ 5 5 5 5 5 5
-DTRs:
Unable to elicit reflexes throughout
Plantar response withdrawal bilaterally.
-Sensory: No deficits to light touch, pinprick, cold sensation,
vibratory sense, proprioception throughout. No extinction to
DSS.
-Coordination: No intention tremor. No dysmetria on FNF
bilaterally.
-Gait: Slow and unsteady, narrow-based
DISCHARGE PHYSICAL EXAM
Vitals: Tm 99.0 BP 95-106/56-76 HR 53-65 RR ___ Spo2 99-100%
General: awake, cooperative, NAD
HEENT: NC/AT, no scleral icterus noted, MMM
Pulmonary: breathing comfortably, no tachypnea or increased WOB
Cardiac: skin warm, well-perfused
Abdomen: soft, ND
Extremities: symmetric, no edema
Neurologic:
-Mental Status: Alert, cooperative. Language is fluent with
intact repetition and comprehension. Able to follow both midline
and appendicular commands.
-Cranial Nerves: PERRL (4 to 3 mm b/l). EOMI without nystagmus.
Facial sensation intact to light touch. Face symmetric at rest
and with activation. Hearing intact to conversation. Palate
elevates symmetrically. ___ strength in trapezii bilaterally.
Tongue protrudes in midline. orbicularis ___ strong
-Motor: Normal tone. No adventitious movements, such as tremor,
noted. Moving all extremities purposefully.
___ at deltoid, biceps, triceps, wrist extensors, finger
flexors,
finger extensors, IP, hamstring, quad, TA, toe extensors
bilaterally
neck flexion/extension ___
-Sensory: Intact to LT throughout. No extinction to DSS. no
temperature gradient
proprioception: able to accurately point where she was touched
on
arm and direction. accurately identifies small/large amplitude
movements bilaterally. There were a few mistakes on L toe.
Improved from prior
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 0 0
R 2 2 2 0 0
toes downgoing b/l.
-Coordination: FNF good, on target, improved, subtle end point
off target. no truncal ataxia
-Gait: narrow based, normal stride, appears improved from
previous day
Pertinent Results:
___ 04:30AM BLOOD WBC-4.8 RBC-4.31 Hgb-13.0 Hct-38.4 MCV-89
MCH-30.2 MCHC-33.9 RDW-11.9 RDWSD-37.2 Plt ___
___ 04:30AM BLOOD ___ PTT-28.5 ___
___ 04:30AM BLOOD Glucose-71 UreaN-10 Creat-0.6 Na-138
K-4.7 Cl-100 HCO3-27 AnGap-11
___ 04:30AM BLOOD Calcium-9.4 Phos-4.4 Mg-1.7
___ 04:30AM BLOOD VitB12-417 Folate-5
___ 04:30AM BLOOD %HbA1c-4.7 eAG-88
___ 04:30AM BLOOD TSH-2.4
___ 04:30AM BLOOD Free T4-0.9*
___ 04:30AM BLOOD IgA-177
___ 04:30AM BLOOD PEP-NO SPECIFI
___ 04:30AM BLOOD SED RATE-Test
___ 05:45PM URINE UCG-NEGATIVE U-PEP-NO PROTEIN
___ 06:08PM CEREBROSPINAL FLUID (CSF) TNC-2 RBC-1 Polys-42
___ Monos-19 Eos-1
___ 06:08PM CEREBROSPINAL FLUID (CSF) TotProt-38 Glucose-54
lyme igm/igg negative
MRI brain w/ w/o contrast ___
"FINDINGS:
Ventricles, sulci, and cisterns appear normal. No parenchymal
signal
abnormality or abnormal intracranial enhancement. There is no
acute infarct, intracranial hemorrhage, or mass effect. The
major vascular flow voids are preserved. Overall mild low
marrow signal is noted.
There is diffuse paranasal sinus mucosal thickening.
IMPRESSION:
1. No evidence of intracranial mass or lesion.
2. Paranasal sinus disease, as described.
3. Nonspecific overall mild low marrow signal is noted. While
finding may be within normal limits for patient of this age,,
similar findings may be seen in the setting of anemia. If
clinically indicated, consider correlation with CBC. "
MRI c spine ___
"IMPRESSION:
1. Study is moderately degraded by motion.
2. Within limits of study, no definite evidence of spinal cord
lesion or
compression.
3. Trace right-sided pleural effusion versus artifact. If
clinically
indicated, consider correlation with dedicated chest imaging.
4. Please see concurrently obtained brain MRI examination for
description of cranial structures. "
Brief Hospital Course:
___ year old woman with history of anxiety and depression who
presented with 3 day history of progressive paresthesias in both
feet and hands, in setting of recent viral upper respiratory
infection. Neurologic examination notable for intact muscle
strength, diffuse arreflexia. No objective sensory deficits to
all modalities on admission. Truncal ataxia, wide based gait
with unsteadiness on admission. Examination worsened while in
the first 24hour of admission, with significant appendicular
ataxia, mild loss of proprioception and paresthesias.
Work up included lumbar puncture with no significant findings.
WBC 2 in CSF, protein 38 glucose 54. MRI brain and c-spine
unremarkable. Polyneuropathy workup included normal B12, TSH,
folate, SPEP/UPEP, A1c. Lyme ab negative, MS profile normal.
Gq1B pending at time of discharge. At the time of admission the
differential included AIDP or a cerebellar process. Given the
worsening of her exam, which was consistent with AIDP, she was
initiated on IVIG. She completed a 5 day course of IVIG with
symptomatic improvement, and an improvement in her exam. Her
gait was much improved on discharge, with subtle loss of
proprioception and inability to tandem. She was evaluated by ___
who recommended outpatient ___. Course was complicated by a mild
positional headache, likely post LP headache, which was present
on discharge. If there is no symptomatic improvement within 1
week, she can be referred to anesthesia for a blood patch. She
know to follow up with her PCP and neurology.
Transitional Issues:
- Follow pending CSF studies
- Neurology follow up with Dr. ___ Dr. ___
- ___ to monitor headache, consider blood patch as needed
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. ALPRAZolam 0.125-0.25 mg PO DAILY:PRN prn anxiety
2. Citalopram 30 mg PO DAILY
3. LORazepam 1 mg PO DAILY:PRN prn
4. Minocycline 100 mg PO Q24H
5. Nortrel 0.5/35 (28) (norethindrone-ethin estradiol) 0.5-35
mg-mcg oral DAILY
Discharge Medications:
1. ALPRAZolam 0.125-0.25 mg PO DAILY:PRN prn anxiety
2. Citalopram 30 mg PO DAILY
3. LORazepam 1 mg PO DAILY:PRN prn
4. Minocycline 100 mg PO Q24H
5. Nortrel 0.5/35 (28) (norethindrone-ethin estradiol) 0.5-35
mg-mcg oral DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
___ Syndrome
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
discharge exam: subtle proprioceptive difficulty in big toe.
reflexes present in BUE, absent in LUE, gait normal based and
stride.
Discharge Instructions:
Dear ___,
___ were admitted to the hospital with progressive sensory
symptoms concerning for neurologic diseases of inflammatory,
infectious or demyelinating causes. MRI of your brain and spine
was performed and showed no evidence of acute process. We did
obtain spinal fluid which was sent for extensive testing. We
have monitored ___ clinically and found that ___ have
significant torso and gait instability. Your tests to date have
been reassuring. As your exam appeared to worsen, we started ___
on a medication called IVIG (immune globulin), which is
basically a large amount of antibodies. This can be a useful
treatment in diseases caused by the immune system in some cases.
This usually can take several weeks before the full effect
occurs. Your symptoms and exam improved while ___ were
hospitalized. ___ completely a full course of IVIG. It is
important ___ continue to be vigilant and monitor for any
changes. We advise ___ see your primary care doctor within the
next week for follow up. ___ will also need to call the
neurology clinic to check on the status of your appointment as
listed below.
We wish ___ the best,
Your ___ Neurology Team
Followup Instructions:
___
|
19706404-DS-11
| 19,706,404 | 24,588,361 |
DS
| 11 |
2167-10-26 00:00:00
|
2167-10-26 13:12:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Erythromycin Base
Attending: ___.
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
ERCP
History of Present Illness:
HMED ATTENDING ADMISSION NOTE
.
ADMIT DATE: ___
ADMIT TIME: 0530
.
PCP: ___
.
___ yo F with bioprosthetic AVR, afib on coumadin, hypothyroidism
and gout who presents from ECF with abdominal pain and jaundice.
.
Patient reports approximately 5 days of intermittent RUQ
abdominal pain (unable to characterize further). Also family
has noticed yellowing of the skin. No nausea, vomiting or
fevers. + weight loss which patient attributes to diuresis.
Decreased appetite. Of note, patient's coumadin has been held
for ___ days.
.
Patient currently resides at ___/rehab facility. She has been
at rehab facility since hospitalization in ___ due to CHF
exacerbation. Prior to this she was living with her daughter,
moved in with daughter after fall and pelvis fracture in ___. Per daughter has had a mild decline since then.
.
Patient presented to ___ in ___. Initial
labs consistent for obstructive liver disease. Patient given iv
levofloxacin and flagyl and transferred to ___.
.
___: 97.4 104/66 90P 16 97%RA; ruq ultrasound showed
distended gb with stones and sludge, wall edema, highly
concerning for acute cholecystitis. No CBD dilatation. Surgery
consulted from ___.
.
ROS per HPI, 10 pt ROS otherwise negative
Past Medical History:
Bioprosthetic AVR
Afib on coumadin
CHF with unkown EF
Hx of DVT x 2
Breast cancer
CKD
Hypothyroidism
Gout
Kidney stones with two surgeries for removal
HLD
S/p appy
Social History:
___
Family History:
No known ___ of hepatobiliary disease
Physical Exam:
VS: 97 112/70 92P 18 96%RA
Appearance: aaox3, NAD
Eyes: eomi, perrl, icteric sclera
ENT: OP clear s lesions, mmd, no JVD, neck supple
Cv: ___ systolic murmur at lusb, 1+ bilateral edema, 2+ dp/pt
bilaterally
Pulm: clear bilaterally
Abd: soft, mild RUQ tenderness to deep palpation, no
rebound/guarding, +bs
Msk: ___ strength throughout
Neuro: cn ___ grossly intact, no focal deficits
Skin: chronic venous stasis changes ble
Psych: appropriate, pleasant, mild short term recall deficits
Heme: no cervical ___
___ Results:
Admission Labs: ___ 01:00AM
URINE RBC-1 WBC-3 BACTERIA-FEW YEAST-NONE EPI-1
GLUCOSE-102* UREA N-38* CREAT-1.6* SODIUM-133 POTASSIUM-4.7
CL-96 CO2-27
ALT(SGPT)-39 AST(SGOT)-108* ALK PHOS-447* BILI-4.5* DIR
BILI-3.7*
LIPASE-77* ALBUMIN-3.4* LACTATE-1.2
WBC-7.9 RBC-3.43* HGB-11.4* HCT-34.0* MCV-99* MCH-33.3*
MCHC-33.6 RDW-16.8*
NEUTS-86.1* LYMPHS-7.2* MONOS-5.4 EOS-0.9 BASOS-0.3
PLT COUNT-111*
___ RUQ U/S: GB distended with stones and sludge w marked
wall edema, highly concerning for acute cholecystitis. No CBD
dilatation.
___ CXR: No acute processes
BCX from outside hospital: Klebsiella sensitive to Cipro
Repeat blood cultures here no growth to date at time of
discharge
Urine culture negative
Discharge Labs: ___ 05:45AM
WBC-5.5 RBC-3.27* Hgb-10.9* Hct-32.3* MCV-99* Plt Ct-99*
___
Glucose-100 UreaN-40* Creat-1.6* Na-136 K-3.7 Cl-98 HCO3-27
AnGap-15
TotBili-1.7*
Brief Hospital Course:
___ yo F with bioprosthetic AVR, afib on coumadin, hypothyroidism
and CHF admitted with obstructive jaundice and acute
cholecystitis.
#Obstructive jaundice, Acute Cholecystitis: LFT's with
cholestatic pattern, normal CBD on ultrasound however multiple
gallstones and elevated bili, therefore high probability of
obstructing stone vs passed stone
--Patient was kept NPO and taken to ERCP where biliary sludge
was noted, but no stones were seen. A plastic stent was placed.
She will need to return to have the plastic stent removed. The
ERCP team will be in touch with the patient to coordinate this,
as her Coumadin will need to be held prior to the procedure.
#Klebsiella bacteremia: Outside hospital blood cultures grew
Klebsiella sensitive to Ciprofloxacin. She was initially treated
with Piperacillin/Tazobactam, which was transitioned to Cipro
when the sensitivities returned. She remained afebrile and her
repeat blood cultures here are no growth to date. She will need
to complete a total of 14 days of antibiotics.
#pAfib: Rate controlled without medications
--Patient's INR was initially supratherapeutic. In anticipation
of her procedure she was given Vitamin K and FFP. Following her
procedure her Coumadin was re-started. Anticoagulation will need
to be coordinated with the ERCP team prior to her return for
repeat ERCP.
#CHF: unknown EF, per history appears to be diastolic heart
failure
--Patient was initially given IV fluids given NPO status and
bacteremia. After her procedure her IV fluids were stopped. On
___ she complained of mild dyspnea on exertion and felt her
lower extremities were more swollen than her baseline. She
received Lasix 40mg PO initially with minimal response; Lasix
80mg PO similarly resulted in only modest urine output. On the
morning of discharge she was given Lasix 40mg IV. This should
continue to be titrated at Rehab. Her Cr remained stable at
1.5-1.6 throughout her stay.
#Cough: On the morning of discharge patient reported persistent
coughing the night prior resulting in "a lot of spit." She
denied sputum production, fevers, chills, or dyspnea at rest. It
was felt her symptoms were likely secondary to throat irritation
from the ERCP. No CXR was obtained. CXR earlier in her
hospitalization showed no acute process.
DNR/DNI per order from ___
HCP: ___ (___) ___ (c), ___ (h) -
updated by phone
Letter sent to ___ ___
Medications on Admission:
Aldactone 25mg daily
Lasix 20mg prn weight gain > 5 lbs
Omeprazole 20mg daily
Senna qhs
Requip 0.25mg daily
Tramadol 25mg bid
Allopurinol ___ daily
Miralax 17gm daily
Vit D 1000 iu daily
Coumadin 1mg daily
Colace 200mg qhs
Synthroid 0.1mg daily
Lovastatin 20mg daily
Lasix 60mg daily
Discharge Medications:
1. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 10 days: Last dose to be given ___.
2. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
3. senna 8.6 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as
needed for constipation.
4. ropinirole 0.25 mg Tablet Sig: One (1) Tablet PO QAM (once a
day (in the morning)).
5. tramadol 50 mg Tablet Sig: 0.5 Tablet PO Q6H (every 6 hours)
as needed for pain.
6. allopurinol ___ mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1)
dose PO DAILY (Daily) as needed for constipation.
8. cholecalciferol (vitamin D3) 1,000 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
9. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
10. levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
___.
13. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
14. camphor-menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
QID (4 times a day) as needed for itching.
15. Lasix 80 mg Tablet Sig: One (1) Tablet PO twice a day:
Monitor for clinical response and follow electrolytes and Cr
closely.
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Klebsiella Bacteremia
Congestive Heart Failure
Thrombocytopenia (low platelets, which you've had before)
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Discharge Instructions:
You were admitted to the hospital with abdominal pain and were
found to have a bloodstream infection. You received antibiotics
and underwent a procedure called an ERCP and had a plastic stent
placed to open up your bile ducts, which you tolerated well.
After your procedure you were re-started on Lasix to help remove
fluid from your lungs and your legs. This will need to be
continued and followed closely at Rehab.
You will need to come back to have your plastic stent removed.
The ERCP team will coordinate this with your Rehab facility.
Followup Instructions:
___
|
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