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19706413-DS-6
| 19,706,413 | 22,191,865 |
DS
| 6 |
2179-02-28 00:00:00
|
2179-03-01 06:39:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
clindamycin
Attending: ___.
Chief Complaint:
Weakness, Lethargy, Shoulder tic
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ yo M with history of bipolar affective
disorder, prior psychiatric hospitalizations, history of 2 past
overdoses, h/o tardive dyskinesia, presenting with one week of
global weakness, gait difficulty, drooling, voice changes, L
shoulder tics over the past week or so in the setting of recent
starting and then weaning off of clozapine.
Patient started clozapine about a month ago. Patient stopped
medication on ___ due to side effects after taper per psych.
He notes not sleeping well. By ___ had progression
of
weakness, as well as pain in L shoulder, legs, and neck. No
fevers/chills. Was seen first in the ___, then ___ ___ on
___ night, given valium for muscle spasm for L shoulder. Was
unsteady and was observed overnight. On ___, was home and
fell x 2 getting up from seated position. Hit his head, no LOC.
Was seen again at ___ ___ night, and was discharged after lab
work with plan for EMG today. No SI/HI, notes difficulty
sleeping, and feeling more irritable.
Other medication changes include recently starting clonazepam
TID, started after prescribed valium this past weekend. Takes
lithium for bipolar, takes ingrezza, an anticholinergic as well.
Past Medical History:
Bipolar Disorder
h/o multiple prior psych hospitalizations
h/o total thyroidectomy taking Synthroid
early childhood seizures
Social History:
___
Family History:
Father with bipolar disorder
Maternal grandfather with PD
No history Autoimmune disorders
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
VS: 100.0 131/87 70 16 95% RA
GENERAL: resting in bed, slightly diaphoretic
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM
NECK: supple, no JVD, no nuchal rigidity
HEART: RRR, S1/S2, no murmurs, gallops, or rubs
LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: nondistended, +BS, nontender
EXTREMITIES: no cyanosis, clubbing, or edema. L shoulder with
frequent tics. good ROM but decreased due to weakness. Some pain
on palpation of L shoulder. No deformity
PULSES: 2+ DP pulses bilaterally
NEURO: A&Ox3, slow to initiate response in movement and
speaking.
Mild dysarthria. Can follow commands. PERRL. Frequent L shoulder
movements. No tremor. Very slow movements. ___ strength in
bilateral IP, with ankle flexion and extension, and at knees.
___
upper strength on exam. Normal sensation throughout
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
DISCHARGE PHYSICAL EXAM:
========================
VS: 98.6, 112/70, 66, 18, 94% RA
GENERAL: flat affect, walking, NAD, not in apparent pain,
occasional jerks of left shoulder
HEENT: AT/NC, EOMI, PERRL, no JVD
HEART: RRR, no m/r/g, nl s1/s2
LUNGS: CTA b/l, no w/r/c
ABDOMEN: BS normoactive, S/ND/NT
EXTREMITIES: WWP, non-edematous, 2+ pulses
NEURO:
A&Ox3, follows commands, bradykinetic, intermittent mild
dysarthria, no tremor.
___ hip strength, equal b/l
4+/5 UE, ___ strength (except hip), equal b/l
1+ reflexes, no asymmetry
Light touch intact
CNII-XII intact
Tone mildly increased, no cogwheeling
Pertinent Results:
ADMISSION LABS:
===============
___ 01:25PM BLOOD WBC-8.6 RBC-4.22* Hgb-12.3* Hct-38.9*
MCV-92 MCH-29.1 MCHC-31.6* RDW-13.2 RDWSD-45.0 Plt ___
___ 01:25PM BLOOD Neuts-64.7 ___ Monos-7.3 Eos-8.1*
Baso-0.7 Im ___ AbsNeut-5.55 AbsLymp-1.63 AbsMono-0.63
AbsEos-0.70* AbsBaso-0.06
___ 01:25PM BLOOD Glucose-94 UreaN-23* Creat-0.9 Na-145
K-4.0 Cl-106 HCO3-25 AnGap-14
___ 01:25PM BLOOD CK(CPK)-271
___ 01:25PM BLOOD TSH-2.4
DISCHARGE LABS:
===============
___ 07:00AM BLOOD ALT-55* AST-35 LD(LDH)-184 CK(CPK)-225
AlkPhos-76 TotBili-0.2
___ 07:00AM BLOOD Albumin-4.2 Calcium-9.7 Phos-4.2 Mg-2.4
___ 01:25PM BLOOD CRP-1.7
___ 01:25PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 07:15AM BLOOD WBC-7.2 RBC-4.44* Hgb-13.0* Hct-41.5
MCV-94 MCH-29.3 MCHC-31.3* RDW-13.2 RDWSD-45.4 Plt ___
___ 07:15AM BLOOD Glucose-82 UreaN-15 Creat-0.8 Na-146
K-4.2 Cl-109* HCO3-25 AnGap-12
___ 07:15AM BLOOD Calcium-9.5 Phos-3.9 Mg-2.2
___ 07:00AM BLOOD ___ CRP-1.6
___ 07:00AM BLOOD Lithium-1.3
IMAGING:
========
___ non-Contrast
Mildly motion degraded exam without acute intracranial process.
Brief Hospital Course:
Mr. ___ is a ___ man with a history of bipolar
disorder, multiple past psychiatric hospitalizations and tardive
dyskinesia who presented with global weakness, lethargy,
dysarthria and tics in the setting of recently being started and
weaned off of Clozaril.
ACUTE ISSUES:
=============
# Global weakness, Lethargy
# Akathesia, Parkinsonism
Patient presented with recent start and weaning of Clozaril and
a long history of various antiepileptics and antipsychotics. He
was noted to be bradykinetic, having masked facies, shuffling
gait, but no cogwheel rigidity consistent with drug-induced
parkinsonism. He also had twitching, restlessness particularly
in the legs, dysarthria consistent with akathisia. Both point
extraparametal symptoms likely from Clozaril. There is no signs
or symptoms of neuroleptic malignant syndrome. His lithium was
mildly elevated in the emergency department but this was not
timed correctly and his overall constellation of symptoms were
not suggestive of lithium toxicity. Nonetheless his dosing was
decreased. Psychiatry was consulted who adjusted his medications
and physical therapy was included to help rebuild strength and
balance. He showed improvement in weakness and was walking
around the hall on day of discharge. He was discharged to
physical therapy with close follow-up from psychiatry to
evaluate for improvement in symptoms.
# Proximal muscle weakness
Notably on presentation the patient was hoarding and was found
on exam to have more pronounced proximal muscle weakness.
Urology was consulted and given initial lack of improvement MRI
spine was ordered which did not show any explanatory lesions.
His ___, CK, CRP were normal pointing away from a myositis
picture. TSH normal not likely cause of myopathy. He is set up
with follow-up with neurology for improvement with physical
therapy and plan for EMG as an outpatient if there is no
recovery.
# Bipolar disorder
Patient's mood was overall stable. His outpatient psychiatrist
was on inpatient consults and adjust his medications
accordingly.
CHRONIC ISSUES:
===============
# Thyroidectomy
# Hypothyroidism
Patient's TSH was within normal range and he was continued on
his Synthroid without problems. This was not felt to be related
to current presentation.
TSH 2.4 on admission.
====================
TRANSITIONAL ISSUES:
====================
[ ] Medications Changed
-- Lithium dose decreased
-- Klonipin dose decreased
[ ] Please follow up with PCP
[ ] Please follow up with Neurology
-- Appointment with Dr. ___ Scheduled
-- Evaluate proximal muscle weakness, consider EMG if
persistent
[ ] Please follow up with Psychiatry
-- Dr. ___ ___
Treatment Plan:
Progress functional mobility: bed mobility, transfers, gait,
stair negotiation
Balance training: standing dynamic
Therex: AROM therex standing
Pt/caregiver education RE: fall risk, benefits of OOB mobility,
D/C planning
Recommendations for Nursing:
-Encourage independence with ADLs and functional mobility as pt
is at risk for deconditioning
-OOB to chair ___ with S
-Amb 3x/day with S
-Please use chair alarm when pt OOB
================
FULL CODE
___ (mother) ___
>30 minutes were spent on this complicated discharge
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lithium Carbonate 600 mg PO QAM
2. Lithium Carbonate 900 mg PO QHS
3. ClonazePAM 0.5 mg PO BID
4. ClonazePAM 1 mg PO QHS
5. Levothyroxine Sodium 250 mcg PO DAILY
6. Ingrezza (valbenazine) 80 mg oral Daily
7. milk thistle unknown mg oral BID
Discharge Medications:
1. ClonazePAM 0.5 mg PO QHS:PRN anxiety
2. Lithium Carbonate 600 mg PO BID
3. Ingrezza (valbenazine) 80 mg oral Daily
4. Levothyroxine Sodium 250 mcg PO DAILY
5. milk thistle unknown oral BID
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Extrapyramidal Symptoms from Anti-Psychotics
Generalized Weakness
Bipolar Disorder
Supratherapeutic Lithium
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you at ___.
WHY DID YOU COME TO THE HOSPITAL?
- You came to the hospital because you were having significant
weakness and jerking of your shoulder.
WHAT HAPPENED WHILE YOU WERE HERE?
- You were tested for causes of these symptoms and seen by
specialists (Neurology and Psychiatry).
- Your medication regimen was adjusted to help reduce potential
side effects.
- Physical therapy evaluated you and helped create a plan to
build your strength back up.
WHAT SHOULD YOU DO WHEN YOU LEAVE THE HOSPITAL?
- Please continue to take all of your medications as directed,
and follow up with all of your doctors.
Again, it was a pleasure taking care of you!
Sincerely,
Your ___ Team
Followup Instructions:
___
|
19706808-DS-13
| 19,706,808 | 24,738,579 |
DS
| 13 |
2139-06-07 00:00:00
|
2139-06-07 15:27:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
___ Complaint:
perforated diverticulitis-abdominal pain
Major Surgical or Invasive Procedure:
___: CT-guided drainage of pericolonic collection
___: CT-guided drainage of pericolonic collection
History of Present Illness:
___ presenting with abdominal pain, diarrhea and pelvic abscess
on CT. Symptoms began 5 days ago with crampy, generalized pelvic
pain. Pain was intermittent with episodes lasting approximately
15 minutes at first, then gradually to an hour as time
progressed. On ___ he developed non-bloody diarrhea and
presented to ___ ED where he was given
medication
for "spasms" and discharged. He presented to his
gastroenterologist today when symptoms did not abate over the
weekend, and a CT was performed which showed diverticulosis and
a
large pelvic abscess with associated inflammation, at which
point
he was transferred to ___. He states he has had approximately
6
similar episodes that were self-limited over the last ___ years.
These were often associated with dairy intake, so he was being
evaluated for lactose intolerance, which is why he was seeing a
gastroenterologist. He endorses difficulty initiating urination,
nausea, fever, chills and presyncope with BMs. He denies nausea,
visual changes, dyspnea, cough, SOB, rash, ecchymosis and
paresthesia.
Past Medical History:
GERD
Social History:
___
Family History:
Diverticulitis - Mother
IBS - Sister
___ - Brother
___ overload - MGM
Skin CA
No bleeding, clotting, IBD or colorectal cancers
Physical Exam:
VSS
GEN: Well appearing, comfortable, in NAD
HEENT: NCAT, EOMI, anicteric
CV: RRR, No JVD
PULM: normal excursion, no respiratory distress
ABD: Abdomen soft, less tender in lower quadrants,non-distended.
No rebound or guarding. Drain in place with sanguineous purulent
fluid
EXT: WWP, no CCE, 2+ B/L radial
NEURO: A&Ox3, no focal neurologic deficits
PSYCH: normal judgment/insight, normal memory, normal
mood/affect
Pertinent Results:
See OMR for all lab and imaging results.
Brief Hospital Course:
Mr. ___ presented to the ED following a CT scan with his
gastroenterologist demonstrating perforated diverticulitis
complicated by pelvic abscess. He was subsequently admitted to
the colorectal service with plan for ___ drainage of the abscess.
___ discovered two separate drainable pockets which were each
drained over two consecutive days. 5.5 cc sero sanguinous fluid
and 10 cc bloody-purulent fluid were removed respectively, with
a drain left in place. Gram stains were negative with cultures
currently pending. Overall the patient tolerated the procedures
well, with further details in the ___ imaging notes. By discharge
Mr. ___ was hemodynamically stable, ambulating well,
tolerating a regular diet with low residues (low fiber no
seeds/nuts/etc.), and moving his bowels appropriately. Pain was
controlled and the patient expressed overall readiness for
discharge.
The patient will be discharged on Augmentin 875 mg BID for 14
days with follow up in place with the CRS to consider future
sigmoid colectomy once this acute episode has resolved. He has
his ___ drain in place to be managed with ___ services.
Social Issues Causing a Delay in Discharge:
[ ] Delay in organization of ___ services
[ ] Difficulty finding appropriate rehab hospital disposition.
[ ] Lack of insurance coverage for ___ services
[ ] Lack of insurance coverage for prescribed medications.
[ ] Family not agreeable to discharge plan.
[ ] Patient knowledge deficit related to ileostomy delaying
dispo
[x] No social factors contributing in delay of discharge.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Pantoprazole 40 mg PO Q24H
Discharge Medications:
1. Amoxicillin-Clavulanic Acid ___ mg PO Q12H Duration: 14 Days
RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tablet(s) by
mouth Every twelve (12) hours Disp #*30 Tablet Refills:*0
2. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain -
Moderate
Please take lowest effective dose
RX *oxycodone 5 mg 1 tablet(s) by mouth every six (6) hours Disp
#*10 Tablet Refills:*0
3. Pantoprazole 40 mg PO Q24H
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Perforated diverticulitis
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 ___
with abdominal pain and underwent a CT scan that revealed
perforated diverticulitis with fluid collections. You were
brought to interventional radiology where the collection was
drained and a drain was left in place. You are now ready to be
discharged home with oral antibiotics.
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.
Drain Information
You will also be going home with your interventional radiology
right drain, which will be removed at your post-op visit. You
will have ___ services that will help attend to your drain.
Please look at the site every day for signs of infection
(increased redness or pain, swelling, odor, yellow or bloody
discharge, warm to touch, fever). Maintain suction of the bulb.
Note color, consistency, and amount of fluid in the drain. Call
the doctor, ___, or ___ nurse if the amount
increases significantly or changes in character. Be sure to
empty the drain frequently. Record the output, if instructed to
do so. You may shower; wash the area gently with warm, soapy
water. Keep the insertion site clean and dry otherwise. Avoid
swimming, baths, hot tubs; do not submerge yourself in water.
Make sure to keep the drain attached securely to your body to
prevent pulling or dislocation. Please flush drain three times a
day. Flush 5cc normal saline into yourself and then flush 5cc
into the tubing of the drain.
Drain care:
Flush with 10cc sterile saline to patient and aspirate back. You
may do this three times per day.
Do not continue to flush if the volume out is significantly less
than the volume in.
If there is pain with flushing this may mean that the abscess
cavity has collapsed.
Troubleshooting: If catheter stops draining suddenly:
1) Check that the stopcock is open.
2) Remove dressing carefully and inspect to make sure that
there is no kink in the catheter.
3) Inspect to be sure that there is no debris blocking the
catheter. If there is, then firmly flush 5 cc of sterile saline
into the catheter towards the patient.
Pain
It is expected that you will have pain after surgery, this will
gradually improve over the first week or so you are home. You
should continue to take 2 Extra Strength Tylenol (___) for
pain every 8 hours around the clock. Please do not take more
than 3000mg of Tylenol in 24 hours or any other medications that
contain Tylenol such as cold medication. Do not drink alcohol
while taking Tylenol.
Thank you for allowing us to participate in your care, we wish
you all the best!
Followup Instructions:
___
|
19706867-DS-6
| 19,706,867 | 29,577,112 |
DS
| 6 |
2154-03-20 00:00:00
|
2154-03-20 14:16:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending: ___
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is an ___ year old gentleman with history of HTN,
HLD, DM2, severe aortic stenosis ___ 0.9, velocity 5.2m/s), and
h/o CVA who presents with chest pain.
Yesterday morning, patient was doing his morning exercises,
lifting weights. He finished his shower and then experienced
right-sided chest tightness. He has never had this kind of pain
before. He rates it a ___ and non-radiating. He says he was
sitting down at the time of the onset of chest pain and
continued to eat his breakfast and the pain resolved
spontaneously in about ___ minutes. He denies any dyspnea
associated with the pain, denies any diaphoresis, n/v. He denies
any DOE, PND, or orthopnea. His wife was concerned and booked
him an urgent care appointment. EKG at the PCP office was
concerning for new onset afib. Given his history and story of CP
with exertion, he was thus referred to the ED.
In the ED, initial vital signs were: 98.3 56 121/90 16 99% RA
- Exam was notable for: ___ holosystolic murmur, no ___ edema
- Labs were notable for: mild anemia 10.8/33.7, INR 1.0, Cr 1.9
(baseline 1.5-1.8), Trop T 0.22-> 0.47 proBNP 1685, INR 1.0
- Imaging: CXR showed No acute intrathoracic process.
- The patient was given: full dose ASA and started on heparin
gtt
- EKG showed NSR, normal axis, normal intervals, no concerning
ischemic chages
- Consults: Atrius Cardiology was consulted, however unclear if
recs were given based on documentations
Vitals on transfer: 97.9 56 129/45 14 100% RA
On the floor patient is feeling well and remains chest pain
free. He has no current complaints.
ROS: positive per HPI, otherwise negative.
Past Medical History:
1. CARDIAC RISK FACTORS: +hypertension, +dyslipidemia,
+diabetes
2. CARDIAC HISTORY:
- CABG: None
- PERCUTANEOUS CORONARY INTERVENTIONS: None
- PACING/ICD: None
3. OTHER PAST MEDICAL HISTORY:
CEREBROVASC DISEASE, UNSPEC
Aortic valve stenosis
COLONIC ADENOMA
TREMOR
Type 2 diabetes, controlled, with renal manifestation
Hydrocephalus
Hypercholesteremia
CKD (chronic kidney disease) stage 3, GFR ___ ml/min
Benign hypertension with chronic kidney disease, stage III
Hypothyroidism
Aortic insufficiency
New onset a-fib
Social History:
___
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death.
Physical Exam:
=======================
ADMISSION PHYSICAL EXAM
=======================
VS: 97.5 143/63 59 18 100% RA
GENERAL: Pleasant, well-appearing, in no apparent distress.
HEENT - normocephalic, atraumatic, no conjunctival pallor or
scleral icterus, PERRLA, EOMI, OP clear.
NECK: Supple, no LAD, no thyromegaly, JVP flat.
CARDIAC: RRR, normal S1/S2, III/VI crescendo/decrescendo murmur
obliterating S2 heard throughout precordium
PULMONARY: Clear to auscultation bilaterally, without wheezes
or rhonchi.
ABDOMEN: Normal bowel sounds, soft, non-tender, non-distended,
no organomegaly.
EXTREMITIES: Warm, well-perfused, no cyanosis, clubbing or
edema.
SKIN: Without rash.
NEUROLOGIC: A&Ox3, CN II-XII grossly normal, normal sensation,
with strength ___ throughout.
=======================
DISCHARGE PHYSICAL EXAM
=======================
VS: T 98.4 F BP 113/53 mmHg P 63 RR 17 O2 99% RA
General: Pleasant, elderly man appearing younger than his stated
age in NAD.
HEENT: PERRL; EOMs intact. Anicteric sclerae.
Neck: Supple, no JVD.
CV: RRR, loud systolic crescendo-descrescedo murmur radiating to
carotids. No rubs or gallops.
Pulm: CTA b/l; no wheezes, rhonchi, or rales.
Abd: Soft, non-tender, non-distended, NABS.
Ext: No edema. Warm and well-perfused. 2+ pulses.
Neuro: A&Ox3. CNs II-XII grossly intact.
Pertinent Results:
==============
ADMISSION LABS
==============
___ 06:55PM BLOOD WBC-9.9 RBC-3.70* Hgb-10.8* Hct-33.7*
MCV-91 MCH-29.2 MCHC-32.0 RDW-14.1 RDWSD-47.0* Plt ___
___ 06:55PM BLOOD Neuts-65.9 ___ Monos-7.4 Eos-3.0
Baso-0.4 Im ___ AbsNeut-6.53* AbsLymp-2.27 AbsMono-0.73
AbsEos-0.30 AbsBaso-0.04
___ 06:55PM BLOOD ___ PTT-28.1 ___
___ 06:55PM BLOOD Glucose-116* UreaN-46* Creat-1.9* Na-134
K-4.3 Cl-97 HCO3-23 AnGap-18
___ 06:55PM BLOOD cTropnT-0.22* proBNP-1685*
============
INTERIM LABS
============
___ 01:00AM BLOOD cTropnT-0.47*
___ 06:29AM BLOOD CK-MB-11* MB Indx-6.7* cTropnT-0.42*
==============
DISCHARGE LABS
==============
___ 05:05AM BLOOD WBC-8.4 RBC-3.72* Hgb-11.0* Hct-34.3*
MCV-92 MCH-29.6 MCHC-32.1 RDW-14.2 RDWSD-47.8* Plt ___
___ 05:05AM BLOOD Glucose-94 UreaN-35* Creat-1.5* Na-138
K-4.6 Cl-105 HCO3-22 AnGap-16
___ 05:05AM BLOOD Calcium-9.6 Phos-4.2 Mg-2.1
===============
IMAGING/STUDIES
===============
CHEST (PA & LAT) (___):
FINDINGS:
PA and lateral views of the chest provided. No convincing
evidence for pneumonia or edema. No large effusion or
pneumothorax. There is subtle increase in reticular markings in
the left lower lobe which may reflect the sequelae of chronic
aspiration in the correct clinical setting. Cardiomediastinal
silhouette appears within normal limits. Bony structures are
intact. Mild scarring projects over the left upper lung.
IMPRESSION:
No acute intrathoracic process.
ECHO (___):
Findings
LEFT ATRIUM: Mildly increased LA volume index.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.
LEFT VENTRICLE: Mild symmetric LVH with normal cavity size and
regional/global systolic function (LVEF>55%). Diastolic function
could not be assessed.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTIC VALVE: Three aortic valve leaflets. Moderately thickened
aortic valve leaflets. Severe AS (area <1.0cm2). Mild (1+) AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP.
Moderate mitral annular calcification. Mild thickening of mitral
valve chordae. Calcified tips of papillary muscles. Minimally
increased gradient consistent with trivial MS. ___ (1+) MR.
[Due to acoustic shadowing, the severity of MR may be
significantly UNDERestimated.]
TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Mild
[1+] TR. Mild PA systolic hypertension.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: Suboptimal image quality - poor echo windows.
Conclusions
The left atrial volume index is mildly increased. There is mild
symmetric left ventricular hypertrophy with normal cavity size
and regional/global systolic function (LVEF>55%). Diastolic
function could not be assessed. Right ventricular chamber size
and free wall motion are normal. There are three aortic valve
leaflets. The aortic valve leaflets are moderately
thickened/calcific. There is severe aortic valve stenosis (valve
area <1.0cm2). Mild (1+) aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. There is no mitral
valve prolapse. There is a minimally increased gradient
consistent with trivial mitral stenosis due to mitral annular
calcification. Mild (1+) mitral regurgitation is seen. [Due to
acoustic shadowing, the severity of mitral regurgitation may be
significantly UNDERestimated.] The tricuspid valve leaflets are
mildly thickened. There is mild pulmonary artery systolic
hypertension. There is no pericardial effusion.
IMPRESSION: Severe calcific aortic stenosis with mild aortic
regurgitation. Mild symmetric left ventricular hypertrophy with
preserved global and regional biventricular systolic function.
Mild mitral regurgitation. Mild pulmonary hypertension.
Brief Hospital Course:
Mr. ___ is an ___ y/o man with a history of hypertension,
hyperlipidemia, type 2 diabetes mellitus, severe aortic stenosis
(aortic valve area 0.9), and stroke, who presented with chest
pain and found to have NSTEMI.
.
# NSTEMI. Troponins peaked at 0.49. After discussion with the
patient, he chose medical management instead of PCI. He was
treated with full dose aspirin x1 and heparin drip for 48 hours.
His atorvastatin was increased to 80 mg daily and lisinopril
continued at 5 mg daily. He was initiated on metoprolol
succinate 12.5 mg qhs.
.
# Atrial tachyarrhythmia. Prior to admission, he was found to
have an atrial tachyarrhythmia, initially concerning for atrial
fibrillation, which appeared to be more consistent with multiple
premature atrial complexes. He will have outpatient event
monitoring to follow-up.
.
# ___. He was found to have an acute kidney injury with a Cr of
1.9. This was thought to be pre-renal in the setting of an acute
event, and his creatinine improved to his baseline of 1.5.
.
==============
CHRONIC ISSUES
==============
# Severe aortic stenosis. ___ 0.9. He noted that he did not want
to pursue intervention, and he had no evidence of heart failure
on examination. He was restarted on his home torsemide once his
kidney function had returned to baseline.
# Hypothyroidism. He was continued on his home levothyroxine.
# Type 2 diabetes mellitus. He was placed on an insulin sliding
scale.
# Hypertension. He was continued on amlodipine and lisinopril.
.
===================
TRANSITIONAL ISSUES
===================
# Discharge Cr: 1.5
# Medication changes. Atorvastatin increased to 80 mg daily.
Started on metoprolol succinate 12.5 mg qhs.
# Event monitoring. Would advise outpatient event monitoring for
further work-up of atrial tachyarrhythmia.
# Travel. Mr. ___ is planning for overseas travel this ___;
please re-evaluate suitability for this and provide a
physician's note if he needs to cancel his trip.
# CODE: FULL
# CONTACT: wife ___ ___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. Lisinopril 5 mg PO DAILY
2. GlipiZIDE XL 2.5 mg PO DAILY
3. Atorvastatin 20 mg PO QPM
4. Levothyroxine Sodium 50 mcg PO DAILY
5. Torsemide 2.5 mg PO 3X/WEEK (___)
6. Amlodipine 10 mg PO DAILY
7. Aspirin 81 mg PO DAILY
8. Ferrous Sulfate 325 mg PO BID
Discharge Medications:
1. Metoprolol Succinate XL 12.5 mg PO QHS
Hold for lightheadedness and dizziness
RX *metoprolol succinate 25 mg 0.5 (One half) tablet(s) by mouth
Every night Disp #*30 Tablet Refills:*0
2. Amlodipine 10 mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. Atorvastatin 80 mg PO QPM
RX *atorvastatin 80 mg 1 (one) tablet(s) by mouth daily Disp
#*30 Tablet Refills:*0
5. Levothyroxine Sodium 50 mcg PO DAILY
6. Lisinopril 5 mg PO DAILY
7. Torsemide 2.5 mg PO 3X/WEEK (___)
8. Ferrous Sulfate 325 mg PO BID
9. GlipiZIDE XL 2.5 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
=================
PRIMARY DIAGNOSES
=================
- non-ST segment elevation myocardial infarction
- atrial tachyarrhythmia
- severe aortic stenosis
- acute kidney injury on chronic kidney disease
===================
SECONDARY DIAGNOSES
===================
- hypothyroidism
- type 2 diabetes mellitus
- hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure caring for you at ___
___. You were admitted because you had a heart attack
(known as an NSTEMI). We discussed the possibility of
intervention, but your preference was management with
medications. You did well and had no complications. The dose of
your atorvastatin has been increased to 80 mg daily. You have
also been started on a new medication called metoprolol, which
you will take at night, to control your heart rate and to help
after your heart attack. It is important that you call your
physician if you have any symptoms of lightheadedness,
dizziness, or chest pain.
Please continue to take all medications as prescribed. Your
discharge follow-up appointments are outlined below.
We wish you the very best!
Warmly,
Your ___ Team
Followup Instructions:
___
|
19706867-DS-7
| 19,706,867 | 28,901,451 |
DS
| 7 |
2154-03-25 00:00:00
|
2154-03-28 17:30:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending: ___
Chief Complaint:
Lightheadedness
Major Surgical or Invasive Procedure:
Cardiac catheterization ___
___ to RCA ___
History of Present Illness:
___ hx severe AS, CAD, CVA, HTN, HLD, DM, ___. Recently admitted
for NSTEMI, medically managed. Declined PCI/TAVR, discharged
home, brought to ___ ED after debilitating symptoms and now
reconsidering procedures.
He was discharged earlier today after admission ___
for NSTEMI. Took shower at home and got dizzy, weak, appeared
pale and diaphoretic. No chest pain/discomfort/tightness, no
numbness/asymmetric weakness, no facial droop or slurred speech.
Patient was offered PCI and TAVR previously and did not want
them therefore unclear what benefit admission would have in
absence of ACS, however patient now amenable to further workup
in anticipation of intervention for severe AS.
In the ED, initial vital signs were: 97.9 64 176/78 18 97% RA.
- Labs notable for: trop 0.43 which is similar to prior ___
and CK-MB negative. Cr 1.6 which is baseline. WBC 12.5, bicarb
19.
- Imaging/studies: EKG unchanged
- The patient was given: 324 ASA
- Consults: ED providers discussed with ___ attending.
Admitted for workup. Admitted to Cardiology for reevaluation.
Vitals prior to transfer were: 97.9 59 120/49 14 99% RA.
Upon arrival to the floor, he recounts the history above. He
states that he completed his shower, he felt as though all the
energy had been drained from his body and felt very tired. He
denies any chest pain, dyspnea, LH, dizziness. He is here
because "my wife and daughter made me come in." Says he spoke to
another doctor in the ED "who convinced me to do the procedure."
=======================
REVIEW OF SYSTEMS: Per HPI. Denies headache, visual changes,
pharyngitis, rhinorrhea, nasal congestion, cough, fevers,
chills, sweats, weight loss, abdominal pain, nausea, vomiting,
diarrhea, constipation, hematochezia, dysuria, rash,
paresthesias, and weakness.
=======================
Past Medical History:
1. CARDIAC RISK FACTORS: +hypertension, +dyslipidemia,
+diabetes
2. CARDIAC HISTORY:
- CABG: None
- PERCUTANEOUS CORONARY INTERVENTIONS: None
- PACING/ICD: None
3. OTHER PAST MEDICAL HISTORY:
CEREBROVASC DISEASE, UNSPEC
Aortic valve stenosis
COLONIC ADENOMA
TREMOR
Type 2 diabetes, controlled, with renal manifestation
Hydrocephalus
Hypercholesteremia
___ (chronic kidney disease) stage 3, GFR ___ ml/min
Benign hypertension with chronic kidney disease, stage III
Hypothyroidism
Aortic insufficiency
New onset a-fib
Social History:
___
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death.
Physical Exam:
ADMISSION PHYSICAL EXAM:
==========================
VITALS: 98.6 138/42 66 18 100/ra
Genl: comfortable, NAD
HEENT: no icterus, PERRLA, MMM, no OP lesions
Neck: no JVP, no LAD
Cor: RRR. loud midpeaking SEM over the precordium a/w carotid
parvus et tardus; s2 is inaudible.
Pulm: no incr WOB, CTAB
Abd: soft, ntnd
Neuro: AOx3, no focal sensory or motor deficits in bilat ___
MSK: ___ without edema, 2+ distal pulses
Skin: no obvious rashes or lesions on torso, UEs, ___
___ PHYSICAL EXAM:
=========================
VITALS: Tm 98.0 140/88 52 20 100% 2.5L
Weight on admission: 78.5kg
GENERAL: Sleeping, but arousable, well-appearing, in NAD
HEENT - NCAT, no conjunctival pallor or scleral icterus, right
eye opacified. left pupil round 2 mm, left EOMI, OP clear.
NECK: Supple, no LAD, no thyromegaly, JVP ~9 cm
CARDIAC: RRR, normal S1/S2, no murmurs rubs or gallops. 1+ DP
pulses bilaterally
PULMONARY: Scattered wheezes posteriorly, decreased BS @ bases,
poor expiratory air movement
ABDOMEN: NABS, soft, non-tender, non-distended, no organomegaly.
GU: ___ scrotal edema, foley in place with clear ~1L clear
urine
EXTREMITIES: Warm, well-perfused, no cyanosis, clubbing. 1+
edema over anterior shins to knees bilaterally.
SKIN: Without rash.
NEUROLOGIC: A&Ox3 (self, ___, year). Follows commands. Moves
all extremities to command/spontaneously.
Pertinent Results:
ADMISSION LABS:
===============
___ 05:05AM BLOOD WBC-8.4 RBC-3.72* Hgb-11.0* Hct-34.3*
MCV-92 MCH-29.6 MCHC-32.1 RDW-14.2 RDWSD-47.8* Plt ___
___ 05:05AM BLOOD Glucose-94 UreaN-35* Creat-1.5* Na-138
K-4.6 Cl-105 HCO3-22 AnGap-16
___ 05:29PM BLOOD cTropnT-0.43*
___ 11:40PM BLOOD CK-MB-4 cTropnT-0.35*
___ 05:29PM BLOOD CK(CPK)-136
___ 05:05AM BLOOD Calcium-9.6 Phos-4.2 Mg-2.1
DISCHARGE LABS:
================
___ Cardiovascular ECG Sinus brady, otherwise Normal
___ 06:10AM BLOOD WBC-10.5* RBC-2.99* Hgb-8.8* Hct-26.8*
MCV-90 MCH-29.4 MCHC-32.8 RDW-14.0 RDWSD-46.3 Plt ___
___ 06:10AM BLOOD Glucose-105* UreaN-28* Creat-1.5* Na-133
K-4.2 Cl-101 HCO3-22 AnGap-14
___ 06:10AM BLOOD Calcium-9.0 Phos-3.9 Mg-2.0
IMAGING and OTHER STUDIES:
=============================
___ Cardiac cath
Impressions:
1. Severe aortic stenosis
2. Three vessel coronary artery disease
3. Successful drug eluting ___ in the mid RCA
4. Residual coronary disease in the LAD, distal PDA, and LCx
Recommendations
1. Dual antiplatelet therapy for at least ___ year.
2. Staged PCI of LAD.
3. TAVR following revascularization.
___ CT chest
1. 3.1 cm mixed attenuation mass in the left upper lobe is
consistent with primary lung adenocarcinoma. Consider PET-CT
for staging purposes if warranted clinically.
2. Other smaller appear ground-glass opacities in the left
upper lobe are nonspecific but could potentially represent
multicentric disease.
3. Heavily calcified aortic valve, consistent with history of
severe aortic stenosis. Atheromatous calcifications of the
thoracic aorta as detailed above. These images are available
for review.
4. Severe diffuse coronary artery calcifications.
5. Trace left pleural effusion.
___ Cardiovascular ECHO
Left Ventricle - Ejection Fraction: 55% >= 55%
Aortic Valve - Peak Velocity: *4.3 m/sec <= 2.0 m/sec
Aortic Valve - Peak Gradient: *73 mm Hg < 20 mm Hg
Aortic Valve - Valve Area: *0.7 cm2 >= 3.0 cm2
CONCLUSION:
The left atrial volume index is mildly increased. There is mild
symmetric left ventricular hypertrophy with normal cavity size
and regional/global systolic function (LVEF>55%). Diastolic
function could not be assessed. Right ventricular chamber size
and free wall motion are normal. There are three aortic valve
leaflets. The aortic valve leaflets are moderately
thickened/calcific. There is severe aortic valve stenosis (valve
area <1.0cm2). Mild (1+) aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. There is no mitral
valve prolapse. There is a minimally increased gradient
consistent with trivial mitral stenosis due to mitral annular
calcification. Mild (1+) mitral regurgitation is seen. [Due to
acoustic shadowing, the severity of mitral regurgitation may be
significantly UNDERestimated.] The tricuspid valve leaflets are
mildly thickened. There is mild pulmonary artery systolic
hypertension. There is no pericardial effusion.
IMPRESSION: Severe calcific aortic stenosis with mild aortic
regurgitation. Mild symmetric left ventricular hypertrophy with
preserved global and regional biventricular systolic function.
Mild mitral regurgitation. Mild pulmonary hypertension.
___ Cardiovascular ECG Sinus rhythm. Tall peaked T waves
in the precordial leads may be consistent with ischemia or
hyperkalemia. Clinical correlation is suggested. No previous
tracing available for comparison.
___ Cardiovascular ECG Sinus brady, otherwise normal ECG
Brief Hospital Course:
Summary
___ hx severe AS ___ 0.9, velocity 5.2m/s), CAD, CVA, HTN, HLD,
DM, ___, was recently admitted for NSTEMI, medically managed,
declined PCI/TAVR, discharged home, brought to ___ ED after
debilitating symptoms. Underwent TAVR workup including cardiac
catheterization with DES placed to RCA. Was also incidentally
found to a have lung mass. Will continue work up as an
outpatient.
Acute issues
# New lung mass
Concern for malignancy based on CT appearance. Alternatively
could be due to previous TB infection or granuloma, however less
likely. Discussed with PCP that we recommend a PET CT and MRI
head for workup. TAVR w/u on hold pending results of lung mass
etiology and patient goals of care. Also has IP follow up for
potential bronchoscopy and biopsy pending above results.
# Severe aortic stenosis: Recently admitted with NSTEMI and
cardiac symptoms thought ___ AS. During recent admission,
offered PCI/TAVR and did not want to pursue intervention.
However, given symptoms, pt returned to ___ just after admission
for reconsideration of procedure. Underwent cardiac
catheterization with RCA and LAD lesions. Had ___ placed
in RCA. Patient will need to continue Plavix ___ year at least.
Continued metoprolol, torsemide and lisinopril.
# CAD s/p NSTEMI: during recent admission. Medically managed
with ASA, heparin gtt, atorva, B-blocker. Underwent cardiac cath
this admission with DES to RCA as above. Also found to have LAD
lesion which will be addressed by cardiology. Continue Plavix
for ___ year at least. Continued ASA, atorvastatin, metoprolol and
lisinopril.
# Atrial tachyarrhythmia vs fibrillation: Patient was sent in
from office as patient was in Afib, confirmed on EKG. Patient
with atrial arrhythmia most c/w multiple PACs on recent
admission. Prior to last admission, he was found to have an
atrial tachyarrhythmia, initially concerning for atrial
fibrillation, which appeared to be more consistent with multiple
premature atrial complexes. Started 3mg warfarin daily for
anticoagulation prior to discharge.
Chronic issues
# ___ v ___: pt's BUN/Cr appear elevated on recent labs;
attributed to ___ during last admission. Unclear baseline renal
function, last creatinine of 1.5. Initially held home lisinopril
but was able to restart prior to discharge.
# T2DM: A1C 6.0 this admission. Held glipizide while admitted nd
put on HISS.
# Hypothyroidism: continued home levothyroxine.
# Hypertension: continued amlodipine 10mg daily and lisinopril
5mg daily.
# Vitamins: continued home iron.
Transitional Issues
- Patient was evaluated by physical therapy and recommended for
acute rehab placement.
- ___ on ___ and will need to continue Plavix for
at least ___ year. It should not be stopped without approval from
his cardiologist.
- At PCP office pt was found to be in afib. On admission and
during stay he remained in sinus rhythm. He was started on 3mg
daily Coumadin on discharge for anticoagulation but may need to
hold this for potential procedures in the next several weeks. He
should have his INR checked in 2 days and dose adjusted
accordingly.
- Discussed work up of lung mass with his PCP and recommend
obtaining a PET-CT and a brain MRI.
- Patient will follow with Dr. ___ Dr. ___ TAVR
workup.
- He will follow with IP in clinic for possibly biopsy of mass
pending PET and MRI findings.
# CONTACT: Daughter HCP ___ ___
# CODE STATUS: Full, confirmed
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Metoprolol Succinate XL 12.5 mg PO QHS
2. Amlodipine 10 mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. Atorvastatin 80 mg PO QPM
5. Levothyroxine Sodium 50 mcg PO DAILY
6. Lisinopril 5 mg PO DAILY
7. Torsemide 2.5 mg PO 3X/WEEK (___)
8. Ferrous Sulfate 325 mg PO BID
9. GlipiZIDE XL 2.5 mg PO DAILY
Discharge Medications:
1. Amlodipine 10 mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 80 mg PO QPM
4. Levothyroxine Sodium 50 mcg PO DAILY
5. Lisinopril 5 mg PO DAILY
6. Torsemide 2.5 mg PO 3X/WEEK (___)
7. Clopidogrel 75 mg PO DAILY
8. Ferrous Sulfate 325 mg PO BID
9. GlipiZIDE XL 2.5 mg PO DAILY
10. Metoprolol Succinate XL 12.5 mg PO QHS
11. Warfarin 3 mg PO DAILY16
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary Diagnosis:
Severe and symptomatic Aortic Stenosis
Lung Mass
Secondary diagnosis:
Coronary artery disease with new ___ placement
___
Hypothyroidism
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were admitted to ___ on ___ after you felt lightheaded
and dizzy. Your EKG did not show any new signs of a heart
attack. You were assessed for TAVR placement and underwent a
cardiac catheterization where a drug-eluting ___ was placed.
There was an additional blockage that may need to be corrected
in the future.
During your work up we also found a new lung mass. Currently we
do not know the cause of this mass, but our concern is that it
could be lung cancer. You will need to follow up with your PCP
and other doctors for additional testing to find out the cause
of this mass.
You were found to have a heart rhythm called atrial
fibrillation. For this reason we started a medication called
Coumadin to prevent strokes. It is important to have your blood
levels checked while on this medication.
It was a pleasure taking care of you, best of luck.
Your ___ medical team
Followup Instructions:
___
|
19707206-DS-18
| 19,707,206 | 20,151,691 |
DS
| 18 |
2118-10-07 00:00:00
|
2118-10-09 15:15:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending: ___
Chief Complaint:
Cough
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ male with history of
hypertension, hyperlipidemia, CAD, and recently diagnosed
multiple myeloma s/p XRT to right clavicular head and currently
on RVD who presents with URI symptoms, admitted for observation.
Having coughing from day prior to admission, intermittently
productive of white or clear sputum. Mild exertional dyspnea. No
sick contacts. Denies fevers, chills, dark or rusty sputum,
wheezing, dyspnea at rest, orthopnea, PND, chest pain, abdominal
pain, n/v/d, rash, leg swelling, or leg pain.
On arrival to the floor, patient reports continued dry cough,
but
says that it improved with duonebs in the ED. No longer having
productive cough, and not currently dyspnea. Neck pain present
but comparable to baseline. Denies subjective fevers, chills,
night sweats, chest pain, abdominal pain, n/v/d, rash, or other
symptoms.
Past Medical History:
PAST ONCOLOGIC HISTORY:
Mr. ___ is a ___ yr old male with a past medical hx positive for
HTN, HLD, CAD, who presented to clinic in late ___ for
evaluation after finding concerning elevation in paraprotein.
Mr.
___ reports that in ___ he was at ___ with
his
grand children riding ___ when the ride jerked and he
"felt my neck snap". Over the next several weeks the pain
persisted and he developed a large lump over his right clavicle.
He was seen by his PCP in late ___ were an xray of his neck
was obtained. No fracture or lesion was noted. Given ongoing
pain Mr. ___ was refereed to Orthopedic medicine in early
___ where an MRI was preformed. The MRI did show that
although he had no fracture in his neck he did have a
nonspecific
lesion in his clavicle warranting further work up which included
SPEP, FLC, and quantitative immunoglobulin. He was found to
have
a moniclonial protein at the time of dx to be 4872 MG/DL, Free
kappa 523.5, IgG 6550, Calcium 11.1, T protein 11.7, B2M 4.0,
LDH
123 and HgB 11.1.
Further work up reveled the following: bone marrow findings
showed Plasma cells comprise 35% of the total aspirate count. By
immunohistochemistry, ___ highlights numerous interstitial
plasma cells comprising approximately 70% of the total core
cellularity, they are kappa restricted by kappa and lambda light
chain immunostains. Cytogeneics FISH: POSITIVE for MONOSOMY 13
and GAIN of CHROMOSOMES 5, 9 and 15. Approximately 90% of
interphase bone marrow plasma cells examined after enrichment by
magnetic separation had abnormal probe signals pattern
consistent
with monosomy 13 and gain of chromosomes 5, 9 and 15. These
findings suggest a hyperdiploid karyotype. There was no evidence
of the other cytogenetic findings commonly observed in plasma
cells neoplasms. These include gain of 1q, rearrangement of the
IGH gene and deletion of the TP53 gene.
Based on the International Staging System (ISS) Mr. ___ is
considered a stage II as he is neither stage I (B2M <3.5 mg/L
and
serum albumin greater than or equal to 3.5 g/dL) or stage III
(B2M greater than or equal to 5.5mg/L).
Given the above findings patient was initiated on RVD therapy.
- ___: C1D1 Velcade/Dex/Radiation Therapy
- ___: C2D1 RVD
PAST MEDICAL HISTORY
HYPERLIPIDEMIA
HYPERTENSION
CORONARY ARTERY DISEASE
ERECTILE DYSFUNCTION
OBESITY
SKIN CANCERS
OBSTRUCTIVE SLEEP APNEA
KNEE PAIN
BENIGN PROSTATIC HYPERTROPHY
RIGHT SHOULDER PAIN
___
Surgical History (Last Verified ___ by ___,
MD):
UMBILICAL HERNIA ___
s/p repair
APPENDECTOMY ___
HEMORRHOIDECTOMY
___
Social History:
___
Family History:
Family History (Last Verified ___ by ___,
MD):
Relative Status Age Problem Onset Comments
Mother ___ ___ BONE CANCER
Sister GLOMERULONEPHRITIS at age ___
CHRONIC KIDNEY
DISEASE
Comments: no known history of early MI, no knonw history of
colon or prostate cancer
Physical Exam:
Temp: 97.9 PO BP: 148/82 HR: 56 RR: 16 O2 sat: 96%
O2 delivery: RA Dyspnea: 0 RASS: 0 Pain Score: ___
GENERAL: WDWN older man in NAD
HEENT: NCAT, sclerae anicteric, normal conjunctivae, PERRL,
EOMI,
oropharynx clear
CARDIAC: RRR, normal s1/s2, no m/r/g
LUNG: CTAB, no increased work of breathing
ABD: Soft, non-tender, non-distended, normoactive BS
EXT: Warm, DP pulses 2+ bilaterally, no edema
NEURO: A&Ox3, CNII-XII intact, strength ___ in upper and lower
extremities bilaterally, sensation intact throughout
SKIN: No significant rashes
Pertinent Results:
___ 02:17PM OTHER BODY FLUID FluAPCR-NEGATIVE
FluBPCR-NEGATIVE
___ 12:31PM GLUCOSE-249* UREA N-25* CREAT-1.0 SODIUM-135
POTASSIUM-3.8 CHLORIDE-98 TOTAL CO2-23 ANION GAP-14
___ 12:31PM estGFR-Using this
___ 12:31PM WBC-7.6 RBC-3.40* HGB-10.7* HCT-33.9*
MCV-100* MCH-31.5 MCHC-31.6* RDW-18.4* RDWSD-67.2*
___ 12:31PM NEUTS-73.8* LYMPHS-11.0* MONOS-13.1* EOS-0.0*
BASOS-0.1 NUC RBCS-0.4* IM ___ AbsNeut-5.64 AbsLymp-0.84*
AbsMono-1.00* AbsEos-0.00* AbsBaso-0.01
___ 12:31PM PLT COUNT-152
Brief Hospital Course:
Mr. ___ is a ___ male with history of
hypertension, hyperlipidemia, CAD, and recently diagnosed
multiple myeloma s/p XRT to right clavicular head and currently
on RVD who presents with URI symptoms, admitted for observation.
# URI
# Cough
1 day of cough productive of clear sputum, exertional dyspnea.
Flu negative. CXR clear. No new EKG changes. No chest pain,
pleuritic discomfort, tachycardia, evidence of DVT on exam.
Afebrile, hemodynamically stable, no leukocytosis,
non-neutropenic. Clinical history and work-up to date suggestive
of viral URI, will monitor inpatient given oncologic history.
Symptoms improved with duonebs. Continued home Bactrim for PCP
___.
# Multiple Myeloma:
Monocloncal IgG MM diagnosed ___. S/p XRTx5 to clavicle head.
On C2 RVD, D1 ___. Continued home acyclovir, Bactrim
prophylaxis
# Anemia/Thrombocytopenia:
Secondary to myeloma and chemotherapy. Hgb comparable to recent
baseline. Platelets have been downtrending, but remaining WNL.
# Cancer-Related Pain
Continued home oxycontin and oxycodone PRN
CHRONIC ISSUES
Continued home metoclopramide
# Hypertension
Continued home nifedipine, metoprolol, and HCTZ
# Hyperlipidemia
Continued home simvastatin, ASA
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acyclovir 400 mg PO Q12H
2. Aspirin 81 mg PO DAILY
3. Hydrochlorothiazide 25 mg PO DAILY
4. Metoprolol Succinate XL 50 mg PO DAILY
5. NIFEdipine (Extended Release) 30 mg PO DAILY
6. Omeprazole 40 mg PO BID
7. OxyCODONE (Immediate Release) 5 mg PO Q8H:PRN Pain - Moderate
8. OxyCODONE SR (OxyconTIN) 10 mg PO QHS
9. Simvastatin 80 mg PO QPM
10. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
11. Metoclopramide 10 mg PO QIDACHS possible gastroparesis
12. Phosphorus 500 mg PO BID
Discharge Medications:
1. Albuterol Inhaler ___ PUFF IH Q6H:PRN WHEEZE/ COUGH
RX *albuterol sulfate 90 mcg ___ puffs IH every 6 hours as
needed Disp #*1 Inhaler Refills:*0
2. Azithromycin 250 mg PO Q24H Duration: 4 Days
start on ___
RX *azithromycin 250 mg 1 tablet(s) by mouth once a day Disp #*4
Tablet Refills:*0
3. Acyclovir 400 mg PO Q12H
4. Aspirin 81 mg PO DAILY
5. Hydrochlorothiazide 25 mg PO DAILY
6. Metoclopramide 10 mg PO QIDACHS possible gastroparesis
7. Metoprolol Succinate XL 50 mg PO DAILY
8. NIFEdipine (Extended Release) 30 mg PO DAILY
9. Omeprazole 40 mg PO BID
10. OxyCODONE (Immediate Release) 5 mg PO Q8H:PRN Pain -
Moderate
11. OxyCODONE SR (OxyconTIN) 10 mg PO QHS
12. Phosphorus 500 mg PO BID
13. Simvastatin 80 mg PO QPM
14. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
VIRAL URI
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 caring of you at ___.
WHY WAS I IN THE HOSPITAL?
- You were admitted for monitoring for a respiratory infection
WHAT HAPPENED TO ME IN THE HOSPITAL?
- You had a chest X ray, which showed no evidence of pneumonia
- You received nebulizers to help with your breathing
- Your vital signs and labs were monitored
- You improved and were well enough to go home
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
- Continue to take all your medicines and keep your
appointments.
- take azithromycin 250mg daily for 4 days starting on ___.
- do not take Revlemid until your oncologist tells you to
restart it.
We wish you the best.
Sincerely,
Your ___ Team
Followup Instructions:
___
|
19707206-DS-20
| 19,707,206 | 25,778,560 |
DS
| 20 |
2119-02-06 00:00:00
|
2119-02-06 15:11:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
chest pain and back pain with associated SOB
Major Surgical or Invasive Procedure:
pheresis line placement: ___
History of Present Illness:
Patient is a ___ male with a
history of multiple myeloma, diabetes presenting with back pain
and chest pain. He said the pain started at 11 ___ the night of
presentation, he reports the pain as being higher up in his back
and radiates across his chest. He denies any recent trauma, the
pain came on while he was laying in bed. He says the pain comes
on in spasms, describes as ___ in severity. Has never felt
pain
like this before. HE is scheduled to get stem cell transfusion
on
___. Reports SOB with the chest and back pain. Took
oxycodone
when the pain started with no relief.
Past Medical History:
PAST MEDICAL HISTORY
HYPERLIPIDEMIA
HYPERTENSION
CORONARY ARTERY DISEASE
ERECTILE DYSFUNCTION
OBESITY
SKIN CANCERS
OBSTRUCTIVE SLEEP APNEA
KNEE PAIN
BENIGN PROSTATIC HYPERTROPHY
RIGHT SHOULDER PAIN
NASH
Surgical History (Last Verified ___ by ___,
MD):
UMBILICAL HERNIA ___
s/p repair
APPENDECTOMY ___
HEMORRHOIDECTOMY
___
PAST ONCOLOGIC HISTORY (per OMR):
- ___: Cycle 1 Velcade/Dexamethasone
- ___: Radiation therapy to right clavicle head, 5
treatments
- ___ - ___: Admission for increasing neck pain. Felt
more
musculoskeletal.
- ___ - ___: Admission for reduced appetite, dyspepsia &
abdominal bloating. EGD showed nonspecific cobblestoning of the
proximal duodenum, with biopsies showing enteritis; started on
high-dose PPI and standing Reglan with meals (for possible
Velcade-induced gastroparesis). Symptoms improved.
- ___: Cycle 2 Velcade, Revlimid 25 mg D ___,
Dexamethasone. Delayed for nausea and concern for delayed
motility
- ___ - ___: Admission for cough/URI. Treated with Z-pak
and inhalers.
- ___: Cycle 3 Velcade, Revlimid 25 mg D ___,
Dexamethasone
- ___: Fever; cough with Influenza B; treated with Tamiflu
- ___: Cycle 4 Velcade, Revlimid 25 mg D ___,
Dexamethasone
- ___: Cycle 5 Velcade HELD d/t increasing neuropathies.
Revlimid 25 mg x 14 days with weekly Dexamethasone.
Social History:
___
Family History:
-mother deceased at age ___ r/t bone cancer
-sister dx with glomerulonephritis at age ___
Physical Exam:
ADMISSION PHYSICAL EXAM
========================
24 HR Data (last updated ___ @ 1723)
Temp: 98.0 (Tm 98.0), BP: 148/75, HR: 70, O2 sat: 97%, O2
delivery: RA, Wt: 198.5 lb/90.04 kg
GENERAL: pacing in room, appears comfortable, no acute distress,
pleasant
EYES: Pupils equally round reactive to light, anicteric sclera
HEENT: Oropharynx clear, no lesions, moist mucous membranes
NECK: Supple, normal range of motion
LUNGS: Clear to auscultation bilaterally without any wheezes
rales or rhonchi. Breathing even and non-labored.
CV: Regular rate and rhythm no murmurs rubs or gallops normal
distal perfusion no edema
ABD: Soft nontender nondistended normoactive bowel sounds, no
rebound or guarding
EXT: No deformity, normal muscle bulk
SKIN: Warm dry, no rash
NEURO: Alert and oriented x3, fluent speech
LINES: PIV
DISCHARGE PHYSICAL EXAM
========================
Temp: 97.8, BP: 142/79, HR: 62, O2 sat: 95%, O2
delivery: RA, Wt: 198.5 lb/90.04 kg
GENERAL: lying down in phresis unit, appears comfortable, no
acute distress, pleasant
EYES: Pupils equally round reactive to light, anicteric sclera
HEENT: Oropharynx clear, no lesions, moist mucous membranes
NECK: Supple, normal range of motion
LUNGS: Clear to auscultation bilaterally without any wheezes
rales or rhonchi. Breathing even and non-labored.
CV: Regular rate and rhythm no murmurs rubs or gallops normal
distal perfusion no edema
ABD: Soft nontender nondistended normoactive bowel sounds, no
rebound or guarding
EXT: No deformity, normal muscle bulk
SKIN: Warm dry, no rash
NEURO: Alert and oriented x3, fluent speech
LINES: tunneled pheresis line-CDI
Pertinent Results:
ADMISSION LABS
====================
___ 03:27AM BLOOD WBC-0.6* RBC-4.19* Hgb-12.7* Hct-39.1*
MCV-93 MCH-30.3 MCHC-32.5 RDW-14.7 RDWSD-50.3* Plt Ct-44*
___ 03:27AM BLOOD Neuts-0* Lymphs-75* Monos-10 Eos-8*
Baso-1 Atyps-4* Myelos-2* AbsNeut-0.00* AbsLymp-0.47*
AbsMono-0.06* AbsEos-0.05 AbsBaso-0.01
___ 03:27AM BLOOD Poiklo-1+* Ovalocy-1+* Tear Dr-1+* RBC
Mor-SLIDE REVI
___ 03:27AM BLOOD ___ PTT-30.9 ___
___ 03:27AM BLOOD Plt Smr-VERY LOW* Plt Ct-44*
___ 03:27AM BLOOD Glucose-135* UreaN-19 Creat-1.2 Na-141
K-4.1 Cl-103 HCO3-25 AnGap-13
___ 06:38AM BLOOD b2micro-2.0
DISCHARGE LABS
====================
___ 12:00AM BLOOD WBC-17.7* RBC-3.39* Hgb-10.3* Hct-31.5*
MCV-93 MCH-30.4 MCHC-32.7 RDW-15.4 RDWSD-52.2* Plt Ct-51*
___ 12:00AM BLOOD Neuts-62 Bands-30* Lymphs-3* Monos-0*
Eos-1 Baso-0 Atyps-1* Metas-1* Myelos-2* NRBC-0.6*
AbsNeut-16.28* AbsLymp-0.71* AbsMono-0.00* AbsEos-0.18
AbsBaso-0.00*
___ 12:00AM BLOOD Anisocy-1+* Poiklo-1+* Polychr-1+*
Ellipto-1+* RBC Mor-SLIDE REVI
___ 12:00AM BLOOD Plt Smr-VERY LOW* Plt Ct-51*
___ 12:00AM BLOOD Glucose-82 UreaN-10 Creat-0.9 Na-146
K-3.5 Cl-103 HCO3-26 AnGap-17
___ 12:00AM BLOOD ALT-10 AST-21 LD(LDH)-443* AlkPhos-100
TotBili-0.3
___ 12:00AM BLOOD Albumin-4.0 Calcium-9.7 Phos-3.0 Mg-1.8
___ 12:00AM BLOOD
Brief Hospital Course:
Mr. ___ is a pleasant ___ year-old male with hx of CAD, HTN, DL,
OSA, ID-T2DM, and MM s/p Velcade, Dex, and Revlimid recently
admitted from ___ for stem cell mobilization with Cytoxan.
He presented to ED ___ with severe lower back, chest pain and
associated SOB after beginning high-dose neupogen 960mcg daily
on ___ in preparation for stem cell collection ___.
#BACK AND HIP PAIN:
#SOB (resolved): Presented with severe chest and back pain with
associated SOB. Concern for PE especially as hypercoagulability
is common in patients with MM vs. aortic dissection vs. ACS vs.
bony pain secondary to GCSF. ACS less likely given NSR EKG and
negative troponin. CXR showed no signs of aortic arch widening
concerning for aortic dissection. CTA with no evidence of PE.
Therefore, given above findings, pain in likely consistent with
bony pain secondary to neupogen especially in the setting of
administration of 960mcg neupogen daily since ___. Pain
improves with PRN IV dilaudid now not requiring off neupogen.
Discharged home to resume prior pain management regimen with PRN
oxycodone.
#IGG KAPPA MULTIPLE MYELOMA:
#NEUTROPENIA: Presented in late ___ with 3 month
history of neck pain, prompting imaging which showed concerning
lesions for multiple myeloma. Work up was notable for a
monoclonal IgG Kappa with one marrow biopsy confirming this
diagnosis with plasma cells comprising approximately 70% of the
total core cellularity. He received XRT to the right clavicle
lesions and was initiated on treatment with RVD(Revlimid held
with ___ cycle d/t ongoing XRT). He has received 4 cycles of
treatment with an excellent response to his treatment based on
monoclonal protein and free kappa levels. Treatment has been
complicated by steroid induced diabetes as well as painful
neuropathy of his legs. Velcade was held for Cycle 5 and he
completed the 14 days of Revlimid(last dose on ___. As he
has had an excellent response, the plan is to reassess his
disease and move forward with autologous transplant. Bone marrow
biopsy for disease assessment with marked decrease in
involvement(< 5%). PET scan with decreased burden of disease. He
received high dose Cytoxan for stem cell mobilization on
___, likely the etiology for neutropenia. He was discharged
home ___ with instruction to administer daily 480mcg neupogen
x6
days then to increase to 960mcg x3 days beginning on ___. He
received 960mcg neupogen SC daily through ___. Now s/p
pheresis line placement and stem cell collection ___, with
collection >16. Continues on monthly Zometa outpatient per
outpatient recs, last given ___. Levofloxacin prophylaxis
discontinued ___ as no longer neutropenic. F/U scheduled with
Dr. ___ admission for auto-SCT ___.
#BOWEL IRREGULARITY (Resolved): No further episodes now
constipated likely from narcotics. On admission patient reported
1 episode of loose stool ___ AM. Not associated with fevers,
abdominal pain or cramping. Typical bowel pattern is formed BM
Q3-4 days per patient.
CHRONIC/RESOLVED ISSUES
=============================
#NEUROPATHY: Marked increase in neuropathies of lower legs in
the setting of Velcade and Revlimid. Most likely exacerbated by
lumbar disc disease and diabetes. Requiring increasing amounts
of Oxycodone, 2 tablets, now every 4 hours. Has now tapered off
gabapentin as he felt it did not help and pain persisted. Prior
to admission for acute pain, his pain regimen consisted of
oxycodone, ___ tablets every ___ hours as needed for pain.
Will continue home pain management regimen at discharge.
#Abnormal uptake on Prostate noted on PET scan: Followed by Dr.
___. PSA in 3 range. Was supposed to get MRI for further
evaluation and holding off on invasive procedures as able but
not able to get MRI with the leg pain (could not lie still).
#STEROID INDUCED DIABETES: Home regimen consisted of metformin,
Lantus and Humalog sliding scale insulin. Better control without
steroids. Restarted metformin at discharge.
#SCC: Skin lesion biopsied which shows SCC extending to margins.
Had surgical re-excision with no residual cancer and well healed
area.
CORE MEASURES
===================
# CODE: Presumed Full
# EMERGENCY CONTACT: ___ Relationship: Wife
Phone number: ___
# DISPO: discharge to home ___ to follow up with Dr. ___
in clinic prior to admission for auto-SCT on ___.
TRANSITIONAL ISSUES
[ ] Patient will be seen by Dr. ___ prior to admission for
auto-SCT-patient to be called with this appointment and time.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acyclovir 400 mg PO Q12H
2. Cyanocobalamin 1000 mcg PO DAILY
3. Metoprolol Succinate XL 50 mg PO DAILY
4. NIFEdipine (Extended Release) 30 mg PO DAILY
5. Omeprazole 40 mg PO BID
6. OxyCODONE (Immediate Release) 10 mg PO Q4H:PRN Pain -
Moderate
7. Pyridoxine 50 mg PO DAILY
8. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
9. Hydrochlorothiazide 25 mg PO DAILY
10. LevoFLOXacin 500 mg PO Q24H
11. MetFORMIN (Glucophage) 500 mg PO BID
12. Filgrastim-sndz 480 mcg SC Q24H
13. Glargine 38 Units Breakfast
Insulin SC Sliding Scale using HUM Insulin
Discharge Medications:
1. Glargine 38 Units Breakfast
Insulin SC Sliding Scale using HUM Insulin
2. Acyclovir 400 mg PO Q12H
3. Cyanocobalamin 1000 mcg PO DAILY
4. Hydrochlorothiazide 25 mg PO DAILY
5. MetFORMIN (Glucophage) 500 mg PO BID
6. Metoprolol Succinate XL 50 mg PO DAILY
7. NIFEdipine (Extended Release) 30 mg PO DAILY
8. Omeprazole 40 mg PO BID
9. OxyCODONE (Immediate Release) 10 mg PO Q4H:PRN Pain -
Moderate
10. Pyridoxine 50 mg PO DAILY
11. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS
==================
MULTIPLE MYELOMA
ACUTE PAIN
SECONDARY DIAGNOSIS
=====================
STEROID INDUCED DIABETES
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 evaluation of acute chest and back pain
likely due to neupogen bony pain. You improved with pain
medication and underwent stem cell collection on ___ which you
tolerated..... Please follow up with Dr. ___ as stated below.
It was a pleasure taking care of you.
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
19707324-DS-9
| 19,707,324 | 21,359,297 |
DS
| 9 |
2168-11-01 00:00:00
|
2168-11-02 13:22:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
Dual chamber St. ___ Pacemaker (___)
History of Present Illness:
___ with h/o atrial fibrillation (on rivaroxaban) presented with
dyspnea x 5 days. Denied orthopnea, uses CPAP at night. Last
night when he got up to use the bathroom he felt dyspneic.
Denies chest pain. He reports eating salty foods lately and his
weight has gone up a few pounds. ___ edema is chronic and
improved. He usually takes 40 po lasix in am and 20 in pm and
took 40mg today. He reports having nightsweats twice this week,
none last night. Denies fevers/chills, abdominal pain.
Past Medical History:
CAD s/p PCI of mLAD (4x18 mm Cypher)
DMII
Hyperlipidemia
Pulmonic stenosis with 8-10 mm Hg mean gradient, congenital
with balloon in ___, stable on Echocardiography
Atrial fibrillation and atrial ectopy - cardioverted ___
Obesity
OSA
Hypothyroidism
dCHF
Social History:
___
Family History:
Male cousin at died ___ of MI - other CAD at advanced ages,
mother died at ___ of ALS and father died at ___ yo with prostate
cancer
Physical Exam:
ADMISSION:
VS: T97.8 HR 34 BP 151/44 RR 20 SPO2 97%
GEN: obese gentleman, sitting on side of bed, NAD
HEENT: MMM, PERRL
PULM: CTAB, no wheezes
CV: Bradycardia, no murmurs
Abd: soft, non-tender, +BS
Ext: warm, well-perfused
DISCHARGE:
GEN: obese gentleman, sitting on side of bed, NAD
HEENT: MMM, PERRL
PULM: CTAB, no wheezes
CV: RRR, no murmurs
Abd: soft, non-tender, +BS
Ext: warm, well-perfused
Pertinent Results:
___ 07:00PM BLOOD WBC-8.2 RBC-4.52* Hgb-14.7 Hct-42.9
MCV-95 MCH-32.6* MCHC-34.4 RDW-14.8 Plt ___
___ 07:01AM BLOOD WBC-8.0 RBC-4.33* Hgb-13.9* Hct-41.5
MCV-96 MCH-32.1* MCHC-33.5 RDW-13.8 Plt ___
___ 07:00PM BLOOD ___ PTT-41.6* ___
___ 07:01AM BLOOD ___ PTT-37.0* ___
___ 07:00PM BLOOD Glucose-183* UreaN-59* Creat-1.5* Na-135
K-5.1 Cl-102 HCO3-20* AnGap-18
___ 07:01AM BLOOD Glucose-136* UreaN-34* Creat-1.0 Na-139
K-4.0 Cl-110* HCO3-20* AnGap-13
___ 07:00PM BLOOD proBNP-2298*
___ 07:00PM BLOOD cTropnT-0.01
___ 07:00PM BLOOD Calcium-9.5 Phos-4.8* Mg-2.8*
___ 07:01AM BLOOD Calcium-9.1 Phos-2.7 Mg-2.1
___ 07:00PM BLOOD Lactate-1.9 K-4.8
EKG ___
Sinus rhythm. High degree A-V block is suggested.
Compared to the previous tracing of ___ A-V block is now
seen.
___
___
EKG ___
Sinus rhythm. Complete heart block is suggested. Clinical
correlation is
suggested. Compared to the previous tracing complete heart block
is now
suggested.
___
___
CXR ___
IMPRESSION:
Interval placement of a dual lead left-sided pacing device with
the leads terminating over the expected location of the right
atrium and right ventricle, respectively. The heart remains
stably enlarged. There is stable enlargement of the pulmonary
artery suggesting underlying pulmonary arterial hypertension.
The interstitium is more prominent as compared to ___ which suggests superimposed mild interstitial edema.
Clinical correlation is recommended. Status post median
sternotomy. No pneumothorax. Minimal blunting of both
costophrenic angles may reflect tiny effusions or pleural
thickening.
Brief Hospital Course:
___ with h/o atrial fibrillation (on rivaroxaban, cardioverted
___, CAD s/p PCI of mLAD (4x18 mm Cypher), last stress ___
w/ no anginal sx or EKG changes, congenital pulmonic stenosis
(last echo w/ severe pulmonic regurg), CHF on home lasix
(40am/20pm) presents with dyspnea x 5 days and is found to be in
thrid degree heart block. He had a dual chamber pacemaker placed
and his symptoms improved and VSS. He needs follow up with
device clinic regarding pacemaker in one week. He was started on
Keflex for antibiotic prophylaxis after pacemaker placement and
needs to continue it for two more days after discharge.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. AcetaZOLamide 250 mg PO HS
2. Rivaroxaban 20 mg PO DAILY
3. Atorvastatin 10 mg PO QPM
4. detemir 40 Units Bedtime
novolog 8 Units Breakfast
novolog 14 Units Lunch
novolog 14 Units Dinner
5. Furosemide 40 mg PO AM
6. Aspirin 81 mg PO BID
7. Levothyroxine Sodium 175 mcg PO DAILY
8. Furosemide 20 mg PO ___
9. Lisinopril 10 mg PO DAILY
10. MetFORMIN XR (Glucophage XR) 1000 mg PO BID
Discharge Medications:
1. AcetaZOLamide 250 mg PO HS
2. Aspirin 81 mg PO BID
3. Atorvastatin 10 mg PO QPM
4. Furosemide 40 mg PO AM
5. Furosemide 20 mg PO ___
6. detemir 40 Units Bedtime
novolog 8 Units Breakfast
novolog 14 Units Lunch
novolog 14 Units Dinner
7. Levothyroxine Sodium 175 mcg PO DAILY
8. Lisinopril 10 mg PO DAILY
9. Rivaroxaban 20 mg PO DAILY
10. MetFORMIN XR (Glucophage XR) 1000 mg PO BID
Do Not Crush
11. Cephalexin 250 mg PO Q6H Duration: 2 Days
RX *cephalexin 250 mg 1 capsule(s) by mouth every six (6) hours
Disp #*9 Capsule Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: Complete heart block
Secondary: CAD, Afib, chronic diastolic CHF
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr. ___,
It was a pleasure taking care of you at ___. You were admitted
with shortness of breath and were found to be in complete heart
block. You received a pacemaker and your symptoms improved. You
should follow up with the pacemaker clinic and with your primary
care provider this week.
Regards,
Your ___ Team
Followup Instructions:
___
|
19707603-DS-3
| 19,707,603 | 22,625,317 |
DS
| 3 |
2128-03-20 00:00:00
|
2128-03-24 22:07:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
hydroxychloroquine / lisinopril / simvastatin
Attending: ___.
Chief Complaint:
nausea
vomit
anorexia
abdominal pain
Major Surgical or Invasive Procedure:
ERCP - sphincterotomy and stent placement
___ - drainage of fluid collection
History of Present Illness:
Ms. ___ is a ___ with diabetes mellitus type 2,
hypertension,hyperlipidemia, and morbid obesity who initially
presented on ___ for surgical management of acute
cholecystitis. She underwent laparoscopic cholecystectomy
without complication that same day and was discharged on POD2
after an uneventful postoperative course. She was started on
ciprofloxacin and metronidazole during her stay due to findings
of marked inflammation and partially gangrenous gallbladder
intraoperatively and discharged with prescriptions to complete a
5 day total course.
She re-presents today to the ED with symptoms of anorexia,
nausea, and vomiting for 3 days. She has RUQ abdominal pain that
has not improved since discharge. She has not been able to
regularly take her discharge medications, including an inability
to complete her course of antibiotics or pain medications. When
she has been able to take her prescribed oxycodone, she feels it
does not improve her pain. She has been passing flatus and
having loose bowel movements. She denies symptoms of fever,
chills, SOB, or chest pain.
Past Medical History:
Hypertension
Diabetes mellitus, type II
Hyperlipidemia
Morbid obesity
Rheumatoid arthritis
Social History:
___
Family History:
- CVA
- DM, II
- Breast Cancer
Physical Exam:
Temp 98.1 BP 135 / 84 HR 86 RR 20 Sat02:98%
General: lying in bed, no acute distress
HEENT: No scleral icterus, mucous membrane is moist
Cardio: Regular rate and rhythm
Pulmonary: No increased work of breathing
Abdomen: mildly distended, tender in RUQ and epigastrium, ___
drain in place
Extremities: Warm and well-perfused, chronic scar to the right
medial malleolus
Pertinent Results:
___ 04:40AM BLOOD WBC-7.8 RBC-3.93 Hgb-12.3 Hct-37.5 MCV-95
MCH-31.3 MCHC-32.8 RDW-14.6 RDWSD-50.5* Plt ___
___ 04:10AM BLOOD WBC-9.7 RBC-3.81* Hgb-11.9 Hct-36.2
MCV-95 MCH-31.2 MCHC-32.9 RDW-14.6 RDWSD-49.6* Plt ___
___ 04:57AM BLOOD WBC-9.7 RBC-3.91 Hgb-11.9 Hct-37.3 MCV-95
MCH-30.4 MCHC-31.9* RDW-14.6 RDWSD-50.0* Plt ___
___ 10:37AM BLOOD WBC-11.7* RBC-4.18 Hgb-12.8 Hct-39.0
MCV-93 MCH-30.6 MCHC-32.8 RDW-14.6 RDWSD-49.2* Plt ___
___ 10:37AM BLOOD Neuts-74.5* Lymphs-8.9* Monos-11.9
Eos-3.5 Baso-0.4 Im ___ AbsNeut-8.74* AbsLymp-1.04*
AbsMono-1.39* AbsEos-0.41 AbsBaso-0.05
___ 04:40AM BLOOD Plt ___
___ 04:10AM BLOOD Plt ___
___ 04:57AM BLOOD Plt ___
___ 04:57AM BLOOD ___ PTT-28.0 ___
___ 10:37AM BLOOD Plt ___
___ 04:40AM BLOOD Glucose-109* UreaN-7 Creat-0.6 Na-144
K-4.1 Cl-105 HCO3-26 AnGap-13
___ 04:10AM BLOOD Glucose-131* UreaN-8 Creat-0.6 Na-144
K-3.7 Cl-105 HCO3-29 AnGap-10
___ 04:57AM BLOOD Glucose-139* UreaN-10 Creat-0.6 Na-142
K-4.4 Cl-105 HCO3-26 AnGap-11
___ 10:37AM BLOOD Glucose-171* UreaN-11 Creat-0.7 Na-142
K-4.4 Cl-101 HCO3-28 AnGap-13
___ 04:40AM BLOOD ALT-39 AST-33 AlkPhos-134* TotBili-0.5
___ 04:10AM BLOOD ALT-45* AST-34 AlkPhos-139* TotBili-0.5
___ 04:57AM BLOOD ALT-57* AST-51* AlkPhos-143* TotBili-0.6
___ 10:37AM BLOOD ALT-69* AST-62* AlkPhos-155* TotBili-0.8
___ 04:56AM BLOOD CK-MB-1 cTropnT-<0.01
___ 04:40AM BLOOD Calcium-7.6* Phos-2.9 Mg-1.7
___ 04:10AM BLOOD Calcium-7.9* Phos-3.1 Mg-1.9
___ 04:57AM BLOOD Calcium-8.0* Phos-3.4 Mg-1.8
___ 10:37AM BLOOD Albumin-3.1*
___ 10:48AM BLOOD Lactate-1.3
Brief Hospital Course:
Mrs. ___ was admitted on ___ when she presented with
anorexia, nausea, vomiting for 3 days and right upper quadrant
abdominal pain that has not improved since discharge she
underwent a laparoscopic cholecystectomy for acute cholecystitis
on ___. An ultrasound on the day of admission showed a
perihepatic hypoechoic collection measuring up to 7.1 cm with
internal hyperechoic echoes suggesting a complex fluid
collection likely representing hematoma versus biloma. No
biliary dilation identified to suggest retained biliary stone.
Patient was kept n.p.o. and was hydrated with IV fluids. She
was started on Cipro/Flagyl, pain was well managed. She was
scheduled to undergo ERCP. On ___ she underwent an ERCP
in which a sphincterotomy was performed and a stent was placed,
she was scheduled for stent pull in 4 weeks. On ___
interventional radiology performed a CT-guided drainage of fluid
collection in the gallbladder fossa, approximately 100 cc of
serosanguineous fluid was aspirated with a sample sent for
microbiology evaluation. Patient tolerated well the procedure
and there were no immediate postprocedural complications. On
___ patient was advanced to a regular diet and all
medicines were converted to p.o. Drain output was followed-up
closely and patient described the pain as only mild and graded
it ___. On ___ patient reported 4 episodes of loose
stools which were sent for testing for C. difficile, results
came back negative patient reported pain has decreased
significantly, although her night she complained of lower chest
and epigastric pain with no arm radiation and EKG was ordered
along with troponins, both came back normal. Patient was
educated on how to take care of the drain, as well as how to
measure output, she was instructed of warning signs and to
please call if drainage increased significantly. She was
tolerating oral medication, managing pain well, and comfortable
taking care of during. Patient was discharged on ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. FoLIC Acid 1 mg PO DAILY
2. glimepiride 8 mg oral DAILY
3. Ibuprofen 800 mg PO DAILY:PRN Pain - Mild
4. Ketoconazole 2% 1 Appl TP BID
5. Lantus U-100 Insulin (insulin glargine) 100 unit/mL
subcutaneous QHS
6. Losartan Potassium 100 mg PO DAILY
7. MetFORMIN (Glucophage) 1000 mg PO BID
8. Methotrexate 7.5 mg PO 1X/WEEK (___)
9. Methotrexate 10 mg PO 1X/WEEK (___)
10. Pravastatin 20 mg PO QPM
11. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain -
Moderate
12. Acetaminophen 1000 mg PO Q8H
13. Docusate Sodium 100 mg PO BID
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
2. Docusate Sodium 100 mg PO BID
3. FoLIC Acid 1 mg PO DAILY
4. glimepiride 8 mg oral DAILY
5. Ibuprofen 800 mg PO DAILY:PRN Pain - Mild
6. Ketoconazole 2% 1 Appl TP BID
7. Lantus U-100 Insulin (insulin glargine) 100 unit/mL
subcutaneous QHS
8. Losartan Potassium 100 mg PO DAILY
9. MetFORMIN (Glucophage) 1000 mg PO BID
10. Methotrexate 10 mg PO 1X/WEEK (___)
11. Methotrexate 7.5 mg PO 1X/WEEK (___)
12. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain -
Moderate
RX *oxycodone 5 mg 1 tablet(s) by mouth q6h prn Disp #*20 Tablet
Refills:*0
13. Pravastatin 20 mg PO QPM
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Drained cystic duct leak
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear ___,
___ was a pleasure taking care of you here at ___
___. You were admitted to our hospital for
abdominal pain and nausea following your laparoscopic
cholecystectomy on ___. You were found to have an a cystic
duct leak which was drained by interventional radiology and you
are going home with a drain. You have recovered and are now
ready to be discharged to home. Please follow the
recommendations below to ensure a speedy and uneventful
recovery.
ACTIVITY:
- Do not drive until you have stopped taking pain medicine and
feel you could respond in an emergency.
- You may climb stairs.
- You may go outside, but avoid traveling long distances until
you see your surgeon at your next visit.
- You may start some light exercise when you feel comfortable.
- Heavy exercise may be started after 6 weeks, but use common
sense and go slowly at first.
- You may resume sexual activity unless your doctor has told you
otherwise.
HOW YOU MAY FEEL:
- You may feel weak or "washed out" for 6 weeks. You might want
to nap often. Simple tasks may exhaust you.
- You may have a sore throat because of a tube that was in your
throat during the endoscopy.
YOUR BOWELS:
- Constipation is a common side effect of medicine such as
Percocet or codeine. If needed, you may take a stool softener
(such as Colace, one capsule) or gentle laxative (such as milk
of magnesia, 1 tbs) twice a day. You can get both of these
medicines without a prescription.
- If you go 48 hours without a bowel movement, or have pain
moving the bowels, call your surgeon.
- After some operations, diarrhea can occur. If you get
diarrhea, don't take anti-diarrhea medicines. Drink plenty of
fluids and see if it goes away. If it does not go away, or is
severe and you feel ill, please call your surgeon.
PAIN MANAGEMENT:
- Your pain should get better day by day. If you find the pain
is getting worse instead of better, please contact your surgeon.
If you experience any of the following, please contact your
surgeon:
- sharp pain or any severe pain that lasts several hours
- pain that is getting worse over time
- pain accompanied by fever of more than 101
- a drastic change in nature or quality of your pain
MEDICATIONS:
- Take all the medicines you were on before the operation just
as you did before, unless you have been told differently.
- If you have any questions about what medicine to take or not
to take, please call your surgeon.
DRAIN CARE:
You are being discharged with drains in place. Drain care is a
clean procedure. Wash your hands with soap and warm water before
performing your drain care, which you should do ___ times a day.
Try to empty the drain at the same time each day. Pull the
stopper out of the bottle and empty the drainage fluid into the
measuring cup. Record the amount of fluid on the record sheet,
and reestablish drain suction.
Clean around the drain site(s) where the tubing exits the skin
with soap and water. Be sure to secure your drains so they don't
hang down loosely and pull out.
-Strip the drain tubing, empty the bulb(s), and record the
output ___ times a day as described above.
-Keep a written record of the daily amount from each drain and
bring this to every follow up appointment. Your drains will be
removed once the output tapers off to an acceptable amount.
Followup Instructions:
___
|
19707824-DS-13
| 19,707,824 | 24,196,542 |
DS
| 13 |
2161-03-15 00:00:00
|
2161-03-15 16:56:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ___
Allergies:
___
Attending: ___.
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ with history of dementia, COPD, HFpEF (last
EF 50% ___, CAD s/p CABG, Afib, and CKD who presents for
persistent nausea/vomiting.
Per history obtained in ED, patient has had persistent
nausea/vomiting for the past few days with up to 20 episodes of
emesis/day. She has been taking Zofran (prescribed by PCP) with
little effect and has been unable to keep down food/fluids.
Additionally, she has been experiencing mild shortness of breath
that is worse with episodes of emesis and cough productive of
black phlegm.
She denies abdominal pain and have been having normal bowel
movements without melena/hematochezia. She denies fevers,
headaches, or sick contacts.
In the ED, initial Vitals: T 97.8 HR 78 BP 131/72 RR 22 O2 91%
Exam notable for:
- General: Appears comfortably on 4L NC
- Cardiac: Irregular rhythm, normal rate, no m/r/g
- Pulmonary: Diminished breath sounds at bases
- Abdomen: Moderately distended, nontender, no rebound/guarding
- Ext: 1+ pitting edema in b/l ___
Labs notable for:
- WBC 6.8, Hgb 9.0
- Ca125 512, CEA 3.8
- BUN 37, Cr 2.0
- pro-BNP 7456
- Flu A/B negative
- trop 0.06 --> 0.07
- pH 7.___
- UA tr protein
Imaging:
- ___ CT abdomen/pelvis w/o contrast
1. 3.7 cm soft tissue mass in left adnexa is incompletely
assessed on this nonenhanced exam but is suspicious for
underlying malignancy.
2. Large volume ascites with peritoneal soft tissue nodularity
which may reflect peritoneal carcinomatosis.
3. Enlarged periaortic lymph node measures up to 1.2 cm.
4. 1.4 cm right lower pole hyperdense renal lesion is
incompletely evaluated on this nonenhanced exam. If it would
alter management this may be further evaluated with nonemergent
renal ultrasound or MRI.
5. 4.2 cm infrarenal abdominal aortic aneurysm.
6. Compression deformities of the L2 and L3 vertebral bodies are
age
indeterminate.
7. Small bilateral pleural effusions.
8. Nodular opacities in the bilateral lung bases are nonspecific
with
differential considerations including pneumonia, aspiration,
metastases or a combination.
- ___ CXR
1. Interval worsening of moderate pulmonary edema. Small
bilateral pleural effusions appear similar.
2. More focal opacities in the lung bases may reflect
atelectasis, though underlying infection or aspiration is not
excluded. Follow up radiographs after diuresis are suggested.
Consults:
- Ob/Gyn: Concern for mullerian cancer, recommend checking
Ca-125, Ca ___, CEA. Consider CTPA to evaluated for PE and
therapeutic paracentesis for symptom control
Interventions notable for:
- Ondansetron, Promethazine
- Zosyn, Vancomycin
ROS: Positives as per HPI; otherwise negative
Past Medical History:
1. CAD s/p CABG in ___ with a LIMA graft to LAD, and SVG to
circumflex marginal and RCA
2. Hypertension
3. Hyperlipidemia
4. Hemorrhoids s/p banding in ___
5. GERD
6. Gastric Ulcer
7. Hypothyroidism
8. Osteoporosis
9. COPD
10. Left TKR
11. Chronic Back Pain
12. Hearing Loss
13. Cataracts
14. ORIF right hip fracture in ___
Social History:
___
Family History:
Non-contributory
Physical Exam:
ADMISSION:
VS: Afebrile BP 127/78 88 20 93-95% 4L NC
GEN: Elderly woman, laying in bed comfortably, in NAD
HEENT: NC/AT, EOMI, dry MM
CV: Irregular rhythm, regular rate, II/VI systolic murmur
RESP: Decreased breath sounds in bases with dullness to
percussion
GI: Distended, firm, nontender to palpation, no appreciable
fluid
wave
EXT: Trace-1+ pitting edema in b/l ___: Warm, well-perfused, no rashes
NEURO: Alert, oriented to self, moving all extremities with
purpose
DISCHARGE:
Vitals: none
GEN: Elderly woman, laying in bed comfortably, in NAD
HEENT: NC/AT
RESP: Decreased breath sounds in bases with dullness to
percussion
GI: deferred
EXT: deferred
SKIN: no rashes
Pertinent Results:
ADMISSION:
___ 05:37PM BLOOD WBC-6.9 RBC-3.17* Hgb-9.0* Hct-30.4*
MCV-96 MCH-28.4 MCHC-29.6* RDW-17.2* RDWSD-60.3* Plt ___
___ 05:37PM BLOOD Neuts-85.2* Lymphs-6.8* Monos-6.7
Eos-0.0* Baso-0.3 Im ___ AbsNeut-5.86 AbsLymp-0.47*
AbsMono-0.46 AbsEos-0.00* AbsBaso-0.02
___ 05:37PM BLOOD ___ PTT-25.7 ___
___ 05:37PM BLOOD Glucose-116* UreaN-37* Creat-2.0* Na-140
K-4.4 Cl-91* HCO3-33* AnGap-16
___ 05:37PM BLOOD ALT-6 AST-20 CK(CPK)-38 AlkPhos-85
TotBili-0.3
___ 05:37PM BLOOD CK-MB-2 cTropnT-0.06* proBNP-7456*
___ 05:37PM BLOOD Albumin-3.5
___ 05:37PM BLOOD CEA-3.8 CA125-512*
___ 03:16AM BLOOD Type-CENTRAL VE pO2-36* pCO2-57* pH-7.40
calTCO2-37* Base XS-7
___ 05:37PM BLOOD CA ___ -PND
ADDITIONAL LABS:
___ 12:00AM BLOOD cTropnT-0.07* proBNP-9644*
___ 02:14PM BLOOD Type-ART pO2-71* pCO2-60* pH-7.40
calTCO2-39* Base XS-___BDOMEN ___
FINDINGS:
LOWER CHEST: Small bilateral pleural effusions are incompletely
evaluated.
These are associated with overlying compressive atelectasis.
Scattered areas
of nodular opacification are seen in the bilateral visualized
lung bases. No
pericardial effusion is seen. Extensive coronary artery
calcifications are
noted.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogeneous attenuation
throughout.
There is some nodular contour of the liver which may be
secondary to the
ascites. Multiple hypoattenuating hepatic lesions are poorly
evaluated on
current exam and measure up to 2.4 x 2.1 cm in the right hepatic
lobe (02:13).
Some may reflect hepatic cysts/biliary hamartomas and others are
not well
characterized. There is no evidence of intrahepatic or
extrahepatic biliary
dilatation. The gallbladder contains gallstones without wall
thickening or
evidence of inflammation.
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.
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: Bilateral kidneys are symmetrically atrophic. There is
a 1.4 x 1.4
cm right lower pole hyperdense renal lesion which is
incompletely evaluated on
this nonenhanced scan (601:41). There is no hydronephrosis.
There is no
nephrolithiasis.
GASTROINTESTINAL: The stomach is unremarkable. No evidence of
bowel
obstruction. Small and large bowel loops are otherwise
unremarkable. The
appendix is not visualized. Large volume ascites. Scattered
ill-defined
areas of peritoneal soft tissue density are seen through out the
peritoneum
including the left upper quadrant where they measure up to 3.3 x
1.9 cm
(601:34) the soft tissue densities are also seen extending into
the anterior
abdominal wall in the left periumbilical space (02:45)
PELVIS: The urinary bladder and distal ureters are unremarkable.
There is
moderate volume fluid in the pelvis.
REPRODUCTIVE ORGANS: The uterus is unremarkable. There is a 3.7
x 3.3 cm soft
tissue mass in the left adnexal (02:54). No definite right
adnexal lesions
are identified.
LYMPH NODES: Enlarged retroperitoneal lymph nodes measure up to
1.2 cm in
short axis at the left parrot aortic station (02:29). No
mesenteric
lymphadenopathy. There is no pelvic or inguinal
lymphadenopathy.
VASCULAR: Aneurysmal dilatation of the infrarenal abdominal
aorta up to 4.2 x
3.5 cm. Extensive atherosclerotic disease is noted.
BONES: Patient is status post fixation for a right femoral
fracture with
demonstration of a displaced lesser trochanteric fracture
fragment. Chronic
fracture deformity of the inferior and superior left pubic ramus
are also
seen. Compression deformities of the L2 and L3 vertebral bodies
are age
indeterminate. Multilevel degenerative changes of the
thoracolumbar spine are
moderate to severe. No aggressive osseous lesions are
identified.
SOFT TISSUES: Soft tissue density seen to the left of the
umbilicus.
IMPRESSION:
1. 3.7 cm soft tissue mass in left adnexa is incompletely
assessed on this
nonenhanced exam but is suspicious for underlying malignancy.
2. Large volume ascites with peritoneal soft tissue nodularity
which may
reflect peritoneal carcinomatosis.
3. Enlarged periaortic lymph node measures up to 1.2 cm.
4. 1.4 cm right lower pole hyperdense renal lesion is
incompletely evaluated
on this nonenhanced exam. If it would alter management this may
be further
evaluated with nonemergent renal ultrasound or MRI.
5. 4.2 cm infrarenal abdominal aortic aneurysm.
6. Compression deformities of the L2 and L3 vertebral bodies are
age
indeterminate.
7. Small bilateral pleural effusions.
8. Nodular opacities in the bilateral lung bases are nonspecific
with
differential considerations including pneumonia, aspiration,
metastases, or a
combination.
Brief Hospital Course:
SUMMARY:
========
Ms. ___ is a ___ with history of dementia, COPD, HFpEF (last
EF 50% ___, CAD s/p CABG, Afib, and CKD who presents for
persistent nausea/vomiting, found to have an adnexal mass and
findings concerning for peritoneal carcinomatosis. She opted for
comfort care only and is discharged to hospice.
TRANSITIONAL:
=============
[] Started CMO, only give medications that make the patient
comfortable
ACUTE:
======
# Adnexal mass
# Concern for peritoneal carcinomatosis
# Goals of care
The patient presented with persistent nausea/vomiting, SOB,
abdominal distention consistent with findings of peritoneal
carcinomatosis on CT. After lengthy goals of care discussion
with family, the decision was made to pursue only
comfort-focused care. They had been looking into transitioning
to hospice and are interested in more information about this. SW
was consulted. Medications were transitioned to symptomatic
management with opioids for air hunger, in addition to nebs,
Zofran, Tylenol, as needed for pain. She was made comfort
measures only and discharged to hospice on ___.
# Hypoxia
Etiology likely multifactorial in the setting of large volume
ascites compressing diaphragm, small pleural effusions, and
possible metastatic disease in chest. The patient underwent a
therapeutic paracentesis on ___. Otherwise treated with opioids
as above.
# ___ on CKD
Baseline unclear but with last Cr 1.5 in ___. This was likely
pre-renal in the setting of poor PO intake/emesis. Given comfort
focused care, we stopped trending labs.
# NSTEMI
Likely due to demand ischemia; currently with no active chest
pain. No further management required.
CHRONIC:
========
# HFpEF - Held medications in light of comfort-focused care.
# COPD
Not on home oxygen. No evidence of COPD exacerbation. Albuterol
nebs PRN as above
# Atrial fibrillation
In afib with controlled rates. Held eloquis in light of
comfort-focused care
CONTACT
Name of health care proxy: ___
Relationship: son
Phone number: ___
CODE: Comfort measures only, DNR/DNI
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Acetaminophen 325 mg PO Q6H:PRN Pain - Mild/Fever
2. Denosumab (Prolia) 60 mg SC Q6 MONTHS
3. Torsemide 60 mg PO DAILY
4. ALPRAZolam 0.5 mg PO 1 TAB QAM, 1 TAB NOON, 2 TABS QHS
5. aspirin 81 mg oral DAILY
6. Atorvastatin 40 mg PO QPM
7. Citalopram 10 mg PO DAILY
8. Docusate Sodium 100 mg PO BID:PRN Constipation - Third Line
9. Fish Oil (Omega 3) 1000 mg PO BID
10. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
11. Levothyroxine Sodium 75 mcg PO DAILY
12. Lidocaine 5% Patch 1 PTCH TD QAM
13. Mirtazapine 30 mg PO QHS
14. Multivitamins 1 TAB PO DAILY
15. Omeprazole 20 mg PO DAILY
16. Polyethylene Glycol 17 g PO DAILY:PRN constipation
17. Alvesco (ciclesonide) 80 mcg/actuation inhalation 2 puffs
once a day
18. Calcitrate-Vitamin D (calcium citrate-vitamin D3) 315-250
mg-unit oral BID
19. Hydrocortisone Acetate Suppository ___ TIMES DAILY
AS NEEDED
20. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation 1
to 2 puffs every 6 hours prn
21. Restasis 0.05 % ophthalmic (eye) 1 drop in each eye q12h
22. Alvesco (ciclesonide) 80 mcg/actuation inhalation DAILY
23. Salmeterol Xinafoate Diskus (50 mcg) 1 INH IH Q12H
Discharge Medications:
1. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN SOB
2. Aluminum-Magnesium Hydrox.-Simethicone ___ mL PO QID:PRN
abdominal discomfort
3. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation
4. HYDROmorphone (Dilaudid) 0.5-1 mg IV Q2H:PRN air hunger/pain
5. Ondansetron ___ mg IV Q8H:PRN Nausea/Vomiting - First Line
Reason for PRN duplicate override: Alternating agents for
similar severity
6. OxyCODONE (Immediate Release) 2.5-5 mg PO Q2H:PRN air hunger
7. Sarna Lotion 1 Appl TP QID:PRN Itching
8. Senna 8.6 mg PO BID:PRN Constipation
9. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild/Fever
10. ALPRAZolam 0.5 mg PO TID:PRN anxiety
11. Torsemide 60 mg PO DAILY:PRN volume overload, shortness of
breath
can take for comfort/prevention of fluid overload for comfort
12. Mirtazapine 30 mg PO QHS
13. Polyethylene Glycol 17 g PO DAILY:PRN constipation
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
=================
Peritoneal carcinomatosis
Acute hypoxemic respiratory failure
Acute kidney injury
Non-ST elevation myocardial infarction
SECONDARY DIAGNOSES:
=====================
Heart failure with preserved ejection fraction
Chronic obstructive pulmonary disease
Atrial fibrillation
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Ms. ___,
WHY WERE YOU ADMITTED TO THE HOSPITAL?
- You were admitted to the hospital because you were short of
breath
WHAT HAPPENED WHILE YOU WERE IN THE HOSPITAL?
- You were found to have findings concerning for a new cancer.
- You improved and were ready to leave the hospital.
WHAT DO YOU NEED TO DO WHEN YOU LEAVE THE HOSPITAL?
- Please take all of your medications as prescribed and go to
your follow up appointments with your doctors ___ below)
- Weigh yourself every morning, before you eat or take your
medications. Call your doctor if your weight increases by more
than 3 pounds
- Please maintain a low salt diet and monitor your fluid intake
- Seek medical attention if you have new or concerning symptoms
It was a pleasure participating in your care. We wish you the
best!
- Your ___ Care Team
Followup Instructions:
___
|
19707837-DS-17
| 19,707,837 | 21,193,920 |
DS
| 17 |
2153-02-05 00:00:00
|
2153-02-05 19:59:00
|
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:
Blood transfusion, total 4 units
History of Present Illness:
___ y/o male with history of multiple myeloma presenting with 6
month history of exertional chest pain and fatigue. Patient
reports substernal chest pain for the last 6 months that has
worsened over the last 4 days. Pain is described as achy,
substernal without radiation into the back, arms or jaw.
Exertional and non-pleuritic, resolves with rest. Reports
lightheadedness with standing. Reports calf pain with ___ mile
walk or climing one flight of stairs. Denies shortness of
breath. Reports bright red blood per rectum for the last several
months secondary to hemorrhoids. Patient returned from 6 month
trip to native ___ on ___. Saw PCP for this complaint on
___, Hb 5.3, told to come to ED.
Denies ASA, Plavix or Coumadin. No Hx CAD. No recent stress.
Never had cath. Denies smoking hx.
On arrival to the ED, patient's vitals were HR 64 BP 129/65 RR
20 SaO2 100% RA. His breath sounds were clear on exam. His labs
were significant for H/H 5.5/18, WBC 2.0, Trop <.01, Na 130, Cr
1.8, INR 1.5, D-Dimer 1297, stool guaiac negative. NCCT chest
showed lytic lesions of the spine and ribs consistent with his
multiple myeloma.
On the floor, vs were: T 97.8 P 67 BP 143/62 R 16 O2 sat 100 RA.
Patient looks well, has no present complaints. Denies current
chest pain.
Past Medical History:
Multiple myeloma
hemorrhoids
DM-II
BPH s/p TURP
Social History:
___
Family History:
No cancer or heart disease
Physical Exam:
ADMISSION PHYSICAL EXAM:
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, poor dentition
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, 2+ pulses, no clubbing, cyanosis or
edema
DISCHARGE PHYSICAL EXAM:
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, poor dentition
Neck: supple, JVP not elevated, no LAD
Lungs: Mild stridor and wheeze throughout. No 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, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
ADMISSION LABS:
___ 01:43PM BLOOD WBC-2.0* RBC-1.57* Hgb-5.5* Hct-18.0*
MCV-115* MCH-35.2* MCHC-30.6* RDW-15.8* Plt ___
___ 01:43PM BLOOD Neuts-50.7 Lymphs-43.6* Monos-3.0 Eos-1.6
Baso-1.1
___ 01:43PM BLOOD ___ PTT-35.3 ___
___ 01:43PM BLOOD Glucose-93 UreaN-29* Creat-1.8* Na-130*
K-4.4 Cl-102 HCO3-24 AnGap-8
___ 01:43PM BLOOD LD(LDH)-351*
___ 01:43PM BLOOD Calcium-8.6 Phos-3.9 Mg-2.0 Iron-58
___ 01:43PM BLOOD calTIBC-151* VitB12-363 Ferritn-195
TRF-116*
___ 02:28PM BLOOD D-Dimer-1297*
DISCHARGE LABS:
___ 07:00AM BLOOD WBC-2.2* RBC-2.75*# Hgb-9.0*# Hct-27.4*#
MCV-100* MCH-32.5* MCHC-32.6 RDW-21.9* Plt ___
___ 07:00AM BLOOD Neuts-47.3* Lymphs-48.3* Monos-3.6
Eos-0.2 Baso-0.5
___ 07:00AM BLOOD Glucose-64* UreaN-24* Creat-1.7* Na-130*
K-3.7 Cl-103 HCO3-24 AnGap-7*
___ 07:00AM BLOOD TotProt-13.7* Calcium-8.6 Phos-3.8 Mg-1.9
IMPORTANT LABS
___ 06:10AM BLOOD b2micro-10.9*
___ 10:12PM URINE Blood-NEG Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
___ 10:12PM URINE Hours-RANDOM Creat-96 Na-112 K-61 Cl-128
TotProt-66 Prot/Cr-0.7*
STUDIES
___ CXR:
1. Ill-defined contour of the aortic knob. In setting of chest
pain, CT should
be considered to further assess. Alternatively if low suspicion
for acute
aortic syndrome, repeat with PA and lateral views can be
performed.
2. Increased opacity projecting over the upper lungs, left
greater than right
likely technical due to overlying soft tissues but can be
further clarified by
a PA and lateral.
3. Osseous findings compatible with patient's known multiple
myeloma.
___ CT Chest
1. No findings to explain patient's chest x-ray abnormality
which was likely
projectional. No mediastinal hematoma.
2. Diffuse lytic lesions throughout the bones compatible the
patient's
history of for multiple myeloma. T11 compression deformity which
may be old.
Soft tissue extension along lesion of the anterior right seventh
rib.
Brief Hospital Course:
___ y/o male with history of multiple myeloma presenting with 6
month history of exertional chest pain and fatigue in setting of
acute on chronic anemia. hemoglobin of 5.5 improved to 9.0
after 4 units of PRBCs.
# Chest Pain. Patient with reports of exertional chest pain over
preceding months. In house pain attributed to demand in setting
of acute on chronic anemia. No concern for acute plaque rupture.
Pain resolved after transfusion. Patient deferred further
cardiac work-up.
# Acute on Chronic Anemia: Likely secondary to underproduction
in setting of known, untreated multiple myeloma and renal
dysfunction. Per PCP documentation, HCT noted to gradually
downtrending over months. On admission Hgb 5.0 which increased
to 9.0 after transfusion of 4 units. No signs of GI bleeding in
house (guaiac negative) Iron studies wnl. Patient was started on
B-12 and folate, given macrocytosis.
[] Continue to trend as an outpatient
[] Repeat CBC/Chem7 on ___, results will be faxed to PCP.
# Multiple Myeloma: Patient with documented history MM. Seen by
heme onc and after discssion patient declined treatment. On
admission, evidence of disease progression as CT demonstrates
obvious lytic bone lesions on CT. Beta2micro elevated at 10.9,
which correlates to stage III multiple myeloma, from ~3 at last
check.
In house, patient continues to decline treatment, but we talked
at length about other treatments, such as bisphosphonates to
slow progress of bone lesions as well as intermittent
transfusions to prevent recurrent chest pain. The patient agreed
to consider supportive therapy as outpatient.
[] Follow-up pending SPEP/UPEP
[] Follow up with primary care and oncology was arranged.
[] Discuss use of bisphosphonates
#Renal Insuffiency: Patient with baseline renal insuffiency
(1.3-1.4 in ___. ON admission, Cr was 1.8. Likely secondary to
multiple myeloma. Cr improved slightly to 1.7 after 4u PRBC.
# Diabetes: Patient does not take his prescribed metformin. His
glucose was not elevated during this admission.
# Full Code
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. This patient is not taking any preadmission medications
Discharge Medications:
1. FoLIC Acid 1 mg PO DAILY
RX *folic acid 1 mg 1 tablet(s) by mouth every day Disp #*30
Tablet Refills:*0
2. Cyanocobalamin 100 mcg PO DAILY
RX *cyanocobalamin (vitamin B-12) 100 mcg 1 tablet(s) by mouth
every day Disp #*30 Tablet Refills:*0
3. Ferrous Sulfate 325 mg PO DAILY
RX *ferrous sulfate 325 mg (65 mg iron) 1 tablet(s) by mouth
every day Disp #*30 Tablet Refills:*0
4. Outpatient Lab Work
Please check chem7 and CBC
Fax to PCP ___: ___
ICD___.0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: Anemia
Secondary: Multiple Myelomma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You came to ___ because you were experiencing fatigue and
chest pain and the doctor at your urgent care found your blood
counts to be very low. We believe this anemia to be due to your
multiple myeloma. You received a transfusion of 2 units of blood
overnight on your first night and your symptoms improved
significantly. Your laboratory tests still showed that you were
still anemic. You were transfused two more units of blood.
We have made an appointmnet with the Oncologist to discuss
whether you should have treatment for the multiple myelomma. He
will also be able to help with treating symptoms if you do not
want to undergo treatment for multiple myelomma.
Please have your labs drawn on ___.
___ MDs
Followup Instructions:
___
|
19707837-DS-18
| 19,707,837 | 23,416,030 |
DS
| 18 |
2153-04-27 00:00:00
|
2153-04-27 17:45:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
anemia
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
___ w/untreated multiple myeloma presents with worsening of his
chronic anemia. Pt found to have Hgb 5.9 Hct 17.7 on routine
labs at ___ office yesterday and was instructed to present to ED
for transfusion. Pt denies hematochezia, hematemesis, melena,
hematuria. No SOB, CP, LH or palp. Does endorse feeling "less
energetic". Pt required transfusions in ___ and ___, no prior
adverse reactions to transfusions. Pt has previously refused all
treatment from oncology for multiple myeloma but now states he
is considering treatment if it will keep him from having to come
to the hospital so frequently because he is old and wants some
quality time at home.
In ED pt received 1u pRBC.
ROS: +as above, otherwise reviewed and negative
Past Medical History:
Multiple myeloma
- c/b CKD and compression fractures
hemorrhoids
DM-II
BPH s/p TURP
Osteoporosis
Glaucoma
Social History:
___
Family History:
No cancer or heart disease
Physical Exam:
Vitals: T:98.4 BP:130/60 P:82 R:18 O2:97%
PAIN: 0
General: nad
Lungs: clear
CV: rrr no m/r/g
Abdomen: bowel sounds present, soft, nt/nd
Ext: no e/c/c
Skin: no rash
Neuro: alert, follows commands
Pertinent Results:
___ 06:00PM GLUCOSE-119* UREA N-40* CREAT-2.4*
SODIUM-126* POTASSIUM-4.6 CHLORIDE-101 TOTAL CO2-24 ANION GAP-6*
___ 06:00PM estGFR-Using this
___ 06:00PM CALCIUM-9.5 PHOSPHATE-4.4 MAGNESIUM-2.1
___ 06:00PM WBC-2.2* RBC-1.92* HGB-6.1* HCT-18.5* MCV-97
MCH-31.9 MCHC-33.1 RDW-18.3*
___ 06:00PM NEUTS-37.2* LYMPHS-58.6* MONOS-2.9 EOS-0.6
BASOS-0.8
___ 06:00PM HYPOCHROM-2+ ANISOCYT-1+ POIKILOCY-NORMAL
MACROCYT-OCCASIONAL MICROCYT-NORMAL POLYCHROM-NORMAL
___ 06:00PM PLT SMR-LOW PLT COUNT-104*
___ 06:00PM ___ PTT-38.3* ___
Brief Hospital Course:
ASSESSMENT AND PLAN: ___ w/untreated multiple myeloma presents
with worsening of his chronic anemia
Heme/onc: Untreated multiple myeloma complicated by anemia,
renal
failure, hypercalcemia and multiple fractures. Anemia due to
myeloma, no signs of active bleeding. He adamantly refuses any
chemotherpy or other treatment for the myeloma and has
repeatedly
said the same since his diagnosis. He does agree to
transfusion.
He does not want palliative care referall.
-Received 4 units of pRBC, hematocrit increased from 18.5 to
25.6, his symptoms of chest pressure and fatigue resolved.
-Discussed with PCP trying outpatient transfusion through a
transfusion center.
Hyponatremia: chronic, currently lower than baseline likely due
to intravascular depeltion from anemia, improved with
transfusion.
Acute on Chronic Kidney Disease: baseline Cr ~2.0, acute
worsening likely ___ anemia, improved with transfusion.
- transfuse as above
DM2: hold metformin, SSI while hospitalized
BPH: cont home meds
FEN: diabetic diet
PPX: TEDs
ACCESS: piv
DNR/DNI: discussed with pt on admission. He reports he would
like
to "go peacefully. If I'm gonna go, I'm gonna go. There's no
need
to drag it out and be in pain."
CONTACT: son/HCP
DISPO: medicine, pending above
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Calcitonin Salmon 200 UNIT NAS DAILY
2. FoLIC Acid 1 mg PO DAILY
3. Ferrous Sulfate 325 mg PO DAILY
4. Cyanocobalamin 1000 mcg PO DAILY
5. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES HS
6. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP BOTH EYES BID
7. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES BID
8. MetFORMIN (Glucophage) 500 mg PO BID
9. Tamsulosin 0.4 mg PO DAILY
10. Multivitamins 1 TAB PO DAILY
11. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES BID
2. Calcitonin Salmon 200 UNIT NAS DAILY
3. Cyanocobalamin 1000 mcg PO DAILY
4. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP BOTH EYES BID
5. Ferrous Sulfate 325 mg PO DAILY
6. FoLIC Acid 1 mg PO DAILY
7. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES HS
8. Multivitamins 1 TAB PO DAILY
9. Tamsulosin 0.4 mg PO DAILY
10. Aspirin 81 mg PO DAILY
11. MetFORMIN (Glucophage) 500 mg PO BID
Discharge Disposition:
Home
Discharge Diagnosis:
Anemia secondary to multiple myeloma.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted for worsening anemia (low red blood cells).
You were given 4 units of red blood cells. You should follow-up
closely with your primary care physician and continue to discuss
starting treatment for your multiple myeloma and to discuss
outpatient blood transfusions.
Followup Instructions:
___
|
19707837-DS-19
| 19,707,837 | 24,840,198 |
DS
| 19 |
2153-06-13 00:00:00
|
2153-06-13 17:51:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
___ Complaint:
Fever
Major Surgical or Invasive Procedure:
Foley Catheter Placement on ___ in ___ ED
History of Present Illness:
PRIMARY DIAGNOSIS: multiple myeloma
PRIMARY HEME/ONC PROVIDER: Dr ___
CHIEF COMPLAINT: fever
HISTORY OF PRESENT ILLNESS:
Mr ___ is an ___ yr old male with multiple myeloma who thus far
has elected for no treatment other than intermittent
transfusions, last at ___ ___.
He was seen at ___ clinic ___ at which time reported his
chronic pain in back and hands, Hgb 6.7. Had rising Ca and Cr
and was started on zometa 3mg as well as velcade and dex.
He presented to ___ ED today with new fever to 102 overnight
in early am. Was febrile on arrival. Complained of cough as well
as pain in R shoulder. Was given dose of vancomycin, cefepime
for possible L lower infiltrate. Shoulder xray showed no acute
fracture or focal lytic lesion. Noted to have Hgb 5.2 with 8pt
HCT drop from 2 weeks ago, guiac stool was negative, he was
transfused 2 U PRBC and tolerated well.
Initial VS in ED 16:19 101.2 90 106/47 24 98% RA
On arrival to floor temp improved to 100.3. Pt states that the
day after chemo (___) he got weak after coming back from store
with his son, ___ get up stairs and sons had to carry him.
In am ___ get out of bed due to generalized waekness and had
fever so EMS called. Denies focal weakness of arms/legs,
numbness, HA. Denies lightheadedness, fall or syncope or chest
pain. Denies DOE. Has cough for few months, unchanged, denies
sputum production. No sore throat, rash, dysuria. Sometimes has
dribbling before he can get to restroom, reportedly had
difficulty urinating in ED and foley was placed. Does have new
eye drainage and redness, R eye irritated, not painful, no
change in vision has glaucoma. No known sick contacst. Has been
eating/drinking ok, no nausea/emesis/diarrhea.
REVIEW OF SYSTEMS:
GENERAL: + fever as above, no chills or rigors
HEENT: No mouth sores, odynophagia, sinus tenderness,
rhinorrhea, or congestion.
CARDS: No chest pain, chest pressure, exertional symptoms, or
palpitations.
PULM: + cough as above, no shortness of breath, hemoptysis, or
wheezing.
GI: No nausea, vomiting, diarrhea, or abdominal pain. No
hematochezia, or melena.
GU: No dysuria, hematuruia or frequency. +hx BPH
MSK: + R shoulder pain. Denies neck pain or other joint pain
DERM: Denies rashes, itching, or skin breakdown.
NEURO: No headache, visual changes, numbness, paresthesias,
focal weakness
HEME: No bleeding or clotting
Past Medical History:
PAST ONCOLOGIC HISTORY: per ___ records
He has refused treatment since he was first diagnosed with IgG
myeloma in ___ with an IgG level of 4 gms, anemia (hct 32) and
bence ___ proteinuria. BM done by Dr ___ showed 30%
plasma cells. Treatment with melphelan/Pred was offered but
denied. He was seen in ___ by Dr ___ at the ___ who
also recommended treatment, at that time with Velcade, decadron
and more recently by Dr ___ in ___ and ___, again
declining chemotherapy. His anemia has worsened and he agreed to
transfusions which were done last ___ (4 units) and
again in mid ___ when he received 1 unit rbc in the ___ ER. He
has longstanding pain in his back and legs and hands and has
bony involvement by plain films with compression fractures of
T11 noted on a metastatic series ___ year ago with mult lucencies
in other bones. Decided in ___ that he is willing to consider
treatment, but also wants to be able to spend ___ months in
___ during the ___. He has refused biphosphonates for
his bone disease but did try calcitonin nasal spray in the fall
which was associated with some epistaxis and he stopped using
it.
Started plan for weekly velcade/dex ___
PAST MEDICAL HISTORY:
Multiple myeloma
- c/b CKD and compression fractures
hemorrhoids
DM-II
BPH s/p TURP
Osteoporosis
Glaucoma
Social History:
-Tobacco: never
-Alcohol: rare
-Illicits: never
-Work: ___
-Lives with: wife, son, daughter
-___: no assist
-ADLs: independent
-IADLs: independent
From ___ originally, moved to ___ in ___.
-Tobacco: never
-Alcohol: rare
-Illicits: never
-Work: ___
-Lives with: wife, son, daughter
-___: no assist
-ADLs: independent
-IADLs: independent
From ___ originally, moved to ___ in ___.
Retired ___ ___. 5 children. No alc, no cigs. Lives with
wife and 2 of his children.
Family History:
No family history of malignancy or heart disease
Physical Exam:
ADMISSION EXAM:
General: NAD
VITAL SIGNS: 100.3 123/63 83 21 100%RA
HEENT: MM tachy, tongue with thrush, no OP lesions,
Neck: supple, no JVD
CV: RR, NL S1S2 no S3S4 or MRG
PULM: CTAB
ABD: BS+, soft, NTND, no masses
EXT: warm well perfused, no edema, 3cm soft tissue mass just
proximal to L olecranon process nontender. R shoulder tender
over ant humerus not bicep/forearm. No spinal tenderness. no
other joint tenderness, no joint effusions
SKIN: No rashes or skin breakdown
NEURO: alert and oriented x 4, ___, EOMI, no nystagmus, face
symmetric, no tongue deviation, full hand grip, shoulder shrug
and bicep flexion, full toe dorsiflexion and hip flexion against
resistance bilateral, sensation intact to light touch, no clonus
DISCHARGE EXAM:
VITALS = 98.1, 74-86, 103-132/58-76, 18, 100% on RA, ___
Pain/Dyspnea, 156.8 lb, Ins 1250, Outs 1750
General: NAD
HEENT: MMM, tongue with thrush, no OP lesions, poor dentition,
neck supple, no JVD
CV: RR, NL S1S2 no S3S4 or MRG
PULM: CTAB aside from transmitted upper airway sounds
ABD: BS+, soft, NTND, no masses
EXT: warm well perfused, no edema, 3cm soft tissue mass just
proximal to L olecranon process nontender. R shoulder tender
over ant humerus not bicep/forearm. No spinal tenderness. no
other joint tenderness, no joint effusions
SKIN: No rashes or skin breakdown
NEURO: alert and oriented x 4, ___, EOMI, no nystagmus, face
symmetric, no tongue deviation, full hand grip, shoulder shrug
and bicep flexion, full toe dorsiflexion and hip flexion against
resistance bilateral, sensation intact to light touch, no
clonus, left arm full ROM and ___ strength, right arm ___
strength but can only abduct 60 degrees with 15 degree forward
movement
Pertinent Results:
ADMISSION LABS:
UA <1 rbc 1 wbc
lactate 1.0
128 104 68 72 AGap=6
3.4 21 3.3
Ca: 8.7 Mg: 1.7 P: 2.7
ALT: 17 AP: 33 Tbili: 0.4 Alb:
AST: 24 LDH: 142
wbc 2.0 hgb 5.2 plt 73
N:62.2 L:33.5 M:3.4 E:0.8 Bas:0.2
___ ___ - free kappa 1060, free lambda low, albumin 2, tot
prot 15, Cr 2.44, Ca ___
IMAGING:
R SHOULDER FINDINGS:
No fracture or dislocation is identified. The humeral head is
well situated within the glenoid fossa. There is diffuse
permeative appearance of the proximal humerus, likely reflecting
underlying for history of multiple myeloma. Moderate to severe
for degenerative changes are seen at the acromioclavicular
joint. The coracoclavicular interval is normal. Mild pulmonary
edema is visualized in the right lung.
CXR - FINDINGS:
No focal consolidation is identified. There is mild atelectasis
at the left lung base. There is mild pulmonary vascular
congestion without overt pulmonary edema. The cardiomediastinal
silhouette is unchanged. Again seen is tortuosity of the
descending thoracic aorta. There is no pleural effusion or
pneumothorax. Acute kyphosis with lower thoracic vertebral body
compression deformities are again noted. Known diffuse lytic
lesions are better assessed on prior CT from ___.
Visualized upper abdomen is unremarkable.
DISCHARGE LABS:
___ 08:15AM BLOOD WBC-1.8* RBC-2.38* Hgb-7.1* Hct-20.9*
MCV-88 MCH-30.0 MCHC-34.1 RDW-19.8* Plt Ct-81*
___ 07:55AM BLOOD Neuts-53.7 Lymphs-42.2* Monos-2.9 Eos-0.8
Baso-0.4
___ 08:00AM BLOOD Ret Aut-0.6*
___ 08:15AM BLOOD Glucose-77 UreaN-34* Creat-1.4* Na-135
K-3.7 Cl-110* HCO3-24 AnGap-5*
___ 08:15AM BLOOD Calcium-7.6* Phos-1.9* Mg-2.1
___ 07:46PM OTHER BODY FLUID FluAPCR-NEGATIVE
FluBPCR-NEGATIVE
Urine Culture No Growth
Blood Cultures NGTD
Brief Hospital Course:
___, an ___ yo M PMHx Multiple Myeloma complicated by
hypercalcemia, pathologic fractures, and severe pancytopenia
requiring transfusion, presented after recent start of
bortezomib/zolendronic acid/dexamethasone therapy on ___ with
fever of 102 along with right shoulder pain (going on for
several weeks, difficultly with abduction and anterior motion
with pain, X-ray negative for fracture, permeative appearance
from multiple myeloma), conjunctivitis (nonpurulent, good
vision, given ciprofloxacin eye drops), cough (CXR final read
negative for infiltrate, resolved), and anemia (Hgb 5.2, given 3
total units of pRBCs, further held off due to concern for
causing hyperviscosity syndrome). He was initially given
vancomycin/cefepime in the ED, but received no antibiotics
subsequently. He was afebrile after arrival and he remained
asymptomatic aside from improving right shoulder pain/range of
motion. He had several morning episode of asymptomatic
hypoglycemia with normal cortisol level. He was discharged to
followup with his outpatient oncology provider for more
chemotherapy.
# Fever/SIRS - Patient with borderline neutropenia (___ 1200),
low IgG. no localizing source aside from conjunctivitis. Patient
has cough but chronic for two weeks, no new infiltrate on CXR.
Does have poor dentition and thrush. UA unremarkable. Given
vanco/cefepime in ED for possible ___ narrow to
ceftriaxone, follow cultures. Flu PCR negative and cultures
negative or no growth at time of discharge. Can have a febrile
reaction to zolendronic acid on ___. Ceftriaxone was
discontinued on ___. Patient had no further fevers off
antibiotics >24 hours. He was continued on ciprofloxacin eye
drops for a ___nd he can continue his multiple
myeloma chemotherapy.
# Multiple Myeloma (IgG) and Severe Anemia: Dx ___ has declined
any treatment until just recently. Started velcade 1.3mg/m2 w/
dex ___ on ___. Total Protein 17. Due to poor PO intake,
nutrition consult recommended regular diet with Ensure Plus TID
and MVI+minerals. He received 3 total units of pRBCs with good
response with Hgb>7. Baseline Hgb ___ since ___ myeloma
and exacerbated by CKD, retic. on folate and iron supp, latter
with unclear benefit given recent transfusions thus will not
continue on admission. Also may have component of hemolysis
with prior low hapto, mild elevated LD. Will repeat hemolysis
labs, consider DAT but less likely AIHA. Completed 2U PRBCs in
ED, transfuse for Hgb <7. Given 1 unit pRBCs on ___. ___
require scheduled transfusions in future but holding at the
moment due to concern for hyperviscosity syndrome (no symptoms
during hospitalization).
# Right Shoulder Pain: With limited RUE adduction. Occurred
about 1 week ago in setting of odd sleeping position. ___ UE
Strength limited by pain but RUE unable to abduct more than 30
degrees or so. 2+ reflexes in UE bilaterally. X-Ray shoulder
negative for fracture. Differential includes peripheral nerve
injury, rotator cuff injury, or muscular injury. In past
patient hesitant to try narcotics, but NSAIDs contraindicated
with renal function and not getting much relief with APAP at
home. Started 2.5-5mg PO oxycodone q6 hours prn pain (no
tramadol due to likely increased analgesia requirement, avoiding
APAP due to fever masking) and well as lidocaine patch. ___
Consult recommended home ___ (was able to walk with walker) and
his symptoms improved but did not resolve over the course of
this hospital stay. Could consider MRI Shoulder if patient
clinically worsens.
# CKD w/ ___: Suspect worsening myeloma kidney w/ markedly
elevated free kappa but no prior for comparison so trend
unknown, also w/ possible prerenal event w/ SIRS past 24hrs.
Denies NSAID use, no other nephrotoxins. Will continue gentle IV
hydration overnight and also received PRBCs as above. Improved
from Cr 3.3 to 1.4 on discharge.
# Hypoglycemia: Glu 57 on AM Lytes on ___. Could be Fanconi
Syndrome or adrenal insufficiency in setting of poor PO intake.
AM cortisol was within normal limits and no AM hypoglycemia
___. Team encouraged nocturnal high protein/fat snack as late
at night as possible to avoid AM hypoglycemia.
# Hypercalcemia: Ca 8.7 corrected to >10 with albumin 1.9. Will
hold zolendronic acid for the time being given possible febrile
reaction.
= CHRONIC ISSUES =
# T2DM: Has been off metformin past year, Hgb A1C nl. On daily
ASA, if platelet count worsens in future risk would outweigh
benefits. Has been hypoglycemic off any diabetes medications.
# BPH: On tamsulosin and Foley placed in ED due to concern of
urinary retention. Foley removed on ___ @ 15:30 with no
further urinary retention.
# Constipation: Chronic stable issue exacerbated by iron
supplementation but controlled in the hospital.
= TRANSITIONAL ISSUES =
- Consider zolendronic dose reduction or elimination from
regimen
- Make sure outpatient ___ is assisting patient with mobility and
right upper extremity movement (discharged with rolling walker,
lidocaine patch, could consider right shoulder MRI if pain
worsens or fails to improve)
- Please check a chem-7 on ___ (discharged on PO Phosphorus due
to persistently low phosphorus ___ to Fanconi's from myeloma)
- Code Status: DNI (but CPR, defibrillation is acceptable)
- Emergency Contact: ___. (son, HCP) at
___
- Followup Tests: Blood Cultures x2 (no growth to date on
discharge)
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES BID
2. Calcitonin Salmon 200 UNIT NAS DAILY
3. Cyanocobalamin 1000 mcg PO DAILY
4. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP BOTH EYES BID
5. Ferrous Sulfate 325 mg PO DAILY
6. FoLIC Acid 1 mg PO DAILY
7. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES HS
8. Multivitamins 1 TAB PO DAILY
9. Tamsulosin 0.4 mg PO DAILY
10. Aspirin 81 mg PO DAILY
11. Acyclovir 400 mg PO BID
Discharge Medications:
1. Walker
Rolling Walker
ICD9: Difficult Ambulating 719.7
Prognosis: Good
Length of Need: 13 Months
2. Lidocaine 5% Patch 1 PTCH TD QAM
RX *lidocaine [Lidoderm] 5 % (700 mg/patch) place one patch
every morning Disp #*30 Patch Refills:*0
3. Ferrous Sulfate 325 mg PO DAILY
4. Acyclovir 400 mg PO BID
5. Aspirin 81 mg PO DAILY
6. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES BID
7. Calcitonin Salmon 200 UNIT NAS DAILY
8. Cyanocobalamin 1000 mcg PO DAILY
9. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP BOTH EYES BID
10. FoLIC Acid 1 mg PO DAILY
11. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES HS
12. Tamsulosin 0.4 mg PO DAILY
13. Phosphorus 500 mg PO BID
RX *sod phos,di & mono-K phos mono [K-Phos-Neutral] 250 mg 2
tablet(s) by mouth twice daily Disp #*28 Tablet Refills:*0
14. OxycoDONE (Immediate Release) 2.5-5 mg PO Q6H:PRN Pain
RX *oxycodone 5 mg ___ tablet(s) by mouth every 6 hours Disp
#*30 Tablet Refills:*0
15. Senna 8.6 mg PO BID:PRN constipation
RX *sennosides [senna] 8.6 mg 1 capsule by mouth twice daily
Disp #*30 Capsule Refills:*0
16. Multivitamins W/minerals 1 TAB PO DAILY
RX *multivitamin,tx-minerals [Vitamins & Minerals] 1 tablet(s)
by mouth daily Disp #*30 Tablet Refills:*0
17. Ciprofloxacin 0.3% Ophth Soln ___ DROP BOTH EYES QID
Duration: 5 Days
Last Day ___
RX *ciprofloxacin 0.3 % 1 drop both eyes 4 times per day
Refills:*0
18. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*60 Capsule Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY:
Febrile Reaction to Zolendronic Acid
Multiple Myeloma complicated by hypercalcemia, fractures, and
anemia requiring transfusion
Conjunctivitis
SECONDARY:
Right Shoulder Pain
Hypoglycemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. ___,
It was a pleasure to take care of you at ___
___. You were admitted because you were having
fevers and had recently started chemotherapy for your Multiple
Myeloma. We determined that this was likely a reaction to the
zolendronate (Zometa(R)) medication you were taking to reduce
your blood calcium. You had no other signs or symptoms of
infection and you went >24 hours without a fever off all
antibiotics. Physical Therapy evaluated you and felt you could
go home with Physical Therapy services and a rolling walker.
Best of luck to you in your future health.
Please take all medications as prescribed (we will give you a
prescription for the lidocaine patch and try to get a prior
authorization for this and you will see how expensive it is and
go from there), attend all doctors ___ as ___,
eat a high protein/fat snack (such as peanut butter-containing
food) to avoid low blood sugar in the morning, and call a doctor
if you have any questions or concerns.
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
19708049-DS-11
| 19,708,049 | 23,446,669 |
DS
| 11 |
2190-03-18 00:00:00
|
2190-03-18 17:41:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
lethargy
Major Surgical or Invasive Procedure:
None
History of Present Illness:
PRIMARY ONCOLOGIST: ___
PRIMARY DIAGNOSIS: Stage IIIC triple negative breast cancer
TREATMENT REGIMEN: adjuvant taxol (on hold)
HISTORY OF PRESENTING ILLNESS:
___ w/ CKD, T2DM, iCVA c/b L hemiparesis, and stage IIIc triple
negative breast cancer now in disease remission s/p adjuvant
taxol (has completed 7 cycles, no further cycles planned),
recent
admissions for sepsis from cellulitis and polymicrobial BSI who
is admitted for ___, weakness over the last 24 hrs. She does not
have any new localizing symptoms, mainly less interactive w/
less
PO intake.
In the ED, she was found to have UTI and was given Cefepime in
addition to IV Vanc. VS hr ___, BP 110s-130s, 100% Ra. Tmax
___.
She had two recent admissions:
1. admitted from ___ for management of RLE cellulitis. Her
hospital course was complicated by acute urinary retention,
electrolyte abnormalities, acute neurologic changes felt to be
recrudence of old stroke, and neutropenia with fever. She was
ultimately discharged on clindamycin to complete therapy for her
cellulitis. Her aspirin was also changed to Plavix during this
admission.
2. admitted ___ to ___ for lichenoid drug eruption and
polymicrobial BSI and had PORT removed, also found to have UTI
and fungemia. discharged on vanc/fluc. she had a PICC Placed c/b
DVT.
REVIEW OF SYSTEMS: Unable to fully obtrain due to depressed MS.
___ Medical History:
PAST ONCOLOGIC HISTORY:
-___: Reportedly first noticed R breast mass and was treated
w
abx in ___ for possible cellulitis
-___: Admitted to ___ for hypoglycemia. R breast mass
noted and Breast Surg Onc, Dr. ___
-___: Right Breast US - At ___ o'clock 13 cm from the
nipple there is a 4.3 by 5.3 x 3.5 cm irregular hypoechoic mass
with minimal internal vascularity. Internal cystic spaces are
noted. This correlates well with the area of clinical concern.
No additional abnormalities are identified in the right breast.
The right axilla was scanned and markedly abnormal lymph nodes
were identified measuring up to 2.1 cm with loss of the fatty
hilum.
-___: CT Chest w/o contrast - 5.1 cm right breast mass
w/level 1 and 2 axillary lymphadenopathy. No distal mets.
-___: CT Abdomen and Pelvis - no abdominopelvic mets.
-___: US guided core bx of the Right Breast mass- Path:
grade 3 invasive ductal carcinoma with necrosis and
lymphoplasmactyic infiltrate, 15mm in this limited sample,
RECEPTORS - ER<1%, PR 0%, HER2 neg on IHC (FISH negative w ratio
of 1.1)
-___: US guided FNA of R axillary node-Path-metastatic
adenocarcinoma c/w breast primary
-___: TTE-EF 55%, Mild LV hypertrophy
-___: Bilateral diagnostic mammogram - Tissue density: B.
RIGHT breast: In the posterior upper outer right breast there is
a 6 x 5.8 x 4.9 cm mass which corresponds to the biopsied mass
on
___. There are benign vascular calcifications. No
additional suspicious mass, architectural distortion or grouped
calcifications.
LEFT breast: There are 2 masses in the lower medial left breast
that are stable dating back to ___ and are benign. There are
benign calcifications in the left breast and vascular
calcifications which are benign. There is no suspicious mass,
architectural distortion or suspicious grouped
micro-calcifications.
-___: PET scan -There is an approximately 5.4 x 4.3 x 5.2
cm right breast mass with SUV max of 24.4, an approximately 3.4
x 2.0 x 2.8 cm right axillary lymph node with SUV max of 22.8,
and an approximately 1.5 x 1.0 cm right sub pectoral lymph node
with SUV max of 3.3. Diffuse uptake in the esophagus compatible
with esophagitis. No FDG avid lesions are seen in abdomen or
pelvis. A gallstone and a 3.1 x 3.0 cm cyst in the upper pole
of the right kidney are noted. No FDG avid lesions are seen in
the musculoskeletal system.
IMPRESSION: A large intensely FDG-avid mass is seen in the
right
breast compatible with the know right breast cancer. There is
a
large intensely
FDG-avid mass in the right axilla and a smaller FDG-avid lesion
in the subpectoral region compatible with lymph node
metastases.
There is no evidence of distant FDG-avid disease.
-___: Seen by Dr. ___ in cards and had stress test that
showed potential reversible defect
-___: Cardiac cath showing 30% L main and 80% OMB
obstruction. No intervention. Med management. Per Dr. ___
to
proceed w anthracycline chemo
-___: C1 ddAC with Neulasta onbody injector.
-___: patient admitted for febrile neutropenia with
pancytopenia; needed 2 units pRBC. Became afebrile on broad
spectrum abx; no source found; had 6 days of IV abx. During
hospital stay she had an episode of R sided weakness,
dysarthria,
confusion. Neuro was called, initial concern for stroke but MRI
brain did not show it. She also had acute on chronic renal
failure w creatinine increasing from baseline of 1.4 to 1.7 on
day of admission to up to 2.5; was seen by nephrology and
discharged when cr was stable around 2.5
-___: Another hospital stay as Cr went up to 3.6 as
outpt. Seen by Renal thought to have post ATN ___. Given gentle
hydration and discharged when cr downtrending
-___: C2 of AC with 30% dose reduction + neulasta support
-___: C3 of AC (same dose as C2)
-___: C4 of AC (same dose as C2/3)
-___: R Wire localized partial mastectomy+ ALND with
lymphaticovenous bypass procedure-path-2.1 cm residual grade 3
invasive ductal carcinoma, treatment effect noted, ___ LN, no
LVI, posterior margin at 1mm, all other margins >5mm; ___.
Repeat ER neg, PR neg, HER2 neg by IHC and FISH
-___: Adjuvant taxol, week 1
-___: Week 2 taxol
-___: Week 3 taxol
-___: Week 4 taxol
-___: Week 5 taxol
-___: Week 6 taxol
-___: Week 7 taxol
-___: Admitted to ___ for management of RLE
cellulitis
PAST MEDICAL HISTORY:
- R breast cancer stage IIIC, triple negative
TREATMENT TO-DATE:
1. Neoadjuvant chemo, sp ddAC X4 cycles: ___
2. R lumpectomy + ALND: ___ - ___
- Hx of CVA in ___ with resultant Left hemiparesis; wheelchair
bound
- T2DM with complications of nephropathy
- CKD w baseline Cr of 1.7-2.0
- Hypertension
- Hyperlipidemia
- Osteoarthritis
- Hx of Sepsis in ___ sp R arm cellulitis
- Chronic mild anemia w baseline Hgb ~10 likely ___ CKD
- L eye blindness
- Bilateral cataract surgery -___
- Excision of R thigh lipoma ___
- Hysterectomy w/o oophorectomy for uterine fibroids
Social History:
___
Family History:
Sister died of some sort of cancer in her ___. Daughter died of
postpartum CVA
Physical Exam:
ADMISSION
VS: 97.5 PO 152 / 80 111 18 100 Ra
GENERAL: Pleasant woman, in no distress, lying in bed
comfortably
and intermittently sleepy but awakens easily, voice slurred,
___ speakign only
HEENT: Anicteric, OP clear. Pupils reactive, cataract
CARDIAC: RRR, normal s1/s2, no m/r/g.
LUNG: Appears in no respiratory distress, clear to auscultation
bilaterally, no crackles, wheezes, or rhonchi.
ABD: Soft, non-tender, non-distended, normal bowel sounds, no
hepatomegaly, no splenomegaly.
EXT: Much improved from prior admission, erythema/
NEURO: notable for chronic L hemiparesis. R upper and lower
motor extremity notable for slightly weak handgrip and inability
to move RLE toes. Is is
oriented to person, place, pressure ulcers on both heels
wrapped.
DISCHARGE
98.0 PO 128 / 80 102 18 98 Ra
GENERAL: Pleasant woman, in no distress, sitting in chair
comfortably, alert, ___ speaking only
HEENT: Anicteric, OP clear. Pupils reactive, cataract
CARDIAC: RRR, normal s1/s2, no m/r/g.
LUNG: Appears in no respiratory distress, clear to auscultation
bilaterally, no crackles, wheezes, or rhonchi.
ABD: Soft, non-tender, non-distended, normal bowel sounds, no
hepatomegaly, no splenomegaly.
EXT: pressure ulcers on both heels wrapped in gauze, no
drainage, clean/dry
NEURO: notable for chronic L hemiparesis. R upper and lower
motor extremity notable for slightly weak handgrip and inability
to move RLE toes. Oriented to person, place
Pertinent Results:
ADMISSION LABS
___ 09:10AM BLOOD WBC-9.7 RBC-3.14* Hgb-9.3* Hct-29.6*
MCV-94 MCH-29.6 MCHC-31.4* RDW-17.9* RDWSD-61.7* Plt ___
___ 09:10AM BLOOD Neuts-77.3* Lymphs-10.0* Monos-7.4
Eos-3.4 Baso-0.5 Im ___ AbsNeut-7.53* AbsLymp-0.97*
AbsMono-0.72 AbsEos-0.33 AbsBaso-0.05
___ 09:10AM BLOOD ___ PTT-31.0 ___
___ 09:10AM BLOOD Glucose-114* UreaN-27* Creat-1.6* Na-137
K-4.3 Cl-100 HCO3-23 AnGap-14
___ 09:10AM BLOOD ALT-22 AST-47* LD(LDH)-239 AlkPhos-102
TotBili-0.2
___ 09:10AM BLOOD Albumin-2.9* Calcium-9.5 Phos-4.6* Mg-2.1
CXR ___
Compared to the examination from 1 day prior, vascular
congestion has
resolved. No new consolidation is seen. Cardiomediastinal
silhouette and
hilar contours are stable. There is no large effusion or
pneumothorax. No acute findings. A left-sided midline is seen.
CXR ___
IMPRESSION:
Compared to chest radiographs since ___ most recently
___ at
15:28.
Left PIC line still ends in the right internal jugular vein.
Heart is mildly enlarged. Lungs clear. No pleural abnormality.
CT HEAD ___
IMPRESSION:
1. No acute intracranial abnormality on noncontrast head CT.
Specifically, no evidence of intracranial hemorrhage.
2. Stable sequelae of prior infarctions, as described above.
___ 7:40 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
PSEUDOMONAS AERUGINOSA. 10,000-100,000 CFU/mL.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
PSEUDOMONAS AERUGINOSA
|
CEFEPIME-------------- 4 S
CEFTAZIDIME----------- 4 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- 16 S
TOBRAMYCIN------------ <=1 S
___ 06:50AM BLOOD WBC-8.4 RBC-2.87* Hgb-8.5* Hct-26.8*
MCV-93 MCH-29.6 MCHC-31.7* RDW-17.9* RDWSD-61.3* Plt ___
___ 06:50AM BLOOD Glucose-115* UreaN-13 Creat-1.1 Na-141
K-4.1 Cl-105 HCO3-23 AnGap-13
Brief Hospital Course:
Ms. ___ is a ___ yo woman with CKD, T2DM, iCVA c/b L
hemiparesis, and stage IIIc triple negative breast cancer now in
disease remission s/p adjuvant taxol (has completed 7 cycles, no
further cycles planned), recent admissions for sepsis from
cellulitis and polymicrobial BSI who was admitted for ___,
generalized weakness, found to have UTI and urinary retention
course complicated by poor UOP and acute medication induced
somnolence
Lethargy with generalized weakness:
This was related to continued decline from her previous
hospitalizations with deconditioning. Her dtr stated she has
not been the same since then. It could also be due to new
infection (UTI), with ___. Otherwise there did not appear to be
any clear derangements. Treated ___ and UTI with ___ consult for
home with maximal services. By discharge, daughter was reporting
some increased strength and energy though far from where she was
months ago.
Pseudomonas UTI:
___:
h/o Urinary retention:
She did not seem to have classic symptoms for UTI but her
lethargy may be related. UA+, several risk factors for UTI.
Urine cx grew pseudomonas. Started Cefepime day 1 = ___ and
completed a 7 day course. Monitored PVR for retention with
intermittent straight cath but ultimately required a Foley
catheter. Urology follow up is recommended after discharge and
scheduled.
Acute encephalopathy with confusional state:
Somnolent on ___ after dose of Remeron for appetite stimulant
at night. ABD, labs, CT head negative. Over the course of
several hours she improved. She appears to be quite sensitive
to psychoactive medications and these should be started with
extreme caution. This resolved over 24 hrs.
Chronic pressure ulcers:
Appreciate wound care input. ___ and frequent turning.
E. faecalis Bloodstream infection (___)
C. glabrata Bloodstream infection (___)
S. epidermidis Bloodstream infection (___)
C. albicans UTI (___)
Nidus of infection likely skin breakdown during period of
neutropenia vs PORT. ID consulted and started on broad spectrum
antibiotics. Port was removed on ___. Fundoscopy by
ophthalmology ruled out endophthalmitis. Based on speciation and
sensitivities was narrowed to vancomycin and fluconazole to be
completed on ___.
- f/u surveillance blood cultures
Acute LUE DVT:
LUE PICC malpositioned:
Poor peripheral venous access:
Underwent port removal due to polymicrobial BSI. Had LUE PICC
placed on ___. On ___ swelling was noted in LUE and near
occlusive DVT was found in brachial vein. Patient started on
enoxaparin. On ___ during episode of dyspnea CXR incidentally
found tip of LUE PICC in R jugular vein. LUE PICC replaced by ___
on ___. Given difficulty/discomfort and concern for injection
at sites with poor skin integrity patient was switched to
apixaban 5mg bid. She now has PICC tip positioned in R
subclavian/IJ vein. Attempts were made to reposition the PICC
non invasively without success. Ordered to have PICC converted
to a midline
Prior CVA with chronic deficits:
Baseline neurologic exam documented previously, appears at
neurologic baseline with exception of generalized weakness
- continued Plavix
- cont baclofen for the spasms
Breast Cancer:
She is s/p neoadjuvant ddAC X4, right partial mastectomy + ALND
and adjuvant taxol. She is now without any macroscopic disease
and does not plan to receive any further chemotherapy at this
time per family and multiple discussions on prior admission.
- f/u Dr ___ as outpatient
___ of care: Patient has been expressing frustration with her
condition and care. She refused to come to hospital until
daughter promised no more chemo. She has also expressed a desire
for less aggressive treatment and she specifically brought up
intubation (unsure if this arose in a different context).
Changed code status to DNR/DNI and encouraged her to discuss
whether she would want planned XRT with oncologist.
Anemia: stable, Likely multifactorial from CKD, prior chemo
Type 2 Diabetes Mellitus: ISS, back to sitagliptin on d/c
CAD: Not having any anginal symptoms, continued statin
HTN: no longer on antihypertensives
EMERGENCY CONTACT HCP:
Name of health care proxy: ___
Relationship: daughter
Cell phone: ___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. Baclofen 10 mg PO TID
2. Acetaminophen ___ mg PO BID:PRN Pain - Mild
3. Clopidogrel 75 mg PO DAILY
4. Ondansetron ___ mg PO Q8H:PRN nausea/vomiting
5. Rosuvastatin Calcium 40 mg PO QPM
6. Senna 8.6 mg PO BID:PRN constipation
7. Vitamin D 1000 UNIT PO DAILY
8. Calcium 500 + D (D3) (calcium carbonate-vitamin D3) 500
mg(1,250mg) -125 unit oral BID
9. linaGLIPtin 5 mg oral DAILY:PRN BS>150
10. Apixaban 5 mg PO BID
11. GuaiFENesin ER 600 mg PO Q12H
12. Guaifenesin-Dextromethorphan 5 mL PO Q6H:PRN cough
13. Triamcinolone Acetonide 0.1% Cream 1 Appl TP BID
14. Vancomycin 750 mg IV Q 24H
15. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN
wheezing/shortness of breath
16. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN Pain - Moderate
Reason for PRN duplicate override: Alternating agents for
similar severity
Discharge Medications:
1. Acetaminophen ___ mg PO BID:PRN Pain - Mild
2. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN
wheezing/shortness of breath
3. Apixaban 5 mg PO BID
4. Baclofen 10 mg PO TID
5. Calcium 500 + D (D3) (calcium carbonate-vitamin D3) 500
mg(1,250mg) -125 unit oral BID
6. Clopidogrel 75 mg PO DAILY
7. GuaiFENesin ER 600 mg PO Q12H
8. Guaifenesin-Dextromethorphan 5 mL PO Q6H:PRN cough
9. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN Pain - Moderate
Reason for PRN duplicate override: Alternating agents for
similar severity
10. linaGLIPtin 5 mg oral DAILY:PRN BS>150
11. Ondansetron ___ mg PO Q8H:PRN nausea/vomiting
12. Rosuvastatin Calcium 40 mg PO QPM
13. Senna 8.6 mg PO BID:PRN constipation
14. Triamcinolone Acetonide 0.1% Cream 1 Appl TP BID
15. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Genealized weakness/lethargy
Acute encephalopathy
Pseudomonas UTI
ARF
PICC assoc DVT
Breast cancer
Acute confusional state
Discharge Condition:
Mental Status: Clear and coherent (speech slurred)
Level of Consciousness: Lethargic but arousable.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Ms. ___,
You were admitted with lethargy after a recent hospitalization.
We found mild kidney injury and UTI. With treatment you
improved. You continued your other chronic medications and
worked with physical therapy. You will be discharegd with a
Foley catheter in place and will follow up with urology.
Close follow up with your PCP and oncologist is recommended
after discharge as well.
It was a pleasure taking care of you.
Sincerely,
Your ___ team
Followup Instructions:
___
|
19708049-DS-13
| 19,708,049 | 27,854,422 |
DS
| 13 |
2190-05-03 00:00:00
|
2190-05-03 20:00:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
lethargy, intermittent confusion
Major Surgical or Invasive Procedure:
None
History of Present Illness:
HISTORY OF PRESENTING ILLNESS:
___ w/ CAD, HTN, CKD, T2DM, iCVA c/b residual L hemiparesis, and
stage IIIc triple negative breast cancer in disease remission
s/p
adjuvant taxol (has completed 7 cycles, no further cycles
planned), just started adjuvant XRT, and multiple admissions for
lethargy attributed to various infections, including port
associated polymicrobial BSI, who is admitted for intermittent
confusion and hallucinations over the last 2 days. She does not
have any new localizing symptoms. She is taking her meds and
eating well. No F/C, no N/V, no diarrhea, no CP/SOB. No new c/o
asides from her chronic leg pain for which she takes baclofen
TID.
In the ED, she was AOx3 but sleepy. UA was suggestive of UTI so
she was started on Meropenem. MS seemed to improve while she was
there.
When I spoke w/ her daughter, ___, she confirmed she is more
concerned about the hallucinations. Started yesterday out of the
blue w/o any new sx. She was up all night w/ hallucinations and
she was sleepy today from not sleeping all night and the
hallucinations worsened. ___ noted that this Has never
occurred
before. No new medications asides melatonin which started last
week, which was when she last took a dose.Taking baclofen TID.
Of note, she has had multiple recent admissions:
1. admitted from ___ for management of RLE cellulitis. Her
hospital course was complicated by acute urinary retention,
electrolyte abnormalities, acute neurologic changes felt to be
recrudescence of old stroke, and neutropenia with fever. She was
ultimately discharged on clindamycin to complete therapy for her
cellulitis. Her aspirin was also changed to Plavix during this
admission.
2. admitted ___ to ___ for lichenoid drug eruption and
polymicrobial BSI and had PORT removed, also found to have UTI
and fungemia. discharged on vanc/fluc. she had a PICC Placed c/b
DVT.
3. admitted ___ to ___ for lethargy, found to have spuedomonas
UTI and ___.
4. admitted ___ to ___ for weakness soft stools found to have
c.diff colitis
REVIEW OF SYSTEMS: 10 point ros reviewed in detail and negative
except for what is mentioned above
Past Medical History:
RECENT PAST MEDICAL HISTORY
L breast cancer (T2N0M0 triple-negative IDC, s/p neoadjuvant
ddAC, R lumpectomy/ALND ___, adjuvant taxol)
taxol-induced lichen planus of lower extremities with extensive
skin breakdown
Polymicrobial bacteremia and fungemia in setting of this skin
breakdown; s/p IV vanc/fluc
Line-associated DVT, on Eliquis
UTI (pseudomonas)
Urinary retention, currently with indwelling Foley
Decuibitus ulcer
Increasing malnutrition and FTT to the setting of the above
history
OTHER PAST MEDICAL HISTORY
CKD
CAD (30% LM, 80% OM)
CVA in ___ with resultant Left hemiparesis; wheelchair bound
DM2
Hypertension
Hyperlipidemia
Osteoarthritis
L eye blindness
s/p TAH/BSO for fibroids
Social History:
___
Family History:
Sister died of some sort of cancer in her ___. Daughter died of
postpartum CVA
Physical Exam:
ADMISSION PHYSICAL EXAM:
==========================
VS: 97.5 PO 152 / 80 111 18 100 Ra
GENERAL: Pleasant woman, in no distress, lying in bed
comfortably
and intermittently having hallucinations
HEENT: Anicteric, OP clear. Pupils reactive
CARDIAC: RRR, normal s1/s2, no m/r/g.
LUNG: Appears in no respiratory distress, clear to auscultation
bilaterally, no crackles, wheezes, or rhonchi.
ABD: Soft, non-tender, non-distended, normal bowel sounds, no
hepatomegaly, no splenomegaly.
EXT: Rash from prior admission much improved w/o erythema
NEURO: Quite sleepy limiting exam, notable for chronic L
hemiparesis. Strength intact in RLE/RUE but ___. AOX3
ACCESS: ___ c/d/I
DISCHARGE PHYSICAL EXAM:
========================
VS: 97.9, 118 / 68, 94, 20, 100% RA
GENERAL: Pleasant woman, in no distress, lying in bed
comfortably
and intermittently having hallucinations
HEENT: Anicteric, OP clear. Pupils reactive
CARDIAC: RRR, normal s1/s2, no m/r/g.
LUNG: Appears in no respiratory distress, clear to auscultation
bilaterally, no crackles, wheezes, or rhonchi.
ABD: Soft, non-tender, non-distended, normal bowel sounds, no
hepatomegaly, no splenomegaly.
EXT: Rash from prior admission much improved w/o erythema
NEURO: Quite sleepy limiting exam, notable for chronic L
hemiparesis. Strength intact in RLE/RUE but ___. AOX3
ACCESS: ___ c/d/i
Pertinent Results:
ADMISSION LABS:
=================
___ 05:20PM BLOOD WBC: 4.4 RBC: 3.15* Hgb: 9.7* Hct:
31.9* MCV: 101* MCH: 30.8 MCHC: 30.4* RDW: 16.2* RDWSD: 59.6*
Plt
Ct: 219
___ 05:20PM BLOOD Neuts: 61.1 Lymphs: ___ Monos: 7.7 Eos:
3.6 Baso: 0.5 Im ___: 0.2 AbsNeut: 2.70 AbsLymp: 1.19* AbsMono:
0.34 AbsEos: 0.16 AbsBaso: 0.02
___ 05:20PM BLOOD Glucose: 91 UreaN: 23* Creat: 1.5* Na:
142
K: 5.7* Cl: 101 HCO3: 24 AnGap: 17
___ 05:49PM BLOOD Lactate: 2.0 K: 5.4*
STUDIES:
========
___ CT HEAD W/ & W/O CONTRA
IMPRESSION:
1. No acute intracranial abnormality, no hemorrhage. No
evidence of
intracranial metastasis.
2. Stable sequela of prior infarctions as described above.
___ CHEST (PA & LAT)
IMPRESSION:
No acute cardiopulmonary abnormality.
DISCHARGE LABS:
================
___ 08:05AM BLOOD WBC-5.0 RBC-2.68* Hgb-8.2* Hct-26.0*
MCV-97 MCH-30.6 MCHC-31.5* RDW-15.9* RDWSD-56.7* Plt ___
___ 08:05AM BLOOD Glucose-79 UreaN-22* Creat-1.3* Na-140
K-4.4 Cl-103 HCO3-21* AnGap-16
___ 08:05AM BLOOD Calcium-8.9 Phos-4.4 Mg-1.7
___ 07:59AM BLOOD VitB12-823 Folate-19
___ 07:59AM BLOOD TSH-1.5
___ 07:59AM BLOOD Free T4-1.0
Brief Hospital Course:
PATIENT SUMMARY:
___ w/ CAD, HTN, CKD, T2DM, iCVA c/b residual L hemiparesis, and
stage IIIc triple negative breast cancer in disease remission
s/p adjuvant taxol (7 TRIALS,LAST ___, recently started
adjuvant XRT at ___, w/ multiple admissions (2x ___, 2x
___ for lethargy attributed to various infections, who p/w
auditory and visual hallucinations for two days, found to have
___.
ACUTE ISSUES:
# Hallucinations
Pt w known propensity to become delirious as presenting symptom
of infection. It was suspect that current hallucinations may be
due to delirium from UTI ___ syndrome vs metabolic
from ___. CXR was clear and EKG non-acute. Neuro exam
non-focal aside from known L hemiplegia. Daughter/care taker
reports pt recently has had declining coordinating and tremor in
right extremity over recent days. Non-con head CT was unchanged
from prior. Folate, B12, and TSH were normal. UCx w fecal
contamination, patient given 2d meropenam which was then
discontinued as she no longer had altered mental status or any
symptoms or lab signs of infection. She recovered to her
neurologic baseline per her daughter without further
intervention and was discharged to follow-up with PCP.
# Recent C.diff infection
Was treated for first c.diff infection earlier in ___, through
___. While on meropenem, patient was given PO vancomycin for
ppx. However, there is no evidence that continuing this ppx in
patients with only one episode of cdiff reduces the risk of
recurrence. Because of this and the fact that she had only
received 2d antibiotics, decision made not to send home on ppx
for cdiff.
# Acute kidney injury on chronic kidney disease
Recent baseline Cr around 1.0, when patient was admitted was
1.5. Decreased to 1.3 after IVF and po intake in hospital.
Likely due to increased metabolic demand.
# Many recent infections
# E. faecalis bloodstream infection (___)
# C. glabrata bloodstream infection (___)
# S. epidermidis bloodstream infection (___)
# C. albicans UTI (___)
Nidus of infections likely skin breakdown during period of
neutropenia vs PORT. Port was removed on ___ and sacral ulcer
healing well. No evidence of further infection this
hospitalization.
# LUE PICC-associated DVT
Noted during hospitalization in ___, associated w PICC. S/p
close to 3mo apixaban, discussed w outpatient oncologist and
decided that she did not need to continue on this medication.
# L hemiparesis
# History of CVA
Hx of CVA in ___ with resultant Left hemiparesis; wheelchair
bound. Baseline neurologic exam documented previously, on
admission appeared at neurologic baseline with exception of
generalized weakness and difficulty feeding herself. Resolved
during admission and patient at baseline per daughter.
CHRONIC ISSUES
# Breast Cancer
Dxed in ___. She is s/p neoadjuvant ddAC X4, right partial
mastectomy + ALND and adjuvant taxol. She is now without any
macroscopic disease and does not plan to receive any further
chemotherapy.
# CAD: continued home statin, Plavix
# Macrocytic anemia: stable, likely multifactorial from CKD, B12
and folate normal, MMA pending at time of discharge.
# Type 2 Diabetes Mellitus: maintained on sliding scale while
inpatient, restarted home sitagliptin upon discharge.
TRANSITIONAL ISSUES
[] F/u MMA levels, if positive consider starting folate
supplementation
[] F/u blood cultures (NGTD at time of discharge)
[] Continue radiation therapy outpatient
[] Apixaban discontinued as patient s/p 3mo treatment for
PICC-associated DVT and PICC was removed.
CODE: DNR/DNI confirmed w/ daughter on admission
CONTACT/HCP: ___, daughter ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 1000 mg PO TID
2. Apixaban 5 mg PO BID
3. Baclofen 10 mg PO TID
4. Clopidogrel 75 mg PO DAILY
5. Rosuvastatin Calcium 40 mg PO QPM
6. Senna 8.6 mg PO BID:PRN constipation
7. Vitamin D 1000 UNIT PO DAILY
8. Calcium 500 + D (D3) (calcium carbonate-vitamin D3) 500
mg(1,250mg) -125 unit oral BID
9. linaGLIPtin 5 mg oral DAILY:PRN BS>150
10. Ondansetron ___ mg PO Q8H:PRN nausea/vomiting
11. Ascorbic Acid ___ mg PO BID
12. Zinc Sulfate 220 mg PO DAILY
13. Lidocaine Jelly 2% 1 Appl TP TID
14. Lidocaine 5% Patch 1 PTCH TD QAM
Discharge Medications:
1. Baclofen 10 mg PO TID:PRN Muscle Spasms
2. Acetaminophen 1000 mg PO TID
3. Ascorbic Acid ___ mg PO BID
4. Calcium 500 + D (D3) (calcium carbonate-vitamin D3) 500
mg(1,250mg) -125 unit oral BID
5. Clopidogrel 75 mg PO DAILY
6. Lidocaine 5% Patch 1 PTCH TD QAM
7. Lidocaine Jelly 2% 1 Appl TP TID
8. linaGLIPtin 5 mg oral DAILY:PRN BS>150
9. Ondansetron ___ mg PO Q8H:PRN nausea/vomiting
10. Rosuvastatin Calcium 40 mg PO QPM
11. Senna 8.6 mg PO BID:PRN constipation
12. Vitamin D 1000 UNIT PO DAILY
13. Zinc Sulfate 220 mg PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnosis:
- Altered Mental Status
- Hallucinations
- Acute kidney injury
Secondary Diagnosis:
- Recent C.diff infection
- Breast cancer
- Type 2 diabetes mellitus
- Macrocytic anemia
- Chronic decubitus ulcers, present on admission
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 WAS I IN THE HOSPITAL?
- You were hospitalized because you had altered mental status.
WHAT HAPPENED TO ME IN THE HOSPITAL?
- While you were hospitalized you were worked up for infections,
started on antibiotics given your frequent history of infections
associated with altered mental status.
- We did not find any evidence of infection and your confusion
improved, so we stopped your antibiotics.
- You were also worked up for new brain injuries, which we did
not find evidence for.
- You were treated with radiation therapy for your breast
cancer.
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
- Continue to take all your medicines and keep your
appointments.
- Follow up with your primary oncologist in ___ weeks
We wish you the best!
Sincerely,
Your ___ Team
Followup Instructions:
___
|
19708049-DS-5
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DS
| 5 |
2189-07-03 00:00:00
|
2189-07-05 16:15:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
hypoglycemia and breast mass
Major Surgical or Invasive Procedure:
FNA, core biopsy, clip placement
History of Present Illness:
History Obtained From:
[X] Patient [X] Family/Friend [ ] Interpreter [ ] Other: medical
records
PRIMARY CARE PHYSICIAN: ___. ___
CHIEF COMPLAINT: Hypoglycemia, R breast mass
HISTORY OF PRESENT ILLNESS: Ms. ___ is a ___ woman
with
PMH diabetes on glimepiride and linagliptin, osteoarthritis,
HTN,
who is presenting with hypoglycemia. Her AM glucose today was
34,
her daughter tried to give her food and juice but she wasn't
able
to take it so she was brought to clinic where she was given oral
glucose gel x2 with improvement to 117. She was brought by
ambulance to ___ and given additional glucose gel en route.
Pertinent ED course: Glucose 49 on arrival, received juice and
amp of D50. She was alert and oriented, noted to have a 5x5 cm
firm R breast mass with erythema and tenderness. Per daughter
this was present two months ago. She was seen by ___ who
recommended a Humalog sliding scale, given ceftriaxone for R
breast lesion concerning for cellulitis.
In the ED, initial VS ___ at 11:123 were:
T 97.6 F BP 152/76 HR 94 RR 18 Sat O2 98% on RA
Upon arrival to the floor, the patient was stable, lying
comfortably with her daughter ___ and granddaughter at the
bedside. She reports her breast mass appeared around ___ and was first noted by her daughter as a round, firm lesion
without erythema or outer skin involvement. It was stable in
size
and persisted over the next two months during which time she
visited ___. In ___, she saw a local physician who
prescribed her an unknown medication (daughter and patient
cannot
recall). She arrived back to the ___. on ___ with worsening
of the mass, and daughter noted there to be new erythema.
Patient
says pain is ___ in her R breast (ranges from 1 to ___ and
worsens with palpation. Her last mammogram was one year ago and
was negative for malignant process per family. She was
asymptomatic during this time until yesterday night when she
experienced significant chills and night sweats. She has
otherwise been afebrile.
REVIEW OF SYSTEMS: Patient endorses sweats/chills yesterday
evening, knee pain bilaterally R>L, L shoulder pain,
constipation
(last bowel movement 2 days ago). Patient denies headache,
vision
changes (cannot open L eye at baseline since stroke),
nausea/vomiting, fever, chest pain, dyspnea, abdominal pain, or
bowel or bladder changes. 10-point ROS otherwise negative except
as noted in HPI.
Past Medical History:
Sepsis secondary to R arm cellulitis in ___ (tx Abx inpt 15
days)
T2DM diagnosed ___ years ago, no known complications
Left sided CVA ___ (residual left sided face/body weakness)
Osteoarthritis
Knee pain bilaterally R>L
s/p cataract surgery (R and L eyes) ___
s/p R thigh excision of benign mass
s/p hysterectomy
Social History:
___
Family History:
non-contributory
Physical Exam:
ADMISSION PHYSICAL EXAM:
VITALS: T 99.2 F BP 155/73 HR 99 RR 18 O2 Sat 97% RA FSBG
189
GENERAL: Well developed, well nourished, alert and cooperative,
lying comfortably, and appears to be in no acute distress.
HEAD: normocephalic.
EYES: Unable to open L eye at baseline. R eye PERRL, EOMI. R eye
vision is grossly intact.
ENT: Hearing grossly intact. No nasal discharge. Oral cavity and
pharynx normal. No inflammation, swelling, exudate, or lesions.
NECK: Neck supple, non-tender without lymphadenopathy, masses or
thyromegaly.
CHEST: R breast mass, round, 6 x 6 x 2 cm firm mass, warm,
erythematous, potentially fixed to underlying tissues. R
axillary
lymphadenopathy. No nipple discharge.
CV: Tachycardic. Normal S1 and S2. No S3, S4 or murmurs. Rhythm
is regular. There is no peripheral edema, cyanosis or pallor.
Extremities are warm and well perfused. Capillary refill is less
than 2 seconds.
RESP: Clear to auscultation and percussion without rales,
rhonchi, wheezing or diminished breath sounds. Decreased
respiratory effort.
ABDOMEN: Obese. Positive bowel sounds. Soft, nondistended,
nontender. No guarding or rebound. No masses.
MSK: Tenderness with palpation of knees bilaterally, R>L.
Adequately aligned spine. ROM intact spine and extremities. No
joint erythema. Normal muscular development. Wheelchair bound.
EXTREMITIES: R first digit amputation. No other significant
deformity or joint abnormality. No edema. Peripheral pulses
intact, 2+ DP and ___ bilaterally. No varicosities.
NEURO: L sided hemiparesis with L facial droop. R sided CN
II-XII
intact. Strength and sensation 4+ on R, 2+ on L. Reflexes 2+
throughout.
SKIN: Skin normal color, texture and turgor with no lesions or
eruptions.
PSYCH: Alert, oriented to person, place, and time.
DISCHARGE PHYSICAL EXAM:
VITALS: 98.1 132/74 82 18% on 93 Ra
Incontinent, urine not recorded accurately
GENERAL: Hemiparetic, no acute distress, conversant
HEENT: L eye permanently mostly closed, pupils reactive
NECK: supple
CV: RRR. Normal S1 and S2. No MRG
RESP: CTAB
ABDOMEN: ND/NT, active bs
MSK: Tenderness with palpation of knees bilaterally, L>R
EXTREMITIES: R first digit amputation. No other significant
deformity or joint abnormality. No c/c/e
NEURO: L sided hemiparesis with L facial droop. R sided CN
II-XII
intact. Sensation intact throughout.
BREAST: bandaged biopsy site with tenderness to palpation +
site
for clip placement
Pertinent Results:
ADMISSION LABS:
===============
FSBG: 55 -> 49 -> 62 -> 111 -> 158
WBC: 10.9 -> 11.9
Diff: 81% PMNs, 11% lymphos, Abs PMN 9.68
Hgb: 11.5 -> 10.9
Hct: 37.3 -> 34.3
ESR 78
Glc: 57
BUN: 22
CR: 2.1 (baseline 1.5-2)
CA ___ = 30 (<38 U/mL)
Urine: +protein 100, trace blood, urine casts 3, rare mucous
Microbiology -
Urine culture NGTD
BLOOD CULTURES ___:
STAPHYLOCOCCUS EPIDERMIDIS.
Isolated from only one set in the previous five days.
SENSITIVITIES PERFORMED PER ___ ___ (___)
___.
FINAL SENSITIVITIES.
Staphylococcus species may develop resistance during
prolonged
therapy with quinolones. Therefore, isolates that are
initially
susceptible may become resistant within three to four
days after
initiation of therapy. Testing of repeat isolates may
be
warranted.
STAPHYLOCOCCUS, COAGULASE NEGATIVE. SECOND MORPHOLOGY.
FINAL SENSITIVITIES.
Staphylococcus species may develop resistance during
prolonged
therapy with quinolones. Therefore, isolates that are
initially
susceptible may become resistant within three to four
days after
initiation of therapy. Testing of repeat isolates may
be
warranted.
STAPHYLOCOCCUS SCHLEIFERI. FINAL SENSITIVITIES.
Staphylococcus species may develop resistance during
prolonged
therapy with quinolones. Therefore, isolates that are
initially
susceptible may become resistant within three to four
days after
initiation of therapy. Testing of repeat isolates may
be
warranted.
BLOOD CULTURES ___: NGTD
BLOOD CULTURES ___: NGTD
ECG/Telemetry - Per report
Rate: 110, PR: 178, QRS: 86, QT: 336, QTc: 423
Sinus tachycardia with an incomplete right bundle-branch block.
Inferior Q waves consistent with prior inferior myocardial
infarction with early anterior R wave transition suggesting
posterior involvement. Diffuse non-specific ST segment
flattening
in the inferolateral leads. Slight respiratory variation in QRS
morphology. Borderline left axis deviation. No prior tracing for
comparison.
Radiology:
CXR ___: No acute cardiopulmonary process
Breast ultrasound ___:
FINDINGS:
The right breast was scanned in its entirety with special
attention paid to the area of clinical concern. At ___ o'clock
13 cm from the nipple there is a 4.3 by 5.3 x 3.5 cm irregular
hypoechoic mass with minimal internal vascularity. Internal
cystic spaces are noted. This correlates well with the area of
clinical concern. No additional abnormalities are identified in
the right breast.
The right axilla was scanned and markedly abnormal lymph nodes
were identified measuring up to 2.1 cm with loss of the fatty
hilum.
Due to difficulty with patient positioning, the left breast was
not scanned by ultrasound at this visit.
IMPRESSION:
Highly suspicious right breast mass and axillary lymph nodes.
CT Chest ___:
FINDINGS:
NECK, THORACIC INLET, AXILLAE, CHEST WALL: Partially visualized
thyroid is
unremarkable. Supraclavicular and left axillary lymph nodes are
nonenlarged.
Multiple abnormal enlarged right level 1 axillary lymph nodes
measure up to 2.3 x 1.7 cm (03:25). Level 2 axillary nodes
measure up to 0.9 cm in short axis however demonstrate loss of
central fatty hilum (03:15) and are
suspicious for disease involvement. Along the right lateral
chest wall is a 5.1 x 4 cm irregular mass. (03:40).
UPPER ABDOMEN: Please refer to dedicated CT abdomen/pelvis for
details.
MEDIASTINUM: Mediastinal lymph nodes are nonenlarged. No
anterior mediastinal mass.
HILA: Hilar lymph nodes are nonenlarged.
HEART and PERICARDIUM: Small pericardial effusion noted. The
heart is normal
in size. Mild coronary artery and aortic valvular
calcifications are noted.
PLEURA: No pleural effusion or pleural calcification. No
pneumothorax.
LUNG:
1. PARENCHYMA: Bibasilar atelectasis is noted. No suspicious
mass.
2. AIRWAYS: The airways patent to the segmental level. No
bronchiectasis.
3. VESSELS: Thoracic aorta is normal in caliber without
aneurysmal
dilatation. Main pulmonary artery is normal in caliber.
CHEST CAGE: Soft tissues are otherwise unremarkable. No focal
lytic or
blastic osseous lesions suspicious for malignancy. There are
severe
degenerative changes throughout the right glenohumeral joint
(series 3, image 11).
IMPRESSION:
1. 5.1 cm right breast mass with right level 1 and level 2
axillary
lymphadenopathy. No distal metastasis.
2. Small pericardial effusion.
CT Abdomen & Pelvis ___:
LOWER CHEST: Please refer to separate report of CT chest
performed on the same day for description of the thoracic
findings.
ABDOMEN:
HEPATOBILIARY: The liver is diffusely hyperdense and otherwise
homogeneous in 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 notable for cholelithiasis without
gallbladder wall edema or gallbladder distension.
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: Bilateral renal cysts are noted measuring 2.4 in the
right upper pole and 1.6 cm in left lower pole. The kidneys are
otherwise of normal and symmetric size. There is no evidence of
worrisome renal lesions within the limitations of an unenhanced
scan. There is nohydronephrosis. There is no nephrolithiasis.
There is no perinephric abnormality.
GASTROINTESTINAL: The stomach is unremarkable. Small bowel
loops demonstrate normal caliber and wall thickness throughout.
The colon and rectum are within normal limits. The appendix is
not visualized, however no secondary signs of acute
appendicitis.
PELVIS: The urinary bladder and distal ureters are unremarkable.
There is no free fluid in the pelvis.
REPRODUCTIVE ORGANS: No large adnexal mass. Uterus is
surgically absent.
LYMPH NODES: Few subcentimeter inguinal lymph nodes are likely
reactive
measuring up to 1 cm in short axis (03:17). 0.6 cm portacaval
node is likely
reactive (03:45). No pelvic, inguinal, retroperitoneal, or
mesenteric lymph
node enlargement by CT size criteria.
VASCULAR: There is no abdominal aortic aneurysm. Moderate
atherosclerotic
disease is noted.
BONES: 0.7 cm subtle lucency within the right iliac wing (3: 87)
is likely
degenerative. There is no evidence of worrisome osseous lesions
or acute
fracture.
SOFT TISSUES: 2.9 x 1.3 cm area fat stranding along the right
gluteal
subcutaneous tissues is likely posttraumatic in nature (3:83).
The abdominal and pelvic wall is otherwise within normal limits.
IMPRESSION:
1. No abdominopelvic metastasis.
2. Cholelithiasis.
3. Please refer to separate CT chest report for findings
regarding the thorax.
FNA ___. POSITIVE FOR MALIGNANT CELLS.
- Metastatic adenocarcinoma consistent with breast primary, see
note.
- Lymphocytes consistent with lymph node sampling.
Note: The prepared cell block has high tumor cellularity. The
tumor cells in the specimen
morphologically resemble those in the concurrent breast biopsy
___, reviewed).
Notable for Hb 10.1, Cr 1.7
Brief Hospital Course:
Ms. ___ is a ___ woman with past medical history of
diabetes (on glimepiride and linagliptin), osteoarthritis,
hypertension who is presenting with hypoglycemia and right
breast mass concerning for breast malignancy.
#Hypoglycemia
Patient's glucose was 49 on arrival. She received juice and an
amp of D50 to good effect. She was seen by ___ who
recommended a Humalog sliding scale. The hypoglycemic event was
likely multi-factorial in nature, precipitated by poor oral
intake, acute on chronic renal kidney disease, and sulfonylurea
usage. Her blood sugars remained stable for the remainder of the
hospitalization. She was discharged on just the Tradjenta 5 mg,
holding the glimepiride 1 mg PO at breakfast until further
evaluation as outpatient.
- BG profile:
___: prehospital-34, 55, 117. ED: 71, 55, 55, 49, 62, 111,
150s,
189, 165
___: 100, 101, 98, 144, 123
#Breast mass: Breast mass is highly concerning for a primary
breast malignancy given the indolent course. Prior
mammograms have been negative except for stable left simple
septated
cysts for 4+ years. Patient was seen by breast surgery service
who performed an ultrasound, core biopsy, FNA, and placed clip.
Ms. ___ also had a CT chest/abdomen/pelvis that showed a 5.1
cm right breast mass with right level 1 and level 2 axillary
lymphadenopathy. It also revealed a small pericardial effusion,
most likely in the setting of malignancy. There was no evidence
of abdominopelvic metastasis.
#Leukocytosis, right breast mass with erythema and tenderness in
setting of history of cellulitis, found to have staph
bacteremia. Patient was initially started on ceftriaxone for
concern for breast abscess, and was then started on 750 mg IV
Q48H vancomycin given staph bacteremia. Did not find source of
possible skin infection on exam. Urine cultures were negative.
No evidence of abscess on CT scan. The blood cultures from ___
came back as coag negative staph, the leukocytosis resolved, and
the second blood cultures were negative. There are pending blood
cultures from ___ that need to be followed. There is a high
likelihood of blood culture contamination, and since the second
blood cultures, we discontinued the Vancomycin. Initial
leukocytosis most likely reactive in the setting of suspected
breast malignancy.
-Patient received 1 dose ceftriaxone on presentation for concern
of breast abscess
-Patient received 2 doses of vancomycin 750 mg IV Q48H for coag
neg staph bacteremia
#Acute on chronic kidney disease: Creatinine peaked at 2.3, and
resolved with IV fluids to baseline Cr 1.7. Urine with 3
granular casts. Cr bump was most likely pre-renal in the setting
of poor oral intake.
#Breast Mass Pain/knee pain
-Tylenol PRN for pain
-Tramadol 50 mg PO BID prn for pain
CHRONIC/STABLE PROBLEMS:
#HTN: SBPS low 90's-150/50-80s on just amlodipine
-Amlodipine 5 mg PO QD
-Holding Nifedipine CR 60 mg PO QD
#CVA: Given history of stroke in ___ with significant residual
deficits and high risk for hypercoagulability, reasonable to
continue home regimen and administer SC heparin for ppx.
-Aspirin 81 mg PO QD
-Rosuvastatin calcium 40 mg
-Heparin SC
#Dementia: Patient is alert and oriented with family at bedside
-Monitor with appropriate precautions in place
#Osteoporosis:
-Calcium carbonate 500 mg PO BID
-Vitamin D3 5000 units PO QD
#Xerophthalmia:
-Artificial tears PRN
TRANSITIONAL ISSUES:
Cr 1.7 on discharge (2.1 on admission)
Hb on discharge 10.1 (10.9 on admission)
WBC 8.0 on discharge (11.9 on admission)
LDH 344; CEA 8.5; CA ___ 30 (wnl)
[ ] Hypoglycemia on oral home medications in setting ___ and
___ oral intake. Per ___ recs, holding glimepiride and
discharge just on Tradjenta until outpatient follow-up. See BG
trend above.
[ ] Held home nifedipine until follow-up with PCP given
controlled BPs on amlodipine alone and concern for hypotension
(SBPs to ___
[ ] Likely anemia of chronic disease in the setting of chronic
kidney disease. It dropped a point over hospital course and
needs further evaluation.
[ ] Pericardial effusion most likely in setting of malignancy,
may consider ECHO as outpatient
[ ] Blood culture follow-up from ___ to rule out blood
infection ___ coag negative staph, ___ negative)
[ ] Cholelithiasis, incidentally seen on CT, asymptomatic
MEDICATIONS HELD AT DISCHARGE
Glimepiride
Nifedipine
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Tradjenta (linagliptin) 5 mg oral DAILY
2. Rosuvastatin Calcium 40 mg PO QPM
3. Acetaminophen ___ mg PO Q12H:PRN Pain - Mild
4. glimepiride 1 mg oral BREAKFAST
5. Aspirin 81 mg PO DAILY
6. amLODIPine 5 mg PO DAILY HTN
7. Artificial Tears ___ DROP BOTH EYES PRN Dry eyes
8. Calcium Carbonate 500 mg PO BID Osteoporosis
9. NIFEdipine (Extended Release) 60 mg PO DAILY HTN
10. TraMADol 50 mg PO BID:PRN Pain - Moderate
11. Senna 8.6 mg PO BID:PRN Constipation
12. Docusate Sodium 100 mg PO BID Constipation
Discharge Medications:
1. Acetaminophen ___ mg PO Q12H:PRN Pain - Mild
2. amLODIPine 5 mg PO DAILY HTN
3. Artificial Tears ___ DROP BOTH EYES PRN Dry eyes
4. Aspirin 81 mg PO DAILY
5. Calcium Carbonate 500 mg PO BID Osteoporosis
6. Docusate Sodium 100 mg PO BID Constipation
7. Rosuvastatin Calcium 40 mg PO QPM
8. Senna 8.6 mg PO BID:PRN Constipation
9. Tradjenta (linagliptin) 5 mg oral DAILY
10. TraMADol 50 mg PO BID:PRN Pain - Moderate
11. HELD- glimepiride 1 mg oral BREAKFAST This medication was
held. Do not restart glimepiride until see PCP.
12. HELD- NIFEdipine (Extended Release) 60 mg PO DAILY HTN This
medication was held. Do not restart NIFEdipine (Extended
Release) until see PCP.
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Masa de ___
Hypoglycemia
Staph Bacteremia, likely contaminant
Acute Renal Failure
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:
Querida Sra. ___,
Gracias por escoger ___ para ___. Ud tenia bajo
nivel de ___ descubrimos
___ masa ___. Empezemos ___ de
___ masa; este ___ ___ a continuar el 4 de ___
___ de ___. Recibio antibioticos para ___ un ___
___ tambien.
Abajo es ___ de sus citas y sus medicaciones.
Followup Instructions:
___
|
19708049-DS-6
| 19,708,049 | 25,217,916 |
DS
| 6 |
2189-08-24 00:00:00
|
2189-08-24 17:46:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Fevers
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___
PRIMARY ONCOLOGIST: Cardiology: ___, MD
PRIMARY CARE PHYSICIAN: ___, MD, MPH
PRIMARY DIAGNOSIS: stage III breast cancer
TREATMENT REGIMEN: ddAC ___
CC: fever, diarrhea
HISTORY OF PRESENTING ILLNESS:
Mrs. ___ is a ___ year-old lady with stage III breast cancer
who
was started on ddAC ___ who presents with fever and
diarrhea found to be neutropenic.
Seen in clinic today to receive c1d8 ddAC but patient reported
having had two large loose bowel movements the night prior.
Temperature in clinic was 100.4 and HR in 110s. Patient received
filgrastim in clinic prior to ED transfer.
ED initial vitals were 100.5 103 151/66 16 99% RA
Tmax 101.8
Prior to transfer vitals were 99.5 105 142/76 16 99% RA
Exam in the ED showed : "Tachycardic, normotensive, febrile
Cachectic, CTABL, S/NT/ND, No B/L edema. No visible rashes, port
appears clean"
ED work-up significant for:
-CBC: WBC: 0.5*. HGB: 9.5*. Plt Count: 96*. Neuts%: 2*.
-Chemistry: Na: 134* . K: 4.6. Cl: 93*. CO2: 27. BUN: 26*.
Creat:
1.3*. Ca: 9.9. Mg: 1.9. PO4: 3.5.
-LFTs: ALT: 9. AST: 18. Alk Phos: 73. Total Bili: 0.7.
-CXR: "Low lung volumes with probable bibasilar atelectasis,
though early infection is difficult to exclude. Probable mild
pulmonary vascular congestion without frank pulmonary edema."
-Flu A/B PCR: negative
ED management significant for:
-Medications: 2L NS, APAP 1g x1, vancomycin 1g, cefepime 2g x1
On arrival to the floor, patient reports feeling mild
non-productive cough and sore throat. Last diarrhea episode last
night, has not had any since last time.
Patient denies night sweats, headache, vision changes,
dizziness/lightheadedness, weakness/numbnesss, shortness of
breath, hemoptysis, chest pain, palpitations, abdominal pain,
nausea/vomiting, diarrhea, hematemesis, hematochezia/melena,
dysuria, hematuria, and new rashes.
Past Medical History:
PAST ONCOLOGIC HISTORY (Per OMR, reviewed):
- ___: Reportedly first noticed R breast mass and was treated
w abx in ___ for possible cellulitis
- ___: Admitted to ___ for hypoglycemia. R breast mass
noted and Breast Surg Onc, Dr. ___
-___: Right Breast US - At ___ o'clock 13 cm from the
nipple there is a 4.3 by 5.3 x 3.5 cm irregular hypoechoic mass
with minimal internal vascularity. Internal cystic spaces are
noted. This correlates well with the area of clinical concern.
No additional abnormalities are identified in the right breast.
The right axilla was scanned and markedly abnormal lymph nodes
were identified measuring up to 2.1 cm with loss of the fatty
hilum.
- ___: CT Chest w/o contrast - 5.1 cm right breast mass
w/level 1 and 2 axillary lymphadenopathy. No distal mets.
- ___: CT Abdomen and Pelvis - no abdominopelvic mets.
- ___: US guided core bx of the Right Breast mass- Path:
grade 3 invasive ductal carcinoma with necrosis and
lymphoplasmactyic infiltrate, 15mm in this limited sample,
RECEPTORS - ER<1%, PR 0%, HER2 neg on IHC (FISH negative w ratio
of 1.1)
- ___: US guided FNA of R axillary node-Path-metastatic
adenocarcinoma c/w breast primary
- ___: TTE-EF 55%, Mild LV hypertrophy
- ___: Bilateral diagnostic mammogram - Tissue density: B.
RIGHT breast: In the posterior upper outer right breast there is
a 6 x 5.8 x 4.9 cm mass which corresponds to the biopsied mass
on
___. There are benign vascular calcifications. No
additional suspicious mass, architectural distortion or grouped
calcifications. LEFT breast: There are 2 masses in the lower
medial left breast that are stable dating back to ___ and are
benign. There are benign calcifications in the left breast and
vascular calcifications which are benign. There is no
suspicious
mass, architectural distortion or suspicious grouped
micro-calcifications.
- ___: PET scan -There is an approximately 5.4 x 4.3 x
5.2
cm right breast mass with SUV max of 24.4, an approximately 3.4
x 2.0 x 2.8 cm right axillary lymph node with SUV max of 22.8,
and an approximately 1.5 x 1.0 cm right sub pectoral lymph node
with SUV max of 3.3. Diffuse uptake in the esophagus compatible
with esophagitis. No FDG avid lesions are seen in abdomen or
pelvis. A gallstone and a 3.1 x 3.0 cm cyst in the upper pole
of the right kidney are noted. No FDG avid lesions are seen in
the musculoskeletal system. IMPRESSION: There is no evidence of
distant FDG-avid disease.
- ___: Seen by Dr. ___ in cards and had stress test
that
showed potential reversible defect
- ___: Cardiac cath showing 30% L main and 80% OMB
obstruction. No intervention. Med management. Per Dr. ___
to
proceed w anthracycline chemo
- ___: C1D1 DDAC
PAST MEDICAL HISTORY (Per OMR, reviewed):
1. Hx of CVA in ___ with resultant Left hemiparesis; wheelchair
bound
2. T2DM with complications of nephropathy
3. CKD w baseline Cr of 1.7-2.0
4. Hypertension
5. Hyperlipidemia
6. Osteoarthritis
7. Hx of Sepsis in ___ sp R arm cellulitis
8. Chronic mild anemia w baseline Hgb ~10 likely ___ CKD
9. L eye blindness
Social History:
___
Family History:
non-contributory
Physical Exam:
VITAL SIGNS: 98.9 PO 130 / 76 93 18 96 Ra
General: NAD, resting in bed w/ family bedside
HEENT: MMM, + lingual thrush
CV: RR, NL S1S2 no S3S4, no MRG
PULM: CTAB, respirations unlabored
ABD: BS+, soft, NTND
LIMBS: No ___
SKIN: No rashes on extremities, L chest port site intact w/o
erythema
NEURO: ___ RUE but has difficulty maintaining arm elevated w/o
flapping, LUE contracture, L hemiplegia baseline, able to lift R
leg off 4+/5, + dysmetria R hand, + dysarthria per family, no
drooling, AOx3, speech otherwise fluent and comprehendible and
appropriate per daughter
Pertinent Results:
CXR ___
FINDINGS: Left Port-A-Cath terminates in the cavoatrial
junction. Heart size is mildly enlarged and mediastinal and
hilar contours are unchanged. Hypoinflation of the lungs. Left
hemidiaphragm is not well defined and is suspicious for
pneumonia. In addition equivocal consolidation versus
atelectasis also noted in the right lower lobe. No signs of
pulmonary congestion. IMPRESSION: in the presence of partial
inspiration bibasilar opacifications are concerning for
atelectasis or developing pneumonia.
Carotid US ___
FINDINGS: RIGHT: The right carotid vasculature has mild
heterogeneous atherosclerotic plaque. The peak systolic velocity
in the right common carotid artery is 66 cm/sec. The peak
systolic velocities in the proximal, mid, and distal right
internal carotid artery are 79, 37, and 39 cm/sec, respectively.
The peak end diastolic velocity in the right internal carotid
artery is 12 cm/sec. The ICA/CCA ratio is 1.2. The external
carotid artery has peak systolic velocity of 75 cm/sec. The
vertebral artery is patent with antegrade flow. LEFT: The left
carotid vasculature has mild heterogeneous atherosclerotic
plaque. The peak systolic velocity in the left common carotid
artery is 78 cm/sec. The peak systolic velocities in the
proximal, mid, and distal left internal carotid artery are 33,
39, and 35 cm/sec, respectively. The peak end diastolic velocity
in the left internal carotid artery is 14 cm/sec. The ICA/CCA
ratio is 0.5. The external carotid artery has peak systolic
velocity of 116 cm/sec. The vertebral artery is patent with
antegrade flow. IMPRESSION: There is less than 40% stenosis
within the internal carotid arteries bilaterally.
TTE ___
Conclusions The left atrium is normal in size. There is mild
symmetric left ventricular hypertrophy with normal cavity size
and global systolic function (LVEF>55%). Due to suboptimal
technical quality, a focal wall motion abnormality cannot be
fully excluded. Right ventricular chamber size and free wall
motion are normal. The aortic valve leaflets (?#) appear
structurally normal with good leaflet excursion. There is no
aortic valve stenosis. No aortic regurgitation is seen. The
mitral valve appears structurally normal with trivial mitral
regurgitation. There is no mitral valve prolapse. The estimated
pulmonary artery systolic pressure is high normal. There is a
trivial/physiologic circumferential pericardial effusion.
IMPRESSION: Suboptimal image quality. Mild symmetric left
ventricular hypertrophy with preserved global biventricular
systolic function. No valvular pathology or pathologic flow
identified. No definite structural cardiac source of embolism
identified. Compared with the prior study (images reviewed) of
___, the findings are similar.
MRI/MRA Brain/Neck ___
FINDINGS: MRI Brain: There is no evidence of acute intracranial
hemorrhage, edema, masses, mass effect, midline shift or slowed
diffusion to suggest acute infarction. Chronic right MCA
infarction involving the right frontal lobe, insula, and basal
ganglia, with associated volume loss. There also chronic
infarctions in the bilateral cerebellum. Wallerian degeneration
right brainstem. Confluent periventricular, deep, and
subcortical white matter T2/FLAIR hyperintensities are likely
sequelae of severe chronic small vessel ischemic disease. MRA
brain: There is moderate severe right and moderate left
cavernous segment ICA narrowing. Moderate right and mild left M1
segment narrowing. Right A1 segment is hypoplastic or occluded..
Widely patent left A1, A-comm supplying both PCAs. Moderate
narrowing distal left V4 segment. Diminished flow related
enhancement in the right V4 segment. Moderate to severe
narrowing left P2 segment. Mild-to-moderate narrowing left P3
segment moderate to severe narrowing right P3 segment. The
intracranial vertebral and internal carotid arteries and their
major branches appear patent without evidence of occlusion, or
aneurysm formation. Incidentally, the distal cervical left
internal carotid artery is tortuous (7:21). MRA neck: Motion
artifact and aliasing limit evaluation of the proximal common
carotid and vertebral arteries. The distal common carotid and
vertebral arteries appear patent, without evidence of stenosis
or occlusion.. Widely patent left proximal ICA without narrowing
by NASCET criteria. Motion artifact limits evaluation of the
proximal right ICA. Origins of the great vessels, subclavian and
vertebral arteries are not well evaluated, due to motion. Small
left pleural effusion partially seen. IMPRESSION: 1. No evidence
of acute intracranial hemorrhage or infarction. 2. Extensive
intracranial atherosclerotic disease involving anterior,
posterior circulation. No occlusion. No aneurysm.. 3. Motion
artifact limits evaluation of the neck vessels.
___ ___
IMPRESSION: 1. Suggestion of gray-white matter differentiation
loss in the left frontal lobe, consider acute infarct. 2.
Chronic right hemispheric, right basal ganglia and cerebellar
infarct. 3. Severe chronic small vessel ischemic changes.
Generalized brain parenchymal atrophy. RECOMMENDATION(S): Brain
MRI without contrast, if indicated. NOTIFICATION: The updated
impression and recommendations were communicated via telephone
by Dr. ___ to Dr. ___ at 11:15 on ___, 10 min
after discovery.
Renal US ___
FINDINGS: The right kidney measures 9.2 cm. There is a large
simple cyst in the upper pole of the right kidney measuring 3.1
x 3.9 x 3.1 cm. The left kidney measures 10.0 cm. There is a
simple cyst in the interpolar region of the left kidney
measuring 1.8 x 2.5 x 1.9 cm. There is no hydronephrosis,
stones, or masses bilaterally. Normal cortical echogenicity and
corticomedullary differentiation are seen bilaterally. The
bladder is only minimally distended and can not be fully
assessed on the current study. IMPRESSION: Normal renal
ultrasound with bilateral simple cysts. No evidence of
hydronephrosis bilaterally.
CXR ___
FINDINGS: Left-sided Port-A-Cath tip terminates at the SVC/right
atrial junction. Lung volumes are low. Heart size remains mildly
enlarged. The mediastinal and hilar contours are similar.
Crowding of bronchovascular structures is present with probable
mild pulmonary vascular congestion. Bibasilar patchy opacities
likely reflect areas of atelectasis. No focal consolidation,
pleural effusion or pneumothorax is present. No acute osseous
abnormalities detected. IMPRESSION: Low lung volumes with
probable bibasilar atelectasis, though early infection is
difficult to exclude. Probable mild pulmonary vascular
congestion without frank pulmonary edema.
___ 07:48PM OTHER BODY FLUID
FluAPCR-NEGATIVE FluBPCR-NEGATIVE
Brief Hospital Course:
___ w/ CAD, CVA ___ w/ residual L hemiparesis (wheelchair
bound), T2DM, HTN, DL, CKD III, L eye blindness, and stage III
breast cancer dx ___, started on ddAC ___ who p/w to
clinic on ___ for C1D8 ddAC where she c/o fever and two large
loose bowel movements, found to be neutropenic and febrile to
102.0F.
She improved w/ broad spectrum abx w/o any source identified.
She improved rapidly but renal function and Platelet count
declined and unfortunately developed new stroke on ___ but
symptoms also improved w/o radiographic e/o stroke (but too
prolonged to be TIA).
# New Slurred Speech
# New R hemiparesis
Unfortunately patient developed acute sx of dysarthria and R
hemiparesis in am ___. She was not hypotensive. Had head CT
and MRI which did not reveal
any acute infarctions or hemorrhage. Sx seem to be waxing and
waning but significantly improved. No obvious infection and
trops negative. Was seen by the neurology service and felt that
it is most likely a small CVA not visible on MRI. Her aspirin
was increased to full dose. She did not have any evidence of
afib on telemetry.
- increased ASA 81 to 325 mg now that TCP improved
- stopped amlodipine and nifedipine as SBP 120s-130s off all bp
meds
[ ] cont outpatient ___ and OT and ST
[ ] mechanical soft and nectar thickened liquid
# Febrile neutropenia:
# Sepsis
She was admitted for sepsis and febrile neutropenia.
Etiology of her fevers undetermined at this time. Her ANC <500
and w/ fevers up to 102.0F. She denied sore throat or mouth
pain,
denied any new cough. She had diarrhea but resolved PTA. No abd
pain. CXR not suggestive of PNA. UA not suggestive of UTI.
Currently pt feels/appears much improved since admission.
Malaria
ag negative. She was treated w/ Vanc and Cefepime.
- Cefepime 2g q8h, ___, end ___ and no further fevers
since
- Received pegfilgrastim which failed, filgrastim last dose
___
- pt had low grade temps of 99 on day of discharge w/o e/o
infection, likely from leukocytosis post neupogen
# Diarrhea:
She Had 2 episodes of loose stools PTA. No abdominal pain
and has not had any further bowel movements since however
starting to recur. C.diff negative.
# Stage 3 breast cancer: Received c1d1 ddAC w/ resulting severe
neutropenia. C1d8 held given F&N.
- Likely to require dose reduction for next infusion
- Dr ___, will see her in clinic
# Hypertension: Does not recall hypertension medications but
carvedilol 6.25 and amlodipine 5 mg were verified during
cardiology appointments. We held her BP meds due to the CVA to
allow
permissive hypertension but her SBP remained in the 120s-130s
and
did not feel she needed any antihypertensives on discharge.
# Type 2 Diabetes Mellitus:
We continued her diabetes medications.
- Linagliptin NF
- Lispro SS
# CAD, CVA
Not having any anginal symptoms
- cont aspirin
- cont home Rosuvastatin
- holding carvedilol
# Anemia: likely from antineoplastic therapy. Labs and smear
reviewed by oncology consult service and not c/w hemolysis.
- s/p 2U PRBC ___ with appropriate bump from 6.9 to 8.9
# Thrombocytopenia:
Likely from antineoplastic therapy, however the decline in plt
and hg counts accelerated, possibly due to sepsis. Plt dropped
PTA so unlikely HIT. Smear and labs not c/w hemolysis. Nadired
at 58 and rose to 188 on day of discharge
# ATN:
Seen by nephrology. Cr peaked at 2.5 and platuead. Non-oliguric.
She had foley
placed to measure her ins/outs closely as she was incontinent.
She
was seen by neprhology who felt this rise in Creatinine is due
to
ATN from sepsis and possible transient hypotension. She
maintained excellent
urine output.
[ ] f/u renal function on ___
[ ] f/u K level ___ - discharged on 10 mEq bid x 3 days per
recs by nephrology
# Hypokalemia: likely related to urine output, repleted. K on
discharge 3.1
# Hypomagnesemia: likely from chemo/diarrhea, repleted
# Osteoporosis: on calcium, vit d
# Xerophthalmia: cont artificial tears
# Hyponatremia: mild, and improving w/ po intake
FEN: Heart Healthy mechanical soft diet
ACCESS: Left Chest wall port
CODE STATUS: Confirmed DNR/DNI
Surrogate/emergency contact: ___ (daughter) ___
DISPO: HOME w/ ___
BILLING: >30 min spent coordinating care for discharge
______________
___, D.O.
Heme/___ Hospitalist
___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Ondansetron 4 mg PO Q8H:PRN nausea
2. Acetaminophen 500 mg PO BID:PRN Pain - Mild
3. linagliptin 5 mg oral DAILY
4. Aspirin 81 mg PO DAILY
5. Artificial Tears ___ DROP BOTH EYES PRN Dry eyes
6. Calcium Carbonate 500 mg PO BID Osteoporosis
7. amLODIPine 5 mg PO DAILY HTN
8. Docusate Sodium 100 mg PO BID:PRN Constipation
9. Rosuvastatin Calcium 40 mg PO QPM
10. Senna 8.6 mg PO BID:PRN Constipation
11. TraMADol 50 mg PO BID cancer pain
12. glimepiride 1 mg oral BREAKFAST
13. NIFEdipine (Extended Release) 60 mg PO DAILY HTN
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Stage 3 breast cancer
Febrile Neutropenia
Pancytopenia
Ischemic Stroke
Coronary artery disease
T2DM
HTN
DL
CKD III
Hypokalemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Bedbound.
Discharge Instructions:
Dear ___,
___ was a pleasure caring for you at ___
___. You were admitted because you were having fevers
and diarrhea. You improved with IV antibiotics. You were treated
with IV antibiotics and Neupogen to help boost your white blood
cells. You had symptoms of a stroke while you were in the
hospital on ___ but they are improving. You had a brain MRI
and CT scan which did not reveal stroke. You were seen by the
neurology team as well. We felt that your symptoms are most
consistent with a stroke and recommend that you increase your
dose of aspirin to 3 baby aspirins rather than 1 every day while
your platelets can handle it. You will need to have your labs
checked on ___.
Regards,
Your ___ team
Followup Instructions:
___
|
19708804-DS-19
| 19,708,804 | 26,038,085 |
DS
| 19 |
2147-07-25 00:00:00
|
2147-07-28 12:52:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: UROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
flank pain
Major Surgical or Invasive Procedure:
Cystoscopy
Bilateral retrograde pyelogram
Bilateral stent placement
History of Present Illness:
___ is a ___ y/o female with a history of nephrolithiasis for
which she was evaluated by Dr. ___ in clinic yesterday.
She has a history of low back pain, but about a week ago
developed severe left sided back and flank pain. A UA showed
hematuria and this prompted a CT scan. That revealed several
small right sided stones and a 2-3 mm left proximal ureteral
stone.
She has been managing her pain, which has migrated anteriorly
and towards the bladder, with tylenol, NSAID's and tramadol
reasonably well. She is also taking flomax.
This has never happened before. She has never seen a urologist
and she does not normally have issues with hematuria or UTI's.
This AM, she awoke with new onset right flank pain more severe
than her left flank pain which was not managed with her
medication regimen. She took a relative's ___ pill and
subsequently had nausea with emesis. She presented to the ED
for further evaluation and management. Urology consulted for
likely admission.
Past Medical History:
PAST MEDICAL HISTORY:
LOW BACK PAIN
MIGRAINE HEADACHES
OBESITY
OVERWEIGHT
TOBACCO ABUSE
PAST SURGICAL HISTORY:
None
Social History:
___
Family History:
Non-contributory
Physical Exam:
AVSS
NAD
Unlabored breathing
Abdomen obese, soft, NT, ND, No guarding or rebound tenderness,
no CVAT bilaterally
No calf tenderness bilaterally, ext wwp, ambulating
Pertinent Results:
___ 06:50AM BLOOD WBC-9.2 RBC-4.45 Hgb-13.0 Hct-39.8 MCV-90
MCH-29.2 MCHC-32.7 RDW-13.4 Plt ___
___ 07:20PM BLOOD WBC-17.6* RBC-5.02 Hgb-14.7 Hct-44.8
MCV-89 MCH-29.4 MCHC-32.9 RDW-13.0 Plt ___
___ 07:20PM BLOOD Neuts-88.1* Lymphs-8.3* Monos-3.2 Eos-0.1
Baso-0.3
___ 06:50AM BLOOD Glucose-89 UreaN-6 Creat-0.7 Na-140 K-3.9
Cl-110* HCO3-25 AnGap-9
___ 07:20PM BLOOD Glucose-83 UreaN-8 Creat-0.8 Na-143 K-4.4
Cl-111* HCO3-21* AnGap-15
___ 06:50AM BLOOD Mg-1.9
___ ___ 7:20 ___
RENAL U.S. Clip # ___
Reason: Please evaluate for stones and hydronephrosis
bilaterally
UNDERLYING MEDICAL CONDITION:
History: ___ with known left-sided kidney stones but
right-sided flank pain.
REASON FOR THIS EXAMINATION:
Please evaluate for stones and hydronephrosis bilaterally
Wet Read: ___ WED ___ 7:57 ___
1. right pelvic fullness extending into proximal ureter is new
from ___.
no frank right hydronephrosis. no stones or mass seen.
2. normal left kidney.
Wet Read Audit # 1
Final Report
INDICATION: Right-sided flank pain. Known left kidney stones.
COMPARISON: US ___, CT ___.
FINDINGS: The right kidney is 13.5 cm and the left kidney is
11.7 cm. Right
pelvic fullness extending into the proximal ureter without frank
hydronephrosis is new from ___. No stone or mass is
identified.
Postvoid, right pelvic fullness remains.
The left kidney is normal without hydronephrosis, stone, or mass
identified.
The study is performed with a partially full, normal-appearing
bladder.
IMPRESSION:
1. Mild right pelviectasis extending into the proximal ureter
is new from
___. Given right flank pain and small stones seen on prior
CT, this may
reflect passing of a small stone. No frank hydronephrosis.
2. Normal left kidney.
Urine culture (two): mixed flora
Brief Hospital Course:
___ was admitted to Dr. ___ service for pain
control and antiemesis. She was taken to the OR for cystoscopy,
bilateral retrograde pyelograms, and bilateral stent placement.
No concerning intraoperative events occurred; please see
dictated operative note for details. He patient received
___ antibiotic prophylaxis. The patient's
postoperative course was uncomplicated. She was observed
overnight for stent symptoms. She remained a-febrile throughout
his hospital stay. On POD1 at discharge, the patient had pain
well controlled with oral pain medications, was tolerating
regular diet, ambulating without assistance, and voiding without
difficulty. She was given pyridium and oral pain medications on
discharge with explicit instructions to follow up for definitive
stone managment in several days.
Prior to discharge home all of her questions were answered as
were those of her mother and as requested a work note through
her surgery date (scheduled ___ was provided.
Medications on Admission:
Ibuprofen
Tramadol
Fluticasone
Flomax
Discharge Medications:
1. Diazepam 5 mg PO Q8H:PRN stent irritation
RX *diazepam 5 mg 1 tab by mouth every eight (8) hours Disp #*15
Tablet Refills:*0
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. Hydrocodone-Acetaminophen (5mg-500mg) 1 TAB PO Q6H:PRN pain
RX *hydrocodone-acetaminophen 5 mg-500 mg 1 tablet(s) by mouth
every six (6) hours Disp #*30 Tablet Refills:*0
4. Phenazopyridine 100 mg PO Q8H:PRN dysuria Duration: 3 Days
RX *phenazopyridine 100 mg 1 tablet(s) by mouth every eight (8)
hours Disp #*9 Tablet Refills:*0
5. Tamsulosin 0.4 mg PO HS
RX *tamsulosin 0.4 mg 1 capsule(s) by mouth at bedtime Disp #*30
Capsule Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Nephrolithiasis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
-You can expect to see occasional blood in your urine and to
possibly experience some urgency and frequency over the next
month; this may be related to the passage of stone fragments or
the indwelling ureteral stent (if there is one).
-The kidney stone may or may not have been removed AND/or there
may fragments/others still in the process of passing.
-You may experience some pain associated with spasm of your
ureter. This is normal. Take the narcotic pain medication as
prescribed if additional pain relief is needed.
-Ureteral stents MUST be removed or exchanged and therefore it
is IMPERATIVE that you follow-up as directed.
-Do not lift anything heavier than a phone book (10 pounds)
-You may continue to periodically see small amounts of blood in
your urine--this is normal and will gradually improve
-Resume all of your pre-admission medications, except HOLD
aspirin until you see your urologist in follow-up AND your foley
has been removed (if not already done)
***-You may or may not have passed all your stones
****Ureteral stent
***
-You MAY be discharged home with a medication called PYRIDIUM
that will help with the "burning" pain you may experience when
voiding. This medication may turn your urine
bright orange.
-Colace has been prescribed to avoid post surgical constipation
and constipation related to narcotic pain medication.
Discontinue if loose stool or diarrhea develops. Colace is a
stool softener, NOT a laxative, and available over the counter.
The generic name is DOCUSATE SODIUM. It is recommended that you
use this medication.
-Do not eat constipating foods for ___ weeks, drink plenty of
fluids to keep hydrated
-No vigorous physical activity or sports for 4 weeks and while
Foley catheter is in place.
-Tylenol should be your first line pain medication, a narcotic
pain medication has been prescribed for breakthrough pain >4.
Replace Tylenol with narcotic pain medication.
-Max daily Tylenol (acetaminophen) dose is 4 grams from ALL
sources, note that narcotic pain medication also contains
Tylenol
-Do not drive or drink alcohol while taking narcotics and do not
operate dangerous machinery. Also, if the Foley catheter and Leg
Bag are in place--Do NOT drive (you may be a passenger).
Followup Instructions:
___
|
19708804-DS-20
| 19,708,804 | 26,910,541 |
DS
| 20 |
2147-08-20 00:00:00
|
2147-08-21 18:25:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: UROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
right flank pain
Major Surgical or Invasive Procedure:
NONE DURING THIS ADMISSION
History of Present Illness:
___ is a ___ y/o female with a history of nephrolithiasis s/p
urgent bilateral stent placement for flank pain on ___ and
subsequent ureteroscopy laser lithotripsy ___. Her right
stent was removed in the clinic on ___. She presents to the
ED for right flank pain and temperature at home to 100.6. Labs
were significant for a leukocytosis of of 17.4, with left shift
of 82.1, no renal insufficiency Cr 1.0, grossly negative UA for
infection. A renal US was obtained, and was significant for no
hydronephrosis, but a right possible subscapular hematoma. In
this context, urology was consulted.
Patient began feeling right sided abdominal pain for several
days prior to presentation to the ED. Thought associated with
menstruation, but persisted. Pain not associated with food.
Endorses nausea, but no vomiting. Poor oral intake. Noted
fevers starting 6 days ago, that was controlled with tylenol.
The patient denied difficulty with urination, hematuria. Denies
sob, dizziness, lightheadedness, cp.
Past Medical History:
PAST MEDICAL HISTORY:
LOW BACK PAIN
MIGRAINE HEADACHES
OBESITY
OVERWEIGHT
TOBACCO ABUSE
Medications:
None
Allergies:
NKDA
PAST SURGICAL HISTORY:
Cystoscopy with bilateral stent placement ___
Ureteroscopy with laser lithotripsy stent placement ___
Social History:
___
Family History:
Non-contributory
Physical Exam:
AVSS
Wdwn F in NAD.
MMM
Unlabored breathing.
Abdomen obese, soft. TTP in RUQ, right flank. No flank
hematoma. Positive mild CVAT right.
Ext WWP
Pertinent Results:
___ 06:30AM BLOOD WBC-13.8* RBC-3.85* Hgb-10.7* Hct-33.7*
MCV-88 MCH-27.8 MCHC-31.7 RDW-14.1 Plt ___
___ 11:45AM BLOOD WBC-17.4*# RBC-4.49 Hgb-12.6 Hct-39.3
MCV-88 MCH-28.1 MCHC-32.1 RDW-12.6 Plt ___
___ 11:45AM BLOOD Neuts-82.1* Lymphs-11.9* Monos-5.4
Eos-0.2 Baso-0.5
___ 11:45AM BLOOD Glucose-83 UreaN-8 Creat-0.7 Na-138 K-4.2
Cl-102 HCO3-23 AnGap-17
___ 03:00PM URINE Color-Yellow Appear-Clear Sp ___
___ 03:00PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-MOD
___ 11:35AM URINE Blood-SM Nitrite-NEG Protein-TR
Glucose-NEG Ketone-40 Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-MOD
___ 03:00PM URINE RBC-1 WBC-9* Bacteri-FEW Yeast-NONE Epi-4
___ 11:35AM URINE RBC-<1 WBC-4 Bacteri-FEW Yeast-NONE Epi-7
TransE-<1
___ 03:00PM URINE Mucous-OCC
___ 11:35AM URINE Mucous-RARE
___ 11:35 am URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
Blood cultures x 2 pending
___ ___ 1:00 ___
COMPLETE GU U.S. (BLADDER & RE Clip # ___
Reason: Presence of hydroureter/hydronephrosis
UNDERLYING MEDICAL CONDITION:
___ year old woman sp ureteral stent removal, c/o right flank
pain + fevers
REASON FOR THIS EXAMINATION:
Presence of hydroureter/hydronephrosis
Wet Read: ___ TUE ___ 1:36 ___
Hypoechoic subcapsular collection adjacent to the right kidney
with septations
exerting mass effect on the right kidney. Appearance is
suggestive of a
subacute subcapsular hematoma, but it is not completely
specific. Lack of
clear anechoic components suggests this collection is not very
liquified. No
hydronephrosis of the right kidney. Mild hydronephrosis of the
left kidney.
Wet Read Audit # 1
Final Report
HISTORY: Right flank pain and fevers after right kidney
lithotripsy and stent
removal.
TECHNIQUE: Grayscale and Doppler ultrasound images of both
kidneys and
bladder were obtained.
COMPARISON: Renal ultrasound ___, CT abdomen and
pelvis ___.
FINDINGS:
There is a subcapsular hypodense collection with internal
septations which is
exerting significant mass effect on the right kidney. The
collection measures
2 cm in maximum transverse dimension. There is no hydronephrosis
of the right
kidney. The left kidney has mild hydronephrosis but is
otherwise
unremarkable. Limited views of the bladder are unremarkable.
IMPRESSION:
1. Subcapsular hypoechoic fluid collection in the right kidney
with internal
septations, which is suggestive of a subacute course. This most
likely
represents a subcapsular hematoma, but these findings are not
entirely
specific.
2. Mild hydronephrosis of the left kidney.
___ ___ 2:58 ___
CTU (ABD/PEL) W/&W/O CONTRAST Clip # ___
Reason: Evaluation of potential subcapsular hematoma on US
(Split bo
Contrast: OMNIPAQUE Amt: 130
UNDERLYING MEDICAL CONDITION:
___ year old woman sp removal right ureteral stent, pw right
flank pain
REASON FOR THIS EXAMINATION:
Evaluation of potential subcapsular hematoma on US (Split
bolus protocol;
noncon then combo delayed/portal venous 10 min later)
CONTRAINDICATIONS FOR IV CONTRAST:
None.
Wet Read: PRib TUE ___ 5:21 ___
Subcapsular collection along the right posterior kidney most
consistent with
hematoma measuring 12.1 x 3.9 x 5.0 cm. No stones or
hydronephrosis.
Wet Read Audit # 1
Final Report
INDICATION: Status post right ureteral stent removal with flank
pain,
evaluation of potential subcapsular hematoma seen on ultrasound.
COMPARISON: Ultrasound on ___bdomen and
pelvis on
___. Renal and bladder ultrasound on ___.
TECHNIQUE: MDCT images were obtained through the abdomen and
pelvis without
contrast and after administration of IV contrast. Two-minute
delayed images
were obtained as well. Coronal and sagittal reformations were
performed.
FINDINGS: The imaged lung bases are clear. The visualized
heart and
pericardium are unremarkable.
The liver enhances homogeneously and there are no focal liver
lesions. The
gallbladder is normal. The pancreas is normal. The spleen is
normal. The
stomach, small bowel, and colon are normal. The appendix is
normal. There
are scattered mildly prominent retroperitoneal lymph nodes. The
left kidney
is normal.
In the right kidney, there is a low-density subcapsular
collection measuring
3.9 AP x 12.1 CC x 5.0 laterally along the posterior portion of
the kidney,
and is consistent with a subacute to chronic hematoma noting rim
enhancement
and low density, not consistent with acute hematoma. Some fat
stranding is
present about the lower pole of the right kidney. No stones are
identified.
There is no hydronephrosis.
PELVIS: The bladder is normal. The uterus and adnexa are
unremarkable. The
rectum is normal. There is no free fluid in the pelvis. There
are no hernias
identified. There is no pelvic or inguinal lymphadenopathy.
The intra-abdominal vasculature is patent.
The bones are unremarkable.
IMPRESSION: Low-density subcapsular collection with rim
enhancement in the
posterior right kidney suggestive of subacute to chronic
evolving hematoma
based on location and relatively recent instrumentation. No
stones are
identified. No hydronephrosis or stones identified.
Brief Hospital Course:
___ was admitted to the urology service for pain control and
IV antibiotics with ceftriaxone. On HD #2, it was determined
that she was stable for discharge. Her pain was well
controlled on oral medications and she was tolerating a regular
diet without nausea. urine culture was negative. Antibiotics
were stopped. She was afebrile with stable vital signs, and no
leukocytosis. She was ambulating independently.
Medications on Admission:
None
Discharge Medications:
1. Acetaminophen 500 mg PO Q6H:PRN pain or fever
2. Docusate Sodium 100 mg PO BID
3. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain greater
than 4
RX *oxycodone 5 mg ONE tablet(s) by mouth Q6hrs Disp #*25 Tablet
Refills:*0
4. Ibuprofen 600 mg PO Q8H:PRN pain
RX *ibuprofen 600 mg ONE tablet(s) by mouth Q8hrs Disp #*40
Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
RIGHT FLANK PAIN likely due to ___ hematoma/fluid
collection
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
-You can expect to see occasional blood in your urine and to
possibly experience some urgency and frequency over the next
month; this may be related to the passage of stone fragments or
the indwelling ureteral stent (if there is one).
-The kidney stone may or may not have been removed AND/or there
may fragments/others still in the process of passing.
-You may experience some pain associated with spasm of your
ureter.; This is normal. Take the narcotic pain medication as
prescribed if additional pain relief is needed.
-Do not lift anything heavier than a phone book (10 pounds) and
refrain from aggressive sports/activities until further advised.
-You may continue to periodically see small amounts of blood in
your urine--this is normal and will gradually improve
-Resume all of your pre-admission medications, except HOLD
aspirin until you see your urologist in follow-up
-You can expect to see occasional blood in your urine and to
possibly experience some urgency and frequency over the next
month; this may be related to the passage of stone fragments or
the indwelling ureteral stent.
-The kidney stone may or may not have been removed AND/or there
may fragments/others still in the process of passing.
-You may experience some pain associated with spasm of your
ureter.; This is normal. Take the narcotic pain medication as
prescribed if additional pain relief is needed.
-Ureteral stents MUST be removed or exchanged and therefore it
is IMPERATIVE that you follow-up as directed.
-Do not lift anything heavier than a phone book (10 pounds)
-You may continue to periodically see small amounts of blood in
your urine--this is normal and will gradually improve
-Resume all of your pre-admission medications, except HOLD
aspirin until you see your urologist in follow-up
-IBUPROFEN (the ingredient of Advil, Motrin, etc.) may be taken
even though you may also be taking Tylenol/Acetaminophen. You
may alternate these medications for pain control. For pain
control, try TYLENOL FIRST, then ibuprofen, and then take the
narcotic pain medication as prescribed if additional pain relief
is needed.
-Ibuprofen should always be taken with food. Please discontinue
taking and notify your doctor should you develop blood in your
stool (dark, tarry stools)
-You MAY be discharged home with a medication called PYRIDIUM
that will help with the "burning" pain you may experience when
voiding. This medication may turn your urine bright orange.
-Colace has been prescribed to avoid post surgical constipation
and constipation related to narcotic pain medication.
Discontinue if loose stool or diarrhea develops. Colace is a
stool softener, NOT a laxative, and available over the counter.
The generic name is DOCUSATE SODIUM. It is recommended that you
use this medication.
-Do not eat constipating foods for ___ weeks, drink plenty of
fluids to keep hydrated
-No vigorous physical activity or sports for 4 weeks
Followup Instructions:
___
|
19709131-DS-4
| 19,709,131 | 23,581,316 |
DS
| 4 |
2174-06-01 00:00:00
|
2174-06-01 15:34:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Right Ankle Pain
Major Surgical or Invasive Procedure:
1. Open reduction, internal fixation of right bimalleolar ankle
fracture.
2. Chondroplasty, anterolateral talar surface.
History of Present Illness:
Mr. ___ is a pleasant ___ year old ___ who
presents today after sustaining a twisting injury to his right
ankle earlier this evening. Patient reports that he had just
finished dinner and was taking his plate to the sink when he
tripped on a small trash can in his living room and twisted his
right ankle. He felt an immediate crack and noticed a swollen
and deformed right ankle. He reports he was in immediate
excruciating pain and thought he had dislocated the ankle. He
states that he "quickly put it back [into position?]". He was
unable to bear any weight through the right lower extremity. He
went to ___ where preliminary x-rays of the right
ankle were obtained and revealed a bimalleolar right ankle
fracture. The patient was placed into a temporizing splint and
transferred to ___ for further evaluation and management.
Currently patient endorses some numbness and paresthesias over
the dorsum of his foot. He endorses some pain/discomfort, but
overall states that his pain is minimal. He denies injuring any
other extremity. He denies frankly falling, or striking his
head. Denies loss of consciousness.
Past Medical History:
None
Social History:
___
Family History:
Non-Contributory
Physical Exam:
On Admission:
In general, the patient is a pleasant middle aged gentleman,
resting comfortably on the emergency department stretcher in no
apparent distress.
Vitals: Tc 99.2, HR 81, BP 138/89, RR 18, SpO2 100%
Right lower extremity:
Skin intact
There is notable swelling about the right ankle. There is
tenderness to palpation along the medial and lateral malleoli.
There are no overlying skin changes. No tederness about the
lower leg or proximal tibiofibular joint.
Full, painless AROM/PROM of hip, knee
___ fire, although APF and ADF is expectedly painful
+SILT SPN/DPN/TN/saphenous/sural distributions. Patient endorses
some numbness in the DPN distribution.
___ pulses, foot warm and well-perfused
On Discharge:
AFVSS
General - Awake and alert. Lying down in bed. NAD.
Right Lower Extremity
- Splint in place, intact, no soiling
- Able to wiggle toes
- Toes are warm and well perfused with brisk capillary refill.
- Sensation intact to light touch at tips of toes.
Pertinent Results:
___ 06:50AM BLOOD WBC-8.8 RBC-4.34* Hgb-13.4* Hct-40.5
MCV-93 MCH-30.9 MCHC-33.2 RDW-12.3 Plt ___
___ 06:50AM BLOOD Glucose-108* UreaN-18 Creat-0.9 Na-140
K-3.9 Cl-105 HCO3-25 AnGap-14
Brief Hospital Course:
The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have a right bimalleolar ankle fracture and was admitted to
the orthopedic surgery service. The patient was taken to the
operating room on ___ for open reduction and internal
fixation of his right ankle fracture and chondroplasty of the
anterior talar surface, which the patient tolerated well (for
full details please see the separately dictated operative
report). The patient was taken from the OR to the PACU in stable
condition and after recovery from anesthesia was transferred to
the floor. The patient was initially given IV fluids and IV
pain medications, and progressed to a regular diet and oral
medications by POD#1. The patient was given perioperative
antibiotics and anticoagulation per routine. The patient's home
medications were continued throughout this hospitalization. The
patient worked with ___ who determined that discharge to home
with home ___ was appropriate. The ___ hospital course was
otherwise unremarkable.
At the time of discharge the patient was afebrile with stable
vital signs that were within normal limits, pain was well
controlled with oral medications, splint was clean/dry/intact,
and the patient was voiding/moving bowels spontaneously. The
patient is non weight bearing in the right lower extremity, and
will be discharged on enoxaparin for DVT prophylaxis. The
patient will follow up in two weeks per routine. A thorough
discussion was had with the patient regarding the diagnosis and
expected post-discharge course, and all questions were answered
prior to discharge.
Medications on Admission:
None
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H
Never exceed 4000 mg in 24 hours.
2. Docusate Sodium 100 mg PO BID
Do not take if having loose bowel movements.
RX *docusate sodium 100 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*0
3. Enoxaparin Sodium 40 mg SC QHS Duration: 2 Weeks
Start: Today - ___, First Dose: Next Routine Administration
Time
RX *enoxaparin 40 mg/0.4 mL 40 mg sc at bedtime Disp #*14
Syringe Refills:*0
4. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN Pain
RX *oxycodone 5 mg 1 tablet(s) by mouth every four (4) hours
Disp #*100 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Right bimalleolar ankle fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
MEDICATIONS:
- Please take all medications as prescribed by your physicians
at discharge.
- Continue all home medications unless specifically instructed
to stop by your surgeon.
- Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
- Narcotic pain relievers can cause constipation, so you should
drink eight 8oz glasses of water daily and take a stool softener
(colace) to prevent this side effect.
ANTICOAGULATION:
- Please take enoxaparin (Lovenox) 40mg daily for 2 weeks
WOUND CARE:
- You may shower. No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- No dressing is needed if wound continues to be non-draining.
- Splint must be left on until follow up appointment unless
otherwise instructed
- Do NOT get splint wet
ACTIVITY AND WEIGHT BEARING:
- You may *NOT* bear weight with the right leg. Keep the splint
on until follow up appointment.
Followup Instructions:
___
|
19709184-DS-8
| 19,709,184 | 27,239,374 |
DS
| 8 |
2133-07-20 00:00:00
|
2133-07-20 10:13:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: OBSTETRICS/GYNECOLOGY
Allergies:
cyclobenzaprine
Attending: ___.
Chief Complaint:
pelvic pain
Major Surgical or Invasive Procedure:
none
Past Medical History:
HISTORY of Abnormal pap smears: denies
HISTORY of STIs: h/o chlamydia, s/p treatment; recent test neg
as
outpatient
ISSUES: pelvic pain, endometriosis (previously followed by Dr.
___ at ___ and seen in consultation by Dr. ___
OB HISTORY:
G: 0
PAST MEDICAL HISTORY:
1. Endometriosis (diagnosed in ___
2. Fractured left hip(Dx ___
3. Left rotator cuff ___
4. Migraines with Aura(Dx ___, previously on topomax)
5. Rheumatoid arthritis
6. Fibromyalgia
PAST SURGICAL HISTORY:
1. Laparoscopic Cystectomy (___)
2. Diagnostic laparoscopy for endometriosis
Physical Exam:
Discharge physical exam
Vitals: VSS
Gen: NAD, A&O x 3
CV: RRR
Resp: no acute respiratory distress
Abd: soft, appropriately tender, no rebound/guarding
Ext: no TTP
Pertinent Results:
___ 12:50PM POTASSIUM-3.9
___ 12:29PM COMMENTS-GREEN TOP
___ 12:29PM K+-6.3*
___ 10:00AM URINE HOURS-RANDOM
___ 10:00AM URINE HOURS-RANDOM
___ 10:00AM URINE UHOLD-HOLD
___ 09:05AM GLUCOSE-87 UREA N-9 CREAT-0.8 SODIUM-134
POTASSIUM-7.0* CHLORIDE-100 TOTAL CO2-24 ANION GAP-17
___ 09:05AM WBC-7.1 RBC-4.08 HGB-12.6 HCT-37.2 MCV-91
MCH-30.9 MCHC-33.9 RDW-11.8 RDWSD-39.3
___ 09:05AM NEUTS-73.9* LYMPHS-15.8* MONOS-9.5 EOS-0.1*
BASOS-0.4 IM ___ AbsNeut-5.27 AbsLymp-1.13* AbsMono-0.68
AbsEos-0.01* AbsBaso-0.03
___ 09:05AM PLT COUNT-187
___ 09:05AM ___ PTT-32.0 ___
Brief Hospital Course:
On ___, Ms. ___ was admitted from the Emergency
Department for management of pelvic pain thought to be due to
endometriosis flare. In the ED she was given morphine and
toradol for pain control. Plvic ultrasound showed no concerning
causes for her pain (normal uterus and endometrium, 1.4 x 1.2 x
1.0 cm cyst or follicle along the peripheral edge of the right
ovary is similar to ___, no free fluid). Urine
pregnancy test and gonorrhea and chlamydia were also negative.
During her hospitalization she received IV toradol, oral
dilaudid, gabapentin, ibuprofen, acetaminophen, benadryl and
vaginal valium suppository.
By hospital day 2, her pain was controlled with oral
medications, she was tolerating a regular diet and ambulating
independently. She was then discharged home in stable condition
with outpatient follow-up scheduled.
Medications on Admission:
Diazepam 5mg per vagina TID PRN pain
folic acid
methotrexate sodium 20mg PO weekly
norethindrone acetate 5mg PO daily
Discharge Medications:
1. Docusate Sodium 100 mg PO BID
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice
daily Disp #*50 Capsule Refills:*0
2. Gabapentin 200 mg PO TID
RX *gabapentin 100 mg 2 capsule(s) by mouth three times a day
Disp #*180 Capsule Refills:*1
3. HYDROmorphone (Dilaudid) 4 mg PO Q4H:PRN Pain - Moderate
Do not drink alcohol or drive while taking this medication.
RX *hydromorphone [Dilaudid] 4 mg 1 tablet(s) by mouth every 4
hours Disp #*20 Tablet Refills:*0
4. Ibuprofen 600 mg PO Q6H:PRN Pain - Moderate
take with food.
RX *ibuprofen 600 mg 1 tablet(s) by mouth every 6 hours Disp
#*50 Tablet Refills:*1
Discharge Disposition:
Home
Discharge Diagnosis:
pelvic pain, endometriosis flare
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 Emergency
Department for pelvic pain, thought to be due to a flare of your
endometriosis. You have recovered well and the team believes you
are ready to be discharged home. Please call Dr. ___
office with any questions or concerns. Please follow the
instructions below.
General instructions:
* Take your medications as prescribed.
* Do not drive while taking narcotics.
* Take a stool softener such as colace while taking narcotics to
prevent constipation.
* Do not combine narcotic 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.
Call your doctor for:
* fever > 100.4F
* severe abdominal pain
* difficulty urinating
* vaginal bleeding requiring >1 pad/hr
* abnormal vaginal discharge
* nausea/vomiting where you are unable to keep down fluids/food
or your medication
To reach medical records to get the records from this
hospitalization sent to your doctor at home, call ___.
Followup Instructions:
___
|
19709220-DS-3
| 19,709,220 | 26,529,662 |
DS
| 3 |
2134-04-19 00:00:00
|
2134-05-07 16:03:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
tramadol
Attending: ___.
Chief Complaint:
unable to care for herself and chronic abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old ___ speaking female with a PMH of
nephrectomy, chronic abdominal pain, HTN, multiple ED visits for
chronic pain and inability to take care of herself at home who
presents again unable to care for herself alone at home.
Patient originally from ___ and ___ been living with family
members in ___. Up until last month, she was living with her
son and daughter in law who have been in ___ for the past
month and was doing well with them, able to make food for
herself. Patient concerned she can no longer take care of
herself
at home, no longer has money and has been trying to get ahold of
her daughter in ___ but has no cellphone.
Denies fevers, chills, nausea, vomiting. Patient with multiple
vague complaints. Has had chronic abdominal pain and
constipation. Abd pain is intermittent, cramping. Also
complaining of b/l knee pain. She has been getting steroid
injections in b/l knees, last injection on ___. Reports
occasional blood mixed with her stool, but not recently. Wears
diapers as she has been incontinent of urine for the past few
years. Reports eating well and is able to go to an ___
restaurant near home for free food at times, but recently has
run
out of money. Reports coughing chronically.
Family dynamics per chart review are complex but currently,
patient seems to be in best contact with her daughter ___ who
is in ___. She does not get along with her daughter ___ and
___ daughter ___ keeps in touch with her mother intermittently
but isn't her primary guardian. She was living previously in
___ with her Son and daughter in law ___ (same name) but
they
have been in ___ for the past month and it is unclear when
they are coming back.
Phone Numbers: **SEE SW NOTE
___: ___
___: ___
___ (daughter: ___
Daughter In Law ___: ___
In the ED, patient HD stable. Patient referred to Elder
Protective Services.
ROS: Pertinent positives and negatives as noted in the HPI. All
other systems were reviewed and are negative.
Past Medical History:
HTN
Nephrectomy
DMII
Social History:
___
___ History:
FAMILY HISTORY: Mother with asthma, denies DMII history
Physical Exam:
ADMISSON EXAM:
VITALS: Afebrile and vital signs stable (see eFlowsheet)
GENERAL: Alert and in no apparent distress, occasionally tearing
up
EYES: Anicteric, pupils equally round
ENT: Ears and nose without visible erythema, masses, or trauma.
Oropharynx without visible lesion, erythema or exudate
CV: Heart regular, no murmur, no S3, no S4. No JVD.
RESP: Lungs clear to auscultation with good air movement
bilaterally. Breathing is non-labored
GI: Abdomen soft, non-distended, non-tender to palpation. Bowel
sounds present. No HSM
GU: some ttp, particularly in LLQ
MSK: Neck supple, moves all extremities, strength grossly full
and symmetric bilaterally in all limbs
SKIN: No rashes or ulcerations noted
NEURO: Alert, oriented, face symmetric, gaze conjugate with
EOMI,
speech fluent, moves all limbs, sensation to light touch grossly
intact throughout
PSYCH: pleasant, appropriate affect
DISCHARGE EXAM
VITALS: Afebrile and vital signs stable (see eFlowsheet)
GENERAL: Alert and in no apparent distress
EYES: Anicteric, pupils equally round
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, mild TTP at right side. Bowel
sounds present.
GU: No suprapubic fullness or tenderness to palpation
MSK: Moves all extremities, strength grossly full and symmetric
bilaterally in all limbs
NEURO: Alert, oriented, face symmetric, gaze conjugate with
PSYCH: pleasant, appropriate affect
Pertinent Results:
___ 01:22PM BLOOD WBC-6.7 RBC-4.33 Hgb-11.0* Hct-36.8
MCV-85 MCH-25.4* MCHC-29.9* RDW-15.5 RDWSD-47.9* Plt ___
___ 07:30AM BLOOD WBC-3.4* RBC-3.98 Hgb-10.3* Hct-33.8*
MCV-85 MCH-25.9* MCHC-30.5* RDW-15.6* RDWSD-47.7* Plt ___
___ 06:20AM BLOOD WBC-4.8 RBC-4.02 Hgb-10.2* Hct-33.7*
MCV-84 MCH-25.4* MCHC-30.3* RDW-15.4 RDWSD-46.5* Plt ___
___ 01:22PM BLOOD Glucose-102* UreaN-9 Creat-0.7 Na-141
K-4.7 Cl-102 HCO3-25 AnGap-14
___ 07:30AM BLOOD Glucose-103* UreaN-13 Creat-0.6 Na-144
K-4.7 Cl-103 HCO3-27 AnGap-15
___ 06:20AM BLOOD Glucose-93 UreaN-15 Creat-0.7 Na-145
K-4.2 Cl-103 HCO3-26 AnGap-16
___ 01:22PM BLOOD ALT-16 AST-24 AlkPhos-68 TotBili-0.4
___ 01:22PM BLOOD Lipase-49
___ 01:22PM BLOOD cTropnT-<0.01
___ 06:20AM BLOOD Calcium-9.1 Phos-4.1 Mg-1.9
___ 07:30AM BLOOD calTIBC-367 VitB12-293 Folate-13
Ferritn-41 TRF-282
ABCT:
1. Patient is status post right nephrectomy with subcentimeter
soft tissue
density in the surgical bed likely postsurgical but prior
imaging should be
used for comparison to confirm and exclude tumor recurrence.
2. 5.6 cm cystic left adnexal mass is noted, and should be
compared with prior
imaging when available. Otherwise, pelvic ultrasound should be
obtained.
3. 1.5 cm enlarged epicardial lymph node of unclear clinical
significance.
This should be compared with prior but if prior imaging cannot
be obtained,
follow-up imaging should be performed in 3 months given history
of malignancy.
RECOMMENDATION(S): Compared with prior imaging. If not
available, consider
pelvic ultrasound for left adnexal mass and repeat CT abdomen
pelvis imaging
for epicardial lymph node in 3 months.
NOTIFICATION: The updated recommendations were discussed with
Dr. ___,
M.D. by ___, M.D. on the telephone on ___ at 9:14 am,
10 minutes
after discovery of the findings.
Pelvic US:
1. 5.5 cm left adnexal cyst.
2. Right ovary not visualized.
RECOMMENDATION(S): Pelvic ultrasound in ___ year.
Brief Hospital Course:
___ year old ___ speaking female with a PMH of nephrectomy,
chronic abdominal pain, HTN, multiple ED visits for chronic pain
and inability to take care of herself at home who presents again
unable to care for herself alone at home incidentally found to
have a left adnexal cyst.
#Abdominal pain
The etiology of her abdominal pain is not immediately clear. She
tolerates a diet without pain. She does note some constipation,
which could contribute. Pelvic US shows left adnexal cyst, but
not convinced this is contributing to her pain. Otherwise,
patient is tolerating regular diet. LFT normal. Lipase normal.
UCX negative. Exam benign. By discharge, her abdominal pain was
improved and she was tolerating a diet. She was continued on
omeprazole.
#Elder neglect
As noted in HPI, complex social history. Patient has been
trouble with housing. Her daughter ___ does not seem to be able
to take care of her. ___ is in ___. Her son does not return
until ___ or so. She was evaluated by SW, EPS and we
contacted her daughter ___. She was discharged with plan for
outpatient services and to the home of her daughter ___.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Levothyroxine Sodium 100 mcg PO DAILY
2. Senna 17.2 mg PO DAILY
3. Omeprazole 20 mg PO DAILY
4. MetFORMIN XR (Glucophage XR) 500 mg PO BID
5. Lisinopril 40 mg PO DAILY
6. Metoprolol Succinate XL 50 mg PO DAILY
7. Artificial Tears Preserv. Free ___ DROP BOTH EYES PRN dry
eyes
8. Acetaminophen 500 mg PO Q6H:PRN Pain - Mild
9. Multivitamins 1 TAB PO DAILY
Discharge Medications:
1. Polyethylene Glycol 17 g PO DAILY
RX *polyethylene glycol 3350 [Miralax] 17 gram/dose 1 powder(s)
by mouth once a day Refills:*0
2. Acetaminophen 500 mg PO Q6H:PRN Pain - Mild
3. Artificial Tears Preserv. Free ___ DROP BOTH EYES PRN dry
eyes
4. Levothyroxine Sodium 100 mcg PO DAILY
5. Lisinopril 40 mg PO DAILY
RX *lisinopril 40 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
6. MetFORMIN XR (Glucophage XR) 500 mg PO BID
RX *metformin 500 mg 1 tablet(s) by mouth twice a day Disp #*60
Tablet Refills:*0
7. Metoprolol Succinate XL 50 mg PO DAILY
RX *metoprolol succinate 50 mg 1 tablet(s) by mouth once a day
Disp #*30 Tablet Refills:*0
8. Multivitamins 1 TAB PO DAILY
9. Omeprazole 20 mg PO DAILY
RX *omeprazole 20 mg 2 capsule(s) by mouth once a day Disp #*30
Capsule Refills:*0
10. Senna 17.2 mg PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Abdominal pain
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Ms. ___, it was a pleasure taking care of you during your
stay at ___. You were admitted for abdominal pain. Your pain
improved and you tolerated a diet. You were seen by our social
work team and elder services. They will help you with services
at home.
We wish your the best,
___
Followup Instructions:
___
|
19709635-DS-8
| 19,709,635 | 28,613,375 |
DS
| 8 |
2156-04-14 00:00:00
|
2156-04-15 10:36:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Cipro
Attending: ___.
Chief Complaint:
Nausea/vomiting/diarrhea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ presents with nausea, vomiting and diarrhea. Patient reports
a week long history of vomiting and diarrhea which has worsened
over past 3 days. Has noted some associated abdominal pain,
predominantly across left side of abdomen. Has not noted fever.
No blood in BMs or stool. Is on oxycodone ___ and OxyContin at
home for her lower extremity pain secondary to her reflex
sympathetic dystrophy, has not had recent changes in her
medication dosing however has had difficulty keeping down her
narcotics secondary to vomiting. No recent travel or exotic food
intake. She notes that she recently had change in her narcotic
regimen - 2 weeks ago was on 60 BID of oxycontin and 25mg q4prn
of oxycodone, now on 80 bid of oxycontin and 15 q4prn of
oxycodone.
Patient reports that she has had 6 surgeries on her left foot
starting in ___, thought to be secondary to playing basketball
and injuries sustained during that. Since ___ she has had pain
in the left foot which is chronic despite multiple surgeries.
She was diagnosed with reflex sympathetic dystrophy in ___,
thought ___ to the multiple surgeries at the left foot. She says
she has chronic left foot pain at baseline, described as sharp,
burning. She gets exacerbations about once a month, lasting ___
days, which prevents her from her daily activities and is
immobilizing. She says her foot gets red/discolored during these
episodes with warmth, and the pain can travel up her leg. She
had spine stimulators placed in ___ which she says has
helped reduce the frequency of exacerbations of her chronic
pain.
Initial ED vitals were 98.2 116 131/80 16 99%. Initial UA w/ mod
leuks, many bacteria and 22 WBC, repeat was completely negative.
Labs in ED notable for: lactate 2.4, ALT 106, AST 76, normal
CBC, Bun/Cr ___. CT Abd/Pelvis: Normal colon without evidence
of diverticulitis, no free pelvic fluid, no abdominal hernia, no
free intraperitoneal air. Per ED nurses note - patient stated
she vomited in ED but no one has witnessed pt. vomiting or
diarrhea. In ED patient was trialed with zofran, ativan IV,
phenergan and compazine in ED. She stated it was not working and
was still unable to tolerate POs. Also was given oxycodone,
oxycontin, gabapentin and ketorolac in ED. Pt was given 4 L NS
total for hydration and was A&Ox3.
On the floor, vs were: T98.2 P65 BP161/84 R18 O2 sat 99% RA.
Patient was sitting in bed, in NAD.
Past Medical History:
Reflex sympathetic dystophy - dx in ___, thought ___ to
multiple left foot surgeries/injuries
Spinal cord stimulator - placed in ___
Depression - was hospitalized at ___ in early ___, had
suicidal ideation without formed plan, has never attempted
suicide
Social History:
___
Family History:
MS (___), uterine cancer (mom), no family h/o CAD/MI, DM, or
mental health issues/substance abuse.
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: T:98.2 BP:161/84 P:65 R:18 O2:99% RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, mild diffuse tenderness to palpation,
non-distended, bowel sounds present, no rebound tenderness or
guarding
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema; left foot with well-healed surgical scar on plantar
surface, no swelling or erythema noted, ROM normal at left
ankle.
Skin: No rashes noted
Neuro: No focal neuro deficits, speech fluent, moving all
extremities.
DISCHARGE PHYSICAL EXAM:
Vitals: T:97.7 ___ R:18 O2:97-99% RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, mild diffuse tenderness to palpation,
non-distended, bowel sounds present, no rebound tenderness or
guarding
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema; left foot with well-healed surgical scar on plantar
surface, no swelling or erythema noted, ROM normal at left
ankle; tenderness to palpation along plantar aspect
Skin: No rashes noted
Neuro: No focal neuro deficits, speech fluent, moving all
extremities.
Pertinent Results:
ADMISSION LABS:
___ 10:15AM BLOOD WBC-7.5 RBC-4.53 Hgb-12.9 Hct-39.1 MCV-86
MCH-28.6 MCHC-33.1 RDW-13.0 Plt ___
___ 10:15AM BLOOD Neuts-67.3 ___ Monos-3.9 Eos-1.1
Baso-0.4
___ 10:15AM BLOOD ___ PTT-40.0* ___
___ 10:15AM BLOOD Glucose-111* UreaN-13 Creat-0.7 Na-136
K-4.3 Cl-100 HCO3-23 AnGap-17
___ 10:15AM BLOOD ALT-106* AST-76* AlkPhos-89 TotBili-0.2
___ 10:15AM BLOOD Albumin-4.5
___ 10:19AM BLOOD Lactate-2.4*
___ 10:05AM URINE RBC-4* WBC-22* Bacteri-MANY Yeast-NONE
Epi-12 TransE-1
___ 10:05AM URINE Blood-SM Nitrite-NEG Protein-30
Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-MOD
___ 12:15PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG
___ 10:05AM URINE Color-Yellow Appear-Hazy Sp ___
___ 12:15PM URINE Color-Straw Appear-Clear Sp ___
DISCHARGE LABS:
___ 07:35AM BLOOD WBC-8.7 RBC-4.23 Hgb-12.3 Hct-36.2 MCV-86
MCH-29.0 MCHC-33.9 RDW-13.1 Plt ___
___ 07:35AM BLOOD Glucose-85 UreaN-9 Creat-0.6 Na-137 K-3.9
Cl-103 HCO3-19* AnGap-19
___ 07:35AM BLOOD ALT-63* AST-36 AlkPhos-69 TotBili-0.2
___ 07:35AM BLOOD Calcium-8.8 Phos-2.8 Mg-1.9
MICRO:
___ 10:05 am URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
BLOOD CULTURE (___): Negative to date as of discharge
IMAGING:
CT ABD/PELVIS (___): IMPRESSION:
1. No evidence of acute diverticulitis.
2. Neural spinal stimulator is limited in its evaluation;
however, no overt
evidence of surrounding inflammation.
3. Mild hepatosteatosis.
ECG ___: Sinus rhythm. Within normal limits. No previous
tracing available for
comparison.
Brief Hospital Course:
ASSESSMENT AND PLAN: ___ with PMHx notable for depression,
reflex sympathetic dystrophy, chronic left foot pain, presents
with 1 week h/o nausea, vomiting and diarrhea.
# Nausea/vomiting/diarrhea: DDx includes viral gastroenteritis
versus possible opioid withdrawal. She may have initially had
viral syndrome but when unable to take PO meds, may have
precipitated withdrawal. Patient did have recent change in
narcotic dosing - may have also contributed to withdrawal
symptoms. CT abdomen and pelvis in the ED was without acute
process. The diarrhea resolved in the ED - while stool studies
were ordered she did not have loose bowel movement during
hospitalization. She was able to tolerate liquids and jello on
the day of discharge without emesis. She was given short-term
prescription for PO zofran to help alleviate any further
nausea/vomiting she may experience.
# Left foot pain/reflex sympathetic dystrophy: Patient has a
history of chronic foot pain, is s/p 6 surgeries to her left
foot, ___ one in mid ___. In addition, patient had spinal
stimulator placed in ___. She reports daily pain ___
at her left foot, and exacerbations ___ per month, where pain
can be up to ___. Her narcotic regimen on admission was 80 mg
BID oxycontin and 15mg q4hrs prn oxycodone. Her prescription
was last filled on ___ (this was confirmed with the
pharmacy). However, there was an error in her oxycontin
prescription - stated that she should take two 80mg oxycontins
BID (script was for 14 days). It was confirmed with the
pharmacy that she received 56 80mg oxycontins. Patient reported
she did not realize they were 80 mg tablets and that she had
been taking 2 tablets BID as prescribed, thus she was taking
160mg BID. On the medical wards she was continued on 80mg BID
oxycontin and 15mg q4prn oxycodone. She expressed concern that
she did not have any more oxycontin or oxycodone at home to last
her through the weekend and to her next PCP ___. After
discussing with her PCP, and noting that her prescription was
filled on ___, and her next appointment was ___, and she had
not used any of her home narcotics while hospitalized, the
decision was made, at the recommendation of her PCP, that she
not be discharged with new prescriptions for oxycodone or
oxycontin. This was communicated to the patient. In addition,
patient was advised that should she have further concerns
regarding her narcotic regimen, that she discuss it with her PCP
or pain clinic at ___ where she has been seen in the
past.
# Hepatosteatosis: CT abd/pelvis showed mild hepatosteatosis.
Patient with mild elevation in LFTs on admission. Trended down
the following morning. Hepatitis serologies were pending at
discharge but returned negative. These findings and pending
tests were discussed with her PCP.
# Depression: patient was admitted to ___ for 2
weeks earlier last year for depression. Patient had suicidal
ideation at the time, but denies ever having a formed plan or an
attempt. Per PCP, patient has had intermittent SI, but never
formed plan nor attempt to his knowledge. Patient denied
suicidal ideation or thoughts of harming herself during her
admission. She was continued on her home Prozac and Klonipin.
TRANSITIONAL ISSUES:
[ ]PCP follow up for recheck of LFT
[ ]PCP follow up regarding further pharmacological management of
chronic pain - Discussed narcotic medications with patient's
PCP, ___ (phone ___. He recommended not
prescribing patient more narcotics as he has follow-up with the
patient on ___.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. OxyCODONE SR (OxyconTIN) 80 mg PO Q12H
2. OxycoDONE (Immediate Release) 15 mg PO Q4H:PRN Pain
3. Gabapentin 600 mg PO HS
4. Gabapentin 400 mg PO TID
5. ClonazePAM 2 mg PO QHS
6. Naproxen 500 mg PO Q8H:PRN Pain
7. Fluoxetine 60 mg PO DAILY
Discharge Medications:
1. ClonazePAM 2 mg PO QHS
2. Fluoxetine 60 mg PO DAILY
3. Gabapentin 600 mg PO HS
4. Gabapentin 400 mg PO TID
5. OxycoDONE (Immediate Release) 15 mg PO Q4H:PRN Pain
6. OxyCODONE SR (OxyconTIN) 80 mg PO Q12H
7. Naproxen 500 mg PO Q8H:PRN Pain
8. Ondansetron 8 mg PO Q8H:PRN nausea
RX *ondansetron 8 mg 1 tablet,disintegrating(s) by mouth every
eight (8) hours Disp #*15 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Nausea/vomiting
Chronic left foot pain
Mild Hepatosteatosis
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 1 week history of nausea, vomiting, diarrhea and
left foot pain. You were given medicine to help with the nausea
and vomiting and given pain medication. In addition, imaging
was done of your abdomen/pelvis which showed some evidence of
mild hepatosteatosis (fat in the liver) but was otherwise
normal. In addition a few of your liver enzymes were elevated
but trended down during your stay. These were discussed with
your PCP and ___ follow-up on them. Your diarrhea resolved,
and you improved clinically and it was determined you were safe
to be discharged to home. Should you develop worsening
abdominal pain, bloody in your stool or urine, or develop high
fevers, you should seek evaluation at a medical facility or your
nearest emergency department.
Followup Instructions:
___
|
19710506-DS-10
| 19,710,506 | 26,502,700 |
DS
| 10 |
2123-06-19 00:00:00
|
2123-06-19 22:54:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Syncope
Major Surgical or Invasive Procedure:
Cardiac Catheterization ___
History of Present Illness:
Patient is a ___ male with history of hyponatremia,
IDDM, TIA, dementia, metastatic prostate cancer, carotid
stenosis s/p CEA, and critical aortic stenosis presenting with
syncope.
Per ED records, patient had syncope at ___ AM this morning.
Patient is a very poor historian and cannot describe the details
of his fainting episode in detail; however, he does state that
he was getting up from a chair and believes that he fell. He
denies any pain. He states that he quickly regained
consciousness. Patient is actively being worked up for an aortic
valve replacement with ___.
Per cardiology notes, over the last month, the patient has been
increasingly fatigued and short of breath. He has required
approximately 160 mg of Lasix daily over the last month which is
an increase from a stable dose of 80 mg for many years. Chest
x-ray normal at ___. Patient's wife provided more details;
reportedly the patient got up from a seated position and could
not move, he slowly dropped to his knees, his wife supported him
and he did not hit his head. He was unconscious for no more than
a minutes per his wife. No loss of bowel or bladder.
Additionally, the patient's PCP called to report lesion on
L-spine MRI, patient denies any symptoms c/f cauda equina/cord
syndrome and do not feel this merits an emergent workup
In the ED, initial VS were: 96.5 70 159/67 18 100% RA
Exam notable for: systolic murmur best heard in apex
Labs showed: Trop 0.02 x 2, MB 2, Hgb 12.4, BNP 609.
Imaging showed: CT Head w/ No acute intracranial process.
Consults: Cardiology
Patient received: 4U insulin, Dipyridamole-Aspirin, galantamine
*NF* 4 mg, Memantine 5 mg, Phosphorus 500 mg, Insulin 8 Units,
Insulin 9 Units
Transfer VS were: 0 98.1 60 144/53 18 97%
On arrival to the floor, patient reports that he came in for his
heart valve and maybe a pacemaker. He states that he fainted
getting out of his chair this morning and next thing he knew he
was being taken to the hospital. Currently, he denies F/C, N/V,
chest pain/dizziness, abdominal pain, constipation/diarrhea,
numbness or weakness. He does have chronic SOB at baseline. He
has lower back pain that sometimes radiates down his R leg but
is currently OK.
REVIEW OF SYSTEMS: 10 point ROS reviewed and negative except as
per HPI
Past Medical History:
1. Hyponatremia.
2. Diabetes.
3. History of TIA.
4. Squamous cell carcinoma.
5. Dementia.
6. Glaucoma.
7. Hypogonadism.
8. Sciatica.
9. Carotid stenosis status post CEA.
10. Hyperlipidemia.
11. Metastatic prostate cancer
Social History:
___
Family History:
Mother ___ ___ ATHEROSCLEROTIC CARDIOVASCULAR DISEASE
Father ___ ___ CANCER
Brother ___ ___ DIABETES MELLITUS
CHRONIC RENAL FAILURE
Brother Unknown ___ HEART DISEASE
CHRONIC RENAL FAILURE
DIABETES TYPE II
Physical Exam:
ADMISSION PHYSCIAL EXAM
=======================
VS: 98.5 PO 96 / 51 L Sitting 75 16 96 RA
GENERAL: Pleasant, NAD
HEENT: AT/NC, anicteric sclera, pink conjunctiva, MMM
NECK: supple, no JVD
HEART: RRR, S1/S2, + murmur, no 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
EXTREMITIES: no cyanosis, clubbing, or edema
NEURO: A&Ox3, moving all 4 extremities with purpose
DISCHARGE PHYSICAL EXAM
=======================
Vital signs stable
GENERAL: Older appearing man, NAD, comfortable.
HEENT: NCAT. EOMI. MMM.
CARDIAC: RRR. ___ systolic murmur over LUSB
with radiation to carotids.
PULMONARY: CTAB. Breathing comfortably on room air.
ABDOMEN: SNTND, +BS, no rebound/guarding
EXTREMITIES: WWP, no ___ edema. Tense, warm R forearm
w/ intact radial pulse, decreased wrist flexion.
NEURO: AOx3. Motor function grossly intact in ___
SKIN: Hematoma over right forearm as above.
Pertinent Results:
ADMISSION LABS
=============
___ 02:50PM BLOOD WBC-8.2 RBC-3.99* Hgb-12.4* Hct-37.0*
MCV-93 MCH-31.1 MCHC-33.5 RDW-14.8 RDWSD-51.3* Plt ___
___ 02:50PM BLOOD Neuts-45.8 ___ Monos-6.6 Eos-1.0
Baso-0.2 Im ___ AbsNeut-3.76 AbsLymp-3.79* AbsMono-0.54
AbsEos-0.08 AbsBaso-0.02
___ 02:50PM BLOOD ___ PTT-24.5* ___
___ 02:50PM BLOOD Glucose-257* UreaN-35* Creat-1.2 Na-140
K-3.7 Cl-97 HCO3-26 AnGap-17
___ 02:50PM BLOOD CK(CPK)-60
___ 02:50PM BLOOD CK-MB-2 proBNP-609
___ 02:50PM BLOOD Calcium-9.4 Phos-2.6* Mg-2.2
IMAGES
======
CT Head (___):
No acute intracranial process.
Cath (___):
1. No significant CAD.
Bone scan (___):
The images show no evidence of abnormal radiotracer uptake.
There is
mild irregularity of the thoracic spine, likely representing
degenerative
changes. A decrease in uptake within the L4-L5 region is noted,
partially
artifactual. The kidneys and urinary bladder are visualized, the
normal route of tracer excretion.
IMPRESSION: No evidence of focal osteoblastic abnormalities.
RUE US (___):
No evidence of deep vein thrombosis in the right upper
extremity. Subcutaneous edema.
CT Torso (___):
Panorex (___):
MICRO
=====
None
DISCHARGE LABS
=============
___ 04:53AM BLOOD WBC-6.4 RBC-2.92* Hgb-9.2* Hct-28.3*
MCV-97 MCH-31.5 MCHC-32.5 RDW-15.2 RDWSD-54.1* Plt ___
___ 04:53AM BLOOD ___ PTT-27.1 ___
___ 04:53AM BLOOD Glucose-230* UreaN-36* Creat-1.0 Na-142
K-4.4 Cl-98 HCO3-31 AnGap-13
PERTINENT LABS
=============
___ 04:53AM BLOOD WBC-6.4 RBC-2.92* Hgb-9.2* Hct-28.3*
MCV-97 MCH-31.5 MCHC-32.5 RDW-15.2 RDWSD-54.1* Plt ___
___ 04:53AM BLOOD Glucose-230* UreaN-36* Creat-1.0 Na-142
K-4.4 Cl-98 HCO3-31 AnGap-13
___ 02:50PM BLOOD CK-MB-2 proBNP-609
___ 02:50PM BLOOD cTropnT-0.02*
___ 05:30AM BLOOD CK-MB-1 cTropnT-0.03*
___ 06:50PM BLOOD CK-MB-2 cTropnT-0.04*
Brief Hospital Course:
___ man with history of diabetes, TIA, dementia,
metastatic prostate cancer, carotid stenosis s/p CEA, and severe
aortic stenosis presented for syncopal episode most likely due
to combination of symptomatic AS, dysautonomia, and mild
hypovolemia.
ACUTE ISSUES:
=============
# SYNCOPE
# SEVERE AORTIC STENOSIS
Presented for single episode syncope upon standing from chair.
Most likely combination of severe aortic stenosis, hypovolemia,
and dysautonomia. Was currently undergoing TAVR evaluation prior
to admission and was expedited while in house. s/p cath ___
without significant coronary disease and c/p CT torso on ___.
Per cardiac surgery, is high risk for procedure. Patient
received compression stockings. Home Lasix dose was decreased to
60 mg daily. Underwent CT Torso and panorex in preparation for
TAVR with plan to continue workup as outpatient. Symptoms
resolved during hospitalization with plan to discharge home with
___. Will be called to return to hospital to undergo TAVR in the
near future.
# CHRONIC DIASTOLIC HEART FAILURE
Recent admission to ___ for CHF exacerbation in early ___
with subsequent up-titration of Lasix. Dry on admission
confirmed with right heart cath. Patient underwent diuresis
holiday, restarted on Lasix 60 mg daily prior to discharge.
# RIGHT ARM HEMATOMA
Due to radial access during cath. Pain on exam and decreased
ROM, though with intact radial pulse with good distal sensation.
Evaluated by hand surgery without concern for compartment
syndrome. US without DVT. ROM improving at time of discharge.
# L5 BONE LESION
In setting of history of prostate cancer. No signs concerning
for cord compression. Recent MRI without central stenosis but
did have concerning lesion. Bone scan ___ without evidence of
osteoblastic lesions.
# TYPE 2 NSTEMI
Mild troponin elevation most likely from cardiac demand in
setting of severe AS. CKMB normal. Pt continued on
aspirin-dipyridamole ___ mg oral QD and atorvastatin 40 mg PO
QPM
CHRONIC ISSUES:
===============
# DEMENTIA
Pt continued on home galantamine 4 mg oral BID and memantine 5
mg PO/NG BID
# METASTATIC PROSTATE CANCER
Unclear exactly what prognosis is at this time. Bone scan
without evidence of lesions. Will follow up as outpatient.
# HYPOTHYROIDISM
Continue Levothyroxine Sodium 88 mcg PO QD
# DIABETES
Continue Lantus 8U w/ breakfast (home 6U). Insulin sliding scale
# GERD
Continued home Omeprazole 20 mg PO DAILY
# GLAUCOMA
Continued home Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH
EYES Q8H. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
# ANXIETY
Continued Sertraline 25 mg PO QD. Alprazolam restarted on
discharge.
TRANSITIONAL ISSUES:
====================
Discharge weight: 60.7 kg
Discharge Cr: 1.0
[ ] Recheck chem-10, weight, and volume status at follow up and
titrate Lasix appropriately. Would aim for slightly wet given
recent syncope with increased diuretic dose.
[ ] Long-acting insulin was increased to 8 units with breakfast.
[ ] Underwent expedited TAVR workup while in house. Will plan to
return to hospital for TAVR procedure in the near future.
[ ] Keep right arm elevated above heart-level until right arm
swelling has resolevd
#CODE STATUS: DNR/DNI (confirmed)
#CONTACT: ___ (wife: ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Brimonidine Tartrate 0.15% Ophth. 1 DROP RIGHT EYE Q8H
2. ALPRAZolam 0.25 mg PO QHS:PRN anxiety
3. Memantine 5 mg PO BID
4. Atorvastatin 40 mg PO QPM
5. Levemir 6 Units Breakfast
Insulin SC Sliding Scale using Novolog Insulin
6. Furosemide 80 mg PO BID
7. galantamine 4 mg oral BID
8. Omeprazole 20 mg PO DAILY
9. Levothyroxine Sodium 88 mcg PO DAILY
10. aspirin-dipyridamole ___ mg oral BID
11. oxyCODONE-acetaminophen ___ mg oral Q6H:PRN
12. mometasone 0.1 % topical ASDIR
13. Mupirocin Ointment 2% 1 Appl TP BID
14. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
15. Sertraline 25 mg PO DAILY
16. Ferrous GLUCONATE 324 mg PO DAILY
17. Ramelteon 8 mg PO QHS:PRN insomnia
Discharge Medications:
1. Furosemide 60 mg PO DAILY
RX *furosemide 20 mg 3 tablet(s) by mouth daily Disp #*90 Tablet
Refills:*0
2. Levemir 8 Units Breakfast
Insulin SC Sliding Scale using HUM Insulin
3. ALPRAZolam 0.25 mg PO QHS:PRN anxiety
4. aspirin-dipyridamole ___ mg oral BID
5. Atorvastatin 40 mg PO QPM
6. Brimonidine Tartrate 0.15% Ophth. 1 DROP RIGHT EYE Q8H
7. Ferrous GLUCONATE 324 mg PO DAILY
8. galantamine 4 mg oral BID
9. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
10. Levothyroxine Sodium 88 mcg PO DAILY
11. Memantine 5 mg PO BID
12. mometasone 0.1 % topical ASDIR
13. Mupirocin Ointment 2% 1 Appl TP BID
14. Omeprazole 20 mg PO DAILY
15. oxyCODONE-acetaminophen ___ mg oral Q6H:PRN severe pain
16. Ramelteon 8 mg PO QHS:PRN insomnia
17. Sertraline 25 mg PO DAILY
18.durable equipment
Equipment: rolling walker
Dx: Muscle weakness (generalized) M62.81
Px: good
___: 13 months
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS
===========================
# SEVERE AORTIC STENOSIS
SECONDARY DIAGNOSES
===========================
# SYNCOPE
# CHRONIC DIASTOLIC HEART FAILURE
# RIGHT ARM HEMATOMA
# L5 BONE LESION
# TYPE 2 NSTEMI
# DEMENTIA
# METASTATIC PROSTATE CANCER
# HYPOTHYROIDISM
# DIABETES
# GERD
# GLAUCOMA
# ANXIETY
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. ___,
It was a pleasure to be part of your care.
You were admitted to the hospital because you fainted. This was
most likely due to your aortic stenosis (the aortic valve in
your heart is narrow and it is hard for blood to flow through).
You started undergoing evaluation by the team that can replace
your aortic valve. You got many studies completed that you need
prior to this procedure. You also underwent a bone scan to look
at the lesion in your spine, which based on the appearance does
not look like metastatic prostate cancer.
You will need to follow up in the heart valve clinic to schedule
the appointment to have your valve replaced. This clinic will
call you.
Weight yourself daily. If you gain more than 3 lbs then call
your cardiologists office.
If you experience any dizziness, lightheadedness, unsteadiness
then please seek medical care.
We wish you the best,
Your ___ Team
Followup Instructions:
___
|
19710506-DS-12
| 19,710,506 | 28,489,223 |
DS
| 12 |
2123-07-28 00:00:00
|
2123-07-28 17:51:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Syncope
Major Surgical or Invasive Procedure:
24 hour Holter Monitor
Echocardiogram
Exercise Treadmill Test
XR Lower Back/Sacrum
History of Present Illness:
___ with recent TAVR on ___ admitted for further
evaluation after a syncopal episode at home on ___.
He had been seen the day prior ___ in the ___ by Dr. ___
with complaints of new onset shortness of breath, shuffling
gait, and dizziness with standing. Of note, he reportedly had
one low blood pressure at home about a week prior to that visit
at 94/57. He also had some bradycardia down to the ___ and
occasional ___ while in the hospital which had improved prior to
discharge. During this cdac visit, he was hypertensive to 188/65
and 195/80. He was started on 5mg of Lisinopril daily and his
Lasix dose was decreased from 60mg BID to 40mg BID. He was sent
home with a holter monitor.
On ___, he had a syncopal episode at home, witnessed by his
wife, in which he sustained a fall. He was brought to ___
___ where trauma imaging was negative, and ultimately was
transferred here for further workup to determine the cause of
syncope including EP eval. EKG showed Sinus bradycardia with
ventricular ectopy.
Past Medical History:
Pertinent PMH:
1. Hyponatremia.
2. Diabetes.
3. History of TIA
4. Squamous cell carcinoma.
5. Dementia.
6. Glaucoma.
7. Hypogonadism.
8. Sciatica.
9. Carotid stenosis status post CEA.
10. Hyperlipidemia.
11. Severe aortic stenosis
12. Heart Failure with preserved EF
Social History:
___
Family History:
Mother ___ ___ ATHEROSCLEROTIC CARDIOVASCULAR DISEASE
Father ___ ___ CANCER
Brother ___ ___ DIABETES MELLITUS
CHRONIC RENAL FAILURE
Brother Unknown ___ HEART DISEASE
CHRONIC RENAL FAILURE
DIABETES TYPE II
Physical Exam:
Admission
VITALS: ___ 1820 Temp: 98.0 PO BP: 181/77 L Sitting HR: 64
RR: 18 O2 sat: 97% O2 delivery: Ra
GENERAL: Well-developed, well-nourished. NAD. Mood, affect
appropriate.
HEENT: PERRL, EOMI. Conjunctiva pink.
NECK: Supple with JVP of 8 cm.
CARDIAC: RRR, normal S1, S2. No murmurs/rubs/gallops. No
thrills,
lifts.
LUNGS: Resp were unlabored, no accessory muscle use. No
crackles,
wheezes or rhonchi.
ABDOMEN: Soft, NTND.
EXTREMITIES: No c/c/e.
SKIN: No stasis dermatitis,.
PULSES: Distal pulses palpable and symmetric
Discharge:
VS: T 97.5 BP 165/66 HR 68 RR 18 SpO2 96%RA
PE:
Gen: Patient comfortably lying in bed in no acute distress.
HEENT: Face symmetrical, trachea midline
Neuro: A/Ox3. Speaking in complete, coherent sentences. No face,
arm, or leg weakness. No tongue deviation. No sensory deficits.
Pulm: Breathing unlabored. Breath sounds clear bilaterally.
Cardiac: No JVD. No thrills or bruits heard on carotids
bilaterally. S1, S2 RRR. I/VI systolic murmur heard best at
base.
Vasc: No edema noted in bilateral upper or lower extremities. No
pigmentation changes noted in bilateral upper or lower
extremities. Skin dry, warm. Bilateral radial pulses palpable
2+,
___ palpable 1+.
Abd: Rounded, soft, non-tender. BS+
Pertinent Results:
=====
LABS
=====
CBC
___ 02:16PM BLOOD WBC-5.3 RBC-3.43* Hgb-10.9* Hct-33.3*
MCV-97 MCH-31.8 MCHC-32.7 RDW-13.6 RDWSD-49.0* Plt ___
___ 06:35AM BLOOD WBC-6.9 RBC-3.14* Hgb-10.0* Hct-30.2*
MCV-96 MCH-31.8 MCHC-33.1 RDW-13.9 RDWSD-48.9* Plt ___
___ 07:40AM BLOOD WBC-5.2 RBC-3.06* Hgb-9.4* Hct-29.7*
MCV-97 MCH-30.7 MCHC-31.6* RDW-13.8 RDWSD-48.9* Plt ___
___ 07:04AM BLOOD Hgb-9.4* Hct-28.5* Plt ___
CHEM
___ 02:16PM BLOOD UreaN-28* Creat-1.1 Na-137 K-4.7 Cl-96
HCO3-31 AnGap-10
___ 06:35AM BLOOD Glucose-253* UreaN-29* Creat-1.1 Na-140
K-4.6 Cl-100 HCO3-27 AnGap-13 Calcium-9.4 Phos-3.5 Mg-2.2
___ 07:40AM BLOOD Glucose-193* UreaN-29* Creat-1.0 Na-141
K-4.3 Cl-100 HCO3-30 AnGap-11 Mg-2.3
___ 07:04AM BLOOD UreaN-27* Creat-0.9 Na-138 K-4.3 Cl-99
HCO3-28 AnGap-11 Mg-2.1
TROP
___ 06:35AM BLOOD cTropnT-0.02*
___ 01:30PM BLOOD cTropnT-0.04*
___ 07:40AM BLOOD cTropnT-0.03*
BNP
___ 02:16PM BLOOD proBNP-699
___ 06:35AM BLOOD proBNP-994*
=========================
XR LUMBAR-SACRAL SPINE
=========================
___ FINDINGS: There is no spondylolisthesis. Patient is
status post L4 laminectomy. Aside from moderate narrowing of
the L5-S1 interspace, vertebral body heights and interspaces
appear preserved in height. Moderate anterior osteophytes are
present throughout the lumbar spine. Degenerative changes are
suspected at L4-L5 and L5-S1 facet joints. There is no evidence
of fracture, dislocation or lysis. Bones appear demineralized.
Vascular calcification is moderate. Surgical clips project over
the lower mid pelvis. There are also cholecystectomy clips in
the right upper quadrant.
IMPRESSION: Similar moderate degenerative changes of the lumbar
spine.
=========================
EXERCISE TREADMILL TEST
=========================
ETT ___: IMPRESSION: Poor exercise tolerance. No anginal
symptoms or pre-syncope with no ischemic ST segment changes.
Resting systolic hypertension with flat blood pressure response
to exercise. In the absence of beta blocker therapy, the heart
rate response was blunted but did increase with exercise. No
sustained tachy- or bradyarrhythmias.
====================
TRANSTHORACIC ECHO
====================
TTE ___: IMPRESSION: 1) No structural cardiac cause of
syncope
identified. 2) Normal left ventricular regional/global systolic
function with grade I LV diastolic dysfunction (severe ___ in absence of significant mitral regurgitation and
low e' velocities). 3) Well seated ___ 3 aortic valve TAVR
with normal gradients and no regurgitation.
================
HOLTER RESULTS
================
___: Sinus, rates 40-99, average HR 58. 17-beat run of atrial
fibrillation, atrial bigeminy, frequent PACs, bradycardia to
___.
Brief Hospital Course:
ASSESSMENT AND PLAN: ___ with history of AS s/p TAVR ___,
h/o TIA, diabetes, ___ transferred to ___ from ___ after syncopal episode at home ___. Negative trauma
workup at ___. Referred here for cardiology admission with
EP
consult to evaluate cause of syncope.
#Syncope: Holter, TTE and ETT results above. While his symptoms
of unheralded syncope are suggestive of a bradyarrhythmic
etiology, none was noticed on Holter worn during time of
syncope.
Additionally TTE does not demonstrate TAVR or structural HD
etiologies for syncope. ETT consistent with failure of BP to
rise, suggesting vasoplegia exacerbated by vasodilation from
exercise.
-No structural or EP intervention required at this time.
-Continue telemetry
-Continue to hold Lasix
-Lisinopril to 2.5 mg nightly
-Compression stockings
#HTN: BPs labile with SBP ranging 130s-190s overnight.
- Continue Lisinopril.
#Aortic stenosis: s/p TAVR with 26 ___ valve done ___
- Continue ASA/Plavix
- Hold Lasix for now
#Back pain in setting of hitting chair during syncopal episode
___. Improved with scheduled Tylenol, not requiring prn
oxycodone since yesterday morning. ___ cleared pt for home with
services as long as pain is controlled.
- Optimize pain management for better mobility.
- Continue around the clock Tylenol ___ Q6hrs x 7 days and
Oxycodone 5mg
Q6hrs prn.
- Encouraged ambulation today with nursing staff to ensure
optimized pain control.
#Constipation: Pt states he has not had BM in 3 days, and
usually
goes daily. He denies abdominal pain, cramping, bloating, urge
to
go. ___ be exacerbated by oxycodone and decreased ambulation.
Abdomen soft, non-distended, BS+.
- Senna daily, Miralax daily prn
- Encouraged ambulation
#HFpEF: Weight is up from admission weight, but fluid status
down
almost 1.5L, euvolemic on exam.
- Hold Lasix as above and re-evaluate as outpatient
- Daily weights, I/O
#TIA:
- Continue plavix and aspirin
#DM: On insulin at home, ISS and Lantus 6units QHS
- Continue home insulin regimen
#Anxiety/Dementia: Well controlled patient exhibits no signs of
either anxiety or dementia during his hospitalization
- Continue home alprazolam and sertraline
- Continue memantine and galantamine
#Hyperlipidemia
-continue atorvastatin
-cardiac diet
DISPO: Home ___ with ___ and ___ services.
Discharge time: 35 min
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
2. ALPRAZolam 0.25 mg PO DAILY PRN anxiety
3. Atorvastatin 40 mg PO QPM
4. Brimonidine Tartrate 0.15% Ophth. 1 DROP RIGHT EYE BID
5. Ferrous Sulfate 325 mg PO DAILY
6. galantamine 4 mg oral BID
7. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
8. Levothyroxine Sodium 88 mcg PO DAILY
9. Memantine 5 mg PO BID
10. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - First
Line
11. Sertraline 25 mg PO DAILY
12. Vitamin D 1000 UNIT PO DAILY
13. Clopidogrel 75 mg PO DAILY
14. Multivitamins 1 TAB PO DAILY
15. Aspirin 81 mg PO DAILY
16. Furosemide 40 mg PO BID
17. Lisinopril 5 mg PO DAILY
18. Levemir 6 Units Bedtime
Insulin SC Sliding Scale using novolog Insulin
19. Pantoprazole 40 mg PO Q24H
Discharge Medications:
1. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN pain
Take only as needed for pain.
2. Senna 8.6 mg PO DAILY
3. Acetaminophen 650 mg PO Q6H
4. Levemir 6 Units Bedtime
Insulin SC Sliding Scale using novolog Insulin
5. Lisinopril 2.5 mg PO QPM
Take this medication at night
6. ALPRAZolam 0.25 mg PO DAILY PRN anxiety
7. Aspirin 81 mg PO DAILY
8. Atorvastatin 40 mg PO QPM
9. Brimonidine Tartrate 0.15% Ophth. 1 DROP RIGHT EYE BID
10. Clopidogrel 75 mg PO DAILY
11. Ferrous Sulfate 325 mg PO DAILY
12. galantamine 4 mg oral BID
13. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
14. Levothyroxine Sodium 88 mcg PO DAILY
15. Memantine 5 mg PO BID
16. Multivitamins 1 TAB PO DAILY
17. Pantoprazole 40 mg PO Q24H
18. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - First
Line
19. Sertraline 25 mg PO DAILY
20. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Syncope
Aortic stenosis s/p TAVR ___
Chronic diastolic heart failure
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
VS: T 97.5 BP 165/66 HR 68 RR 18 SpO2 96%RA
PE:
Gen: Patient comfortably lying in bed in no acute distress.
HEENT: Face symmetrical, trachea midline
Neuro: A/Ox3. Speaking in complete, coherent sentences. No face,
arm, or leg weakness. No tongue deviation. No sensory deficits.
Pulm: Breathing unlabored. Breath sounds clear bilaterally.
Cardiac: No JVD. No thrills or bruits heard on carotids
bilaterally. S1, S2 RRR. I/VI systolic murmur heard best at
base.
Vasc: No edema noted in bilateral upper or lower extremities. No
pigmentation changes noted in bilateral upper or lower
extremities. Skin dry, warm. Bilateral radial pulses palpable
2+,
___ palpable 1+.
Abd: Rounded, soft, non-tender. BS+
Discharge Instructions:
You were admitted for further evaluation after your episode of
passing out at home.
You had a holter monitor, echocardiogram, and exercise stress
test, which were reviewed by the doctors. You were also seen by
the heart rhythm doctors (___). Your holter
monitor did not show any slow rhythms or pauses that could
explain you passing out. Your echocardiogram showed your valve
is in a good place with no structural abnormalities that could
explain you passing out. The exercise stress test showed that
your blood pressure did not rise with exercise, which suggests
that your vessels do not constrict with exertion but stay open.
This is why your blood pressure did not rise appropriately, and
may explain why you passed out at home. Because of this, we have
made changes to your home medications.
Please continue your home medications with the following
changes:
-Stop Lasix
-Decrease Lisinopril to 2.5mg nightly. Take this medication at
night, not in the morning.
You had an X-Ray of your lower back, which did not show any
fracture or dislocation. For your lower back pain, you may
continue take Tylenol ___ every 6 hours. You were taking it
scheduled while you were in the hospital, and your pain
improved. If you need additional relief from pain, you may take
oxycodone 5mg as needed twice a day. A written prescription has
been given to you. You must get this filled at your pharmacy.
Take Senna and Miralax daily to help with constipation. Please
stop these medications once you have a bowel movement. You may
also try drinking prune juice. Call your primary care doctor if
you do not have a bowel movement by ___.
Please weigh yourself every day in the morning after you go to
the bathroom and before you get dressed. If your weight goes up
by more than 3 lbs in 1 day or more than 5 lbs in 3 days, please
call your heart doctor or your primary care doctor and alert
them to this change.
You are also being given a prescription for a rolling walker.
Please use this when you walk, especially at night. You may take
this prescription to your local medical supply store.
A visiting nurse and physical therapist ___ start seeing you
at home. They will call you to schedule a time to visit once you
are discharged.
If you have any urgent questions that are related to your
hospitalization or are experiencing any symptoms that are
concerning to you and you think you may need to return to the
hospital, please call the ___ HeartLine at ___ to
speak to a cardiologist or cardiac nurse practitioner.
If you are followed at ___, please call
___ or your Doctor's office.
It has been a pleasure to have participated in your care and we
wish you the best with your health!
Your ___ Cardiac Care Team
Followup Instructions:
___
|
19710521-DS-29
| 19,710,521 | 26,463,510 |
DS
| 29 |
2193-02-01 00:00:00
|
2193-02-03 06:27:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Bactrim
Attending: ___
___ Complaint:
Hypoxia, cough
Major Surgical or Invasive Procedure:
none.
History of Present Illness:
___ is a ___ yo female with a h/o COPD on ___,
CHF, Afib on coumadin, CKD, a 40+ pack year history with a
recent admission for LUL treated with levofloxacin p/w SOB,
productive cough, and O2 sat of 87% at home (per ___ on 3L NC.
Of note, admission on ___ for LUQ pneumonia/COPD
exacerbation based on CXR and clinical picture, treated with
levofloxacin and steroids.
Patient just left rehab facility on ___, has been staying
with daughter since. Daughter reports patient was delerious with
sundowing during SNF stay, and noted slurring of speech and
confusion since release from rehab. No facial droop. Patient has
had cough, non-productive. Complains of generalized weakness/not
feeling well since discharge. ___ noted that patient was hypoxic
to 87% on home ___, and so patient was sent to hospital.
Patient had previously been living by herself with periodic
nurse visitation in the evenings. Prior to episode of pneumonia,
patient had been feeling well, no weight loss or cough.
In the ED, initial vital signs were T98 HR86 BP147/79 RR18 O2
96% 4L. At one point patient was febrile to 101 and tachypneic
to 33. Patient was given tylenol, a dose of IV vanc and
azythromycin and inhalers, and .5 L NS. She had a ___, CT
Chest (PE protocol), CXR and ___ Dopplers.
Review of Systems:
(+) fever, chills, cough, shortness of breath, diarrhea (one
episode yesterday), confusion
(-) night sweats, headache, weight loss, vision changes,
rhinorrhea, congestion, sore throat, sick contacts, chest pain,
abdominal pain, nausea, vomiting, constipation, BRBPR, melena,
hematochezia, dysuria, hematuria.
Past Medical History:
-Hypertension
-Diastolic CHF (preserved EF of 60% in ___
-GERD
-Osteoporosis
-Depression
-Atrial fibrillation on Coumadin
-Sick sinus syndrome s/p PPM ___ EnRhythm dual-chamber
placed in ___
-Coronary artery disease status post MI ___
-COPD on 3L home oxygen
-Squamous cell carcinoma s/p MOHS surgery
-Anemia
-Chronic renal insufficiency (baseline sCr 1.8)
Social History:
___
Family History:
Notable for father who died age ___ from MI. Uncle with colon
cancer at age ___.
Physical Exam:
ADMISSION EXAM:
.
T96.4 HR86 BP137/75 RR18 O2 97% 4L.
General- Alert, oriented, no acute distress
HEENT- Sclera anicteric, pupils fixed (cataract surgery ___,
arcus senilus, with pigmentation on sclera, slightly dry mucous
membranes, oropharynx clear
Neck- supple, JVP not elevated, no LAD or enlarged thryoid
Lungs- crackles in left upper lung field, dimminished sounds at
bases
CV- Regular rate and rhythm, normal S1/S2
Abdomen- soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU- no foley
Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro- CNs2-12 intact, motor function grossly normal, AOx3, has
some word finding difficulties, somewhat distractable, and
occasionally confused as to recent events/history
.
DISCHARGE EXAM:
.
T97.3 HR85 BP156/64 RR20 O2 94% 4L following nebs
General- Alert, not-oriented to time or place, oriented, no
acute distress
HEENT- Sclera anicteric, pupils fixed (cataract surgery ___,
arcus senilus, with pigmentation on sclera, slightly dry mucous
membranes, oropharynx clear
Neck- supple, JVP not elevated, no LAD or enlarged thryoid
Lungs- crackles in left upper lung field, dimminished sounds at
bases, some wheeze in b/l upper fields
CV- Regular rate and rhythm, normal S1/S2
Abdomen- soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU- no foley
Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro- CNs2-12 intact, motor function grossly normal, AOx3, has
some word finding difficulties, somewhat distractable, and
occasionally confused as to recent events/history
Pertinent Results:
ADMISSION LABS:
.
___ 03:34PM ___ PO2-30* PCO2-46* PH-7.39 TOTAL
CO2-29 BASE XS-0 INTUBATED-NOT INTUBA
___ 03:34PM O2 SAT-48
___ 02:50PM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 02:50PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.5
LEUK-NEG
___ 01:38PM ___ COMMENTS-GREEN TOP
___ 01:38PM LACTATE-0.9
___ 01:35PM GLUCOSE-78 UREA N-20 CREAT-1.0 SODIUM-141
POTASSIUM-4.3 CHLORIDE-107 TOTAL CO2-25 ANION GAP-13
___ 01:35PM estGFR-Using this
___ 01:35PM WBC-4.4# RBC-3.95* HGB-11.2* HCT-35.0* MCV-88
MCH-28.2 MCHC-31.9 RDW-16.4*
___ 01:35PM NEUTS-75.1* LYMPHS-15.7* MONOS-6.8 EOS-2.0
BASOS-0.4
___ 01:35PM PLT COUNT-243
___ 01:35PM ___ PTT-40.9* ___
.
ADMISSION IMAGING:
.
___ CTA CHEST W&W/O C&RECON: 1. Left upper lobe mass-like
consolidation (4.7 x 2.6 x 5.3 cm) with surrounding septal
thickening and possible accompanying left hilar lymphadenopathy.
Given recurrence or persistence since ___ despite treatment,
the possibility of neoplasm should be considered. Consider
pulmonary consultation to determine the role of bronchoscopy.
2. Right upper lobe peribronchovascular consolidative opacities
could reflect a second site of infection with accompanying
bibasilar pleural effusions.
3. Unchanged mid thoracic spine compression fractures.
___ BILAT LOWER EXT VEINS: No lower extremity DVT.
___ CHEST (PA & LAT): Left upper lobe consolidative
opacities worsened from ___ suggesting recurrent or residual
pneumonia; however given recurrence/persistence neoplasm must
also be considered. See subsequent CT for further details.
___ CT HEAD W/O CONTRAST:No acute intracranial process.
___ ECG:Atrial fibrillation. Poor R wave progression.
Consider prior anteroseptal myocardial infarction of
indeterminate age. Non-specific inferior ST-T wave changes.
Compared to the previous tracing of ___ ventricular
premature beats are not seen on the current tracing. The
findings are otherwise similar
.
DISCHARGE LABS:
.
___ 08:00AM BLOOD WBC-4.2 RBC-3.72* Hgb-10.6* Hct-32.4*
MCV-87 MCH-28.4 MCHC-32.6 RDW-16.3* Plt ___
___ 01:35PM BLOOD Neuts-75.1* Lymphs-15.7* Monos-6.8
Eos-2.0 Baso-0.4
___ 08:00AM BLOOD Plt ___
___ 08:00AM BLOOD Glucose-81 UreaN-19 Creat-1.1 Na-143
K-4.2 Cl-107 HCO3-28 AnGap-12
___ 08:00AM BLOOD Vanco-9.7*
Brief Hospital Course:
___ is a ___ yo female with a h/o COPD on ___,
CHF, Afib on coumadin, CKD, a 40+ pack year history with a
recent admission for LUL treated with levofloxacin p/w SOB,
productive cough, fever and hypoxia found here to have a
persistent LUL consolidation on Chest CT.
.
ACUTE ISSUES:
.
# Sepsis/Pneumonia: Given IV vanc, cefepime and azithro in the
ED. Febrile, tachypneic and hypoxic on admission, but improved
with increase in NC 02, remained stable on the floor throughout
stay. Chest CT showed persistent LUL consolidation, suspicious
for underlying malignancy. A discussion was had with patient and
daughter and decision was made to not further work up, but
simply to treat possible HCAP. Given IV zosyn and vanc while
inpatient, transitioned to PO linezolid on discharge (initially
on linezolid/cefpodoxime, but geriatric fellow asked to stop
cefpodoxime at discharge), will complete a 6 day course on ___.
HOLD PATIENT'S MIRTAZAPINE WHILE ON LINEZOLID, out of concern
for serotonin syndrome.
.
CHRONIC ISSUES:
#COPD: Continued home inhalers, with additional duonebs prn
# Paroxysmal atrial fibrillation: INR on admission 2.3. continue
home coumadin (4mg daily), metoprolol tartrate and diltiazem.
# CAD, HTN, Diastolic CHF: continue home diltiazem, metoprolol,
pravastatin. Patient had been on lasix in past, held on last
admission, continue to hold.
#Anemia: seems to be a chronic issue, normocytic with wide RDW
suggesting iron deficiency or anemia of chronic disease.
#Diarrhea: per daughter, patient has always taken 3 immodium at
bedtime to prevent fecal incontience, but she became constipated
at ___ ans this was stopped. Will continue to hold, as it may be
contributing to delerium.
# GERD: patient continued omeprazole.
# HLD: patient continued pravastatin.
# Depression: patient continued home mirtazapine.
# Osteoporosis: patient continued vitamin D and calcium.
.
FOLLOW UP:
.
Department: GERONTOLOGY
When: ___ at 2:00 ___
With: ___
Building: ___
Campus: ___ Best Parking: ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Warfarin 4 mg PO DAILY16
2. Tiotropium Bromide 1 CAP IH DAILY
3. LOPERamide 2 mg PO QID:PRN diarrhea
4. Vitamin D 1000 UNIT PO DAILY
5. Diltiazem 90 mg PO BID
6. Lorazepam 0.5 mg PO HS
7. Metoprolol Tartrate 25 mg PO BID
8. Mirtazapine 22.5 mg PO HS
9. Pravastatin 20 mg PO DAILY
10. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
Discharge Medications:
1. Diltiazem 90 mg PO BID
2. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
3. Metoprolol Tartrate 25 mg PO BID
4. Mirtazapine 22.5 mg PO HS
5. Pravastatin 20 mg PO DAILY
6. Tiotropium Bromide 1 CAP IH DAILY
7. Vitamin D 1000 UNIT PO DAILY
8. Warfarin 4 mg PO DAILY16
9. Linezolid ___ mg PO Q12H Duration: 6 Days
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
# Primary:
- Pneumonia
# Secondary:
-Hypertension
-Atrial fibrillation on Coumadin
-COPD on 3L home oxygen
Discharge Condition:
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Mental Status: Confused - always (able to reorient patient, does
occasionally become agitated at night).
Level of Consciousness: Alert and interactive.
Discharge Instructions:
Dr ___,
It was a pleasure to take care of you at ___
___.
You were admitted because you were having difficulty breathing
and you were found to have pneumonia. We were concerned because
chest imaging showed that there might also be a mass in your
lung. We had a discussion with you and your daughter and decided
not to pursue further work-up of the mass, but rather just to
treat the pneumonia. We started you on IV antibiotics, but we
are sending you home on oral medications.
Your new medications are:
- linezolid ___ twice daily for 6 day course (complete on:
___ WHILE ON THIS ANTIBIOTIC SHE SHOULD NOT TAKE HER
MIRTAZAPINE. She can restart her mirtazapine once this
antibiotic course is completed.
You are being discharged to a rehab facility because we still
feel that you need nursing care while you recover from your
pneumonia.
You should follow up with Dr ___ in Geriatrics on ___
at 2:00 ___. She will make sure you are getting better on the
antibiotics.
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs.
Followup Instructions:
___
|
19710962-DS-21
| 19,710,962 | 29,109,522 |
DS
| 21 |
2145-12-24 00:00:00
|
2145-12-25 19:57:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
cephalexin / codeine / Penicillins / Sulfa (Sulfonamide
Antibiotics)
Attending: ___
Chief Complaint:
Left periprosthetic hip fracture
Major Surgical or Invasive Procedure:
ORIF Left Hip (___)
History of Present Illness:
___ female hx dementia, ___ resident, DNR/DNI/DNH, other
comorbidities as outlined below presents with a left
periprosthetic fracture s/p mechanical fall. Yesterday at an
unknown time, the patient fell from standing in an unwitnessed
fall. Per ___ records, +HS, -LOC, +instant hip pain. Transferred
to ___, where NCCT head cspine were negative. XR of L hip
demonstrated L periprosthetic hip fx, and transferred to ___
for orthopedics evaluation. On admission, patient was confused
and cannot comment on physical symptoms.
Past Medical History:
DNR/DNI/___
dementia/___ resident
HTN
CHF (unknown if systolic or diastolic)
CAD
hearing loss
COPD
GERD
Osteoarthritis
Social History:
___
Family History:
Non-contributory
Physical Exam:
ADMISSION PHYSICAL EXAM:
=======================
Vitals: 97.7 72 129/53 21 100% 2L NC
General: Well-appearing female in no acute distress.
Left lower extremity:
- Skin intact
- LLE is shortened and externally rotated. Thigh is slightly
swollen but soft. Otherwise, no deformity, edema, ecchymosis,
erythema, induration
- TTP L anterior inguinal crease. Otherwise Soft, non-tender
thigh and leg
- Full, painless ROM at hip, knee, and ankle
- Fires ___
- SILT S/S/SP/DP/T distributions
- 1+ ___ pulses, WWP
DISHCHARE PHYSICAL EXAM:
=======================
Vitals: Temp 97.9F BP 122/76 HR 98 RR 20 97% on 2L NC
General: Elderly female in NAD. Appears younger than stated age.
Confused, alert.
HEENT: NC/AT. Sclera anicteric, MMM.
Neck: supple
Lungs: Normal respiratory effort. Faint crackles over bases. No
wheezes or rhonchi.
CV: Irregularly irregular rhythm, normal rate. Normal S1 and S2.
No murmurs, rubs or gallops appreciated.
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no guarding or masses appreciated.
Ext: warm, well perfused, no ___ edema or erythema. Left hip with
large incision with stables, healing well without surrounding
erythema.
Neuro: Alert, oriented to name. Unable to do other CN ___
inability to follow commands. 4+/5 strength in BUE. Moves all
extremities.
Skin: Warm, dry. No rashes.
Pertinent Results:
ADMISSION LABS:
==============
___ 05:35AM BLOOD WBC-11.6* RBC-3.20* Hgb-10.1* Hct-31.7*
MCV-99* MCH-31.6 MCHC-31.9* RDW-12.9 RDWSD-46.8* Plt ___
___ 05:35AM BLOOD Neuts-85.3* Lymphs-7.0* Monos-6.6
Eos-0.2* Baso-0.3 Im ___ AbsNeut-9.86* AbsLymp-0.81*
AbsMono-0.76 AbsEos-0.02* AbsBaso-0.03
___ 05:35AM BLOOD Glucose-148* UreaN-25* Creat-1.0 Na-138
K-5.2 Cl-100 HCO3-25 AnGap-13
___ 09:50PM BLOOD Calcium-8.1* Phos-4.5 Mg-2.1
PERTINENT LABS/MICRO:
====================
___ 05:43AM BLOOD WBC-5.3 RBC-2.16* Hgb-6.7* Hct-21.7*
MCV-101* MCH-31.0 MCHC-30.9* RDW-13.2 RDWSD-48.3* Plt ___
___ 05:06AM BLOOD CK-MB-2 cTropnT-0.12*
___ 12:21AM BLOOD CK-MB-2 cTropnT-0.12*
___ 06:40AM BLOOD proBNP-9294*
___ 06:40AM BLOOD TSH-1.3
___ 12:27AM BLOOD Lactate-2.0
___ Urine culture:
ESCHERICHIA COLI
|
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- 8 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
DISCHARGE LABS:
==============
___ 08:10AM BLOOD WBC-10.7* RBC-2.96* Hgb-9.0* Hct-29.9*
MCV-101* MCH-30.4 MCHC-30.1* RDW-14.3 RDWSD-51.8* Plt ___
___ 08:10AM BLOOD Glucose-96 UreaN-31* Creat-0.9 Na-142
K-4.6 Cl-100 HCO3-30 AnGap-12
___ 08:10AM BLOOD Phos-3.1 Mg-2.1
PERTINENT IMAGING:
================
___ Left Femur Xray:
Mildly displaced periprosthetic fracture of the proximal left
femur. No
dislocation.
___ CXR:
New near complete opacification of the right upper lobe may
reflect the
sequelae of an aspiration event or near complete upper lobe
collapse secondary
to mucous plugging.
___ CXR:
Resolution of right upper lobe collapse which likely reflected
sequela of
mucous plugging.
___ CXR:
Interstitial abnormality is stable. Cardiomediastinal
silhouette is stable.
There is atherosclerotic calcification involving the aorta. No
pneumothorax is seen. There are small bilateral effusions.
___ TTE:
The left atrial volume index is normal. The inferior vena cava
diateter is normal. There is mild symmetric left ventricular
hypertrophy with a normal cavity size. There is normal regional
and global left ventricular systolic function. Quantitative
biplane left ventricular ejection fraction is 68 %. Left
ventricular cardiac index is normal (>2.5 L/min/m2). There is no
resting left ventricular outflow tract gradient. No ventricular
septal defect is seen. Tissue Doppler suggests an increased left
ventricular filling pressure (PCWP greater than 18mmHg). Mildly
dilated right ventricular cavity 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. The aortic valve leaflets (3) are mildly thickened.
There is no aortic valve stenosis. There is trace aortic
regurgitation. The mitral valve leaflets are mildly thickened
with no mitral valve prolapse. There is moderate mitral annular
calcification. There is mild [1+] mitral regurgitation. Due to
acoustic shadowing, the severity of mitral regurgitation could
be UNDERestimated. The tricuspid valve leaflets appear
structurally normal. There is mild [1+] tricuspid regurgitation.
There is moderate pulmonary artery systolic hypertension. There
is no pericardial effusion.
IMPRESSION: Normal regional and lobal left ventricular function
with mild symmetric LVH. Moderate pulmonary artery systolic
hypertension.
___ DVT BLE Ultrasound:
No evidence of deep venous thrombosis in the right or left lower
extremity
veins.
Brief Hospital Course:
Ms. ___ is a ___ female with a hx of dementia (___ resident,
DNR/DNI/DNH), HFpEF, CAD, COPD with reportedly no baseline
oxygen requirement, GERD, and OA who presented following a
mechanical fall and subsequently underwent operative repair
(___). Her post operative course was complicated by acute
desaturation, followed by acute hypoxic respiratory failure and
afib with RVR. She was treated with diuresis and increasing
doses of metoprolol with improvement in symptoms.
#S/p fall
#ORIF
The patient presented following an unwitnessed fall while at ___
resulting in left periprosthetic hip fracture. Etiology of the
fall was unclear though felt likely mechanical. She was
initially admitted to the orthopedic surgery service and
underwent ORIF on ___ without issues. Her wound was healing
well and her pain was well controlled with acetaminophen and low
dose oxycodone as needed. She worked with physical therapy and
occupational therapy. She should continue acetaminophen for
pain, enoxaparin for 4 weeks (end date ___, and regular
physical therapy as tolerated.
#Acute hypoxic respiratory failure
She was noted to be desatting during surgery and in the PACU.
CXR consistent with mucus plug, which resolved. She then
developed a new persistent O2 requirement several days following
the surgery. CXR showed mild pulmonary edema and BNP was
elevated, concerning for a heart failure exacerbation. DVT
ultrasound was negative and CTA was not pursed given GOC, family
interest in avoiding procedures/anticoagulation. She was
diuresed with IV Lasix with improvement in her oxygenation.
Additionally, she as given duonebs for any component of
underlying COPD. She should continue home O2 with goal of
weaning as tolerated. Goal O2 sat >90%.
#Afib w/ RVR
Developed atrial fibrillation with RVR early on ___, which was
reportedly a new diagnosis for the patient. Etiology remained
unknown though she has many risk factors, including recent
surgery, HFpEF, anemia, and COPD. There was also consideration
of cardiac ischemia vs infection vs PE. TSH was normal. She had
several episodes of RVR with rates to the 130-150s, treated with
IV metoprolol and increasing doses of po metoprolol.
Additionally, she remained on enoxaparin for anticoagulation
given her recent fracture. Further systemic anticoagulation was
held given GOC, frailty/age, and concern for falls despite a
CHADSVASC of 6. Her heart rate stabilized and she was discharged
on metoprolol 37.5 mg QID.
#___
Carried a diagnosis of CHF without known EF. TTE done on ___ in
the setting of atrial fibrillation. There was concern for heart
failure exacerbation given new hypoxia, mild pulmonary edema on
CXR, and elevated BNP to 10,000. She was given IV Lasix with
good response and then transitioned to torsemide 40 mg daily.
She will need slight further diuresis over the next few days.
#S/p STEMI
Following an episode of afib w/ RVR, an EKG showed ST elevations
in V2 with borderline elevation in V1-V3. Troponin peaked at
0.12 and there was difficulty assessing symptoms. Cardiology was
consulted, felt to be type II. Recommended medical management.
She was continued on aspirin and metoprolol was uptitrated.
Atorvastatin was not felt to be within her GOC given age and
other comorbidities.
#Asymptomatic bacteruria
UA on admission showed inflammation and culture growing E.coli.
Unable to assess symptoms given the patient's baseline mental
status. Given lack of symptoms, fever, HD instable, and lack of
progression without antibiotics, it was felt that urine was more
likely due to asymptomatic bacteruria.
#Normocytic anemia
#Acute blood loss anemia
Hgb 10 on admission, down to 6.7 after surgery following acute
blood loss. She received 2u pRBC with appropriate response and
blood counts remains stable thereafter.
#Urinary retention
She developed urinary retention during this hospitalization. She
had no history of urinary retention at home and the trigger was
felt to be recent surgery. The issue later resolved.
#GOC
The patient's daughter and healthcare proxy, ___, described
several times that the goal was to return the patient to the
nursing home with minimal interventions. This shaped several
decisions as described above. We discussed the possibility of
keeping the patient here for ongoing rate control and diuresis.
She wished for the patient to go home, which was felt to be
reasonable given her stable clinical condition and overall goals
of care.
TRANSITIONAL ISSUES:
====================
[ ] Needs follow up with her primary care physician ___ ___ days
and orthopedic surgery on ___
[ ] Monitor blood pressure and heart rate, titrate metoprolol as
necessary (Goal SBP 100-110s, HR <100)
[ ] Discharged on torsemide 40 mg daily. Monitor weight and
breathing, titrate dose as necessary.
[ ] Repeat BMP/CBC in 1 week to evaluate electrolytes, Cr, and
Hgb
[ ] Discharged on supplemental oxygen, wean as able. Goal
O2>90-92%
[ ] Anticoagulation held for atrial fibrillation given GOC. Will
remain on Enoxaparin for fracture until ___
[ ] Urine culture with E.coli, felt to be asymptomatic
bacteruria. Follow up as outpatient to monitor for symptoms,
consider repeat UA if concerned for true infection
# Emergency contact: ___ (___)
# Code: DNR/DNI/DNH
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild
2. Furosemide 40 mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. Ranitidine 150 mg PO DAILY
5. Cyanocobalamin 500 mcg PO DAILY
6. Atenolol 50 mg PO DAILY
7. LOPERamide 4 mg PO QID:PRN diarrhea
8. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
9. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB/wheezing
10. Milk of Magnesia 30 mL PO Q4H:PRN Constipation - First Line
Discharge Medications:
1. Enoxaparin Sodium 30 mg SC Q24H
2. Metoprolol Tartrate 37.5 mg PO Q6H
3. Torsemide 40 mg PO DAILY
4. Vitamin D 800 UNIT PO DAILY
5. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild
6. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB/wheezing
7. Aspirin 81 mg PO DAILY
8. Cyanocobalamin 500 mcg PO DAILY
9. LOPERamide 4 mg PO QID:PRN diarrhea
10. Milk of Magnesia 30 mL PO Q4H:PRN Constipation - First Line
11. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
12. Ranitidine 150 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
___ Diagnosis:
#Primary:
Fall
Left periprosthetic hip fracture
#Secondary:
Atrial fibrillation with rapid ventricular rate
Heart failure with preserved ejection fraction
Acute hypoxic respiratory failure
STEMI
Asymptomatic bacteruria
Urinary retention
Normocytic anemia
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. ___,
It was a pleasure caring for you at ___
___!
Why you were admitted to the hospital:
- You had a fall and fractured the large bone in your leg
What happened while you were here:
- You had surgery to correct the fracture
- Following surgery, you had issues with oxygen levels requiring
supplemental oxygen and fluid removal
- You had an irregular heart rhythm called atrial fibrillation,
which was slowed down with medications
What you should do once you return home:
- Continue taking your medications as prescribed
- Follow up at the appointments outlined below. You should see
your primary care provider ___ ___ days and follow up in the
orthopedic surgery clinic on ___ at 2pm
INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY:
- You were in the hospital for orthopedic surgery. It is normal
to feel tired or "washed out" after surgery, and this feeling
should improve over the first few days to week.
- Resume your regular activities as tolerated, but please follow
your weight bearing precautions strictly at all times.
ACTIVITY AND WEIGHT BEARING:
- Touchdown weight bearing in left lower extremity
ANTICOAGULATION:
- Please take lovenox 30 mg daily for 4 weeks
WOUND CARE:
- You may shower. No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- Incision may be left open to air unless actively draining. If
draining, you may apply a gauze dressing secured with paper
tape.
- Splint must be left on until follow up appointment unless
otherwise instructed.
- Do NOT get splint wet.
DANGER SIGNS:
Please call your PCP or surgeon's office and/or return to the
emergency department if you experience any of the following:
- Increasing pain that is not controlled with pain medications
- Increasing redness, swelling, drainage, or other concerning
changes in your incision
- Persistent or increasing numbness, tingling, or loss of
sensation
- Fever > 101.4
- Shaking chills
- Chest pain
- Shortness of breath
- Nausea or vomiting with an inability to keep food, liquid,
medications down
- Any other medical concerns
Followup Instructions:
___
|
19711017-DS-4
| 19,711,017 | 29,307,519 |
DS
| 4 |
2149-09-05 00:00:00
|
2149-09-09 20:19:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
latex gloves
Attending: ___.
Chief Complaint:
Bilateral Lower extremity edema
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year-old woman with PMH dementia (lives at ___ in
her assisted living apartment), anxiety, hypertension, Diabetes
Mellitus, CKD presenting with subacute lower extremity edema and
worsening dyspnea.
Patient was referred to ED for increasing bilateral lower
extremity edema and SOB from an assisted living memory unit. Of
note referral to ED comments that she has anxiety, can be
emotionally labile and is usually redirectable.
She had some increasing erythema over RLE for which she was
treated with a course of Keflex on ___ (end date unknown). Due
to worsening ___ edema she was started on lasix 20 mg PO on ___ (per outpatient notes). ACE wraps and elevation were also
advised for component of chronic venous stasis, patient
describes
history of itchy, dry skin and has been itching her legs often.
Pt denies f/c, headache, changes in vision, chest pain, abd
pain,
n/v/d, urinary symptoms (although does report increasing
urination since starting lasix).
She has no known history of arrhythmia, no history of ischemic
heart disease, no history of PE/clots. She has no recent TTEs
(most recent Echo ___: LVEF >55%).
In the ED, initial VS were: T: 96.9 HR: 73 BP: 161/71 RR:
16
SO2: 96% RA
Exam notable for: No acute distress, no murmurs rubs gallops or
audible s3 noted; mild crackles to the bases bilaterally, 2+
pitting edema to the knees bilaterally with well demarcated
erythema extending from the ankles to the knee
ECG: rate 74 irregular rhythm, like sinus with premature beats,
stable q waves in anterior leads, no acute ischemic changes.
normal axis
Labs showed: trop 0.05, bnp 2869, Cr 1.7.
Imaging showed: CXR: Mild cardiomegaly with mild interstitial
pulmonary edema and small bilateral pleural effusions. Mild
bibasilar atelectasis.
Past Medical History:
Diabetes Mellitus Type 2
Hypertension
Dementia
anxiety
chronic fatigue
depression situational
eczema
edema
hernia, unilateral inguinal w/ ___
hyperparathyroidism
hypokalemia
insomnia
polyarthralgia
thyromegaly
urinary incontinence
vitamin d deficiency
h/o breast cancer
Social History:
___
Family History:
Non-contibutory
Physical Exam:
Admission Physical Examination
==============================
VS: ___ 0011 Temp: 97.7 BP: 146/72 L Lying HR: 80 RR: 18
O2
sat: 95% O2 delivery: RA
GENERAL: NAD
HEENT: AT/NC, anicteric sclera, MMM, JVP to mandible
+hepatojuglar reflux
NECK: supple, no LAD
CV: irregular, S1/S2 +s3, no murmurs, gallops, or rubs
PULM: CTAB, bilateral lower lobe rales, no wheezes nor rhonchi,
breathing comfortably without use of accessory muscles
GI: abdomen soft, nondistended, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: erythema bilateral lower extremities, 2+ edema to
kneesm no cyanosis, clubbing
PULSES: 2+ radial pulses bilaterally
NEURO: Alert, oriented to self, moving all 4 extremities with
purpose, face symmetric
DERM: warm and well perfused, no excoriations or lesions, no
rashes
Discharge Physical Examination
==============================
VS: ___ 1122 Temp: 97.3 PO BP: 146/77 HR: 58 RR: 16 O2 sat:
96% O2 delivery: Ra
GENERAL: Elderly woman, appears anxious and startled when woken
CV: Regular rate, irregular rhythm, normal s1/s2, no MRG
RESP: CTAB, no wheezes/crackles/rhonchi. No accessory muscle
usage.
ABD: Bowel sounds normoactive, soft and NTND, no HSM.
Ext: Erythema to 2 inches below the knees bilaterally,
blanching.
Trace pitting edema to the knee bilaterally.
SKIN: No rashes/lesions. No jaundice. Warm. Dry, flaky skin on
shins bilaterally.
Pertinent Results:
ADMISSION LABS
==============
___ 05:15PM WBC-6.9 RBC-3.43* HGB-11.2 HCT-34.2 MCV-100*
MCH-32.7* MCHC-32.7 RDW-14.0 RDWSD-51.1*
___ 05:15PM NEUTS-64.7 LYMPHS-13.3* MONOS-13.7* EOS-7.2*
BASOS-0.4 IM ___ AbsNeut-4.47 AbsLymp-0.92* AbsMono-0.95*
AbsEos-0.50 AbsBaso-0.03
___ 05:15PM PLT COUNT-216
___ 05:15PM GLUCOSE-135* UREA N-53* CREAT-1.6* SODIUM-139
POTASSIUM-4.6 CHLORIDE-101 TOTAL CO2-25 ANION GAP-13
___ 05:15PM CALCIUM-8.7 PHOSPHATE-5.0* MAGNESIUM-2.3
___ 05:15PM CK-MB-5 cTropnT-0.05* proBNP-2869*
___ 07:50PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-100*
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
DISCHARGE LABS
==============
___ 05:50AM BLOOD WBC-8.9 RBC-3.39* Hgb-10.9* Hct-33.2*
MCV-98 MCH-32.2* MCHC-32.8 RDW-13.4 RDWSD-47.8* Plt ___
___ 05:50AM BLOOD ___ PTT-29.2 ___
___ 05:50AM BLOOD Glucose-119* UreaN-63* Creat-1.8* Na-143
K-4.9 Cl-102 HCO3-26 AnGap-15
___ 05:50AM BLOOD Calcium-8.7 Phos-4.1 Mg-2.3
IMAGING:
=======
Chest X ray (___)
Final Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: History: ___ without formal diagnosis of heart
failure presenting
with exertional dyspnea and lower extremity edema.// Evaluate
for pulmonary
vascular congestion, pulmonary edema, cardiomegaly.
TECHNIQUE: Chest PA and lateral
COMPARISON: Chest radiograph ___
FINDINGS:
Heart size is mildly enlarged, increased from the prior exam.
Mild central
mediastinal venous distension is noted with mild interstitial
pulmonary edema.
Mediastinal and hilar contours are otherwise similar. There are
small
bilateral pleural effusions. Patchy atelectasis is noted in the
lung bases.
No pneumothorax. No acute osseous abnormality. 2 clips are
seen within the
anterior left chest wall.
IMPRESSION:
Mild cardiomegaly with mild interstitial pulmonary edema and
small bilateral
pleural effusions. Mild bibasilar atelectasis.
Echocardiogram (___)
========================
IMPRESSION:
Mild symmetric left ventricular hypertrophy with normal cavity
size, and regional/
global systolic function. Mild mitral regur
gitation. Mild tricuspid regur
gitation. Mild pulmonary artery
systolic hypertension. Bilateral pleural ef
fusions.
Compared with the prior TTE ___, the findings are
similar.
Brief Hospital Course:
___ yo F PMHx dementia, anxiety, hypertension, DM2, and CKD
presenting with worsening bilateral lower extremity edema and
dyspnea, which resolved with IV furosemide. Subsequently
developed atrial tachycardia which improved with metoprolol.
Transitioned to PO diuretics and was stable for discharge to
rehab.
ACTIVE ISSUES:
===============
#Acute on Chronic Heart Failure with Preserved Ejection
Fraction:
-The patient was sent from the ___ after it was noted
that she had increased bilateral lower extremity swelling,
shortness of breath, and increased weakness. She was recently
started on furosemide 20 mg PO daily by her PCP, however her
edema continued to worsen. On admission, we began IV Lasix, and
transitioned to PO when euvolemic. On ___ we performed an
echocardiogram which showed left ventricular hypertrophy. This
was unchanged from the TTE performed in ___. Her
creatinine then stabilized at 1.8 on day of discharge and
discharge weight was 139 lbs. She was discharged on Lasix 20mg
PO daily.
#Atrial tachycardia
The patient triggered on ___ for supraventricular tachycardia.
Patient was asymptomatic with rates in the 150s-170s. She did
not have any subjective dyspnea or associated chest pain. She
was hemodynamically stable. Lopressor 5 mg IV was pushed, which
normalized her heart rate. Cardiology confirmed this as atrial
tachycardia, and there was no indication for anticoagulation. We
then began the patient on metoprolol tartrate, and eventually
consolidated to metoprolol succinate.
#Acute on Chronic kidney disease
The last known baseline of this patient's creatinine was 1.3 in
___. The patient had a mild ___ during her stay, likely
from cardiorenal syndrome. Her Cr improved with diuresis and at
discharge, was 1.8.
CHRONIC ISSUES:
===============
#Dementia
Per ___, the patient is prone to labile moods but is
easily redirectable. During this hospitalization, we continued
her home memantine and donepezil, and also continued her
risperidone 0.5 mg p.o. nightly and 0.25 mg p.o. twice daily as
needed for severe agitation.
#Depression
In the setting of chronic kidney disease with an acutely
elevated creatinine, we decreased the patient's venlafaxine dose
to 75 mg p.o. nightly.
#Diabetes mellitus
We discontinued the patient's glyburide while in the hospital,
given the risk of hypoglycemia with this medication. We checked
the patient's sugars qACHS and found that she was relatively
normoglycemic in the mornings, but hyperglycemic in the 240s at
night. We did not supply her with any exogenous insulin. We
would suggest that she be transitioned to glimepiride or
linagliptin as an outpatient. We held her glyburide at
discharge.
TRANSITIONAL ISSUES
===================
[ ]Recheck chem10 in one week. Discharge Cr 1.8
[ ]Discharge weight is 139 lbs. Continue daily weights
[ ]Continued home Lasix 20mg PO daily. Consider titrating dose
as Qdaily or QOD depending weights and volume exam
[ ]Due to mild ___ and hypotension, held lisinopril. Please
consider restarting as outpatient as appropriate
[ ]Metoprolol Succinate may need to be titrated up if she
becomes symptomatic
[ ]Held glyburide as she was normoglycemic off of it. Consider
transitioning to glimepiride or linagliptin as an outpatient
[ ]Patient was constipated during her stay. Please consider
uptitrating bowel regimen as indicated
[ ]FYI: patient has LVH and mild pulmonary artery systolic
hypertension on TTE. continue to monitor
[ ]Continue nutritional supplements with ensure enlive and magic
cups
[ ]Consider glimepiride or linagliptin instead of glyburide
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Risamine (menthol-zinc oxide) 0.44-20.6 % topical DAILY:PRN
2. Sarna Lotion 1 Appl TP DAILY:PRN rash
3. Ascorbic Acid ___ mg PO DAILY
4. Calcitriol 0.25 mcg PO DAILY
5. Cyanocobalamin 100 mcg PO DAILY
6. Donepezil 10 mg PO QHS
7. Furosemide 20 mg PO DAILY
8. gelatin 600 mg oral DAILY
9. GlyBURIDE 2.5 mg PO DAILY
10. Lisinopril 2.5 mg PO DAILY
11. Memantine 10 mg PO DAILY
12. Multivitamins 1 TAB PO DAILY
13. Venlafaxine 112.5 mg PO DAILY
14. RisperiDONE 0.5 mg PO QHS
15. RisperiDONE 0.25 mg PO BID:PRN severe agitation
Discharge Medications:
1. Metoprolol Succinate XL 50 mg PO DAILY
2. Miconazole Nitrate Vag Cream 2% 1 Appl VG QHS Duration: 7
Days
Continue through ___. Polyethylene Glycol 17 g PO DAILY
4. Senna 8.6 mg PO BID
5. RisperiDONE 0.25 mg PO BID:PRN severe agitation
6. Venlafaxine XR 75 mg PO DAILY
7. Ascorbic Acid ___ mg PO DAILY
8. Calcitriol 0.25 mcg PO DAILY
9. Cyanocobalamin 100 mcg PO DAILY
10. Donepezil 10 mg PO QHS
11. Furosemide 20 mg PO DAILY
12. gelatin 600 mg oral DAILY
13. Memantine 10 mg PO DAILY
14. Multivitamins 1 TAB PO DAILY
15. Risamine (menthol-zinc oxide) 0.44-20.6 % topical DAILY:PRN
16. RisperiDONE 0.5 mg PO QHS
17. RisperiDONE 0.25 mg PO BID:PRN severe agitation
18. Sarna Lotion 1 Appl TP DAILY:PRN rash
19. HELD- Lisinopril 2.5 mg PO DAILY This medication was held.
Do not restart Lisinopril until you see your PCP
___:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary Diagnosis
=================
1. Acute on Chronic Heart Failure with Preserved Ejection
Fraction
2. Atrial Tachycardia
Secondary Diagnosis
===================
1. Acute Kidney Injury on Chronic Kidney Disease
2. Candidal Vaginitis
3. Diabetes Mellitus
4. Depression
5. Dementia
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 ___
___!
WHY WERE YOU ADMITTED?
-You were admitted to the hospital because your legs were
getting swollen, you were having trouble breathing, and you were
feeling weaker than normal.
WHAT HAPPENED IN THE HOSPITAL?
-This was felt to be due to a condition called heart failure,
where your heart does not pump hard enough and fluid backs up
into your lungs.
-You were given a diuretic medication through the IV to help get
the fluid out. You improved considerably and were ready to leave
the hospital.
-You developed a really fast heart rate so we gave you
medications to slow it down (metoprolol)
-We did an ultrasound of your heart which was normal
WHAT SHOULD YOU DO AT HOME?
-Please take all of your medications as prescribed, especially
your furosemide and metoprolol
-Please follow up with your primary care provider ___ 1 week
after discharge from rehab
-Continue walking several times a day
- Your weight at discharge is 139 lbs. Please weigh yourself
today at home and use this as your new baseline
- Please weigh yourself every day in the morning. Call your
doctor if your weight goes up by more than 3 lbs.
- Seek medical attention if you have new or concerning symptoms
or you develop swelling in your legs, abdominal distention, or
shortness of breath at night.
Thank you for allowing us be involved in your care, we wish you
all the best!
Your ___ Team
Followup Instructions:
___
|
19711333-DS-17
| 19,711,333 | 27,784,816 |
DS
| 17 |
2186-07-13 00:00:00
|
2186-07-13 13:01:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
fall
Major Surgical or Invasive Procedure:
ERCP ___
History of Present Illness:
Patient is a ___ with history of dementia, NPH s/p shunt, and
prostate cancer transferred for outside hospital with concern
for bile duct obstruction.
History is limited due to patient's dementia and inability to
get in touch with family members. Per ___ report and chart
review, patient presented to ___ yesterday after
slipping and falling at home. There, work-up was negative
including head CT, CXR, labs. However he was found to have
direct bilirubinemia and transaminitis (Tbili 5 Dbili 3.3
Indirect 1.7, AST 122 ALT 142 ALP 277)) Normal WBC. He denies
any sxs including abdominal pain, though interview limited by
dementia. Patient denies changes in bowel habits, nausea,
vomiting. He was transferred for consideration for ERCP
In the ___ ___, initial VS were: 98.4 51 136/58 16 94% RA
___ physical exam was recorded as:
Icteric sclerae
Abd: soft, NDNT, no rebound or guarding
___ labs were notable for:
Cr 1.3, BUN 22
AST 108, ALT 124, ALK phos 281, Tbili 3.8, Dbili 2.5, Alb 3.2
Hb 12.8
WBC 7.8
INR 1.2
Lactate 1.2
CT abd showed:
Small left pleural effusion bronchial thickening and atelectasis
in the posterior lung bases, mild intrahepatic biliary ductal
dilation normal caliber CBD. No definite pancreatic mass
identified. Given reported painless jaundice, and mild
intrahepatic biliary ductal dilation, consider MRCP to further
assess. VP shunt tubing terminates in the right lateral mid
abdomen. Urinary bladder is decompressed around a Foley
catheter though the wall appears thickened, correlate for
cystitis.
Patient was given NS
Transfer VS were: HR 49 BP 126/81 sats 96%
REVIEW OF SYSTEMS:
A ten point ROS was conducted and was negative except as above
in the HPI.
Past Medical History:
Dementia
NPH s/p shunt
Prostate cancer
Social History:
___
Family History:
Unable to obtain
Physical Exam:
Admission exam:
Gen: NAD, A&Ox0, slow to respond to questions, lying in bed
Eyes: EOMI, sclerae icteric
ENT: MMM, OP clear
Cardiovasc: RRR, no MRG, full pulses, no edema
Resp: normal effort, no accessory muscle use, lungs CTA ___.
GI: soft, NT, ND, BS+
MSK: No significant kyphosis. No palpable synovitis.
Skin: No visible rash. No jaundice.
Neuro: AAOx0. No facial droop.
GU: Foley catheter in place draining clear urine
Discharge exam:
VS: Reviewed. AF. HRs mostly ___ on tele
GEN: lying in bed, just waking up, no distress
HEENT/Neck: PER, MMMs, OP clear
HEART: bradycardia, regular
LUNGS: poor effort on exam. mild lower L side crackles, improved
with cough
ABD: soft NT/ND +BS no rebound or guarding
EXT: warm well perfused, no pitting edema, distal pulses intact
NEURO: not oriented to location or year although able to pick
year from multiple choice; mostly responds to questions/commands
appropriately; speech somewhat slowed; ___ forwards ok but not
backwards; strength symmetric in UEs and LEs, tongue midline,
trace L nasolabial flattening but smile symmetric
Psych: pleasant affect
Pertinent Results:
============================================
Pertinent data from admission:
ALT gradually from 124 -> 48
AST gradually from 108 -> 32
Alk Phos gradually from 296 ->196
Tbili gradually from 3.8 -> 1.9
K mildly low, 3.2 day of discharge
Mild anemia, HGB 11.8 day of discharge
TSH 2.6
CT A/P:
1. Intrahepatic biliary ductal dilation, mild, mild prominence
of the
pancreatic duct without definite signs of pancreatic head
lesion. Given
history of painless jaundice, MRCP is advised to exclude
underlying lesion. Small hypodensity in the midbody pancreas
can also be further assessed at the time of MRCP.
2. Tiny pleural effusions at the lung bases with bronchial wall
thickening
likely the sequelae of chronic aspiration. Emphysema noted.
3. Thickening of the urinary bladder, correlate for infection.
ERCP ___
Impression: Limited exam of the esophagus was normal
Limited exam of the stomach was normal
Limited exam of the duodenum was normal
The scout film was normal.
The major papilla was slightly prominent and appeared stenosed.
The overlying mucosa however, was normal.
The CBD was successfully cannulated with the CleverCut 3V
sphincterotome preloaded with a 0.025in guidewire.
The guidewire was advanced into the intrahepatic biliary tree.
Contrast injection revealed severely dilated CBD to
approximately 12mm in diameter to the level of the ampullay with
a possible area of narrowing at the level of the ampulla.
The intrahepatic biliary tree appeared normal. No filling
defects were noted.
A sphincterotomy was successfully performed at the 12 o'clock
position. No post sphicnterotomy bleeding was noted.
A polypoid, soft tissue-like mass was noted to be protuding at
the sphincterotomy site.
Brushings and cold forceps biopsies were successfully obtained
at the major papilla.
A ___ x 6 cm ___ plastic stent was successfully
placed across the ampulla.
There was excellent drainage of bile and contrast at the end of
the procedure.
The PD was not injected or cannulated.
Recommendations: Return to ward for on going care.
NPO overnight with aggressive IV hydration with LR at 200 cc/hr
If no abdominal pain in the morning, advance diet to clear
liquids and then advance as tolerated
No aspirin, Plavix, NSAIDS, Coumadin for 5 days.
Continue with antibiotics - Ciprofloxacin 500mg BID x 5 days.
Repeat ERCP in ___ weeks for stent pull and re-evaluation.
Follow up with cytology reports. Please call Dr. ___
___ ___ in 7 days for the pathology results
Follow for response and complications. If any abdominal pain,
fever, jaundice, gastrointestinal bleeding please call Advanced
Endoscopy Fellow on call ___
Headt CT ___. Findings could suggest hydrocephalus. Prior imaging for
comparison would be helpful.
2. Right posterior approach ventriculoperitoneal shunt
terminates in the
occipital horn of the right lateral ventricle.
3. No intracranial hemorrhage or large vascular territory
infarct.
============================================
Brief Hospital Course:
A/P: Patient is a ___ with history of dementia, NPH s/p shunt,
and prostate cancer transferred for outside hospital with
concern for bile duct obstruction. ERCP with sphincterotomy
performed ___, found to have ampullary mass. Stent placed and
pathology pending.
#Biliary obstruction likely due to ampullary mass:
Painless jaundice incidentally found on eval for mechanical fall
at OSH. Patient was asymptomatic. LFTs were trending down prior
to ERCP with stent placement and continued to trend down
afterward as well. Will need to call for pathology results and
follow-up for repeat ERCP in ___ weeks for stent pull. ERCP team
contact info below.
#Metabolic encephalopathy
#NPH with VP shunt
#Dementia
Patient had agitated delirium early during hospitalization which
improved. However he remained disoriented beyond his baseline
throughout the hospitalization. No new focal neurologic
findings. CT head was obtained on ___ due to his persistent
encephalopathy. There was initial concern for ventriculomegaly
and ?VP shunt malfunction but neurosurgery consulted and felt
this was unlikely. However this assessment was difficult to make
with certainty due to lack of prior imaging. Per discussion with
his wife his current encephalopathy seems similar to prior
hospital-acquired encephalopathy episodes. Overall feel that
shunt malfunction highly unlikely at this time. Head CT will be
provided on CD so that can be uploaded at ___ when
he follows up with neurosurgery.
#Sinus bradycardia:
HR ___ on presentation, asymptomatic, BP normal. EKGs
variable but overall suggest sinus brady with premature
beats/ectopy. Cardiology consulted. HRs increased to ___ with
activity, so felt to be benign. Metoprolol held and HRs overall
increased, remaining in ___ during the 24 hours prior to
discharge. Will require ongoing monitoring but suspect that beta
blockers should be avoided unless has critical indication in the
past. TTE may be considered in the future.
#HTN:
Nifedipine continued but hydralazine and lisinopril held.
Lisinopril restarted at discharge since BPs mildly elevated.
Will require ongoing monitoring and considering whether to
restart hydralazine. Metoprolol held due to bradycardia.
#Hypokalemia:
Mild, started on repletion and discharged on repletion with plan
to continue following and wean if possible. Mag low-normal.
___, Wife
Phone number: ___
=======================================================
#Transitional issues:
(1) obtain repeat LFTs and BMP twice weekly
(2) if potassium stable can wean potassium supplementation
(3) monitor BP; consider restarting hydralazine if BPs elevated.
consider holding lisinopril if BPs low
(4) please ensure follow-up with neurosurgery at ___, and
please ensure CD of head CT is brought with him for upload;
should his encephalopathy worsen or fail to improve then he
should be evaluated there to address the question of VP shunt
malfunction
(5) consider TTE in the future as further workup for his
bradycardia and ectopy
(6) should likely remain off beta blockers for life, but can
consider low dose if critical infication in future
(7) ERCP/GI follow-up:
- pathology results available in 1 week - Dr. ___
___
- ERCP in ___ weeks for stent removal
- based on pathology results will need further plan determined
moving forward
(8) augmentin should be continued through ___ (post-procedure
prophylaxis)
=======================================================
>30 minutes in patient care/coordination of discharge
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Allopurinol ___ mg PO DAILY
2. Donepezil 10 mg PO DAILY
3. Citalopram 20 mg PO DAILY
4. Metoprolol Succinate XL 50 mg PO DAILY
5. Losartan Potassium 100 mg PO DAILY
6. Cyanocobalamin 250 mcg PO DAILY
7. Vitamin D 800 UNIT PO DAILY
8. HydrALAZINE 12.5 mg PO TID
Discharge Medications:
1. Acetaminophen 500 mg PO Q6H:PRN Pain - Mild/Fever
2. Amoxicillin-Clavulanic Acid ___ mg PO Q12H
Continue through ___. Potassium Chloride 40 mEq PO DAILY
for 1 week unless ongoing hypokalemia
4. Allopurinol ___ mg PO DAILY
5. Citalopram 20 mg PO DAILY
6. Cyanocobalamin 250 mcg PO DAILY
7. Donepezil 10 mg PO DAILY
8. Losartan Potassium 100 mg PO DAILY
9. Vitamin D 800 UNIT PO DAILY
10. HELD- HydrALAZINE 12.5 mg PO TID This medication was held.
Do not restart HydrALAZINE until instructed by your doctor
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Bile Obstruction due to ampullary mass
Severe Sinus Bradycardia
Acute encephalopathy
Dementia
NPH
HTN
Hypokalemia
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:
Mr. ___ was hospitalized for evaluation of bile obstruction
and jaundice found incidentally after a mechanical fall at home.
During his hospitalization, he was found to have a very low
heart rate that our cardiologists ultimately determined was
sinus rhythm. He ultimately underwent ERCP, which showed that
there may have been a mass causing the obstruction, although the
nature of this mass remains unclear. Dr. ___ can be
contacted in 1 week to find out the results of the pathology
from this mass. He will also need a follow-up procedure in ___
weeks to remove the plastic stent that was placed into his bile
duct. While here Mr. ___ also experienced confusion, similar
to prior hospitalizations. We expect this will improve with
time. We have included a CT scan of the brain that was performed
while he was here. We recommend that this be brought to ___
___ and that he follow-up with his neurosurgeon there.
Should his mental status fail to improve then this evaluation
should occur sooner in case there is a problem with his stent,
although at this time we do not suspect that. We also started
potassium pills due to low potassium, but we anticipate the need
for these will be short term. He will need to have his potassium
checked again in ___ weeks.
Summary of gastroenterology plan:
-Repeat ERCP in ___ weeks for stent pull and re-evaluation (you
should be contacted to schedule this and if not please call the
number below)
-Follow up with cytology reports. Please call Dr. ___
___ ___ in 7 days for the pathology results
-If any abdominal pain, fever, jaundice, gastrointestinal
bleeding please call ___ and ask the operator for the
Advanced Endoscopy Fellow on call
Followup Instructions:
___
|
19711702-DS-22
| 19,711,702 | 27,352,944 |
DS
| 22 |
2147-10-24 00:00:00
|
2147-10-28 01:20:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
adhesive bandage / cefepime
Attending: ___
Chief Complaint:
left femoral neck fracture
Major Surgical or Invasive Procedure:
Open reduction and internal fixation of femoral neck fracture.
History of Present Illness:
Ms. ___ is a ___ year old female with intravascular
lymphoma currently in remission, day ___ s/p autoSCT,
presenting after a fall with a left femoral neck fracture. Ms.
___ has been doing particularly well recently, walking up
to 2 miles per day. Last evening, she was in the bathroom
preparing for bed and was putting on her pajamas. She then fell
over and landed on her left shoulder and her left hip. She
developed pain immediately and was taken to the ED. The patient
does not remember the fall. She denied chest pain, palpitations
or shortness of breath preceeding the event. Her husband does
not think she hit her head, but the ED was told she hit her head
and had a brief period of loss of consciousness. She has had a
low grade temperature since this event and is feeling flushed.
She was not given pain medication in the ED and denies pain
presently. She was given valium 5 mg po once in the ED. In the
ED, imaging demonstrated a left femoral neck fracture. She was
admitted with a plan for ORIF tomorrow.
Past Medical History:
ONCOLOGIC HISTORY:
1) Mrs. ___ had her first event in ___ when she
was diagnosed with small left inferior cerebellar embolic
infarcts in the subacute stage found on a regularly scheduled
MRI for follow-up of her meningiomas. At that time, she was
asymptomatic and on aspirin. CTA of the head/neck and ECHO were
unremarkable. She was discharged on simvastatin, fish oil and
aspirin 325mg daily.
2) ___: She developed new gait unsteadiness and
"wooziness". MR spectroscopy on ___ revealed multiple stable
areas of patchy FLAIR signal hyperintensity within the left
frontal centrum semiovale and periventricular white matter
without evidence of enhancement or increased perfusion. An LP
was performed and all CSF studies were negative.
3) ___: She had worsening dizziness, unsteadiness and
fatigue. Repeat MRI on ___ showed new tiny foci of slow
diffusion in the right inferomedial cerebellum and left middle
cerebellar peduncle, possibly representing subacute infarcts.
Repeat TTE was normal. Aspirin was discontinued and she started
on clopidogrel 75mg PO daily. A hypercoaguability work-up was
unremarkable. TEE was normal. PET was negative.
4) ___: She developed dysarthria and re-presented to the ER.
MRI/A of the head revealed multiple small acute and subacute
infarctions in the right cerebellar hemisphere and in the
superior vermis bilaterally. Neck MRA was normal. CT torso on
___ was without any evidence of malignancy. Additional
testing for antiphospholipid antibody syndrome was negative.
Factor VIII was slightly elevated at 175% and b2 microglobulin
was elevated at 2.7 mg/L (0.8-2.2). She was treated with both
aspirin and clopidogrel.
5) ___: She presented with new acute and subacute infarcts
in the cerebellar hemispheres, right greater than left, the
right parasagittal pons, multiple foci in the vermis, the right
genu of the internal capsule, the right splenium of the corpus
callosum, and the right centrum semiovale. She was continued on
aspirin and clopidogrel.
6) ___: Angiogram suggested vasospasm, but she did not
tolerate Verapamil and Cilostazol, both of which caused her to
feel dizzy. Autonomic testing showed exaggerated postural
tachycardia.
7) ___: She suffered a fall and was found to have new
memory problems and weakness on neurologic exam. MRI showed new
acute infarction in the anterior right cerebellar hemisphere and
right cerebellar peduncle, as well as smaller new early subacute
infarctions in the right splenium of the corpus callosum and
right frontal white matter. A REVEAL device was implanted on
___ to determine if she was having arrhythmias leading to
embolic strokes.
8) ___: She presented with dysarthria and gait
instability. MRI ___ showed multiple subacute infarcts in the
right frontal, splenium of corpus callosum, right cerebellum,
and cerebellar peduncle with interim tiny new infarcts in the
right cerebellum. REVEAL device did not show any arrhythmias.
Repeat LP was unremarkable. She was discharged with a plan to
undergo a cerebral biopsy to r/o intravascular lymphoma or CNS
vasculitis.
9) ___: Readmitted for worsening fatigue and somnolence. MRI
on ___ showed numerous acute infarcts in a variety of
vascular territories, superimposed on the evolving small
infarcts.
10) ___: She underwent a brain biopsy on ___ which
showedintravascular lymphoma.
11) ___: Bone marrow biopsy on ___ was negative for any
evidence of lymphoma. Repeat CT torso on ___ was negative
for any evidence of malignancy.
12) ___: Received C1 HD MTX (7040mg/m2).
13) ___: Received C1 R-CHOP (with dexamethasone instead of
prednisone)
14) ___: Received C2 R-CHOP
15) ___: Received C2 HD-MTX (dose reduced to 3.5g/m2)
16) ___: Received C3 R-CHOP
17) ___: Received C3 HD-MTX
18) ___: Received C4 R-CHOP
19) ___: Received C4 HD-MTX
20) ___: Received C5D1 R-CHOP
21) Admitted from ___ due to pain from pubic rami,
sacral ala and L4 compression fractures. Chemotherapy was held.
Repeat MRIs, LP, and CT scans did not show any evidence of
recurrent lymphoma. She was managed conservatively and
discharged to rehab for ongoing physical therapy.
22) PET scan ___ was without any evidence of lymphoma.
23) ___: Received HD-MTX (3.5gm/m2) and ifosfamide as last
cycle of chemotherapy
.
OTHER PAST MEDICAL HISTORY:
DEPRESSION
MIGRAINE HEADACHE
RECURRENT CVA (CEREBELLAR)
MENINGIOMA
Presented ___ with focal seizures.
Two meningiomas: high right frontal vertex adjacent to
interhemispheric falx with mass effect on superior sagittal
sinus; s/p resection ___ with mild residual left leg weakness.
Second smaller lesion in right parietal extra-axial space,
unchanged on serial imaging.
SEIZURES
Focal seizures: left leg paresthesias occasionally progressing
to left leg clonus and once with abdominal twitching; no LOC or
confusion. In past, occurred multiple times per day, but now
well controlled since ___. Secondary to parasagittal
meningioma, resected ___. Last event in ___.
HYPOTHYROIDISM
OSTEOPOROSIS
s/p TONSILLECTOMY
s/p APPENDECTOMY
s/p CHOLECYSTECTOMY
s/p C-SECTION X2
Reveal device implanted, ___
Social History:
___
Family History:
Her mother had breast CA. Her father died in his ___.
Physical Exam:
Physical Exam on Admission:
VS: 99.3 140/80 81 18 97% RA
Gen: fatigued, falls asleep easily, no pain/distress
HEENT: oral thrush noted, mucus membranes moist
Car: regular rhythm, tachycardic
Chest: port c/d/i, accessed
Resp: clear to auscultation bilaterally--but anterior/lateral
exam only with poor inspiratory effort
Abd: soft, not tender, not distended
Ext: left leg externally rotated, pulses palpable
Physical Exam on Discharge:
VS: T98.5, BP132/70, HR:84, RR16, O2sat:100%2LNC
Gen: NAD, A+Ox3
HEENT: no oral thrush appreciated
Car: RRR, no M/R/G
Ext: left leg with full ROM, non-tender
Exam otherwise unchanged from admission
Pertinent Results:
Lab Results on Admission:
___ 08:25AM BLOOD WBC-3.8* RBC-3.58* Hgb-12.0 Hct-35.0*
MCV-98 MCH-33.4* MCHC-34.2 RDW-13.0 Plt ___
___ 12:00AM BLOOD WBC-3.4* RBC-3.34* Hgb-11.7* Hct-32.8*
MCV-98 MCH-34.9* MCHC-35.6* RDW-13.1 Plt ___
___ 12:00AM BLOOD Neuts-46* Bands-0 ___ Monos-13*
Eos-2 Baso-0 ___ Myelos-0
___ 08:25AM BLOOD Glucose-115* UreaN-7 Creat-0.5 Na-142
K-3.4 Cl-102 HCO3-31 AnGap-12
___ 12:00AM BLOOD Glucose-108* UreaN-7 Creat-0.6 Na-141
K-3.3 Cl-106 HCO3-29 AnGap-9
___ 08:25AM BLOOD ALT-13 AST-17 AlkPhos-88 TotBili-0.2
___ 12:00AM BLOOD ALT-13 AST-15 AlkPhos-80 TotBili-0.3
___ 08:25AM BLOOD Albumin-4.4 Calcium-9.0 Phos-2.8 Mg-1.8
___ 12:00AM BLOOD Calcium-8.4 Phos-3.0 Mg-1.7
Imaging:
-Noncontrast CT head: no acute process. stable post-operative
changes. minimally decreased right parietal meningioma (prelim
read)
.
-CT C-spine: no acute process (prelim)
.
-CT Pelvis: bones are demineralized. no acute fracture evident.
deformity of left inferior and superior pubic ramus related to
prior trauma evident. djd (prelim
.
Pathology Examination
Name ___ Age ___ # ___ MRN#
___ ___ ___
___
Report to: ___. ___ by: ___. ___
SPECIMEN SUBMITTED: Femoral Head Reaming.
Procedure date Tissue received Report Date Diagnosed
by
___. ___. ___
Previous biopsies: ___ immunophenotyping - PB
___ BONE MARROW (1 JAR)
___ immunophenotyping - BM
___ immunophenotyping - RT occipital lobe BX
(and more)
DIAGNOSIS:
Femoral head (left), reamings:
Scant fragments of tendoligamentous tissue, bone, and
admixed fibrin.
Clinical: Left hip fracture.
___: The specimen is received fresh labeled with the
patient's name ___, the medical record number,
and additionally labeled "left femoral head reaming". It
consists of multiple fragments of red soft tissue measuring 0.3
x 0.2 x 0.2 cm in aggregate. The specimen is entirely submitted
in cassette A.
.
Radiology ReportLOWER EXTREMITY FLUORO WITHOUT RADIOLOGIST IN
O.R. LEFTStudy Date of ___ 3:13 ___
Fluoroscopic assistance provided to the surgeon in the OR
without the
radiologist present. Two spot views obtained. These demonstrate
the left
hip, with screw placement along the femoral neck. Assessment of
fine bony
detail is limited by RF technique. Correlation with real-time
findings and
when appropriate conventional radiographs is recommended for
full assessment.
Fluoro time recorded as 60.4 seconds on the electronic
requisition.
.
Lab Results on Discharge:
___ 05:56AM BLOOD WBC-4.1 RBC-3.37* Hgb-10.9* Hct-34.2*
MCV-102* MCH-32.3* MCHC-31.9 RDW-12.5 Plt ___
___ 05:56AM BLOOD Neuts-64.6 ___ Monos-8.9 Eos-1.5
Baso-0.4
___ 05:56AM BLOOD ___ PTT-34.1 ___
___ 05:56AM BLOOD Glucose-113* UreaN-4* Creat-0.6 Na-138
K-3.6 Cl-102 HCO3-31 AnGap-9
___ 12:00AM BLOOD ALT-13 AST-15 AlkPhos-80 TotBili-0.3
___ 05:56AM BLOOD Calcium-8.5 Phos-3.1 Mg-1.6
Brief Hospital Course:
Primary Reason for Hospitalization: Ms. ___ is a ___ year
old female with a history of intravascular lymphoma in
remission, on admission day ___ s/p autologous stem cell
transplant, presenting after a fall with a left hip fracture.
.
ACUTE CARE:
1. Hip fracture/Fall: The patient has known autonomic neuropathy
and is on fludrocortisone. She also has a history of cerebellar
infarcts and at baseline depends on a walker for mobility. The
description of patient's fall that results in femoral neck
fracture suggests a mechanical event, without preceding or
subsequent symptoms. She was at the bathroom sink and bent down
to pick something up on the ground and lost her balance and
fell. She underwent surgical fixation of the fracture without
major complication. She will receive Lovenox 40 mg subcutaneous
for 4 weeks to prevent DVT, and pain control with oxycodone. She
will also continue vitamin D.
.
CHRONIC CARE
1. Intravascular lymphoma/s/p autologous SCT: Patient's counts
are currently stable on this admission. Patient was found to be
neutropenic two weeks ago for unclear reason, but WBC improved
today. Remains on Bactrim and acyclovir for prophylaxis after
transplant. Has cognitive changes that have been attributed to
her prior strokes and are not anticipated to improve. She has
been making improvements in her status since her transplant.
Prophylactic antimicrobials were continued for this admission.
.
2. History of seizures: Patient was continued with her
outpatient regimen of Keppra and lamotrigine.
.
3. Hypothyroidism: continued outpatient levothyroxine
.
4. Depression/Anxiety: continued outpatient fluoxetine
.
TRANSITIONS IN CARE:
1. CONTACT/ HCP: ___ (HUSBAND) ___
2. MEDICATION CHANGES: Please START Enoxaparin 40 mg/0.4 mL
Syringes, 1 injection daily for the next 4 weeks to prevent a
lower extremity blood clot.
Please START Oxycodone 2.5 mg every 4 hours as needed for pain.
This medication may cause constipation and sedation.
3. FOLLOW-UP:
Please follow up in the Orthopaedic Trauma Clinic in ___ days
post-operation for evaluation and any suture/staple removal.
Call ___ to schedule appointment upon discharge.
.
Please follow up with your PCP regarding this admission and any
new medications/refills.
.
Department: HEMATOLOGY/___
When: ___ at 10:00 AM
With: ___
Building: ___
Campus: ___ Best Parking: ___
.
Department: HEMATOLOGY/ONCOLOGY
When: ___ at 10:00 AM
With: ___
Building: ___
Campus: ___ Best Parking: ___
.
Department: HEMATOLOGY/___
When: ___ at 9:00 AM
With: ___
Building: ___
Campus: ___ Best Parking: ___
4. OUTSTANDING CLINICAL ISSUES:
-follow-up appointments, slowly re-introducing weight-bearing
Medications on Admission:
Acyclovir 400 mg tid
Fludrocortisone 0.2 mg daily
Fluoxetine 20 mg daily
Folate 1 mg daily
Lamotrigine 50 mg bid
Keppra 1500 mg bid
Levothyroxine 1000 mcg daily
Ondansetrone 8 mg tid
Protonix 40 mg daily
Bactrim SS daily
Vitamin D3 ___ mg daily
Thiamine 100 mg daily
Nephrocaps daily
Discharge Medications:
1. enoxaparin 40 mg/0.4 mL Syringe Sig: One (1) Subcutaneous
DAILY (Daily) for 4 weeks.
Disp:*28 syringes* Refills:*0*
2. acyclovir 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours).
3. fludrocortisone 0.1 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
4. fluoxetine 20 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
5. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. lamotrigine 25 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day).
7. levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. sulfamethoxazole-trimethoprim 400-80 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
9. cholecalciferol (vitamin D3) 1,000 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
10. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
12. oxycodone 5 mg Tablet Sig: 0.5 Tablet PO Q4H (every 4 hours)
as needed for pain not responding to Tylenol.
Disp:*24 Tablet(s)* Refills:*0*
13. levetiracetam 750 mg Tablet Sig: Two (2) Tablet PO twice a
day.
14. ondansetron 8 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO three times a day as needed for nausea.
15. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary:
Femoral Neck Fracture
.
Secondary:
Intravascular Lymphoma
Depression
Hypothyrodisim
Osteoporosis
Seizure Disorder
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair with touchdown weightbearing.
Discharge Instructions:
Ms. ___,
You came to the hospital after suffering a femur fracture from a
fall. You had fixation of the fracture, and will need further
outpatient follow up from ___ orthopedic department. You and
your husband requested home physical therapy, not in patient
phyiscal therapy, and will be receiving home physical therapy.
Please do not weightbear on your affected leg until further
instructed by your orthopedic surgeon.
.
Please note the following changes in your medications:
Please START Enoxaparin 40 mg/0.4 mL Syringes, 1 injection daily
for the next 4 weeks to prevent a lower extremity blood clot.
Please START Oxycodone 2.5 mg every 4 hours as needed for pain.
This medication may cause constipation and sedation.
.
No further changes have been made in your medications. Please
continue to take them as usually prescribed.
.
It has been a pleasure taking care of you! We wish you a speedy
recovery.
Followup Instructions:
___
|
19711702-DS-26
| 19,711,702 | 20,287,392 |
DS
| 26 |
2149-02-26 00:00:00
|
2149-02-27 13:26:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
adhesive bandage / cefepime / chlorhexidine
Attending: ___.
Chief Complaint:
Aspiration, Synchope
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Patient is a ___ with history of autologous stem cell transplant
for NH lymphoma complicated by stroke, seizures, chronic UTIs
presented from outside ED choked on raisin bread today. Her
husband reports that the patient lost consciousness for ___
minutes. He performed chest compressions for ___ minutes, but
was not noted to have lost pulses. EMS noted that patient
vomited once upon transport. She initially presented to OSH
where she was found to have UTI. She was given levofloxacin
500mg and transported to ___.
In the ED, initial vital signs were 98.0 113 104/68 24 96%. A
CXR here demonstrated heterogeneous opacities through much of
the right lung fields predominantly in the right middle lobe,
apparently slightly improved from earlier same day examination,
noted preliminarily to be compatible with aspiration. Labs
demonstrated UA suspicious for infection, mild leukocytosis to
11.6k (N90%, L5%), and negative troponin. Blood cultures were
drawn and were pending upon admission. Prior to admission, she
received additional 250mg levofloxacin and clindamycin.
Upon arrival to the floor, her vitals were stable (with
tachycardia) and patient is resting comfortably.
Review of Systems:
(+) Per HPI
(-) fever, chills, night sweats, headache, vision changes,
rhinorrhea, congestion, sore throat, cough, shortness of breath,
chest pain, abdominal pain, nausea, vomiting, diarrhea,
constipation, BRBPR, melena, hematochezia, dysuria, hematuria.
Past Medical History:
Lymphoma s/p autoSCT ___
Lymphomatous cerebral vasculitis
Left hip fracture s/p repair ___
Depression
Migraine headaches
Meningioma
Seizure disorder
Hypothyroidism
Osteoporosis
S/p tonsillectomy
S/p appendectomy
S/p cholecystectomy
S/p c-section x 1
Reveal device implanted, ___
Social History:
___
Family History:
Her mother had breast CA. Her father died in his ___.
Physical Exam:
Admission Physical Exam:
Vitals- 98.5, 108/72, 118, 18, 94% 1 L NC
General: awake, baseline neurological deficit, no acute distress
HEENT: Moist mucus membranes, EOMI, anicteric sclera
Neck: supple, no JVD
CV: RRR, normal S1 and S2, no M/G/R
Lungs: clear to ascultation, no wheezes or crackles
Abdomen: soft, non-tender, non-distended
GU: no CVA tenderness
Ext: pulses equal and symmetric throughout, no edema
Neuro: able to follow commands, ambulates normally
Skin: warm, dry, no rashes
Discharge Physical Exam:
Vitals- 98.4, 97/64, 89, 18, 99% RA
General: awake, baseline neurological deficit (she is not
verbalizing well but is able to follow commands), no acute
distress
HEENT: Moist mucus membranes, EOMI, anicteric sclera
Neck: supple, no JVD
CV: RRR, normal S1 and S2, no M/G/R
Lungs: clear to ascultation, no wheezes or crackles
Abdomen: soft, non-tender, non-distended
GU: no CVA tenderness
Ext: pulses equal and symmetric throughout, no edema
Neuro: able to follow commands, ambulates normally
Skin: warm, dry, no rashes
Pertinent Results:
Admission Labs:
___ 11:45AM ___ PTT-28.7 ___
___ 11:45AM NEUTS-89.5* LYMPHS-5.4* MONOS-4.4 EOS-0.5
BASOS-0.3
___:45AM WBC-11.6*# RBC-3.99* HGB-13.2 HCT-37.7 MCV-95
MCH-33.2* MCHC-35.1* RDW-12.7
___ 11:45AM cTropnT-<0.01
___ 11:45AM estGFR-Using this
___ 11:45AM GLUCOSE-108* UREA N-16 CREAT-0.7 SODIUM-142
POTASSIUM-3.7 CHLORIDE-105 TOTAL CO2-28 ANION GAP-13
___ 11:56AM LACTATE-1.2
___ 11:56AM ___ COMMENTS-GREEN TOP
___ 02:45PM URINE MUCOUS-FEW
___ 02:45PM URINE HYALINE-2*
___ 02:45PM URINE RBC-154* WBC->182* BACTERIA-FEW
YEAST-NONE EPI-0
___ 02:45PM URINE BLOOD-LG NITRITE-NEG PROTEIN-100
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5
LEUK-LG
___ 02:45PM URINE COLOR-Yellow APPEAR-Hazy SP ___
.
Discharge Labs:
___ 04:05PM BLOOD WBC-9.8 RBC-3.61* Hgb-12.1 Hct-34.5*
MCV-96 MCH-33.4* MCHC-34.9 RDW-12.3 Plt ___
___ 05:20AM BLOOD Glucose-101* UreaN-15 Creat-0.8 Na-141
K-3.8 Cl-104 HCO3-32 AnGap-9
.
Microbiology:
Blood Cultures x2 (___): Pending
Urine Cultures (___): No growth
.
Pathology: None.
.
Imaging/Studies:
CXR (___): IMPRESSION:Heterogeneous opacities through much
of the right lung slightly improved from earlier same day
examination compatible with aspiration.
Brief Hospital Course:
Patient is a ___ with history of autologous stem cell transplant
for NH lymphoma complicated by stroke, seizures, chronic UTIs
presented from outside ED choked on raisin bread today.
Active Diagnoses:
# Aspiration: Patient was found to be choking on a piece of
raisin bread this morning. She lost conscioussness for 1 minute
and was rescussitated by her husband. Her CXR on ___ showed a
likely aspiration. On admission, she was requiring NC to keep
her sats in the ___. She was started on IV clindamycin. On ___
she no longer requied the nasal canula. Speech and swallow
evaluated her on ___. She passed her swallow evaluation. She
was tolerating her oral medications without any difficuly. The
IV clindamycin was discontinued on ___. She was then discharged
home on ___. She will follow up with her PCP ___ 5 days.
.
# UTI: She finished a course of oral ciprofloxacin in late
___ ___ for a UTI but she states that she gets UTIs
frequently. WBC count was 11.6 on admission. Afebrile. Foley in
place. She was given 500mg Levofloxacin upon transfer to ___.
On ___ the levofloxacin was discontinued and IV ceftriaxone was
started. The foley catheter was discontinued on ___ because she
felt like she had the strength to go to the bathroom. She was
discharged with a prescription for oral ciprofloxacin which she
will continue until ___.
Chronic Diagnoses:
# Seizure disorder: Stable. Has a history of lymphomatous
cerebral vasculitis. She continued all home seizure medicines
during this hospitalization.
# Lymphoma: s/p BM transplant in ___. Oncology was made aware
of her admission. She will follow up with oncology as an
outpatient.
Transitional Issues:
# She will follow up with her PCP ___ 5 days and keep all of her
regularly scheduled oncology appointments.
Medications on Admission:
1. Acyclovir 400 mg PO Q8H
2. Fludrocortisone Acetate 0.2 mg PO DAILY
3. Fluoxetine 20 mg PO DAILY
4. FoLIC Acid 2 mg PO DAILY
5. LaMOTrigine 50 mg PO BID
6. LeVETiracetam 1500 mg PO BID
7. Levothyroxine Sodium 100 mcg PO DAILY
8. methenamine hippurate *NF* 1 gram Oral BID UTI prophylaxis
9. modafinil *NF* 50 mg Oral daily
10. Nystatin Cream 1 Appl TP Q12H:PRN fungal infection
11. Pantoprazole 40 mg PO Q24H
12. Potassium Chloride 20 mEq PO BID
Hold for K > 4.9
13. Ascorbic Acid ___ mg PO Q6H
14. calcium carbonate-vitamin D3 *NF* 500 mg clacium (1250mg)
125 unit tablet Oral daily
15. Vitamin B Complex With C *NF* (B-complex with vitamin C) 1mg
1,750 unit tablet Oral Daily
Discharge Medications:
1. Acyclovir 400 mg PO Q8H
2. Ascorbic Acid ___ mg PO Q6H
3. Fludrocortisone Acetate 0.2 mg PO DAILY
4. Fluoxetine 20 mg PO DAILY
5. FoLIC Acid 2 mg PO DAILY
6. LaMOTrigine 50 mg PO BID
7. LeVETiracetam 1500 mg PO BID
8. Levothyroxine Sodium 100 mcg PO DAILY
9. Pantoprazole 40 mg PO Q24H
10. Ciprofloxacin HCl 500 mg PO Q12H Duration: 5 Days
RX *ciprofloxacin 500 mg 1 tablet(s) by mouth twice a day Disp
#*10 Tablet Refills:*0
11. calcium carbonate-vitamin D3 *NF* 500 mg clacium (1250mg)
125 unit tablet Oral daily
12. methenamine hippurate *NF* 1 gram Oral BID UTI prophylaxis
13. modafinil *NF* 50 mg Oral daily
14. Nystatin Cream 1 Appl TP Q12H:PRN fungal infection
15. Potassium Chloride 20 mEq PO BID
16. Vitamin B Complex With C *NF* (B-complex with vitamin C) 1mg
1,750 unit tablet Oral Daily
Discharge Disposition:
Home
Discharge Diagnosis:
UTI and Aspiration
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 ___,
___ your hospital stay, you were found to have likely
aspiration after chocking on raisin bread on ___. You were
also found to have a UTI. On the morning of ___ you were able
to breath well with supplemental oxygen and you passed your
swallow evaluation. Your IV antibiotics were discontinued and
you were placed on oral Ciprofloxacin. You were then
discharged. Please continue the Ciprofloxacin until ___ for a
total of five days. Please follow up with your PCP ___ 2 days
and keep all of your regularly scheduled oncology appointments.
Followup Instructions:
___
|
19711702-DS-28
| 19,711,702 | 25,118,271 |
DS
| 28 |
2151-03-14 00:00:00
|
2151-03-21 14:48:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
adhesive bandage / cefepime / chlorhexidine / Chloraprep
Attending: ___.
Chief Complaint:
Somnolence
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ y/o woman with a PMH of seizure disorder
(cerebral lymphomatous vasculitis), migraine headaches, stroke,
Non Hodgkin's Lymphoma s/p R-CHOP, autologous stem cell
transplant with monthly IVIG infusions, and recurrent UTI who
presented with increasing somnolence over the last three months,
most notably over the past few weeks. Keppra dosages have
recently been titrated down in the setting of this increased
somnollence. She saw PCP today, who was concerned about her
mental status and fatigue. Recently had a tooth extraction on
___, with no antibiotics required. No fevers at home
(temperatures between ___. In the past, has had urinary
color change, malodor, and fatigue along with increased urinary
frequency associated with UTIs. At baseline, alert, makes eye
contact, oriented to person and place, conversant only in
phrases, able to feed herself, has a commode by the bed, but has
not been able to do these for the past few weeks.
In the ED, initial vitals were: T 98.1F P ___ BP 104/63 RR 19 O2
97% RA
Labs were notable for normal serum chemistries (with K of 4.3
and Cr of 0.6) and normal CBC (with WBC of 5.6, H/H of 12.4/36.2
and PLT of 196) with 64.7% neutrophils. UA notable for cloudy
appearance, large leukocytes, moderate blood, positive nitrites,
300 protein and >182 RBCs, >182 WBCs and many bacteria. Lactate
1.0.
Patient was given:
___ 14:33 IVF 1000 mL NS 500 mL
___ 15:43 IV CeftriaXONE 1 gm
On the floor, No fevers or chills. No cough, no nausea,
vomiting, no diarrhea. No chest pain, or shortness, endorses
increasing frequency and darkened urine. Has had some hematuria;
no dysuria.
Past Medical History:
-Non-Hodgkins Lymphoma s/p autoSCT ___
-Lymphomatous cerebral vasculitis
-Left hip fracture s/p repair ___
-Reveal device implanted, ___
-Depression
-Migraine headaches
-nephrolithiasis
-Meningioma (___) s/p resection
-recurrent UTIs
-Seizure disorder
-Hypothyroidism
-Osteoporosis
-S/p tonsillectomy
-S/p appendectomy
-S/p cholecystectomy
-S/p c-section x 1
Social History:
___
Family History:
Her mother had breast CA. Her father died in his ___.
Physical Exam:
=======================
ADMISSION PHYSICAL EXAM
=======================
Vitals: T 98.3F BP 119/67 P 86 RR 20 O2 96% RA
General: Somnolet, but arousable, in NAD. Answering yes/no
questions.
HEENT: Sclera anicteric, MMM, OP clear. No evidence of dental
abscess. EOMs intact; PERRL.
CV: RRR, no MRGs; normal S1/S2.
Pulm: CTA b/l; no wheezes, rhonchi, or rales.
Chest: Port in place.
Abd: Soft, non-tender, non-distended. NABS.
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. Oriented to person and
place as per baseline.
======================
DISCHARGE PHYSICAL EXAM
=======================
Vitals: 97.8 115/68 69 18 97% RA
General: Somnolent, but arousable, in NAD. Answering yes/no
questions.
HEENT: Sclera anicteric, MMM. EOMs intact
CV: RRR, no MRGs; normal S1/S2.
Pulm: CTA b/l; no wheezes, rhonchi, or rales.
Abd: Soft, non-tender, non-distended. NABS.
GU: No foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: Difficult to perform CN exam due to poor cooperation. ___
strength upper/lower extremities, gait deferred.
Pertinent Results:
==============
ADMISSION LABS
==============
___ 02:34PM BLOOD WBC-5.6 RBC-3.83* Hgb-12.4 Hct-36.2
MCV-95 MCH-32.4* MCHC-34.3 RDW-11.9 RDWSD-40.9 Plt ___
___ 02:34PM BLOOD Neuts-64.7 ___ Monos-11.2 Eos-2.3
Baso-0.5 Im ___ AbsNeut-3.63 AbsLymp-1.17* AbsMono-0.63
AbsEos-0.13 AbsBaso-0.03
___ 02:34PM BLOOD Glucose-99 UreaN-12 Creat-0.6 Na-138
K-4.3 Cl-101 HCO3-29 AnGap-12
___ 02:46PM BLOOD Lactate-1.0
==============
DISCHARGE LABS
==============
___ 05:57AM BLOOD Glucose-92 UreaN-16 Creat-0.6 Na-142
K-3.9 Cl-104 HCO3-27 AnGap-15
___ 05:57AM BLOOD WBC-3.9* RBC-3.33* Hgb-10.8* Hct-32.0*
MCV-96 MCH-32.4* MCHC-33.8 RDW-11.9 RDWSD-40.9 Plt ___
=======
IMAGING
=======
CHEST (PA & LAT) (___)
IMPRESSION:
Streaky basilar opacity, best seen on the lateral view, most
likely represents atelectasis and vascular structures rather
than focal consolidation.
============
MICROBIOLOGY
============
___ 2:34 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
Brief Hospital Course:
Ms. ___ is a ___ y.o. woman with hx of seizure disorder
(cerebral lymphomatous vasculitis), migraine headaches, CVA, Non
Hodgkin's Lymophoma s/p R-CHOP and autologous stem cell
transplant with monthly IVIG infusions, and recurrent UTI who
presented with increasing lethargy over several weeks.
============
ACUTE ISSUES
============
# Failure to thrive
Mrs. ___ has a poor cognitive substrate at baseline, in
the setting of stroke, seizure disorder, and lymphomatous
cerebral vasculitis, with a known history of decreased
responsiveness in the setting of infections. The tempo of her
present symptoms was thought to be an acute on chronic
deterioration of her overall functional status. There was no
evidence of cerebral hypoperfusion (no focal neurologic signs)
or meningitis. There were also no signs of seizure at this time.
She responded appropriately with fluids and antibiotics, and was
continued on maintenance fluids. She returned to her baseline
and was discharged on an outpatient course of antibiotics.
# UTI
The patient had a history of recurrent UTIs, with pansensitive
E. coli in the past. Per husband, she had dark, malodorous
urine, and increasing frequency. She also has a history of
recurrent vaginitis, but had not endorsed any symptoms of
foul-smelling or malodorous vaginal discharge. There was no
leukocytosis or fever. She was initially started on ceftriaxone,
which was switched to ciprofloxacin 500 mg q12h, to be completed
after discharge on ___. Her home methenamine and ascorbic acid
were continued.
# Seizure disorder
Ms. ___ has a seizure history in the setting of
parafalcine meningioma s/p resection. Her Keppra dose had been
recently down-titrated in the setting of increasing somnolence.
There were no focal neurologic findings. She was continued on
Keppra 500 mg QAM and 750 QHS per home dosing as well as
lamotrigine 50 mg bid.
==============
CHRONIC ISSUES
==============
# Autologous stem cell transplant. Ms. ___ has a history of
Hodgkin's lymphoma s/p R-CHOP and ASCT in ___ with monthly IVIG
infusions. She was continued on home acyclovir 400 mg PO q8h and
home fludrocortisone 0.2 mg PO daily
# Depression. She was continued on home fluoxetine 20 mg PO
daily.
# Osteoporosis. She was continued on calcium 500 mg and vitamin
D 1000 units PO daily
# GERD. Home pantoprazole 40 mg was continued.
# Hypothyroidism. Continued home levothyroxine 125 mcg daily.
===================
TRANSITIONAL ISSUES
===================
# UTI treatment. The patient will complete her course of
ciprofloxacin on ___.
# CODE: Full.
# CONTACT: Husband, ___. ___ cell:
___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acyclovir 400 mg PO Q8H
2. Ascorbic Acid ___ mg PO Q6H
3. Fludrocortisone Acetate 0.2 mg PO DAILY
4. Fluoxetine 20 mg PO DAILY
5. LaMOTrigine 50 mg PO BID
6. LeVETiracetam 500 mg PO QAM
7. Levothyroxine Sodium 125 mcg PO DAILY
8. Pantoprazole 40 mg PO Q24H
9. methenamine hippurate 1 gram oral BID
10. Potassium Chloride 20 mEq PO BID
11. LeVETiracetam 750 mg PO QPM
12. cromolyn 4 % ophthalmic Q4H:PRN itchiness
13. Calcium Carbonate 500 mg PO DAILY
14. Vitamin D 1000 UNIT PO DAILY
Discharge Medications:
1. Acyclovir 400 mg PO Q8H
2. Ascorbic Acid ___ mg PO Q6H
3. Calcium Carbonate 500 mg PO DAILY
4. Fludrocortisone Acetate 0.2 mg PO DAILY
5. Fluoxetine 20 mg PO DAILY
6. LaMOTrigine 50 mg PO BID
7. LeVETiracetam 500 mg PO QAM
8. LeVETiracetam 750 mg PO QPM
9. Levothyroxine Sodium 125 mcg PO DAILY
10. Pantoprazole 40 mg PO Q24H
11. Vitamin D 1000 UNIT PO DAILY
12. cromolyn 4 % ophthalmic Q4H:PRN itchiness
13. methenamine hippurate 1 gram oral BID
14. Ciprofloxacin HCl 500 mg PO Q12H Duration: 4 Days
RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth every twelve
hours Disp #*8 Tablet Refills:*0
15. Potassium Chloride 20 mEq PO BID
Discharge Disposition:
Home
Discharge Diagnosis:
=================
PRIMARY DIAGNOSES
=================
- failure to thrive
- urinary tract infection
===================
SECONDARY DIAGNOSES
===================
- Non-Hodgkin's lymphoma
- lymphomatous cerebral vasculitis
- seizure disorder
- depression
- osteoporosis
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:
Dear Ms. ___,
It was a pleasure caring for you at ___
___. You were admitted for weakness and a urinary
tract infection. We treated your urinary tract infection with
antibiotics. We are prescribing you a course of ciprofloxacin
for this that you can finish as an outpatient. For your
weakness, we informed your regular physicians, Dr. ___,
and ___, and we recommend making close follow-up with
them, especially Dr. ___
___ continue to take all medications as prescribed. Your
discharge appointments are outlined below.
We wish you the very best!
Warmly,
Your ___ Team
Followup Instructions:
___
|
19711968-DS-14
| 19,711,968 | 21,018,022 |
DS
| 14 |
2152-12-02 00:00:00
|
2152-12-03 08:21:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Shortness of breath.
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
Mr. ___ is a ___ year old man with past medical history
of OSA, HTN, HLD, NIDDM, depression s/p ECT in ___, alcohol
abuse (last drink >1 week ago), recently discharged from ___.
___ for detox, who presented with SOB for the past 4
days.
The shortness of breath started 4 days ago, is not positional,
and is mainly exacerbated with ambulation. He says it started
after discharge from ___. He was seen at the day of
presentation at his PCP office in ___ as part of his follow
up after his recent hospital discharge. He was found to be
hypoxic and with new ECG changes (flipped T waves in anterior
leads, has RBBB at baseline), so he was given 325mg aspirin due
to concern for possible ischemia and was sent to ___ ED.
He denies chest pain, fever, chills. He reports a minor cough.
Has chronic left lower extremity swelling, which is at its
baseline. He denies recent travel and history of blood clots.
In the ED, initial vitals were: 97.2 74 189/118 26 93% 4L NC
-Labs notable for: D-Dimer: 4095, proBNP: 980, Trop-T: <0.01
Na 139 K 3.7 Cr 0.9
WBC 7.8 H/H 12.7/36.3 platelets 230 Lactate:1.1
-Imaging notable for: CXR showed mild pulmonary vascular
congestion and small left pleural effusion. CT showed extensive
bilateral segmental and subsegmental pulmonary emboli, with
central extension into the left main pulmonary artery.
-Patient was given: Enoxaparin Sodium 135 mg
Vitals prior to transfer: 98.0 74 165/94 24 94% RA
On the floor, BP 178 / 102, patient was feeling anxious about
having pulmonary embolism. Denied chest pain, SOB, headache,
lightheadedness, dizziness. He reports that he had a TIA a
couple of weeks ago. He had presented to a detox center, and
when he stood up to walk to the counter, he had difficulty
walking. He was taken to the ER, evaluated by neurology, and MRI
was attempted, but he was too large to fit in the machine. He
therefore did not get an MRI and was told to follow up as an
outpatient. He has not had an MRI. All neurologic sequela of TIA
have resolved. Has not drank since 1 week ago prior to detox.
For hypertension, patient give 100mg labetalol, with repeat BP
106/53.
ROS:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain.
Denies headache, sinus tenderness, rhinorrhea or congestion.
Denies cough. Denies palpitations. Denies nausea, vomiting,
diarrhea, constipation or abdominal pain. No recent change in
bowel or bladder habits. No bloody bowel movements. No dysuria.
Denies arthralgias or myalgias.
Past Medical History:
OSA
HTN
HLD
NIDDM
?COPD
Depression s/p ECT in ___
Alcohol abuse
Social History:
___
Family History:
Grandparent had 2 strokes. Grandfather had DM 1.
Physical Exam:
Admission Exam:
Vital Signs: 98.2 PO, 178 / 102, 72, 21, 95 RA
General: Alert, oriented, visibly anxious, no acute distress,
obese
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL,
neck supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Decreased breath sounds throughout entire left lung.
Clear to auscultation on right, 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, 2+ pulses, no clubbing, cyanosis or
edema. Left calf larger than right calf. Deformity of right
foot.
Neuro: CNII-XII intact, ___ strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally. Slight limp
with walking, which is baseline.
Discharge Exam:
VITALS: 98.1, 114 / 64, 64, 22, 94 CPAP
General: Alert, oriented, no acute distress, obese
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL,
neck supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally (previously decreased
breath sounds on left); 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, 2+ pulses, no clubbing, cyanosis or
edema. Left calf larger than right calf (baseline). Deformity of
R foot.
Neuro: CNII-XII intact, ___ strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally. Gait not
assessed.
Pertinent Results:
Admission Labs:
___ 05:41PM BLOOD WBC-7.8 RBC-4.09* Hgb-12.7* Hct-36.3*
MCV-89 MCH-31.1 MCHC-35.0 RDW-14.8 RDWSD-47.4* Plt ___
___ 05:41PM BLOOD Neuts-67.2 Lymphs-13.4* Monos-16.2*
Eos-2.3 Baso-0.5 Im ___ AbsNeut-5.22 AbsLymp-1.04*
AbsMono-1.26* AbsEos-0.18 AbsBaso-0.04
___ 05:41PM BLOOD ___ PTT-25.9 ___
___ 05:41PM BLOOD Glucose-114* UreaN-11 Creat-0.9 Na-139
K-3.7 Cl-103 HCO3-25 AnGap-15
___ 05:41PM BLOOD cTropnT-<0.01
___ 12:30PM BLOOD CK-MB-2 cTropnT-<0.01
___ 05:41PM BLOOD proBNP-980*
___ 12:30PM BLOOD Calcium-8.9 Phos-3.7 Mg-2.1 Iron-PND
___ 05:41PM BLOOD D-Dimer-4095*
___ 05:41PM BLOOD VitB12-335
___ 05:41PM BLOOD TSH-1.0
___ 05:49PM BLOOD Lactate-1.1
Discharge Labs:
___ 07:54AM BLOOD WBC-5.6 RBC-3.89* Hgb-12.0* Hct-35.0*
MCV-90 MCH-30.8 MCHC-34.3 RDW-14.6 RDWSD-46.8* Plt ___
___ 07:54AM BLOOD ___ PTT-31.7 ___
___ 07:54AM BLOOD Glucose-101* UreaN-10 Creat-0.9 Na-140
K-3.9 Cl-103 HCO3-23 AnGap-18
___ 07:54AM BLOOD Calcium-8.6 Phos-4.5 Mg-2.2
Imaging:
CXR:
IMPRESSION:
Mild pulmonary vascular congestion and small left pleural
effusion. Patchy opacities in lung bases may reflect areas of
atelectasis, though infection cannot be completely excluded in
the correct clinical setting.
CTA Chest:
FINDINGS:
Included portions of the thyroid gland enhance homogeneously.
No supraclavicular, axillary or mediastinal lymphadenopathy by
size criteria. Scattered mediastinal lymph nodes measure up to
7 mm in the left prevascular station. There is a 14 mm hilar
lymph node on the right(3:99), likely reactive.
Heart is normal in size, without a pericardial effusion. Left
ventricular myocardium appears thickened. Coronary
calcifications are noted. Thoracic aorta is normal in course and
caliber with no evidence for dissection or intramural hematoma.
Main pulmonary trunk is dilated, measuring up to 3.9 cm in
diameter (3:78), suggestive of pulmonary arterial hypertension.
There are extensive segmental and subsegmental pulmonary emboli
involving all pulmonary arterial branches. On the left, there
is central extension of clot burden into the left main pulmonary
artery (3:80). There is no evidence of right heart strain.
Airways are patent to the segmental bronchi bilaterally.
Scattered parenchymal abnormalities are noted. Several
wedge-shaped peripheral opacities in the right lower lobe and
left lower lobe likely represent small pulmonary infarcts
(02:59, 74, 79). There is a 5 mm mixed attenuation nodule in
the right middle lobe (3:88). Several additional opacities are
nonspecific and may represent an underlying inflammatory process
; for instance, there is a lobulated 1.1 x 0.8 cm perifissural
opacity in the inferior right upper lobe (3:99) and an
additional 0.7 cm nodular opacity in the posterior segment of
the right upper lobe (3:67).
Small pleural effusion on the left. No pleural effusion on the
right. No pneumothorax.
Limited images of the upper abdomen reveals a diffusely
hypoattenuating liver, suggestive of hepatic steatosis.
No fractures are identified. Degenerative changes throughout
the thoracic spine. There is a 1.4 cm skin lesion extending
into the subcutaneous fat along the central upper back (3:61),
which may represent a sebaceous cyst.
IMPRESSION:
1. Extensive bilateral segmental and subsegmental pulmonary
emboli, with central extension into the left main pulmonary
artery.
2. Dilatation of the main pulmonary artery however no evidence
of right heart strain.
3. Bilateral scattered wedge-shaped peripheral parenchymal
opacities, suspicious for pulmonary infarcts. Additional
parenchymal opacities in the right upper lobe are of unclear
etiology and may represent nonspecific inflammation. A
follow-up chest CT in 3 months is recommended to evaluate
resolution.
4. 5 mm mixed attenuation nodule in the right middle lobe, which
could also be re-evaluated at time of follow-up.
5. Prominent right hilar lymph node is likely reactive.
6. Small left pleural effusion.
7. Hepatic steatosis.
8. 1.4 cm superficial skin/subcutaneous lesion along the central
upper back, may represent a sebaceous cyst.
RECOMMENDATION(S): Chest CT in 3 months.
Cardiac Echo:
The left atrial volume index is mildly increased. No atrial
septal defect or patent foramen ovale is seen by 2D, color
Doppler or saline contrast with maneuvers. There is mild
symmetric left ventricular hypertrophy. The left ventricular
cavity size is top normal/borderline dilated. Overall left
ventricular systolic function is normal (LVEF>55%). Tissue
Doppler imaging suggests a normal left ventricular filling
pressure (PCWP<12mmHg). The right ventricular cavity is mildly
dilated with moderate global free wall hypokinesis. The aortic
valve leaflets (3) are mildly thickened but aortic stenosis is
not present. No aortic regurgitation is seen. The mitral valve
leaflets are structurally normal. Trivial mitral regurgitation
is seen. The pulmonary artery systolic pressure could not be
determined. There is no pericardial effusion.
IMPRESSION: Suboptimal image quality. Mild right ventricular
cavity dilatation with moderate global hypokinesis. Mild
symmetric left ventricular hypertrophy with borderline dilated
cavity size and preserved systolic function. No cardiac source
of embolism identified.
___:
IMPRESSION:
No evidence of deep venous thrombosis in the right or left lower
extremity
veins.
Carotid U/S:
IMPRESSION:
Mild atherosclerotic plaque with bilateral ___ ICA stenosis.
Antegrade
vertebral flow.
Brief Hospital Course:
___ yo man with h/o OSA, HTN, HLD, NIDDM, depression s/p ECT in
___, alcohol abuse (last drink >1 week ago), recently
discharged from ___ for detox, who presented with
SOB for the past 4 days.
#Pulmonary embolism: patient had CTA chest notable for
submassive PE (extensive bilateral segmental and subsegmental
pulmonary emboli, with central extension into the left main
pulmonary artery). He was normotensive to hypertensive in the
ED. Troponins and CKMB negative x2. BNP 980 although no prior.
EKG showed flipped T-waves in anterior leads; RBBB at baseline
(seen since ___. He had ___ dopplers that were negative for DVT
bilaterally. He had a TTE with bubble study which was limited
due to body habitus but showed mild right ventricular cavity
dilatation with moderate global hypokinesis. PA was unable to be
adequately visualized. Given this RV finding, his case was
reviewed with ___ (PE/thrombolysis team) and he will follow
up as an outpatient. He remained normotensive, minimally
symptomatic with mild DOE, and was satting well on RA. With
exertion, he was noted to desat to 91% intermittently but
improved spontaneously. He was initially treated with
therapeutic lovenox before being transitioned to Xarelto for a
planned ___t minimum. The etiology of his PE is
unclear. He was noted to have a 5 mm pulmonary nodule on CT
chest which will require follow up in 3 months to rule out
malignancy. Patient was made aware and results of this CT
communicated to PCP. He has no prior colonoscopy to r/o GI
malignancy. No family history of coagulopathy. No recent
immobilization. He has multiple comorbidities, including
obesity, OSA, HTN, HLD, DM which may have contributed to PE.
#HTN: was hypertensive to 170s-180s multiple times this
admission; he was maintained on his home lisinopril (30 mg) and
PO labetalol PRN; he is being discharged on lisinopril 40 mg.
#Anemia: found to have normocytic anemia with lab studies
notable for normal RDW, low iron, low TIBC, normal ferritin
(although in setting of PE), normal B12, normal TSH. Labs more
consistent with anemia of chronic disease, although difficult to
interpret ferritin in setting of acute illness. Transferrin
saturation is low at ~13% which can be seen with iron deficiency
and/or ACD. Patient should have further work up including
colonoscopy as above.
#?TIA Hx: he had a recent admission at ___ for a TIA
(left AMA). Given this, he had carotid U/S done that showed mild
atherosclerotic plaque with bilateral ___ ICA stenosis. Bubble
study was done with TTE but study was too limited by body
habitus to definitively rule out PFO. He is planned for follow
up with neurology per prior admission at ___.
CHRONIC ISSUES:
#Depression: continued on his home regimen.
#DM: home metformin was held; managed on sliding scale without
issue.
#?COPD: continued on his home regimen.
#OSA: continued with home CPAP machine.
#HLD: increased from 20 to 40 mg QD given concern for
comorbidities such as HLD contributing to PE
TRANSITIONAL ISSUES
- Please repeat CT chest in 3 months (approx. ___ to
evaluate 5 mm lung nodule to rule out malignancy
- Please do screening colonoscopy given concern for malignancy
provoking PE
- Please continue rivaroxaban for at least 6 months for
unprovoked PE (patient discharged on 15 mg BID x21 days to be
followed by 20 mg daily x6 months at least)
- Patient will follow up with ___ (PE team) as an outpatient
- Please consider heme/onc consult as outpatient for other
etiology of PE if other work up unrevealing
- Please ensure follow up with neurology given recent history of
TIA (pt seen at ___); was planned for MRI but was unable to
fit in scanner due to body habitus. If possible to obtain open
MRI, please arrange given h/o ?TIA.
- Patient's home atorvastatin increased to 40 mg qHS
- Patient's home lisinopril increased to 40 mg QD given
persistently hypertensive to 150s systolic
- Full code
- CONTACT: Saw (wife) ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. MetFORMIN (Glucophage) 1000 mg PO DAILY
2. Dulera (mometasone-formoterol) 100-5 mcg/actuation inhalation
DAILY
3. OXcarbazepine 2400 mg PO QHS
4. Escitalopram Oxalate 30 mg PO DAILY
5. TraZODone 50-200 mg PO QHS:PRN insomnia
6. Atorvastatin 20 mg PO QAM
7. Lisinopril 30 mg PO DAILY
8. TEGretol XR (carBAMazepine) 100 mg oral DAILY
Discharge Medications:
1. Atorvastatin 40 mg PO QPM
RX *atorvastatin 40 mg 1 tablet(s) by mouth qPM Disp #*30 Tablet
Refills:*0
2. Rivaroxaban 15 mg PO BID PE Duration: 21 Days
with food
RX *rivaroxaban [___] 15 mg (42)- 20 mg (9) 1 tablets(s) by
mouth BID for 21 days then daily Disp #*1 Dose Pack Refills:*0
3. Lisinopril 40 mg PO DAILY
RX *lisinopril 40 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
4. Dulera (mometasone-formoterol) 100-5 mcg/actuation
inhalation DAILY
5. Escitalopram Oxalate 30 mg PO DAILY
6. MetFORMIN (Glucophage) 1000 mg PO DAILY
7. OXcarbazepine 2400 mg PO QHS
8. TEGretol XR (carBAMazepine) 100 mg ORAL DAILY
9. TraZODone 50-200 mg PO QHS:PRN insomnia
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Pulmonary embolism: Extensive bilateral segmental and
subsegmental pulmonary emboli, with central extension into the
left main pulmonary artery.
Secondary:
OSA
HTN
HLD
NIDDM
depression s/p ECT
etOH abuse
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
We have cared for you in the hospital for the blood clots in
your lungs. Fortunately, your clinical status is stable and we
have started you on a blood thinner for the blood clots. It is
unclear at this point why you had the blood clots, but we have
arranged for a number of tests to be done in conjunction with
your PCP as an outpatient. You will need to have a colonoscopy
as soon as possible. Please also have a CT scan of your chest to
evaluate for a lung nodule in 3months (approx. ___. Your
medication changes are as follows: rivaroxaban 15 mg twice a day
with meals (for the first 21 days and this will be changed to 20
mg once a day afterwards); atorvastatin from 20 to 40 mg, and
lisinopril from 30 to 40 mg. The length of your rivaroxaban
treatment will depend on your improvement but will most likely
be at least 6 months. Please return to be evaluated immediately
if you develop worsening shortness of breath, chest pain,
increasing warmth, redness or pain in your legs, or any other
severely concerning symptoms.
We have greatly appreciated taking part in your care.
Best wishes,
___ Care Team
Followup Instructions:
___
|
19711968-DS-15
| 19,711,968 | 29,512,884 |
DS
| 15 |
2154-03-13 00:00:00
|
2154-03-13 18:43:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Alcohol withdrawal
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ yo M pt w/ hx of ETOH abuse presenting to the emergency
department for evaluation of alcohol intoxication.
The patient reported going through hard social situations and
job problems leading to increase drinking. He can drink up to 2
bottles.
His last drink was on morning of the day of presentation. He
complained of symptoms of headache, blurry vision, ataxia and
inability to coordinate his hand. He has had prior episodes of
alcohol withdrawal, but mentioned that none are this severe.
The patient was brought by EMS. He was found very unsteady on
his feet. The patient gave history of frequent falls but no head
strike. He has multiple bruises on them. He has a history of PE
in the past but is no longer on anticoagulation. He was
previously on Xarelto.
The patient also mentioned that he presented to an OSH ED for
detox. However, there were no beds available and hence he
returned back home to drink.
In the ED
=============
Initial vitals: 98.6 151 134/74 24 97% RA
The patient triggered on arrival for tachycardia to 150's. Was
given 2 L NS bolus and started on dilt IV and PO. Due to
uncontrolled HR, he was started on dilt ggt with slight
improvement especially when dilt was given with ___.
On exam he is very slurred speech and has multiple bruising on
all of his extremities but has now midline C-spine or L or
T-spine tenderness palpation. He also has no bony pain/ttp in
the extremities.
Labs were significant for
14.3 MCV= 88
11.4>------<141
41.2
143 96 14 AGap=27**
------------< 166
4.4 20 1.0
Ca: 8.7 Mg: 1.5 P: 2.3
ALT: 59 AP: 90 Tbili: 0.9 Alb: 4.3
AST: 98 Lip: 71
Serum EtOH 402
Serum ASA, Acetmnphn, ___, Tricyc Negative
UA: positive for protein, Bact, prot.
Imaging showed
CT head: No acute intracranial process.
CXR: No acute cardiopulmonary process.
The patient received:
a total of 180 mg IV dilt
a total of 60 mg PO dilt
started on a dilt ggt
given 2+1 L of IVF
Diazepam ___ hours apart to control his symptoms.
The patient was shifted to the ICU. In the ICU, the patient was
anxious and tremulous and unable to fit stabily. He also is
thirsty. He is alert to place and time and person. smells of
EtOH.
Past Medical History:
OSA
HTN
HLD
NIDDM
?COPD
Depression s/p ECT in ___
Alcohol abuse
Bipolar
History of PE with completion of 7 month of anticoagulation with
rivaroxiban
Social History:
___
Family History:
Grandparent had 2 strokes. Grandfather had DM 1.
Physical Exam:
Admission physical exam
VS: Reviewed in MetaVision and notable for tachycardia from
Aflutter with 2:1 conduction
GEN: Alert, lying in bed, no acute distress
HEENT: Moist MM, crusty blood around the edge of the mouth.
Anicteric sclerae, no conjunctival pallor. PERRLA, EOMI.
NECK: Supple without LAD
PULM: full air entry bilaterally, no crackle. no wheeze. no
rhonchi
HEART: RRR (+)S1/S2 no m/r/g
ABD: Soft, distended with fat, tender in the right lower quad on
deep palpatoin. No rebound/guarding. BS+
EXTREM: Warm, well-perfused, no edema
NEURO: CN II-XII intact, strength ___ in b/l ___, SLIT
Discharge physical exam
Vitals: 97.7 124/82 93 20 95 RA
GEN: Sleeping with CPAP machine, lying in bed, no acute distress
HEENT: Moist. Anicteric sclerae, no conjunctival pallor. PERRLA,
EOMI.
NECK: Supple without LAD
PULM: CTAB without increased WOB
HEART: RRR (+)S1/S2 no m/r/g
ABD: Soft, obese. No rebound/guarding. BS+
EXTREM: Warm, well-perfused, no edema
NEURO: Grossly moving all extremities
Pertinent Results:
Admission labs:
===================
___ 06:27PM URINE HOURS-RANDOM
___ 06:27PM URINE UHOLD-HOLD
___ 06:27PM URINE COLOR-Straw APPEAR-Clear SP ___
___ 06:27PM URINE BLOOD-SM* NITRITE-NEG PROTEIN-TR*
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
___ 06:27PM URINE RBC-<1 WBC-<1 BACTERIA-FEW* YEAST-NONE
EPI-0
___ 03:27PM GLUCOSE-166* UREA N-14 CREAT-1.0 SODIUM-143
POTASSIUM-4.4 CHLORIDE-96 TOTAL CO2-20* ANION GAP-27*
___ 03:27PM estGFR-Using this
___ 03:27PM ALT(SGPT)-59* AST(SGOT)-98* ALK PHOS-90 TOT
BILI-0.9
___ 03:27PM LIPASE-71*
___ 03:27PM ALBUMIN-4.3 CALCIUM-8.7 PHOSPHATE-2.3*
MAGNESIUM-1.5*
___ 03:27PM ASA-NEG ___ ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
___ 03:27PM WBC-11.4* RBC-4.68 HGB-14.3 HCT-41.2 MCV-88
MCH-30.6 MCHC-34.7 RDW-15.2 RDWSD-48.3*
___ 03:27PM NEUTS-79.8* LYMPHS-11.6* MONOS-6.4 EOS-0.7*
BASOS-1.1* IM ___ AbsNeut-9.07* AbsLymp-1.32 AbsMono-0.73
AbsEos-0.08 AbsBaso-0.12*
___ 03:27PM PLT COUNT-141*
Imaging tests:
=======================================
___: CT head: No acute intracranial process.
___: CXR: No acute cardiopulmonary process.
___: Echo: The left atrium is mildly dilated. No atrial
septal defect is seen by 2D or color Doppler. There is moderate
symmetric left ventricular hypertrophy. The left ventricular
cavity size is normal. Regional left ventricular wall motion is
normal. Overall left ventricular systolic function is normal
(LVEF>55%). There is considerable beat-to-beat variability of
the left ventricular ejection fraction due to an irregular
rhythm/premature beats. Tissue Doppler imaging suggests a normal
left ventricular filling pressure (PCWP<12mmHg). The right
ventricular cavity is mildly dilated with normal free wall
contractility. The aortic root is mildly dilated at the sinus
level. The ascending aorta is mildly dilated. The aortic valve
leaflets (3) appear structurally normal with good leaflet
excursion and no aortic stenosis or aortic regurgitation. The
mitral valve leaflets are structurally normal. Mild (1+) mitral
regurgitation is seen. The estimated pulmonary artery systolic
pressure is normal. There is no pericardial effusion.
IMPRESSION: Suboptimal image quality. Moderate symmetric left
ventricular hypertrophy with preserved left ventricular systolic
function in the setting of beat-to-beat variability. Mildly
dilated, normally functioning right ventricle. Mildly dilated
aortic root and ascending aorta. Mild mitral regurgitation.
___: RUQUS: 1. Markedly echogenic liver consistent with
severe steatosis. Other forms of liver disease including
steatohepatitis, hepatic fibrosis, or cirrhosis cannot be
excluded on the basis of this examination. No focal liver
lesions are identified.
2. No ascites or splenomegaly.
3. Views of the kidneys show bilateral pelvocaliectasis, which
is most likely related to the markedly distended urinary
bladder.
Microbiology:
===============
___ URINE CULTURE (Final ___: < 10,000 CFU/mL.
Discharge labs:
===============
___ 07:45AM BLOOD WBC-6.2 RBC-4.00* Hgb-12.3* Hct-35.3*
MCV-88 MCH-30.8 MCHC-34.8 RDW-15.9* RDWSD-49.5* Plt Ct-88*
___ 06:18AM BLOOD Glucose-84 UreaN-12 Creat-0.8 Na-140
K-3.4 Cl-101 HCO3-26 AnGap-13
___ 05:20AM BLOOD ALT-34 AST-26 AlkPhos-86 TotBili-0.8
___ 06:18AM BLOOD Mg-2.0
___ 07:03PM BLOOD Hapto-89
___ 05:20AM BLOOD VitB12-419 Folate-9
___ 07:03PM BLOOD HBsAg-NEG HBsAb-NEG HBcAb-NEG
___ 07:03PM BLOOD HIV Ab-NEG
Brief Hospital Course:
Summary
___ with history of DM, HTN, bipolar II, h/o PE (not on
anticoagulation), EtOH abuse who presented with symptoms of
alcohol withdrawal, found to be in Aflutter with RVR. He was
treated with phenobarbital taper and his withdrawal improved. He
spontaneously converted to sinus rhythm with diltiazem rate
control and was discharged with a holter monitor.
# ATRIAL FLUTTER
Improved with diltiazem and he converted to NSR on ___. Suspect
a provoked event iso withdrawal. He was initiated on
anticoagulation however discontinued due to low plt count and
low chads-vasc score (1). TTE was without evidence of
significant structural heart disease. He was discharged on
diltiazem ER 120mg daily. Anticoagulation was held for now and
he was discharged with a 48 hour holter monitor. He will follow
with his PCP this week.
# ALCOHOL WITHDRAWAL
# ALCOHOL USE DISORDER
Was drinking 2 litres of vodka per day. Symptoms markedly
improved with phenobarbital taper. He was counseled extensively
abstaining from alcohol in the future.
# ___ TEAR
I/s/o retching and vomiting. Did not require any transfusion and
improved with supportive care.
# THROMBOCYTOPENIA
Suspect secondary to alcohol and underlying liver disease. 4T
score was low, and there was no concern for HIT. Heme onc was
consulted and felt this was likely due to etoh and liver
disease. Plt on discharge were 88,000. He will followup with
heme as outpatient.
# BIPOLAR II DISORDER
Continued home divalproex.
# DEPRESSION
Continued home vortioxetene.
# HTN.
Continued home Lisinopril, amlodipine. Home HCTZ was held iso
starting diltiazem and can be restarted if he is hypertensive as
an outpatient.
# T2DM
Continued home metformin.
# OSA
Continue home CPAP.
# HLD
Continue home Atorvastatin 40mg qhs.
Transitional issues
- Started on diltiazem ER 120mg for rate control in case patient
goes back into afib or flutter. Would titrate as outpatient
pending heart rates.
- HCTZ was held in setting of well controlled BPs on diltiazem
and other home regimen.
- Was sent with 48H Holter monitor and off anticoagulation. Will
see PCP this week and consider AC if he has other episodes of
flutter or fib.
- Will follow in clinic with PCP and hematology (for
thrombocytopenia).
Next of Kin: ___
Relationship: SISTER
Phone: ___
# CODE STATUS: full (presumed)
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lisinopril 40 mg PO DAILY
2. MetFORMIN (Glucophage) 1000 mg PO DAILY
3. Atorvastatin 40 mg PO QPM
4. BusPIRone 20 mg PO BID
5. amLODIPine 10 mg PO DAILY
6. Trintellix (vortioxetine) 20 mg oral DAILY
7. Pantoprazole 40 mg PO Q24H
8. Hydrochlorothiazide 25 mg PO DAILY
9. Divalproex (EXTended Release) 1500 mg PO DAILY
Discharge Medications:
1. Diltiazem Extended-Release 120 mg PO DAILY
RX *diltiazem HCl 120 mg 1 capsule(s) by mouth daily Disp #*30
Capsule Refills:*0
2. amLODIPine 10 mg PO DAILY
3. Atorvastatin 40 mg PO QPM
4. BusPIRone 20 mg PO BID
5. Divalproex (EXTended Release) 1500 mg PO DAILY
6. Lisinopril 40 mg PO DAILY
7. MetFORMIN (Glucophage) 1000 mg PO DAILY
8. Pantoprazole 40 mg PO Q24H
9. Trintellix (vortioxetine) 20 mg oral DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Etoh withdrawal
Atrial flutter
Secondary:
Thrombocytopenia
Bipolar disorder
HTN
T2DM
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You came to ___ due to alcohol withdrawal and we found you to
have an abnormal heart rate. This improved with medication,
however it is essential to avoid alcohol in the future. Please
take the medication we have prescribed and follow with your
outpatient doctors.
It was a pleasure taking care of you,
Your ___ medical team
Followup Instructions:
___
|
19711968-DS-17
| 19,711,968 | 24,032,758 |
DS
| 17 |
2155-10-03 00:00:00
|
2155-10-02 15:39:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Alcohol Withdrawal
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Patient reports he has been drinking heavily this week. Last
drink ___ at 11a. Reports he was suicidal today, planning to
cut
himself with a kitchen knife. Reports he last thought about
killing himself in ___, when he walking up to a roof and
thought about jumping while sober. Reports history of alcohol
withdrawal seizure. Suicidal thoughts in setting of his
girlfriend breaking up with him 2 days ago. Denies violent
thoughts or hallucinations. Vomiting earlier today. Intermittent
diarrhea. Denies fever, chills, chest pain, shortness of breath,
change in bladder function, change in vision or hearing,
bruising, adenopathy, new rash or lesion.
Per initial psych note, was brought to the ED by EMS after he
called ___ reporting SI in the setting of alcohol intoxication.
Psychiatry is consulted for safety assessment. On approach,
patient is laying down in bed in NAD. When asked he states that
he feels "still drunk". BAL 3 hours prior to interview was 329.
Patient was notably slurring some words during encounter. He
stated that he called ___ tonight because he was having SI with
thoughts of cutting himself. "I was holding the knife up like
this" to his wrist. He reports that he feels his depression is
"out of control" and would like to seek more treatment for it.
He
denies HI. He reports feeling tremulous and like he is entering
alcohol withdrawal.
In the ED,
- Initial Vitals: 98.4, HR 70, BP 151/66, 95% RA, RR 16
- Exam: AOx3, smells of alcohol, NAD, suicidal ideation with
plan
- Labs: Na 146, K 3.6, Cr 0.9, BUN 13, HCO3 24, serum EtOH 329,
serum ASA, tylenol, TCA negative; WBC 6.6, Hgb 15.6, Plt 169,
- Imaging: None
- Consults: None
- Interventions: CIWA protocol (diazepam 20mgx2, 10mgx6;
lorazepam 2mgx2) phenobarbital 650mg, Zofran 4mg, 1L NS,
diltiazem 10mg x2
ROS: Positives as per HPI; otherwise negative.
Past Medical History:
1. CARDIAC RISK FACTORS
- Diabetes
- Hypertension
- Dyslipidemia
-TIA in ___ ___ ___ (left AMA)
2. CARDIAC HISTORY
- Atrial flutter
3. OTHER PAST MEDICAL HISTORY
- bipolar disorder type 2
- Unprovoked PE in ___ (extensive bilateral segmental and
subsegmental
pulmonary emboli, with central extension into the left main
pulmonary artery) previously on anticoagulation with Xarelto for
7
months
- Obesity
- OSA
- Depression requiring ECT in the past
- EtOH abuse
Social History:
___
Family History:
Father CABG in his ___.
Physical Exam:
ADMISSION PHYSICAL EXAM
========================
VS: reviewed in metavision
GENERAL: somnolent but arousable, clear thought and logic
HEENT: short neck, MMM
CARDIAC: RR, tachycardic, no MRG
LUNGS: CTAB, no wheezes, rales or ronchi
ABDOMEN: soft, nt, BS+
EXTREMITIES: no lower extremity edema, pulses ___ 2+
NEUROLOGIC: no clonus, moves all 4 extremities with purpose,
face
symmetric, CN II-XII grossly intact, insightful
DISCHARGE PHYSICAL EXAM
===========================
___ ___ Temp: 97.6 PO BP: 117/77 R Lying HR: 59 RR: 18 O2
sat: 99% O2 delivery: Cpap FSBG: 95
General: obese, lying in bed, CPAP in place but easily
arousable.
HEENT: OP moist, no LAD appreciated, face symmetric
Resp CTA B, no rales, wheezes anteriorly. Normal respiratory
effort
CV RRR without murmurs, distant heart sounds
GI soft, NT, ND, NABS
MS: no edema
Back with tenderness in area of right upper buttock.
Neuro: alert/oriented X3, moves comfortably in bed. No tremor
Psych: Appropriate
Pertinent Results:
ADMISSION LABS
=================
___ 08:12PM BLOOD WBC-6.6 RBC-5.10 Hgb-15.6 Hct-44.0 MCV-86
MCH-30.6 MCHC-35.5 RDW-15.3 RDWSD-46.0 Plt ___
___ 08:12PM BLOOD Neuts-51.2 ___ Monos-9.7 Eos-1.8
Baso-1.4* Im ___ AbsNeut-3.39 AbsLymp-2.35 AbsMono-0.64
AbsEos-0.12 AbsBaso-0.09*
___ 08:00PM BLOOD ___ PTT-25.8 ___
___ 08:12PM BLOOD Glucose-146* UreaN-13 Creat-0.9 Na-146
K-3.6 Cl-101 HCO3-24 AnGap-21*
___ 08:12PM BLOOD ASA-NEG ___ Acetmnp-NEG
Tricycl-NEG
___ 11:40PM URINE bnzodzp-POS* barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG oxycodn-NEG mthdone-NEG
INTERVAL LABS
================
___ 02:58PM BLOOD D-Dimer-1427*
___ 02:58PM BLOOD ALT-28 AST-29 LD(LDH)-259* AlkPhos-76
TotBili-1.7*
___ 08:00PM BLOOD ALT-26 AST-24 LD(LDH)-235 AlkPhos-78
TotBili-1.8*
___ 04:04AM BLOOD ALT-22 AST-19 LD(LDH)-206 AlkPhos-73
TotBili-1.3
___ 04:04AM BLOOD Albumin-3.6 Calcium-8.3* Phos-3.7 Mg-2.3
___ 01:08AM BLOOD %HbA1c-5.9 eAG-123
___ 04:04AM BLOOD TSH-5.2*
___ 04:04AM BLOOD Free T4-1.3
DISCHARGE LABS
================
___ 05:38AM BLOOD WBC-5.5 RBC-4.48* Hgb-13.8 Hct-39.8*
MCV-89 MCH-30.8 MCHC-34.7 RDW-16.1* RDWSD-50.8* Plt ___
___ 05:38AM BLOOD Glucose-104* UreaN-12 Creat-0.9 Na-139
K-3.5 Cl-101 HCO3-23 ___
MICRO
=======
N/A
PERTINENT IMAGING/STUDIES
===========================
___ CTA CHEST
FINDINGS:
CHEST PERIMETER: No thyroid findings require any further imaging
evaluation.
Supraclavicular and axillary lymph nodes are not enlarged. No
soft tissue
abnormalities in the chest wall.
This study is not appropriate for subdiaphragmatic diagnosis but
shows no
adrenal mass or subphrenic collection. Steatosis of the liver
is severe.
CARDIO-MEDIASTINUM: Esophagus is unremarkable. Atherosclerotic
calcification is not apparent head neck vessels, but is
scattered in at least left anterior descending coronary artery.
Aorta is normal size and the lumen is intact.
Dilatation of the main pulmonary artery, 35 mm, has improved
since ___, previously 39 mm, when the patient had multiple
pulmonary emboli. Left atrium is newly enlarged, 51 mm in
transverse diameter, previously 38 mm. Right ventricle is not
enlarged. Cardiac evaluation would require echocardiography.
PULMONARY ARTERIES:
Main, right, left, and lobar pulmonary arteries are normal.
Right and left descending pulmonary arteries are normal.
Because of severe respiratory motion, small filling defects are
impossible to separate from motion artifacts in the lower lobes.
Even if present one would not expect these to have much
clinical impact.
THORACIC LYMPH NODES: No lymph nodes in the chest are
pathologically enlarged.
LUNGS, AIRWAYS, PLEURAE: Lungs are grossly clear.
Tracheobronchial tree is
normal to subsegmental levels and there is no pleural effusion
or other
pleural abnormality.
CHEST CAGE:
No evidence of malignancy or infection. No compression
fracture.
IMPRESSION:
No pulmonary emboli in major pulmonary vessels. Subsegmental
emboli not
excluded in the lower lobes because of motion artifact.
Previous pulmonary artery dilatation has improved.
New left atrial enlargement. No pulmonary edema.
Echocardiography
recommended.
Upper extremity ultrasound ___:
1. No evidence of deep vein thrombosis in the right upper
extremity.
2. Short segment thrombosed superficial vein in the area of
patient reported
swelling is compatible with superficial thrombophlebitis.
Brief Hospital Course:
Brief ICU course:
___ y.o w/ EtOH use disorder c/b withdrawal/hallucinations,
bipolar disorder type 2, prior PE in ___ s/p 7mo AC with
xarelto, atrial flutter, HTN/dyslipidemia, T2DM, depression, and
OSA who presents with alcohol intoxication and suicidal
ideation, now with alcoholwithdrawal, admitted to ___ for
high-risk withdrawal, then transferred to floor on 1:1 sitter to
await psychiatry placement.
ACUTE ISSUES
=======================
#Alcohol withdrawal
#Alcohol use disorder
At ED, received multiple doses of Diazepam per CIWA protocol,
and was escalated to ICU withdrawal protocol, receiving 650mg
phenobarbital (10mg/kg) loading dose prior to transfer to ICU.
He developed atrial flutter (HR 140-150s) in setting of
withdrawal, although HDS, and started and titrated to diltiazem
45mg TID with reversion to normal sinus rhythm while at the ICU.
Withdrawal symptoms were minimal after phenobarbital loading
dose, so he did not receive additional dosage. He received
clonidine for adrenergic hyperactivity. Transferred to floor as
patient was >24h post-phenobarbital, and stable.
Last drink on ___ at 11am. Has prior history of seizures and
atrial fibrillation in ___ i/s/o withdrawal. Initially, BAL 329
and tremulous. Received diazepam per CIWA protocol, and
transitioned to ICU withdrawal protocol for high-risk
withdrawal. Phenobarb loaded in the ED and transferred to the
ICU, where he received clonidine for adrenergic hyperactivity.
No evidence of acute alcoholic hepatitis. He also received
thiamine 500mg IV TID for 3 days during phenobarbital, followed
by 200mg IV daily. His clonidine was tapered to 1 patch on
___, and should be stopped completely on ___.
#Suicidal ideation
Active SI with plan to use knife to cut wrists. Reports past
suicide attempt in ___ where he overdosed on lorazepam with
alcohol, waking up 3d later. Initially on ___, however as
he became sober he had no more SI. Psychiatry was consulted and
recommended inpatient psychiatry.
#Atrial fibrillation with RVR
Has known history of aflutter. He was tachycardic to 150 BMP,
but hemodynamically stable. Per medication filling history, is
written for diltiazem 120mg ER. At ED, he received diltiazem
10mg x2, but patient remained in afib. He eventually broke his
tachycardia with 45 mg diltiazem TID. ___ 2 (T2DM, HTN),
currently not on AC. Had previously been on Xarelto for 7 months
for unprovoked PE in ___. At last hospitalization at ___,
___, AC was held given high-risk EtOH use (risk of falls).
D-dimer 1427 at ED and CTA negative ruling out PE. He was
stable on diltiazem 120 mg po daily. Anticoagulation was
discussed, but he declined and will discuss with his pcp.
#Superficial thrombophlebitis
He noted some erythema and tenderness posterior to his right arm
and the location of prior IV. Ultrasound confirmed a
superficial thrombosis in this area. He had no air fever at
this point. Despite prior history of DVT this is likely a
provoked small superficial clot. He was started on ibuprofen
for pain management and inflammation and cold packs. This
should be continued at discharge. If he develops fevers or
chills or tracking erythema, would start antibiotics for MRSA
coverage given hospital-associated development - either Bactrim
or clindamycin.
CHRONIC ISSUES
=======================
#HTN
Initially held home lisinopril 40mg QD and amlodipine 10mg given
afib+RVR. Restarted lisinopril 20 mg po daily, but still
hypertensive. Because of the clonidine for alcohol withdrawal,
he did not require amlodipine 10 mg po daily. Lisinopril 40 was
started at discharge, and amlodipine should be restarted on
___, and clonidine stopped on ___.
#DM
Placed on ISS
#CAD
Continued home ASA 81mg and atorvastatin 40mg QPM
# Type II diabetes mellitus
Resumed home metformin at discharge.
TRANSITIONAL ISSUES
====================
Anticoagulation for atrial fibrillation, balancing fall risk and
kickboxing, should be discussed with pcp.
Hypertension: amlodipine held at dc. Should be restarted on
___, prior to dc of clonidine on ___.
Left atrial enlargement: consider outpatient echo.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. FoLIC Acid 1 mg PO DAILY
3. Multivitamins W/minerals 1 TAB PO DAILY
4. Thiamine 100 mg PO DAILY
5. Atorvastatin 40 mg PO QPM
6. Lisinopril 40 mg PO DAILY
7. MetFORMIN (Glucophage) 1000 mg PO DAILY
8. amLODIPine 10 mg PO DAILY
9. QUEtiapine Fumarate 100 mg PO QHS:PRN insomnia
10. Venlafaxine XR 150 mg PO DAILY
11. Mirtazapine 7.5 mg PO QHS
12. HydrOXYzine 25 mg PO Q4H:PRN anxiety
13. Gabapentin 300 mg PO TID
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
2. Clonidine Patch 0.1 mg/24 hr 1 PTCH TD QTUES Duration: 3
Days
Remove on ___. Diltiazem Extended-Release 120 mg PO DAILY
4. Ibuprofen 400 mg PO Q8H Duration: 5 Days
5. Aspirin 81 mg PO DAILY
6. Atorvastatin 40 mg PO QPM
7. FoLIC Acid 1 mg PO DAILY
8. HydrOXYzine 25 mg PO Q4H:PRN anxiety
9. Lisinopril 40 mg PO DAILY
10. MetFORMIN (Glucophage) 1000 mg PO DAILY
11. Mirtazapine 7.5 mg PO QHS
12. Multivitamins W/minerals 1 TAB PO DAILY
13. QUEtiapine Fumarate 100 mg PO QHS:PRN insomnia
14. Thiamine 100 mg PO DAILY
15. HELD- amLODIPine 10 mg PO DAILY This medication was held.
Do not restart amLODIPine until advised by your pcp
___:
Extended Care
Discharge Diagnosis:
PRIMARY DIAGNOSIS
===================
Alcohol use disorder
SECONDARY DIAGNOSES
====================
Bipolar disorder with suicidal ideation
Atrial fibrillation
Obstructive sleep apnea
Diabetes mellitus, type II
Hypertension
Discharge Condition:
tolerating diet.
Discharge Instructions:
Dear Mr ___,
It was a pleasure taking care of you at the ___
___.
Why did you come to the hospital?
-You came to the hospital because you were withdrawing from
alcohol, and you are having thoughts of killing yourself.
What happened while you were in the hospital?
-You were given medications to prevent side effects from
withdrawing from alcohol, like seizures.
-You met with the psychiatry team, and they recommended
inpatient psychiatry treatment.
- You developed a superficial clot in your right arm, where
there was an IV.
What should you do once you leave the hospital?
- You should not drink alcohol anymore.
-If you are having thoughts of hurting herself or killing
yourself, he should reach out to your doctor, ___, or
friends. There are also numbers that you can call, likely a
suicide prevention hotline (___).
- Please take your medications as prescribed and go to your
future appointments which are listed below.
- take ibuprofen for 5 days for the thrombophlebitis
- remove the clonidine patch in 3 days
We wish you all the best!
- Your ___ Care Team
Followup Instructions:
___
|
19712053-DS-10
| 19,712,053 | 26,290,291 |
DS
| 10 |
2114-08-04 00:00:00
|
2114-08-04 17:42:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
___
Attending: ___
Chief Complaint:
BRBPR
Major Surgical or Invasive Procedure:
___ EGD with Small Bowel Enteroscopy
___ Colonoscopy
History of Present Illness:
Mr. ___ is a ___ year old man with a past medical history of
hypertension, DM2, recent admission with GI bleed secondary to
duodenal ulcer vs. small bowel diverticular bleed who presents
with bright red blood per rectum.
The patient was admitted to ___ from ___ after transfer
from ___ for GI bleed. He reported ___ weeks of melenic
stools. He then stopped eating for a week and presented to the
ED with lightheadedness. He was transferred from ___ for
consideration of ___ procedure after EGD at ___ on ___ did
not show a clear etiology for bleed. His Hb remained 7.2-8.7 at
___. Creatinine was 1.9 on admission. Lactate 3.9. He had
a tagged RBC scan with active GI bleed in the region of small
bowel diverticula of the left portion of the abdomen.
At ___, a CTA was performed that showed small bowel
diverticulosis without active extravasation. GI was consulted
and underwent endoscopy that showed a 1 cm duodenal ulcer with
active arterial bleed in the bulb which was treated with 4 clips
and epinephrine. He was placed on BID IV PPI for 72 hours
post-proceure and discharged with PO PPI. Discharge Hb 7.4
His course was complicated by RUE DVT after PICC line placement.
He was placed on heparin IV for 48 hours with stable Hb in the
___ range and was discharged on apixaban (10mg BID for 7 days to
complete ___ then 5mg BID on ___.
The patient was discharge to rehab on ___. At rehab he developed
multiple episodes of bright red stool beginning the morning of
___. He was given 500cc NS before arrival. In the ED he denied
chest pain, nausea, vomiting, shortness of breath. he had mild
abdominal discomfort.
In ED initial VS:
T 98.7 HR 81 BP 101/57 RR 16 SaO2 98% RA
Labs significant for:
Hb 5
Lactate 2
Cr 1.8
INR 2.6
Patient was given:
40mg IV pantoprazole
Consults: GI
VS prior to transfer:
T 97.7 HR 68 BP ___ RR 16 SaO2 100% RA
On arrival to the MICU, the patient confirms the above. He is
not having lightheadedness, shortness of breath, chest pain,
abdominal pain, nausea, vomiting.
REVIEW OF SYSTEMS: 10 point review of systems negative except
as noted above.
Past Medical History:
RUE ___ associated DVT ___
Upper GI Bleed with Duodenal ulcer ___
Hypertension
Diverticulosis with small bowel diverticula
Diabetes
Obesity
Social History:
___
Family History:
Mother with lung cancer.
Physical Exam:
ADMISSION PHYSICAL EXAM
=======================
VITALS: Reviewed in metavision
GENERAL: Alert and in no apparent distress
EYES: Anicteric, pupils equally round
ENT: Ears and nose without visible erythema, masses, or trauma.
Oropharynx without visible lesion, erythema or exudate
CV: Heart regular, no murmur
RESP: Lungs clear to auscultation with good air movement
bilaterally. Breathing is non-labored
GI: Abdomen soft, non-distended, non-tender to palpation. Bowel
sounds present. No HSM
GU: No suprapubic fullness or tenderness to palpation
MSK: Neck supple, moves all extremities. RUE swelling.
PSYCH: pleasant, appropriate affect
NEUROLOGIC: Moves all extremities.
MENTATION: alert and cooperative. Oriented to person and place
and time.
DISCHARGE PHYSICAL EXAM
=========================
___ 0811 Temp: 98.1 PO BP: 120/66 L Sitting HR: 66 RR: 18
O2
sat: 92% O2 delivery: Ra FSBG: 142
GENERAL: NAD
HEENT: AT/NC, PERRL, anicteric sclera, pink conjunctiva
NECK: supple, difficult to appreciate JVP due to habitus
HEART: RRR, nl S1/S2, no murmurs
LUNGS: CTAB no wheezing rales or ronchi
ABDOMEN: Obese, soft, nontender, nondistended, no rebound or
guarding
EXTREMITIES: WWP, trace edema bilaterally to thighs, wrinkles
present at ankles. No edema in b/l UE.
Pertinent Results:
ADMISSION LABS
===============
___ 12:45PM BLOOD WBC-6.1 RBC-1.62* Hgb-5.1* Hct-16.1*
MCV-99* MCH-31.5 MCHC-31.7* RDW-18.8* RDWSD-68.7* Plt ___
___ 12:45PM BLOOD Neuts-76.2* Lymphs-10.1* Monos-10.1
Eos-1.3 Baso-0.2 NRBC-0.3* Im ___ AbsNeut-4.61
AbsLymp-0.61* AbsMono-0.61 AbsEos-0.08 AbsBaso-0.01
___ 12:59PM BLOOD ___ PTT-31.7 ___
___ 12:59PM BLOOD ___ 12:59PM BLOOD Glucose-171* UreaN-50* Creat-1.8* Na-131*
K-5.7* Cl-103 HCO3-20* AnGap-8*
___ 04:50PM BLOOD ALT-11 AST-25 AlkPhos-87 TotBili-0.5
___ 12:59PM BLOOD cTropnT-<0.01
___ 12:59PM BLOOD Calcium-7.7* Phos-3.7 Mg-1.7
___ 05:04PM BLOOD ___ pO2-32* pCO2-38 pH-7.34*
calTCO2-21 Base XS--5
___ 01:23PM BLOOD Lactate-2.0 Na-130* K-3.9
DISCHARGE LABS
===================
___ 06:05AM BLOOD WBC-3.6* RBC-2.64* Hgb-8.1* Hct-25.4*
MCV-96 MCH-30.7 MCHC-31.9* RDW-17.1* RDWSD-59.6* Plt ___
___ 06:05AM BLOOD Glucose-107* UreaN-12 Creat-1.2 Na-140
K-4.5 Cl-103 HCO3-24 AnGap-13
___ 06:05AM BLOOD Calcium-8.3* Phos-3.5 Mg-1.7
NOTABLE LABS
=============
___ 03:00AM BLOOD WBC-4.7 RBC-2.26* Hgb-6.8* Hct-20.9*
MCV-93 MCH-30.1 MCHC-32.5 RDW-17.8* RDWSD-59.8* Plt ___
___ 04:19AM BLOOD ___ PTT-29.0 ___
___ 04:19AM BLOOD Ret Aut-3.1* Abs Ret-0.07
___ 04:19AM BLOOD Glucose-159* UreaN-20 Creat-0.8 Na-140
K-3.7 Cl-104 HCO3-21* AnGap-15
MICROBIOLOGY
===================
__________________________________________________________
___ 9:30 am BLOOD CULTURE Source: Venipuncture.
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
__________________________________________________________
___ 1:11 pm BLOOD CULTURE Source: Line-tlcl.
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
__________________________________________________________
___ 9:42 am BLOOD CULTURE Source: Line-tlcl #2.
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
IMAGING
========
___ CXR
The tip of an endotracheal tube projects 3.7 cm from the carina.
The right internal jugular central venous catheter tip projects
over the mid SVC. There is moderate pulmonary edema. Bibasilar
opacities, left greater than right likely reflect atelectasis.
The small to moderate left pleural effusion is also suspected.
No pneumothorax. The size of the cardiac silhouette is enlarged
but unchanged.
___ EGD with Small Bowel Enteroscopy
Normal esophagus. Normal stomach. Previous ulcer with 2 clips in
place noted in the duodenum with no evidence of active bleeding.
2mm Polyp in ___ part of duodenum just opposite the ampulla.
Multiple diverticula of various sizes (small and large) were
noted in the examined portion of the jejunum. There was no
evidence of bleeding.
___ (PORTABLE AP) IMPRESSION:
ET tube tip is 5 cm above the carinal. NG tube is in the
proximal stomach and might be further advanced. Assessment is
slightly limited due to motion artifact but there is impression
of minimal improvement in vascular congestion and still present
left pleural effusion. There is also most likely new left lower
lobe atelectasis with left mediastinal shift.
___ (PORTABLE AP) IMPRESSION:
Right internal jugular line tip is at the level of superior SVC.
Heart size and mediastinum are stable. Right perihilar opacity
and right basal consolidation are unchanged, concerning for
infection. No appreciable pneumothorax is seen. Left basal
consolidation has improved.
___ Report
CONCLUSION:
The left atrium is mildly dilated. The right atrium is
moderately enlarged. There is mild symmetric left ventricular
hypertrophy with a mildly increased/dilated cavity. There is
suboptimal image quality to assess regional left ventricular
function. Global left ventricular systolic function is at least
mildly depressed. The visually estimated left ventricular
ejection fraction is 45%. There is no resting left ventricular
outflow tract gradient. Moderately dilated right ventricular
cavity with depressed free wall motion. There is abnormal
interventricular septal motion c/w right ventricular pressure
and volume overload. The aortic sinus is mildly dilated with
mildly dilated ascending aorta. There is a mildly dilated
descending aorta. The aortic valve leaflets (3) are mildly
thickened. There is no aortic valve stenosis. There is no aortic
regurgitation. The mitral leaflets
are mildly thickened. There is no mitral valve stenosis. There
is trivial mitral regurgitation. There is no pericardial
effusion. Moderate pulmonary hypertension
IMPRESSION: Suboptimal image quality. At least mild
biventricular contractile dysfunction. Tricuspid regurgitation
is present but could not be quantified with certainty and may be
significant. At least moderate pulmonary hypertension.
___ UP EXT VEINS US IMPRESSION:
No evidence of deep vein thrombosis in the bilateral upper
extremities.
Previously seen DVT and superficial thrombophlebitis have
resolved.
___ Colonoscopy
Normal mucosa in the whole colon and 10cm into the terminal
ileum. Mild diverticulosis of the ascending colon and sigmoid
colon. There were two small polyps <5mm in the transverse colon
and at the tattoo site. These were not removed given this
colonoscopy was done for evaluation of obscure overt GIB. Tattoo
next to the 1cm submucosal lesion was noted. Submucosal lesion
had normal ovelrying mucosa with no ulceration or stigmata of
bleeding. Internal hemorrhoids. External hemorrjoids.
Brief Hospital Course:
___ w/ PMHx of HTN, DM2, recent admission with GI bleed ___
duodenal ulcer vs small bowel diverticuli course c/b
PICC-associated RUE DVT who p/w BRBPR found to have hypotension
likely caused by acute blood loss anemia also found to have
volume overload in setting of new diastolic heart failure.
# New Diagnosis Diastolic Heart Failure: Pt presented with
symptoms of orthopnea, ___ edema, BNP >14K c/f CHF. TTE showed EF
45% with mild biventricular systolic dysfunction, moderate
pulmonary HTN. Patient received IV Lasix diuresis with good
urine output response and significant symptom improvement.
Patient discharged on 40mg PO furosemide BID.
# GIB: Recent upper GI bleed secondary to duodenal ulcer that
was visualized on EGD and treated with clips and epi on ___.
Presented this admission with anemia (Hb 5) in setting of
starting anticoagulation for precipitated RUE DVT. Patient
received total of 6U pRBC and 2 U FFP for admission HgB 5 and
hypotension thought secondary to acute blood loss. S/p EGD ___
and colonoscopy ___ without evidence of bleeding source. Likely
bleeding was due to jejunal diverticulosis. No further episodes
of BRBPR and Hb stable during admission. Patient was started on
BID PPI, to continue for ___ weeks. Afterwards, he will need
daily PPI as he is also on ASA daily.
CHRONIC/RESOLVED ISSUES
======================
# Pneumonia: Pt presented with cough. CXR w/ RLL infiltrate and
leukopenia concerning for PNA. S/p levofloxacin (___). No
further cough.
# Right upper extremity DVT: Provoked partially occlusive R
brachial vein thrombus and occlusive right cephalic vein
thrombus diagnosed at OSH in setting of PICC line placement. Pt
was started on apixiban at that time; likely contributed GIB.
Given distal location in UE, improving R arm swelling and GIB
withholding further anticoagulation. Repeat UE US (___) shows
no evidence of deep vein thrombosis in the bilateral upper
extremities.
# T2DM: Last Hgb A1c 4.0% on ___. On metformin, glipizide,
pioglitazone at home. Received insulin sliding scale during
hospitalization with good blood sugar control. Home glipizide
and pioglitazone held on discharge
# HTN: On losartan, amlodipine, metoprolol at home. Was on HCTZ
and recently stopped. Home metoprolol succinate 100 mg QD was
restarted and home dose of losartan was decreased from 100mg QD
to 50 mg QD in setting of soft BP. Home amlodipine 10 mg QD was
held in setting of soft BP.
# ___, resolved
Creatinine 1.8 admission with discharge creatinine 0.9. Etiology
likely pre-renal in the setting of acute blood loss and
hypotension. Improved w/ blood transfusion.
TRANSITIONAL ISSUES:
===================
[] Please continue to monitor blood pressure. Restart amlodipine
and/or increase losartan back to 100 mg QD pending BP
[] Will need BID PPI for ___ weeks, then if taking ASA will
need daily PPI for life after initial ___ weeks of bid
[] Needs outpatient sleep study
[] Nighttime O2 at rehab
[] Discharge on Lasix 40 mg PO BID. If weight increases or
decreases by 3 lbs call notify MD immediately. ___ need
adjustment of PO Lasix regimen.
[] Please obtain daily standing weight and daily monitor fluid
status
[] Repeat CBC and serum chemistries ___.
[] Discharge weight 153.9kg/ 339.29 lbs
[] Discharge creatinine 1.2
[] Dischage Hemoglobin 8.1 Hematocrit 25.4.
[] Metformin restarted at d/c. Home glipizide and pioglitazoe
given low insulin requirements and HbA1c 4% in ___. f/u with
managing physician for ongoing diabetes management
[] Repeat CXR in 6 weeks to ensure resolution of pneumonia
[] If ongoing or recurrent overt GI bleeding, could consider
capsule endoscopy as next step for evaluation (patient has
signficant jejunal diverticulosis and capsule endoscopy could
suggest if these are the source of his overt bleeding)
[] If general health allows, outpatient colonoscopy for removal
of polyps could be considered. Polyps are small and
non-worrisome
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. amLODIPine 10 mg PO DAILY
2. Losartan Potassium 100 mg PO DAILY
3. Metoprolol Succinate XL 100 mg PO DAILY
4. Bisacodyl 10 mg PO/PR DAILY:PRN constipation
5. Docusate Sodium 100 mg PO BID
6. Milk of Magnesia 30 mL PO Q6H:PRN constipation
7. Pantoprazole 40 mg PO Q12H
8. Senna 8.6 mg PO BID
9. Apixaban 5 mg PO BID
10. Aspirin 81 mg PO DAILY
11. GlipiZIDE XL 5 mg PO DAILY
12. MetFORMIN (Glucophage) 1000 mg PO BID
13. Pioglitazone 45 mg PO DAILY
Discharge Medications:
1. Furosemide 40 mg PO BID
2. Losartan Potassium 50 mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. Bisacodyl 10 mg PO/PR DAILY:PRN constipation
5. Docusate Sodium 100 mg PO BID
6. MetFORMIN (Glucophage) 1000 mg PO BID
7. Metoprolol Succinate XL 100 mg PO DAILY
8. Milk of Magnesia 30 mL PO Q6H:PRN constipation
9. Pantoprazole 40 mg PO Q12H
10. Senna 8.6 mg PO BID
11. HELD- amLODIPine 10 mg PO DAILY This medication was held.
Do not restart amLODIPine until OK by your PCP
12. HELD- GlipiZIDE XL 5 mg PO DAILY This medication was held.
Do not restart GlipiZIDE XL until OK by your PCP
13. HELD- Pioglitazone 45 mg PO DAILY This medication was held.
Do not restart Pioglitazone until OK by your PCP
___:
Extended Care
Facility:
___
Discharge Diagnosis:
Diastolic heart failure
Acute GI bleed
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 Mr. ___,
It was a pleasure caring for you at ___.
WHY WAS I IN THE HOSPITAL?
- You were here because you were bleeding and your blood
pressure was dangerously low.
WHAT HAPPENED TO ME IN THE HOSPITAL?
- You received medications to treat a pneumonia.
- You underwent endoscopy to look for active sites of bleeding,
and we found none.
- You received blood transfusions.
- You received medications to decrease extra fluid build-up in
your body.
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
- Continue to take all your medicines and keep your
appointments.
- Please check your weight daily and call MD if your weight
increases or decreases by 3 lbs.
- New medication: furosemide 40mg twice daily.
- New medication: pantoprazole 40mg twice daily. Take this twice
daily for the next ___ weeks then once daily afterwards.
- Changed medication: Losartan 50mg daily (decreased from your
home dose of 100mg daily).
We wish you the best!
Sincerely,
Your ___ Team
Followup Instructions:
___
|
19712371-DS-4
| 19,712,371 | 25,686,052 |
DS
| 4 |
2116-05-16 00:00:00
|
2116-05-17 13:56:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
hydrochlorothiazide / Milk of Magnesia
Attending: ___.
Chief Complaint:
___ weakness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ year old right-handed woman with PMH of
obesity, OSA on CPAP, HTN, hypercalcemia, breast cancer (treated
___, cervical cancer (remote, treated at ___,
anemia, schizophrenia presents with 4 months of worsening lower
extremity weakness. She was sent to ED for evaluation for MRI
and
evaluation for possible myelopathy.
She had worsening left shoulder pain in ___ when she was
admitted to ___ for evaluation. She was discharged in ___ to ___. Patient says that when she left
the
hospital she was no longer able to walk. She had been using
rollator/ walker for about a year. In rehab, she could not walk
even with a walker and felt generalized fatigue. Now she lives
at
___.
She feels that her arms are weak as well and was weak before the
legs. She attributes upper extremity weakness to a previous fall
which caused pain/soreness. Pain is especially bad in her left
shoulder and she does not move her left arm much as a result.
The
weakness gradually worsened and two weeks ago she could not move
her legs at all. Previously, she couldn't walk but could still
lift them up. Now she cannot even turn in bed.
She also complains about numbness in both hands described has
"like one big blister" on her hands and fingers. This has made
it
more difficult for her to open a bag of chips or a box of
cookies. Denies parathesias.
Patient has had long standing urinary incontinence since ___.
She wears diapers for this. No bowel incontince. She complains
of
constipation and says it is difficult to have bowel movements.
She also has a longstanding history of chronic back pain and
spinal disease on imaging.
She reports dysuria.
Past Medical History:
ANEMIA
OBSTRUCTIVE SLEEP APNEA
HYPERTENSION
SCHIZOPHRENIA
HYPERCALCEMIA
OSTEOARTHRITIS
BACK PAIN
H/O BREAST CANCER
- treated at ___ ___ - s/p AI therapy completed ___
H/O CERVICAL CANCER
- per report remote - treated at ___
Social History:
Country of Origin: U.___.
Marital status: Widowed
Children: Yes: 1 daughter, ___
Lives with: Other: ___
Lives in: Group Setting
Tobacco use: Never smoker
Alcohol use: Denies
Recreational drugs Denies
Comments: Her daughter ___, ___.
- ___ Rankin Scale:
[] 0: No symptoms
[] 1: No significant disability - able to carry out all usual
activities despite some symptoms
[] 2: Slight disability: able to look after own affairs without
assistance but unable to carry out all previous activities
[] 3: Moderate disability: requires some help but able to walk
unassisted
[] 4: Moderately severe disability: unable to attend to own
bodily needs without assistance and unable to walk unassisted
[x] 5: Severe disability: requires constant nursing care and
attention, bedridden, incontinent
[] 6: Dead
Family History:
Sister - ___
Sister - breast cancer
Brother - stroke, heart attack
Brother - stroke
Physical ___:
Vitals: T:98 HR:83 BP:148/83 RR:16 SaO2:100% RA
General: Awake, cooperative, obese elderly woman, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx.
Neck: Supple. No nuchal rigidity.
Pulmonary: Normal work of breathing.
Cardiac: RRR, warm, well-perfused.
Abdomen: Soft, non-distended.
Extremities: No ___ edema.
Skin: No rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented to self, ___, ___. Able
to relate history though not clearly. Attentive, can do DOWb.
Language is fluent with intact repetition and comprehension.
Normal prosody. There were no paraphasic errors. Able to name
both high and low frequency objects. Mild dysarthria/hoarseness.
Able to follow both midline and appendicular commands. There was
no evidence of apraxia or neglect.
-Cranial Nerves:
II, III, IV, VI: PERRL 1.5 to 1mm 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.
-Motor: Flaccid at the knees and hips. Rest and intention
tremor
in b/l UE and RLE.
[Delt][Bi] Tri ECR FE [___]
L 4* 5-* 5 4+* 4* ___ 0 0 4 5 4* 4
R 4+ 5 5 4* 4* ___ 0 1 4 5 4* 4
*pain limited
**+Hoover's sign when testing R IP, but negative on L IP.
-Sensory: No deficits to light touch, pinprick, temperature
throughout. No paraspinal numbness to pinprick along back.
Decreased vibration in both great toes, present but decreased.
Joint position sense intact in b/l toes.
-Reflexes: Negative jaw jerk. Negative ___.
[Bic] [Tri] [___] [Pat] [Ach]
L 2 2 2 0 0
R 2 2 2 0 0
Plantar response was withdrawal bilaterally.
-Coordination: rest tremor intention tremor. No dysmetria on
FNF
on RUE
-Gait: unable to ambulate
DISCHARGE
General examination:
General: Comfortable and in no distress
Head: No irritation/exudate from eyes, nose, throat
Cardio: Regular rate and rhythm, warm
Lungs: Unlabored breathing
Abdomen: Soft, non tender, non distended
Neurologic examination:
Mental status:
Ms. ___ is awake and pleasant. She can hold a normal
conversation. No errors in speech.
Cranial nerves:
EOMI. Face symmetric. No dysarthria. Shoulders sit
symmetrically.
Motor:
Ms. ___ has frequent involuntary movement of her tongue,
fingers, and toes. There is atrophy of the intrinsic muscles of
the hands. Ms. ___ has no pronator drift of the right arm,
but
cannot perform testing of the left arm because of pain limited
proximal weakness. There is evidence of muscle activation at
the
hip flexor muscles on both sides with some subtle movement
within
plan of bed. This is also true for her hip abduction muscles.
Her hip adduction muscles are strong and her legs cannot be
spread. Her quadriceps, tibialis anterior, and gastrocnemius
strength are symmetric and in the ___ range.
Pertinent Results:
___ 03:12PM BLOOD WBC-5.8 RBC-3.64* Hgb-11.1* Hct-34.3
MCV-94 MCH-30.5 MCHC-32.4 RDW-14.2 RDWSD-48.7* Plt ___
___ 03:12PM BLOOD Neuts-52.6 ___ Monos-8.1 Eos-1.2
Baso-0.3 Im ___ AbsNeut-3.05 AbsLymp-2.18 AbsMono-0.47
AbsEos-0.07 AbsBaso-0.02
___ 03:12PM BLOOD ___ PTT-30.8 ___
___ 03:12PM BLOOD Glucose-92 UreaN-12 Creat-0.6 Na-140
K-4.1 Cl-102 HCO3-29 AnGap-9*
___ 07:11AM BLOOD Calcium-10.4* Phos-3.2 Mg-1.6 Cholest-166
___ 07:11AM BLOOD VitB12-454
___ 07:11AM BLOOD %HbA1c-4.5 eAG-82
___ 07:11AM BLOOD Triglyc-49 HDL-77 CHOL/HD-2.2 LDLcalc-79
___ 07:11AM BLOOD TSH-2.3
___ 07:11AM BLOOD CRP-6.8*
___ 12:55PM URINE RBC-<1 WBC-10* Bacteri-MOD* Yeast-NONE
Epi-<1 TransE-<1
___ 12:55PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-SM*
___ 12:55PM URINE Color-Yellow Appear-Hazy* Sp ___
___ 12:55 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
___ Imaging MRI CERVICAL, THORACIC,
1. Multilevel cervical degenerative disease, as detailed above,
with complete fusion of C4 and C5 vertebral bodies and kyphotic
angulation centered at C4-C5. Spinal canal stenosis is
moderate at C3-C4 with spinal cord remodeling, mild-to-moderate
at C4-C5, and mild at C5-C6 and C6-C7. Evaluation of cervical
cord signal is limited by artifact; mild cord edema or
myelomalacia at C3-C4 cannot be excluded.
2. Chronic T9 vertebral body fracture. Mild multilevel thoracic
degenerative
disease without significant spinal canal narrowing. No thoracic
spinal cord
signal abnormalities.
3. Extensive multilevel lumbar degenerative disease, as detailed
above. Mild
narrowing of the thecal sac without significant intrathecal
nerve root
crowding. Mass effect on multiple exiting and traversing nerve
roots, as
detailed above.
4. No evidence for pathologic contrast enhancement.
Brief Hospital Course:
Ms. ___ is a ___ year old right handed woman with PMH most
pertinent for cervical spondylosis, schizophrenia, tardive
dyskinesia secondary to long standing antipsychotic use,
obstructive sleep apnea, and chronic pain who we are assessing
for bilateral lower extremity weakness with no ability to walk.
Neurologic examination is pertinent for frequent, involuntary
movements of tongue, fingers, toes consistent with known history
of tardive dyskinesia. Pain limited weakness of the left arm.
She has bilateral leg weakness with the hip flexors and hip
abductors being most prominently affected. She can provide
resistance but is symmetrically weak at hamstrings, quadriceps,
tibialis anterior, and gastrocnemius. She has proprioceptive
loss in the toes. Ms. ___ has hyporeflexia in the ankles,
patella, and brachioradialis, but normal reflexes in biceps and
triceps.
MRI CTL spine showed cervical spine disease that is most
pronounced where there is narrowing of the canal at C3/C4 and
C5/6 with possible cord tightening. Her lumbar spine does not
look to have narrowing of the canal, but there is extensive
disease throughout as the nerve roots exit the spinal canal.
Additionally there is moderate thoracic and lumbar degenerative
change with diffuse neuroforaminal narrowing.
Her inability to walk is multifactorial, with possible
contributions from obesity, deconditioning, pain, effort,
cervical spine disease, lumbar spine disease and likely
peripheral neuropathy. Based on her neurologic examination and
imaging, I favor that her leg weakness neurologically is most
driven from peripheral neuropathy (lumbar root disease and
length dependent neuropathy). We have low suspicion for a
chronic inflammatory demyelinating process, but this could be
evaluated with an outpatient EMG.
Additionally, the patient complains of chronic left shoulder
pain and paresthesias. She did not find any relief with the
lidocaine patch. We continued her home regimen of gabapentin 300
mg 3 times daily. We will send her for referral with chronic
pain management in the outpatient setting.
For her obstructive sleep apnea, she was continued on her home
CPAP at bedtime.
TRANSITIONAL ISSUES
-Suspicion for an inflammatory demyelinating polyneuropathy is
low. However, this can be evaluated with an outpatient EMG. Her
symptoms are chronic and do not appear to be rapidly
progressing.
-Referred to chronic pain management for left shoulder pain.
-Follow-up with ___.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. amLODIPine 10 mg PO DAILY
2. Atorvastatin 10 mg PO QPM
3. Enalapril Maleate 10 mg PO QHS
4. Meclizine 25 mg PO Q8H:PRN vertigo
5. Pantoprazole 40 mg PO Q24H
6. RisperiDONE 4 mg PO QHS
7. TraMADol 25 mg PO Q6H:PRN Pain - Moderate
8. TraZODone 50 mg PO QHS:PRN insomnia
9. Acetaminophen 500 mg PO BID:PRN Pain - Mild/Fever
10. Aspirin 81 mg PO DAILY
11. Vitamin D 1000 UNIT PO DAILY
12. Docusate Sodium 100 mg PO BID
13. Senna 8.6 mg PO BID:PRN Constipation - First Line
14. Gabapentin 300 mg PO TID
15. Perphenazine 4 mg PO TID
16. Venlafaxine XR 75 mg PO DAILY
Discharge Medications:
1. Acetaminophen 500 mg PO BID:PRN Pain - Mild/Fever
2. amLODIPine 10 mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. Atorvastatin 10 mg PO QPM
5. Docusate Sodium 100 mg PO BID
6. Enalapril Maleate 10 mg PO QHS
7. Gabapentin 300 mg PO TID
8. Meclizine 25 mg PO Q8H:PRN vertigo
9. Pantoprazole 40 mg PO Q24H
10. Perphenazine 4 mg PO TID
11. RisperiDONE 4 mg PO QHS
12. Senna 8.6 mg PO BID:PRN Constipation - First Line
13. TraMADol 25 mg PO Q6H:PRN Pain - Moderate
14. TraZODone 50 mg PO QHS:PRN insomnia
15. Venlafaxine XR 75 mg PO DAILY
16. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
___ Diagnosis:
Cervical, thoracic, and lumbar degenerative spine disease
Polyneuropathy
Chronic pain of the left shoulder
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Ms. ___,
You came into the hospital because you were having trouble
walking. We did imaging of your back that did not show any
sudden change that would require urgent treatment.
When you leave the hospital you should:
- Take all of your medications as prescribed.
- Attend all scheduled clinic appointments.
- Follow-up with a spine doctor to see if there is any role for
surgery.
- Follow-up with pain clinic for your shoulder.
It was a pleasure taking care of you,
Your ___ Care Team
Followup Instructions:
___
|
19712454-DS-24
| 19,712,454 | 21,996,141 |
DS
| 24 |
2157-05-06 00:00:00
|
2157-05-07 16:04:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
Syncope and fall
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with h/o afib on Warfarin, T2DM, HLD, HTN, and prostate
cancer presents to the ED s/p fall. He reports that he was in
the kitchen on his way to the bathroom when he fell suddenly,
without prodrome. When he came to, he found that he had been
incontinent of his bowels. It took him a long time to get up,
and when he tried to, he hit his head on the stove. He does not
remember
falling, and this has never happened to him before. He denies
any headache, vision changes, chest pain, SOB, palpitations,
abdominal pain, N&V, or changes in bowel habits. He denies any
extremity weakness or numbness/tingling.
Past Medical History:
ATRIAL FIBRILLATION
COLONIC POLYPS
DIABETES TYPE II
HYPERCHOLESTEROLEMIA
HYPERTENSION
OSTEOARTHRITIS
h/o prostate cancer s/p seed implant ___ (pt unable to confirm)
h/o thigh hematoma while on anti-coagulation
Past Surgical History
appendectomy
umbilical hernia repar and R hemicolectomy for 6
cm cecal adenoma (no invasion);
___ Dr. ___
___ incisional hernia repair bilateral component,
separation panniculectomy and lysis of adhesions;
___. ___ repair by component
separation; panniculectomy.
Social History:
___
Family History:
(per chart, confirmed with pt):
Son with heart problem, specifics unknown
Physical Exam:
ADMISSION PHYSICAL:
===================
VS: T 98.5 HR 60 BP 145 / 72 RR 18 SAT 95% O2 on RA
GENERAL: Pleasant, lying in bed comfortably
HEENT: large ecchymosis on back of head.
CARDIAC: RRR, III/VI SEM with radiation to the carotids.
LUNG: Mild respiratory distress, lungs clear to auscultation
bilaterally, no crackles, wheezes, or rhonchi
ABD: Normal bowel sounds, soft, nontender, nondistended, no
hepatomegaly, no splenomegaly
EXT: Warm, well perfused, trace lower extremity edema
PULSES: 2+ radial pulses, 2+ ___ pulses, 2+ DP pulses
NEURO: Alert, oriented x3, CN II-XII intact, motor and sensory
function grossly intact. No dysmmetria, no dysdiadochokinesia.
SKIN: No rashes
DISCHARGE PHYSICAL:
===================
VS: 24 HR Data (last updated ___ @ 1218)
Temp: 97.3 (Tm 98.5), BP: 102/65 (102-136/65-74), HR: 64
(61-65), RR: 18 (___), O2 sat: 97% (93-97), O2 delivery: Ra,
Wt: 213.8 lb/96.98 kg
GENERAL: Pleasant, sitting in bed, in no acute distress.
CARDIAC: Regular rate and rhythm. Grade ___ harsh systolic
murmur
heard loudest at right second intercostal space, radiates to the
carotids.
LUNG: Clear to auscultation bilaterally. No crackles, wheezes,
or
rhonchi.
ABD: Soft, nontender, nondistended. No hepatomegaly, no
splenomegaly
EXT: Warm, well perfused. 2+ pitting edema bilaterally to shins.
PULSES: 2+ pedal and radial pulses bilaterally
NEURO: AAOx3. Motor and sensory function grossly intact.
Pertinent Results:
ADMISSION LABS:
===============
___ 06:43AM cTropnT-0.02*
___ 02:45AM GLUCOSE-202* UREA N-32* CREAT-1.2 SODIUM-140
POTASSIUM-5.1 CHLORIDE-99 TOTAL CO2-23 ANION GAP-18
___ 02:45AM estGFR-Using this
___ 02:45AM ALT(SGPT)-27 AST(SGOT)-35 CK(CPK)-252 ALK
PHOS-51 TOT BILI-0.5
___ 02:45AM LIPASE-60
___ 02:45AM cTropnT-0.03*
___ 02:45AM ALBUMIN-4.2 CALCIUM-9.7 PHOSPHATE-2.8
MAGNESIUM-1.8
___ 02:45AM DIGOXIN-1.2
___ 02:45AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
tricyclic-NEG
___ 02:45AM WBC-10.1* RBC-4.27* HGB-13.0* HCT-38.5*
MCV-90 MCH-30.4 MCHC-33.8 RDW-13.9 RDWSD-44.7
___ 02:45AM NEUTS-74.6* LYMPHS-10.8* MONOS-12.7 EOS-0.1*
BASOS-0.1 IM ___ AbsNeut-7.51* AbsLymp-1.09* AbsMono-1.28*
AbsEos-0.01* AbsBaso-0.01
___ 02:45AM PLT COUNT-118*
___ 02:45AM ___ PTT-30.7 ___
PERTINENT LABS:
===============
___ 05:29AM BLOOD ___ PTT-28.1 ___
DISCHARGE LABS:
===============
___ 06:18AM BLOOD WBC-6.7 RBC-4.04* Hgb-12.3* Hct-37.0*
MCV-92 MCH-30.4 MCHC-33.2 RDW-14.0 RDWSD-46.5* Plt ___
___ 06:18AM BLOOD Glucose-167* UreaN-25* Creat-1.0 Na-141
K-3.9 Cl-99 HCO3-27 AnGap-15
IMAGING/DIAGNOSTICS:
====================
___
EXAMINATION: CT C-SPINE W/O CONTRAST Q311 CT SPINE
IMPRESSION:
1. No acute fractures or traumatic malalignment.
2. Moderate cervical spondylosis with multilevel
mild-to-moderate vertebral canal narrowing and severe neural
foraminal stenosis, particularly at the left C3-C4 and C5-C6
levels.
3. 1 cm nodule in the right lobe of the thyroid is unchanged
from prior exam.
___
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
IMPRESSION:
1. No acute intracranial abnormalities on noncontrast head CT.
Specifically no intracranial hemorrhage or large territory
infarct.
2. Bilateral chronic lacunar infarcts.
3. 6 mm thick left occipital scalp hematoma without acute
displaced calvarial fracture.
___
EXAMINATION: TRANSTHORACIC ECHO
CONCLUSION:
The left atrial volume index is SEVERELY increased. The right
atrium is mildly enlarged. There is mild symmetric left
ventricular hypertrophy with a normal cavity size. There is
normal regional and global left ventricular systolic function.
Quantitative biplane left ventricular ejection fraction is 72 %.
There is no resting left ventricular outflow tract gradient.
Tissue Doppler suggests a normal left ventricular filling
pressure (PCWP
less than 12mmHg). 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 are
moderately thickened. There is moderate aortic valve stenosis
(valve area 1.0-1.5 cm2). There is no aortic regurgitation. The
mitral
valve leaflets appear structurally normal with no mitral valve
prolapse. There is mild [1+] mitral regurgitation. The tricuspid
valve leaflets appear structurally normal. There is physiologic
tricuspid regurgitation. There is mild pulmonary artery systolic
hypertension. There is no pericardial effusion.
IMPRESSION:
Suboptimal image quality. Moderate aortic valve stenosis. Mild
symmetric left ventricular hypertrophy with normal cavity size
and regional/global biventricular systolic function. Mild mitral
regurgitation. Mild pulmonary artery systolic hypertension.
Compared with the prior TTE (images reviewed) of ___, the
severity of aortic stenosis is now increased.
MICROBIOLOGY: None
Brief Hospital Course:
___ M with PMH of atrial fibrillation on Coumadin admitted for
syncope and fall, of uncertain etiology but suspected due to
moderate aortic stenosis vs orthostatic hypotension vs
arrhythmia.
ACUTE ISSUES:
=============
#Syncope
Pt was monitored on telemetry for ~48 hours which did not reveal
any arrhythmia. For further evaluation of any arrhythmias, he
was fitted with ___ Hearts cardiac monitor. A
transthoracic echo was performed, and showed moderate aortic
stenosis. Pt had mild orthostatic hypotension upon evaluation by
physical therapy. Digoxin was discontinued given possibility of
contributing to arrhythmia.
#Atrial fibrillation
Pt had subtherapeutic INR during hospitalization. Warfarin dose
was increased while inpatient for goal INR ___. Pt to continue
regular home dose at discharge. Digoxin was discontinued and
patient was rate-controlled with metoprolol without any evidence
of atrial fibrillation.
CHRONIC ISSUES:
===============
#T2DM: Held home metformin while inpatient. Pt to resume home
metformin on discharge.
#Depression: Continued home citalopram
#HLD: Continued home statin
#HTN: Continued home lisinopril
TRANSITIONAL ISSUES:
====================
# Aortic Stenosis:
- Moderate by TTE criteria. Follow up with cardiologist.
#Syncope:
-Patient is being sent home with ___ of Hearts cardiac event
monitor. He should follow up with his PCP and his new
cardiologist for evaluation of any arrhythmias.
#Atrial Fibrillation:
-Discontinued digoxin. Pt was rate controlled on metoprolol. Pt
should follow up with cardiologist for further management of
atrial fibrillation.
-Pt had subtherapeutic INR during admission. He should follow up
with his PCP to manage his warfarin doses.
# Code: full (limited trial of life-saving measures)
# Contact: Son
Phone number: ___
Cell phone: ___
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Citalopram 20 mg PO DAILY
2. Digoxin 0.375 mg PO DAILY
3. Lisinopril 10 mg PO DAILY
4. MetFORMIN (Glucophage) 500 mg PO BID
5. Metoprolol Tartrate 50 mg PO DAILY
6. Simvastatin 20 mg PO QPM
7. Warfarin 5 mg PO DAILY16
8. Aspirin 81 mg PO DAILY
9. Cyanocobalamin ___ mcg PO DAILY
10. Docusate Sodium 100 mg PO BID
11. Multivitamins 1 TAB PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Citalopram 20 mg PO DAILY
3. Cyanocobalamin ___ mcg PO DAILY
4. Docusate Sodium 100 mg PO BID
5. Lisinopril 10 mg PO DAILY
6. MetFORMIN (Glucophage) 500 mg PO BID
7. Metoprolol Tartrate 50 mg PO DAILY
8. Multivitamins 1 TAB PO DAILY
9. Simvastatin 20 mg PO QPM
10. Warfarin 5 mg PO DAILY16
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSES:
-Syncope
-Moderate aortic stenosis
-Atrial fibrillation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking part in your care here at ___!
Why was I admitted to the hospital?
- You were admitted for loss of consciousness and a fall.
What was done for me while I was in the hospital?
- An ultrasound of your heart was performed to look at the
narrowing of one of your heart valves. You will follow up with
your new cardiologist when you leave the hospital.
- You were monitored for an abnormal heart rhythm. We did not
see any dangerous rhythm, but we are sending you home with a
device to monitor your heart rhythm for several weeks.
What should I do when I leave the hospital?
- You should continue to take your medications as prescribed.
- You should follow up with a new cardiologist.
- You should use your ___ of Hearts cardiac monitor if you feel
symptomatic.
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
19712454-DS-25
| 19,712,454 | 27,092,151 |
DS
| 25 |
2158-08-25 00:00:00
|
2158-08-25 17:00:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending: ___.
Major Surgical or Invasive Procedure:
Cardioversion (___)
attach
Pertinent Results:
INITIAL LABS:
-------------
CBC/COAGS
___ 02:25PM BLOOD WBC-6.8 RBC-3.55* Hgb-10.4* Hct-33.7*
MCV-95 MCH-29.3 MCHC-30.9* RDW-14.9 RDWSD-51.7* Plt ___
___ 02:25PM BLOOD Neuts-52.6 ___ Monos-18.2*
Eos-0.7* Baso-0.3 Im ___ AbsNeut-3.56 AbsLymp-1.85
AbsMono-1.23* AbsEos-0.05 AbsBaso-0.02
___ 02:25PM BLOOD ___ PTT-40.5* ___
CMP
___ 02:25PM BLOOD Glucose-127* UreaN-33* Creat-1.2 Na-137
K-5.0 Cl-99 HCO3-23 AnGap-15
___ 02:25PM BLOOD ALT-17 AST-23 AlkPhos-71 TotBili-0.4
___ 02:25PM BLOOD Albumin-4.3 Calcium-9.3 Phos-3.8 Mg-2.0
CARDIAC
___ 02:25PM BLOOD cTropnT-0.01
___ 02:25PM BLOOD proBNP-1207*
IRON
___ 02:25PM BLOOD Ferritn-32
OTHER
___ 02:25PM BLOOD TSH-1.2
___ 02:38PM BLOOD Lactate-0.6
STUDIES:
___ ECG
Atrial fibrillation
Right bundle branch block
Anterolateral infarct, age indeterminate
___ Imaging CHEST (PORTABLE AP)
Moderate cardiomegaly and bibasilar atelectasis is unchanged. No
pulmonary
edema or definite focal consolidation to suggest pneumonia.
TTE ___:
IMPRESSION: Suboptimal image quality. Mild symmetric left
ventricular hypertrophy with mild to moderate global hypokinesis
c/w non-ischemic cardiomyopathy or other diffuse process. Mildly
dilated right ventricle with moderate free wall hypokinesis.
Mildly dilated thoracic aorta.
Moderate calcific aortic stenosis. Mild aortic regurgitaiton. At
least mild to moderate eccentric mitral regurgitation. Mild
pulmonary hypertension. Compared with the prior TTE (images
reviewed) of ___ , biventricular systolic function is now
reduced. There is severe aortic stenosis
Duplex b/l lower extremities ___:
IMPRESSION:
Patent bilateral iliofemoral vessels with diameters as noted.
DISCHARGE LABS:
---------------
CBC:
___ 07:53AM BLOOD WBC-6.9 RBC-3.22* Hgb-9.4* Hct-30.5*
MCV-95 MCH-29.2 MCHC-30.8* RDW-14.5 RDWSD-50.0* Plt ___
COAGS:
___ 07:53AM BLOOD ___
BMP:
___ 07:53AM BLOOD Glucose-126* UreaN-44* Creat-1.5* Na-140
K-4.6 Cl-99 HCO3-26 AnGap-15
___ 07:53AM BLOOD Calcium-9.3 Phos-4.0 Mg-2.0
Brief Hospital Course:
PATIENT SUMMARY:
___ year old man with paroxysmal atrial fibrillation on warfarin,
moderate aortic stenosis, and type II diabetes, who presented to
his ___ office with several months of worsening lower extremity
edema, found to be hypotensive with systolics to the ___, which
normalized without intervention. He was found to be in atrial
fibrillation with heart rates in the 100-120s and moderately
volume overloaded. ECHO showed worsening EF (35-45%) and severe
AS. Cardioverted back into sinus rhythm twice, tweaked
metoprolol dosing and started amiodarone loading (which will
transition to maintenance in ___. Rates were better
controlled but still had persistent ectopy. He was diuresed to
euvolemia and started on daily PO lasix. TAVR workup started and
will continue planning as outpt.
TRANSITIONAL ISSUES:
====================
PCP:
[] INR re-check on ___ - INR on d/c 4.1, reduced warfarin dose
to 2 mg daily given now on amiodarone, but should adjust as
needed for INR goal of ___
[] STOPPED aspirin - confirm no longer taking
[] Lisinopril 10mg QD held d/t lower BPs - consider whether d/c
or restart for TIIDM protection
[] For prostate cancer, recommend repeat MRI L spine in 3 months
(ie ___ - hemangiomas vs metastatic disease.
CARDS
[] TAVR outpt f/u - discussion with Dr. ___ outpt
visit with structural team
[] For AC for afib, consider DOAC instead of warfarin
[] Started amiodarone 200mg BID load (until ___, then 200mg QD
ongoing from then
ACTIVE ISSUES:
===============
# Bilateral lower extremity swelling:
# Aortic stenosis
Pt reports months of bilateral lower extremity swelling that
appears to be worsening; uses ___ stockings at home. On
admission, JVP ~ 10cm, mild weight gain (104.6 kg up from 102.3
kg); otherwise, denied dyspnea, orthopnea, PND or increased
abdominal girth. His proBNP was elevated at 1200, no priors in
system. No known heart failure. TTE showed worsening EF (35-45%
down from 72% in ___ and severe AS. Leg swelling due to volume
overload from atrial fibrillation in the setting of aortic
stenosis/pre-load dependent state. Underwent IV diuresis bolus
until euvolemic and discharged on lasix 40mg QD. Underwent TAVR
workup with US which showed good access. Will see structural
team as outpt for planning.
# Atrial fibrillation with mean ventricular rates of 100-120s:
Patient with paroxysmal atrial fibrillation on warfarin,
presenting in afib with HRs in the 110-120s. It is likely that
his tachycardia and known AS led to volume overload, though it
is also possible that volume overload led to uncontrolled atrial
fibrillation. Of note, he was on digoxin in the past (unclear
when stopped); it is unknown whether he has undergone
cardioversion. He was cardioverted back into sinus rhythm twice,
BB was tweaked and he was loaded on amiodarone (200mg BID with
plan to go to maintenance). TSH WNL, discharged on metoprolol
tartrate 100mg QD. At discharge, INR supratherapeutic (4.1)
after restarting home dosing (6mg QD). Decreased dose to 2mg a
day given also started on amiodarone. Will need INR follow up in
___ days.
# Episodic nausea with diaphoresis:
Pt describes episodes without clear trigger, often at rest,
resolves with lying flat for 20 minutes. No associated chest
pain, pressure, palpitations, shortness of breath or light
headedness. Etiology unclear, may be vasovagal or gastritis
given mild anemia on warfarin/aspirin. Did not have any symptoms
throughout rest of hospitalization.
# Hypotension, transient:
Presented to outpatient clinic where pressures were noted to be
in the ___ upon arrival to the ED, SBP again in the ___ though
ultimately maintained in the ___. Lactate 0.6. Baseline
(outpatient) pressures appear to be about 100-120/60-70s. On the
floor, pts BPs at baseline. He is asymptomatic and has not felt
symptoms of hypotension at home. He remained warm on exam. Held
lisinopril given presentation and normal/lower pressures during
admission - can decide as outpt if need to restart.
#Coag Neg Staph - 1+ BCx
Was found to grow GPCs and was started on IV antibiotics for 1
day, speciated to Coag Neg Staph so abx were d/c'ed. BCx
remained negative, only 1 bottle was found to be positive.
CHRONIC ISSUES:
================
# Anemia, normocytic:
Hb ___, down from recent ___. Iron studies wnl.
# Thrombocytopenia:
Mild, at baseline.
# Diabetes, type II:
Held metformin and placed on ISS.
# Depression:
Continued citalopram 20 mg daily
# Hyperlipidemia:
Continued simvastatin while inpatient
# Health maintenance:
Discontinued aspirin 81 mg while inpatient; he is on warfarin
and the combination increases his risk of bleed. Discussed with
patient who was in agreement.
# Prostate cancer:
Unknown history in terms of past treatments. He does report some
difficulty urinating as of late. Of note, MRI of L spine from
___ shows a 1.6 cm L5 anterior body lesion demonstrating
hypointensity; also additional lesions along L2 and T12; this
may represent hemangiomas though cannot rule out metastatic
disease given known history. Recommended repeat MRI L spine in 3
months (ie ___
==================
# LANGUAGE: ___
# CODE STATUS: Full code, limited trial of life sustaining
measures
# CONTACT:
1. ___ (son) ___ home: ___
2. ___ (son) ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Warfarin 6 mg PO QHS
2. Metoprolol Tartrate 50 mg PO DAILY
3. Citalopram 20 mg PO DAILY
4. Simvastatin 20 mg PO QPM
5. MetFORMIN (Glucophage) 500 mg PO BID
6. Lisinopril 10 mg PO DAILY
7. Cyanocobalamin ___ mcg PO DAILY
8. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Amiodarone 200 mg PO BID
Take this 2x a day for 3 weeks (finish ___ you
will start taking it 1x a day
RX *amiodarone 200 mg 1 tablet(s) by mouth twice a day Disp #*60
Tablet Refills:*0
2. Furosemide 20 mg PO DAILY
RX *furosemide 20 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
3. Metoprolol Succinate XL 100 mg PO DAILY
RX *metoprolol succinate 100 mg 1 tablet(s) by mouth once a day
Disp #*30 Tablet Refills:*0
4. Warfarin 2 mg PO QHS
RX *warfarin [Coumadin] 1 mg 2 tablet(s) by mouth once a day
Disp #*60 Tablet Refills:*0
5. Citalopram 20 mg PO DAILY
6. Cyanocobalamin ___ mcg PO DAILY
7. MetFORMIN (Glucophage) 500 mg PO BID
8. Simvastatin 20 mg PO QPM
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
Heart failure
paroxysmal atrial fibrillation
moderate aortic stenosis
Hypotension
SECONDARY DIAGNOSIS:
Type 2 diabetes mellitus
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you at the ___
___!
WHY WAS I IN THE HOSPITAL?
==========================
- You were admitted because you had swelling in your legs.
WHAT HAPPENED IN THE HOSPITAL?
==============================
- This was felt to be due to a condition called heart failure,
where your heart does not pump hard enough and fluid backs up
into your lungs. You were given a diuretic medication through
the IV to help get the fluid out. You improved considerably and
were ready to leave the hospital.
WHAT SHOULD I DO WHEN I GO HOME?
================================
- Be sure to take all your medications and attend all of your
appointments listed below.
- Your new medications include a medication for your heart
rhythm (amiodarone) and a water pill (lasix). Your heart rate
medication dosing was tweaked (metoprolol)
- Your weight at discharge is 224lbs. Please weigh yourself
today at home and use this as your new baseline, as all scales
are different
- Please weigh yourself every day in the morning. Call your
doctor if your weight goes up by more than 3 lbs.
Thank you for allowing us to be involved in your care, we wish
you all the best!
Your ___ Healthcare Team
Followup Instructions:
___
|
19712479-DS-18
| 19,712,479 | 29,916,269 |
DS
| 18 |
2113-04-18 00:00:00
|
2113-04-18 14:15:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Bilateral SDH, right greater than left
Major Surgical or Invasive Procedure:
___ right burr hole for subdural hematoma evacuation
History of Present Illness:
___ y/o male with PMH on Coumadin for Afib s/p multiple falls
transferred from ___ with bilateral SDH, right
greater than left.
He woke overnight and was disoriented. He fell and struck the
posterior aspect of the left side of his head. He is unsure if
he
lost consciousness. He was taken to ___ and
underwent a ___ which showed a subacute on chronic right SDH
measuring 2.4cm with 8.5cm MLS and an acute left occipital SDH
measuring 6.9mm. His INR was noted to be 1.9 and he was given
FFP
and one dose of Vitamin K. He also received 1g Keppra and was
transferred to ___ for further evaluation. Upon arrival, his
repeat INR was 1.6 and he received another unit of FFP.
The patient states that he fell several times over the past few
weeks with headstrike. He reports presenting to ___
___
after one of these falls he presented to ___ and
underwent a CT of the head which he reports was negative and he
was discharged to home.
He reports posterior left head pain at site of the laceration.
He
denies nausea, vomiting, fever, chills, dizziness, confusion,
diplopia, blurred vision, speech difficulties or weakness, pain
or paresthesias of the upper and lower extremities bilaterally.
Past Medical History:
-Afib on Coumadin
-Hypertension
-Hyperlipidemia
-h/p prostate CA s/p prostatectomy in ___
Social History:
Denies the use of etoh or illicit drugs. Remote history of
tobacco use, but quit ___ years ago. Retired ___.
Resides with his wife and daughter. Son is his health care
proxy.
Physical Exam:
PHYSICAL EXAMINATION ON ADMISSION:
T: 99.4 BP: 140/81 HR: 117 RR: 20 O2Sats 95% RA
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: 3-2mm bilaterally. EOMs intact throughout.
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, 3mm to
2mm bilaterally.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
XI: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power ___ throughout. No pronator drift.
Sensation: Intact to light touch bilaterally.
PHYSICAL EXAMINATION ON DISCHARGE:
Awake, alert, oriented x3. Nonfocal on exam. MAE full except L
ham 4+/5 secondary to pain. Incision C/D/I with staples
Pertinent Results:
Please see OMR for pertinent lab or imaging results.
Brief Hospital Course:
___ M admitted to neurosurgery service s/p fall with right
subacute SDH and smaller left acute SDH
#Bilateral SDH, right greater than left
The patient was transferred to the ED at ___ on ___ from
___ after the CT of the head demonstrated
bilateral SDHs. His INR was 1.9 at OSH and he received FFP and
Vitamin K prior to transfer. His repeat INR upon arrival was 1.6
and he received another unit of FFP. He was admitted to the ___
for close neurologic monitoring. He was started on Keppra for
seizure prophylaxis. Repeat CT ___ showed improved MLS but
small increased in acute left SDH. This was stable on repeat CT
___. He was closely monitored and taken to the OR on ___
for right burr hole evacuation of ___ with Dr. ___
___ was well tolerated. Post operative CT showed expected
evaluation of R SDH and stable L SDH. Subdural drain was in
place to thumbprint suction. Repeat CT ___ showed re-expansion
of brain and stable L SDH. Subdural drain was removed on ___
without complication. A CT head on ___ was stable with interval
reaccumulation of CSF, no new hemorrhage. Patient was cleared
for rehab dispo.
#Afib
Coumadin was held and reversed with 2units FFP and Vit K x 3
doses. Coumadin continued to be held to prevent further bleeding
into the subdural space.
#Pannus
Imaging revealed c1/2 stenosis secondary to degenerative pannus
formation, without signal change in the cord. This is chronic
and no surgical intervention was indicated.
#L thigh spasm
He was started on lidocaine patch and flexeril from chronic L
thigh spasms.
#Dispo
He was evaluated by ___, who recommended acute rehab.
Medications on Admission:
Vitamin C 500mg PO daily; Lisinopril 10mg PO daily; Loratadine
10mg PO daily; Metoprolol Succinate ER 12.5mg PO daily;
Omeprazole 20mg PO daily; Simvastatin 10mg PO QPM; Timolol 0.25%
1 drop ___ Warfarin 5mg frequency unknown
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Moderate
Do not exceed 4g/day.
2. Bisacodyl 10 mg PO/PR DAILY:PRN constipation
3. Cyclobenzaprine 5 mg PO TID:PRN muscle spasm
4. Docusate Sodium 100 mg PO BID
5. LevETIRAcetam 500 mg PO BID
6. Multivitamins 1 TAB PO DAILY
7. Ramelteon 8 mg PO QHS:PRN insomnia
8. Senna 8.6 mg PO BID:PRN constipation
9. TraMADol 25 mg PO Q6H:PRN pain
___ request partial fill.
10. Lisinopril 10 mg PO DAILY
11. Loratadine 10 mg PO DAILY
12. Metoprolol Succinate XL 12.5 mg PO DAILY
13. Omeprazole 20 mg PO DAILY
14. Simvastatin 10 mg PO QPM
15. Timolol Maleate 0.25% 1 DROP BOTH EYES DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Subdural hematoma with brain compression
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Discharge Instructions
Brain Hemorrhage with Surgery
Surgery
· You underwent a surgery called a burr hole evacuation to
have blood removed from your brain.
· Please keep your staples along your incision dry until
they are removed.
· It is best to keep your incision open to air but it is ok
to cover it when outside.
· Call your surgeon if there are any signs of infection like
redness, fever, or drainage.
Activity
· We recommend that you avoid heavy lifting, running,
climbing, or other strenuous exercise until your follow-up
appointment.
· You make take leisurely walks and slowly increase your
activity at your own pace once you are symptom free at rest.
___ try to do too much all at once.
· No driving while taking any narcotic or sedating
medication.
· If you experienced a seizure while admitted, you are NOT
allowed to drive by law.
· No contact sports until cleared by your neurosurgeon. You
should avoid contact sports for 6 months.
Medications
· Please do NOT take any blood thinning medication (Aspirin,
Ibuprofen, Plavix, Coumadin) until cleared by the neurosurgeon.
· You have been discharged on Keppra (Levetiracetam). This
medication helps to prevent seizures. Please continue this
medication for 7 days from ___. It is important that you
take this medication consistently and on time.
· You may use Acetaminophen (Tylenol) for minor discomfort
if you are not otherwise restricted from taking this medication.
What You ___ Experience:
· You may have difficulty paying attention, concentrating,
and remembering new information.
· Emotional and/or behavioral difficulties are common.
· Feeling more tired, restlessness, irritability, and mood
swings are also common.
· You may also experience some post-operative swelling
around your face and eyes. This is normal after surgery and most
noticeable on the second and third day of surgery. You apply
ice or a cool or warm washcloth to your eyes to help with the
swelling. The swelling will be its worse in the morning after
laying flat from sleeping but decrease when up.
· You may experience soreness with chewing. This is normal
from the surgery and will improve with time. Softer foods may be
easier during this time.
· Constipation is common. Be sure to drink plenty of fluids
and eat a high-fiber diet. If you are taking narcotics
(prescription pain medications), try an over-the-counter stool
softener.
Headaches:
· Headache is one of the most common symptoms after a brain
bleed.
· Most headaches are not dangerous but you should call your
doctor if the headache gets worse, develop arm or leg weakness,
increased sleepiness, and/or have nausea or vomiting with a
headache.
· Mild pain medications may be helpful with these headaches
but avoid taking pain medications on a daily basis unless
prescribed by your doctor.
· There are other things that can be done to help with your
headaches: avoid caffeine, get enough sleep, daily exercise,
relaxation/ meditation, massage, acupuncture, heat or ice packs.
When to Call Your Doctor at ___ for:
· Severe pain, swelling, redness or drainage from the
incision site.
· Fever greater than 101.5 degrees Fahrenheit
· Nausea and/or vomiting
· Extreme sleepiness and not being able to stay awake
· Severe headaches not relieved by pain relievers
· Seizures
· Any new problems with your vision or ability to speak
· Weakness or changes in sensation in your face, arms, or
leg
Call ___ and go to the nearest Emergency Room if you experience
any of the following:
· Sudden numbness or weakness in the face, arm, or leg
· Sudden confusion or trouble speaking or understanding
· Sudden trouble walking, dizziness, or loss of balance or
coordination
· Sudden severe headaches with no known reason
Followup Instructions:
___
|
19712479-DS-19
| 19,712,479 | 23,796,590 |
DS
| 19 |
2113-06-11 00:00:00
|
2113-06-11 18:32:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Unsteady gait and confusion
Major Surgical or Invasive Procedure:
___ - Left Craniotomy for Subdural hematoma evacuation
History of Present Illness:
___ yo M hx Afib known to Neurosurgery for bilat SDH Right > Left
and s/p right burr hole evacuation of ___ on ___ presented
with worsening unsteady gait over the past week and fall, no
headstrike, 4 days prior. Coumadin was stopped at his last
hospitalization. He complains also of general weakness. He
denies numbness, vision changes, nausea, vomiting.
Past Medical History:
-Afib on Coumadin
-Hypertension
-Hyperlipidemia
-h/p prostate CA s/p prostatectomy in ___
Social History:
___
Family History:
NC
Physical Exam:
ON ADMISSION:
O: T:98.3 BP: 126/95 HR:88 R20 O2Sats97%
Gen: WD/WN, comfortable, NAD.
HEENT: right burr hole incision well healed
Neck: Supple.
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date, difficulty
with
month.
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, 3 to 2
mm bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
XI: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power ___ throughout with the exception
of
right tricep 4+/5
Bilateral upward drift
Sensation: Intact to light touch bilaterally.
Toes downgoing bilaterally
Coordination: normal on finger-nose-finger
========================================
ON DISCHARGE:
Pertinent Results:
Please refer to ___ for pertinent imaging and lab results.
Brief Hospital Course:
Mr. ___ is an ___ year old male known to the
neurosurgery service s/p right burr hole evacuation on ___
for chronic bilateral subdural hematoma. Patient was readmitted
on ___ from OSH with worsening gait and confusion, found to
have worsening bilateral SDH Left > right.
#Chronic bilateral Subdural hematoma
Mr. ___ was admitted to neurosurgery service on ___
with worsening chronic bilateral SDH, Left>right. Consent was
obtained from health care proxy, and patient was taken to the OR
on ___ for Left burr holes for subdural hematoma evacuation
with placement of left subdural drain. The procedure went
accordingly with no intraoperative compilations. Please refer to
op note in OMR for further intraoperative details. Patient was
taken to Post operative area for further monitoring, where he
remained intact on exam, and was then transferred to the step
down unit for continued care. Post op head CT demonstrated a an
area of hyperdenisty at the drain terminus concerning for new
hemorrhage. The patient remained intact and a repeat CT on ___
remained stable. Subdural drain was pulled on ___. The patient
was evaluated by ___ and OT on ___ who recommended discharge
home with inhome ___ services. Patient remained stable and was
cleared to be discharged home on ___.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Metoprolol Succinate XL 25 mg PO DAILY
2. Omeprazole 20 mg PO DAILY
3. Simvastatin 10 mg PO QPM
4. Timolol Maleate 0.25% 1 DROP BOTH EYES BID
5. Loratadine 10 mg PO DAILY
6. TraZODone 25 mg PO QHS:PRN sleep
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN mild pain
2. LevETIRAcetam 500 mg PO BID
RX *levetiracetam [Keppra] 500 mg 1 tablet(s) by mouth twice a
day Disp #*10 Tablet Refills:*0
3. Loratadine 10 mg PO DAILY
4. Metoprolol Succinate XL 25 mg PO DAILY
5. Omeprazole 20 mg PO DAILY
6. Simvastatin 10 mg PO QPM
7. Timolol Maleate 0.25% 1 DROP BOTH EYES BID
8. TraZODone 25 mg PO QHS:PRN sleep
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Bilateral subdural hematomas
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Surgery
- You underwent a surgery called burr holes to have blood
removed from your brain.
- Please keep your staples along your incision dry until they
are removed.
- It is best to keep your incision open to air but it is ok to
cover it when outside.
- Call your surgeon if there are any signs of infection like
redness, fever, or drainage.
Activity
- We recommend that you avoid heavy lifting, running, climbing,
or other strenuous exercise until your follow-up appointment.
- You make take leisurely walks and slowly increase your
activity at your own pace once you are symptom free at rest.
___ try to do too much all at once.
- No driving while taking any narcotic or sedating medication.
- If you experienced a seizure while admitted, you are NOT
allowed to drive by law.
- No contact sports until cleared by your neurosurgeon. You
should avoid contact sports for 6 months.
Medications
- Please do NOT take any blood thinning medication (Aspirin,
Ibuprofen, Plavix, Coumadin) until cleared by the neurosurgeon.
- You have been discharged on Keppra (Levetiracetam). This
medication helps to prevent seizures. Please continue this
medication as indicated on your discharge instruction. It is
important that you take this medication consistently and on
time.
- You may use Acetaminophen (Tylenol) for minor discomfort if
you are not otherwise restricted from taking this medication.
What You ___ Experience:
- You may have difficulty paying attention, concentrating, and
remembering new information.
- Emotional and/or behavioral difficulties are common.
- Feeling more tired, restlessness, irritability, and mood
swings are also common.
- You may also experience some post-operative swelling around
your face and eyes. This is normal after surgery and most
noticeable on the second and third day of surgery. You apply
ice or a cool or warm washcloth to your eyes to help with the
swelling. The swelling will be its worse in the morning after
laying flat from sleeping but decrease when up.
- You may experience soreness with chewing. This is normal from
the surgery and will improve with time. Softer foods may be
easier during this time.
- Constipation is common. Be sure to drink plenty of fluids and
eat a high-fiber diet. If you are taking narcotics (prescription
pain medications), try an over-the-counter stool softener.
Headaches:
- Headache is one of the most common symptoms after a brain
bleed.
- Most headaches are not dangerous but you should call your
doctor if the headache gets worse, develop arm or leg weakness,
increased sleepiness, and/or have nausea or vomiting with a
headache.
- Mild pain medications may be helpful with these headaches but
avoid taking pain medications on a daily basis unless prescribed
by your doctor.
- There are other things that can be done to help with your
headaches: avoid caffeine, get enough sleep, daily exercise,
relaxation/ meditation, massage, acupuncture, heat or ice packs.
When to Call Your Doctor at ___ for:
- Severe pain, swelling, redness or drainage from the incision
site.
- Fever greater than 101.5 degrees Fahrenheit
- Nausea and/or vomiting
- Extreme sleepiness and not being able to stay awake
- Severe headaches not relieved by pain relievers
- Seizures
- Any new problems with your vision or ability to speak
- Weakness or changes in sensation in your face, arms, or leg
Call ___ and go to the nearest Emergency Room if you experience
any of the following:
- Sudden numbness or weakness in the face, arm, or leg
- Sudden confusion or trouble speaking or understanding
- Sudden trouble walking, dizziness, or loss of balance or
coordination
- Sudden severe headaches with no known reason
Followup Instructions:
___
|
19712781-DS-9
| 19,712,781 | 28,904,191 |
DS
| 9 |
2171-06-06 00:00:00
|
2171-06-06 23:20:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
___ Complaint:
Hand pain and swelling
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ WF with a PMH of drug abuse, venous stasis
ulcer who presents with c/o right hand swelling after sustaining
a laceration from putting her right hand through a glass window
2 days ago that was further complicated by a dog bite to the
same site. She put her hand through a window trying to get into
her boyfriends home and on the same day she was also bitten by
her dog whom is not UTD with its shots. She has pain and
swelling in the hand and says her thumb feels stiff. She has no
fevers/chills or night sweats. She also incidentally has
bilateral chronic venous stasis ulcers that she believes are
infected. Of note, she was in police custody until bail was
posted to be tranferred to ___.
In the ED, initial vs were T:98.6 P:78 BP: 148/70 RR:18 Pox:98%.
Received dilaudid, vancomycin, rabies vaccine, Rabies Ig x2, and
methadone 15mg, in addition to her home meds.
On arrival to the floor, patient reports continued pain in her
right hand and pain in her legs from her venous stasis ulcers.
REVIEW OF SYSTEMS:
+ hand pain, bilateral leg pain.
-fever, chills, night sweats, headache, vision changes,
rhinorrhea, congestion, sore throat, cough, shortness of breath,
chest pain, abdominal pain, nausea, vomiting, diarrhea,
constipation, BRBPR, melena, hematochezia, dysuria, hematuria.
Past Medical History:
Anxiety
Depression
bilateral Venous stasis ulcers
h/o opiod abuse on methadone
Social History:
___
Family History:
DM- maternal grandmother
HTN- mother
___- father
Physical ___:
ADMISSION PHYSICAL EXAM:
VS:98.2 BP:145/85 P:82 RR:18 Pox:99% on RA
GEN: Alert, oriented, no acute distress
HEENT: NCAT MMM EOMI sclera anicteric, OP clear
NECK: supple, no JVD, no LAD
PULM: Good aeration, CTAB no wheezes, rales, ronchi
CV: RRR normal S1/S2, no mrg
ABD: obese, soft NT ND normoactive bowel sounds, no rebound or
guarding
NEURO: CNII-XII intact, motor function grossly normal
SKIN: venous stasis ulcers on both legs. Right leg: 2 ulcers,
RUE: hand swollen around thenar eminence/radial aspect, closed
"dog bite" over proximal phalange of thumb, and 2 puncture marks
in 1 web space dorsally. The "glass laceration" is tranverse
~3cm
and is over the ___ CMC joint. This wound is open and draining
non-purulent fluid. She has numbness over the dorsal aspect of
the ___ distal to this laceration.. She can flex and extend all
digits but has limited range of motion of the thumb ___
swelling. She has significant pain along the course of the EPL
with passive flexion. Good cap refill in all digits
Right leg: 2 ulcers 3-4 cm in diameter
Left leg: multiple ulcers largest 5cm in diameter. Bilateral
edema to knees
Discharge Physical Exam:
Vitals: T: 97.9 BP 110/61 P:74 RR:18 Pox: 98% on RA
GEN: Alert, oriented, no acute distress
HEENT: NCAT MMM EOMI sclera anicteric
NECK: supple, no JVD, no LAD
PULM: CTAB no wheezes, rales, ronchi
CV: RRR normal S1/S2
ABD: obese, soft NT ND normoactive bowel sounds, no rebound or
guarding
___: Hand swollen but erythema improving compared to admission
exam, still with some numbness
Right leg: 2 ulcers 3-4 cm in diameter, Left leg multiple ulcers
largest 5cm in diameter. Bilateral edema to knees
SKIN: venous stasis ulcers on both legs. Right leg: 2 ulcers
Pertinent Results:
___ 06:15AM PLT COUNT-232
___ 06:15AM NEUTS-67.8 ___ MONOS-3.1 EOS-0.4
BASOS-0.6
___ 06:15AM WBC-8.3 RBC-3.64* HGB-11.1* HCT-33.0* MCV-91
MCH-30.5 MCHC-33.7 RDW-14.5
___ 06:15AM estGFR-Using this
___ 06:15AM GLUCOSE-86 UREA N-10 CREAT-0.6 SODIUM-138
POTASSIUM-4.0 CHLORIDE-100 TOTAL CO2-23 ANION GAP-19
___ 06:25AM LACTATE-2.0
___ Hand x-ray: No radiopaque foreign body or fracture.
Brief Hospital Course:
Ms. ___ is a ___ WF with a PMH of drug abuse, venous stasis
ulcer who presents with right hand swelling after sustaining a
laceration further complicated by a dog bite to the same hand.
#Hand laceration: Pt apparently punched her right hand through a
glass window 1 day PTA. She was subsequently bitten by her
non-immunized dog at a different site on the same hand. She
then noticed increased pain and swelling which brought her to
medical attention. An x-ray of her hand showed no fracture or
retained foreign body. Due to concern for possible infection
due to increased pain, erythema, and swelling she was put on
unasyn 3g Q6H for polymicrobial coverage from bite wound and was
transitioned to Augmentin. Hand wound was managed by plastic
surgery who recommend OT consult for a custom orthoplast thumb
SPICA splint which the patient received. She was instructed on
TID hand soaks with ___ strength betadine and warm water for
20min daily. Dressing changes daily with non-adherant dressing,
vasoline gauze, and kerlix. She was also instructed keep arm
held above head to minimize bleeding.
#Dog Bite Wound: Please see above. Pt has received 2 dose of
rabies vaccine in the hospital as well as rabies Ig. She will
need rabies vaccine (___ or PCECV) 1mL IM tomorrow then again
on ___ and ___ as an outpatient. Pt was referred to
___ and if can't make it there to go to local ED to get
rabies vaccine.
#Venous stasis ulcers: Chronic medical problem that is active
due to significant wounds present on both shins. Pt states that
she has had MRSA in the past and thought the uclers were
infected. However ulcer don't appear to be infected. Wound care
nurse for ulcer care and pt was instructed to elevate ___ while
sitting.
#Anxiety and Depression: Chronic problem that is stable on
buspar, paxil, and klonopin.
#H/O Opiod abuse. She was given methadone 35mg PO Daily.
#Alcohol Abuse: Pt has a history of significant alcohol abuse.
She was placed on withdrawal precautions (CIWA protcol, given
diazepam if CIWA>10) but did not show signs of withdrawal.
Transitional Issues:
- Blood cultures pending
- Needs to complete rabies vaccine series
- Plastic surgery f/u for hand laceration
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from Patient.
1. BusPIRone 60 mg PO DAILY
2. Paroxetine 40 mg PO DAILY
3. Methadone 35 mg PO DAILY
4. Furosemide 40 mg PO DAILY
5. Clonazepam 1 mg PO TID
Discharge Medications:
1. BusPIRone 60 mg PO DAILY
2. Clonazepam 1 mg PO TID
3. Furosemide 40 mg PO DAILY
4. Methadone 35 mg PO DAILY
5. Paroxetine 40 mg PO DAILY
6. Amoxicillin-Clavulanic Acid ___ mg PO Q12H Wound Infection
RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tablet by mouth
every twelve (12) hours Disp #*9 Tablet Refills:*0
7. Wound Care Supplies
Moisture barrier ointment
Apply moisture barrier ointment to the periwound tissue with
each dressing change.
Dispense quantity sufficient for 1 month supply
8. Wound Care Supplies
Dispense Spiral Ace Wraps
Apply Spiral Ace Wraps to B/L ___ from just above toes to just
below knees before getting out of bed.
Remove Ace Wraps at bedtime.
Please provide qauntity sufficient for 1 month
9. Wound Care Supplies
Please dispense dry gauze, sofsorb sponge, and kling wrap.
Change dressing daily
Dispense quantity sufficient for 1 month of supplies
10. Povidone Iodine ___ Strength 1 Appl TP TID hand soaks
Please dilute with warm water and soak hand wound three times
per day
RX *Betadine 10 % Dilute in warm water to ___ strength three
times a day Disp #*1 Bottle Refills:*3
Discharge Disposition:
Home
Discharge Diagnosis:
Hand Laceration
Dog Bite wound
Venous stasis ulcers
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure caring for you on your recent admission to
___. You were admitted to the hospital because you had pain
and swelling in your right hand after having injured and cut
your hand on a glass window. In addition you were also bitten
in the hand by a dog that had not been vaccinated. An x-ray of
your hand showed that there were no broken bones. While you were
hospitalized you received antibiotics to prevent an infection in
your hand and you also received a vaccine and immunoglobulin to
try to prevent rabies. You were also instructed on how to soak
your wounds 3 times per day. You were given a thumb splint and
should wear it until your appointment with the hand clinic next
week.
We also treated the ulcers on your legs. Continue to take your
furosemide (water pill) to help prevent fluid accumulation in
your legs. Please follow up with your wound care clinic for
continued management of these ulcers.
Dear Ms. ___,
It was a pleasure caring for you on your recent admission to
___. You were admitted to the hospital because you had pain
and swelling in your right hand after having injured and cut
your hand on a glass window. In addition you were also bitten
in the hand by a dog that had not been vaccinated. An x-ray of
your hand showed that there were no broken bones. While you were
hospitalized you received antibiotics to prevent an infection in
your hand and you also received a vaccine and immunoglobulin to
try to prevent rabies. You were also instructed on how to clean
and care for your wounds. You were given a thumb splint and
should wear it until your appointment with the hand clinic next
week.
We also treated the ulcers on your legs. Continue to take your
furosemide (water pill) to help prevent fluid accumulation in
your legs. Please follow up with your wound care clinic for
continued management of these ulcers.
You should also receive 2 more Rabies vaccines, one on ___
and a second one on ___. Please call the ___ clinic to
schedule these appointments ___. Otherwise, you can
go to your local emergency department.
You may also schedule an appointment with Vascular @ ___ for evaluation of your varicose veins.
Your medications changes include:
Augmentin 825mg Q12H for 4 days to prevent wound infection
Oxycodone 5mg Q6H PRN for pain
Please see wound care recommendations below:
For your leg ulcers:
Apply Commercial wound cleanser to irrigate/cleanse all open
wounds.
Pat the tissue dry with dry gauze. Apply moisture barrier
ointment to the periwound tissue with each dressing change.
Apply Aquacel AG to all open wounds (silver ion dressing). Cover
with dry gauze, Sofsorb sponge, Kling wrap. Change dressing
daily.
Wound Care for your hands:
Please soak your hand wound in betadine and warm water soaks
three times per day.
Apply Spiral Ace Wraps to B/L ___ from just above toes to just
below knees before patient gets OOB or after elevating ___ for
30 minutes.
Remove Ace Wraps at bedtime.
Followup Instructions:
___
|
19713049-DS-15
| 19,713,049 | 25,204,183 |
DS
| 15 |
2183-07-06 00:00:00
|
2183-07-09 10:09:00
|
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, N/V, bloody diarrhea
Major Surgical or Invasive Procedure:
___ VAC dressing removed
___ ___ pigtail for ant abd collection
___ botox injection, incisional debridement, VAC dressing
___ skin flaps, skin closure (fascia not closed)
___ AbThera change, loss of domain measuring 34x34cm
___ colostomy creation, partial fascial closure, ABThera
___ abdominal washout, placement of RP drain, abthera
___ ex-lap, abdominal washout, colon resection, open
abdomen
___ ___ drain
History of Present Illness:
Ms. ___ is a ___ old woman with history of colonic
resection for diverticulitis, who now presents as a transfer
from an OSH with concerns for bowel perforation.
She states that she started having abdominal pain ___, ___ the
middle of the night, without any inciting event. Over the next
few days, she also had some intermittent nausea, a few episodes
of vomiting, and some bloody diarrhea, which she describes not
as real bowel movements but bursts of flatus with blood
splattering ___ toilet. She does continue to pass flatus. She has
been unable to tolerate much PO ___ the past few days, has kept
down a small amount of fluid. She endorses some sweating and
subjective fevers. At the OSH she was given zosyn and flagyl.
She underwent a CT A/P with IV contrast, which showed concern
for perforation near the prior anastomosis. She was therefore
transferred here for further care. Of note, prior to transfer,
she had a transient desaturation to 89% which improved with
placement on 2L nasal cannula. A chest xray showed some haziness
at the left base which could represent a developing pneumonia.
Upon evaluation ___ the ED now, she continues to have lower
abdominal/pelvic pain. She is, however, able to move around
freely ___ the bed without too much discomfort.
Past Medical History:
MI ___ ___ s/p stent, HTN, asthma
Past Surgical History: umbilical hernia repair (___), colonic
resection for diverticulitis with concomitant TAH/BSO (___),
resiting of colostomy, colostomy reversal ___ or ___
Social History:
___
Family History:
father w/CABGx5, diverticulosis, pancreatitis, Alzheimer's;
mother with lung CA
Physical Exam:
V/S: T98.3, HR90, BP107/54, RR18, Sat94% 2L NC
GEN: A&O, NAD
HEENT: No scleral icterus, mucus membranes dry
CV: RRR, No M/G/R
PULM: normal effort, scattered expiratory wheezing bilaterally
ABD: Soft, nondistended, tender to palpation diffusely, but more
concentrated ___ central pelvis, no rebound or guarding
Ext: No ___ edema, ___ warm and well perfused
Physical examination upon discharge: ___:
General: NAD
CV: ns1, s2, no murmurs
LUNGS: Course throughout, no wheezing
ABDOMEN: Ostomy left side abdomen with retracted stoma, pigtail
left side abdomen, right side abdomen healing abdominal wound
with wet to dry dressing, cauterized for bleeding sites x 2,
prior to dressing replaced
EXT: no pedal edema bil, no calf tenderness bil
NEURO: alert and oriented x 3, speech clear
Pertinent Results:
___ 07:09AM BLOOD WBC-8.9 RBC-3.27* Hgb-9.4* Hct-31.2*
MCV-95 MCH-28.7 MCHC-30.1* RDW-15.7* RDWSD-53.3* Plt ___
___ 06:35AM BLOOD WBC-9.6 RBC-3.11* Hgb-9.0* Hct-29.9*
MCV-96 MCH-28.9 MCHC-30.1* RDW-15.9* RDWSD-53.8* Plt ___
___ 02:00AM BLOOD WBC-12.6* RBC-4.90 Hgb-14.5 Hct-45.1*
MCV-92 MCH-29.6 MCHC-32.2 RDW-13.5 RDWSD-46.2 Plt ___
___ 02:00AM BLOOD Neuts-86* Bands-10* Lymphs-2* Monos-2*
Eos-0 Baso-0 ___ Myelos-0 AbsNeut-12.10*
AbsLymp-0.25* AbsMono-0.25 AbsEos-0.00* AbsBaso-0.00*
___ 07:09AM BLOOD Plt ___
___ 09:15AM BLOOD Plt ___
___ 05:28AM BLOOD ___
___ 07:09AM BLOOD Glucose-91 UreaN-7 Creat-0.5 Na-143 K-4.3
Cl-103 HCO3-27 AnGap-13
___ 09:15AM BLOOD Glucose-107* UreaN-8 Creat-0.6 Na-142
K-4.1 Cl-101 HCO3-27 AnGap-14
___ 06:35AM BLOOD Glucose-87 UreaN-10 Creat-0.4 Na-141
K-4.1 Cl-101 HCO3-29 AnGap-11
___ 09:40PM BLOOD ALT-6 AST-11 AlkPhos-79 TotBili-0.3
___ 01:39AM BLOOD ALT-8 AST-10 LD(LDH)-127 AlkPhos-63
TotBili-0.3
___ 02:00AM BLOOD Lipase-40
___ 07:09AM BLOOD Calcium-8.7 Phos-4.5 Mg-2.2
___ 04:33AM BLOOD calTIBC-170* Ferritn-520* TRF-131*
___ 04:33AM BLOOD Triglyc-232*
___ 02:50AM BLOOD Type-ART pO2-49* pCO2-42 pH-7.50*
calTCO2-34* Base XS-7
___ 02:50AM BLOOD Lactate-1.7
___: CT abdomen/pelvis:
1. A segment of sigmoid colon along the anastomosis appears
perforated with extensive extra-luminal locules of gas,
surrounding fat stranding, and bowel contents, possibly
secondary to diverticulitis. Rectal contrast is noted within
this collection and extends into the proximal colon.
2. Retroperitoneal air is seen to extend along the left flank to
the spleen
___: CT abd. and pelvis:
1. Extensive extra-luminal locule of gas and stranding appears
increased since the prior study compatible with colonic
perforation. No focal fluid
collections are seen.
2. A tiny focus of extra-luminal contrast ___ the pelvis and
contrast within the descending colon likely reflects prior
rectal contrast administration.
___: ___ drainage:
Successful CT-guided placement of ___ pigtail catheter into
the lower
abdominal collection predominantly containing gas. Sample of
aspirated
necrotic fluid ___ this region was sent for microbiology
evaluation.
___: CT abdomen and pelvis:
-
. Mild interval increase ___ extensive extra-luminal gas and
fluid since
___, with some of these areas for example inferior to
the right kidney becoming more organized when compared to the
prior examination from ___.
2. Tiny focus of extra-luminal oral contrast just distal to the
large bowel
anastomosis (601, 49) ___ a similar location to prior which
likely reflects the site of perforation.
___: ECHO:
he left atrial volume index is normal. No atrial septal defect
is seen by 2D or color Doppler. The estimated right atrial
pressure is at least 15 mmHg. Left ventricular wall thickness,
cavity size and regional/global systolic function are normal
(LVEF >55%). Right ventricular chamber size and free wall motion
are normal. The diameters of aorta at the sinus, ascending and
arch levels are normal. The mitral valve appears structurally
normal with trivial mitral regurgitation. There is no mitral
valve prolapse. The pulmonary artery systolic pressure could not
be determined. There is no pericardial effusion.
IMPRESSION: Normal left ventricular wall thickness, cavity size,
and regional/global systolic function. No definite pathologic
valvular flow identified.
___: CXR:
IMPRESSION:
ET tube tip is 4 cm above the carina. NG tube tip is ___ the
stomach. Right internal jugular line tip is at the level of
lower SVC. Right PICC line tip is at the level of mid SVC.
There is interval progression of ___ lower lobe opacities
concerning for aspiration or pneumonia. Vascular congestion is
new but no overt pulmonary edema is present ___ particular on the
right. No pneumothorax.
___: CXR:
Interstitial edema has worsened. Support lines and tubes
unchanged.
Bilateral effusions right greater than left are stable.
Cardio-mediastinal silhouette is unchanged. No pneumothorax is
seen.
___: CXR
Lungs are low volume with improving pulmonary edema. Small
bilateral
effusions are stable. Cardio-mediastinal silhouette is
unchanged. The ETT has been removed. The NG tube and
right-sided central lines are unchanged ___ position. No
pneumothorax is seen.
___: CTA chest:
1. No pulmonary embolism or acute aortic abnormality.
2. There is a small to moderate amount of low-attenuation fluid
and stranding ___ the abdomen and pelvis. This fluid appears more
organized ___ the right lower quadrant (series 2:154) and the
left lower quadrant extending into the pelvis (series 2:164). ___
addition, there is a small organized pocket of fluid measuring 2
x 2 cm (series 2:166), non drainable given its size and
location.
3. Adjacent to the end colostomy site, there is a subcutaneous
fluid
collection measuring 5.2 x 2.0 cm ___ the left mid abdomen
(series 2:154).
4. Status post and colostomy without evidence of obstruction.
5. 2 drains terminate ___ the anterior abdominal wall. 1 inferior
approach
drain terminates ___ the pelvis.
6. Small bilateral pleural effusions with associated compressive
atelectasis.
___: CT abdomen and pelvis:
1. New rim enhancing gas and fluid containing collection within
the pelvis
adjacent to the proximal jejunum at site of prior drains, with
several
loculations insinuating deeper into the pelvis. Associated
inflammatory
changes of the adjacent small bowel.
2. Interval increase size of left anterior abdominal rim
enhancing collection.
3. No evidence of mechanical bowel obstruction.
4. Centri-lobular nodular opacities within the right lower lobe,
likely
infectious/inflammatory. Aspiration is a differential
consideration.
5. Stable postsurgical changes of a left hemi-colectomy with
left lower
quadrant colostomy. Large ventral wall hernia containing
non-obstructed large and small bowel appears unchanged.
___: ___ drainage:
Successful CT-guided placement of ___ pigtail catheters
into the left
upper abdominal and lower abdominal/pelvic collections. Samples
were sent for microbiology evaluation.
___: CT abdomen and pelvis:
1. Near complete resolution of previously seen fluid collections
___ the pelvis and left lower abdomen. Small amount of residual
fluid persists just anterior to the rectal stump.
2. No new collection seen ___ the abdomen and pelvis.
3. Interval decrease ___ size of the fluid collection ___ the
anterior abdominal wall.
4. Persistent centri-lobular opacities ___ the right lower lobe
which have
slightly increased ___ extent, likely secondary to aspiration.
___: CT abd and pelvis:
1. Since ___, there has been interval removal of the
superior left abdominal abscess drain. Along the tract of the
removed drainage catheter is a 4.3 x 1.6 cm fluid collection
with peripheral enhancement which is not significantly changed
from the prior study.
2. The lower drainage catheter is unchanged ___ position with
near complete
resolution of the collection.
3. No new abscess is identified.
4. There is increased gas and skin ulceration along the midline
anterior
abdominal wall scar spanning greater than 10 cm. Findings are
concerning for dehiscence. No abscess is identified. However,
underlying infection cannot be excluded. Clinical correlation
is requested.
5. Subcutaneous fluid collection along the inferior margin of
the scar
measuring 2.7 cm, decreased ___ size since prior.
6. 3.3 x 2.3 x 4.2 cm fat soft tissue density with a
hyperattenuating rim
suggestive of an omental infarct.
___: CT abd. and pelvis:
. Irregular 11 cm anterior intra-abdominal collection
surrounding the
transverse colon and adjacent to the colostomy. This is
technically amenable for CT-guided drainage.
2. Extensive postsurgical changes as detailed above.
3. No significant amount of fluid surrounding the left pelvic
drain. This can be potentially removed.
___ CXR:
previously seen right PICC has been removed. There is
elevation of the
right hemi-diaphragm with overlying sub-segmental atelectasis,
similar to
previous. There is minimal sub-segmental atelectasis at the
left lung base. The heart is not enlarged. There may be a
trace left effusion.
___: ___ drainage:
Successful CT-guided placement of a ___ pigtail catheter
into the
anterior abdominal collection. Samples were sent for
microbiology evaluation.
___: Abd and pelvis:
1. No residual fluid collection/abscess is identified within the
subcutaneous tissues or pelvis. 2 percutaneous pigtail drainage
catheters remain ___ stable position, without significant
surrounding fluid.
2. Persistent centri-lobular nodules within the right lower
lobe, suspicious for aspiration pneumonitis/pneumonia.
3. Postsurgical changes from left hemi-colectomy and left lower
quadrant
colostomy.
___: Abscess:
___ 5:30 pm ABSCESS RETROPERITONEAL ABSCESS.
**FINAL REPORT ___
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
4+ (>10 per 1000X FIELD): GRAM NEGATIVE ROD(S).
3+ ___ per 1000X FIELD): GRAM POSITIVE ROD(S).
2+ ___ per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS AND SINGLY.
SMEAR REVIEWED; RESULTS CONFIRMED.
WOUND CULTURE (Final ___:
MIXED BACTERIAL FLORA.
This culture contains mixed bacterial types (>=3) so an
abbreviated workup is performed. Any growth of
P.aeruginosa,
S.aureus and beta hemolytic streptococci will be
reported. IF
THESE BACTERIA ARE NOT REPORTED, THEY ARE NOT PRESENT
___ this
culture.
ANAEROBIC CULTURE (Final ___:
MIXED BACTERIAL FLORA.
Mixed bacteria are present, which may include anaerobes
and/or
facultative anaerobes. The presence of B.fragilis,
C.perfringens,
and C.septicum is being ruled out.
BACTEROIDES FRAGILIS GROUP. HEAVY GROWTH.
BETA LACTAMASE POSITIVE.
___ 11:00 am ABSCESS Source: ___ ant abd.
**FINAL REPORT ___
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final ___: NO GROWTH.
ANAEROBIC CULTURE (Final ___: NO GROWTH.
FUNGAL CULTURE (Final ___: NO FUNGUS ISOLATED.
___ 11:20 pm STOOL CONSISTENCY: NOT APPLICABLE
**FINAL REPORT ___
C. difficile DNA amplification assay (Final ___:
Reported to and read back by ___ @ ___ ON ___ -
___.
CLOSTRIDIUM DIFFICILE.
Positive for toxigenic C difficile by the Cepheid
nucleic
amplification assay. (Reference
Range-Negative).
___ 6:21 pm URINE Source: ___.
**FINAL REPORT ___
URINE CULTURE (Final ___:
YEAST. >100,000 CFU/mL.
ENTEROCOCCUS FAECIUM. 10,000-100,000 CFU/mL.
SENSITIVITIES: MIC expressed ___
MCG/ML
_________________________________________________________
ENTEROCOCCUS FAECIUM
|
AMPICILLIN------------ =>32 R
LINEZOLID------------- 2 S
NITROFURANTOIN-------- 64 I
TETRACYCLINE---------- =>16 R
VANCOMYCIN------------ =>32 R
___ 5:00 pm ABSCESS Source: abdominal abscess.
**FINAL REPORT ___
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS AND CLUSTERS.
4+ (>10 per 1000X FIELD): GRAM NEGATIVE ROD(S).
3+ ___ per 1000X FIELD): GRAM POSITIVE ROD(S).
FLUID CULTURE (Final ___:
STREPTOCOCCUS ANGINOSUS (___) GROUP. SPARSE GROWTH.
SENSITIVITIES: MIC expressed ___
MCG/ML
_________________________________________________________
STREPTOCOCCUS ANGINOSUS (___)
GROUP
|
CEFTRIAXONE----------- 0.5 S
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN----------<=0.12 S
PENICILLIN G----------<=0.06 S
VANCOMYCIN------------ 1 S
ANAEROBIC CULTURE (Final ___:
MIXED BACTERIAL FLORA.
Mixed bacteria are present, which may include anaerobes
and/or
facultative anaerobes. The presence of B.fragilis,
C.perfringens,
and C.septicum is being ruled out.
BACTEROIDES FRAGILIS GROUP. SPARSE GROWTH.
BETA LACTAMASE POSITIVE.
Brief Hospital Course:
___ old woman with history of CAD c/b recent MI s/p stent
(___), perforated diverticulitis s/p sigmoid resection (___)
with colostomy s/p reversal who initially presented as a
transfer from an OSH with concerns for bowel perforation. She
reported onset of lower abdominal pain that progressively
worsened with associated nausea, vomiting, and bloody diarrhea.
She initially presented to an OSH where she underwent CT A/P
with concern for ___ perforation
Ms. ___ was admitted to the ICU with the diagnosis of
perforated sigmoid diverticulitis on ___. She was started
on Ceftazidime/Flagyl. ___ considered that there was no drainable
collection. Vital signs and abdominal exam remained stable. She
was transferred to the floor later ___ the day.
hospital course ___
On ___, she was taken to the operating room for exploratory
laparotomy, colonic resection, open abdomen, and temporary
abdominal closure with Abthera vac. Briefly, it appeared that
she had a ___ anastomosis perforation with chronic
interloop abscess that tracked into the pelvis and laterally and
up into the paracolic gutters. For full details of the
operation, please refer to the separately dictated operative
report. Because of her open abdomen and bowel discontinuity, she
was taken to the ICU post-operatively, intubated, for
monitoring, with plans for serial takeback ___ the next few days.
Over the next few days from ___ to ___, she underwent 4
subsequent operations for washout including placement of an
___ for continuous irrigation of the retroperitoneum
where the abscess had been, culminating on ___ with an
abdominal closure via skin flaps over visceral with open fascia.
She tolerated this procedures were and while on a small amount
of levophed for pressure support, she was able to wean off of
this and extubate before her last operation. She thereafter went
back to the ICU, extubated, for monitoring. On ___, given her
stability, she was transferred to the floor.
On the floor, she was doing well initially then had increasing
respiratory support requirement and was desaturating. She was
placed on a nonrebreather and maintained a saturation ___ the
high ___. She was also using her accessory muscles at this
point. An ABG showed low PO2. She underwent an emergent CTA
chest/CT abdomen which showed no evidence of PE. She was
thereafter transferred to the ICU for further monitoring. She
received 20mg IV Lasix, and had put out >700cc of urine, and
subsequently had improved respiratory status.
On ___, patient underwent a CT scan of the abdomen pelvis
which demonstrated improved fluid collections. On ___ the
drain ___ the right upper quadrant was removed and psychiatry was
consulted. Psychiatry recommended adding Remeron for sleep
nightly. On ___ patient's white blood cell count was
17,000 with increased left shift, and a UA and chest x-ray was
obtained. On ___, patient's white blood cell count was
noted to be downtrending to 15.1 from 17. The patient's stool
culture demonstrated c. difficile so she was started on a 14 day
course of oral vancomycin.
On ___ the patient was taken to the operating room for
Botox injection and skin closure revision followed by wound VAC
placement. For details of the surgical procedure please see
surgeon's operative note. Postoperatively bleeding from the
skin was noted and was cauterized. On ___, the patient was
restarted on Plavix and white blood cell counts continue to down
trend 13.7.
On ___, patient was transfused 1 unit of packed red blood
cells for hematocrit of 21.6. On ___, the wound VAC was
changed. And based on infectious disease recommendations the
patient was started on cefepime and Flagyl. CK level was
obtained and and the patient was started on daptomycin.
Based on sensitivities, the patient was started on Unasyn on 0
___. On ___, CT of the abdomen pelvis was obtained
which did not demonstrate any drainable collection by
interventional radiology. On ___ left-sided drain under
bulb suction was removed. On ___, the wound VAC was
changed. Stoma was noted to be retracted. On ___, the
patient completed the course of oral vancomycin. Unasyn was
also discontinued. The VAC dressing was removed on ___ and the
patient transitioned to wet to dry daily dressing changes. On
___, following completion of stoma training with the family
and the patient, the patient was deemed appropriate for
discharge home with services. On the day of discharge, the
patient was noted to have bleeding from the wound right abdomen
associated with removal of fragments of the VAC black sponge.
Silver nitrate was applied to the sites and a wet to dry
dressing was applied. There was no further evidence of
bleeding. The left drain was left ___ place to a gravity bag.
All appropriate follow-up instructions were given to the patient
and all questions were answered. Prior to discharge the patient
was tolerating a diet, pain was controlled on oral regimen
alone, and patient was ambulate independently. ___ services were
provided to assist with drain and ostomy care. A follow-up
appointment was made ___ the acute care clinic. The patient
requested a new primary care provider ___. An appointment was
made for her to follow-up ___ 1 week ___ Health Care Associates
with her new primary care provider.
Medications on Admission:
Had lapse ___ insurance and has not taken any medications ___ the
past 2months, but previously had been on metoprolol,
atorvastatin, ASA, and plavixThe Preadmission Medication list.
1. Metoprolol Tartrate 12.5 mg PO BID
2. Clopidogrel 75 mg PO DAILY
3. Atorvastatin 40 mg PO QPM
4. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Docusate Sodium 100 mg PO BID:PRN constipation
RX *docusate sodium 100 mg 1 tablet(s) by mouth twice a day Disp
#*28 Tablet Refills:*0
2. Furosemide 20 mg PO DAILY
please follow-up with your PCP for continuation of this
medication
RX *furosemide 20 mg 1 tablet(s) by mouth once a day Disp #*14
Tablet Refills:*0
3. Mirtazapine 7.5 mg PO QHS
RX *mirtazapine 7.5 mg 1 tablet(s) by mouth at bedtime Disp #*10
Tablet Refills:*0
4. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain -
Moderate
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*20 Tablet Refills:*0
5. Pantoprazole 40 mg PO Q24H
RX *pantoprazole 40 mg 1 tablet(s) by mouth once a day Disp #*14
Tablet Refills:*0
6. Polyethylene Glycol 17 g PO DAILY:PRN constipation
RX *polyethylene glycol 3350 17 gram/dose 17 gm powder(s) by
mouth once a day Disp #*6 Packet Refills:*1
7. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation
Q6H:PRN
wheezing, shortness of breath
RX *albuterol sulfate [ProAir HFA] 90 mcg 1 spray every six (6)
hours Disp #*1 Inhaler Refills:*0
8. Senna 8.6 mg PO BID:PRN decreased ostomy o/p
RX *sennosides [senna] 8.6 mg 1 tab by mouth once a day Disp
#*14 Tablet Refills:*0
9. Simethicone 40-80 mg PO QID:PRN gas
10. Aspirin 81 mg PO DAILY
RX *aspirin 81 mg 1 tablet(s) by mouth once a day Disp #*14
Tablet Refills:*0
11. Atorvastatin 40 mg PO QPM
RX *atorvastatin 40 mg 1 tablet(s) by mouth at bedtime Disp #*14
Tablet Refills:*0
12. Clopidogrel 75 mg PO DAILY
RX *clopidogrel 75 mg 1 tablet(s) by mouth once a day Disp #*14
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 #*28 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
perforated diverticulitis
abdominal wall abscesses
colostomy
respiratory failure
pneumonia
c.diff
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 abdominal pain. There
was concern for bowel perforation near the previous anastomosis
site. Your abdominal pain worsened, and ___ were taken to the
operating room for an exploratory laparotomy and lysis of
adhesions. ___ underwent creation of a colostomy. ___
subsequently returned to the operating room for additional
wound debridements and closure of the abdominal wound. A vac
dressing was placed and removed. ___ now have a small dressing
over the wound. ___ have received colostomy teaching. A drain
was placed ___ the left abdominal abscess which was left ___ place
at discharge. Your vital signs have been stable. ___ are being
discharged with the following instructions: ___ have an
appointment scheduled with the Acute care clinic and your new
PCP
___ experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If ___ are vomiting and cannot keep down 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.
___ experience burning when ___ urinate, have blood ___ your
urine, or experience a discharge.
___ have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change ___ your symptoms, or any new symptoms that concern
___.
Please resume all regular home medications , unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
___ are being discharged with the abdominal drain ___ place,
please follow these instructions:
___ Drain Care:
-Please look at the site every day for signs of infection
(increased redness or pain, swelling, odor, yellow or bloody
discharge, warm to touch, fever).
-Note color, consistency, and amount of fluid ___ the drain. Call
the doctor, ___, or ___ nurse if the amount
increases significantly or changes ___ character.
-Be sure to empty the drain bag or bulb frequently. Record the
output daily. ___ should have a nurse doing this for ___ may shower; wash the area gently with warm, soapy water.
-Keep the insertion site clean and dry otherwise.
-Avoid swimming, baths, hot tubs; do not submerge yourself ___
water.
- If ___ develop worsening abdominal pain, fevers or chills
please call Interventional Radiology at ___ at ___
and
page ___.
-When the drainage total is LESS THAN 10cc/ml for 2 days ___ a
row, please have the ___ call Interventional Radiology at ___
at ___ and page ___. This is the Radiology fellow on
call who can assist ___.
Followup Instructions:
___
|
19713049-DS-19
| 19,713,049 | 26,993,648 |
DS
| 19 |
2183-12-13 00:00:00
|
2183-12-28 15:16:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Foul smelling wound drainage
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with an extensive past surgical history including exlap,
LOA, resection of prior colorectal anastomosis with
end-colostomy, prolonged open abdomen ___ pelvis sepsis due to
perforated diverticulitis and subsequent abdominal closure with
skin flaps c/b flap necrosis most recently s/p ___
revision
and incisional hernia repair w/ ___ component separation now seen
in consultation for midline wound evaluation. Pt was recently
admitted to surgical service for management of this midline
wound
which appeared slightly open. Pt was discharged on ___ with a
wound vac in place which she has continued until today. Pt
reports that ___ took down her vac earlier today and noted a
foul
smell without any notable drainage; given the foul smell which
is
an acute change, she was sent to ___ ED for further workup and
management.
Aside from foul smell, pt denies any issues with her wound such
as increasing pain, change in size, fevers, chills, nausea, or
vomiting. She does report decreased ostomy output during the day
today but no obstipation.
Past Medical History:
PSHx:
- CAD c/b MI in ___ s/p drug-eluting stent x1, on Aspirin
81mg indefinitely and ticagrelor 90mg PO BID for at least ___ year
- Morbid obesity
- HTN
- HLD
- Asthma
- Adjustment disorder
PSHx:
s/p exlap, LOA, resection of prior colorectal anastomosis w/ end
colostomy, prolonged open abdomen ___ pelvic sepsis due to
perforated diverticulitis and subsequent abdominal
closure with skin flaps c/b flap necrosis requiring wound
debridement and injection of botox into the abdominal wall
musculature to assist with regaining abdominal domain s/p
revision of ___ and repair of giant incisional hernia
using bilateral component separation technique with mesh in
Social History:
___
Family History:
father w/CABGx5, diverticulosis, pancreatitis, Alzheimer's;
mother with lung CA
Physical Exam:
Admission Physical Exam:
98.9 68 92/56 16 95%RA
Gen: NAD, comfortable
CV: RRR
R: clear ___
Abd: soft, NT/ND, stoma is patent but with a small amt of hard
stool palpated, there is an approximate 6cm x4cm midline wound
which is foul smelling. the base appears clean. there is no
purulent drainage. there are no fistulae.
Ext: no c/c/e
Discharge Physical Exam:
VS: 98.4, 106/70, 65, 18, 91 Ra
Gen: A&O. lying comfortably in bed.
CV: HRR
Pulm: LS ctab
Abd: soft, NT/ND. Midline abdominal wound beefy red with healthy
granulating tissue. VAC replaced prior to discharge.
Ext: WWP no edema
Pertinent Results:
___ 06:42AM BLOOD WBC-7.8 RBC-3.50* Hgb-9.8* Hct-31.8*
MCV-91 MCH-28.0 MCHC-30.8* RDW-16.0* RDWSD-52.8* Plt ___
___ 04:44PM BLOOD WBC-12.8* RBC-3.99 Hgb-11.1* Hct-36.0
MCV-90 MCH-27.8 MCHC-30.8* RDW-15.9* RDWSD-52.4* Plt ___
___ 06:42AM BLOOD Glucose-76 UreaN-10 Creat-0.7 Na-143
K-4.4 Cl-104 HCO3-26 AnGap-13
___ 04:44PM BLOOD Glucose-85 UreaN-15 Creat-0.9 Na-138
K-4.5 Cl-98 HCO3-26 AnGap-14
___ 06:42AM BLOOD Calcium-8.5 Phos-4.0 Mg-1.9
IMAGING:
CT Abd / Pelvis:
1. Interval decrease in rim enhancing fluid collection in the
pelvis located
between the vaginal stump, rectal stump and the urinary bladder.
2. Wide open midline pelvic wall with extensive subcutaneous fat
stranding and
inflammatory stranding between the subcutaneous fat and the
peritoneal lining
in the right lower pelvis. 2 small rim enhancing fluid
collections enclosing
tiny locules of free air are seen within this inflammatory soft
tissue
stranding.
3. There is no extravasation/leak of orally ingested contrast
from the small
bowel loops into either of the above described collections or
into the
peritoneal cavity.
4. Right lower quadrant colostomy is intact
Brief Hospital Course:
___ w/ extensive surgical history admitted for wound evaluation.
Pt is currently stable and afebrile, but with a foul smelling
wound which does not demonstrate any evidence purulent
discharge. The wound VAC was taken down and dakins dressing
applied. On HD2, the patient was seen by Dr ___ was
pleased with how the wound looked and was not concerned about
any foul odor or infection. The VAC was replaced and the patient
was discharged home to resume ___ with q3d vac changes.
During this hospitalization, the patient ambulated early and
frequently, was adherent with respiratory toilet and incentive
spirometry, and actively participated in the plan of care. The
patient received subcutaneous heparin and venodyne boots were
used during this stay.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet, ambulating, voiding without assistance, and pain was well
controlled. The patient was discharged home with ___ services
for wound care. The patient received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with the discharge plan.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Albuterol Inhaler 1 PUFF IH Q6H:PRN shortness of breath
2. Furosemide 20 mg PO DAILY
3. Atorvastatin 40 mg PO QPM
4. FLUoxetine 40 mg PO DAILY
5. Mirtazapine 7.5 mg PO QHS
6. Pantoprazole 40 mg PO Q24H
7. Aspirin 81 mg PO DAILY
8. Metoprolol Tartrate 12.5 mg PO BID
9. Polyethylene Glycol 17 g PO DAILY
10. Docusate Sodium 100 mg PO BID
11. OxyCODONE (Immediate Release) 10 mg PO 3X/WEEK (___)
Discharge Medications:
1. Docusate Sodium 100 mg PO BID
2. Albuterol Inhaler 1 PUFF IH Q6H:PRN shortness of breath
3. Aspirin 81 mg PO DAILY
4. Atorvastatin 40 mg PO QPM
5. FLUoxetine 40 mg PO DAILY
6. Furosemide 20 mg PO DAILY
7. Metoprolol Tartrate 12.5 mg PO BID
8. Mirtazapine 7.5 mg PO QHS
9. OxyCODONE (Immediate Release) 10 mg PO 3X/WEEK (___)
RX *oxycodone 5 mg ___ tablet(s) by mouth Q3D Disp #*20 Tablet
Refills:*0
10. Pantoprazole 40 mg PO Q24H
11. Polyethylene Glycol 17 g PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Draining abdominal wound
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to ___ with concerns about your abdominal
wound. The wound was evaluated and did not seem to be infected.
You are ready to be discharged home to continue your recovery.
The ___ should resume changing the VAC dressing every 3 days. We
will see you in clinic for follow-up.
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:
___
|
19713100-DS-62
| 19,713,100 | 28,902,046 |
DS
| 62 |
2177-08-28 00:00:00
|
2177-08-28 17:12:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
Amitiza / Oxybutynin / Bactrim
Attending: ___.
Chief Complaint:
Abnormal movements
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is an ___ man with hypotonic bladder with chronic
foley c/b multiple drug-resistant UTIs (MRSA and ESBL E. Coli),
CAD s/p CABG, s/p bovine AVR, DM, and HTN who was discharged
from ___ on ___ after treatment for Cipro-sensitive
Acinetobacter and Enterobacter UTI. Had been doing well until
yesterday when he began experiencing uncontrollable tremors of
his face and neck. No fevers documented at rehab. + chills. Also
noted to be hypoxic to 90% on room air-> 94% on 3L at rehab. ___
WNL. Of note, he had a witnessed fall onto his left face on
___. Sent to ED for tremors and hypoxemia. He is able to
answer questions and follow commands but has difficulty with
articulating words due to facial tremors. He denies ever having
these symptoms before. Also denies focal weakness, paresthesias,
or confusion. Only other complaint at this time is left groin
pain. 10-point ROS reviewed and was otherwise negative.
.
Vitals in ED: 98.0 60 92/61 20 94% 4L. Given Levofloxacin IV
750mg x1.
Past Medical History:
1. Hypotonic bladder with incomplete emptying, s/p indwelling
foley since ___ c/b frequent Multidrug resistent UTIs, incl
MRSA and ESBL E Coli
2. BPH
3. CAD s/p CABG x 3 in ___
- CABG anatomy: LIMA to LAD, SVG to OM, and SVG to RCA
- s/p stenting ___ of mid RCA, PTCA of proximal RCA and PDA
- redo single vessel CABG in ___ with Dr. ___.
4. Bovine AVR in ___. Type 2 Diabetes Mellitus: diet controlled
6. Hypertension
7. Hx of Chronic constipation
8. Hyperlipidemia
9. Depression /Anxiety
10. Asbestosis
11. Spinal stenosis
12. R kidney mass - Followed by urology w/ serial imaging,
likely RCC
13. Osteoarthritis
14. Carotid stenosis - chronic occlusion of ___, ___ with 40%
stenosis
Social History:
___
Family History:
Daughter- died at ___,breast cancer.
Father- died from ___ in his ___.
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death.
Physical Exam:
Admission Exam:
Vitals: 98.2 122/70 84 20 93% 2L
Gen: uncontrollable facial twitching, can only articulate few
words, A&Ox3, appears uncomfortable
HEENT: OP clear, MMM
Neck: supple, no LAD
CV: RRR, S1/S2 nl, no MRG
Lungs: CTAB except decreased breath sounds at bases
Abd: soft, NT, ND, NABS
Ext: 2+ bilat pitting edema to knees
Neuro: tremors of head, neck, and upper extremities, further
exam limited ___ tremors
Skin: abrasions on face from fall
Psych: appropriate
Discharge Exam:
General: Elderly Caucasian M, sitting up at bedside,
cooperative, NAD
HEENT: NCAT, MMM, OP clear
Neck: Supple. decreased ROM
Pulmonary: CTAB without R/R/W
Cardiac: RRR,
Abdomen: soft, obese, NT, mildly distended with normoactive
bowel
sounds, no masses appreciated (difficult to assess ___ body
habitus)
Extremities: Warm, well-perfused bilaterally
Skin: No rashes or lesions,
Neurologic Exam:
-Mental Status: A&O x 2 stated it was ___. Able to relate
history with moderate difficulty and dysarthria.
Language is fluent with intact repetition
and comprehension. Normal prosody. dysarthria and difficulty
forming words secondary to tremor,
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 4-->2.5mm brisk bilaterally. VF.
III, IV, VI: EOMI without nystagmus. Normal saccades.
V: Facial sensation intact to light touch.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes midline.
-Motor: Normal bulk and tone. able to maintain arms and legs
antigravity. No tremors or abnormal movements noted.
-Sensation: Intact to light touch
-DTRs:
Plantar response was extensor bilaterally.
-Coordination: no dysmetria on FNF
Pertinent Results:
___ 02:44AM BLOOD WBC-7.1 RBC-4.49* Hgb-13.4* Hct-38.6*
MCV-86 MCH-29.9 MCHC-34.8 RDW-16.4* Plt ___
___ 02:44AM BLOOD Neuts-67.0 ___ Monos-5.7 Eos-4.4*
Baso-1.0
___ 02:44AM BLOOD Glucose-122* UreaN-20 Creat-1.0 Na-136
K-4.2 Cl-99 HCO3-28 AnGap-13
___ 02:44AM BLOOD Lactate-1.1 K-4.4
.
BCx, UCx (___): pending, NGTD
.
CXR (___):
1. Persistent left basilar atelectasis and pleural effusion, new
pneumonia and/or increase in pleural effusion may well be
present. Conventional radiographs recommended, when feasible.
2. Probable subsegmental atelectasis in the right lung base.
3. No overt pulmonary edema.
CT head ___:
IMPRESSION: No acute intracranial process.
EEG ___:
Preliminary read shows right frontocentral slowing without any
epileptiform features.
Brief Hospital Course:
Mr. ___ is an ___ man with hypotonic bladder with chronic
foley c/b multiple drug-resistant UTIs (MRSA and ESBL E. Coli),
CAD s/p CABG, s/p bovine AVR, DM, and HTN, recent discharge for
Acinetobacter and Enterobacter UTI admitted for work-up and mgmt
of hypoxemia and increased tremors likely ___ new pneumonia.
.
## Tremors: likely ___ PNA vs. recent fall vs. Ciprofloxacin.
Electrolytes ok. Neurology consulted, who recommended starting
Clonazepam, which improved the tremors significantly. Statin was
held but can probably be restarted. CT head was negative for
intracranial bleed. Patient was transferred to the Neurology
service for EEG monitoring to rule out seizure activity.
Clonazepam was held and his EEG showed right frontocentral
slowing without any epileptiform features. By ___ his
abnormal movements had completely resolved. Of note pt has
previously been evaluated by Dr. ___ in movement disorders
clinic for "tremors" (last seen in ___. We will have him
follow up with Drs. ___ within 2 months.
.
## Acinetobacter/Enterobacter UTI: Ciprofloxacin was stopped on
admission and he was treated with Zosyn instead through ___.
Needs outpatient Urology follow-up.
.
## HCAP: He was treated with Zosyn during his admission for
aspiration pneumonitis vs. pneumonia. He was transitioned to
Clindamycin 300mg PO QID upon discharge to complete a total 10
day course.
.
## Hypoxemia: Likely due to aspiration. See above for management
of pneumonia. There was no sign of volume overload on CXR. He
was maintained on supplemental O2 via NC which was gradually
weaned down.
## CAD s/p CABG, s/p AVR, HTN, HL: Continued on home cardiac
meds.
.
## Carotid artery stenosis: Continued on home ASA.
.
## Depression: Celexa dose was decreased due to tremors.
.
## h/o Renal mass: Needs outpt Urology follow-up.
.
## Code status: DNR/DNI.
.
## Dispo: He was discharged back to his rehab facility in good
condition on ___. He was instructed to follow up with Drs.
___ within 2 months in neurology clinic.
Medications on Admission:
Ciprofloxacin 500mg BID (until ___
Lasix 20mg daily (started ___
Atorvastatin 80mg QHS
Tolterodine 4mg QHS
Celexa 40mg daily
Toprol XL 25mg daily
Isosorbide mononitrate 60mg daily
ASA 81mg daily
Omeprazole 20mg daily
Calcium carbonate 1300mg QPM
Vit D3 1000U daily
Colace 100mg BID
Miralax daily PRN
Trazodone 75mg QHS PRN
Lotrisone cream BID
Dulcolax 10mg daily PRN
Discharge Medications:
1. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig:
One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
2. isosorbide mononitrate 60 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
3. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
4. cholecalciferol (vitamin D3) 1,000 unit 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. polyethylene glycol 3350 17 gram Powder in Packet Sig: One
(1) Powder in Packet PO DAILY (Daily) as needed for
constipation.
7. trazodone 50 mg Tablet Sig: 1.5 Tablets PO HS (at bedtime) as
needed for insomnia.
8. clotrimazole 1 % Cream Sig: One (1) Appl Topical BID (2 times
a day).
9. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
HS (at bedtime) as needed for constipation.
10. tolterodine 2 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
11. calcium carbonate 500 mg calcium (1,250 mg) Tablet Sig: One
(1) Tablet PO QPM (once a day (in the evening)).
12. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
13. citalopram 40 mg Tablet Sig: One (1) Tablet PO once a day.
14. clindamycin HCl 300 mg Capsule Sig: One (1) Capsule PO four
times a day for 7 days.
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Abnormal movements - likely related to infection/medication
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 Mr. ___,
You were admitted to ___ on
___ for abnormal movements and low oxygen
saturation. The abnormal movements you were having seem to have
been due to the antibiotic you were on to treat your UTI. For
that reason, that medication was stopped and changed to a new
antibiotic called Zosyn. Your low oxygen level was also found
to be due to a new pneumonia and the Zosyn will also treat this.
You will be changed to a different antibiotic called Clindamycin
upon discharge which can be taken orally for the next 7 days to
complete your treatment. After stopping the other antibiotic
(Cipro), the abnormal movements stopped as well and you have
been doing well. An EEG showed no evidence of seizure activity.
We made the following changes to your medications:
Discontinued Ciprofloxacin
Started Clindamycin 300mg four times per day
If you experience any of the below listed danger signs, please
call your doctor or go to the nearest Emergency Department.
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs.
It was a pleasure taking care of you during your hospital stay.
Followup Instructions:
___
|
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| 63 |
2177-09-24 00:00:00
|
2177-09-24 23:30:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
___ / Oxybutynin / Bactrim
Attending: ___.
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
PICC line placement
Foley catheter exchange
History of Present Illness:
___ w/hx CAD s/p CABG, chronic foley for hypotonic bladder c/b
recurrent MDR UTIs, DM & HTN recently admitted for a UTI and
pneumonia now re-presents from home where he was awakened from
sleep by substernal non-radiating chest pain. Describes pain as
both dull and sharp, lasting a few hours. Took full strength
aspirin at home prior to admission. We note that he had been
discharged to ___ on ___ sent home only 3 days
prior to admission. Review of OMR demonstrates that cardiac
catheterization showing 3 vessel disease was performed ___ yr ago,
no subsequent stress testing.
.
In the ED, initial VS: 98.2 77 90/55 20 98% 4LxNC. He recieved
Ciprofloxacin IV for positive UA. Serial troponins were 0.05 and
0.06 with Cr 1.0. ED EKG NSR w/RBBB, rate 78 bpm, no ST segment
changes. Admitted to the cardiology service for ___. On arrival
to the floor he describes pain as above, said it is "very mild"
and "better." Denies dyspnea, cough, syncope, dizziness,
palpitations, abdominal pain, fevers, chills.
Past Medical History:
1. Hypotonic bladder with incomplete emptying, s/p indwelling
foley since ___ c/b frequent MDR UTIs including MRSA and ESBL E
Coli
2. BPH
3. CAD s/p CABG x ___
- CABG anatomy: LIMA to LAD, SVG to OM, and SVG to RCA
- s/p stenting ___ of mid RCA, PTCA of proximal RCA and PDA
- redo single vessel CABG in ___ with Dr. ___.
4. Bovine AVR in ___. Type 2 Diabetes Mellitus: diet controlled
6. Hypertension
7. Hx of Chronic constipation
8. Hyperlipidemia
9. Depression /Anxiety
10. Asbestosis
11. Spinal stenosis
12. R kidney mass - Followed by urology w/ serial imaging,
likely RCC
13. Osteoarthritis
14. Carotid stenosis - chronic occlusion of ___, ___ with 40%
stenosis
Social History:
___
Family History:
Daughter- died at ___ from breast cancer.
Father- died from MI in his ___.
Physical Exam:
ADMISSION EXAM:
VS - 76, RR: 22, BP: 120/80, O2Sat: 95, 3L NC
GENERAL - Alert, interactive, well-appearing in NAD
HEENT - PERRLA, EOMI, sclerae anicteric, MMM, OP clear
NECK - Supple, no thyromegaly, no JVD, no carotid bruits
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 - WWP, no c/c/e, 2+ peripheral pulses . Healing
right heel ulcer, no signs of infection.
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
.
CARDIOLOGY TO MEDICINE TRANSFER EXAM:
T 96, BP 144/94, HR 96, RR 20, O2 93% RA
General: AOx3, sometimes slightly tangential but redirectable
Mouth: Dry MM
Neck: No elevated JVD
Heart: RRR, normal S1, S2, no extra heart sounds, no MRG
Lungs: CTAB
Abd: slight TTP
Extremeties: Legs wrapped and in multipodus boots, edema
improved
GU: Foley with clear, yellow urine
Skin: Seborrhea on face
.
DISCHARGE EXAM
VS Tm 98.1 Tc 98.1 146/80 (120-140s/70-90s) 86 20 92/RA
GEN elderly man lying down in bed w/1 pillow, NAD, breathing
comfortably and speaking in full sentences
HEENT NCAT MMM EOMI, conjunctiva non-injected, OP clear
NECK supple, JVP flat, no LAD
PULM CTAB, min bibasilar rales, no rhonchi or wheeze; no cough
CV RRR normal S1/S2, no mrg
ABD obese NT ND normoactive bowel sounds, no suprapubic
tenderness, R groin tender to deep palpation, no r/g, no CVAT
FOLEY in place, no tenderness or discharge from urethral meatus,
clear yellow urine, no sediment
EXT WWP 2+ pulses palpable bilaterally, waffle boots and
ACE-wraps in place, symmetric bilateral nonpitting pedal edema,
R heel eschar well-healing
NEURO AOX3, speech fluent but perseverating and anxious-seeming,
thought process non-linear, CN intact, strength ___ throughout,
gait not assessed
Pertinent Results:
ADMISSION LABS
___ 04:10AM BLOOD WBC-6.5 RBC-4.68 Hgb-13.4* Hct-41.9
MCV-90 MCH-28.7 MCHC-32.0 RDW-16.4* Plt ___
___ 04:10AM BLOOD Neuts-65.6 ___ Monos-4.8 Eos-5.6*
Baso-0.9
___ 04:10AM BLOOD ___ PTT-28.7 ___
___ 04:10AM BLOOD Glucose-122* UreaN-28* Creat-1.0 Na-136
K-4.9 Cl-100 HCO3-28 AnGap-13
___ 04:10AM BLOOD CK-MB-7
___ 04:10AM BLOOD cTropnT-0.05*
___ 01:04PM BLOOD CK-MB-7 cTropnT-0.06*
___ 04:10AM BLOOD Calcium-9.2 Phos-3.7 Mg-2.0
.
PERTINENT LABS
___ 04:10AM BLOOD cTropnT-0.05*
___ 01:04PM BLOOD CK-MB-7 cTropnT-0.06*
___ 06:55PM BLOOD CK-MB-5 cTropnT-0.09*
.
DISCHARGE LABS
___ 06:45AM BLOOD WBC-5.3 RBC-5.45 Hgb-15.0 Hct-48.4 MCV-89
MCH-27.6 MCHC-31.1 RDW-16.8* Plt ___
___ 06:45AM BLOOD Neuts-69.5 ___ Monos-5.6 Eos-6.1*
Baso-0.7
___ 06:45AM BLOOD Glucose-108* UreaN-16 Creat-0.9 Na-137
K-3.8 Cl-100 HCO3-28 AnGap-13
___ 06:45AM BLOOD Calcium-9.2 Phos-2.9 Mg-1.6
.
MICROBIOLOGY
.
URINALYSIS
___ 04:10AM URINE Color-Yellow Appear-Cloudy Sp ___
___ 04:10AM URINE Blood-MOD Nitrite-POS Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-LG
___ 04:10AM URINE RBC-11* WBC->182* Bacteri-MANY Yeast-NONE
Epi-0 TransE-<1
___ 04:10AM URINE WBC Clm-FEW
.
___ URINE CULTURE (Final ___:
ESCHERICHIA COLI. >100,000 ORGANISMS/ML..
STAPHYLOCOCCUS, COAGULASE NEGATIVE >100,000 ORGANISMS/ML.
_________________________________________________________
ESCHERICHIA COLI
| STAPHYLOCOCCUS,
COAGULASE NEGATIVE
| |
AMPICILLIN------------ 8 S
AMPICILLIN/SULBACTAM-- 4 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ <=1 S =>16 R
LEVOFLOXACIN---------- =>8 R
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S <=16 S
OXACILLIN------------- =>4 R
TETRACYCLINE---------- 4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
VANCOMYCIN------------ 2 S
.
___ URINE CULTURE (Final ___: GRAM NEGATIVE ROD(S).
~1000/ML.
.
___ BLOOD CULTURE X2 - NEGATIVE (FINAL)
___ BLOOD CULTURE (Preliminary):
STAPHYLOCOCCUS, COAGULASE NEGATIVE.
Isolated from only one set in the previous five days.
Susceptibility testing requested by ___. ___
___
(___).
___ BLOOD CULTURE
.
IMAGING
.
___ CXR
Chest, PA and lateral radiographs demonstrate stable elevation
of left hemidiaphragm and adjacent left lower lobe atelectasis
obscuring left heart border. Left pleural effusion. Stable right
lower lung opacifications, likely representing atelectasis. No
overt pulmonary edema evident. Stable small left pleural
effusion. No pneumothorax identified. Mediastinal and hilar
contours are unchanged.
IMPRESSION:
1. Stable left lower lung atelectasis and pleural effusion.
2. No overt pulmonary edema.
.
___ CXR
Moderate-to-large left pleural effusion has improved. Right
lower lobe
opacity consistent with atelectasis has worsened. The left
hemidiaphragm is elevated as before. Mild vascular congestion is
probably unchanged. There is no evidence of pneumothorax.
Sternal wires are aligned. Cardiac size cannot be evaluated, it
is obscured by pleural or parenchymal abnormality.
.
___ RIGHT GROIN ULTRASOUND
Ultrasound of the right groin focused in the inguinal region
demonstrates no evidence for hernia.
IMPRESSION: No hernia in right groin.
.
___ RENAL ULTRASOUND
MPRESSION:
1. Please note that ultrasound is insensitive technique for
evaluating
pyelonephritis. The patient has a known solid mass in the upper
pole of the right kidney, but no evidence for hydronephrosis or
stones.
2. No perinephric abscess is identified.
.
___ CXR (PICC PLACEMENT)
IMPRESSION: Left PICC line terminates in the left
brachiocephalic vein.
.
OTHER STUDIES
.
___ EKG
Sinus rhythm. HR 78. Right bundle-branch block. Compared to the
previous tracing of ___ no diagnostic interim change
.
___ TTE
The left atrium and right atrium are normal in cavity size.
There is mild symmetric left ventricular hypertrophy with normal
cavity size and regional/global systolic function (LVEF>55%).
Right ventricular chamber size and free wall motion are normal.
The aortic valve is not well seen. There is mild aortic valve
stenosis (valve area 1.2-1.9cm2). No aortic regurgitation is
seen. The mitral valve leaflets are mildly thickened. Trivial
mitral regurgitation is seen.
IMPRESSION: Very limited study. Normal global and regional
biventricular systolic function. Probable mild aortic stenosis.
If more detailed evaluation of cardiac structures is desired,
recommend a transesophageal examination or a cardiac MRI.
Compared with the prior study (images reviewed) of ___,
the findings are similar.
.
___ TTE
The left ventricle is not well seen. There is mild symmetric
left ventricular hypertrophy. The left ventricular cavity size
is normal. Due to suboptimal technical quality, a focal wall
motion abnormality cannot be fully excluded. Overall left
ventricular systolic function is normal (LVEF>55%). The right
ventricular free wall is hypertrophied. Right ventricular
chamber size is normal. The aortic valve is not well seen. No
masses or vegetations are seen on the aortic valve, but cannot
be fully excluded due to suboptimal image quality. No aortic
regurgitation is seen. The mitral valve leaflets are not well
seen. No masses or vegetations are seen on the mitral valve, but
cannot be fully excluded due to suboptimal image quality. No
masses or vegetations are seen on the tricuspid valve, but
cannot be fully excluded due to suboptimal image quality. The
pulmonary artery systolic pressure could not be determined.
There is no pericardial effusion.
IMPRESSION: Suboptimal image quality. Unable to adequately
assess for the absence/presenceof valvular vegetations or
abscesses.
.
PENDING STUDIES AT DISCHARGE
___ & ___ BLOOD CULTURES ___ will call rehab with
results)
Brief Hospital Course:
___ w/ hx of hypotonic bladder requiring chronic foley c/b
multiple MDR urinary tract infections, coronary artery disease
s/p CABG, type 2 diabetes mellitus and hypertension who was
initially admitted to the Cardiology service with chest pain and
then transferred to the General Medicine service for management
of E.coli and coagulase negative urinary tract infections.
Hospital course was notable for coagulase negative staph
septicemia.
.
# ATYPICAL CHEST PAIN
Patient presented with chest pain with non-ischemic EKG,
minimally-elevated troponin and negative CK-MD. ___
echocardiogram was performed and was not significantly changed
from prior with preserved EF and no regional hypokinesis. Chest
pain was treated with tylenol; pain recurred frequently during
this admission, whenever the patient was anxious or agitated and
improved with low dose benzodiazpines and pain medications. It
was also noted to be transient and migratory, appearing variably
in his chest, abdomen and right groin. He was transferred from
cardiology to medicine because pain was felt to be
non-cardiogenic.
.
#CAD s/p CABG
No evidence of active ischemia. Pt previously on a statin which
was held during a prior admission because of myoclonic jerking.
Not restarted on the cardiology service - deferred for scheduled
neurology follow-up. Patient continued on home aspirin with
addition of lisinopril and metoprolol for hypertension and
managment of peripheral edema.
.
#Urinary tract infections/Coagulase negative staph septicemia:
Patient has history of frequent multidrug resistant UTIs likely
complicated by his chronic foley which he has for chronic
bladder hypotonia. He had a grossly positive UA on admission and
was initially treated with ciprofloxacin based upon prior
culture data. Antibiotics were switched to macrobid when
speciation/sensitivities showed Cipro-R E coli and coag negative
staph. Vancomycin was added when blood cultures drawn
subsequently (during episode of transient hypotension, fluid
responsive) grew coag negative staph. Infectious Disease was
consulted and a repeat TTE showed no vegetation, but was not of
good quality. After consultation with ID, pt was discharged with
plan for 12-day additional course both vancomycin & macrobid,
for 14-day course of both (PICC placed before discharge). Note:
foley exchanged on admission on ___.
.
#VENOUS INSUFFICIENCY
Bilateral symmetric leg edema was noted on admission. Cardiology
felt it likely ___ venous insufficiency rather than heart
failure as patient was not grossly volume overloaded. Patient's
legs were wrapped with ace bandages.
#Acute on chronic diastolic heart failure:
Patient experienced volume overload after fluid resuscitation
for hypotension which was likely related to receiving
isosorbide. He improved substantially after he was diuresed 3+
liters with PO lasix. Will continue 20mg PO lasix QD on
discharge.
.
# DEPRESSION/ANXIETY
Patient endorsed and manifested both depression and anxiety
during this admission. Considered a possible contributor to his
migratory aches and pains. Home celexa was decreased to 20 mg QD
to comply w/recent DFA warning. Trazodone continued qHS
(daughter requests this prescription *not* be PRN, pt takes
trazodone nightly at home and has hx of sundowning in
hospitals/rehab when he does not take trazodone). Seen by social
work during this admission, for counseling and support
surrounding his difficulty with current medical situation and
ongoing grief over loss of his wife.
.
# MIGRATORY ACHES AND PAIN
Patient has chronic migratory aches and pains, especially noted
to correlate with anxiety and agitated in the hospital. Daughter
reports similar symptoms at home whenever she leaves him with a
caregiver, however briefly. He does have known R renal cell
carcinoma (not being treated by urology, following
radiographically) which could cause discomfort). Treated
in-hospital with 1x doses pRN 5 mg PO oxycodone and/or 1 mg PO
ativan with good effect. Also prescribed standing tylenol ___
TID. ___ rehab MD prescribe oxycodone/ativan on a PRN
basis; no scripts provided at discharge.
.
# CHRONIC CONSTIPATION
Continued home laxatives.
.
# HX BLADDER SPASM
Continued home Tolterodine 2 mg PO BID
.
# HX GERD
Continued omeprazole 20 mg Capsule PO DAILY
.
# HX ___ INTERTRIGO
Previously on clotrimazole 1 % Cream Sig: One (1) Appl Topical
BID, no e/o ___ intertrigo on exam during this admission -
held.
.
TRANSITIONAL ISSUES
*Needs physical therapy
*Needs ongoing social work/counseling surrounding
depression/anxiety/grief
*Consider starting oxycodone and/or ativan as-needed for
migratory pain and anxiety
*Needs follow-up electrolyte check (Na, K, Mg, Phos, Cr) -
patient started on lisinopril and lasix during this admission
*Needs follow-up UA/UCx, BCx in 12 days when antibiotics
completed.
*Needs PICC pulled after antibiotic course completed (minimum 14
days vancomycin)
*Consider restarting Imdur (60 mg QD) if SBP >110 for at least 2
days off antibiotics.
*Needs daily wound care to R heel eschar (wound care recs for
nursing on page 1)
NOTE: We will call with results of pending blood cultures.
Medications on Admission:
1. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig:
One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
2. isosorbide mononitrate 60 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
3. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
4. cholecalciferol (vitamin D3) 1,000 unit 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. polyethylene glycol 3350 17 gram Powder in Packet Sig: One
(1) Powder in Packet PO DAILY (Daily) as needed for
constipation.
7. trazodone 50 mg Tablet Sig: 1.5 Tablets PO HS (at bedtime) as
needed for insomnia.
8. clotrimazole 1 % Cream Sig: One (1) Appl Topical BID (2 times
a day).
9. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
HS (at bedtime) as needed for constipation.
10. tolterodine 2 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
11. calcium carbonate 500 mg calcium (1,250 mg) Tablet Sig: One
(1) Tablet PO QPM (once a day (in the evening)).
12. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
13. citalopram 40 mg Tablet Sig: One (1) Tablet PO once a day.
14. clindamycin HCl 300 mg Capsule Sig: One (1) Capsule PO four
times a day for 7 days.
Discharge Medications:
1. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig:
One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
Disp:*30 Tablet Extended Release 24 hr(s)* Refills:*2*
2. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. nitrofurantoin monohyd/m-cryst 100 mg Capsule Sig: One (1)
Capsule PO Q12H (every 12 hours) for 9 days.
Disp:*18 Capsule(s)* Refills:*0*
7. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. polyethylene glycol 3350 17 gram Powder in Packet Sig: One
(1) packet PO once a day as needed for constipation.
9. trazodone 50 mg Tablet Sig: 1.5 Tablets PO HS (at bedtime):
please give at 9 pm.
10. tolterodine 2 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
11. bisacodyl 10 mg Suppository Sig: One (1) suppository Rectal
at bedtime as needed for constipation.
12. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
13. cholecalciferol (vitamin D3) 1,000 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
14. calcium carbonate 500 mg calcium (1,250 mg) Tablet Sig: One
(1) Tablet PO at bedtime.
15. vancomycin in D5W 1 gram/200 mL Piggyback Sig: One (1)
piggyback Intravenous Q 12H (Every 12 Hours) for 14 days.
Disp:*24 piggyback * Refills:*0*
16. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO TID (3
times a day): maximum 6 tabs per day.
17. vancomycin 750 mg Recon Soln Sig: One (1) piggyback
Intravenous every twelve (12) hours for 14 days.
Disp:*28 piggybacks* Refills:*0*
Discharge Disposition:
Extended Care
Facility:
___
___ Diagnosis:
PRIMARY DIAGNOSES
Complicated urinary tract infection
Septicemia from urinary source
Atypical chest pain
Heart failure with preserved ejection fraction (55%)
.
SECONDARY DIAGNOSES
Coronary artery disease
Hypertension
Bladder dystonia
Spinal stenosis
Hyperlipidemia
Diabetes mellitus
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of ___ at ___.
___ were admitted for evaluation of your chest pain. Labs and
studies suggested your pain was not related to your heart.
.
___ were found to have accumulated fluid in your legs (edema),
so a heart ultrasound (ECHO) was performed to check for heart
failure. ___ edema improved with a new medication called lasix.
.
___ were also found to have another urinary tract infection. ___
were treated with macrobid and vancomycin - ___ will receive ___
additional 14 days of antibiotics at rehab. Your PICC line will
be removed after the antibiotics finish and your infection
clears.
The following changes were made to your medications:
STOP IMDUR (ISOSORBIDE MONONITRATE)
STOP CLOTRIMAZOLE
STOP CLINDAMYCIN
START LISINOPRIL, TAKE 2.5 MG ___ OF A 5 MG TABLET) DAILY
START LASIX (FUROSEMIDE), ONE 20 MG TABLET DAILY
START MACROBID (ANTIBIOTIC), 1 TAB EVERY 12 HOURS FOR 9 DAYS
START VANCOMYCIN (ANTIBIOTIC), 1 750 mg INFUSION EVERY 12 HOURS
FOR 14 DAYS
DECREASED CELEXA (CITALOPRAM) TO ONE 20 MG TABLET DAILY
.
NOTE: ___ received some oxycodone and ativan here in the
hospital to treat aches and anxiety. We did not prescribe these
medications, but recommend the rehab MD consider doing so if ___
suffer similar symptoms there.
PLEASE REVIEW THIS LIST OF MEDICATIONS WITH THE REHAB MD ON
ARRIVAL, AND WITH YOUR PRIMARY CARE DOCTOR AT YOUR NEXT
APPOINTMENT.
.
While at rehab, ___ should be weighed every morning, & rehab
staff should call MD if your weight goes up more than 3 lbs. ___
should continue to do this at home after ___ leave rehab, too.
Followup Instructions:
___
|
19713100-DS-64
| 19,713,100 | 26,503,964 |
DS
| 64 |
2177-11-02 00:00:00
|
2177-11-02 17:24:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
___ / Oxybutynin / Bactrim
Attending: ___.
Chief Complaint:
groin pain
Major Surgical or Invasive Procedure:
NONE
History of Present Illness:
___ yo man with pmhx of hypotonic bladder with chronic foley c/b
multiple drug-resistant UTIs (MRSA and ESBL E. Coli), CAD s/p
CABG, s/p bovine AVR, DM, and HTN who initially presented to the
emergency department because he noticed his foley bag was empty
this morning. He was concerned when he awoke this mornign and
didn't see any urine the the bag. He also had groin pressure at
that time. After he sat up, he noted that urine went into the
bag and his groin pain resolved. He currently denies groin pain,
hematuria. No chest pain or shortness of breath.
In the emergency department, initial vitals were 97.4 99 147/100
18 97% on RA. Patinet was incidentally noted to have left leg
redness and swelling on examination. He had a left lower
extremity ultrasound, which did not show a DVT. He had blood and
urine cultures taken. He received a dose of vancomycin for
cellulitis and was admitted to medicine service for treatment of
cellulitis. Vitals on transfer were 97.7, 86, 20, 100/64, 100%.
On the floor, patinet complains that he is very tired and would
like to sleep. He has not been sleeping well at home. He thinks
his left leg redness and swelling are somewhat worse than
normal. He had subjective fevers at home but did not take his
temperature. His groin pain is resolved.
REVIEW OF SYSTEMS:
Denies chills, night sweats, headache, vision changes,
rhinorrhea, congestion, sore throat, cough, shortness of breath,
abdominal pain, nausea, vomiting, diarrhea, constipation, BRBPR,
melena, hematochezia, hematuria.
Past Medical History:
1. Hypotonic bladder with incomplete emptying, s/p indwelling
foley since ___ c/b frequent Multidrug resistent UTIs, incl
MRSA and ESBL E Coli
2. BPH
3. CAD s/p CABG x 3 in ___
- CABG anatomy: LIMA to LAD, SVG to OM, and SVG to RCA
- s/p stenting ___ of mid RCA, PTCA of proximal RCA and PDA
- redo single vessel CABG in ___ with Dr. ___.
4. Bovine AVR in ___. Type 2 Diabetes Mellitus: diet controlled
6. Hypertension
7. Hx of Chronic constipation
8. Hyperlipidemia
9. Depression /Anxiety
10. Asbestosis
11. Spinal stenosis
12. R kidney mass - Followed by urology w/ serial imaging,
likely RCC
13. Osteoarthritis
14. Carotid stenosis - chronic occlusion of LICA, ___ with 40%
Social History:
___
Family History:
Daughter- died at ___,breast cancer.
Father- died from MI in his ___.
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
VS - 98.1, 90/58, 90, 20, 94% on RA
GENERAL - Alert and interactive, but keeping eyes closes most of
visit, appears tired
HEENT - PERRL, EOMI, sclerae anicteric, MMM, OP clear
NECK - Supple, no thyromegaly, no carotid bruits
HEART - RRR, nl S1-S2, no MRG
LUNGS - Clear to auscultation b/l, no wheezes/rales/rhonchi
ABDOMEN - NABS, soft/NT/ND, no masses or HSM
EXTREMITIES - LLE edema > RLE, Healing right heel ulcer with
minimial surrounding erythema, LLE with erythema extending from
foot to mid calf, blister on anterior right ankle/shin
SKIN - LLE erythema
LYMPH - no cervical, axillary, or inguinal LAD
NEURO - awake, ___, CNs II-XII grossly intact
DISCHARGE PHYSICAL EXAM:
========================
VS - 98.0; 97-140/58-78; 80-96; 18; 95RA
EXTREMITIES - LLE edema > RLE, LLE with mild erythema extending
from foot to mid calf, non-tender, no fluctuance
onychomycosis of all 10 toe nails
3 cm ulcer with mild fibrinous exudate on right posterior heel
c/w pressure ulcer, no surrounding erythema, non-tender, no
drainage, does not probe to bone
GU- foley in place, draining clear urine
Exam otherwise unchanged since admission
Pertinent Results:
ADMISSION LABS:
___ 08:05PM BLOOD WBC-9.6# RBC-4.79 Hgb-13.5* Hct-41.0
MCV-86 MCH-28.1 MCHC-32.8 RDW-18.0* Plt ___
___ 08:05PM BLOOD Neuts-74.1* Lymphs-17.1* Monos-4.4
Eos-4.0 Baso-0.4
___ 08:05PM BLOOD Glucose-132* UreaN-26* Creat-1.0 Na-137
K-4.5 Cl-99 HCO3-29 AnGap-14
___ 06:25AM BLOOD Calcium-8.6 Phos-3.1 Mg-1.7
___ 06:25AM BLOOD %HbA1c-6.5* eAG-140*
DISCHARGE LABS:
___ 06:45AM BLOOD WBC-4.9 RBC-4.54* Hgb-12.7* Hct-40.1
MCV-88 MCH-28.0 MCHC-31.7 RDW-18.9* Plt ___
___ 06:45AM BLOOD Glucose-111* UreaN-18 Creat-0.8 Na-140
K-4.2 Cl-105 HCO3-27 AnGap-12
___ 06:45AM BLOOD Calcium-8.7 Phos-3.5 Mg-1.8
MICRO/PATH:
Urine culture ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH
FECAL CONTAMINATION.
Blood cultures ___: no growth to date at the time of
discharge
IMAGING/STUDIES:
___ LLE U/S:
The left common femoral, superficial femoral, and popliteal
veins demonstrate normal compressibility, flow, and
augmentation. The left
posterior tibial veins demonstrate flow. The left peroneal veins
are not seen.
IMPRESSION: No evidence for left lower extremity deep vein
thrombosis.
___ CXR:
There is no focal consolidation or pleural effusion. Elevation
of
the left hemidiaphragm is stable. Linear opacities at the right
base are
either atelectasis or scarring. The upper lung zones are clear.
There is
mild enlargement of the cardiac silhouette. Median sternotomy
wires are
present and intact. Again seen are calcified pleural plaques in
the periphery of the left hemithorax.
IMPRESSION: Atelectasis or scarring at the right base. No focal
consolidation.
Brief Hospital Course:
___ with PMHx of hypotonic bladder with chronic foley c/b
multiple drug-resistant UTIs (MRSA and ESBL E. Coli), CAD s/p
CABG, s/p bovine AVR, known Right upper pole kidney mass
concerning for RCC, DM, and HTN presenting initially because his
foley catheter was not draining.
# Positive UA: Patient has extensive history of urinary tract
infections and multi-drug resistant organisms in the setting of
a chronic indwelling foley catheter. Initial UA with many WBC,
positive nitrate and positive leuks. Exam without CVA or
suprapubic tenderness. No fever, leukocytosis, tachycardia,
hematuria, suprapubic pain. Urine Cx growing mixed bacterial
flora. Repeat UA with small leuks, no nitrate, 12 WBC and few
bacateria. Likely colonization due to chronic indwelling
catheter instead of true infection. Catheter was replaced and
draining appropriately throughout hospitalization. Antibiotics
not initiated given the lack of evidence suggesting infection.
# Left lower extremity redness: Patient with dependent erythema
of both lower extremities, left greater than right. No
tenderness to palpation or warmth although he has pain of the
left foot related to prior closed trauma while riding in a
scooter. LLE U/S negative for DVT. Likely stasis dermatitis.
# Right heel ulcer: Patient with healing ulcer on right heel.
On exam, ulcer mostly covered with eschar, with small area of
soft tissue ulceration, without drainage or surrounding erythema
or tenderness. Ulcer does not probe to bone. No fevers or
leukocytosis concerning for soft tissue infection or
osteomyelitis. Wound care per wound care nurse, and instruction
given to his daycare nurse to continue wound care.
# Coronary artery disease: Continued aspirin 81 mg daily,
atorvastatin 80 mg daily.
# Hypotonic bladder: Continued tolterodine 2 mg BID.
# GERD: Continued omeprazole 20 mg daily.
# Hypertension: Continued lisinopril, furosemide, and
metoprolol.
# Depression/Anxiety: Continued Celexa and Cymbalta.
# Chronic constipation: Continued colace 100 mg BID,
polyethylene glycol PRN, senna.
TRANSITIONAL ISSUES:
====================
- code status: DNR/DNI
- Blood culture NGTD at the time of discharge, will follow by
primary team
Medications on Admission:
Metoprolol succinate 25 mg daily
aspirin 81 mg dialy
colace 100 mg bid
citalopram 20 mg daily
cymbalta 20 mg daily
lisinopril 2.5 mg daily
furosemide 20 mg daily
polyethylene glycol 17 gram daily PRN constipation
trazodine 50 mg qHS
tolterodine 2 mg BID
bisacodyl ___aily PRN
omeprazole 20 mg daily
cholecalciferol 1000 units daily
calcium carbonate 500 mg qHS
acetaminophen 650 mg TID PRN
atorvastatin 80 mg daily
Discharge Medications:
1. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig:
One (1) Tablet Extended Release 24 hr PO once a day.
2. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
6. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. polyethylene glycol 3350 17 gram Powder in Packet Sig: One
(1) Powder in Packet PO DAILY (Daily) as needed for
constipation.
8. trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed for insomnia.
9. tolterodine 2 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
10. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
11. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
12. cholecalciferol (vitamin D3) 1,000 unit Tablet Sig: One (1)
Tablet PO once a day.
13. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
Sig: One (1) Tablet, Chewable PO DAILY (Daily).
14. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO every
eight (8) hours as needed for fever, pain.
15. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
16. Cymbalta 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary:
- Foley dysfunction and suprapubic pain
- ___ edema and dependent erythema
Secondary:
-Hypotonic bladder requiring chronic foley
-CHF
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you! You were admitted to ___
___ for concern of urinary tract
infection and left leg cellulitis. It turns out you experienced
bladder discomfort related to your foley tubing being clamped
and you were determined not to have had a urinary tract
infection. You were further determined to not have an infection
in your left leg. Your foley was changed after initial doses of
antibiotics and you were monitored clinically off antibiotics
and you demonstrated no evidence of infection. You are being
discharged home.
It is important to note that you do not need to come to the
hospital for occasional ordinary discomfort related to your
foley catheter. Reasons to come to the hospital with relation to
the catheter include fevers, blood in the foley, or severe
discomfort.
The following changes have been made to your medications:
- No changes were made to your home medications
- Please continued taking your other home medications as
previously instructed
Please follow-up as advised below.
Followup Instructions:
___
|
19713100-DS-65
| 19,713,100 | 24,884,495 |
DS
| 65 |
2177-11-13 00:00:00
|
2177-11-13 23:48:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
___ / Oxybutynin / Bactrim
Attending: ___.
Chief Complaint:
tremors, confusion
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ yo M w/ hypotonic bladder with incomplete emptying
necessitating chronic indwelling foley since ___ c/b frequent
multidrug resistent UTIs (MRSA and ESBL E Coli) brought to the
ER by his daughter for concern of altered mental status and
tremors. Patient recently admitted, received a brief course of
antibiotics for concern of UTI and cellulitis. DC'd home
without antibiotics as there was low concern for infection. Per
his daughter, on the evening of discharge on ___, patient was
his usual self, ate dinner, and was interacting well with his
family. After dinner, she noticed that he has tremors that
started in his hands, then eventually spread to his entire body,
associated with feeling hot. He was oriented to person and
place, but kept grasping at the air, thinking he is falling
while in bed. The daughter does not believe he has
hallucinations.
ED COURSE: In the ED, 103; 147/112; 24; 96%3LNC. Patient was
given cipro, ceftriaxone for dirty UA. Also given home meds and
clonazepam. CXR showed atelectasis. CT head without acute
intracranial process; 1.8 posterior fossa meningioma unchanged.
CT abd/pelvis with unchange right renal mass, and fecal loading.
CBC, chem 10 wnl.
VS on transfer: 103, RR: 24, BP: 147/112, O2Sat: 96%, O2Flow: 3L
(Nasal Cannula).
On arrival to the medical floor, the patient drowsy but
arousable. AAOx2.5. Moving all extremities. Cannot answer
questions appropriately.
Past Medical History:
1. Hypotonic bladder with incomplete emptying, s/p indwelling
foley since ___ c/b frequent Multidrug resistent UTIs, incl
MRSA and ESBL E Coli
2. BPH
3. CAD s/p CABG x 3 in ___
- CABG anatomy: LIMA to LAD, SVG to OM, and SVG to RCA
- s/p stenting ___ of mid RCA, PTCA of proximal RCA and PDA
- redo single vessel CABG in ___ with Dr. ___.
4. Bovine AVR in ___. Type 2 Diabetes Mellitus: diet controlled
6. Hypertension
7. Hx of Chronic constipation
8. Hyperlipidemia
9. Depression /Anxiety
10. Asbestosis
11. Spinal stenosis
12. R kidney mass - Followed by urology w/ serial imaging,
likely RCC
13. Osteoarthritis
14. Carotid stenosis - chronic occlusion of LICA, ___ with 40%
Social History:
___
Family History:
Daughter- died at ___,breast cancer.
Father- died from MI in his ___.
Physical Exam:
ADMISSION EXAM:
VS - 98.4; 85; 126/74; 18; 99%RA
GENERAL - Drowsy but arousable. appears tired. oriented to
person, place, year, answers mostly yes/no questions
HEENT - PERRL, sclerae anicteric, MMM, OP clear
NECK - Supple, no thyromegaly
HEART - RRR, nl S1-S2, no MRG
LUNGS - Clear to auscultation from anterior fields (cannot sit
up)
ABDOMEN - NABS, soft/NT/ND, no masses or HSM
EXTREMITIES - Healing right heel ulcer with minimial surrounding
erythema, LLE with erythema extending from foot to mid calf,
nontender, not warm
LYMPH - no cervical, axillary, or inguinal LAD
NEURO - CNs II-XII grossly intact, able to lift bilateral arms,
cannot follow commands to lift legs
DISCHARGE EXAM:
VS - 97.7; 103-142/67-87; 74-82; 18; 93%RA
GENERAL - Awake, alert, oriented to time, place, person. answers
appropriately.
HEENT - PERRL, sclerae anicteric, MMM, OP clear, b/l eyes with
crusting over eyelids, minimal drainage, no conjuctival
injection, b/l ears with cerumen.
NECK - Supple, no thyromegaly
HEART - RRR, nl S1-S2, no MRG
LUNGS - CTAB
ABDOMEN - NABS, soft/NT/ND, no masses or HSM
EXTREMITIES - Healing right heel ulcer with minimial surrounding
erythema, ulcer covered with eschar, non-draining, nontender,
not warm
NEURO - CNs II-XII grossly intact
SKIN - facial erythematous patches with crusting and peeling
markedly improved
Pertinent Results:
ADMISSION LABS:
___ 06:45AM BLOOD WBC-4.9 RBC-4.54* Hgb-12.7* Hct-40.1
MCV-88 MCH-28.0 MCHC-31.7 RDW-18.9* Plt ___
___ 11:15PM BLOOD Neuts-68.3 ___ Monos-5.6 Eos-4.7*
Baso-0.6
___ 06:45AM BLOOD Glucose-111* UreaN-18 Creat-0.8 Na-140
K-4.2 Cl-105 HCO3-27 AnGap-12
___ 06:45AM BLOOD Calcium-8.7 Phos-3.5 Mg-1.8
___ 11:17PM BLOOD Lactate-2.0
DISCHARGE LABS:
___ 09:00AM BLOOD WBC-5.9 RBC-5.63 Hgb-15.7 Hct-50.6 MCV-90
MCH-27.9 MCHC-31.0 RDW-18.6* Plt ___
___ 09:00AM BLOOD Glucose-124* UreaN-21* Creat-1.0 Na-141
K-4.5 Cl-101 HCO3-34* AnGap-11
MICROBIOLOGY:
___ Urine culture
**FINAL REPORT ___
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH
FECAL CONTAMINATION.
IMAGING:
CT Head W/O Contrast ___:
There is no evidence of intracranial hemorrhage, edema, masses
or
mass effect. The gray-white matter differentiation is normal.
The ventricles and sulci are moderately enlarged, consistent
with moderate involutional changes. The basal cisterns are
normal. Again seen is a partially calcified extraaxial lesion
along the left lateral aspect of the posterior cranial fossa
overlying the mastoid portion of the temporal bone (4:9), now
measuring 1.7 x 1.0 cm, stable since the prior study 1.6 x 0.8
cm. No significant mass effect is seen in the adjacent
parenchyma. Moderate calcifications are seen in the cavernous
portion of both internal carotid arteries.
The imaged paranasal sinuses and mastoid air cells are clear.
Bilateral
intraocular lens implants are noted.
IMPRESSION: No acute intracranial pathology.
CT Abd & Pelvis With Contrast ___. The appendix is not definitely visualized. No secondary signs
of
appendicitis are seen. The presence of motion at this level
limits further
evaluation.
2. Enhancing right upper pole renal mass, concerning for renal
cell
carcinoma, stable since the recent prior study of ___.
3. Cholelithiasis.
4. Moderate fecal loading throughout the entire colon.
5. Stable mild compression of L1 vertebral body, unchanged.
6. Extensive coronary arterial calcification and aortic annular
calcification.
CXR ___:
In comparison with the study of ___, there is little interval
change. Continued elevation of the left hemidiaphragmatic
contour with mild atelectatic changes at the bases and calcified
pleural plaques at the periphery of the left hemithorax. Upper
zones remain clear and there is no evidence of vascular
congestion.
No change in the intact median sternotomy wires.
Brief Hospital Course:
___ with PMHx of hypotonic bladder with chronic foley c/b
multiple drug-resistant UTIs (MRSA and ESBL E. Coli), CAD s/p
CABG, s/p bovine AVR, DM, and HTN presented with altered mental
status and tremors.
# Altered Mental Status - Per patient's daugher, patient was
confused the evening he returned home (thinking he is falling),
but otherwise oriented to time, person and place. Evening
symptoms could be from sun-downing in an elderly gentleman. For
his tremors, patient is followed by outpatient neurology for
secondary myoclonus of unknown etiology. Patient received
clonazepam in the ED for agitation and became difficult to
arouse once on arrival to the floor. Infectious workup negative
no change on CXR and no infectious etiology on CT abdomen. U/A
chronically with bacteria, likely colonization from chronic
indwelling foley, culture with mixed flora. No history of
trauma, and CT head negative for bleed. No electrolyte
abnormalities or hypoglycemia. By the second morning of
admission, patient awake, alert, AAOx3, back to his baseline.
Geriatrics consulted to help managed his psychopharmacology.
Recommended stopping celexa and tolterodine, increasing cymbalta
to 30mg daily, and uptitrate trazodone as needed for sleep (but
do not exceed 100mg qHS) which was done.
# Positive UA: Patient has extensive history of urinary tract
infections and multi-drug resistant organisms in the setting of
a chronic indwelling foley catheter. UA with WBC, + nitrate, +
leuks and bacteria, but culture showed mixed
flora/contamination. Exam without CVA or suprapubic tenderness.
No fever, leukocytosis, tachycardia, hematuria, suprapubic pain.
Likely colonization due to chronic indwelling catheter instead
of true infection. Catheter was replaced a few days ago on
previous hospitalization. Catheter usually replaced in Dr.
___ every ___ week. Discontinued tolterodine in the
setting of anti-cholingeric contributing to his delirium.
# Depression/Anxiety: Tapered off Celexa. Increased cymbalta
to 30mg daily.
# Conjunctivitis: Significant thick drainage from bilateral
eyes. patient with poor eye hygiene. Symptoms improved with
5-day course of erythromycin eye gel.
# Seborrheic dermatitis: Improved with topical triamcinolone
cream.
# Hypertension: Patient with SBP 90-110s. Continued metoprolol
but stopped furosemide and lisinopril.
CHRONIC ISSUES:
# Left lower extremity redness: Stasis dermatitis. LLE U/S
negative for DVT on ___.
# Right heel pressure ulcer: Patient with healing ulcer on right
heel. Low concern for soft tissue infection or osteomyelitis.
# Coronary artery disease: Continued aspirin 81 mg daily,
atorvastatin 80 mg daily.
# Hypotonic bladder: Stopped tolterodine (see above). Continued
chronic indwelling foley, last changed on ___.
# GERD: Continued omeprazole 20 mg daily.
# Chronic constipation: Continued colace 100 mg BID,
polyethylene glycol PRN, senna.
# Transitional issues:
- code status: DNR/DNI
- Patient will transition from Dr. ___ to new PCP in
___
- Neurology and urology f/u
Medications on Admission:
1. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig:
One (1) Tablet Extended Release 24 hr PO once a day.
2. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
6. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. polyethylene glycol 3350 17 gram Powder in Packet Sig: One
(1) Powder in Packet PO DAILY (Daily) as needed for
constipation.
8. trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed for insomnia.
9. tolterodine 2 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
10. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
11. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
12. cholecalciferol (vitamin D3) 1,000 unit Tablet Sig: One (1)
Tablet PO once a day.
13. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
Sig: One (1) Tablet, Chewable PO DAILY (Daily).
14. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO every
eight (8) hours as needed for fever, pain.
15. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
16. Cymbalta 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
Discharge Medications:
1. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig:
One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
2. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
4. polyethylene glycol 3350 17 gram Powder in Packet Sig: One
(1) Powder in Packet PO DAILY (Daily) as needed for
constipation.
5. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
6. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
7. cholecalciferol (vitamin D3) 1,000 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
8. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
Sig: One (1) Tablet, Chewable PO DAILY (Daily).
9. acetaminophen 325 mg Tablet Sig: ___ Tablets PO every six (6)
hours as needed for pain.
10. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
12. duloxetine 30 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
13. trazodone 100 mg Tablet Sig: One (1) Tablet PO at bedtime as
needed for insomnia.
14. Triamcinolone cream for facial lesions
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Delirium
Myoclonic tremors
Hypotonic Bladder
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Mr. ___,
It was a pleasure participating in your care at ___. You were
admitted for tremors. There was a infectious workup which was
negative and your symptoms improved.
We made the following changes to your medications:
STOPPED Celexa
STOPPED Tolterodine
INCREASED Cymbalta to 30mg daily
STARTED triamcinolone cream for facial lesions
STOPPED Lisinopril
STOPPED Lasix
Followup Instructions:
___
|
19713100-DS-66
| 19,713,100 | 23,578,711 |
DS
| 66 |
2178-01-13 00:00:00
|
2178-01-14 10:52:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
___ / Oxybutynin / Bactrim
Attending: ___.
Chief Complaint:
Constipation and low O2 sat
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is an ___ man with a history of CAD, T2DM, HLD,
chronic urinary colonization with chronic indwelling Foley, and
chronic constipation who presents with constipation and
abdominal pain. He states that his last bowel movement was 1 day
ago but was small and pellet-like. He does not remember the last
time he had a softer bowel movement. He frequently has the urge
to go and strains to have bowel movements but only gets small
pellets if anything at all. He also has associated crampy
abdominal/groin pain for the past 3 weeks. He denies any N/V,
bloody stools, melena, changes in diet or unusual foods, fever,
chills, or night sweats.
His daughter later called the ___ and said that his inital
complaint at home had been CP and SOB, but when EMS arrived, he
denied these symptoms and was only reported abdominal pain. He
continues to deny that he has any CP or SOB. He also denies and
palpitations, orthopnea, PND, leg swelling, cough, or increased
fatigue.
In the ___, his initial VS were T 96.9, HR 88, BP 122/80, RR 18,
sat 93% RA, pain ___ lower abdomen. His exam was notable for a
soft abdomen with mild tenderness to palpation in the lower
quadrants and guaiac negative rectal exam. His labs were notable
for Trop-T 0.08, lytes and CBC wnl, and UA positive for moderate
leuks and bacteria, nitrites, and 15 WBCs. A KUB showed moderate
fecal loading in the ascending colon, rectum and sigmoid colon,
and an abdominal CT showed no signs of an acute process,
moderate fecal loading, and a stable right renal mass concerned
for RCC. He was given 1L NS, 1g ceftriaxone, and 650mg
acetaminophen and admitted for constipation. His VS prior to
transfer were T 98.0, BP 119/87, HR 83, RR 18, sat 95% on 3L NC.
On the floor, he continues to complain of lower abdominal pain
and constipation, and denies any CP or SOB. He is also
complaining of a longstanding ulcer on his penis near the meatus
around the Foley.
Past Medical History:
1. Hypotonic bladder with incomplete emptying, s/p indwelling
foley since ___ c/b frequent Multidrug resistent UTIs, incl
MRSA and ESBL E Coli
2. BPH
3. CAD s/p CABG x 3 in ___
- CABG anatomy: LIMA to LAD, SVG to OM, and SVG to RCA
- s/p stenting ___ of mid RCA, PTCA of proximal RCA and PDA
- redo single vessel CABG in ___ with Dr. ___.
4. Bovine AVR in ___. Type 2 Diabetes Mellitus: diet controlled
6. Hypertension
7. Hx of Chronic constipation
8. Hyperlipidemia
9. Depression /Anxiety
10. Asbestosis
11. Spinal stenosis
12. R kidney mass - Followed by urology w/ serial imaging,
likely RCC
13. Osteoarthritis
14. Carotid stenosis - chronic occlusion of LICA, ___ with 40%
Social History:
___
Family History:
Daughter- died at ___,breast cancer.
Father- died from MI in his ___.
Physical Exam:
ADMISSION EXAM:
Vitals: T 98.1, BP 142/59, HR 88, RR 22, sat 95% on 3L NC
General: Alert, oriented, distressed when left alone, drifts off
to sleep but easily awakened and refocused
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: CTAB, no wheezes, rales, ronchi
CV: RRR, normal S1/S2, ___ systolic ejection murmur heard best
at the RUSB with no radiation to carotids
Abdomen: obese, non-distended, NABS, soft, mildly tender to deep
palpation in RLQ and suprapubic area, no rebound tenderness or
guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses; no clubbing or cyanosis; 1+
pitting edema to the knee bilaterally (chronic per patient);
some erythema of the medial compartment of the L lower limb
(chronic per patient)
DISCHARGE
VS: Tc 97.6, Tm 98.1, BP 153/60 (140s-150s/50s-60s), HR 86
(80s-100s), RR 24, sat 99% on RA
Abdomen: obese, non-distended, NABS, soft, nontender
GU: Mild suprapubic tenderness, 1cm stage 2 ulcer at meatus
without erythema, purulence, or evidence of recent bleeding
Ext: Warm, well perfused, 2+ pulses; no clubbing or cyanosis; 1+
pitting edema to the knee bilaterally (chronic, unchanged); some
erythema of the medial compartment of the L lower limb (chronic,
unchanged)
Neuro: CNII-XII intact, strength and sensation intact and
symmetric bilaterally
Exam otherwise unchanged since admission
Pertinent Results:
ADMISSION LABS
___ 06:50AM BLOOD WBC-7.0 RBC-4.55* Hgb-13.2* Hct-40.4#
MCV-89 MCH-29.1 MCHC-32.7 RDW-17.5* Plt ___
___ 06:50AM BLOOD Neuts-65.7 ___ Monos-6.3 Eos-3.8
Baso-0.3
___ 06:50AM BLOOD ___ PTT-29.3 ___
___ 06:50AM BLOOD Glucose-119* UreaN-20 Creat-0.9 Na-135
K-4.3 Cl-100 HCO3-28 AnGap-11
___ 06:57AM BLOOD Lactate-0.8
CARDIAC ENZYMES
___ 06:50AM BLOOD CK-MB-6
___ 06:50AM BLOOD cTropnT-0.08*
___ 01:10PM BLOOD cTropnT-0.07*
UA
___ 06:50AM URINE Color-Yellow Appear-Hazy Sp ___
___ 06:50AM URINE Blood-NEG Nitrite-POS Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-2* pH-6.5 Leuks-MOD
___ 06:50AM URINE RBC-2 WBC-15* Bacteri-MOD Yeast-NONE
Epi-<1
___ 06:50AM URINE Mucous-RARE
MICRO
Urine and blood cultures from ___: pending
IMAGING
ABDOMEN (SUPINE & ERECT) Study Date of ___ 3:06 AM
IMPRESSION: Moderate fecal loading in the ascending colon,
rectum and sigmoid colon.
CHEST (PA & LAT) Study Date of ___ 5:10 AM
IMPRESSION: New right lower lobe plate-like atelectasis.
Unchanged calcified pleural plaques.
CT ABD & PELVIS WITH CONTRAST Study Date of ___ 8:17 AM
IMPRESSION: 1. No evidence of acute intra-abdominal process. 2.
Stable right renal mass concerning for RCC. 3. Cholelithiasis
without any evidence of cholecystitis. 4. Moderate fecal
loading.
Brief Hospital Course:
This is an ___ man with a history of CAD, T2DM, HLD, chronic
urinary colonization with chronic indwelling Foley, and chronic
constipation who presents with constipation and suprapubic pain
but no signs of acute infection.
# Constipation: He has had a chronic problem with constipation.
His last bowel movement was 1 day prior to admission and was
small and pellet-like, as his stools typically are. He takes
Senna and Colace regularly at home and said he usually responds
well to Dulcolax but hadn't taken it recently. His constipation
is likely a combination of poor hydration and immobility. He
does not take narcotics or other constipating medications. His
diet consists of lots of fruit and fish, and he avoids pasta and
junk foods that might be constipating. He was given an agressive
bowel regimen of standing senna, colace, miralax, bisacodyl, and
fleets enema. He also underwent manual disimpaction and had milk
of magnesia x1, all of which resulted in a very large bowel
movements prior to dischargen. He felt significant relief of his
abdominal pain and suprapubic discomfort after the bowel
movement.
# Suprapubic pain w/ positive UA: He has a known hypotonic
bladder with incomplete emptying and has had an indwelling Foley
since ___ for this issue. His UA in the ___ was positive for
moderate leuks and bacteria, nitrites, and 15 WBCs. He was given
in 1g ceftriaxone in the ___, but antibiotics were not continued
on the floor as he was afebrile, mentating normally, and did not
have an elevated WBC count to suggest infection. Urine and blood
cultures were sent and were still pending at the time of
discharge. His pain became much more severe on the night of
admission and he was frequently calling out in pain. He was
started on tolterodine 1g BID. After his large bowel movement
the morning after admission (see above), his suprapubic pain was
greatly improved, so the tolterodine was stopped given prior
episodes of altered mental status while taking this medication.
Ultimately it was thought that his suprapubic pain was caused by
his known bladder spasm and made worse by his constipation.
Will follow up with Dr. ___ in late ___.
# Hypoxia: He denied SOB on this admission, but per his
daughter, he was reporting increasing SOB at home prior to EMS
arrival. He reported that his O2 sat goes to 89% on RA at home,
but he remains asymptomatic. His CXR showed plate-like in the
right middle lobe, but no signs of infiltrate or infection. His
lung exam was clear. There was some concern for PE given his
risk factors of immobility and likely RCC but given that he was
not complaining of chest pain and his EKG did not show sinus
tach or new right heart strain, a CTA was deferred. A D-dimer
also was not sent given the high likelihood of a false positive
in the setting of RCC and chronic urinary colonization. He was
encouraged to use incentive spirometry and had O2 sats of 99% on
room air the morning after admission.
# Chest pain: Per his daughter, he was complaining of CP and SOB
prior to EMS arrival, but he consistently denied CP during
admission. There was some concern for PE (see above "hypoxia").
His EKG showed no changes from prior and no signs of acute
ischemia. His CK-MB was not elevated, and his TropT was mildly
elevated (0.07, 0.08) but at his baseline of 0.04-0.09.
# Penile ulcer: He has had four recent ___ visits on ___ and
___ for a penile ulcer around the meatus that is being irritated
by his Foley catheter. On exam, he had a 1-cm stage 2 ulcer near
the meatus that was tender to palpation but had minimal
erythema, no purulent discharge, and no signs of bleeding. Per
his outpatient urologist, a suprapubic catheter has been offered
on multiple occasions, and the patient has always refused. A
wound care consult was called to dress the wound.
# Depression/Anxiety: He is a frequent visitor to the ___ with
many somatic complaints. He frequently expressed fear on this
admission that he was going to die and did not like to be left
alone for very long. He still struggles with death ___ years ago
of his wife of ___ years. He was continued on his home duloxetine
and trazodone QHS for insomnia.
# Hypertension: His BPs were 140s-160s/60s-80s on the floor. He
was first started on metoprolol tartrate 12.5 mg BID and then
increased to 25 mg BID. Plans were made to discharge him on
metoprolol succinate 50 mg QD. Starting an ACE inhibitor instead
of increasing his metoprolol was considered given his known DM
and CAD, but his ACE inhibitor had previously been discontinued
due to hypokalemia. It was elected to leave the decision about
starting an ACE inhibitor to the discretion of his PCP in
ongoing ___. BP checks were planned for his ___ sessions at
daycare at home.
# Left lower extremity erythema: He reports that this has been a
chronic problem since a prior trauma to the leg. The erythema
extended along the medial aspect of his L lower extremity from
ankle to knee. There was no warmth or tenderness to palpation to
suggest acute cellulitis, and the compartment was soft. Given
the chronicity of the problem and his benign exam, LENIS were
not done.
# Coronary artery disease: He is s/p CABG LIMA->LAD,
SVG->ramus->PDA; catheterization in ___nd DOE -> Stents to PDA, mRCAx2, pRCA. ___ P-MIBI WNL; and a
single redo CABG with AVR and a porcine valve in ___. He is
followed by Dr. ___. He denies any chest pain on this
admission, although his daughter says he was complaining of some
chest pain at home (see above "chest pain"). He EKG and cardiac
enzymes were negative for any signs of acute ischemia.
# GERD: He was continued on his home omeprazole.
# T2DM: His blood sugars are controlled by diet alone at home.
His glucose was followed with his daily lytes, and was not
elevated above 150.
# Limited mobility: He reports a maximum of ___ steps of
ambulation at home and uses a wheelchair to get around. He
receives home ___ at daycare. ___ was consulted to assess his ___
needs following discharge.
Transitional issues
-Code status: DNR/DNI, confirmed with patient
-Pending studies: blood and urine cultures from ___
-Medication changes: daily miralax, dulcolax if he hasn't had a
bowel movement in more than one day, increase dose of metoprolol
succinate from 25mg to 50mg QD.
-Plan to check BP with new PCP ___ ___
-Plan for BP ___ and consideration of restarting an ACE
inhibitor with his PCP
___ on ___:
Preadmission medications listed are correct and complete.
Information was obtained from webOMR.
1. Metoprolol Succinate XL 25 mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Docusate Sodium 100 mg PO BID:PRN constipation
4. Polyethylene Glycol 17 g PO DAILY:PRN constipation
5. Bisacodyl 10 mg PO DAILY:PRN constipation
6. Omeprazole 20 mg PO DAILY
7. Vitamin D 1000 UNIT PO DAILY
8. Calcium Carbonate 500 mg PO DAILY
9. Acetaminophen 325-650 mg PO Q6H:PRN pain
10. Atorvastatin 80 mg PO DAILY
11. Senna 1 TAB PO BID:PRN constipation
12. Duloxetine 30 mg PO DAILY
13. traZODONE 100 mg PO HS:PRN insomnia
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN pain
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 80 mg PO DAILY
4. Bisacodyl 10 mg PO DAILY:PRN constipation
RX *bisacodyl 5 mg 2 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
5. Calcium Carbonate 500 mg PO DAILY
6. Docusate Sodium 100 mg PO BID:PRN constipation
RX *docusate sodium 100 mg 1 tablet(s) by mouth twice a day Disp
#*30 Tablet Refills:*0
7. Duloxetine 30 mg PO DAILY
8. Omeprazole 20 mg PO DAILY
9. Polyethylene Glycol 17 g PO DAILY
Hold for loose stools.
RX *polyethylene glycol 3350 17 gram/dose 1 packet by mouth
daily Disp #*30 Packet Refills:*0
10. Senna 2 TAB PO BID
Hold if patient has loose stools.
RX *senna 8.6 mg 2 tablets by mouth twice a day Disp #*60 Tablet
Refills:*0
11. traZODONE 100 mg PO HS:PRN insomnia
12. Vitamin D 1000 UNIT PO DAILY
13. Metoprolol Succinate XL 50 mg PO DAILY
RX *metoprolol succinate 50 mg 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Constipation
Hypoxia
Hypotonic bladder
Urinary colonization
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure to take care of you during your hospital stay.
You were admitted to ___ for constipation and low oxygen
saturation. You also had some worsening of your chronic groin
pain. You were given a number of laxatives and had a large bowel
movement, after which you felt much better. Your oxygen
saturation came back to normal without any supplemental oxygen.
The following changes were made to your medications:
- Please CONTINUE taking Senna and Colace on a daily basis along
with at least 2 liters of fluids daily.
- Please START taking Miralax on a daily basis
- Please START taking Dulcolax if it has been more than 1 day
since your last bowel movement.
- Please INCREASE your dose of metoprolol from 25mg daily to
50mg daily.
No other changes were made to your medications. You should
continue all of your other medications as you were before you
were admitted to the hospital.
Followup Instructions:
___
|
19713100-DS-70
| 19,713,100 | 26,972,142 |
DS
| 70 |
2178-05-18 00:00:00
|
2178-05-18 16:01:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Amitiza / Oxybutynin / Bactrim
Attending: ___.
Chief Complaint:
multidrug resistant uti treatment
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. ___ is an ___ year old man with a hypotonic bladder, BPH,
chronic indwelling foley and multiple recent multidrug resistant
urinary tract infections who was sent to the ED by his PCP for
admission and iv antibiotics for a UTI. He has multiple other
chronic medical problems (see below). He was last admitted to
___ from ___ to ___ for treatment of a UTI. He was
treated with meropenem initially then narrowed to po
ciprofloxacin on which he was discharged home.
Patient denies fevers or chills, but he complains of a dull
suprapubic ache which has worsened over the course of the last
three days. He does not have back pain.
In the ED, initial VS were:97.6, hr 88, bp 86/47, rr 20, sat
95%. His subsequent blood pressures ranged from 108-118/71-76,
even before he recieved fluid. He was given NS x 1 Liter and
cefepime 2g iv once.A #20 right EJ was inserted.
Transfer vitals were 97.2 oral, HR 79, BP 108/74, RR ___, O2
sat 2L NC.
On arrival to the floor, he had mild suprapubic discomfort.
Past Medical History:
1. Hypotonic bladder with incomplete emptying, s/p indwelling
foley since ___ c/b frequent Multidrug resistent UTIs, incl
MRSA and ESBL E Coli
2. BPH
3. CAD s/p CABG x 3 in ___
- CABG anatomy: LIMA to LAD, SVG to OM, and SVG to RCA
- s/p stenting ___ of mid RCA, PTCA of proximal RCA and PDA
- redo single vessel CABG in ___ with Dr. ___.
4. Bovine AVR in ___. Type 2 Diabetes Mellitus: diet controlled
6. Hypertension
7. Hx of Chronic constipation
8. Hyperlipidemia
9. Depression /Anxiety
10. Asbestosis
11. Spinal stenosis
12. R kidney mass - Followed by urology w/ serial imaging,
likely RCC
13. Osteoarthritis
14. Carotid stenosis - chronic occlusion of ___, ___ with 40%
Social History:
___
Family History:
Daughter- died at ___,breast cancer.
Father- died from MI in his ___.
Physical Exam:
Admission exam:
VS - Temp 97.9 F, BP 105/76, HR 76, R 20, O2-sat 97% 3LNC
GENERAL - NAD, comfortable
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MM dry, OP clear
NECK - supple, no thyromegaly, no JVD, no carotid bruits
LUNGS - CTA bilat except for fine crackles in the bases
bilaterally, no r/rh/wh, good air movement, resp unlabored, no
accessory muscle use
HEART - RRR, no MRG, nl S1-S2
ABDOMEN - NABS, soft/ND, no masses or HSM, no rebound/guarding.
There is mild ttp in the suprapubic area.
BACK: no cva tenderness
EXTREMITIES - There is moderate edema in both lower extremities
with discoloration and erythema especially in the left leg--it
is not warm nor tender, 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
___ on flexion of r hip, 4- on flextion of left hip, upper
extremity strength is ___ bilaterally, sensation grossly intact
throughout, gait was not assessed.
Discharge exam:
VS - Temp 97.7 F, BP 110-130/60-64, HR 78-86, R 20, O2-sat
92-94%/RA
GENERAL - NAD, comfortable
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear
NECK - supple, no thyromegaly, no JVD, no carotid bruits
LUNGS - CTA bilat except for fine crackles in the bases
bilaterally, no r/rh/wh, good air movement, resp unlabored, no
accessory muscle use
HEART - RRR, no MRG, nl S1-S2
ABDOMEN - NABS, soft/ND, no masses or HSM, no rebound/guarding.
Non-tender.
BACK: no cva tenderness
EXTREMITIES - There is moderate edema in both lower extremities
with discoloration and erythema especially in the left leg--it
is not warm nor tender, 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
___ on flexion of r hip, 4- on flextion of left hip, upper
extremity strength is ___ bilaterally, sensation grossly intact
throughout, gait was not assessed.
Discharge exam:
T 97.9 112-142/61-70 ___ 94%/RA 20
GENERAL - elderly man, lying in bed in no apparent distress
LUNGS - CTA bilat
HEART - RRR, no MRG, nl S1-S2
ABDOMEN - soft, non-tender, non-distended
BACK: no cva tenderness
EXTREMITIES - trace edema in both lower extremities with
discoloration and erythema especially in the left leg--it is not
warm nor tender
Skin: Rash on right check with crusted blood, erythematous rash
on face.
NEURO - A&Ox3.
Pertinent Results:
Admission labs:
___ 11:30PM BLOOD WBC-6.6 RBC-4.15* Hgb-12.3* Hct-36.0*
MCV-87 MCH-29.7 MCHC-34.2 RDW-17.6* Plt ___
___ 11:30PM BLOOD Neuts-66.0 ___ Monos-6.8 Eos-5.8*
Baso-0.4
___ 05:32AM BLOOD ___ PTT-31.5 ___
___ 10:15PM BLOOD Glucose-126* UreaN-25* Creat-1.0 Na-138
K-4.3 Cl-101 HCO3-28 AnGap-13
___ 08:00PM BLOOD CK-MB-6 cTropnT-0.09*
___ 05:25AM BLOOD CK-MB-6 cTropnT-0.08*
___ 10:15PM BLOOD Calcium-9.2 Phos-4.5 Mg-2.2
Microbiology:
___ 7:25 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
PSEUDOMONAS AERUGINOSA. >100,000 ORGANISMS/ML..
Piperacillin/Tazobactam sensitivity testing performed
by ___
___.
FOSOMYCIN Susceptibility testing requested by ___.
___
PAGER ___.
.
ZONE SIZE FOR FOSOMYCIN IS 27 MM.
Zone size determined using a method that has not been
standardized for this drug-.
organism combination and for which no CLSI or
FDA-approved
interpretative standards exist. Interpret results with
caution.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
PSEUDOMONAS AERUGINOSA
|
AMIKACIN-------------- 4 S
CEFEPIME-------------- 8 S
CEFTAZIDIME----------- 2 S
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ =>16 R
MEROPENEM------------- =>16 R
PIPERACILLIN/TAZO----- S
TOBRAMYCIN------------ =>16 R
___ 11:05 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
PSEUDOMONAS AERUGINOSA. >100,000 ORGANISMS/ML..
SENSITIVITIES PERFORMED ON CULTURE # ___-___
___.
___ 9:01 am URINE Source: Catheter.
**FINAL REPORT ___
URINE CULTURE (Final ___:
___ PARAPSILOSIS. >100,000 ORGANISMS/ML..
IDENTIFICATION REQUESTED BY ___ ___ ___
___.
___ 5:19 pm DIRECT ANTIGEN TEST FOR VARICELLA-ZOSTER VIRUS
**FINAL REPORT ___
DIRECT ANTIGEN TEST FOR VARICELLA-ZOSTER VIRUS (Final
___:
Negative for Varicella zoster by immunofluorescence.
Refer to culture results for further information.
___ 5:19 pm
Direct Antigen Test for Herpes Simplex Virus Types 1 & 2
**FINAL REPORT ___
Direct Antigen Test for Herpes Simplex Virus Types 1 & 2
(Final
___:
Negative for Herpes simplex by immunofluorescence.
Refer to culture results for further information.
Imaging:
___ CXR:
As compared to the previous radiograph, there is unchanged
evidence
of elevation of the left hemidiaphragm and subpleural partly
calcified scars. Status post CABG. Minimal atelectasis at the
right lung base but no evidence of current pneumonia or fluid
overload. Unchanged appearance of the cardiac silhouette.
___ Abdominal X-ray:
There is moderate colonic fecal load with minimally dilated
cecum. Air is seen in scant loops of nondilated small bowel.
This is a nonobstructive bowel gas pattern. Remnant contrast
material is seen in the large bowel. There is no supine
radiographic evidence of pneumoperitoneum or pneumatosis.
IMPRESSION:
Moderate colonic fecal load. Nonobstructive bowel gas pattern.
CXR ___ Cardiac size is top normal. The main pulmonary
arteries are larger as before. Elevation of the left
hemidiaphragm is longstanding. There are low lung volumes.
Bibasilar atelectases have increased. Bilateral calcified
pleural plaques are again noted. There are probably small
bilateral pleural effusions. There is no pneumothorax.
Kidney ultrasound ___:
The right kidney measures 10.2 cm. The left kidney measures
10.4 cm.
Bilateral kidneys are without evidence of hydronephrosis or
stones. The
vascular right upper pole tumor is again noted measuring 3.3 x
3.6 x 2.9 cm. The bladder is decompressed and not evaluated.
There is no evidence of distinct collections.
IMPRESSION:
No evidence of distinct collections. Right upper pole solid
tumor is again identified measuring 3.3 x 3.6 x 2.9 cm.
Abdominal X-ray ___
There is a nonobstructing bowel gas pattern. There is air in
the ascending and transverse colon. There is fecal material in
the descending colon. There is no air in the rectum. There are
few air fluid levels in the small bowel loops that are
nondistended. There are severe degenerative changes in the
lumbar spine. There are vascular calcifications.
CXR ___
Elevated left hemidiaphragm is redemonstrated. No definitive
opacity except for minimal bibasilar atelectasis is
demonstrated. Pulmonary nodules seen in the left mid lower lung
are demonstrated and might represent at least in part pleural
calcifications. No pneumothorax is seen.
Brief Hospital Course:
Acute issues:
# Urinary tract infection: Patient with BPH and hypotonic
bladder with incomplete emptying, s/p indwelling foley since
___ c/b frequent multidrug resistent UTIs, including MRSA, ESBL
E Coli, Pseudomonas, and Klebsiella. Had multiple ED visits the
week of admission, initially treated with Cipro then switched to
Keflex when culture grew Klebsiella resistant to Cipro. Repeat
culture grew Pseudomonas, so patient admitted to the hospital
for IV antibiotics and was started on cefepime. He was trialed
on fosfomycin, but deteriorated clinically so cefepime was
resumed. Patient continued to complain of suprapubic pain,
repeat UA suggestive of infection and culture grew yeast
___ PARAPSILOSIS) and patient was started on fluconazole to
complete a ___onstipation: Patient with significant abdominal pain and
distension, abdominal X-ray on ___ showed large amount of
dense stool. Patient disimpacted without significant success,
given MoviPrep with good result. Bowel regimen up-titrated, but
patient with no bowel movements for next 3 days. MoviPrep given
again, again with good success.
# Tremors: Patient with intermittant somnolence and tremor of
chin and hands in the context of possibly worsening UTI. Patient
had similar tremors on hospitalization in ___, which were
thought to be myoclonus secondary to infection. Neurology
consulted, recommended discontinuing duloxetine, trazodone,
oxycodone and starting clonazepam, as that seemed to help
previuosly. However, clonazepam then held due to patient
lethargy.
# Depression: Patient's duloxetine held due to tremors. Patient
with decreased appetite, tearfulness, hopelessness. Started on
low dose ___ likely need uptitration on an
outpatient basis.
# Delirium/acute encephalopathy: patient with waxing and waning
mental status throughout hospitalization. UTI and constipation
thought to be main contributing factors, treated as above. EKG
repeatedly unchanged from baseline, electrolytes and LFTs
normal, CXR normal.
# Hypoxia: patient with intermittant desats into the high
___ on room air. No signs of acute pulmonary process on
multiple chest x-rays, improved with deep breathing/incentive
spirometry.
# Facial rash: patient with crusted rash on right side of face,
DFA negative for zoster or HSV. Also with erythematous rash on
forehead.
Chronic issues:
# Penile ulcer: Few small areas of penile irritation, but no
frank ulcer noted. The ulcer on his penis was swabbed and
purulent discharge cultured on previous admission. RPR,
GC/Chlamydia, and HSV had been negative in outpatient setting.
The ulcer was thought to result from irritation due to his
indwelling foley.
# Hypotonic bladder/BPH - chronic issue, patient with indwelling
foley. To follow up with urology as an outpatient.
# normocytic normochromic Anemia: Likely anemia of chronic
disease. Stable
# Right Kidney Mass - concerning for rcc and stable on recent ct
scan; patient has not wished to pursue further workup of this
mass.
# HTN: stable on metoprolol succinate 50mg daily
# CAD s/p CABG: stable on ASA, metoprolol. Atorvastatin
decreased to 40mg daily while patient is on fluconazole
#Chronic Diastolic Congestive Heart Failure: stable on lasix and
beta blockade; lisinopril had been stopped due to hypotension
# DM2 - Hgb A1c 6.5 ___. Not on outpatient treatment at
present, sugars well controlled in house.
Transitional issues:
- titrate ___ dose to effect
- recheck LFTs after course of fluconazole completed, increase
atorvastatin dose back to 80mg daily
- titrate bowel regimen to acheive daily bowel movements if
possible
- increase furosemide back to 40mg daily if patient appears to
be retaining fluid on 20mg daily
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 80 mg PO DAILY
3. Bisacodyl 10 mg PO DAILY:PRN constipation
4. Calcium Carbonate 500 mg PO DAILY
5. Docusate Sodium 100 mg PO BID
6. Duloxetine 30 mg PO DAILY
7. Furosemide 40 mg PO DAILY
8. Lactulose 30 mL PO DAILY
9. Metoprolol Succinate XL 50 mg PO DAILY
hold for HR<55, bp<95
10. Multivitamins 1 TAB PO DAILY
11. Omeprazole 20 mg PO DAILY
12. Polyethylene Glycol 17 g PO DAILY
13. Senna 1 TAB PO BID
14. traZODONE 100 mg PO HS:PRN insomnia
15. Vitamin D 800 UNIT PO DAILY
16. Milk of Magnesia 30 mL PO Q6H:PRN constipation
17. Naproxen 500 mg PO Q8H:PRN pain
18. Lidocaine Jelly 2% 1 Appl TP DAILY: PRN penile pain/foley
pain
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Calcium Carbonate 500 mg PO DAILY
3. Docusate Sodium 100 mg PO BID
4. Furosemide 20 mg PO DAILY
5. Metoprolol Succinate XL 50 mg PO DAILY
hold for HR<55, bp<95
6. Milk of Magnesia 30 mL PO Q6H:PRN constipation
7. Multivitamins 1 TAB PO DAILY
8. Omeprazole 20 mg PO DAILY
9. Polyethylene Glycol 17 g PO DAILY
10. Senna 1 TAB PO BID
11. Vitamin D 800 UNIT PO DAILY
12. Acetaminophen 650 mg PO Q6H:PRN pain
13. Lidocaine Jelly 2% 1 Appl TP DAILY: PRN penile pain/foley
pain
14. Bisacodyl 10 mg PR HS constipation
15. Bisacodyl 10 mg PO DAILY constipation
16. Atorvastatin 40 mg PO DAILY
17. CefePIME 2 g IV Q12H
18. Fluconazole 200 mg PO Q24H Duration: 5 Days
19. Mirtazapine 7.5 mg PO HS
20. Lactulose 30 mL PO BID
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Complicated urinary tract infection
Hypotonic bladder
Constipation
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Mr. ___,
You were admitted to the hospital with a urinary tract
infection. You were treated with intravenous antibiotics and
will be discharged on an additional 7 days of antibiotics. You
were also found to have yeast in your urine and were started on
an antifungal medication which you will continue for an
additional 5 days.
You had shaking tremors, so we changed your antidepressant and
stopped some of your sedating medications. You were also found
to be very constipated and were treated with aggressive
laxatives which improved your pain.
Weigh yourself every morning, call your MD if your weight goes
up more than 3 lbs.
It was a pleasure taking care of you during your hospitalization
and we wish you the best going forward.
Followup Instructions:
___
|
19713100-DS-71
| 19,713,100 | 22,677,918 |
DS
| 71 |
2178-06-10 00:00:00
|
2178-06-10 17:56:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
___ / Oxybutynin / Bactrim
Attending: ___.
Chief Complaint:
UTI, delirium
Major Surgical or Invasive Procedure:
foley catheter exchange ___
History of Present Illness:
___ year old man with a hypotonic bladder, BPH, chronic
indwelling foley and multiple recent multidrug resistant urinary
tract infections and h/o CHF (EF >55%), who was brought in from
___ for facial twitching, found to have evidence of a UTI.
Patient notes lower central abdominal pain x 1 week; this has
been intermittent. No urinary frequency. No fevers, chills,
nausea, vomiting, diarrhea, hematuria, hematochezia. "Twitching"
was noted by facility at 10 am, but patient thinks it may have
been going on for months.
In the ED, initial vital signs were 96.4 80 100/60 16 98%. Labs
were notable for potassium 5.9, BUN/cr ___, wbc 8.2, hct
45.2, plt 263, bnp 2232, AST 51. Potassium on recheck was 5.2.
UA was floridly positive w/ >182 WBCs and many bacteria. Lactate
was 1.8. Blood and urine cx were sent. CXR was done which was
read as no acute process, mild CHF. Patient was given a 500 cc
bolus for boderline blood pressures with response and 2 grams of
cefepime. He was admitted to medicine for further evaluation and
management. VS on transfer were: 97 97/62 24 94%.
On arrival to the floor, the patient is comfortable. He denies
any current abdominal pain. He was not hungry. He was not
bothered by mild shaking that he had. VS on arrival were: 98.0
150/96 86 22 95%2L 93.4 kg.
Review of Systems:
(+) As noted above.
(-) fever, chills, night sweats, headache, vision changes,
rhinorrhea, congestion, sore throat, cough, shortness of breath,
chest pain, nausea, vomiting, diarrhea, constipation, melena,
hematochezia, dysuria, hematuria.
Past Medical History:
1. Hypotonic bladder with incomplete emptying, s/p indwelling
foley since ___ c/b frequent Multidrug resistent UTIs,
including MRSA and ESBL E Coli
2. BPH
3. CAD s/p CABG x 3 in ___
- CABG anatomy: LIMA to LAD, SVG to OM, and SVG to RCA
- s/p stenting ___ of mid RCA, PTCA of proximal RCA and PDA
- redo single vessel CABG in ___ with Dr. ___.
4. CHF was preserved EF 55% in ___
5. Bovine AVR in ___. Type 2 Diabetes Mellitus: diet controlled
7. Hypertension
8. Hx of Chronic constipation
9. Hyperlipidemia
10. Depression/Anxiety
11. Asbestosis
12. Spinal stenosis
13. R kidney mass - Followed by urology w/ serial imaging,
likely RCC
14. Osteoarthritis
15. Carotid stenosis - chronic occlusion of LICA, ___ with 40%
Social History:
___
Family History:
Daughter- died at ___,breast cancer.
Father- died from MI in his ___.
Physical Exam:
Admission Exam:
Vitals- 98.0 150/96 86 22 95%2L 93.4 kg.
General- Alert, oriented, no acute distress
HEENT- Sclera anicteric, MMM, oropharynx clear
Neck- supple, JVP not elevated, no LAD
Lungs- Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV- Regular rate and rhythm, mechanical S1 + normal S2, no
murmurs, rubs, gallops
Abdomen- soft, mild TTP in lower central abdomen, non-distended,
bowel sounds present, no rebound tenderness or guarding, no
organomegaly
GU- + foley
Ext- warm, well perfused, 2+ pulses. 1+ nonpitting BLE. No
clubbing or cyanosis
Neuro- CNs2-12 intact, motor function grossly normal
Discharge Exam:
Alert and oriented x 3
groin rash appreciated, erythematous c/w candidiasis
Pertinent Results:
Admission Labs:
___ 06:55PM SODIUM-140 POTASSIUM-5.2* CHLORIDE-105
___ 02:48PM LACTATE-1.8
___ 02:40PM URINE COLOR-Yellow APPEAR-Hazy SP ___
___ 02:40PM URINE BLOOD-TR NITRITE-POS PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5
LEUK-LG
___ 02:40PM URINE RBC-11* WBC->182* BACTERIA-MANY
YEAST-NONE EPI-0
___ 02:40PM URINE MUCOUS-FEW
___ 02:30PM GLUCOSE-121* UREA N-22* CREAT-1.0 SODIUM-139
POTASSIUM-5.9* CHLORIDE-101 TOTAL CO2-25 ANION GAP-19
___ 02:30PM estGFR-Using this
___ 02:30PM ALT(SGPT)-19 AST(SGOT)-51* ALK PHOS-66 TOT
BILI-0.5
___ 02:30PM LIPASE-35
___ 02:30PM proBNP-2232*
___ 02:30PM ALBUMIN-4.0 CALCIUM-9.4 PHOSPHATE-4.0
MAGNESIUM-2.2
___ 02:30PM WBC-8.2# RBC-5.21 HGB-15.0 HCT-45.2 MCV-87
MCH-28.8 MCHC-33.2 RDW-16.8*
___ 02:30PM NEUTS-73.2* ___ MONOS-5.1 EOS-2.6
BASOS-0.6
___ 02:30PM PLT COUNT-263
___ 02:30PM ___ PTT-30.1 ___
Discharge labs:
___ 06:30AM BLOOD WBC-5.3 RBC-4.39* Hgb-12.6* Hct-37.8*
MCV-86 MCH-28.8 MCHC-33.4 RDW-16.8* Plt ___
___ 06:30AM BLOOD Plt ___
___ 06:30AM BLOOD Glucose-103* UreaN-17 Creat-0.7 Na-141
K-3.8 Cl-102 HCO3-30 AnGap-13
___ 06:30AM BLOOD Calcium-8.7 Phos-3.1 Mg-1.9
___ 10:41AM BLOOD ___ pO2-55* pCO2-52* pH-7.38
calTCO2-32* Base XS-3
___ 2:40 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
KLEBSIELLA PNEUMONIAE. >100,000 ORGANISMS/ML..
Ertapenem AND Tigecycline Susceptibility testing
requested by S.
___ ___ ___.
Piperacillin/Tazobactam sensitivity testing performed
by ___
___.
Ertapenem SENSITIVE sensitivity testing performed by
___.
Tigecycline 1.0 MG/ML SENSITIVE Sensitivity testing
performed by
Etest.
MIC interpretations are based on manufacturer's
guidelines that
are FDA approved.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
KLEBSIELLA PNEUMONIAE
|
AMPICILLIN/SULBACTAM-- =>32 R
CEFAZOLIN------------- =>64 R
CEFEPIME-------------- 16 I
CEFTAZIDIME----------- =>64 R
CEFTRIAXONE----------- =>64 R
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- 256 R
PIPERACILLIN/TAZO----- S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- 4 R
Blood culture ___ and ___ all pending
CXR ___: Low lung volumes without acute findings.
CT HEAD NONCON ___: There is no evidence of hemorrhage,
edema, or acute infarct. Hypodense foci in the left basal
ganglia is unchanged compared to ___ and likely
represents a prior lacunar infarct. There is re- demonstration
of the partially calcified extra-axial lesion on the mastoid
portion of the left temporal bone relatively unchanged compared
to prior study measuring 1.8 x 1.0 cm and without mass effect on
the adjacent parenchyma. Mastoid air cells, middle ear cavities
and visualized paranasal sinuses are clear. No softtissue
swelling. IMPRESSION: No acute process. Stable posterior fossa
partially calcified meningioma.
CXR ___: In comparison with study of ___, there are
continued low lung volumes with elevation of the left
hemidiaphragmatic contour. A thick band of atelectasis is seen
at the right base with mild streaks of atelectasis above the
elevated left hemidiaphragm. Midline sternal wires remain
intact and calcified pleural plaques are again seen.
Brief Hospital Course:
___ year old man with a hypotonic bladder, BPH, chronic
indwelling foley and multiple recent multidrug resistant urinary
tract infections here with symptomatic UTI with an multidrug
resistant klebsiella complicated by acute delirium.
ACTIVE ISSUES:
1. URINARY TRACT INFECTION: patient prone to repeat infections
due to his chronic indwelling foley. While he presented with a
grossly positive urinalysis, his chronic and colonized foley
obscures the interpretation of this finding- we initially
suspected asymptomatic bacteriuria due to a complaint of only
minimal suprapubic tenderness which would not necessitate
treatment (and which would only foster resistance) however he
became densely encephalopathic with tremors which prompted us to
treat. He started cefepime which was changed to
imipenem/cilastin on ___ when a MDR klebsiella grew out.
His mental status quickly improved, as did his suprapubic pain
within 24hr. He will be discharged to complete 10d of ertapenem
daily IM injections ending on ___. His foley was changed
on ___. It must be changed every ___ weeks to prevent
infection. Per his urology team, he has refused suprapubic
catheters in the past.
ID was consulted to help direct antibiotic selection and the
need for treatment of frequently positive UA- it is suggested
that urinalyses only be done and treated if the patient has
symptoms of UTI, such as fevers, severe delirium, upper-urinary
tract symptoms.
2. TOXIC METABOLIC ENCEPHALOPATHY: Patient showed waxing and
waning mental status on HD1 and 2, which fluctuated several
times over the course of the day. It was probably due to his
klebsiella UTI, as he cleared after receiving appropriate
carbapenem treatment. CT head, electrolytes, and other
infectious workup was negative. He does tend to sundown at his
baseline, however.
3. MYOCLONIC JERKS: Had brief and sudden jerking movements
while delirious- Was seen by neuro in the past suggesting it was
due to encephalopathy. It improves has his mental status clears.
4. GROIN CANDIDIASIS: his groin pain was likely due to
candidiasis. Prescribed BID ketoconazole cream and recommend
drying agents as tolerated.
INACTIVE PROBLEMS:
# HTN: Stable on metoprolol succinate 50mg daily as outpatient.
# CAD s/p CABG: Stable on ASA, metoprolol.
# Chronic Diastolic Congestive Heart Failure: not exacerbated
# Right Kidney Mass: concerning for RCC and stable on recent CT
scan; he had declined tx in the past
# DM2 - Hgb A1c 6.5 ___. Not on outpatient treatment at
present, sugars well controlled in house.
# Prophylaxis: Subcutaneous heparin, bowel regimen, pain control
with
# Access: peripherals
# Code: DNR/DNI (confirmed with patient)
# Communication: Patient, HCP is daughter ___ (Phone
number: ___, Cell phone: ___
PENDING TESTS AT DISCHARGE:
-blood cultures pending ___
TRANSITIONAL CARE ISSUES:
- check UA only in context of clinical infection
- finishing ertapenem for MDR klebsiella
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Calcium Carbonate 500 mg PO DAILY
3. Docusate Sodium 100 mg PO BID
4. Furosemide 20 mg PO DAILY
5. Metoprolol Succinate XL 50 mg PO DAILY
hold for HR<55, bp<95
6. Milk of Magnesia 30 mL PO Q6H:PRN constipation
7. Multivitamins 1 TAB PO DAILY
8. Omeprazole 20 mg PO DAILY
9. Polyethylene Glycol 17 g PO DAILY
10. Senna 1 TAB PO BID
11. Vitamin D 800 UNIT PO DAILY
12. Acetaminophen 650 mg PO Q6H:PRN pain
13. Lidocaine Jelly 2% 1 Appl TP DAILY: PRN penile pain/foley
pain
14. Bisacodyl 10 mg PR HS constipation
15. Bisacodyl 10 mg PO DAILY constipation
16. Atorvastatin 40 mg PO DAILY
17. Mirtazapine 7.5 mg PO HS
18. Lactulose 30 mL PO BID
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Bisacodyl 10 mg PO DAILY constipation
3. Calcium Carbonate 500 mg PO DAILY
4. Furosemide 20 mg PO DAILY
5. Metoprolol Succinate XL 50 mg PO DAILY
hold for HR<55, bp<95
6. Multivitamins 1 TAB PO DAILY
7. Omeprazole 20 mg PO DAILY
8. Vitamin D 800 UNIT PO DAILY
9. Atorvastatin 40 mg PO DAILY
10. Docusate Sodium 100 mg PO BID
11. Senna 1 TAB PO BID
12. Mirtazapine 7.5 mg PO HS
13. Bisacodyl 10 mg PR HS constipation
14. Milk of Magnesia 30 mL PO Q6H:PRN constipation
15. Acetaminophen 650 mg PO Q6H:PRN pain
16. Polyethylene Glycol 17 g PO DAILY
17. Lidocaine Jelly 2% 1 Appl TP DAILY: PRN penile pain/foley
pain
18. ertapenem *NF* 1 gram Injection DAILY
LAST DOSE ON ___
RX *ertapenem [Invanz] 1 gram 1 gram injected daily Disp #*9
Gram Refills:*0
19. Ketoconazole 2% 1 Appl TP BID
apply to groin
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Urinary tract infection, complicated by chronic foley
acute toxic metabolic encephalopathy
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Mr. ___,
You were admitted with a urinary tract infection. You are prone
to these infections because you need to have a foley catheter in
place chronically. We treated you with antibiotics and you
improved. You will need to continue getting a daily shot of
antibiotics ending on ___.
You were also very delirious while hospitalized due to your
infection, you improved with antibiotics. You also have a groin
rash that we are treating with antifungal medicine
The following changes have been made to your medications
1. START ERTAPENEM daily through ___
2. START KETACONAZOLE CREAM BID until your groin rash improves
No other changes were made to your medications
Followup Instructions:
___
|
19713100-DS-72
| 19,713,100 | 29,718,045 |
DS
| 72 |
2178-07-06 00:00:00
|
2178-07-06 19:52:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
___ / Oxybutynin / Bactrim
Attending: ___.
Chief Complaint:
altered mental status
Major Surgical or Invasive Procedure:
foley removal and placement
History of Present Illness:
Mr ___ is an ___ male with history of hypotonic bladder,
BPH, chronic indwelling foley and multiple recent multidrug
resistant UTIs and h/o CHF (EF >55%) presenting from rehab with
altered mental status and dysuria. Per daughter, the patient has
been progressively more disoriented and confused for the past 4
days. He was describing general malaise and burning with
urination for the past ___ days. He denies fevers or chills. No
n/v/d.
Importantly, he has been admitted twice in the past 2 months for
UTIs complicated by AMS. First UTI was imipenem resistant
pseudomonas treated ultimately with cefepime. Second UTI, he was
treated with cefepime which was switched to imipenem/cilastin
given MDR klebsiella. Last foley change on ___.
In the ED, 97.7 92 137/78 20 93. Grossly positive UA. CXR
without infiltrate. Labs WNL. Patient received zosyn 4.5gm IV
x2, Imipenem x1, Morphine 4mgIV x1, Acetaminophen 1000mg po x1,
phenazopyridine 100mg x1.
VS prior to transfer: 97.7 73 143/56 20 99% At time of transfer
patient A+Ox2, slurred speech which is consistent with recent
pt's baseline.
On arrival to the floor initial vital signs: 98.1 121/75 73 16
99 2L. He continued to describe lethargy with burning on
urination.
ROS: per HPI, denies fever, chills, night sweats, headache,
vision changes, rhinorrhea, congestion, sore throat, cough,
shortness of breath, chest pain, abdominal pain, nausea,
vomiting, diarrhea, constipation, BRBPR, melena, hematochezia,
hematuria.
Past Medical History:
1. Hypotonic bladder with incomplete emptying, s/p indwelling
foley since ___ c/b frequent Multidrug resistent UTIs,
including MRSA and ESBL E Coli
2. BPH
3. CAD s/p CABG x 3 in ___
- CABG anatomy: LIMA to LAD, SVG to OM, and SVG to RCA
- s/p stenting ___ of mid RCA, PTCA of proximal RCA and PDA
- redo single vessel CABG in ___ with Dr. ___.
4. CHF was preserved EF 55% in ___
5. Bovine AVR in ___. Type 2 Diabetes Mellitus: diet controlled
7. Hypertension
8. Hx of Chronic constipation
9. Hyperlipidemia
10. Depression/Anxiety
11. Asbestosis
12. Spinal stenosis
13. R kidney mass - Followed by urology w/ serial imaging,
likely RCC
14. Osteoarthritis
15. Carotid stenosis - chronic occlusion of LICA, ___ with 40%
Social History:
___
Family History:
Daughter- died at ___,breast cancer.
Father- died from MI in his ___.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS 98.1 121/75 73 16 99 2LNC
GEN Alert, oriented to person, partially to place, not oriented
to time, 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 + suprapubic tenderness, ND normoactive bowel sounds
EXT trace lower leg edema L>R. WWP 2+ pulses palpable
bilaterally, no c/c/e
NEURO CNs2-12 intact, motor function grossly normal
SKIN: Stage ___ sacral decub ulcer, 2cm area of
tenderness/erythema along penile shaft.
PHYSICAL EXAM:
VS - 97.6 134/85 83 20 95RA
GENERAL - alert, oriented x3NAD, comfortable, appropriate
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear
NECK - supple, 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, no
rebound/guarding
SKIN: Stage ___ sacral pressure ulcer, 2cm area of
tenderness/erythema along penile shaft.
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
Pertinent Results:
ADMISSION LABS
___ 10:05PM BLOOD WBC-5.5 RBC-4.86 Hgb-13.7* Hct-42.3
MCV-87 MCH-28.3 MCHC-32.5 RDW-17.2* Plt ___
___ 10:05PM BLOOD Neuts-64.7 ___ Monos-7.2 Eos-3.2
Baso-0.9
___ 10:05PM BLOOD Glucose-131* UreaN-19 Creat-0.9 Na-142
K-4.1 Cl-102 HCO3-29 AnGap-15
___ 10:27PM BLOOD ___ pO2-74* pCO2-50* pH-7.40
calTCO2-32* Base XS-4
___ 10:27PM BLOOD Lactate-1.2
DISCHARGE LABS:
___ 06:00AM BLOOD WBC-7.2 RBC-4.67 Hgb-13.2* Hct-40.7
MCV-87 MCH-28.3 MCHC-32.5 RDW-17.1* Plt ___
___ 06:00AM BLOOD Glucose-139* UreaN-11 Creat-0.8 Na-141
K-3.3 Cl-102 HCO3-30 AnGap-12
___ 06:00AM BLOOD Calcium-8.1* Phos-2.4*# Mg-1.5*
MICROBIOLOGY:
___
|
AMIKACIN-------------- <=2 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN--------- 1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- 256 R
PIPERACILLIN/TAZO----- <=4 S
TRIMETHOPRIM/SULFA---- <=1 S
IMAGING:
EKG: Normal sinus rhythm. Right bundle-branch block. Since the
previous tracing of ___ right bundle-branch block has
appeared.
Rate PR QRS QT/QTc P QRS T
81 ___ 41 0 41
CXR: Frontal and lateral views of the chest were obtained.
There is no focal consolidation, pleural effusion or
pneumothorax. Right basilar atelectasis is seen. Elevation of
left hemidiaphragm is unchanged. Cardiac and mediastinal
silhouettes are stable. Median sternotomy wires are intact
status post CABG. IMPRESSION: No acute intrathoracic process.
___: Grayscale and color Doppler sonographic evaluation was
performed of the left lower extremity. Normal compressibility,
flow and response to augmentation is seen in the common femoral,
superficial femoral and popliteal veins. Normal compressibility
and flow is seen in the posterior tibial and peroneal veins.
IMPRESSION: No left lower extrmemity DVT.
PICC LINE PLACEMENT ___:
PROCEDURE DETAILS:
The patient was brought to the angiographic suite and placed
supine on the
table. A preprocedure timeout was performed using three patient
identifiers. The skin of the right upper extremity was prepped
and draped in the usual sterile fashion including the indwelling
single-lumen PICC catheter.
An initial scout image demonstrated the PICC to be in the mid
axillary line. A nitinol wire was advanced through the PICC;
however, this would not pass more centrally in the mid axillary
line. The PICC was withdrawn and a 4.5 ___ peel-away sheath
was advanced over the wire. A 5 ___ Kumpe catheter was
advanced over the wire and we attempted to inject contrast;
however, contrast could not be injected via the catheter. The
catheter was gradually withdrawn until there was opacification
of an axillary vein; however, clearly a false tract had been
created. So, this catheter was removed and firm manual
compression was applied for 5 minutes. Following this, we
attempted to place a new PICC. A second right upper extremity
vein was selected; this appeared to be the right basilic vein. 1
cc of lidocaine was infiltrated into the skin and subcutaneous
tissues for local anesthesia. Using direct ultrasound
visualization, a micropuncture needle was advanced into the
vein. Ultrasound images were saved prior to and after
venopuncture, confirming patency of the vein. A nitinol wire
advanced through the micropuncture needle without difficulty. A
small skin incision was made and the micropuncture needle was
exchanged for a 4.5 ___ peel-away sheath. The nitinol wire
was advanced readily into the IVC confirming venous positioning.
The wire was withdrawn into the SVC to estimate the length of
required tubing. A new single-lumen Power PICC was selected,
flushed and cut to 42 cm. This advanced over the
nitinol wire without difficulty. The peel-away sheath was
gradually removed
as the catheter was advanced. The nitinol wire was removed.
Following completion of this maneuver, the tip of the catheter
was in the distal SVC.
The catheter was secured to the skin with a StatLock device. The
catheter was aspirating and flushing without difficulty. There
were no immediate
post-procedure complications. IMPRESSION: Unsuccessful
repositioning of a PICC, a new single-lumen Power PICC has been
placed with the tip in the distal SVC. The catheter has been
flushed and is ready for use.
Brief Hospital Course:
ASSESSMENT & PLAN:
Mr ___ is an ___ male with history of hypotonic bladder,
BPH, chronic indwelling foley and multiple recent multidrug
resistant UTIs who presented with altered mental status, general
malaise and was found to have UTI.
ACTIVE ISSUES:
#URINARY TRACT INFECTION: He presented with altered mental
status in the setting of chronic indwelling foley and a recent
history of UTI pseudomonas (resistant to imipenem) and MDR
Klebsiella. Urinalysis positive and it was decided to treat for
UTI (rather than just colonization) because of AMS and malaise.
His indwelling foley catheter was replaced on ___. He initially
received imipenem and Zosyn in the ED, but was tapered to Zosyn
based on prior urine culture sensitivities. Urine culture
resulted (___) however Zosyn kept on board
because of likelihood of inadequate urine culture and clinical
presentation. He received an ___ guided PICC line and will
continue Zosyn for total of 10days. His mental status improved
with IV abx treatment.
#ACUTE DELERIUM: He initially presented with confusion and
altered mental status in the setting of UTI. He was refusing
oral medications and was not oriented to place or time, however
this resolved by ___. On discharge, he was alert, oriented x3.
# Left lower extremity swelling: His left leg was asymetrically
edematous (1+)on presentation however was not warm to touch or
erythematous. LENIS negative. Edema resolved. On discharge,
there was bilateral trace edema. Notable asymmety in exam.
CHRONIC ISSUES:
# Wound care: He has chronic Stage ___ sacral pressure ulcers on
left ischium. This was treated according to ulcer protocol with
Mepilex. No dressing to coccyx was necessary on patchy skin
overlying coccyx. Also there is 2cm area of
tenderness/erythema along penile shaft that will need excellent
skin care along the penile shaft as the drainage from the
urethra will be chronic.
# HTN: stable.
# CAD s/p CABG: Stable, continued statin ASA, metoprolol. He
was transitioned from metoprolol tartrate to metoprolol
succinate prior to discharge.
# DM2 - Hgb A1c 6.5 ___. FSG was monitored closely and she
was kept on humalog ISS.
# History of right Kidney Mass: concerning for RCC and stable on
recent CT scan; he had declined tx in the past. Has appointment
with Dr. ___.
TRANSITIONAL:
-DNR/DNI
-Will follow-up with Dr. ___ right kidney mass.
-Patient should be told that he can leave Rehab only after his
anitbiotic infusions are completed and he can stand and transfer
by himself.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Bisacodyl 10 mg PO DAILY constipation
3. Calcium Carbonate 500 mg PO DAILY
4. Furosemide 20 mg PO DAILY
5. Metoprolol Succinate XL 50 mg PO DAILY
hold for HR<55, bp<95
6. Multivitamins 1 TAB PO DAILY
7. Omeprazole 20 mg PO DAILY
8. Vitamin D 800 UNIT PO DAILY
9. Atorvastatin 40 mg PO DAILY
10. Docusate Sodium 100 mg PO BID
11. Senna 1 TAB PO BID
12. Mirtazapine 7.5 mg PO HS
13. Milk of Magnesia 30 mL PO Q6H:PRN constipation
14. Acetaminophen 650 mg PO Q6H:PRN pain
15. Polyethylene Glycol 17 g PO DAILY
16. Lidocaine Jelly 2% 1 Appl TP DAILY: PRN penile pain/foley
pain
17. Ketoconazole 2% 1 Appl TP BID
apply to groin
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 40 mg PO DAILY
4. Bisacodyl 10 mg PO DAILY constipation
5. Calcium Carbonate 500 mg PO DAILY
6. Docusate Sodium 100 mg PO BID
7. Furosemide 20 mg PO DAILY
8. Ketoconazole 2% 1 Appl TP BID
apply to groin
9. Lidocaine Jelly 2% 1 Appl TP DAILY: PRN penile pain/foley
pain
10. Milk of Magnesia 30 mL PO Q6H:PRN constipation
11. Mirtazapine 7.5 mg PO HS
12. Multivitamins 1 TAB PO DAILY
13. Omeprazole 20 mg PO DAILY
14. Polyethylene Glycol 17 g PO DAILY
15. Senna 1 TAB PO BID
16. Vitamin D 800 UNIT PO DAILY
17. Metoprolol Succinate XL 50 mg PO DAILY
hold for HR<55, bp<95
18. Piperacillin-Tazobactam 4.5 g IV Q8H
RX *piperacillin-tazobactam 4.5 gram Infuse 4.5gm IV every 8
hours Disp #*21 Unit Refills:*0
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Complicated Urinary Tract Infection
Acute Delerium
Dehydration
Pressure Ulcer
Urethral shaft inflammation
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you while you were admitted to
___. You were admitted with confusion and a urinary tract
infection. You were treated with IV fluids and antibiotics
which you tolerated well. You had a PICC line placed so that
you can continue antibiotic infusion over the next 7 days when
you return to your skilled nursing facility.
You were also seen by wound care regarding pressure ulcers on
your sacrum and inflamed tissue on your penis. This wound care
will continue at rehab.
You will continue your treatment at rehab until your anitbiotic
infusions are completed and you can stand and transfer by
yourself.
Followup Instructions:
___
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19713100-DS-73
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DS
| 73 |
2178-07-13 00:00:00
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2178-07-14 10:46:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
___ / Oxybutynin / Bactrim
Attending: ___
___ Complaint:
Groin pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ male with history of hypotonic bladder, BPH, chronic
indwelling foley and multiple recent multidrug resistant UTIs
(3x in the last two months), CAD s/p CABG, CHF EF55%, and likely
RCC on imaging now presenting with mild pelvic and severe groin
pain after recent discharge on ___ for multidrug
resistant UTI on pip/tazo.
Patient states he has had this pain since his last bladder
infection, it initially improved but seems to have gotten worse
over the last several days. He denies any fevers or chills or
back pain. He denies any abdominal pain. He denies any chest
pain, shortness of breath, cough, sore throat, runny nose.
On exam in the ED, patient had no abdominal pain. He does have
some mild suprapubic tenderness, which he says is the same pain
he had during his last urinary tract infection. He denies any
back pain has no CVA tenderness and he is afebrile. UA showed 61
WBCs, 28 RBCs, No bacteria, and many yeast. Other labs were
unremarkable. Pt had foley catheter changed in ED, with urine
and blood cultures sent, and was started on cefepime. Pt was
also started on fluconazole IV and admitted to medicine.
Currently, Pt reports feeling "lousy." When asked to point to
where his pain is, he points to his groin. This groin pain, R >
L, has been worsening since his discharge. Pt denies any fever,
or chills. Reports chronic cough but denies rhinorrhea, sore
throat, myalgias. No nausea or vomiting. Reports constipation.
No focal numbness or weakness. Pt does not feel confused and is
appropriately alert and interactive. He is very distressed about
the frequency of his UTIs and hospitalizations.
Of note, he has been admitted 3x in the past 3 months for
UTIs and altered mental status. First UTI in ___ was
sensitive Klebsiella and imipenem resistant pseudomonas treated
ultimately with cefepime. He also had a urine culture w/ > 100k
colonies of ___ parapsilosis, which was treated with
fluconazole 200mg po daily for 1 week. Second UTI, he was
treated with cefepime which was switched to imipenem/cilastin
given MDR klebsiella. During most recent admission in early ___, Pt's UCx showed PROVIDENCIA STUARTII, but this was felt to
be due to an inadequate urine culture, and Pt was discharged on
___ on 10 day course of pip/tazo.
Past Medical History:
1. Hypotonic bladder with incomplete emptying, s/p indwelling
foley since ___ c/b frequent Multidrug resistent UTIs,
including MRSA and ESBL E Coli
2. BPH
3. CAD s/p CABG x 3 in ___
- CABG anatomy: LIMA to LAD, SVG to OM, and SVG to RCA
- s/p stenting ___ of mid RCA, PTCA of proximal RCA and PDA
- redo single vessel CABG in ___ with Dr. ___.
4. CHF was preserved EF 55% in ___
5. Bovine AVR in ___. Type 2 Diabetes Mellitus: diet controlled
7. Hypertension
8. Hx of Chronic constipation
9. Hyperlipidemia
10. Depression/Anxiety
11. Asbestosis
12. Spinal stenosis
13. R kidney mass - Followed by urology w/ serial imaging,
likely RCC
14. Osteoarthritis
15. Carotid stenosis - chronic occlusion of LICA, ___ with 40%
Social History:
___
Family History:
Daughter- died at ___,breast cancer.
Father- died from MI in his ___.
Physical Exam:
ADMISSION PHYSICAL EXAM:
97.5, 122/71, 73, 90% RA.
GENERAL - well-appearing man in NAD, appropriate
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear
NECK - supple, no thyromegaly, no JVD, no carotid bruits
LUNGS - minor inspiratory crackles in bases, mild expiratory
wheezes, no accessory muscle use
HEART - RRR, no MRG, nl S1-S2
ABDOMEN - NABS, soft, mild tenderness to suprapubic palpation,
otherwise non-tender, no rebound/guarding
Pelvic - several sacral decub ulcers in various stages w/ large
dressing in place. Small scrotal ulcer. Bilateral erythema and
edema in inguinal skin folds R > L. Skin is warm and very tender
to palpation. Brown stool-like substance and creamy white
substance in bilateral inguinal folds. Foley in place, mild
excoriation of head of penis.
EXTREMITIES - WWP, lower extremities in bilateral compression
stockings, trace edema bilaterally, 2+ peripheral pulses
(radials, DPs)
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
___ throughout, sensation grossly intact throughout
DISCHARGE PHYSICAL EXAM:
97.7 147/84 75 18 94%ra
GENERAL - well-appearing man in NAD, appropriate
HEENT - NC/AT, MMM, OP clear
LUNGS - CTAB
HEART - RRR, no MRG, nl S1-S2
ABDOMEN - NABS, soft, NT/ND, no rebound/guarding, no HSM
Pelvic - several sacral decub ulcers in various stages w/ large
dressing in place. Bilateral erythema in inguinal skin folds
significantly improved from prior examination. Inguinal skin
only mildly tender to palpation. No obvious breakes in the skin.
Foley in place, mild excoriation of head of penis.
EXTREMITIES - WWP, lower extremities in bilateral compression
stockings, trace edema bilaterally, 2+ peripheral pulses
(radials, DPs)
NEURO - awake, A&Ox3. no focal deficits
Pertinent Results:
LABS:
___ 07:58PM BLOOD WBC-8.9 RBC-4.83 Hgb-13.4* Hct-41.5
MCV-86 MCH-27.8 MCHC-32.4 RDW-17.4* Plt ___
___ 05:42AM BLOOD WBC-9.4 RBC-4.66 Hgb-13.1* Hct-40.4
MCV-87 MCH-28.2 MCHC-32.5 RDW-17.6* Plt ___
___ 05:20AM BLOOD WBC-6.0 RBC-4.76 Hgb-13.0* Hct-40.9
MCV-86 MCH-27.4 MCHC-31.9 RDW-17.5* Plt ___
___ 07:58PM BLOOD Glucose-113* UreaN-15 Creat-1.0 Na-139
K-4.4 Cl-102 HCO3-29 AnGap-12
___ 05:42AM BLOOD Glucose-114* UreaN-13 Creat-0.8 Na-142
K-3.8 Cl-104 HCO3-29 AnGap-13
___ 05:20AM BLOOD Glucose-109* UreaN-12 Creat-0.8 Na-143
K-3.8 Cl-105 HCO3-31 AnGap-11
___ 07:58PM BLOOD ALT-12 AST-28 AlkPhos-57 TotBili-0.3
___ 05:42AM BLOOD ALT-11 AST-17 LD(LDH)-211 AlkPhos-57
TotBili-0.4
___ 05:42AM BLOOD Calcium-8.4 Phos-2.7 Mg-1.7
___ 08:01PM BLOOD Lactate-1.3
MICROBIOLOGY:
___ 4:15 pm STOOL CONSISTENCY: NOT APPLICABLE
Source: Stool.
**FINAL REPORT ___
C. difficile DNA amplification assay (Final ___:
Negative for toxigenic C. difficile by the Illumigene DNA
amplification assay.
(Reference Range-Negative).
__________________________________________________________
___ 8:05 pm BLOOD CULTURE
Blood Culture, Routine (Pending):
__________________________________________________________
Time Taken Not Noted Log-In Date/Time: ___ 8:11 pm
BLOOD CULTURE
Blood Culture, Routine (Pending):
__________________________________________________________
___ 7:40 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
YEAST. >100,000 ORGANISMS/ML..
__________________________________________________________
___ 10:05 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
__________________________________________________________
___ 3:30 am BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
__________________________________________________________
___ 10:05 pm URINE Site: NOT SPECIFIED
**FINAL REPORT ___
URINE CULTURE (Final ___:
Culture workup discontinued. Further incubation showed
contamination
with mixed fecal flora. Clinical significance of
isolate(s)
uncertain. Interpret with caution.
PROVIDENCIA ___. >100,000 ORGANISMS/ML..
GENTAMICIN & TOBRAMYCIN sensitivity testing performed
by ___
___.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
___ ___
|
AMIKACIN-------------- <=2 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN--------- 1 S
GENTAMICIN------------ S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- 256 R
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ R
TRIMETHOPRIM/SULFA---- <=1 S
=
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Brief Hospital Course:
___ male with history of hypotonic bladder, BPH, chronic
indwelling foley and multiple recent multidrug resistant UTIs
(3x in the last two months), CAD s/p CABG, CHF EF55%, and likely
RCC on imaging now presenting with groin pain after recent
discharge on ___ for multidrug resistant UTI on
pip/tazo.
# Inguinal intertrigo: Initial exam showed significant b/l
inguinal erythema with tenderness to palpation. Patient stated
his groin pain has been relatively constant since his last
hospitalization. Pt was noted to have intertrigo during his
admission in ___ and was prescribed ketoconazole cream bid,
which has stayed on his medication list per our paperwork but
was actually not given upon speaking with his SNF. He was
instead treated with topical zinc oxide for his intertrigo.
Intertrigo was treated with miconazole powder with significant
improvement of erythema and pain. He should be continued on
miconazole topical powder upon discharge to SNF.
# candiduria: Pt had many yeast on admission UA. He previously
grew > 100k colonies of ___ parapsilosis on urine Cx from
___ and was treated for 1 week with fluconazole 200mg po
daily. Pt had a renal ultrasound in ___, which did not show
any evidence of fungus balls. Per IDSA guidelines from ___
[Clin Infect Dis. ___ most appropriate
treatment for symptomatic candiduria is with fluconazole 200mg
po daily x 2 weeks. Pt's indwelling foley was switched out in
ED. Patient treated with 14-day course of PO fluconazole 200mg
daily (end date ___. Baseline LFTs were wnl. Patient should
have repeat LFTs after completing course of fluconazole.
# Bacterial UTI: With regards to continuing treatment for recent
bacterial UTI, his admission UA shows no bacteria, and it is
unlikely that Pt failed bacterial UTI therapy on pip/tazo.
Treatment with pip/tazo was resumed and he is scheduled to
finish his 10-day course for complicated bacterial UTI on
___.
# known right kidney mass: concerning for RCC and stable on
recent CT scan and renal ultrasound. Will f/u with Dr. ___
urology.
# HTN: continued home metoprolol, furosemide
# CAD s/p CABG: stable, continued home atorvastatin, ASA,
metoprolol.
# DM2 - Hgb A1c 6.5 ___. Sliding scale while inpatient.
# depression: continued home duloxetine. Added mirtazapine given
poor appetite.
# insomnia: continued home trazodone qhs prn
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================================================================
TRANSITIONAL ISSUES
#Intertrigo: continue treatment with topical miconazole powder
until clinically resolved
#UTI: f/u final urine cultures. continue fluconazole 200mg daily
until ___. Re-check LFTs at end of fluconazole course to
assess for azole-induced hepatic injury. Zosyn for bacterial UTI
from previous admission to end ___. After final dose of
Zosyn, right PICC line can be discontinued
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY Start: In am
2. Calcium Carbonate 500 mg PO DAILY Start: In am
3. Furosemide 20 mg PO DAILY Start: In am
hold for sbp < 90
4. Loratadine *NF* 10 mg Oral daily
5. Metoprolol Succinate XL 50 mg PO DAILY Start: In am
hold for sbp < 90 or HR < 55
6. Multivitamins 1 TAB PO DAILY Start: In am
7. zinc oxide *NF* unknown Topical tid
to groins and buttocks
8. Omeprazole 20 mg PO DAILY Start: In am
9. Vitamin D 800 UNIT PO DAILY Start: In am
10. Atorvastatin 40 mg PO DAILY Start: In am
11. Docusate Sodium 100 mg PO BID Start: In am
hold for diarrhea
12. Acetaminophen 650 mg PO TID
3 gm max daily
13. Senna 2 TAB PO HS
hold for loose stool
14. traZODONE 25 mg PO HS:PRN insomnia
15. Acetaminophen 650 mg PO Q4H:PRN pain, fever
Do not exceed 4gm per day.
16. Bisacodyl 10 mg PR HS:PRN constipation
17. Fleet Enema ___AILY:PRN constipation
18. Lidocaine Jelly 2% 1 Appl TP ASDIR
as needed for penile / foley pain
19. Milk of Magnesia 30 mL PO Q6H:PRN constipation
20. Polyethylene Glycol 17 g PO DAILY:PRN constipation
21. Polyethylene Glycol 17 g PO DAILY
ordered ___
22. Duloxetine 30 mg PO QHS
23. Piperacillin-Tazobactam 4.5 g IV Q8H
Discharge Medications:
1. Acetaminophen 650 mg PO TID
3 gm max daily
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 40 mg PO DAILY
4. Bisacodyl 10 mg PR HS:PRN constipation
5. Calcium Carbonate 500 mg PO DAILY
6. Docusate Sodium 100 mg PO BID
hold for diarrhea
7. Duloxetine 30 mg PO QHS
8. Furosemide 20 mg PO DAILY
hold for sbp < 90
9. Lidocaine Jelly 2% 1 Appl TP ASDIR
as needed for penile / foley pain
10. Metoprolol Succinate XL 50 mg PO DAILY
hold for sbp < 90 or HR < 55
11. Milk of Magnesia 30 mL PO Q6H:PRN constipation
12. Multivitamins 1 TAB PO DAILY
13. Piperacillin-Tazobactam 4.5 g IV Q8H
14. Polyethylene Glycol 17 g PO DAILY:PRN constipation
15. Senna 2 TAB PO HS
hold for loose stool
16. traZODONE 25 mg PO HS:PRN insomnia
17. Vitamin D 800 UNIT PO DAILY
18. Fluconazole 200 mg PO Q24H Duration: 14 Days
19. Miconazole Powder 2% 1 Appl TP TID
20. Mirtazapine 7.5 mg PO HS
21. OxycoDONE (Immediate Release) 2.5 mg PO Q4H:PRN pain
22. Acetaminophen 650 mg PO Q4H:PRN pain, fever
Do not exceed 4gm per day.
23. Fleet Enema ___AILY:PRN constipation
24. Loratadine *NF* 10 mg Oral daily
25. Omeprazole 20 mg PO DAILY
26. Polyethylene Glycol 17 g PO DAILY
ordered ___
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Intertrigo
___ urinary tract 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:
Dear Mr. ___,
It was a pleasure taking part in your care here at ___. You
were admitted for a fungal infection in your groin called
intertrigo. This was treated with antifungal powder and
improved. You were also found to have a fungal bladder
infection. This will be treated with 2 weeks of an antifungal
pill.
I wish you a speedy recovery!
Followup Instructions:
___
|
19713100-DS-76
| 19,713,100 | 24,017,443 |
DS
| 76 |
2178-09-10 00:00:00
|
2178-09-14 09:03:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
___ / Oxybutynin / Bactrim
Attending: ___.
Chief Complaint:
Altered mental status
Major Surgical or Invasive Procedure:
None
History of Present Illness:
The pt is a ___ from ___ Short Term Rehabilitation
Facility. History of chronic indwelling foley and multiple
recent multidrug resistant UTIs (Klebsiella, ___), CAD
s/p CABG, CHF EF55%, and likely Renal Cell Carcinoma. Multiple
admission for UTI in the past year, 3 over several weeks. Most
recent discharge on ___. Last night the pt presented from ___
with AMS and shaking chills. Per report, the patient was doing
well, until last night around 11PM, when he began complaining
that he didn't feel well. He was noted to have generalized
twitching, most prominent in the facial muscles. His mental
status began to decline and he was not answering questions
appropriately, prompting transport to the ___. Per the ___
nursing staff, this is very similar to how he has presented with
his multiple prior UTIs. His baseline mental status is normally
very coherent and generally oriented x2 and answers questions
appropriately.
Past Medical History:
1. Hypotonic bladder with incomplete emptying, s/p indwelling
foley since ___ c/b frequent Multidrug resistent UTIs,
including MRSA and ESBL E Coli
2. BPH
3. CAD s/p CABG x 3 in ___
- CABG anatomy: LIMA to LAD, SVG to OM, and SVG to RCA
- s/p stenting ___ of mid RCA, PTCA of proximal RCA and PDA
- redo single vessel CABG in ___ with Dr. ___.
4. CHF was preserved EF 55% in ___
5. Bovine AVR in ___. Type 2 Diabetes Mellitus: diet controlled
7. Hypertension
8. Hx of Chronic constipation
9. Hyperlipidemia
10. Depression/Anxiety
11. Asbestosis
12. Spinal stenosis
13. R kidney mass - Followed by urology w/ serial imaging,
likely RCC
14. Osteoarthritis
15. Carotid stenosis - chronic occlusion of ___, ___ with 40%
Social History:
___
Family History:
Daughter- died at ___,breast cancer.
Father- died from MI in his ___
Physical Exam:
ADMISSION EXAM:
Vital Signs: Temp 98.2, BP 111/95, HR 51, RR 22, O2sat 96% on RA
GENERAL: Elderly male, sitting on the bed, intermittent
myoclonus
HEENT: NC/AT, PERRLA, EOMI, conjectiva erythematous, dry mucus
membranes
NECK: supple, no LAD, no JVP elevation.
LUNGS: Fine crackles at bases, no wheezing
HEART: RRR, no MRG, nl S1-S2
ABDOMEN: normal bowel sounds, soft, non-tender, non-distended
EXTREMITIES: no edema, 2+ pulses radial and dp. Right heel w/
stage II pressure ulcer, mild blanchable erythema in LLE .
NEURO: awake, oriented x 2 (self and hospital), muscle strength
___ in UE and less in LEs.
DISCHARGE EXAM:
Vital Signs: 97.5 149/91 68 22 98%/2L nc
GENERAL: NAD. Much more alert and interactive than yesterday.
Fluently conversant.
NECK: supple, no LAD, no JVP elevation.
LUNGS: CTA bilat, no r/rh/wh, good air movement, resp unlabored,
no accessory muscle use
HEART/Chest: RRR, no MRG, nl S1-S2. Reproducible tenderness to
palpation over anterior left chest wall.
ABDOMEN: normal bowel sounds, soft, non-tender, non-distended,
no rebound or guarding, no masses
EXTREMITIES: no edema, 2+ pulses radial and dp. Right heel w/
stage II pressure ulcer.
Neuro: Alert and oriented x2. no focal deficits
Pertinent Results:
LABS:
___ 02:20AM BLOOD WBC-9.8 RBC-4.81 Hgb-13.7* Hct-41.9
MCV-87 MCH-28.6 MCHC-32.8 RDW-18.0* Plt ___
___ 10:45AM BLOOD WBC-6.0 RBC-4.73 Hgb-13.6* Hct-41.7
MCV-88 MCH-28.7 MCHC-32.5 RDW-18.0* Plt ___
___ 07:30AM BLOOD WBC-4.7 RBC-4.85 Hgb-13.8* Hct-43.1
MCV-89 MCH-28.5 MCHC-32.0 RDW-18.0* Plt ___
___ 02:20AM BLOOD Glucose-135* UreaN-24* Creat-0.8 Na-139
K-3.9 Cl-102 HCO3-25 AnGap-16
___ 09:15AM BLOOD Glucose-98 UreaN-25* Creat-1.0 Na-142
K-4.5 Cl-102 HCO3-32 AnGap-13
___ 07:40AM BLOOD Glucose-107* UreaN-17 Creat-0.8 Na-143
K-4.3 Cl-103 HCO3-36* AnGap-8
___ 05:20PM BLOOD Glucose-90 UreaN-16 Creat-0.8 Na-141
K-4.1 Cl-102 HCO3-30 AnGap-13
___ 07:30AM BLOOD Glucose-108* UreaN-14 Creat-0.7 Na-142
K-4.0 Cl-106 HCO3-28 AnGap-12
___ 07:40PM BLOOD CK-MB-4 cTropnT-0.15*
___ 11:57PM BLOOD CK-MB-4 cTropnT-0.18*
___ 07:00AM BLOOD CK-MB-5 cTropnT-0.20*
___ 06:00PM BLOOD CK-MB-5 cTropnT-0.16*
___ 10:45AM BLOOD CK-MB-5 cTropnT-0.14*
___ 07:30AM BLOOD CK-MB-5 cTropnT-0.10*
___ 02:36AM BLOOD Lactate-2.3*
___ 08:08PM BLOOD Lactate-1.0
=========================================================
MICROBIOLOGY
__________________________________________________________
___ 2:30 pm BLOOD CULTURE
Blood Culture, Routine (Pending):
__________________________________________________________
___ 2:30 am URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
PSEUDOMONAS AERUGINOSA. >100,000 ORGANISMS/ML..
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
PSEUDOMONAS AERUGINOSA
|
CEFEPIME-------------- 2 S
CEFTAZIDIME----------- <=1 S
CIPROFLOXACIN--------- 1 S
GENTAMICIN------------ 2 S
MEROPENEM------------- 0.5 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
__________________________________________________________
___ 2:20 am BLOOD CULTURE
Blood Culture, Routine (Pending):
================================================================
IMAGING/OTHER STUDIES:
CXR ___:
IMPRESSION:
1. No acute cardiac or pulmonary findings.
2. Marked elevation of the left hemidiaphragm, not
significantly changed
compared to CT from ___.
GU U/S ___:
1. Fluid/debris level within the bladder, likely related to the
known
infections.
2. Prostate volume of 51 mL.
3. Stable 3.1 x 2.8 x 2.9 cm right upper pole solid mass likely
represents a renal cell carcinoma.
CXR ___:
FINDINGS: As compared to the previous radiograph, there is
persistent
elevation of the left hemidiaphragm. A lucency projecting over
the right
upper abdomen is slightly more conspicuous than on the prior
image, to exclude potential small pneumothorax. Close clinical
and radiographic followup is recommended. The findings were
discussed at the time of the initial image evaluation.
Unchanged appearance of the cardiac silhouette and of the lung
parenchyma
EKG ___:
Sinus rhythm with borderline prolongation of the P-R interval.
Right
bundle-branch block. Indeterminate QRS axis in the frontal
plane. Borderline P-R interval prolongation of the Q-T interval.
Compared to the previous tracing of ___ the rate has
decreased. The other findings are similar
CHEST CTA ___:
IMPRESSION:
1. No pulmonary embolism.
2. Bibasilar atelectasis or consolidations, which may be
consistent with
pneumonia in the correct clinical setting.
3. Calcified pleural plaques, consistent with prior asbestos
exposure.
Brief Hospital Course:
Patient is an ___ male with PMH of hypotonic bladder w/ chronic
indwelling foley since ___ complicated by numerous UTI's (some
of which were MDR) who presents to the hospital from REHAB with
myoclonus and AMS, similar symptoms to previous UTI's. He was
found to have positive UA and admitted to medicine for treatment
of UTI and AMS.
#Pseudomonas UTI: Patient had a chronic indwelling foley
catheter for hypotonic bladder since ___ and has had numerous
UTI's with various organisms. The latest organisms that have
grown include Pseudomonas, Providencia, and Klebsiella, all of
which have been sensitive to zosyn. His current presentation of
AMS, myoclonus, and positive UA is nearly identical to previous
UTI presentations. His Foley was last changed at ___
on ___. Foley was changed on day of admission after first
dose of Zosyn was administered. Treated UTI with Zosyn x 2 days.
Sensitivities showed ciprofloxacin susceptibility, so switched
to PO ciprofloxacin 500mg BID on ___. He was discharged on
this medication to finish a total of 7 days of antibiotics for
complicated UTI.
#Metabolic encephalopathy: On presentation, patient was
lethargic and oriented x 0, with myoclonus. He could follow some
simple commands, was moving all 4 extremities equally, and could
answer some yes/no questions with head nod/shake. His baseline
MS according to ___ nursing staff is alert and oriented x2,
fluentally conversant and appropriate. Given patient's myoclonic
jerks and evidence of UTI on UA along with his history, AMS was
attributed to metabolic encephalopathy ___ UTI. Per ___ staff,
he has had nearly identical symptomatology/mental status changes
during his numerous previous UTIs. By time of discharge, mental
status had improved back to baseline, with patient alert,
oriented to self, place, and situation. He was fluently
conversant and appropriate.
#NSTEMI - On the evening of ___, patient experienced
mid-sternal chest pain. Although reproduciblity of chest pain
with palpation was suggestive of costochondritis; given his
extensive coronary history and elevation in troponins (peak of
0.20), pt. was treated medically as NSTEMI. Unclear if this was
related to clot (type I) or demand ischemia (type II), but given
patient's history of severe CAD, treated as type I NSTEMI.
Patient received ASA 325mg, metoprolol, atorvastatin 80mg,
supplemental O2, and heparin gtt x 48 hours. At discharge,
troponins had downtrended to 0.10 and patient was chest pain
free. He will be scheduled for close followup with his
cardiologist.
#Right heel stage II pressure ulcer: No evidence of infection.
Wound care consult was obtained. They recommended cleanse with
commercial cleanserpat dry aloe vesta cream aound woundadaptic
and dry gauzewrap with kling. Change dressing daily.
#Multiple admissions for recurrent UTIs: Patient has been
admitted to ___ 54 times for UTIs since placement of Foley
catheter in ___. Per urology notes, the reason for Foley
placement was "hypotonic bladder"; however, patient's daughter
states that Foley was placed because of incontinence and
resultant skin-breakdown/infections. A primary goal of this
admission was to take measures to prevent future UTIs and
re-admissions for Mr. ___. To this end, his Foley catheter
was removed on ___ for a voiding trial. Patient voided
spontaneously without any evidence of urinary retention for
remainder of admission. Patient was incontinent. Groin area was
kept dry and clean with BID cleansing of the area, as well as by
keeping a towel above and below the genitals and changing the
towel BID. Ketoconazole cream also was applied to genitals,
inguinal folds, and pannus fold BID. Foley catheter should
remain OUT at rehab to decrease risk of recurrent UTI. If
patient demonstrates AMS, complains of suprapubic pain, or does
not void for 8 hours, he should be straight cathed. Under no
circumstance should Foley catheter be replaced without
discussion with Mr. ___ PCP, ___ MD Phone:
___
#Depression/Anxiety- severe per prior notes and geriatrics note:
Held mirtazapine and duloxetine in setting of AMS. Restarted
upon discharge.
# Known right kidney mass: concerning for RCC and stable on
recent CT scan and renal ultrasound. Being followed by urology
=
=
=
=
=
================================================================
TRANSITIONAL ISSUES:
#RECURRENT ADMISSIONS FOR UTIs: See above section #Multiple
re-admissions for recurrent UTIs. Again, If patient demonstrates
AMS, complains of suprapubic pain, or does not void for 8 hours,
he should be straight cathed. Under no circumstance should Foley
catheter be replaced without discussion with Mr. ___ PCP,
___ MD Phone: ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO Q8H:PRN pain
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 40 mg PO DAILY
4. Bisacodyl 10 mg PO DAILY:PRN constipation
5. Calcium Carbonate 500 mg PO DAILY
6. Duloxetine 30 mg PO QHS
7. Furosemide 20 mg PO DAILY
hold for SBP<100
8. Metoprolol Succinate XL 50 mg PO DAILY
hold for SBP<100 or HR<50
9. Milk of Magnesia 30 mL PO Q6H:PRN constipation
10. Mirtazapine 15 mg PO HS
11. Multivitamins 1 TAB PO DAILY
12. Omeprazole 20 mg PO DAILY
13. Polyethylene Glycol 17 g PO DAILY
14. Senna 2 TAB PO HS
15. traZODONE 50 mg PO HS
16. Vitamin D 800 UNIT PO DAILY
17. Lidocaine Jelly 2% 1 Appl TP ASDIR
18. Loratadine *NF* 10 mg Oral daily
19. Docusate Sodium 100 mg PO BID
20. OxycoDONE (Immediate Release) 2.5 mg PO Q4H:PRN pain
hold for sedation or RR<10
21. Fleet Enema ___AILY:PRN constipation
22. Vigamox *NF* (moxifloxacin) 0.5 % ___ 1 gtt TID
Discharge Medications:
1. Acetaminophen 650 mg PO Q8H:PRN pain
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 80 mg PO DAILY
4. Bisacodyl 10 mg PO DAILY:PRN constipation
5. Calcium Carbonate 500 mg PO DAILY
6. Docusate Sodium 100 mg PO BID
7. Milk of Magnesia 30 mL PO Q6H:PRN constipation
8. Multivitamins 1 TAB PO DAILY
9. Polyethylene Glycol 17 g PO DAILY
10. Senna 2 TAB PO HS
11. Vitamin D 800 UNIT PO DAILY
12. Ciprofloxacin HCl 500 mg PO Q12H
RX *ciprofloxacin [Cipro] 500 mg 1 tablet(s) by mouth twice a
day Disp #*7 Tablet Refills:*0
13. Ketoconazole 2% 1 Appl TP BID
RX *ketoconazole 2 % Apply to affected areas BID:PRN Disp #*1
Tube Refills:*3
14. Duloxetine 30 mg PO QHS
15. Fleet Enema ___AILY:PRN constipation
16. Furosemide 20 mg PO DAILY
17. Loratadine *NF* 10 mg Oral daily
18. Metoprolol Succinate XL 50 mg PO DAILY
19. Mirtazapine 15 mg PO HS
20. Omeprazole 20 mg PO DAILY
21. traZODONE 50 mg PO HS
22. Vigamox *NF* (moxifloxacin) 0.5 % ___ 1 gtt TID
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary:
Metabolic encephalopathy
Urinary tract infection
Non ST segment elevation myocardial infarction
Secondary:
Hypertension
Pressure Ulcer
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Mr. ___,
You were admitted to ___ for altered mental status and a
bladder infection. You were treated with antibiotics and your
mental status returned to baseline and your bladder infection
cleared. We removed your Foley catheter because this is likely
causing your recurrent bladder infections. You were able to
urinate without the catheter. We will provide detailed
instructions to the staff at your rehab facility about how to
properly care for your hygiene.
Also, during this admission, you had chest pain and were found
to have a very small heart attack. You were treated with blood
thinners and your chest pain improved.
Followup Instructions:
___
|
19713100-DS-78
| 19,713,100 | 27,606,339 |
DS
| 78 |
2178-12-21 00:00:00
|
2178-12-25 13:25:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
___ / Oxybutynin / Bactrim
Attending: ___.
Chief Complaint:
Tremors, Weakness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ male presents with facial and b/l upper extremity
tremor/myoclonus x ___ days, possibly chronic, unclear at this
time. Seen by ___ in setting of these tremors who contacted on
call physician of PCP group. Family had contacted her because
patient was having twitching of his hands and face. This has
been a recurrent issue in the setting of UTIs for which the
patient has been evaluated multiple times. With the goal of
avoiding an ED visit, patient was treated empirically with a
course of Bactrim for one day. Patient did not improve and
patient brought to ED this afternoon.
There was a report of desat of 89-90% with somnolence per EMS,
mental status improved significantly with 4L N/C by EMS. Patient
has no complaints at this time other than the tremor. Previously
has been treated with meropenem for ESBL klebsiella in the past.
In the ED, initial vitals were: 97.2 80 152/103 16 100% 4L NP.
Labs were notable for a normal white count and normal lactate.
UA showed evidence of infection and pt has history of ESBL
klebsiella, which previous ID recommendations list meropenem as
a potential herapeutic option on prior visits. Pt was given
500mg meropenem IV x 1. CXR was obtained, which showed no focal
infiltrates.
On the floor, patient continues to have tremors in face. Patient
afebrile, with good urine output.
Past Medical History:
PAST MEDICAL & SURGICAL HISTORY:
1. Hypotonic bladder with incomplete emptying, s/p indwelling
foley since ___ c/b frequent Multidrug resistent UTIs,
including MRSA and ESBL E Coli
2. BPH
3. CAD s/p CABG x 3 in ___
- CABG anatomy: LIMA to LAD, SVG to OM, and SVG to RCA
- s/p stenting ___ of mid RCA, PTCA of proximal RCA and PDA
- redo single vessel CABG in ___ with Dr. ___.
4. CHF was preserved EF 55% in ___
5. Bovine AVR in ___. Type 2 Diabetes Mellitus: diet controlled
7. Hypertension
8. Hx of Chronic constipation
9. Hyperlipidemia
10. Depression/Anxiety
11. Asbestosis
12. Spinal stenosis
13. R kidney mass - Followed by urology w/ serial imaging,
likely RCC
14. Osteoarthritis
15. Carotid stenosis - chronic occlusion of LICA, ___ with 40%
Social History:
___
Family History:
Denies significant family history of early MI, arrhythmia or
sudden cardiac death. Daughter died at ___, breast cancer. Father
died from MI in his ___.
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: 97.7, 79, 144/103, 18, 100% 2L
GENERAL: Facial twitching present. Appears in no acute distress.
Alert and interactive.
HEENT: Normocephalic, atraumatic.
___: Regular rate and rhythm, without murmurs, rubs or gallops.
S1 and S2 normal.
RESP: CTAB in all lung fields. No wheezing, rhonchi or crackles.
NO labored breathing.
ABD: soft, NT, ND
GU: skin around groin and scrotum no erythema or ulcers.
EXTREM: no c,c,e, RLE pressure ulcer, 1cm x 1cm, stage 3, with
fibrinous debris without purulence.
NEURO: Alert and oriented x person, place, and year. Speech
slurred.
DISCHARGE PHYSICAL EXAM:
VS: 97.9/98.4, 118/76 (116-132/76-82), 89 (76-89), 20, 100%2L
(on RA at discharge)
GENERAL: NAD, alert, interactive.
HEENT: NC/AT, sclerae anicteric, MMM
LUNGS: Clear to auscultation except minor crackles at b/l bases,
otherwise no w/r/r
HEART: Regular rate and rhythm, without murmurs, rubs or
gallops.
S1 and S2 normal.
ABDOMEN: NABS, soft/NT/ND.
EXTREMITIES: WWP
NEURO: awake, A&Ox3.
Pertinent Results:
Labs on Admission
==================
___ 12:15PM BLOOD WBC-5.6 RBC-4.73 Hgb-12.8* Hct-39.7*
MCV-84 MCH-27.2 MCHC-32.3 RDW-17.5* Plt ___
___ 12:15PM BLOOD Neuts-64.6 ___ Monos-5.9 Eos-2.5
Baso-0.8
___ 12:15PM BLOOD Plt ___
___ 12:15PM BLOOD Glucose-108* UreaN-26* Creat-0.9 Na-140
K-4.6 Cl-103 HCO3-27 AnGap-15
___ 12:29PM BLOOD Lactate-1.7
Imaging
========
CXR ___:
1. Findings suggest minimal interstitial edema.
2. Stable elevated hemidiaphragm and bibasilar atelectasis.
Possible
small/trace left pleural effusion.
Micro
======
Urine culture (___): ENTEROCOCCUS SP.
Blood culture 1 (___): pending
Blood culture 2 (___): pending
Labs on Discharge
==================
___ 06:30AM BLOOD WBC-5.4 RBC-4.84 Hgb-12.9* Hct-40.3
MCV-83 MCH-26.6* MCHC-32.0 RDW-17.6* Plt ___
___ 06:30AM BLOOD Glucose-117* UreaN-18 Creat-0.6 Na-144
K-4.2 Cl-104 HCO3-28 AnGap-16
___ 06:30AM BLOOD Calcium-8.9 Phos-2.9 Mg-1.9
Brief Hospital Course:
This patient is an ___ yo M with PMH of hypotonic bladder with
multidrug resistant UTIs, BPH, CAD, CHF (LVEF 55%), AS s/p AVR,
diet-controlled DM, HTN, and HLD who presented with tremors and
weakness and was found to have enterococcus UTI.
Active Problems
==============
#Urinary tract infection: Pt was initially started on Meropenem
for treatment of his UTI before culture grew, as Meropenem had
been recommended for his previous UTIs. After one day of
meropenam, pt had minimal improvement in his symptoms and SBP
decreased to ___, so one dose of daptomycin was given in
addition. Pt clinically improved after 36 hours of antibiotics.
Urine culture sensitivities grew enterococcus sensitive to
ampicillin, so ampicillin 2g q6h IV was started, and
transitioned to Ampicillin 500mg q6h PO upon discharge, which
the pt should continue for a total of 2 weeks (end on ___.
Blood cultures pending, NGTD.
#Pain: Pt complained of pelvic pain and groin pain (apparently
chronic). Improved with acetaminophen.
#Delirium: Pt had been occasionally confused on first day of
admission, much improved after day 1. Likely related to the UTI,
which is now being appropriately treated with ampicillin.
#Nutrition: There was a concern for aspiration while eating and
drinking. Speech and swallow was consulted for concern for
aspiration. Pt refused bedside swallow study ___, and the
speech team was not able to return before patient was
discharged. Nutrition was consulted and Vitamin C 500 mg x 14
days was started per nutrition recs.
Chronic Problems
===============
#Coronary artery disease: Continued aspirin, beta-blocker and
statin throughout hospital course.
#Hypertension: Continued home Metoprolol throughout hospital
course.
#Hyperlipidemia: Continued statin throughout hospital course.
#Chronic CHF: Questionable diagnosis of ischemic cardiomyopathy
with preserved EF 55% in ___. Home regimen includes
beta-blocker and furosemide. Continued home dose metoprolol XL
throughout hospital course and held furosemide during acute
illness. Restarted furosemide upon discharge.
#Diabetes mellitus: Diet controlled, last HbA1c 6.5% in ___.
Pt was put on insulin sliding scale during his hospital course
and blood sugars remained < 150, but this was discontinued upon
discharge.
#Right heel stage III pressure ulcer: no evidence of acute
infection, managed by nursing with mepilex.
#Depression and anxiety: Severe per prior notes and geriatrics.
Continued mirtazapine and duloxetine throughout hospital course
and upon discharge. Discontinued his previously prescribed
Trazadone for concern of polypharmacy and oversedation.
#Known right kidney mass: Concerning for RCC and stable on
recent CT scan and renal ultrasound. Being followed by Urology
as outpatient
Transitional Issues
==============
- Pt going home with services that he already has in place.
- Pt has follow-up appointment with his PCP ___ nurse
(___) on ___ at 2pm
- Blood cultures x 2 (___) pending
- Pt could benefit from re-evaluation of his statin as an
outpatient
- Pt may benefit from a swallow evaluation in the future given
the concern for aspiration while eating.
- Urology should f/u known right kidney mass - renal US
scheduled for ___.
- Confirmed with pt that he is DNR
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO Q8H:PRN pain
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 80 mg PO DAILY
4. Bisacodyl 5 mg PO DAILY:PRN constipation
5. Calcium Carbonate 500 mg PO DAILY
6. Duloxetine 30 mg PO DAILY
7. Fleet Enema ___AILY:PRN constipation
8. Docusate Sodium 100 mg PO BID
9. Furosemide 20 mg PO DAILY
do not give if SBP<100
10. Milk of Magnesia 30 mL PO Q6H:PRN constipation
11. Mirtazapine 15 mg PO HS
12. Multivitamins 1 TAB PO DAILY
13. Omeprazole 20 mg PO DAILY
14. Polyethylene Glycol 17 g PO DAILY
15. Senna 2 TAB PO BID
16. TraZODone 50 mg PO HS
17. Vitamin D 1000 UNIT PO DAILY
18. Metoprolol Succinate XL 25 mg PO DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO Q8H:PRN pain
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 80 mg PO DAILY
4. Bisacodyl 5 mg PO DAILY:PRN constipation
5. Calcium Carbonate 500 mg PO DAILY
6. Docusate Sodium 100 mg PO BID
7. Duloxetine 30 mg PO DAILY
8. Fleet Enema ___AILY:PRN constipation
9. Metoprolol Succinate XL 25 mg PO DAILY
10. Milk of Magnesia 30 mL PO Q6H:PRN constipation
11. Mirtazapine 15 mg PO HS
12. Multivitamins 1 TAB PO DAILY
13. Omeprazole 20 mg PO DAILY
14. Polyethylene Glycol 17 g PO DAILY
15. Senna 2 TAB PO BID
16. Vitamin D 1000 UNIT PO DAILY
17. Ampicillin 500 mg PO Q6H
Take this medication one pill (500mg) every 6 hours.
RX *ampicillin 500 mg 1 (One) capsule(s) by mouth Every 6 hours
Disp #*50 Capsule Refills:*0
18. Ascorbic Acid ___ mg PO DAILY Duration: 14 Days
RX *ascorbic acid ___ mg 1 (One) tablet(s) by mouth daily Disp
#*12 Tablet Refills:*0
19. Furosemide 20 mg PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnosis
Enterococcus urinary tract infection
Discharge Condition:
Level of Consciousness: Alert and interactive.
Activity Status: Bedbound.
Mental Status: Confused - sometimes.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you. You were admitted to the
hospital because you were feeling weak. You were found to have a
urinary tract infection, which is being treated with the
antibiotic Ampicillin. You should continue taking this
antibiotic for 12 more days (for a total of 2 weeks), through
___.
You have a follow up appointment at Dr. ___ office with his
nurse (___) on ___ at 2pm.
Followup Instructions:
___
|
19713100-DS-79
| 19,713,100 | 26,548,607 |
DS
| 79 |
2179-01-31 00:00:00
|
2179-02-14 21:42:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Amitiza / Oxybutynin / Bactrim
Attending: ___.
Chief Complaint:
CC: UTI and malaise
Major Surgical or Invasive Procedure:
None
History of Present Illness:
The patient is a ___ year old community dwelling male with MMP
including CAD s/p CABG, hypotonic bladder with incomplete
emptying, c/b frequent Multidrug resistent UTIs, including MRSA
and ESBL E Coli who now presents from home with malaise- per ED
dash altered MS, tachycardia, hypoxia but per EMS run pt was not
altered,tachycardia nor hypoxic but did have wheezing on exam
and referred in by home ___. In ED UA c/w infection,
leukocytosis on labs, CXR with mild congestive heart failure.
Discussed with ID who advised administering cipro following the
cultures. If patient gets sick, suggest to administer meropenem
to cover previous resistent bugs. Recent organisms are
sensitive.
The patient tells me that he was feeling badly starting today.
No n/v/cp/sob/no constipation or diarrhea. No HA, slurred
speech/neuro sx, no clear weight loss or weight gain. + shivers
but no clear fevers, penile pain this morning but has since
resolved. no dysuria. No URI sx. No new MSK, no rashes.
.
Of note he was recently admitted in ___ with tremors and found
to have a UTI. Urine cultures grew ampicillin sensitive
enteroccocus sensitive to ampicillin. There is no culture in our
system but per Dr ___ urine culture on ___ was
negative.
.
In ER: (Triage Vitals:0 97.8 88 121/85 22 94% Nasal Cannula )
Meds Given:cipro
Fluids given:none
Radiology Studies: CxR and renal US
consults called: ID and geriatrics
.
PAIN SCALE: ___
________________________________________________________________
[+ ]Medication allergies [ ] Seasonal allergies
[X]all other systems negative except as noted above
Past Medical History:
PAST MEDICAL & SURGICAL HISTORY:
1. Hypotonic bladder with incomplete emptying, s/p indwelling
foley since ___- Indwelling foley removed ___
including MRSA and ESBL E Coli
2. BPH
3. CAD s/p CABG x 3 in ___
- CABG anatomy: LIMA to LAD, SVG to OM, and SVG to RCA
- s/p stenting ___ of mid RCA, PTCA of proximal RCA and PDA
- redo single vessel CABG in ___ with Dr. ___.
4. CHF was preserved EF 55% in ___
5. Bovine AVR in ___. Type 2 Diabetes Mellitus: diet controlled
7. Hypertension
8. Hx of Chronic constipation
9. Hyperlipidemia
10. Depression/Anxiety
11. Asbestosis
12. Spinal stenosis
13. R kidney mass - Followed by urology w/ serial imaging,
likely RCC
14. Osteoarthritis
15. Carotid stenosis - chronic occlusion of LICA, ___ with 40%
Social History:
FROM ___ and ___ d/c summmary
Was at rehab and recently moved home, lives with his daughter.
He has had at least 20 ED visits this year. He worked in
___ (in the ___) and was also in the Navy
(Phillipines in the 1960s). His wife died ___ years ago. He has a
100 pack year history of smoking, quit in the 1980s, no etoh, no
illicits. He is able to walk about 5 steps with a walker and
climb 4 or 5 stairs with the support of a railing.
==============
His daughter ___ puts all of his pills in a pill box. He can
dress himself but he needs assistance to bathe. He lives with
his daughter. Dtr does bills and cooks.
He quit smoking many years ago.
He used to drink heavily when he was in the service in ___
___ but not since then.
He is a retired ___. He uses a wheelchair at home. He
has an aide who comes morning and night 7 days per week. His
aide takes him out to the store.
He is a widower.
He confirms that he does not use oxygen at home.
Family History:
His father died of an MI in his mid ___.
His mother died of an MI in her mid ___ as well.
Physical Exam:
PHYSICAL EXAM: I3 - PE >8
1. VS: T = 97.5 P 85 BP = 137/52 RR = 16 O2Sat on __93%% on
2L __ liters O2 Wt, ht, BMI
GENERAL: Elderly male laying in bed. He is extremely hard of
hearing.
Nourishment: OK
Grooming: good
Mentation: alert,speaks in full sentences
2. Eyes: [X] WNL
EOMI without nystagmus, Conjunctiva: clear
3. ENT [] WNL
Dry MM
4. Cardiovascular [] WNL
Irregular, S1, S2, no m/r/g
[X] Edema RLE 1+ - 2+
[X] Edema LLE 1+ 2+
DPP pulses not appreciated but dopplered by RN
[] Vascular access [x] Peripheral [] Central site:
5. Respiratory [ ]
RLL crackles
Decreased BS on the L side.
6. Gastrointestinal [ X] WNL
Soft,nt, obesely disteded,
7. Musculoskeletal-Extremities [] WNL
[ ] Tone WNL [ X]Upper extremity strength ___ and symmetrical
[ ]Other:
[ ] Bulk WNL [X] Lower extremity strength ___ and symmetrica
[ ] Other:
[] Normal gait []No cyanosis [ ] No clubbing [] No joint
swelling
8. Neurological [] WNL
[ X] Alert and Oriented x 3 CN II-XII intact [ X] Normal
attention but unable to DOMYB
9. Integument [] WNL
Erythema at L ankle c/w venstatsis.
10. Psychiatric [x] WNL
[X] Appropriate [] Flat affect [] Anxious [] Manic []
Intoxicated [x] Pleasant with a good sense of humor [] Depressed
[] Agitated [] Psychotic
Discharge physical exam:
VS: 96.7 BP: 134/76 HR: 83 R: 18 O2: 92% RA
Sitting in chair in NAD. HOH.
HEENT: MMM, Oropharynx clear
Lungs: Clear B/L on ausculatation
___: RRR S1, S2 present no m/r/g
Abd: Soft, NT, ND
GU: No foley
Ext: No edema
Neuro: Awake, alert and oriented x ___. Mental status fluctuates
from awake and alert to intermittently agitated.
Pertinent Results:
___ 02:34PM LACTATE-1.7
___ 02:25PM GLUCOSE-119* UREA N-16 CREAT-0.7 SODIUM-143
POTASSIUM-4.5 CHLORIDE-102 TOTAL CO2-32 ANION GAP-14
___ 02:25PM estGFR-Using this
___ 02:25PM CK(CPK)-54
___ 02:25PM cTropnT-0.01
___ 02:25PM CK-MB-4
___ 02:25PM WBC-6.0 RBC-4.72 HGB-12.6* HCT-38.0* MCV-81*
MCH-26.7* MCHC-33.1 RDW-18.8*
___ 02:25PM NEUTS-70.1* ___ MONOS-7.1 EOS-2.3
BASOS-0.5
___ 02:25PM PLT COUNT-270
___ 01:05PM URINE COLOR-Straw APPEAR-Cloudy SP ___
___ 01:05PM URINE BLOOD-SM NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-LG
___ 01:05PM URINE RBC-7* WBC->182* BACTERIA-FEW YEAST-NONE
EPI-1
___ 01:05PM URINE WBCCLUMP-MANY
==================
EKG: SR with PACs, RBB, no acute changes at 89 bpm.
.
LAST ___
There is mild symmetric left ventricular hypertrophy. The left
ventricular cavity size is normal. Due to suboptimal technical
quality, a focal wall motion abnormality cannot be fully
excluded. Overall left ventricular systolic function is normal
(LVEF>55%). The right ventricular free wall is hypertrophied.
Right ventricular chamber size is normal. The aortic valve is
not well seen. No masses or vegetations are seen on the aortic
valve, but cannot be fully excluded due to suboptimal image
quality. No aortic regurgitation is seen. The mitral valve
leaflets are not well seen. No masses or vegetations are seen on
the mitral valve, but cannot be fully excluded due to suboptimal
image quality. No masses or vegetations are seen on the
tricuspid valve, but cannot be fully excluded due to suboptimal
image quality. The pulmonary artery systolic pressure could not
be determined. There is no pericardial effusion.
IMPRESSION: Suboptimal image quality. Unable to adequately
assess for the absence/presenceof valvular vegetations or
abscesses.
.
CXR:
Mild congestive heart failure, slightly progressed compared to
the previous exam, with small left pleural effusion. Mild
bibasilar atelectasis.
.
Abdominal US:
ReportNo hydronephrosis. Unchanged right upper pole mass likely
represents a renal Preliminary Reportcell carcinoma.
.
Urine Culture:
___ 1:05 pm URINE Site: CATHETER
**FINAL REPORT ___
URINE CULTURE (Final ___:
KLEBSIELLA PNEUMONIAE. >100,000 ORGANISMS/ML..
Piperacillin/tazobactam sensitivity testing available
on request.
KLEBSIELLA PNEUMONIAE. >100,000 ORGANISMS/ML.. ___
MORPHOLOGY.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
KLEBSIELLA PNEUMONIAE
| KLEBSIELLA PNEUMONIAE
| |
AMPICILLIN/SULBACTAM-- =>32 R =>32 R
CEFAZOLIN------------- =>64 R =>64 R
CEFEPIME-------------- =>64 R 16 I
CEFTAZIDIME----------- =>64 R =>64 R
CEFTRIAXONE----------- =>64 R =>64 R
CIPROFLOXACIN---------<=0.25 S <=0.25 S
GENTAMICIN------------ <=1 S <=1 S
MEROPENEM-------------<=0.25 S <=0.25 S
NITROFURANTOIN-------- <=16 S 64 I
PIPERACILLIN/TAZO----- 16 S
TOBRAMYCIN------------ <=1 S <=1 S
TRIMETHOPRIM/SULFA---- 2 S 2 S
Brief Hospital Course:
The patient is a complicated ___ year old male with multiple
medical problems including CAD s/p CABG x 2, s/p bioprosthetic
AVR, incomplete bladder emptying who presented with malaise,
leukocytosis and UTI and also new oxygen requirement concerning
for acute diastolic heart failure, confirmed on CXR. Given IV
lasix and Cipro-> to Meropenem empirically due to myoclonic
jerking previously described. Transitioned back to Ciprofloxacin
with improvement in myoclonus. Also with troponin leak and
stable EKG consistent with demand ischemia from CHF. Also
concerns for dementia and night terrors. Followed by geriatrics
and started on low dose olanzipine for agitation.
#Acute encephalopathy/Malaise:
Likely related to recurrent bacterial UTI, hypernatremia and
diastolic CHF (see below). Also with report of months of
insomnia and shouting at night. Daughter concerned for
underlying dementia, psych condition, or ? PTSD. Consulted
Geriatrics. Geriatric depression screen was negative. His mental
status began to improve begining ___ as his tremors resolved
and his Na improved to the 130s. The patient would benefit from
futher evaulation and work up of his subacute change in mental
status once his urinary tract infection has been treated. He
remains oriented x2-3 with intermittent periods of agitation and
confusion.
#Klebsiella UTI: Positive UA and similar presentation to prior.
Was started on Cipro at first given recent sensitive urine
cultures. However, has h/o ESBL organisms. Per previous neuro
note, cipro increased myoclonic jerking, so changed to Meropenem
pending urine culture. Also monitoring PVR given known
retention, currently in the 200s. The culture was later Cipro
sensitive and was switched back (following discussion with the
patients daughter that stated she believes it was the UTI and
not the cipro that makes him jerking more pronounced). The
patient has no further episodes of myoclonic jerking. He was
discharged on oral Cipro to complete a ___cute diastolic CHF:
CXR with pulmonary edema and troponin leak. Continued on BB and
statin. Given IV lasix with good results. The patient was
resumed on his home dose of Lasix 20mg daily on discharge.
Weight is 185.
# Hypernatremia: In the setting of diruresis and poor water
intake the pts Na went up to 147. He became increasingly
lethargic. He was given 2L of free water and his Na and mental
status appeared to improve over the same time course. Sodium on
discharge is 141.
# Myoclonic jerking: Of hands, neck, and face. Discussed with
daughter and this increases with UTI. Has been seen by neuro in
the past for this. Although prior notes have recommended
avoiding Fluoroquinolones the patients jerking appeared to
improve in the setting of UTI tx and free water correction. No
further episodes of myoclnic jerking on discharge.
# Urinary Retention: The pt was noted to have cloudy urine. A
foley was attempted by nursing but unsuccesful. Urology was
consulted on ___ and a foley was placed for acute urinary
retention. The patient has a history of increased urinary tract
infections when he had a chronic foley catheter therefore the
decision had been made in ___ to discontinue the ___. The
patient had his foley removed this admission and had post void
residuals checked which were less than 200cc. He was discharged
home WITHOUT a foley in place.
#Depression and anxiety:
Severe per prior notes and geriatrics. The patient continued to
express depressive symptoms while hospitalized. He continued
mirtazapine and duloxetine and may benefit from further
psychiatric evaulation as an outpatient.
Chronic issues:
# CAD/CABG: Troponin increase with stable EKG consistent with
demand ischemia in setting of CHF and UTI. trending. Continued
ASA, BB, statin
# Hypertension: Continued home Metoprolol
#Hyperlipidemia: Continued statin
# Diabetes mellitus:
Diet controlled on SSI while hospitalized.
- Diabetic diet.
Transitional issues:
***Known right kidney mass: Concerning for RCC and stable on
recent CT scan and renal ultrasound. Being followed by Urology
as outpatient
- Patient was discharged without a foley catheter- this should
only be placed for urinary retention with PVR >500cc per
urology.
- Should have continued follow up with PCP for ___ of
agitation and depression
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Acetaminophen 650 mg PO Q8H:PRN pain
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 80 mg PO DAILY
4. Bisacodyl 5 mg PO DAILY constipation
5. Calcium Carbonate 500 mg PO DAILY
6. Docusate Sodium 100 mg PO BID
7. Duloxetine 30 mg PO DAILY
8. Fleet Enema ___AILY:PRN constipation
9. Metoprolol Succinate XL 25 mg PO DAILY
10. Milk of Magnesia 30 mL PO Q6H:PRN constipation
11. Mirtazapine 15 mg PO HS
12. Multivitamins 1 TAB PO DAILY
13. Omeprazole 20 mg PO DAILY
14. Polyethylene Glycol 17 g PO DAILY
15. Senna 2 TAB PO BID
16. Vitamin D 1000 UNIT PO DAILY
17. Ampicillin 500 mg PO Q6H
Take this medication one pill (500mg) every 6 hours.
18. Ascorbic Acid ___ mg PO DAILY
19. Furosemide 20 mg PO DAILY
Taken from OMR- the patient does not know his medications.
Discharge Medications:
1. Acetaminophen 650 mg PO Q8H:PRN pain
2. Ascorbic Acid ___ mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. Atorvastatin 80 mg PO DAILY
5. Bisacodyl 5 mg PO DAILY constipation
6. Calcium Carbonate 500 mg PO DAILY
7. Docusate Sodium 100 mg PO BID
8. Duloxetine 30 mg PO DAILY
9. Fleet Enema ___AILY:PRN constipation
10. Furosemide 20 mg PO DAILY
11. Metoprolol Succinate XL 25 mg PO DAILY
12. Milk of Magnesia 30 mL PO Q6H:PRN constipation
13. Mirtazapine 30 mg PO HS
14. Multivitamins 1 TAB PO DAILY
15. Omeprazole 20 mg PO DAILY
16. Polyethylene Glycol 17 g PO DAILY
17. Senna 2 TAB PO BID
18. Vitamin D 1000 UNIT PO DAILY
19. OLANZapine (Disintegrating Tablet) 2.5-5 mg PO BID:PRN
agitation
RX *olanzapine [Zyprexa Zydis] 5 mg ___
tablet,disintegrating(s) by mouth BID PRN Disp #*14 Tablet
Refills:*0
20. Ciprofloxacin HCl 500 mg PO Q12H Duration: 2 Days
RX *ciprofloxacin 500 mg 1 tablet(s) by mouth twice a day Disp
#*4 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Klebsiella UTI
Urinary Retention
Acute encephalopathy
Acute on chronic diastolic CHF
CAD/CABG
Hypotonic bladder
BPH
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:
It was a pleasure taking care of you during your recent
admission to ___. You were admitted with confusion and
weakness and found to have a recurrent urinary tract infection
and heart failure. You were treated with antibiotics and
improved. You also had a bladder catheter for a short time. This
was removed prior to discharge.
For your heart failure, you were treated with IV furosemide. You
no longer need oxygen and you should take the same dose of
furosemide you were taking prior to admission.
You will need to take 2 additional days of antibiotics after
discharge.
Followup Instructions:
___
|
19713162-DS-11
| 19,713,162 | 24,044,018 |
DS
| 11 |
2142-01-26 00:00:00
|
2142-01-26 11:14:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: ORTHOPAEDICS
Allergies:
Codeine
Attending: ___
Chief Complaint:
cellulitis to right leg (s/p R TKA on ___
Major Surgical or Invasive Procedure:
None during this admission
History of Present Illness:
___ year old male
Past Medical History:
hyperlipidemia
Social History:
___
Family History:
Mother died of MI at age ___.
Brother died age ___ of MI.
Brother had bypass ___ years ago.
Physical Exam:
Well appearing in no acute distress
Afebrile with stable vital signs
Pain well-controlled
Respiratory: CTAB
Cardiovascular: RRR
Gastrointestinal: NT/ND
Genitourinary: Voiding independently
Neurologic: Intact with no focal deficits
Psychiatric: Pleasant, A&O x3
Musculoskeletal Lower Extremity:
* Cellulitis right lower extremity, improving within marked
borders
* Aquacel dressing C/D/I
* Thigh full but soft
* No calf tenderness
* ___ strength
* SILT, NVI distally
* Toes warm
Pertinent Results:
___ 06:45AM BLOOD WBC-9.6 RBC-3.15* Hgb-10.0* Hct-29.9*
MCV-95 MCH-31.7 MCHC-33.4 RDW-12.2 RDWSD-42.5 Plt ___
___ 06:40AM BLOOD WBC-9.7 RBC-3.06* Hgb-9.7* Hct-29.1*
MCV-95 MCH-31.7 MCHC-33.3 RDW-12.3 RDWSD-42.6 Plt ___
___ 06:10AM BLOOD WBC-8.9 RBC-3.17* Hgb-10.2* Hct-30.8*
MCV-97 MCH-32.2* MCHC-33.1 RDW-12.1 RDWSD-43.0 Plt ___
___ 08:00PM BLOOD WBC-10.0 RBC-3.18* Hgb-10.5* Hct-31.0*
MCV-98 MCH-33.0* MCHC-33.9 RDW-12.0 RDWSD-42.4 Plt ___
___ 08:00PM BLOOD Neuts-75.3* Lymphs-10.8* Monos-12.4
Eos-0.3* Baso-0.4 Im ___ AbsNeut-7.51* AbsLymp-1.08*
AbsMono-1.24* AbsEos-0.03* AbsBaso-0.04
___ 08:00PM BLOOD ___ PTT-31.5 ___
___ 06:45AM BLOOD Creat-0.6
___ 06:10AM BLOOD Glucose-224* UreaN-9 Creat-0.6 Na-137
K-4.9 Cl-103 HCO3-23 AnGap-11
___ 07:40PM BLOOD Glucose-182* UreaN-10 Creat-0.8 Na-137
K-4.4 Cl-98 HCO3-23 AnGap-16
___ 06:10AM BLOOD Calcium-8.5 Phos-3.8 Mg-2.0
___ 06:10AM BLOOD CRP-187.2*
___ 07:40PM BLOOD CRP-267.7*
___ 01:25PM BLOOD Vanco-4.7*
___ 10:13PM BLOOD Lactate-1.2
___ 07:46PM BLOOD Lactate-3.5*
Brief Hospital Course:
The patient was admitted to the Orthopaedic surgery service for
cellulitis of the right leg (had his right knee replaced on
___. Patient was started on IV antibiotics - Ancef &
Vancomycin.
Postoperative course was remarkable for the following:
HD#2, the patient was started on Gabapentin for complaints of
sharp, burning pain. He was also given a steroid cream for a
rash on his back (not correlated to the antibiotics).
HD#3, vanco trough was 4.7 and dose was increased to 1500mg Q12.
Cellulitis was improving and patient continued IV Antibiotics
for additional 24 hours.
HD#4, cellulitis continued to improve. Patient was transitioned
to oral antibiotics upon discharge (Keflex ___ QID x 2 weeks).
Otherwise, pain was controlled with oral pain medications. The
patient received Lovenox daily for DVT prophylaxis. The surgical
dressing will remain in place until ___. The patient was
seen daily by physical therapy. Labs were checked throughout the
hospital course and repleted accordingly. At the time of
discharge the patient was afebrile with stable vital signs. The
patient's hematocrit was acceptable and pain was adequately
controlled on an oral regimen.
The patient's weight-bearing status is weight bearing as
tolerated on the operative extremity with no range of motion
restrictions. Please use walker or 2 crutches, wean as able.
Mr. ___ is discharged to home with services in stable
condition.
Medications on Admission:
1. Lisinopril 5 mg PO DAILY
2. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
3. Rosuvastatin Calcium 40 mg PO QPM
4. Vitamin D 1000 UNIT PO DAILY
5. Acetaminophen 1000 mg PO Q8H
6. Docusate Sodium 100 mg PO BID:PRN Constipation - First Line
7. Senna 8.6 mg PO BID:PRN Constipation - First Line
8. Metoprolol Succinate XL 150 mg PO DAILY
9. Enoxaparin Sodium 40 mg SC Q24H
10. Aspirin 81 mg PO DAILY
11. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain
Discharge Medications:
1. Cephalexin 500 mg PO Q6H
2. Gabapentin 100 mg PO TID
3. Acetaminophen 1000 mg PO Q8H
4. Docusate Sodium 100 mg PO BID:PRN Constipation - First Line
5. Enoxaparin Sodium 40 mg SC Q24H
6. Lisinopril 5 mg PO DAILY
7. Metoprolol Succinate XL 150 mg PO DAILY
8. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
9. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain
10. Rosuvastatin Calcium 40 mg PO QPM
11. Senna 8.6 mg PO BID:PRN Constipation - First Line
12. Vitamin D 1000 UNIT PO DAILY
13. HELD- Aspirin 81 mg PO DAILY This medication was held. Do
not restart Aspirin until Lovenox course completed.
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
cellulitis to right leg (s/p R TKA on ___
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:
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs.
1. Please return to the emergency department or notify your
physician if you experience any of the following: severe pain
not relieved by medication, increased swelling, decreased
sensation, difficulty with movement, fevers greater than 101.5,
shaking chills, increasing redness or drainage from the incision
site, chest pain, shortness of breath or any other concerns.
2. Please follow up with your primary physician regarding this
admission and any new medications and refills.
3. Resume your home medications unless otherwise instructed.
4. You have been given medications for pain control. Please do
not drive, operate heavy machinery, or drink alcohol while
taking these medications. As your pain decreases, take fewer
tablets and increase the time between doses. This medication can
cause constipation, so you should drink plenty of water daily
and take a stool softener (such as Colace) as needed to prevent
this side effect. Call your surgeons office 3 days before you
are out of medication so that it can be refilled. These
medications cannot be called into your pharmacy and must be
picked up in the clinic or mailed to your house. Please allow an
extra 2 days if you would like your medication mailed to your
home.
5. You may not drive a car until cleared to do so by your
surgeon.
6. Please call your surgeon's office to schedule or confirm your
follow-up appointment.
7. SWELLING: Ice the operative joint 20 minutes at a time,
especially after activity or physical therapy. Do not place ice
directly on the skin. You may wrap the knee with an ace bandage
for added compression. Please DO NOT take any non-steroidal
anti-inflammatory medications (NSAIDs such as Celebrex,
ibuprofen, Advil, Aleve, Motrin, naproxen etc) until cleared by
your physician.
8. ANTICOAGULATION: Please continue your Lovenox for four (4)
weeks
to help prevent deep vein thrombosis (blood clots). If you were
taking Aspirin prior to your surgery, you should hold this
medication while on the one-month course of anticoagulation
medication.
9. WOUND CARE: Remove Aquacel dressing on ___. Dry sterile
dressing changes daily as needed for drainage after Aquacel is
removed. Check wound regularly for signs of infection such as
redness or thick yellow drainage. Staples will be removed by
your doctor at follow-up appointment approximately 2 weeks after
surgery.
10. ___ (once at home): Home ___, dressing changes as
instructed, and wound checks.
11. ACTIVITY: Weight bearing as tolerated on the operative
extremity. Two crutches or walker. Wean assistive device as
able. Mobilize. ROM as tolerated. No strenuous exercise or heavy
lifting until follow up appointment.
Physical Therapy:
WBAT RLE
ROMAT
Wean assistive device as able (i.e. 2 crutches or walker)
Mobilize frequently
Treatments Frequency:
remove Aquacel dressing on ___
wound checks daily
dry sterile dressing changes daily as needed after aquacel
removed
ice and elevation
Followup Instructions:
___
|
19713183-DS-13
| 19,713,183 | 25,629,356 |
DS
| 13 |
2195-07-06 00:00:00
|
2195-07-06 17:05:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Keflex
Attending: ___.
Chief Complaint:
Chest Pain
Major Surgical or Invasive Procedure:
cardiac catheterization with 2 drug eluting stents to the
proximal left anterior descending artery
History of Present Illness:
This patient is a ___ year old female who presented with CC of
CP. The patient was in her usual state of health when at 1240
she got up to answer the doorbell and on getting back developed
non-radiating ___ CP with diaphoresis. She called the
ambulance and presented to the ED. En-route she got a 12-lead
EKG which revealed ST-elevations in V1-3, 1, AVL, AVR and
reciprocal changes in 2, 3, AVF and V4-6. In the ED she got ASA
and fentanyl which helped the pain. She denied any shortness of
breath or back pain or any preivous hx of CP/angina. She went to
the cath lab for primary PCI.
.
On review of systems, s/he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, cough, hemoptysis, black stools or red stools.
S/he denies recent fevers, chills or rigors. S/he denies
exertional buttock or calf pain. All of the other review of
systems were negative.
.
Cardiac review of systems is notable for absence of chest pain,
paroxysmal nocturnal dyspnea, orthopnea, ankle edema,
palpitations, syncope or presyncope.
Past Medical History:
1. CARDIAC RISK FACTORS: + Diabetes, + Dyslipidemia, +
Hypertension
2. OTHER PAST MEDICAL HISTORY:
- s/p hysterectomy
- severe degenerative arthritis
- s/p hip replacements X 2, knee replacements X 2
- Rt ankle underwent cutdown in ___ - recurrent venous stasis
ulcerations of her right medial ankle
- Hx of colitis and pseudopolyps
Social History:
___
Family History:
Father died of CAD at ___
Physical Exam:
On Admission:
GENERAL: NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with JVP not visualised.
CARDIAC: PMI located in ___ intercostal space, midclavicular
line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or
S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
NEURO: AAOx3, CNII-XII intact, ___ strength biceps, triceps,
wrist, knee/hip flexors/extensors, 2+ reflexes biceps,
brachioradialis, patellar, ankle.
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ ___ 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ ___ 2+
On Discharge:
GENERAL: ___ yo F in no acute distress, sitting up in chair
HEENT: mucous membs moist, no lymphadenopathy, JVP 2 cm above
clavicle
CHEST: ctab
CV: S1 S2, ? S3
ABD: soft, non-tender, non-distended, BS normoactive.
EXT: wwp, no edema. DPs, PTs 1+.
NEURO: CNs II-XII intact. ___ strength in U/L extremities.
SKIN: no rash
PSYCH: alert, anxious
Pertinent Results:
___ 01:40PM BLOOD WBC-7.9 RBC-4.18* Hgb-12.6 Hct-36.1
MCV-86 MCH-30.1 MCHC-34.8 RDW-13.4 Plt ___
___ 10:35PM BLOOD Hct-31.1* Plt ___
___ 05:25AM BLOOD WBC-8.1 RBC-4.07* Hgb-12.2 Hct-34.5*
MCV-85 MCH-30.1 MCHC-35.5* RDW-13.0 Plt ___
___ 03:28AM BLOOD WBC-10.2 RBC-4.09* Hgb-12.1 Hct-35.0*
MCV-86 MCH-29.7 MCHC-34.6 RDW-13.4 Plt ___
___ 07:05AM BLOOD WBC-8.4 RBC-3.91* Hgb-11.8* Hct-34.3*
MCV-88 MCH-30.2 MCHC-34.4 RDW-13.5 Plt ___
___ 07:29AM BLOOD WBC-5.7 RBC-3.60* Hgb-10.6* Hct-32.9*
MCV-92 MCH-29.6 MCHC-32.3 RDW-13.7 Plt ___
___ 01:40PM BLOOD ___ PTT-28.9 ___
___ 03:28AM BLOOD ___ PTT-33.6 ___
___ 07:05AM BLOOD ___
___ 07:29AM BLOOD ___
___ 05:25AM BLOOD Glucose-140* UreaN-16 Creat-0.4 Na-136
K-3.5 Cl-99 HCO3-22 AnGap-19
___ 07:29AM BLOOD Glucose-130* UreaN-20 Creat-0.5 Na-139
K-3.8 Cl-108 HCO3-23 AnGap-12
___ 10:35PM BLOOD CK(CPK)-541*
___ 03:28AM BLOOD CK(CPK)-298*
___ 01:40PM BLOOD cTropnT-0.02*
___ 05:25AM BLOOD CK-MB-39* MB Indx-7.2* cTropnT-1.42*
___ 03:28AM BLOOD CK-MB-14* MB Indx-4.7 cTropnT-0.77*
.
Imaging
___
Cardiac Catheterization
1. Anterior STEMI with thrombotic occlusion of the proximal LAD.
2. Severe LCX (distal OM) disease and totally occluded RCA.
3. Severe proximal right common iliac calcific stenosis.
4. Dual antiplatelet therapy for at least 12 months.
5. Successful treatment of the culprit lesion (90% in proximal
LAD and a
hazy 60% tandem stenosis) with deployment of a 3.0 x 12 mm and
2.5 x 8
mm Resolute stents in overlapped fashion leaving no residual
satenoses
in the treated segment.
.
___
Echocardiogram
The left atrium is mildly dilated. The estimated right atrial
pressure is ___ mmHg. Left ventricular wall thicknesses are
normal. The left ventricular cavity size is normal. Overall left
ventricular systolic function is severely depressed (LVEF= ___
%) secondary to akinesis of the apex, and distal segments of all
LV walls, and hypokinesis of the mid segments. The basal
segments are hyperdynamic. No masses or thrombi are seen in the
left ventricle. Right ventricular chamber size is normal. with
focal hypokinesis of the apical free wall. The ascending aorta
is mildly dilated. The aortic arch is mildly dilated. The aortic
valve leaflets (3) are mildly thickened but aortic stenosis is
not present. Trace aortic regurgitation is seen. The mitral
valve appears structurally normal with trivial-mild mitral
regurgitation. There is moderate pulmonary artery systolic
hypertension. There is no pericardial effusion.
IMPRESSION: Severe focal and global left ventricular function
involving predominantly the mid-distal LV segments c/w Takotsubo
or ischemic cardiomyopathy (multivessel CAD). Moderate pulmonary
artery systolic hypertension.
.
___
ECG
Artifact is present. Sinus rhythm. The P-R interval is 200
milliseconds.
There is ST segment elevation in the anterior leads consistent
with acute
myocardial infarction. There are reciprocal changes in the
inferior and
anterolateral leads
___ US:
FINDINGS: Targeted sonogram was performed to the right groin in
the region of recent cardiac catheterization, demonstrating a 4
x 3.6 x 1.8 cm hematoma. Just medial to this, there is apparent
contiguity between the common femoral vein and proximal
superficial femoral artery, with arterialized venous flow in
this region, consistent with an arteriovenous fistula. No
pseudoaneurysm is demonstrated.
IMPRESSION:
1. Findings concerning for arteriovenous fistula between
proximal superficial femoral artery and common femoral vein.
2. Large right groin hematoma.
On Discharge:
Brief Hospital Course:
Ms. ___ is a ___ year old woman with diabetes,
hypertension, and hyperlipidemia who presented with a STEMI. She
received two drug eluting stents to the proximal LAD.
.
# Anterior STEMI s/p DES to pLAD: ___ year old female with
diabetes, but no cardiac history who was in her usual state of
health until around 12 ___ on the day of admission when she
developed the acute onset of subseternal chest pain
EMS was called, and a 12 lead ECG demonstrated ST elevations in
I, avL, V1-V3, with ST depressions in II, III, aVF, V5-V6. The
patient was taken emergently to the cath lab where there was a
thrombotic appearing lesion in the proximal LAD prior to the
first diagonal, as well as a lesion in the distal LCx that was
not thought to be the culprit, and a totally occluded proximal
RCA with left to right collaterals. The patient's LAD lesion was
stented with good result, and resolution of her ECG changes. The
patient was hemodynamically stable post-procedure and without
chest pain, shortness of breath, palpitations or orthopnea. Her
ECG revealed resolution of anterior STE but there were residual
1 mm STD in inferior and lateral precordial leads. An echo
demonstrated severely depressed left ventricular systolic
function with EF ___ % from akinesis of the apex, and distal
segments of all LV walls, and hypokinesis of the mid segments.
She will remain on plavix for at least ___ year, aspirin
indefinitely although the dose can be decreased from 325 to 81mg
at one month post stenting, lisinopril that can be increased to
10 mg as tolerated, metoprolol XL that can be increased as
tolerated, atorvastatin, SL nitro prn, and warfarin. Of note,
after intervention, pt did have right groin bleeding with an
enlargening ecchymosis necessitating epi injection which stopped
bleeding temporarily. There has been some oozing, but this has
stabilized.
.
# Apical Akinesis: After echo results discussed above, it was
decided to start patient on lovenox and warfarin to prevent left
ventricular thrombus from apical and distal akinesis. Pt
initially started on warfarin 5 mg, but due to brisk INR
response, this was decreased to 2.5 mg. The patient was not
discharged on Lovenox, given a therapuetic INR. Decision to
continue anticoagulation will be left to primary cardiologist
after repeat echo to see if there is apical recovery.
.
# Acute Systolic Heart Failure: Post MI, her echocardigram
showed an ejection fraction of ___ with complete akinesis of
the apex and distal segments, and hypokinesis of the mid
segments . She was given IV lasix that was transitioned to PO
lasix 20 mg. She was given heart failure teaching. She was
initiated on lisinopril and metoprolol.
.
# Hypertension: She was placed on an ace inhibitor and
metoprolol.
.
# HLD: high dose atorvastatin as above
.
# Diabetes mellitus: Pt was switched to ISS in house.
Discharged on home metformin.
.
# CODE: Ms. ___ code status was DNR/DNI during this
admission.
.
Transitional Issues
- One month of aspirin 325 mg for 1 month and then reduce to
aspirin 81 mg at follow-up.
- Can increase metoprolol and lisinopril for HR, blood pressure,
and MI/CHF as tolerated. Good HR control takes precedence.
- Repeat echo in ___ months to evaluate for recovery of LV
function and specifically apical function to assess need for
continued anticoagulation
Medications on Admission:
- atenolol 25mg one daily
- simvastatin 20 mg HS
- percocet ___ one tab QID
- metformin 500 BID
- neopolydex eye drops one gtt right eye BID for 30 days
- lidoderm patch 5% one patch daily for 12 hours
- ofloxacin 0.3% one gtt BID daily for 30 days (filled one month
ago)
- trazadone 100mg one tab at bedtime
- trizmterene HCTZ ___ one daily
- triamcinalone cream 0.25% top BID for rash on hand
Discharge Medications:
1. aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. oxycodone-acetaminophen ___ mg Tablet Sig: One (1) Tablet
PO four times a day as needed for pain.
4. atorvastatin 80 mg 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. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily).
7. nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual ASDIR (AS DIRECTED) as needed for chest
pain.
8. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):
HOld SBP < 100.
9. trazodone 100 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed for insomnia.
10. metformin 500 mg Tablet Sig: One (1) Tablet PO twice a day.
11. furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day.
12. warfarin 2.5 mg Tablet Sig: One (1) Tablet PO once a day.
13. metoprolol succinate 50 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO once a day.
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
ST Elevation myocardial infarction
New Acute systolic congestive heart failure
Hypertension
Dyslipidemia
Diabetes Mellitus
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
It was a pleasure taking care of you at ___.
You had chest pain and an ECG showed that you were having a
heart attack. You were brought to ___ and taken to the
catheterization lab and a blockage was found in one of your
large heart arteries. The blockage was cleared and two drug
eluting stents were placed to keep the artery open. It is
extrememely important that you take aspirin and clopidogrel
(Plavix) every day without fail to prevent the stents from
clotting off and causing another heart attack. Do not stop
taking aspirin and clopidogrel (Plavix) or miss any doses
unless Dr. ___ you it is OK. Your right groin area will
be bruised and sore for a few weeks. You should call the
Heartline if you notice that it has started bleeding again or
the soreness and swelling worsens.
You heart is weaker after the heart attack and you needed some
medicine to remove extra fluid in the hospital. You will need to
watch your weight carefully every day to make sure that you are
not retaining fluid again. Weigh yourself every morning before
breakfast and call Dr. ___ you notice that your weight is
increasing more than 3 pounds in 1 day or 5 pounds in 3 days.
You also need to follow a low sodium diet. Information about
this was given to you.
.
We made the following changes to your medicines:
1. START taking aspirin (325 mg) and Clopidogrel every day to
prevent the stents from clotting off
2. STOP taking simvastatin, take atorvastatin instead to lower
your cholesterol for now.
3. Take nitroglycerin as needed for chest pain
4. Take colace as needed for constipation
5. STOP taking Atenolol, take metoprolol instead to lower your
heart rate and help your heart pump better
6. STOP taking triamterene/HCTZ for your blood pressure
7. START taking warfarin to prevent a blood clot long term, you
will need to get your warfarin level )INR) checked frequently to
make sure it is more than 2.0 and less than 3.0.
8. START taking lisinopril to help your heart recover from the
heart attack.
Followup Instructions:
___
|
19713183-DS-15
| 19,713,183 | 25,072,624 |
DS
| 15 |
2197-04-11 00:00:00
|
2197-04-11 22:44:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Keflex
Attending: ___.
Chief Complaint:
chest pressure
Major Surgical or Invasive Procedure:
cardiac catheterization
History of Present Illness:
___ yo F with h/o CAD s/p ant STEMI in ___ s/p 2 DES to LAD,
HTN, HLD, CHF (EF ___, DM presenting with chest pressure.
Recent URI (bad cough) 3 days ago, now with DOE and chest
pressure. Trops elevated to 0.14, EKG notable for new TWIs
V2-V6, 1, aVL, and inferiorly. Patient currently CP free and HD
stable. Of note, pt recalls having "massive explosion in my
chest" during her STEMI in ___, unlike her current symptoms.
In the ED, initial vitals were Pain 0 T97.5 P73 BP106/54 RR10 O2
sat 95%. Labs were significant for TnT 0.14, AG 17 with a
Lactate of 3.3. CXR showed. EKG showed NSR, borderline ___ AVB
(PR 202), diffuse TWI I/aVL, V2-V6, II/III/aVF. Patient was dx
with NSTEMI given recommend ASA 325, heparin gtt and admitted to
___.
Denies any recent fevers/chills, rigors, myalgias.
Past Medical History:
1. CARDIAC RISK FACTORS: +Diabetes, +Dyslipidemia, +Hypertension
2. CARDIAC HISTORY:
- CABG:
- PERCUTANEOUS CORONARY INTERVENTIONS: ___ 2 to LAD
- PACING/ICD:
3. OTHER PAST MEDICAL HISTORY:
CHF (EF ___
1. Cardiac disease as above.
2. AV fistula in the right groin, followed by Dr. ___,
___ status ___ open ligation of AV fistula ___.
3. Hypertension.
4. Hyperlipidemia.
5. Hysterectomy.
6. Left hip replacement.
7. Bilateral knee replacements.
8. Laminectomy.
9. Cataract surgery
Social History:
___
Family History:
Father died of CAD at ___. No family history of early MI,
arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise
non-contributory.
Physical Exam:
admission exam
VS: Wt=71.2kg (156.64lb) T= 98 BP=119/60 HR=81 RR=20 O2 sat= 96%
RA
General: no acute distress, lying comfortably in bed, speaking
full sentences
HEENT: NCAT, EOMI, PERRL
Neck: no JVP elevation
CV: rrr, normal S1 and S2, no m/r/g
Lungs: ctab, good respiratory effort
Abdomen: soft, nd, nt, +bs
GU: no foley
Ext: wwp, trace edema in L ankle (c/w baseline), no edema in R
ankle
Neuro: mentating well
Skin: intact
PULSES: 2+ distal pulses
discharge exam
VS: 98.9 122/61 (92/51-123/81) 70s 19 98% RA
weight 75.7kg
I/O - 1080/2275 (24H), ___ (8H)
General: no acute distress, sitting comfortably in bed
HEENT: NCAT, EOMI, PERRL
Neck: JVP does not appear elevated
CV: rrr, normal S1 and S2, no m/r/g
Lungs: ctab, good respiratory effort
Abdomen: soft, nd, nt, +bs
GU: no foley
Ext: wwp, no edema. left groin site with no hematoma or bruit.
dressing c/d/i.
PULSES: 2+ distal pulses
Pertinent Results:
admission labs
___ 10:55AM BLOOD WBC-10.2# RBC-3.94*# Hgb-12.0# Hct-37.1#
MCV-94 MCH-30.4 MCHC-32.3 RDW-13.3 Plt ___
___ 10:55AM BLOOD Neuts-72.2* ___ Monos-5.5 Eos-2.9
Baso-0.6
___:44PM BLOOD ___ PTT-40.5* ___
___ 10:55AM BLOOD Glucose-160* UreaN-22* Creat-0.7 Na-139
K-3.7 Cl-102 HCO3-20* AnGap-21*
___ 10:55AM BLOOD proBNP-5737*
___ 04:00AM BLOOD Albumin-3.5 Calcium-8.5 Phos-3.2# Mg-1.5*
___ 11:03AM BLOOD Lactate-3.3*
___ 10:55AM BLOOD cTropnT-0.14*
___ 07:44PM BLOOD cTropnT-0.11*
___ 05:50AM BLOOD cTropnT-0.14*
discharge labs
___ 05:50AM BLOOD Hct-35.1* Plt ___
___ 05:50AM BLOOD Glucose-130* UreaN-11 Creat-0.6 Na-138
K-4.0 Cl-103 HCO3-25 AnGap-14
___ 05:50AM BLOOD Calcium-8.9 Phos-4.2 Mg-1.9
micro:
URINE CULTURE (Final ___:
ESCHERICHIA COLI. >100,000 ORGANISMS/ML..
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ <=2 S
AMPICILLIN/SULBACTAM-- <=2 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
admission ECG: EKG showed NSR, borderline ___ AVB (PR 202),
diffuse TWI I/aVL, V2-V6, II/III/aVF
CXR: Trace bilateral pleural effusions. Mild bibasilar
atelectasis
ECHO: ___
The left atrium is mildly dilated. Left ventricular wall
thicknesses and cavity size are normal. There is mild to
moderate regional left ventricular systolic dysfunction with
mild hypokinesis of the distal half of the inferolateral and
inferoseptal walls, and apex. The remaining segments contract
well (LVEF 45-50%). No mass/thrombus is seen in the left
ventricle. A small perimembranous ventricular septal defect is
suggested (clips 34, 43, 62). No muscular VSD is suggested.
Right ventricular chamber size and free wall motion are normal.
The ascending aorta and aortic arch are mildly dilated. The
aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. Trace aortic regurgitation is seen. The
mitral valve leaflets are structurally normal. No mitral
regurgitation is seen. The estimated pulmonary artery systolic
pressure is high normal. There is a trivial/physiologic
pericardial effusion.
IMPRESSION: Normal left ventricular cavity size with regional
systolic dysfunction c/w CAD. Dilated thoracic aorta. Possible
small perimembranous VSD. Dilated ascending aorta.
Compared with the prior study (images reviewed) of ___
overall left ventricular dysfunction is markedly improved and
the estimated PA systolic pressure is now much lower. A possible
small perimembranous VSD is now suggested (the area was not as
well examined on the prior study and is not reported on the
___ of ___. The area was also not examined on
the prior OR TEE of ___.
If clinically indicated a TEE or TTE with saline contrast may
allow for the clarification of the possible perimembranous VSD.
If the patient is going for left heart catheterization, a left
ventriculogram would also allow for a more definitive diagnosis.
If a right heart catheterization is going to be performed, a
saturation run is suggested, though the defect/flow is very
small.
Cardiac catheterization ___
1.Severe two vessel CAD.
2.Known CTO RCA. Progression of severe diffuse LCX and Om1.
3.Successful PTCA and stenting of the LCX as described above
with deployment of 3 overlapping DESs, with excellent result.
4.Successful deployment of ___ AngioSeal to the L CF
arteriotomy.
5.ASA 325 mg po daily x1 month then 81 mg daily indefinitely.
6.Clopidogrel 75 mg po daily x12 months minimum.
7.Hydration and ___ renal function.
8.No step-up in O2 saturation. Therefore, if indeed a
membranous
VSD suspected on TTE is present, it is likely hemodynamically
insignificant.
Brief Hospital Course:
___ yo F with h/o CAD s/p ant STEMI in ___ s/p 2 DES to LAD,
HTN, HLD, CHF (EF ___, DM presenting with NSTEMI.
# NSTEMI: Patient presented with shortness of breath and some
chest pressure. ECG showed diffuse TWI I/aVL, V2-V6, II/III/aVF.
Troponin noted to be 0.14. Patient was treated for ACS with ASA,
plavix, atorastatin, beta blocker, and a heparin gtt. ECHO
showed normal left ventricular cavity size with regional
systolic dysfunction c/w CAD. Systolic dysfunction improved with
EF 45-50%. Dilated thoracic aorta. Possible small perimembranous
VSD. Dilated ascending aorta. She ultimately underwent a cardiac
catheterization on ___ which showed severe 2 vessel disease.
She had 3 overlapping DES placed in L. circumflex. She also had
a right heart catheterization during this time given concern for
possible perimembranous VSD. This did not she any step-up in O2
saturation. therefore, if VSD is present, it is hemodynamically
insignificant. Patient tolerated the procedure well. She was
instructed to continue aspirin and plavix for at least one year
and discharged with plans to follow up with her outpatient
cardiologist.
# Chronic congestive heart failure with systolic dysfunction:
LVEF ___ on previous ECHO, however repeat echo on this
admission showed improvement in systolic function to 45-50%. She
appeared euvolemic on exam and was continued on her current
lasix dosing. She was switched from metoprolol tartrate to
metoprolol succinate. She was continued on her low dose
lisinopril.
# HLD: continued atorvastatin 80mg daily
# DM: held oral hypoglycemics. She was treated with insulin
sliding scale while in house.
# UTI: pt asymptomatic. UA positive. Ucx showing >100K E. coli
that is pan sensitive. She completed a 3 day course of
ceftriaxone.
# Insomnia: Continued home trazodone and gabapentin
# chronic pain: continued home percocet
# transitional issues:
- continue aspirin and plavix for at least ___ year
- blood culture pending at time of discharge
# CODE: DNR/DNI
# CONTACT: Patient, Father ___ (friend): ___
Cell phone: ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Lisinopril 1.25 mg PO DAILY
3. Furosemide 20 mg PO BID
4. Metoprolol Succinate XL 25 mg PO DAILY
5. Atorvastatin 40 mg PO DAILY
6. MetFORMIN (Glucophage) 500 mg PO BID
7. TraZODone 100 mg PO HS
8. Pantoprazole 40 mg PO Q12H
9. Gabapentin 1000 mg PO HS
10. Nitroglycerin SL 0.4 mg SL PRN chest pain
11. Percocet (oxyCODONE-acetaminophen) 5mg-500mg oral qid prn
pain
12. Systane (peg 400-propylene glycol) 0.4-0.3 % ophthalmic QAM
13. Oxycodone-Acetaminophen (5mg-325mg) 1 TAB PO QD:PRN back
pain
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Furosemide 20 mg PO BID
3. Gabapentin 1000 mg PO HS
4. Lisinopril 1.25 mg PO DAILY
5. Nitroglycerin SL 0.4 mg SL PRN chest pain
6. Pantoprazole 40 mg PO Q12H
7. TraZODone 100 mg PO HS
8. MetFORMIN (Glucophage) 500 mg PO BID
please do not start this medication until the evening of ___
given recent cardiac catheterization
9. Metoprolol Succinate XL 25 mg PO DAILY
10. Percocet (oxyCODONE-acetaminophen) 5mg-500mg oral qid prn
pain
11. Systane (peg 400-propylene glycol) 0.4-0.3 % ophthalmic QAM
12. Atorvastatin 80 mg PO DAILY
13. Clopidogrel 75 mg PO DAILY
14. Oxycodone-Acetaminophen (5mg-325mg) 1 TAB PO QD:PRN back
pain
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
primary diagnosis: non ST elevation myocardial infarcation
secondary diagnosis: diabetes type 2, chronic systolic
congestive heart failure
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Ms. ___,
It was a pleasure taking care of you at the ___
___. You were admitted here because of the
concern that you had another heart attack. You were treated
medically for this heart attack with a blood thinner as well as
some other heart medications. You remained stable and chest
pain-free during your admission. You underwent a catheterization
and had 3 new DRUG ELUDING STENTS placed. It is important that
you take your aspirin and plavix everyday and do not miss any
doses.
You were also treated for a urinary tract infection (UTI) during
this hospitalization.
- It is important that you continue to take your heart
medications at home: aspirin, plavix, lisinopril, metoprolol,
Lipitor.
- For your congestive heart failure, it is important to continue
to take your lasix as well as to weigh yourself every morning,
call MD if weight goes up more than 3 lbs.
___ MD's
Followup Instructions:
___
|
19713183-DS-16
| 19,713,183 | 28,197,786 |
DS
| 16 |
2199-06-10 00:00:00
|
2199-06-10 16:15:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Keflex
Attending: ___.
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
Cardiac catheterization with DES to LCX ___
History of Present Illness:
___ with a history of CAD s/p anterior STEMI in ___ w/ 2 DES to
LAD, and NSTEMI ___ treated with 3 overlapping ___ of the
LCX, mild sCHF (LVEF of 50-55%), diastolic heart failure, HLD,
orothostatic hypotension, T2DM, who presents to ED with chest
pain.
She was watching HG TV at ___ and suddenly, felt ___ pain in
chest, radiating to the back and down both shoulders. She felt
clammy, had nausea with 3x episodes of vomiting. Was given 2x
Sublingual nitro and aspirin with no benefit. Pain was
unrelenting and patient asked to be taken to the ED.
In the ED, initial vitals were: 6 97.4 87 162/77 18 97% RA and
EKG showed ST elevations in the inferior leads. Was Given 324mg
of Aspirin, started on heparin gtt and sent to the Cath lab. R
radial arm approach was found to be tortuous and was ultimately
aborted, TR band placed. L arm groin access worked, ___ sheath,
95% LCx stenosis proximal to prior stent, ballooned, then
stented with DES. Sheath was left in. She was started on
ticagrelor 180 loading dose.
On Arrival to CCU, patient stated chest pain fully resolved
after the procedure. Denied any nausea/vomiting, shortness of
breath.
REVIEW OF SYSTEMS:
(+) per HPI
Past Medical History:
1. CAD as above.
2. AV fistula in the right groin followed by Dr. ___,
at ___, now status ___ ligation of AV
fistula ___.
4. Hyperlipidemia.
5. Hysterectomy.
6. Left hip replacement.
7. Bilateral knee replacement.
8. Laminectomy.
9. Cataract surgery.
10. Orthostatic hypotension.
11. T2DM
Social History:
___
Family History:
No early CAD
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.
Physical Exam:
Admission exam:
VS: 97.6 73 127/49 78 14 98%
Tele: Sinus
GEN: pleasant Elderly female, lying in bed, no acute distress
HEENT: PERRL, Moist mucous membranes, posterior oropharynx
NECK: JVD not distended
CV: RRR, normal S1/S2 no murmurs rubs or gallops
LUNGS: Clear throughout, diminished breath sounds
ABD: Non-tender, non-distended, +BS
EXT: Warm, well perfused, 2+ distally
SKIN: clear
NEURO: CN III-XII intact
Discharge exam:
VS: 98.6 HR ___ BP ___ RR 18 99% RA
Wt: 71 kg I/O ___
Tele: Sinus
GEN: pleasant elderly female, lying in bed, no acute distress
HEENT: PERRL, Moist mucous membranes, posterior oropharynx
NECK: JVD not distended
CV: RRR, normal S1/S2 no murmurs rubs or gallops
LUNGS: Clear throughout, diminished breath sounds in bases
bilaterally
ABD: Non-tender, non-distended, +BS
EXT: Warm, well perfused, 2+ distally
SKIN: clear
NEURO: CN III-XII intact
Pertinent Results:
Admission exam:
___ 11:12PM WBC-8.9 RBC-3.49* HGB-10.6* HCT-33.4* MCV-96
MCH-30.4 MCHC-31.7* RDW-14.2 RDWSD-49.1*
___ 11:12PM ___ PTT-32.5 ___
___ 11:12PM ___
___ 11:12PM LIPASE-47
___ 11:12PM UREA N-39* CREAT-1.2*
___ 11:19PM GLUCOSE-199* LACTATE-3.6* NA+-138 K+-3.7
CL--104 TCO2-18*
___ 11:19PM HGB-11.1* calcHCT-33 O2 SAT-95 CARBOXYHB-2
MET HGB-0
___ 02:27AM ALT(SGPT)-11 AST(SGOT)-26 LD(LDH)-210 ALK
PHOS-70 TOT BILI-0.1
___ 02:27AM CALCIUM-8.7 PHOSPHATE-4.3 MAGNESIUM-1.5*
___ 07:51AM CK-MB-26* MB INDX-7.2* cTropnT-1.06*
___ 07:51AM CK(CPK)-363*
Discharge labs:
___ 07:10AM BLOOD WBC-7.0 RBC-3.10* Hgb-9.4* Hct-30.0*
MCV-97 MCH-30.3 MCHC-31.3* RDW-14.6 RDWSD-51.2* Plt ___
___ 07:10AM BLOOD Glucose-169* UreaN-16 Creat-0.8 Na-139
K-3.6 Cl-103 HCO3-22 AnGap-18
___ 07:10AM BLOOD Calcium-8.9 Phos-4.8*# Mg-2.4
IMAGING:
TTE ___
The left atrium is elongated. No atrial septal defect is seen by
2D or color Doppler. The estimated right atrial pressure is ___
mmHg. Left ventricular wall thicknesses and cavity size are
normal. There is mild regional left ventricular systolic
dysfunction with hypokinesis of the basal halves of the inferior
and inferolateral walls. The remaining segments contract
normally (LVEF = 40-45 %). The estimated cardiac index is normal
(>=2.5L/min/m2). There is no ventricular septal defect. Right
ventricular chamber size and free wall motion are normal. The
diameters of aorta at the sinus, ascending and arch levels are
normal. The aortic valve leaflets (3) are mildly thickened but
aortic stenosis is not present. Trace aortic regurgitation is
seen. The mitral valve leaflets are mildly thickened. There is
no mitral valve prolapse. Mild (1+) mitral regurgitation is
seen. There is mild pulmonary artery systolic hypertension.
There is an anterior space which most likely represents a
prominent fat pad.
IMPRESSION: Suboptimal image quality. Normal left ventricular
cavity size with regional systolic dysfunction c/w CAD (PDA
distribution). Mild mitral regurgitation. Mild pulmonary artery
systolic hypertension.
Cath ___
Interventional Details
A ___ Fr XB-3.5 guide provided good support. Heparin given and a
therapeutic ACT confirmed. Crossed
with moderate difficulty into the distal OM branch using a
Prowater wire due to significant proximal
angulation of the LCx origin complicated by proximal lesion
location. The lesion was serially predilated
with 2.0mm and 3.0mm balloons at ___ atm with complete
expansion. A 3.0x18mm Resolute Integrity
would not cross. Further predilatation was performed with a
3.0mm NC balloon at ___ atm, and a
Choice ___ XS wire was placed as a buddy wire, however the stent
would still not cross. A 3.0x8mm
Xience ___ stent was then attempted without success. The
Prowater wire was then removed and with
further serial predilatation using a 3.0x8mm NC balloon at 18
atm and the support of a Guideliner passed
into the proximal LCx, a 2.5x12mm Xience ___ stent was
advanced with difficulty and deployed at 15
atm overlapping the previously placed stents and extending
proximally to near the LCx origin. The entire
stent and overlap zone were post-dilated with a 3.0mm NC balloon
at 18 atm. Final angiography
demonstrated no residual, no dissection, and normal flow. The
patient had resolving chest pain at
procedure end and left the cath lab in hemodynamically stable
condition.
Intra-procedural Complications: None
Impressions:
Successful PCI of the LCx with drug-eluting stent
Brief Hospital Course:
___ with a history of CAD s/p anterior STEMI in ___ w/ 2 DES to
LAD, and NSTEMI ___ treated with 3 overlapping ___ of the
LCX, mild sCHF (LVEF of 50-55%), mild systolic congestive heart
failure, HLD, T2DM, who presents with STEMI 95% LCx stenosis
proximal to prior stent s/p DES.
# CORONARIES: CAD s/p multiple STEMI and stents as above
# PUMP: LVEF = 40-45 %, 1+ MR
# RHYTHM: NSR; on telemetry noted to have second degree block
with Mobitz I.
#STEMI: Sister ___ presented with acute onset chest pain and
was found to have ST elevations in inferior leads. She underwent
cardiac catheterization and was found to have 95% left
circumflex stenosis proximal to prior LCX stents. Given
proximity to prior stent, this is considered in stent
thrombosis. She had a DES placed in the LCX and was placed on
ticagrelor 90 mg BID for planned 12 month course. Her home
atorvastatin was increased to 80 mg qHS and she will continue on
aspirin 81 for a lifelong course. She was started on lisinopril
5 mg daily and continued on home metoprolol.
#Second degree heart block: During her hospital course, patient
was intermittently found to have second degree heart block in
___ I/___ pattern. She was briefly symptomatic during
one of these episodes and so was discharged with ___ of
Hearts monitor. She may be considered for pacemaker if she
continues to be symptomatic.
#)Congestive heart failure: Patient with a history of CHF, NYHA
class III, on Lasix 40 mg qAM and 20 qPM. Previous LVEF was 55%;
repeat TTE this admission showed LVEF 40-45% with
inferior/inferolateral hypokinesis. She was started on
lisinopril 5 mg this admission and continued on home metoprolol
12.5 XL.
#Diarrhea: ___ hospital course complicated by diarrhea,
thought to be ___ drug effect. Her CDiff was negative, and she
was placed on immodium with symptomatic improvement.
CHRONIC ISSUES:
================
#GERD: continued on home omeprazole
#Hyperlipidemia: placed on atorvastatin 80 mg qHS, increased
from home dose of atorvastatin 40 mg qHS.
#Type 2 diabetes mellitus: Patient was maintained on SSI during
hospital course, transitioned to home metformin by time of
discharge.
TRANSITIONAL ISSUES
-Patient had DES to LCX placed and should continue on ticagrelor
x12 months, ending ___
-Patient noted to have intermittent second degree Mobitz I heart
block during admission and was short of breath around the time
of one episode of block. As such, she had ___ of Hearts
monitor placed at discharge for monitoring. If she continues to
be symptomatic and coinciding with heart block, she may be
considered for permanent pacemaker.
- For ___ providers: patient is in our system with ___ ___:
___ and ___. Medical records office was made aware of
the duplication and will merge. In the meantime, please review
both ___ records for full patient data.
- Full code
- Contact: ___ (sister superior) ___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 40 mg PO QPM
2. Furosemide 40 mg PO QAM
3. Gabapentin 1000 mg PO QHS
4. MetFORMIN (Glucophage) 500 mg PO BID
5. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN Chest pain
6. Omeprazole 20 mg PO DAILY
7. TraZODone 100 mg PO QHS:PRN insomnia
8. Acetaminophen 650 mg PO Q6H:PRN pain
9. Vitamin D Dose is Unknown PO DAILY
10. Furosemide 20 mg PO QHS
11. Metoprolol Succinate XL 12.5 mg PO DAILY
12. Potassium Chloride 20 mEq PO DAILY
13. Aspirin 81 mg PO DAILY
14. Systane (peg 400-propylene glycol) 0.4-0.3 % ophthalmic BID
Discharge Medications:
1. Potassium Chloride 20 mEq PO DAILY
Hold for K >
2. Acetaminophen 650 mg PO Q6H:PRN pain
3. Aspirin 81 mg PO DAILY
4. Atorvastatin 80 mg PO QPM
5. Furosemide 40 mg PO QAM
6. Furosemide 20 mg PO QPM
7. Gabapentin 1000 mg PO QHS
8. Metoprolol Succinate XL 12.5 mg PO DAILY
9. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN Chest pain
10. Omeprazole 20 mg PO DAILY
11. TraZODone 100 mg PO QHS:PRN insomnia
12. Lisinopril 5 mg PO DAILY
13. LOPERamide 2 mg PO QID:PRN diarrhea
14. TiCAGRELOR 90 mg PO BID
15. MetFORMIN (Glucophage) 500 mg PO BID
16. Systane (peg 400-propylene glycol) 0.4-0.3 % ophthalmic BID
17. Vitamin D 400 UNIT PO DAILY
**UNKNOWN HOME DOSE**
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary diagnosis:
ST elevation myocardial infarction with 95% left circumflex
stenosis, s/p drug eluding stent x1
Second degree Mobitz I heart block
Secondary diagnosis:
Coronary artery disease with history of anterior STEMI in ___
with 2 DES to LAD, NSTEMI ___ with 3 overlapping DES to LCX
Mild systolic congestive heart failure
Hyperlipidemia
Type 2 diabetes mellitus
GERD
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. ___,
You were seen at ___ due to
chest pain. This was due to a heart attack; you have a blockage
in one of the arteries to your heart. You underwent a
catheterization of the arteries, and a new stent was placed. You
will need to continue on medications due to this stent,
specifically ticagrelor (aka Brilinta), for a full year (ending
___. You will need to be on aspirin for a lifelong course.
In addition, you had an abnormal heart rhythm. This is not a
dangerous rhythm but if you continue to have symptoms from it,
you may do well with a pacemaker. To monitor how frequently this
rhythm occurs, we are discharging you on a heart monitor called
a ___ of Hearts" monitor. Your cardiologist will be able to
follow up the information on this monitor and determine if you
should have a pacemaker placed.
Please take all medications as prescribed and please follow up
with the appointments we have arranged.
It was a pleasure taking care of you at ___.
Sincerely,
Your ___ care team
Followup Instructions:
___
|
19713531-DS-4
| 19,713,531 | 26,257,129 |
DS
| 4 |
2185-05-19 00:00:00
|
2185-05-19 16:19:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Coffee ground emesis, tarry stool, transfer from ___
Major Surgical or Invasive Procedure:
Intubation for EGD ___
EGD ___
Extubation ___
History of Present Illness:
Mr. ___ is ___ year old M with h/o EtOH cirrhosis (MELD 17) c/b
esophageal varices who presents to the ED (___ from ___ same
day) with concern for upper GI bleed.
On presentation, he endorsed three days of weakness, dark
vomiting, and dark tarry stools. He notes that it was
"projectile" out of "both ends." He became so significantly weak
that he decided to present to ED at ___. He denies any
headache, fever, chest pain, SOB, or abdominal pain. He has
intermittently had abdominal pain in the past and that he also
chronically has poor appetite (he reports not having eaten
anything for 3 weeks). He reports that he takes NSAIDs daily.
He was seen at ___ where he was found to be hypotensive
(101/45), HR 105, INR 2.02, potassium 4.3, creatinine 1.26,
total
bilirubin 1.6, AST 34, ALT 18, Hgb 5.0, Hct 15.4.
He was given Octreotide (25cc/hr), PPI, Ceftriaxone, 1L IVF, and
ordered for 1u PRBC. He was transferred to ___ for ICU
admission.
Of note, he was admitted for similar episode recently in ___ to ___. At the time, he had presented
from his sober living house with one day of black tarry stools
and hematemesis of black/dark-colored blood. He had a known
extensive history of esophageal varices which have required
clipping and banding in the past, most recently as of ___. At the time, he had also been taking significant
Advil/ibuprofen at home. His Hgb was found to be 7. He was
started on protonix and octreotide infusions and admitted to the
ICU. He received 1u pRBC, and EGD did not reveal active
bleeding,
only portal HTN gastropathy; nadolol was started and octreotide
was weaned. His course was complicated by hepatic encephalopathy
and improved on lactulose. He was continued on antibiotic
prophylaxis for SBP (Bactrim). At that discussion, his sister
(___) confirmed code status as DNR/DNI.
EGD ___
An ___ endoscope was used. With the patient in left lateral
decubitus position, esophagus was intubated under direct vision.
The scope passed through the esophagus into stomach and
duodenum.
The duodenal bulb and second portion appeared normal. There was
no evidence of bleeding there. The stomach was carefully
examined.
There was moderately severe portal hypertensive gastropathy with
snake skin-like mucosa and multiple petechiae noted, especially
in the mid and high fundus. Retroflexion did not demonstrate
any
definite gastric varices. On withdrawal, a small erosion was
seen in the region of the GE junction. The esophagus was
carefully examined. A small variceal chain that completely
flattens with air insufflation is seen in the thoracic area.
Overall, the varices in the esophagus appeared largely
obliterated and there are no stigmata of recent hemorrhage.
IMPRESSION:
1. Largely obliterated esophageal varices.
2. Moderately severe portal hypertensive gastropathy.
3. Erosion at the gastroesophageal junction.
Prior to this, he had also presented to our ___ from ___ - ___ for hematemesis. On arrival to
the ED his hemoglobin was 4.7. In the ED he received 4 units of
packed red blood cells, 2 units of FFP, and 10 mg of vitamin K.
An upper endoscopy was done the same day that showed 3 large
esophageal varices with copious amount of blood in the
esophagus.
He had recurrence of his bleed several times during the hospital
stay and had several bands placed. He required pressors for
hypotension and was intubated for airway protection. His course
was complicated by pseudomonal VAP with 14 day course of
meropenem.
On this presentation--
Initial Vitals:
T 97.2 HR 118 BP 100/58 RR 16 O2 Sat 100% RA
Exam:
Pale, appears unwell
Tachycardic
Bilateral breath sounds, no wheezing or crackles
Abdomen soft, no focal tenderness, no rebound or guarding
Labs: (At ___
CBC: WBC 6.9, Hgb 5.0, Hct 15.4, Plt 62, MCV 93.3
Coags: INR 2.02, ___ 22.8, PTT 37
Chem panel: Na 136 K 4.3 Cl 106 CO2 21 BUN 47 Cr 1.26 Glc 120 AG
9
Ca 8.0
LFTs: AST 34 ALT 18 AP 54 Tbili 1.6 Alb 2.3 Tprot 4.2
Imaging:
RUQ US ___
1. Patent TIPS.
2. Cholelithiasis. Circumferential gallbladder wall edema is
likely due to underlying liver disease.
Consults: None
Interventions: Getting 1U RBC
VS Prior to Transfer:
T 99.1 HR 100 BP 97/55 RR 13 O2 Sat 99% 2L NC
On presentation to ICU, he reports dry mouth and also requests
200mg ambien. He is understandable that since it is 6AM, he will
not be getting sleep medications and that he can get sponge/ice
cubes for his mouth but otherwise we would like to keep NPO.
ROS: Positives as per HPI; otherwise negative.
Past Medical History:
- EtoH cirrhosis c/b EV s/p banding ___, SBP, & HE
- TIPS ___
- Portosystemic shunt embolization ___
- Alcohol use disorder, now sober
- Insomnia
- Psoriasis
- Anti-E antibody
- Depression/anxiety
- Hx of LUE DVT, provoked in setting of PICC, noted in ___ hospitalization (AC deferred given bleeding risk)
Social History:
___
Family History:
Mother is alive and healthy, father died in his ___ to "cancer"
Physical Exam:
ADMISSION EXAM:
==============
VS: BP 118/68. HR 103. RR 18. O2 Sat 100% RA.
GEN: Well-appearing male, restless, lifting his legs up out of
bed
HEENT: PERRL, EOMI. Pale conjunctivae.
NECK: No lymphadenopathy. No thyroidomegaly
CV: Regular rhythm, tachycardic to low 100s. No murmurs
appreciated.
RESP: Normal work of breathing, decreased inspiratory effort,
no
wheezes or crackles appreciated.
GI: Soft, nontender, slightly distended. No large pocket
visualized on US.
MSK: Warm, SCDs in place. No lower extremity edema.
SKIN: Small spider angioma on chest. Pale skin with decreased
capillary refill.
NEURO: Alert, oriented, good attention. Can do MOYB and DOWB.
Able to recite last two presidents.
PSYCH: Odd affect, tangential speech.
DISCHARGE EXAM:
==============
VITALS: 24 HR Data (last updated ___ @ 2335)
Temp: 98.1 (Tm 98.6), BP: 112/63 (95-112/47-64), HR: 76
(76-82), RR: 20 (___), O2 sat: 100% (96-100), O2 delivery: Ra
GENERAL: Alert and interactive. In no acute distress.
HEENT: Sclera anicteric and without injection. Moist mucous
membranes, good dentition.
NECK: No JVD.
CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No
murmurs/rubs/gallops.
LUNGS: Clear to auscultation bilaterally w/appropriate breath
sounds appreciated in all fields. No wheezes, rhonchi or rales.
No increased work of breathing.
ABDOMEN: NBS. Softly distended abdomen. Non-tender to palpation
in all quadrants. Unable to appreciate liver edge. Umbilical
hernia present.
EXTREMITIES: No clubbing, cyanosis, or edema.
NEUROLOGIC: A&Ox3. No asterixis. Appropriate mood and affect
Pertinent Results:
ADMISSION LABS:
==============
___ 05:14AM BLOOD WBC-5.6 RBC-1.64* Hgb-5.0* Hct-15.8*
MCV-96 MCH-30.5 MCHC-31.6* RDW-17.6* RDWSD-60.8* Plt Ct-33*
___ 05:14AM BLOOD Neuts-64.9 ___ Monos-9.2 Eos-1.3
Baso-0.2 Im ___ AbsNeut-3.62 AbsLymp-1.33 AbsMono-0.51
AbsEos-0.07 AbsBaso-0.01
___ 05:14AM BLOOD ___ PTT-23.0* ___
___ 05:14AM BLOOD ___
___ 05:14AM BLOOD Glucose-135* UreaN-45* Creat-1.0 Na-140
K-5.9* Cl-112* HCO3-20* AnGap-8*
___ 05:14AM BLOOD ALT-17 AST-44* LD(LDH)-302* AlkPhos-46
TotBili-1.1
___ 05:14AM BLOOD Albumin-2.3* Calcium-7.9* Phos-4.1 Mg-1.6
___ 05:14AM BLOOD Hapto-<10*
___ 09:07AM BLOOD ___ pO2-30* pCO2-42 pH-7.38
calTCO2-26 Base XS--1
___ 06:05AM BLOOD K-5.5*
___ 09:07AM BLOOD Lactate-1.7 K-4.5
___ 09:07AM BLOOD freeCa-1.18
___ 08:50AM URINE Color-Straw Appear-Clear Sp ___
___ 08:50AM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
INTERVAL LABS:
=============
CBC labs:
___ 05:44PM BLOOD WBC-5.6 RBC-2.33* Hgb-6.9* Hct-21.3*
MCV-91 MCH-29.6 MCHC-32.4 RDW-18.3* RDWSD-57.8* Plt Ct-39*
___ 11:04PM BLOOD WBC-5.5 RBC-2.66* Hgb-8.0* Hct-24.2*
MCV-91 MCH-30.1 MCHC-33.1 RDW-18.0* RDWSD-58.4* Plt Ct-42*
___ 09:47AM BLOOD WBC-5.0 RBC-2.60* Hgb-7.6* Hct-23.1*
MCV-89 MCH-29.2 MCHC-32.9 RDW-18.1* RDWSD-55.9* Plt Ct-37*
___ 03:13AM BLOOD WBC-5.0 RBC-2.48* Hgb-7.3* Hct-21.9*
MCV-88 MCH-29.4 MCHC-33.3 RDW-18.0* RDWSD-55.1* Plt Ct-44*
___ 02:15PM BLOOD WBC-5.8 RBC-2.64* Hgb-7.8* Hct-23.8*
MCV-90 MCH-29.5 MCHC-32.8 RDW-18.3* RDWSD-55.8* Plt Ct-55*
DISCHARGE LABS:
==============
___ 04:38AM BLOOD WBC-4.0 RBC-2.52* Hgb-7.6* Hct-22.9*
MCV-91 MCH-30.2 MCHC-33.2 RDW-19.1* RDWSD-56.8* Plt Ct-31*
___ 04:38AM BLOOD ___ PTT-30.9 ___
___ 04:38AM BLOOD Glucose-98 UreaN-6 Creat-0.7 Na-141 K-3.6
Cl-108 HCO3-27 AnGap-6*
___ 04:38AM BLOOD ALT-19 AST-28 AlkPhos-65 TotBili-1.2
___ 04:38AM BLOOD Calcium-8.2* Phos-3.9 Mg-1.4*
NOTE: received IV Mg prior to discharge
IMAGING/REPORTS:
===============
___ RUQ U/S WITH DOPPLERS
FINDINGS:
The liver appears diffusely coarsened and nodular consistent
with known
cirrhosis. No focal liver lesions are identified. There is no
ascites. There is stable splenomegaly, with the spleen measuring
16.0 cm. There is no intrahepatic biliary dilation. The CHD
measures 5 mm. Cholelithiasis. Circumferential gallbladder wall
edema is likely due to underlying liver disease.
The main portal vein is patent with hepatopetal flow.
The TIPS is patent and demonstrates wall-to-wall flow.
Portal vein and intra-TIPS velocities are as follows:
Main portal vein: 41 cm/sec, previously 66 cm/sec
Proximal TIPS: 99 cm/sec, previously 117cm/sec
Mid TIPS: 84 cm/sec, previously 161 cm/sec
Distal TIPS: 95 cm/sec, previously 127 cm/sec
Flow within the left portal vein is towards the TIPS shunt. Flow
within the right anterior portal vein is towards the TIPS.
Appropriate flow is seen in the hepatic veins and IVC.
PANCREAS: The imaged portion of the pancreas appears within
normal limits, without masses or pancreatic ductal dilation,
with portions of the pancreatic tail obscured by overlying bowel
gas.
KIDNEYS: Limited views of the kidneys demonstrate no
hydronephrosis.
RETROPERITONEUM: Visualized portions of aorta and IVC are within
normal
limits.
IMPRESSION:
1. Cirrhotic liver, patent TIPS.
2. Cholelithiasis. Circumferential gallbladder wall edema is
likely due to underlying liver disease.
___ CXR
Low lung volumes, however improved since ___. Minimal
retrocardiac atelectasis without focal consolidations. Cardiac
size is mildly enlarged. There is no pulmonary edema. Somewhat
linear hyperdensities projecting over the lower mediastinum and
upper mid abdomen could represent high-density material within
known esophageal varices. Heterotopic calcification of the left
humerus is again seen. There are old left-sided rib and
proximal left humerus fractures.
___
1. Patent appearing TIPS stent.
2. Cirrhotic liver morphology with sequela of portal
hypertension, including moderate splenomegaly and small volume
ascites, improved from prior study.
3. Unchanged appearance of a linear hypodensity within hepatic
segment VII, likely representing a chronically thrombosed
accessory right hepatic vein.
4. Cholelithiasis.
5. Fat-containing umbilical hernia
MICRO:
=====
URINE CULTURE (Final ___: < 10,000 CFU/mL.
___ 8:51 am BLOOD CULTURE x2
Blood Culture, Routine (Pending): No growth to date.
Brief Hospital Course:
Mr. ___ is ___ year old M with h/o EtOH cirrhosis (MELD 17) c/b
esophageal varices presents to the ED with c/o GIB.
ACUTE ISSUES
===============
# Acute blood loss anemia
# Upper GI bleed
Presenting Hgb 5 from a baseline of around ___ in setting of
reporting coffee ground emesis and dark tarry stool. He has a
history of EV s/p banding in ___ and he is s/p TIPS during
previous ___ admission. Last EGD on ___ which did not
show any active varices. He has an anti-E antibody pertinent for
blood product matching. He was admitted to the MICU on ___ and
remained HD stable. No further GI bleeding while in ICU.
Initially on octreotide gtt, IV PPI and ceftriaxone. He
underwent EGD (requiring temporary intubation) on ___ which was
notable for ___ tear requiring clipping. He received
3U PRBCs on ___. He was hemodynamically stable afterward without
GI bleeding while here and is called out to the floor ___. He
was monitored on the floor and was found to be hemodynamically
stable with stable H&H. He was continued on ceftriaxone and
transitioned to ___ on discharge with plan to complete a 7 day
course. He should continue PPI BID x 8 weeks. He should continue
sucralfate 1gm QID x 2 weeks. He should have a repeat EGD in 8
weeks with duodenal biopsies. Hgb on day of discharge: 7.6.
# Alcoholic cirrhosis
# Severe protein-calorie malnutrition
MELD 17. Child class C. RUQ u/s on admission without PVT or
biliary dilation.
- Volume: held diuretics initially while in ICU, restarted on
___.
- Ascites: No tappable pocket on bedside u/s so diagnostic para
not performed
- Infection: Empirically started on CTX iso GI bleeding;
infectious work up otherwise negative.
- Bleeding: as above
- HE: lactuose/rifixamin
- Screening: RUQUS without sign of malignancy
- Trend MELD labs daily
- Will need nutrition consult once able to tolerate PO intake;
on MVI/thiamine/folate
# Altered mental status
# Hepatic encephalopathy
S/p TIPS on ___ and portosystemic shunt embolization on
___. Prior MRI ___ showed hypodensities seen on CT in
the right temporal and inferior right frontal lobes which
correspond to areas of gliosis from prior chronic infarction.
Initially on admission to ICU, no asterixis but had some odd
affect and tangential speech. Continued lactulose/ rifixamin
with mental status at baseline on day of discharge.
# Code Status
Per ___ records, DNR/DNI after discussion with his HCP
sister ___. Patient was insistent on full code so code status
was left as full code and discussed with HCP as being full code
on admission to ICU.
CHRONIC ISSUES
===============
# Hx of LUE DVT: In the setting of ___, noted in ___
hospitalization (Soleal vein) but anticoagulation deferred given
risk of variceal bleeding.
# Insomnia: Held Seroquel & doxepin in ICU. Restart as
clinically indicated.
TRANSITIONAL ISSUES:
======================
- ANTI-E antibody, difficult match for blood products - it will
take an hour for blood bank to obtain blood for him as long as
T&S is active
- Odd affect, tangential speech at times, but not
encephalopathic, not delirious
- Patient this admission elected for full code. ___ sister
reported DNR/DNI on admission per ___ report sin the past.
HCP states he makes his own medical decisions when he is doing
well.
- To discharge discussion about hepatology follow-up and
potential workup for liver transplantation can be considered
- Omeprazole 40mg BID x 8 weeks, sucralfate 1g QQID x 2 weeks
- Complete 7 day ceftriaxone course
- NO NSAIDs. Patient has been told this on multiple admissions
but denies that this was ever discussed. ___.
- F/u on tTg IgA and total IgA
- Plan for repeat EGD in 8 weeks with duodenal biopsies
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Doxepin HCl 25 mg PO HS insomnia
2. FoLIC Acid 1 mg PO DAILY
3. Furosemide 20 mg PO DAILY
4. QUEtiapine Fumarate 100 mg PO QHS insomnia
5. Spironolactone 50 mg PO DAILY
6. Thiamine 100 mg PO DAILY
7. Lactulose 30 mL PO BID
8. Rifaximin 550 mg PO BID
9. Multivitamins 1 TAB PO DAILY
10. Pantoprazole 40 mg PO Q24H
11. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB/wheezing
12. Acetaminophen 500 mg PO Q12H:PRN Pain - Mild/Fever
Discharge Medications:
1. Sucralfate 1 gm PO QID
2. Lactulose 30 mL PO TID
3. Acetaminophen 500 mg PO Q12H:PRN Pain - Mild/Fever
4. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB/wheezing
5. FoLIC Acid 1 mg PO DAILY
6. Furosemide 20 mg PO DAILY
7. Multivitamins 1 TAB PO DAILY
8. Pantoprazole 40 mg PO Q24H
9. Rifaximin 550 mg PO BID
10. Spironolactone 50 mg PO DAILY
11. Thiamine 100 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSES:
==================
- ___ tear
- Blood loss anemia
- Hepatic encephalopathy
SECONDARY DIAGNOSES:
====================
- Cirrhosis
- Esophageal varices
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure caring for you at ___
___.
WHY WERE YOU IN THE HOSPITAL?
- You were admitted to the hospital because you were having
episodes of forceful vomiting with blood in your vomit.
WHAT HAPPENED WHEN YOU WERE IN THE HOSPITAL?
- We looked in your esophagus (the tube that runs from your
mouth to your stomach) and saw that you had a small tear that
was causing the bleeding. We closed this tear and your bleeding
resolved.
- We provided you with blood products and supportive medications
as needed.
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:
___
|
19713635-DS-19
| 19,713,635 | 29,145,813 |
DS
| 19 |
2145-06-15 00:00:00
|
2145-06-16 19:59:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
amoxicillin / Bactrim / ___
Attending: ___
Chief Complaint:
Rash
Major Surgical or Invasive Procedure:
Biopsy of left abdominal wall
History of Present Illness:
___ F with PMHx anxiety and depression, recently treated for
UTI
with ___ and Bactrim, who presents with flu-like symptoms
and 1 day of pruritic rash over her upper and lower extremities,
chest, and back.
Of note, she was recently treated for UTI, initially with
___ x 7 days, then Bactrim. She says she initially had
dysuria, and her PCP called in ___ x 7 days. She completed
this course with initial improvement, but urgency and dysuria
returned. She was seen at urgent care and started on Bactrim.
Reports UA and urine cultures have otherwise been negative. She
took her last dose of Bactrim yesterday to complete 7 day
course.
However, over the last 3 days she has had new flu-like symptoms,
including fevers/chills, joint pains, nausea. Tmax 100 at home.
Reports decreased PO intake due to malaise and decreased
appetite. Then on day ___ of Bactrim, she noted onset of
erythematous, mildly pruritic rash over her chest and thighs.
Since then, it has progressed down her legs and arms, now with
"burning" sensation and worsening pruritis.
Otherwise, no sensation of throat closing, SOB, wheezing,
abdominal pain, vomiting, diarrhea, dizziness/LH. No other new
medications. No blistering of rash or mucosal involvement.
In the ED, initial VS were: T: 100.5, HR: 119, BP: 134/79, RR:
19, 99% RA
Exam notable for:
Gen: NAD
HEENT: oropharynx without erythema, exudate, or edema
CV: RRR; no m/r/g
Resp: CTAB
Abd: Soft; mild discomfort to palpation in left abdomen; ND; no
___ sign; no CVA tenderness
Skin: diffuse, warm, erythematous, coalesced urticarial rash
over
face, UEs, back, torso, and thighs; no weeping or discharge; no
skin sloughing; no involvement at mucocutaneous borders
LN: no cervical or axillary LAD
Labs showed:
- Transaminitis: ALT 136, AST 160
- Thrombocytopenia: Plt 92
- WBC 4.1, HgB 12.0, Hct 35.1
- UA: neg leuks, neg nitrites, mod blood
- Chemistry panel within normal limits
Imaging showed: None
Consults:
Dermatology: Favor DRESS/DIHS (drug induced hypersensitivity
reaction) most likely to Bactrim, with associated
thrombocytopenia related to Bactrim. The differential diagnosis
would also include morbilliform drug rash (which can also be
associated with fevers) and less likely, infectious
mononucleosis. Preformed punch biopsy in ED. Plan to admit for
steroids.
Patient received: N/A
Transfer VS were: T: 98.8, BP: 109/62, HR: 108, RR: 17, 98% Ra
On arrival to the floor, patient recounts history as above. She
endorses burning and itching of her rash, diffuse across upper
and lower extremities, chest, and back. She has no
fevers/chills,
N/V, abdominal pain.
REVIEW OF SYSTEMS: 10 point ROS reviewed and negative except as
per HPI
Past Medical History:
PAST MEDICAL AND SURGICAL HISTORY:
- Anxiety, depression
- IBS
- ADHD
Social History:
___
Family History:
Paternal grandmother: CABG, CVA, T2DM
Maternal grandmother: ___ disease
Father: ___
Physical ___:
ADMISSION PHYSICAL EXAM:
VS: ___ 0042 Temp: 98.8 PO BP: 109/62 R Sitting HR: 108
RR:
17 O2 sat: 98% O2 delivery: Ra
GENERAL: NAD
HEENT: AT/NC, anicteric sclera, MMM
NECK: supple, no LAD
CV: RRR, S1/S2, no murmurs, gallops, or rubs
PULM: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
GI: abdomen soft, nondistended, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: no cyanosis, clubbing, or edema
PULSES: 2+ radial pulses bilaterally
NEURO: Alert, moving all 4 extremities with purpose, face
symmetric
DERM: Confluent erythematous, blanching macules and papules
coalescing into patches over the chest, back, and bilateral
upper
and lower extremities. No mucosal involvement. No blistering,
sloughing. Otherwise, warm and well perfused.
DISCHARGE PHYSICAL EXAM
GENERAL: NAD, uncomfortable,
HEENT: AT/NC, anicteric sclera, MMM
NECK: supple, no LAD
CV: RRR, S1/S2, no murmurs, gallops, or rubs
PULM: CTAB, no wheezes, rales, rhonchi, painful breathing with
deep inspiration
GI: abdomen soft, nondistended, tender in all quadrants to light
palpation worst in the RUQ, no rebound/guarding, no
hepatosplenomegaly
EXTREMITIES: no cyanosis, clubbing, or edema
PULSES: 2+ radial pulses bilaterally
NEURO: Alert, moving all 4 extremities with purpose, face
symmetric
DERM: Confluent mildly erythematous, blanching macules and
papules coalescing into patches over the chest, upper and lower
extremities. Right upper extremity has stable petichie. With
improvement from prior days. No mucosal involvement. No
blistering, sloughing. Otherwise, warm and well perfused.
Pertinent Results:
Important Results
=============
___ 06:17PM BLOOD WBC-4.1 RBC-4.05 Hgb-12.0 Hct-35.1 MCV-87
MCH-29.6 MCHC-34.2 RDW-13.4 RDWSD-42.5 Plt Ct-92*
___ 06:17PM BLOOD Neuts-52.5 ___ Monos-10.5 Eos-6.6
Baso-0.2 Im ___ AbsNeut-2.16 AbsLymp-1.22 AbsMono-0.43
AbsEos-0.27 AbsBaso-0.01
___ 06:17PM BLOOD Plt Smr-LOW* Plt Ct-92*
___ 07:22AM BLOOD ___ PTT-29.1 ___
___ 07:22AM BLOOD Plt ___
___ 06:17PM BLOOD Glucose-84 UreaN-10 Creat-0.8 Na-139
K-4.3 Cl-103 HCO3-21* AnGap-15
___ 07:22AM BLOOD Glucose-135* UreaN-9 Creat-0.8 Na-139
K-4.5 Cl-102 HCO3-21* AnGap-16
___ 06:17PM BLOOD ALT-136* AST-160* AlkPhos-82 TotBili-0.3
___ 07:22AM BLOOD ALT-253* AST-244* LD(LDH)-477* AlkPhos-86
TotBili-0.4
___ 07:40AM BLOOD Lipase-12
___ 06:17PM BLOOD Albumin-4.2
___ 07:22AM BLOOD Calcium-8.7 Phos-3.2 Mg-1.9
___ 07:55AM BLOOD WBC-6.3 RBC-3.75* Hgb-11.1* Hct-32.7*
MCV-87 MCH-29.6 MCHC-33.9 RDW-13.3 RDWSD-42.4 Plt ___
___ 07:40AM BLOOD WBC-6.7 RBC-3.84* Hgb-11.1* Hct-32.8*
MCV-85 MCH-28.9 MCHC-33.8 RDW-13.2 RDWSD-41.1 Plt ___
___ 02:27AM BLOOD WBC-7.7 RBC-3.90 Hgb-11.1* Hct-33.2*
MCV-85 MCH-28.5 MCHC-33.4 RDW-13.2 RDWSD-41.6 Plt ___
___ 07:40AM BLOOD Neuts-45.0 ___ Monos-9.0 Eos-4.3
Baso-0.3 Im ___ AbsNeut-3.01 AbsLymp-2.75 AbsMono-0.60
AbsEos-0.29 AbsBaso-0.02
___ 07:55AM BLOOD Plt ___
___ 07:55AM BLOOD ___ PTT-25.6 ___
___ 03:35PM BLOOD Parst S-NEGATIVE FOR INTRACELLULUAR AND
EXTRACELLULAR PARASITS
___ 07:55AM BLOOD Glucose-97 UreaN-10 Creat-0.6 Na-142
K-4.0 Cl-104 HCO3-28 AnGap-10
___ 07:55AM BLOOD ALT-235* AST-99* LD(LDH)-243 AlkPhos-79
TotBili-0.4
___ 07:55AM BLOOD Calcium-8.6 Phos-3.9 Mg-2.1
RUQ US
IMPRESSION:
Normal abdominal ultrasound.
Brief Hospital Course:
ASSESSMENT & PLAN:
==================
___ F with PMHx anxiety and depression, recently treated for
UTI with ___ and Bactrim, who presents with flu-like
symptoms and 1 day of progressive, diffuse, pruritic rash with
thrombocytopenia and Transaminitis initially concerning for
DRESS, but less likely after derm evaluation/biopsy.
Self-resolving symptoms off steroids, likely related to other
causes of acute hepatitis including viral vs parasitic.
ACUTE ISSUES:
===============
#acute hepatitis
#Thrombocytopenia
#Anemia
Patient presenting with flu-like symptoms and whole-body rash
beginning about 1 week after starting Bactrim. Labs notable for
transaminitis, thrombocytopenia, and elevated INR. Differential
diagnosis included DRESS, morbilliform drug rash (which can also
be associated with fevers) infectious mononucleosis, tick ___
illness, acute HIV, acute viral infection and autoimmune
hepatitis. Prednisone was started for possible DRESS syndrome
however after 2 doses were discontinued as DRESS was deemed less
likely due to a risk assessment model, skin biopsy pathology,
and per recommendations from dermatology. Topical ointments were
used to address patient's pruritus. The patient's LFTs were
trended during her hospital course with a peak AST of 244 and
ALT of 302 with an LDH of 477 which all down trended prior to
discharge. On ___ on the patient developed significant
abdominal and chest wall pain that was pleuritic in nature.
Chest x-ray and EKG did not demonstrate any signs of acute
infection or pericarditis. The patient's abdominal pain was
mostly localized to the right upper quadrant and epigastrium and
left upper quadrant; there were no peritoneal signs. Right upper
quadrant ultrasound was negative for any hepatic cysts or
obstructive processes. The patient's pain was treated with
oxycodone and her pain subsequently resolved. On ___ the
patient's rash improved significantly and her pain decreased.
Bactrim was added to allergy list. Heme/onc smear revealed
reactive lymphocytes, RBC smear revealed occaisional
schistocytes but had low retics, parasite smear x 2 were
negative, ferritin was 276, AMA negative, ___ negative, HIV
negative, Smooth muscle Ab negative, Heb B immune, HCV negative,
monospot negative.
CHRONIC ISSUES:
===============
#UTI
Has completed 7 day course of Bactrim for UTI. UA without
evidence of infection on admission.
#Depression:
Continue home escitalopram
#ADHD:
Continue home Adderall PRN
Transitional Issues
=============================
[] Will need punch biopsy stitch removal in 2 weeks
[] Recommend checking TSH in 6 weeks for late onset autoimmune
hypothyroidism
[] Repeat labs on ___, please ensure LFTs downtrending and
CBC normalized
[] Adderall held at discharge given liver injury, consider
re-starting after labs on ___
[] The following laboratory studies will need follow up:
- HHV ___
- babesia PCR
- anaplasma PCR
- CMV
- RPR w/ prozone
- Parvovirus B19
- The last of 3 parasite smears
Medications Added
========================
-Betamethasone Dipro 0.05% Oint 1 Appl TP BID Duration: 2 Weeks
-Lidocaine 5% Patch 1 PTCH TD QPM
-Sarna Lotion 1 Appl TP QID:PRN itch
-Ranitidine 75 mg PO/NG DAILY
-OxyCODONE (Immediate Release) 5 mg PO/NG Q8H:PRN
Medications Held
========================
-Amphetamine-Dextroamphetamine 5 mg PO BID:PRN inattention
Cr: 0.6
Code: FULL
Contact: ___ ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Escitalopram Oxalate 5 mg PO DAILY
2. Amphetamine-Dextroamphetamine 5 mg PO BID:PRN inattention
Discharge Medications:
1. Betamethasone Dipro 0.05% Oint 1 Appl TP BID Duration: 2
Weeks
RX *betamethasone dipropionate 0.05 % Apply TP twice a day
Refills:*0
2. OxyCODONE (Immediate Release) 5 mg PO Q8H:PRN Pain - Severe
RX *oxycodone 5 mg 1 tablet(s) by mouth QH8:PRN Disp #*6 Tablet
Refills:*0
3. Ranitidine 75 mg PO DAILY
RX *ranitidine HCl [Heartburn Relief (ranitidine)] 75 mg 1
tablet(s) by mouth daily Disp #*30 Tablet Refills:*0
4. Sarna Lotion 1 Appl TP QID:PRN itch
RX *camphor-menthol [Sarna Anti-Itch] 0.5 %-0.5 % 1 Appl TP
QID:PRN Refills:*0
5. Escitalopram Oxalate 10 mg PO DAILY
6. HELD- Amphetamine-Dextroamphetamine 5 mg PO BID:PRN
inattention This medication was held. Do not restart
Amphetamine-Dextroamphetamine until your doctor checks your
liver function
7.Outpatient Lab Work
573.3 Hepatitis, unspecified
___, MD
CBC with dif, Chem-10, LFTs, Coags
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis
==================
Acute hepatitis
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 at ___.
WHY WAS I IN THE HOSPITAL?
-You were in the hospital due to a rash that covered your body
and abdominal pain.
WHAT HAPPENED TO ME IN THE HOSPITAL?
- You were seen by internal medicine, dermatology and infectious
disease who ordered laboratory tests that showed abnormal liver
and blood markers. Tests were sent to assess the cause of these
abnormalities.
- You improved considerably and were felt well enough to leave
the hospital
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
- Continue to take all your medicines and keep your
appointments.
- We recommend seeing your primary care physician to discuss
your medications within the next 2 weeks.
We wish you the best!
Sincerely,
Your ___ Team
Followup Instructions:
___
|
19713771-DS-6
| 19,713,771 | 22,029,535 |
DS
| 6 |
2188-05-21 00:00:00
|
2188-05-23 11:58:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: OBSTETRICS/GYNECOLOGY
Allergies:
gluten / egg
Attending: ___.
Chief Complaint:
Nausea and vomiting
Major Surgical or Invasive Procedure:
Exploratory laparotomy, left salpingo-oophorectomy
History of Present Illness:
HPI: ___ G0 who presented to ___ ED yesterday after
developing persistent n/v/d and abd pain which persisted. Was
unable to tolerate any po since ___. Otherwise denies f/c,
uri sx, dysuria, joint/muscle pains outside of her usual.
Prior to ___, had actually been feeling very well since
starting rituximab. Has been walking and much more active than
prior. Does report 6 pound weight loss and possibly slightly
less than normal apetite but was actively calorie counting and
dieting over this past month (eating 1200-1500 calories) per
day.
AT ___ was found to have ___ with Cr 2.9 and started on
IVF. Non-contract CT scan showed a 25cm cystic abdominal mass
and she was transferred to ___ for further workup.
Here her pain is relatively well controlled with po meds,
creatinine is improving with IVF, at 1.9 this am. Continues to
deny f/c. N/V/D also currently resolved.
ROS otherwise negative
Past Medical History:
OB/Gyn hx:
-G0
-amenorrheic on mirena
-denies hx STI, fibroids, ovarian cysts or other gyn issues
PMH:
-RA on rituximab since ___
-eosinophilic esophagitis
-hypothyroid
-bipolar
PSH:
-OMFS surgery to correct jaw alignment
Social History:
___
Family History:
Father with CAD, possible UC, possible RA
Mother with A-fib
Grandmother died of melanoma
Physical Exam:
Admission PE
VS: 98 70 118/86 16 100% RA
Gen: NAD, resting comfortably in bed
HEENT: EOMI, PERRLA, MMM, OP clear
CV: RRR nl s1s2 no m/r/g
Resp: CTAB no w/r/r
Abd: soft, diffuse mild tenderness, no rebound or guarding, ND,
+BS
Ext: no c/c/e
Neuro: CN II-XII intact, ___ strength throughout
Skin: warm, dry no rashes
On day of discharge:
Afebrile, vitals stable
No acute distress
CV: regular rate and rhythm
Pulm: clear to auscultation bilaterally
Abd: soft, appropriately tender, nondistended, incision
clean/dry/intact, no rebound/guarding
___: nontender, nonedematous
Pertinent Results:
___ 07:25PM GLUCOSE-101* UREA N-19 CREAT-2.2*# SODIUM-140
POTASSIUM-3.9 CHLORIDE-105 TOTAL CO2-21* ANION GAP-18
___ 07:25PM CALCIUM-9.4 PHOSPHATE-4.1 MAGNESIUM-2.7* URIC
ACID-8.8*
___ 07:25PM CEA-1.5 CA125-11
___ 07:25PM LITHIUM-1.7*#
Pelvic US ___:
IMPRESSION:
1. Normal-sized bilateral ovaries, with normal flow. Only the
right ovary was identified by transvaginal ultrasound. The left
ovary was seen by transabdominal approach.
2. Large predominantly anechoic cystic structure in the mid to
left upper
abdomen, correlating with findings on the earlier outside
hospital CT. It is unclear if this structure originates from
the ovaries, but no direct
connection to either ovary was identified on this study.
MRI pelvis ___:
IMPRESSION:
Large simple appearing cystic lesions which appears to be
arising from the
pelvis extending into the abdomen, likely from the left ovary.
Its
characteristics are most consistent with an ovarian serous
cystadenoma. Given the lack of complex features, a serous
cystadenocarcinoma is thought to be less likely. The other
differential consideration is a benign mesenteric cyst.
Brief Hospital Course:
___ year old female with PMH of rheumatoid arthritis on
rituximab, bipolar disorder and hypothyroidism admitted to
medicine after presenting with 5 days of nausea, vomiting,
diarrhea, poor PO intake and crampy lower abdominal pain found
to have large pelvic cystic mass. Patient transferred to Gyn-Onc
for exploratory laparotomy and left salpingoo-phorectomy for
mesosalpinx inclusion cyst. Please see operative note for
details.
Pre-operative:
*) Pelvic mass/nausea/vomiting: 22 cm abdominopelvic mass. ACS
general surgery and Gyn consulted. Abd/Pelvic MRI and PUS -
likely peritoneal inclusion cyst or a large left ovarian cyst
with plan for removal given patients symptoms. Nausea and pain
improved with IVF, pain meds and anti-emetics.
*) ___: Pre-renal acute kidney injury due to dehydration. Had
very limited PO intake over 4 days prior to presenting with
slightly elevated lithium level potentially contributing to ___.
No evidence of obstruction on CT. Creatinine 2.9 on admission,
improved to 0.9 on day of discharge after IV fluid
resuscitation.
*) RA: Currently asymptomatic, last received rituximab on
___. Patient discharged with instructions to f/u with
rheumatology.
Post-operative:
Her post-operative course is detailed as follows. Immediately
postoperatively, her pain was controlled with IV dilaudid and
toradol. Her diet was advanced without difficulty and she was
transitioned to oxycodone, acetaminophen, and ibuprofen. On
post-operative day #1, her urine output was adequate so her
Foley catheter was removed and she voided spontaneously.
By post-operative day #1, 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:
The Preadmission Medication list is accurate and complete.
1. Levothyroxine Sodium 100 mcg PO DAILY
2. Lithium Carbonate SR (Lithobid) 900 mg PO QHS
3. LaMOTrigine 200 mg PO QHS
Discharge Medications:
1. Acetaminophen ___ mg PO Q6H:PRN pain
do not exceed 4000 mg in 24 hours
RX *acetaminophen [Acetaminophen Extra Strength] 500 mg ___
tablet(s) by mouth every 6 hours Disp #*40 Tablet Refills:*0
2. Docusate Sodium 100 mg PO BID
take while using oxycodone for pain
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice
a day Disp #*40 Capsule Refills:*0
3. Ibuprofen 400 mg PO Q8H:PRN Pain
RX *ibuprofen 400 mg 1 tablet(s) by mouth every 8 hours Disp
#*20 Tablet Refills:*0
4. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
do not drive while taking, use with a stool softener
RX *oxycodone [Oxecta] 5 mg ___ tablet(s) by mouth every 4 hours
Disp #*35 Tablet Refills:*0
5. LaMOTrigine 200 mg PO QHS
6. Levothyroxine Sodium 100 mcg PO DAILY
7. Lithium Carbonate SR (Lithobid) 900 mg PO QHS
Lithobid SR
Discharge Disposition:
Home
Discharge Diagnosis:
Mesosalpinx inclusion cyst
Final pathology pending
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 gynecologic oncology service after
undergoing the procedures listed below. You have recovered well
after your operation, and the team feels that you are safe to be
discharged home. Please follow these instructions:
.
* Take your medications as prescribed.
* Do not drive while taking narcotics.
* Do not combine narcotic and sedative medications or alcohol.
* Do not take more than 4000mg acetaminophen (APAP) in 24 hrs.
* 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.
* If you have steri-strips, leave them on. If they are still on
after ___ days from surgery, you may remove them.
.
To reach medical records to get the records from this
hospitalization sent to your doctor at home, call ___.
.
Call your doctor at ___ for:
* fever > 100.4
* 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
* chest pain or difficulty breathing
* onset of any concerning symptoms
Followup Instructions:
___
|
19713924-DS-9
| 19,713,924 | 20,665,354 |
DS
| 9 |
2182-08-28 00:00:00
|
2182-09-04 16:35:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Headache
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ is a ___ year old right handed man who presented to
the
ED for evaluation of a headache that has been present for the
past 4 days. He says that 4 days ago he started to get a
headache
that he felt mostly over the right side of his head. It came on
gradually and continued to get worse. He described it as being
bot pounding and squeezing at times. He also states that he
noticed that the headache would get more bearable when he stood
up. He says that usually within 1 minute of standing or lying
down it would change the severity of the headache (being worse
and unbearable when lying down). He tried some aspirin and
tylenol but felt that neither was relieving the headache. He has
been unable to sleep well over the past few days due to the pain
and states that he feels exhausted now because he has slept so
little. He has not noticed any other associated symptoms with
the
headache, no visual changes, no tinitus, no sensory changes, no
weakness and no incoordination. He has noted no change in his
bowel or bladder habits. No fevers and no stiff neck. He says
that he never gets headaches and that is why this makes him
particularly concerned. He has had no neck injuries in the past
and no car accidents. He has never had a concussion injury.
Past Medical History:
abdominal hernia
Social History:
___
Family History:
Father died ___ years ago from a stomach cancer
Mother - hypertension
2 children - both healthy
Physical Exam:
Vitals: 97.2 68 136/77 16 99% RA
General: Awake, cooperative, has some head pain, but not in
acute
distress.
HEENT: NC/AT
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: CTABL
Cardiac: RRR, no murmurs
Abdomen: soft, nontender, nondistended
Extremities: no edema, pulses palpated
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented x 3. Able to relate history
without difficulty. Attentive, digit span to 7. Language is
fluent with intact repetition and comprehension. Normal
prosody.
There were no paraphasic errors. Pt. was able to name both high
and low frequency objects. Able to read without difficulty.
Speech was not dysarthric. Able to follow both midline and
appendicular commands. Pt. was able to register 3 objects and
recall ___ at 5 minutes. The pt. had good knowledge of current
events. There was no evidence of apraxia or neglect.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 3 to 2mm and brisk. VFF to confrontation. Funduscopic
exam revealed no papilledema, exudates, or hemorrhages.
III, IV, VI: EOMI. ___ beats of end-gaze nystagmus on left
lateral gaze. Normal saccades.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally.
No adventitious movements, such as tremor, noted. No asterixis
noted.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 5 ___ ___ 5 5 5 5 5 5 5
R 5 ___ ___ 5 5 5 5 5 5 5
-Sensory: No deficits to light touch, pinprick, cold sensation,
vibratory sense, proprioception throughout. No extinction to
DSS.
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 2 1
R 2 2 2 2 1
Plantar response was flexor bilaterally.
-Coordination: No intention tremor, no dysdiadochokinesia noted.
No dysmetria on FNF or HKS bilaterally.
-Gait: Good initiation. Narrow-based, normal stride and arm
swing. Able to walk in tandem without difficulty. Romberg
absent.
Discharge Physical Exam: Normal, as documented above.
Pertinent Results:
___ 05:00PM CEREBROSPINAL FLUID (CSF) PROTEIN-36
GLUCOSE-68
___ 05:00PM CEREBROSPINAL FLUID (CSF) WBC-1 RBC-1* POLYS-4
___ ___ 10:00AM GLUCOSE-106* UREA N-13 CREAT-0.9 SODIUM-140
POTASSIUM-5.1 CHLORIDE-106 TOTAL CO2-24 ANION GAP-15
___ 10:00AM estGFR-Using this
___ 10:00AM CALCIUM-9.0 PHOSPHATE-3.2 MAGNESIUM-2.0
___ 10:00AM WBC-6.6 RBC-4.92 HGB-15.1 HCT-44.1 MCV-90
MCH-30.7 MCHC-34.3 RDW-13.2
___ 10:00AM NEUTS-61.1 ___ MONOS-5.4 EOS-2.3
BASOS-1.4
___ 10:00AM PLT COUNT-291
___ 10:00AM ___ PTT-36.9* ___
CTA: IMPRESSION:
1. No acute intracranial hemorrhage or mass effect. Mild
mucosal thickening in the ethmoid air cells.
2. Patent major intra- and extra-cranial arteries as described
above. No abnormal enhancement in the cavernous sinuses during
the arterial phase images to suggest an obvious arteriovenous
communication.
3. Mild degenerative changes noted in the cervical spine,
without significant
canal stenosis. Anterior osteophytes are also noted in the
upper thoracic spine imaged. Other
details as above.
Brief Hospital Course:
___ is a ___ year old right handed man who presented to
the ED for evaluation of a headache that has been present for
the past 4 days. The patient was admitted to Neurology for
further work-up and observation. He received a LP that
demonstrated high normal pressure. A CT scan was normal without
evidence of bleeding or blood clot. His headache improved
overnight with IVF and conservative treatments.
He was discharged in good condition with Topamax for headache
prophylaxis.
Medications on Admission:
None
Discharge Medications:
1. Topiramate (Topamax) 25 mg PO DAILY
qhs
RX *topiramate 25 mg See Instructions Tablet(s) by mouth at
bedtime Disp #*60 Each Refills:*1
2. Acetaminophen-Caff-Butalbital ___ TAB PO Q6H:PRN headache
RX *Fioricet 50 mg-325 mg-40 mg ___ Tablet(s) by mouth q6-8
hours Disp #*18 Each Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Headache
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Neuro Exam: Normal neurologic exam.
Discharge Instructions:
Mr. ___, you were admitted with a headache. You received a
spinal tap that demonstrated high normal pressure. A CT scan was
normal without evidence of bleeding or blood clot. You did well
overnight without further episodes.
You are being discharged with a medication that can help prevent
headaches, called Topamax. You should start with 25 mg at
bedtime and increase to 50 mg at bedtime in 2 weeks. You should
get some basic labs done the week following increasing that
medication. This medication can cause a tingling feeling in your
hands and can decrease your appetite. It also puts you at risk
for kidney stones, so it is important to stay hydrated. You
should continue taking any of your regular home medications.
When you get a headache, you should take Fioricet ___ tabs every
___ hours or ibuprofen 600 mg every 6 hours as needed. Take
ibuprofen with food. If you need either of these medications
more than 3 days in a row, please call your doctor as this
medication can cause stomach problems and give you rebound
headaches.
Followup Instructions:
___
|
19714173-DS-11
| 19,714,173 | 24,019,764 |
DS
| 11 |
2142-01-17 00:00:00
|
2142-01-17 17:00:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
hyperglycemia, DKA
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Patient is a ___ female history of type 1 diabetes,
complicated by recurrent episodes of gastroparesis, DKA,
initially transferred from ___ for DKA iso EtOH
intoxication and missed doses of insulin.
Intially presented to ___ with glucose greater than 500.
Initial labs notable for a potassium of 3.3, a bicarbonate of
13->8 with positive ketones and initial blood pH of 7.3. The
patient was given 3 L normal saline, insulin drip, and
transferred to ___ given lack to ICU beds at ___.
On arrival to ED here, initial VS notably only for tachycardia
to
120's. Labs again revealed bicarb of 7, glucose of 147, pH of
7.19. Patient was started on an insulin drip and admitted to
MICU. Her gap closed and she was transitioned to subQ insulin
on
___. However, shortly thereafter, she became hypoglycemic to
the 70's for dinner and again to 50's-60's AM of transfer. Pt
seen by ___ who recommended dose reducing her Levemir from
18->14->10 BID and decreasing Humalog to 4TID with meals.
When seen on the floor, pt appears well and c/o just some mild
nausea. She otherwise denies further fevers/chills, SOB, cough,
abdominal pain, dysuria, or urinary frequency. FSBG's have been
in the low 200's.
Past Medical History:
1. Type 1 DM
2. Gastroparesis
3. GERD
4. Generalized anxiety disorder
5. Mitral valve prolapse recently diagnosed due to exertional
dyspnea, orthostatic hypotension, and persistent tachycardia
6. Chronic otitis media with right eardrum perforation
Social History:
___
Family History:
Father with 2 heart attacks in his ___. Mother with breast
cancer. Healthy siblings
Physical Exam:
Admission to the floor:
VITALS: PO 149 / 89 96 20 99 RA
GENERAL: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
NECK: supple, JVP not elevated, no LAD
LUNGS: Clear to auscultation bilaterally, no respiratory
distress
CV: RRR, normal S1 S2, III/VI systolic murmur heard best in the
LUSB
ABD: soft, non-tender, non-distended, bowel sounds present, no
rebound tenderness or guarding, no organomegaly
EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
NEURO: AOx3, CNII-XII intact. Strength and sensation grossly
intact.
Discharge physical exam:
VSS: T: 98.3PO 114 / 76L Sitting 93 18 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 respiratory
distress
CV: RRR, normal S1 S2, ___ systolic murmur heard best in the
LUSB
ABD: soft, non-tender, non-distended, bowel sounds present, no
rebound tenderness or guarding, no organomegaly
EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
NEURO: AOx3, CNII-XII intact. Strength and sensation grossly
intact
Pertinent Results:
ADMISSION LABS:
___ 02:20AM BLOOD Neuts-83.8* Lymphs-8.3* Monos-7.0
Eos-0.0* Baso-0.1 Im ___ AbsNeut-16.86* AbsLymp-1.68
AbsMono-1.40* AbsEos-0.00* AbsBaso-0.02
___ 02:20AM BLOOD WBC-20.1* RBC-3.62* Hgb-10.3* Hct-34.0
MCV-94 MCH-28.5 MCHC-30.3* RDW-14.8 RDWSD-51.3* Plt ___
___ 07:22AM BLOOD WBC-13.1* RBC-3.28* Hgb-9.3* Hct-31.7*
MCV-97 MCH-28.4 MCHC-29.3* RDW-15.1 RDWSD-53.0* Plt ___
___ 02:00AM BLOOD WBC-7.6 RBC-3.28* Hgb-9.3* Hct-29.6*
MCV-90# MCH-28.4 MCHC-31.4* RDW-15.2 RDWSD-50.1* Plt ___
___ 03:04AM BLOOD WBC-5.1 RBC-3.35* Hgb-9.5* Hct-29.7*
MCV-89 MCH-28.4 MCHC-32.0 RDW-15.1 RDWSD-48.9* Plt ___
___ 05:28AM BLOOD WBC-5.6 RBC-3.59* Hgb-10.1* Hct-31.7*
MCV-88 MCH-28.1 MCHC-31.9* RDW-15.0 RDWSD-48.5* Plt ___
___ 06:15AM BLOOD WBC-5.2 RBC-3.86* Hgb-10.9* Hct-34.1
MCV-88 MCH-28.2 MCHC-32.0 RDW-14.9 RDWSD-47.4* Plt ___
___ 05:34AM BLOOD WBC-6.0 RBC-3.95 Hgb-11.1* Hct-35.0
MCV-89 MCH-28.1 MCHC-31.7* RDW-14.9 RDWSD-47.1* Plt ___
___ 05:47AM BLOOD WBC-6.6 RBC-3.91 Hgb-11.1* Hct-34.6
MCV-89 MCH-28.4 MCHC-32.1 RDW-14.7 RDWSD-46.5* Plt ___
___ 02:20AM BLOOD ___ PTT-27.2 ___
___ 02:20AM BLOOD Plt ___
___ 07:22AM BLOOD Plt ___
___ 10:35AM BLOOD ___ PTT-25.0 ___
___ 02:00AM BLOOD ___ PTT-23.6* ___
___ 02:00AM BLOOD Plt ___
___ 03:04AM BLOOD ___ PTT-31.2 ___
___ 03:04AM BLOOD Plt ___
___ 05:28AM BLOOD Plt ___
___ 03:04AM BLOOD ___ PTT-31.2 ___
___ 06:15AM BLOOD Plt ___
___ 05:34AM BLOOD Plt ___
___ 05:47AM BLOOD Plt ___
___ 02:20AM BLOOD Glucose-176* UreaN-10 Creat-0.7 Na-135
K-4.0 Cl-104 HCO3-7* AnGap-28*
___ 07:22AM BLOOD Glucose-124* UreaN-8 Creat-0.6 Na-136
K-4.1 Cl-112* HCO3-12* AnGap-16
___ 10:30AM BLOOD Glucose-194* UreaN-8 Creat-0.5 Na-136
K-3.7 Cl-112* HCO3-11* AnGap-17
___ 02:51PM BLOOD Glucose-227* UreaN-5* Creat-0.5 Na-135
K-4.1 Cl-112* HCO3-13* AnGap-14
___ 08:55PM BLOOD Glucose-77 UreaN-3* Creat-0.4 Na-141
K-3.2* Cl-117* HCO3-16* AnGap-11
___ 02:00AM BLOOD Glucose-132* UreaN-<3* Creat-0.4 Na-140
K-3.8 Cl-116* HCO3-17* AnGap-11
___ 05:08PM BLOOD Glucose-79 UreaN-3* Creat-0.4 Na-140
K-3.6 Cl-111* HCO3-19* AnGap-14
___ 03:04AM BLOOD Glucose-90 UreaN-<3* Creat-0.3* Na-145
K-3.3 Cl-113* HCO3-23 AnGap-12
___ 05:28AM BLOOD Glucose-211* UreaN-7 Creat-0.4 Na-142
K-3.9 Cl-106 HCO3-26 AnGap-14
___ 06:15AM BLOOD Glucose-251* UreaN-10 Creat-0.4 Na-134
K-4.0 Cl-99 HCO3-25 AnGap-14
___ 02:20AM BLOOD ALT-15 AST-25 AlkPhos-86 TotBili-0.2
___ 02:00AM BLOOD ALT-11 AST-14 LD(LDH)-155 AlkPhos-67
TotBili-0.2
___ 02:20AM BLOOD Albumin-4.2 Calcium-8.3* Phos-2.3* Mg-2.1
___ 10:30AM BLOOD Calcium-7.6* Phos-1.4* Mg-2.1
___ 08:55PM BLOOD Calcium-7.6* Phos-1.6* Mg-2.0
___ 02:00AM BLOOD Calcium-8.0* Phos-1.3* Mg-2.0 Iron-70
___ 05:08PM BLOOD Calcium-8.6 Phos-2.9 Mg-1.9
___ 03:04AM BLOOD Calcium-8.2* Phos-3.2 Mg-1.8
___ 05:28AM BLOOD Calcium-8.5 Mg-2.1
___ 06:15AM BLOOD Calcium-9.0 Phos-3.9 Mg-2.0
___ 05:34AM BLOOD Calcium-9.1 Phos-3.5 Mg-2.0
___ 05:47AM BLOOD Calcium-9.2 Phos-4.2 Mg-2.1
___ 02:00AM BLOOD calTIBC-255* Ferritn-66 TRF-196*
___ 01:00PM BLOOD D-Dimer-435
___ 05:28AM BLOOD TSH-1.8
___ 01:00PM BLOOD HCG-<5
___ 02:20AM BLOOD HCG-<5
___ 02:20AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-9*
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 02:24AM BLOOD ___ pO2-23* pCO2-22* pH-7.19*
calTCO2-9* Base XS--19
___ 02:32AM BLOOD Comment-GREEN
___ 10:44AM BLOOD Type-ART pO2-88 pCO2-27* pH-7.34*
calTCO2-15* Base XS--9
___ 03:11PM BLOOD ___ pO2-41* pCO2-30* pH-7.33*
calTCO2-17* Base XS--8
___ 09:17PM BLOOD ___ pO2-41* pCO2-30* pH-7.37
calTCO2-18* Base XS--6
___ 02:24AM BLOOD Glucose-169*
___ 02:32AM BLOOD Lactate-2.1*
___ 10:44AM BLOOD Lactate-0.6
Urine culture:
**FINAL REPORT ___
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 CFU/mL. PRESUMPTIVE
IDENTIFICATION.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ <=2 S
AMPICILLIN/SULBACTAM-- <=2 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
CTA chest ___
FINDINGS:
The aorta and its major branch vessels are patent, with no
evidence of
stenosis, occlusion, dissection, or aneurysmal formation. There
is no
evidence of penetrating atherosclerotic ulcer or aortic arch
atheroma present.
The pulmonary arteries are well opacified to the subsegmental
level, with no evidence of filling defect within the main,
right, left, lobar, segmental or subsegmental pulmonary
arteries. The main and right pulmonary arteries are normal in
caliber, and there is no evidence of right heart strain. A
right-sided PICC line terminates within the proximal right
atrium.
There is no supraclavicular, axillary, mediastinal, or hilar
lymphadenopathy. The thyroid gland appears unremarkable.
There is no evidence of pericardial effusion. There is no
pleural effusion.
There is no evidence of pulmonary parenchymal abnormality. The
airways are
patent to the subsegmental level.
Limited images of the upper abdomen are unremarkable.
No lytic or blastic osseous lesion suspicious for malignancy is
identified.
IMPRESSION:
No evidence of pulmonary embolism or aortic abnormality.
Chest X-ray ___
No acute cardiopulmonary process
DISCHARGE LABS:
___ 05:47AM BLOOD WBC-6.6 RBC-3.91 Hgb-11.1* Hct-34.6
MCV-89 MCH-28.4 MCHC-32.1 RDW-14.7 RDWSD-46.5* Plt ___
___ 05:47AM BLOOD Glucose-307* UreaN-17 Creat-0.5 Na-134
K-4.1 Cl-98 HCO3-22 AnGap-18
___ 03:04AM BLOOD ALT-12 AST-16 LD(LDH)-166 AlkPhos-66
TotBili-0.2
___ 05:47AM BLOOD Calcium-9.2 Phos-4.2 Mg-2.1
Brief Hospital Course:
Patient is a ___ female history of type 1 diabetes,
complicated by recurrent episodes of gastroparesis, DKA,
transferred from ___ for DKA.
# DKA:
Pt presented with ___ with AGMA with glucose >600, ketones
in the urine in the setting of missing doses of home insulin.
Pt
does not c/o obvious localizing symptoms but UA grossly dirty
and
culture growing >100,00K Ecoli so UTI may also be possible
trigger. Pt noted to have some hypoglycemia s/p restarting SubQ
insulin but most recent FSBG's have been in the low 200's range.
___ was following and home levemir changed to to 12 units
bid and with 6U TID Humalog and 1:50 ISS for FSBG >150. FSBG's
on this regimen were stabilized largely in the 200's. Pt
encouraged to f/u closely with her Endocrinologist
post-discharge.
# Leukocytosis/fever
# UTI
Pt presented with leukocytosis to 20, recorded low grade fever
of
100.4 with positive UA and culture >100K E.coli. She was
treated with 7 day course of cipro for complicated UTI given
poorly controlled MD
# Tachycardia:
Pt presented with tachycardia to the 110's-120's. Likely ___ an
element of volume depletion form DKA, however, did not seem to
respond very well to fluid resuscitation. Patient with baseline
supraventricular tachycardia/orthostatic hypotension/dyspnea on
exertion w/ recent ECHO showing MVP. Patient undergoing
outpatient work-up for this. HR's on transfer to the floor have
been in the 90's, however upon standing and ambulating is going
to 130s. CT-PE protocol ordered and is negative for PE.
Discussed ___ with pt's OP Cardiologist, Dr. ___,
___ she plans on continuing work-up with holter monitor after pt
is discharged.
CHRONIC ISSUES:
=================
# Insomnia: Continued home Mirtazapine
# GAD: Continued home Venlafaxine
#GERD: Continued omeprazole
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. Verapamil SR 120 mg PO Q24H
2. Omeprazole 20 mg PO DAILY
3. Mirtazapine 15 mg PO QHS
4. Venlafaxine XR 150 mg PO DAILY
5. Atorvastatin 40 mg PO QPM
6. Levemir 15 Units Breakfast
Levemir 25 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
Discharge Medications:
1. Ciprofloxacin HCl 500 mg PO Q12H Duration: 3 Days
RX *ciprofloxacin HCl [Cipro] 500 mg 1 tablet(s) by mouth every
12 hours Disp #*6 Tablet Refills:*0
2. Docusate Sodium 100 mg PO BID
3. Ferrous Sulfate 325 mg PO DAILY
4. Levemir 15 Units Breakfast
Levemir 25 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
5. Omeprazole 20 mg PO BID
6. Atorvastatin 40 mg PO QPM
7. Mirtazapine 15 mg PO QHS
8. Venlafaxine XR 150 mg PO DAILY
9. Verapamil SR 120 mg PO Q24H
Discharge Disposition:
Home
Discharge Diagnosis:
Hyperglycemia
Tachycardia
UTI
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Ms. ___,
You were hospitalized for elevated sugars. Your insulin dosage
was adjusted while you were hospitalized. You were also treated
for a UTI while you were here.
You were also evaluated for your elevated heart rate and your
shortness of breath. Your CT of your chest did not show evidence
of a pulmonary embolism. Please ___ with your Cardiologist
for further w/u of this. She will also reschedule your Holter
Monitor placement.
We wish you all the best in your recovery.
Best wishes,
Your ___ team
Followup Instructions:
___
|
19714298-DS-14
| 19,714,298 | 25,768,961 |
DS
| 14 |
2159-06-07 00:00:00
|
2159-06-07 21:26:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
levofloxacin / Dilaudid / Celexa / Flagyl
Attending: ___.
Chief Complaint:
dizziness and headache
Major Surgical or Invasive Procedure:
cardiac cath -- endovascular with stent placement in left
subclavian artery
History of Present Illness:
Ms ___ is a ___ female with a history of
moderate/severe aortic stenosis, A. fib on warfarin, HTN and
previous PE, t/f left vertebral artery dissection who presented
from ___ w/ reported chest pain radiating into her right
arm, intermittent shortness of breath and neck pain
The patient states she has had intermittent dizziness over the
course of 1.5 weeks that occurred about ___ times. Each time
lasting on the order of ___ seconds. She was able to recall
one
time in which it occurred while standing up and got better with
sitting down. She reports that she has had occasional dizziness
over the past year but usually not this frequent. She also
reported that dizziness was different from prior episodes. Prior
episodes were usually the room spinning. These were described as
lightheadedness that affected her vision. She also endorsed
intermittent headache. She thinks that she was not drinking
enough water during this time. She denies chest pain/pressure
during this episodes and stated she did not have any leading up
to this admission. The last episode of dizziness occurred about
___ days ago.
However, over the past few days she then developed neck pain and
arm pain. As the pain built up she then experienced pain her
chest and felt short of breath. Additionally, she had numbness
in
her arm. Denies difficulty walking, numbness/tingling to the
lower extremities. She was worried that she was having a heart
attack which prompted her to go the the ED. At ___-P, there was
concern for a neurologic process for which she was transferred
to
___.
Of note, she last saw outpt cardiologist Dr. ___ on ___
at
that appointment metoprolol was restarted.
In the ED, initial vitals: Afeb HR 80, BP 160/90, RR 20, 97% RA
- Exam notable for: well appearing elderly female in NAD,
AOx3,
nystagmus with central stare, CN2-12 grossly intact, Sensation
intact to light touch in all extremities, moving all extremities
spontaneously, FNF intact, gait normal.
- Labs notable for:
CBC WNL
BMP WNL
Trop < 0.01
___: 30.4 | PTT 39.7 | INR 2.5
- Imaging notable for:
___ MRI & MRA brain:
Preliminary Read:
IMPRESSION:
1. No acute intracranial abnormality, specifically no evidence
of
acute infarct, hemorrhage or intracranial mass.
2. No evidence of dissection of the vertebral arteries
bilaterally. The right vertebral artery is dominant and the left
vertebral artery is diminutive.
3. Patent circle of ___ without evidence of stenosis,
occlusion, or aneurysm.
4. Patent bilateral cervical carotid and vertebral arteries
without evidence of stenosis, occlusion, or dissection.
- Patient was given:
___ 06:15 PO Acetaminophen 1000 mg
___ 10:42 PO Metoprolol Succinate XL 25 mg
___ 10:42 PO/NG Levothyroxine Sodium 75 mcg
___ 13:18 PO/NG Digoxin .125 mg
- Consults: Neurology:Overall we do not think that her symptoms
are due to cerebral ischemia, most likely musculoskeletal
tension, induced by using special pillow. (A treatment for
dissection would be
anticoagulation, which she is already on)
Decision was made to admit for cardiac structural etiology of
her
dizziness.
- Vitals prior to transfer:
85 | 172/98 | 18 | 98% RA
On arrival to the floor, she reported that she felt much better
an did not have any dizziness. She denied having dizziness in
the
ED.
Past Medical History:
PMH: CHF, HTN, afib, HLD, PE, hypothyroidism, anxiety, asthma,
back pain, bladder cancer, cervical herniated disc, insomnia,
compression fractures, osteoporosis, degenerative joint disease
with tendinitis, history of small bowel obstruction, glucose
intolerance
PSH:
- cystectomy w/ ileal conduit
- exploratory laparotomy and LOA for SBO
- open CCY
- TAH/BSO
Social History:
___
Family History:
Family history was noncontributory to this issue.
Physical Exam:
ADMISSION PHYSICAL EXAM:
===================
VS: ___ 1511 Temp: 97.6 PO BP: 122/67 HR: 60 RR: 16
GENERAL: Pleasant, lying in bed comfortably
HEENT: No nystagmus. MMM
CARDIAC: Regular rate, irregular rhythm. Systolic III/VI murmur
loudest at ___ and ___ with minimal radiation to carotids. No
rub or gallop
LUNG: CTAB, no crackles, wheezes, or rhonchi
ABD: Soft, nontender, nondistended, no hepatomegaly, no
splenomegaly
EXT: Warm, well perfused, no lower extremity edema
PULSES: 2+ radial pulses, 2+ ___ pulses, 2+ DP pulses
NEURO: Alert, oriented, CN II-XII intact, motor and sensory
function grossly intact
SKIN: No significant rashes
DISCHARGE PHYSICAL EXAM:
==================
___ ___ Temp: 98.2 PO BP: 112/70 L Lying HR: 84 RR: 18 O2
sat: 99% O2 delivery: Ra
GENERAL: Pleasant, laying in bed.
CARDIAC: Regular rate, irregularly irregular rhythm. Systolic
III/VI murmur loudest at ___ and ___. No rub or gallops.
Carotid bruit heard L>R but milder
LUNG: CTAB, no crackles, wheezes, or rhonchi
ABD: Soft, nontender, nondistended, + ostomy, no erythema or
tenderness around bag/site
EXT: Warm, well perfused, trace lower extremity edema to mid
shin
bilaterally
PULSES: 2+ radial pulses, 2+ ___ pulses, 2+ DP pulses
NEURO: Alert, oriented, CN II-XII intact, motor and sensory
function grossly intact
Pertinent Results:
ADMISSION LABS:
===========
___ 03:59PM BLOOD WBC-9.1 RBC-5.33* Hgb-14.5 Hct-48.7*
MCV-91 MCH-27.2 MCHC-29.8* RDW-14.5 RDWSD-48.0* Plt ___
___ 03:59PM BLOOD Plt ___
___ 11:03AM BLOOD ___ PTT-39.8* ___
___ 11:03AM BLOOD Glucose-103* UreaN-14 Creat-0.7 Na-143
K-4.5 Cl-106 HCO3-26 AnGap-11
___ 11:03AM BLOOD Calcium-9.4 Phos-3.7 Mg-1.9
DISCHARGE LABS:
============
___ 04:50AM BLOOD WBC-8.5 RBC-4.77 Hgb-12.8 Hct-41.8 MCV-88
MCH-26.8 MCHC-30.6* RDW-14.3 RDWSD-45.8 Plt ___
___ 04:50AM BLOOD ___ PTT-34.1 ___
___ 04:50AM BLOOD Plt ___
___ 04:50AM BLOOD Glucose-105* UreaN-18 Creat-0.7 Na-142
K-4.3 Cl-106 HCO3-27 AnGap-9*
___ 04:50AM BLOOD Calcium-9.1 Phos-3.4 Mg-1.9
IMAGING:
========
___ MRI/MRA Brain
1. No acute intracranial abnormality. Specifically, no evidence
of acute
infarct, hemorrhage or intracranial mass.
2. Right temporal lobe encephalomalacia, presumably sequela of
prior infarct
is identified.
3. There is severe short-segment stenosis, with near occlusion
of the left
subclavian artery just prior to the takeoff of the left
vertebral artery and
of the proximal left vertebral artery. There is distal
reconstitution of the
left subclavian artery. There is retrograde flow through the
remainder of the
left vertebral artery from the mid V1 segments to the V4
segment.
4. No T1 hyperintense signal of the left vertebral artery to
suggest mural
thrombus and acute dissection.
5. There is approximately 40% stenosis of the left cervical
internal carotid
artery by NASCET criteria and 70% stenosis of the right cervical
internal
carotid artery by NASCET criteria. The remainder of the MRA
neck is
unremarkable.
6. Unremarkable MRA of the head.
7. Additional findings described above.
TTE ___:
Moderate to severe aortic valve stenosis with thickened/deformed
leaflets and trace
aortic regurgitation. Mild symmetric left ventricular
hypertrophy with normal cavity size and
regional/global biventricular systolic function. Moderate
pulmonary artery systolic hypertension.
Moderate mitral regurgitation.
___ carotid series complete:
Right ICA 40-59% stenosis.
Left ICA <40% stenosis. Retrograde flow in the left vertebral
artery which
can be seen in left subclavian steal.
___ Cardiac cath endovascular
Normal left and right heart filling pressures. Aortic valve area
of 1.4mm2 with peak-to-peak
gradient of ~18mmhg. Normal augmentation with Dobutamine without
increase in peak-to-peak
gradient. Overall consistent with only moderate aortic stenosis.
Low normal cardiac function.
Moderate non-obstructive coronary artery disease.
Severe left subclavian artery disease just proximal to the
take-off of the vertebral artery. S/p
BMS 6x20mm
Brief Hospital Course:
BRIEF HOSPITAL COURSE
=================================
Ms. ___ is a ___ yo F with history of moderate/severe aortic
stenosis, A Fib on warfarin, HTN, and previous PE who presented
to ___ with chest pain radiating to her left arm,
intermittent shortness of breath, and neck pain. She also
reported multiple episodes of dizziness over the past couple
weeks. She had a full neurological workup including MRI/MRA that
showed no acute process but did show subclavian stenosis and
diminutive left vertebral artery without evidence of dissection,
with reversal of flow suggestive of subclavian steal syndrome.
Upon admission to ___, she reported that her dizziness has
mostly resolved. She had a vascular medicine consult who
recommended cardiac catheterization with upper extremity
evaluation, to evaluate her aortic valve, coronary arteries, and
intervene on subclavian stenosis. The catheterization
demonstrated moderate non-obstructive coronary artery disease,
moderate aortic stenosis, and severe left subclavian artery
disease just proximal to take off of vertebral artery, now s/p
stent placement with good anterograde flow. She was started on
triple therapy for the stent with aspirin, Plavix, and Eliquis
BID. She did well and remained hemodynamically stable.
TRANSITIONAL ISSUES:
=================================
[] There is approximately 40% stenosis of the left cervical
internal carotid artery by NASCET criteria and 70% stenosis of
the right cervical internal carotid artery by NASCET criteria.
Follow up as outpatient
[] plan to continue triple therapy for 1 month and then
discontinue aspirin 81 mg --> please ensure patient stops
aspirin after 1 month (approximately ___
[] follow up if left arm numbness/tingling symptoms have
resolved after stent placement
MEDICATIONS:
- New Meds: plavix 75 mg daily, aspirin 81 mg daily, Eliquis 5
mg BID
- Stopped Meds: warfarin
- Changed Meds: simvastatin --> rosuvastatin 20 mg nightly
# CODE: Full
# CONTACT: ___ ___
___ ___
ACUTE ISSUES:
==========
# Subclavian steal syndrome:
MRA with subclavian stenosis and reversal of vertebral artery
flow. Her symptoms of intermittent lightheadedness with left arm
pain/numbness were consistent with a diagnosis of subclavian
steal syndrome. She was evaluated by the vascular medicine team
(see below) and underwent a cardiac angiogram with stent placed
in left subclavian artery.
# Low flow, low gradient mild-moderate aortic stenosis
Patient with history of aortic stenosis. She had an echo done
inpatient that showed moderate to severe aortic valve stenosis
with thickened/deformed leaflets and trace
aortic regurgitation. On coronary cath, however, she had normal
augmentation with dobutamine, without increase in gradient,
suggesting the presence of low flow, low gradient AS, with
severity overestimated by echo due to low flow state. Her AS
should be classified as mild-moderate based on cath.
# Atrial fibrillation
Patient with history of A Fib on anticoagulation. She was
maintained on daily dose of warfarin with goal INR ___ until
cath scheduled. Warfarin was held in the setting of cath and day
of INR was 1.9. Her warfarin was restarted for goal INR ___.
# Difficult venous access
Patient with very difficult venous access with inability to get
labs despite multiple attempts by experienced IV nurses. ___ had
a PICC placed for lab draws and this resolved the issue.
CHRONIC ISSUES:
============
# Hypothyroidism
- Continue home levothyroxine 100mg
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Digoxin 0.125 mg PO DAILY
2. Levothyroxine Sodium 75 mcg PO DAILY
3. Simvastatin 20 mg PO QPM
4. Warfarin 4 mg PO DAILY16
5. Vitamin D 400 UNIT PO DAILY
6. flaxseed oil 1,000 mg oral DAILY
7. Metoprolol Succinate XL 25 mg PO DAILY
Discharge Medications:
1. Apixaban 5 mg PO/NG BID
RX *apixaban [Eliquis] 5 mg 1 tablet(s) by mouth twice a day
Disp #*30 Tablet Refills:*1
2. Aspirin 81 mg PO DAILY
RX *aspirin 81 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
3. Clopidogrel 75 mg PO DAILY to prevent stent thrombosis
RX *clopidogrel 75 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*1
4. Rosuvastatin Calcium 20 mg PO QPM
RX *rosuvastatin 20 mg 1 tablet(s) by mouth once a day at night
Disp #*30 Tablet Refills:*0
5. Levothyroxine Sodium 100 mcg PO DAILY
6. Digoxin 0.125 mg PO DAILY
7. flaxseed oil 1,000 mg oral DAILY
8. Metoprolol Succinate XL 25 mg PO DAILY
9. Vitamin D 400 UNIT PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
==============
Dizziness/lightheadedness
Subclavian steal syndrome
Moderate/severe aortic stenosis
SECONDARY DIAGNOSIS:
=================
Atrial fibrillation on anticoagulation
Hypothyroidism
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking part in your care here at ___!
Why was I admitted to the hospital?
- You were admitted for arm pain and dizziness
What was done for me while I was in the hospital?
- You were monitored closely for further symptoms
- You had an ultrasound of your heart
- You were seen by the vascular medicine team
- You underwent a cardiac angiogram and they put a stent in your
left subclavian artery to help with your arm symptoms
What should I do when I leave the hospital?
Please take all your home medications as prescribed. Please go
to all of your follow up appointments and alert your doctor if
you have any concerning symptoms (see below).
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
19714545-DS-14
| 19,714,545 | 28,460,336 |
DS
| 14 |
2175-01-03 00:00:00
|
2175-01-03 16:12:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
s/p MVC
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ year old male without significant past
medical history who has been brought in by EMS status post EMS.
The Patient was an unrestrained driver of a Jeep who struck
another car and went off the road, striking a stone wall head-on
at unknown speeds. There was no airbags in the vehicle, and
patient was found unresponsive by a physician
first responder outside of his vehicle with a leftward gaze.
Patient eventually regained consciousness after approximately 4
minutes but was amnestic and perseverant. EMS arrived on scene,
stabilized the patient, and brought him to the ___ ED without
further issues.
His injuries include left ___ left transverse process fractures,
T5-10 spinous process fractures and a left ear laceration. He
complained of back pain, neck pain, and left ear pain. He
denied, numbness, weakness, tingling, bowel or bladder
incontinence.
Past Medical History:
None
Social History:
___
Family History:
Non-contributory.
Physical Exam:
On admission:
Temp: 98 HR: 78 BP: 144/111 Resp: 20 O(2)Sat: 100 Normal
Constitutional: Boarded and collared
HEENT: Pupils equal, round and reactive to light,
Extraocular muscles intact
Blood in the left naris. C. collar in place. Abrasion to
The back of the head
Chest: Breast sounds equal bilaterally. Trachea midline. No
chest wall tenderness or crepitus
Cardiovascular: Regular Rate and Rhythm, Normal first and
second heart sounds
Abdominal: Soft, Nontender, Nondistended
Extr/Back: Multiple abrasions to all extremities
Neuro: Speech fluent, strength and sensation grossly normal
throughout
On discharge:
VS: 98.1, 84, 135/87, 14, 99% on room air.
Pertinent Results:
___ 06:57PM BLOOD WBC-15.5* RBC-5.48 Hgb-16.4 Hct-48.2
MCV-88 MCH-29.9 MCHC-34.0 RDW-12.3 Plt ___
___ 06:57PM BLOOD Plt ___
___ 06:57PM BLOOD ___ PTT-32.4 ___
___ 06:57PM BLOOD ___ 06:57PM BLOOD UreaN-16 Creat-0.9
___ 06:57PM BLOOD Lipase-34
___ 06:57PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 07:04PM BLOOD Glucose-108* Na-143 K-3.6 Cl-106
calHCO3-22
IMAGING:
CT Torso: T5-10 Spinous process fractures, L2-4 Left Transverse
process fx
___ CT c-spine without contrast
No acute fracture or traumatic malalignment.
___ CT chest, abdomen and pelvis with contrast
Fracture of the left transverse process of L2 to L4. No other
acute abnormality.
___ MRI cervical and thoracic spine
1. Severe spinal canal narrowing at C6-7 with disc protrusion
indenting and remodeling of the spinal cord. There is no spinal
cord signal abnormality, although artifact somewhat degrades
image quality.
2. Left paracentral disc protrusion at T7-T8 resulting in
flattening and
remodeling of the ventral spinal cord.
3. No evidence of fracture or ligamentous injury.
4. Small bilateral pleural effusions.
Brief Hospital Course:
Mr. ___ was admitted to the inpatient ward under the Acute
Care Surgery service after his involvement in a motor vehicle
collision. As previously discussed, his injuries include T5 - 9
spinous process fractures, left 2 - 4 transverse process
fractures, left ear laceration and small vertex subgaleal
hematoma. The patient arrived in a cervical collar, which
remained in place until CT and MR imaging confirmed there were
no acute fractures or ligamentous injuries. The Plastic surgery
service sutured the patient's left ear using dissolvable
sutures.
On hospital day 2, the patient was seen by physical and
occupational therapy. Based on occupational therapy's
evaluation, the patient had no cognitive deficits warranting
outpatient follow up. The patient was ambulating independently,
although somewhat limited by pain, but was safe to be discharged
home without services. During this time, Mr. ___ was eating
a regular diet and tolerating it well. He was resumed on his
home medication regimen. He had no issues voiding.
Mr. ___ was discharged home the afternoon of ___. He was
afebrile, hemodynamically stable and in no acute distress. He
will be following up with the Neurosurgery team in approximately
one month. He was given a prescription for short-term pain
medication. He was also instructed to place bacitracin ointment
to his ear three times daily for the next week.
Medications on Admission:
Lisinopril-HCTZ ___, lorazepam 0.5 PRN ___ times daily,
wellbutrin XL 300 daily, viagra 100qday, valacyclovir 500'',
amlodipine 5mg'
Discharge Medications:
1. Acetaminophen ___ mg PO Q6H:PRN pain
2. Amlodipine 5 mg PO DAILY
3. Bacitracin-Polymyxin Ointment 1 Appl TP TID
4. BuPROPion (Sustained Release) 300 mg PO DAILY
5. Hydrochlorothiazide 25 mg PO DAILY
6. Lisinopril 20 mg PO DAILY
7. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*45 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
- T5 - T9 spinous process fractures
- L2 - L4 transverse process fractures
- Left ear laceration
- Small subgaleal hematoma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to ___ on
___ after you were involved in a motor vehicle collision. On
further evaluation, you were wound to have the following
injuries:
- T5 - T9 spinous process fractures
- L2 - L4 transverse process fractures
- Left ear laceration
- Small subgaleal hematoma
You were evaluated by the neurosurgery team. Due to concerns of
a cervical spine (neck) fracture or injury, you were kept in a
cervical collar until your MRI was completed. Those results
showed you had no fracture to your cervical spine or ligament
injury. Your collar was removed.
Your spinous process and transverse process fractures are
non-operative. You are being discharged on pain medications to
control the pain that they may cause.
You were seen by occupational and physical therapy prior to
discharge. You are now safe to be discharged home.
Please take any medications you were taking prior to admission
to the hospital.
While taking narcotic pain medications, you should not drive or
operate heavy machinery. If you become constipated from the
pain medications, you may take Colace (docusate sodium) 100mg
twice a day to prevent constipation. A laxative may be utilized
to facilitate a bowel movement.
Followup Instructions:
___
|
19714547-DS-8
| 19,714,547 | 25,371,645 |
DS
| 8 |
2183-04-04 00:00:00
|
2183-04-04 23:24:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
back abscess
Major Surgical or Invasive Procedure:
___ line placement ___
TEE ___
History of Present Illness:
___ yo M with a history of hypertension, insulin dependent
diabetes and stage V CKD not on dialysis, who presented to the
emergency room today with back abscess with purulent drainage,
found to have significant electrolyte abnormalities concerning
for DKA, admitted to ICU on insulin gtt.
On arrival to the ER, initial vital signs were 97.6 88 97/51 16
100%. Labs were notable for WBC 32, Na 125, K 3.0, Cr 8.8,
bicarb 12, gap 24. He received 1.5L of NS and repeat labs showed
persistent hypokalemia, hyponatremia, hypochloremia and low
bicarb. ABG 7.26/25/114/12. Lactate was 1.1. He was started on
the DKA pathway given low bicarb with insulin gtt at 3 units/h
and D5NS + 20mEq of K @ 200cc/h.
His abscess was I&D'ed with yellow purulence. There was drainage
from the surrounding tissue concerning for deeper infection,
thus a CT was performed which showed that the infection was
confined to subcutaneous tissue with surrounding edema. Patient
received a dose of vancomycin.
On transfer, vitals were: 99.0 90 138/68 16 100% RA
On arrival to the MICU, VS were T 101.0 BP 129/81 HR 115 RR 18
O2 100% RA. Patient reports that for the last ___ days he has
been feeling increasingly lethargic, with vomiting in the
morning, poor appetite, and difficult to control blood sugars in
the 300-400 range. He also has had episodes of diarrhea. He has
not taken his temperature, and denies chills. He denies dysuria
or hematuria, nor back pain. The cyst on his back was developing
for several days, but worse in the last ___ days. His brother
popped it the night prior to presentation to the ER.
He denies polydipsia, and has been trying to control his sugar
intake. He has been drinking water and diet cranberry juice
primarily. He reports increased urinary frequency.
Of note, he was hospitalized at ___ on ___ for
a planned eye surgery complicated by respiratory failure
requiring brief intubation lasting approximately ___ hours.
Review of systems:
(+) Per HPI
(-) Denies chest pain or shortness of breath, but currently
feels palpitations. He started feeling lightheaded last night
prior to presentation to the ER. He has shortness of breath when
taking long walks but otherwise denies dyspnea. He denies
abdominal pain, constipaiton. he occasionally has lower
extremity swelling which improves with furosemide
Past Medical History:
Stage V chronic kidney disease
DM- insulin dependent
Hypertension
Diabetic retinopathy
h/o imperforate anus s/p repair
Sickle cell trait
Congenital radial abnormality of left arm s/p multiple surgeries
Retinal detachment s/p repair ___ and ___ (bilateral)
s/p eye surgery ___ (drain placed)
Social History:
___
Family History:
Mother: DM, HTN, deceased d/t MI
Father: DM, HTN
Brother: died at ___ of MI
Uncle: lung ca
Physical Exam:
ADMISSION PHYSICAL EXAM
===========================
Vitals- T 101.0 BP 129/81 HR 115 RR 18 O2 100% RA
GENERAL: Alert, oriented, no acute distress
HEENT: Sclera anicteric, conjunctival injection bilaterally,
cataracts bilaterally, blind bilaterally. EOMI intact on left.
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 S1S2, grade II/VI systolic
murmur best heard at apex
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. Patient has a congenital abnormality of his left arm with
missing radius.
SKIN: on the right side of the upper back there is a 4x4cm skin
defect packed with guaze with edema and firm tissue underneath,
no surrounding erythema.
NEURO: A+Ox3
DISCHARGE PHYSICAL EXAM
=========================
General: Awake, alert, appropriate, answering questions
appropriately.
HEENT: Blind in right eye with bilateral cataracts.
CV: S1S2 RRR w/o murmurs.
Lungs: CTA bilaterally w/o crackles or wheezing.
Ab: Positive BSs, NT/ND, no HSM.
Ext: Congenital absence of the left radius. No lower extremity
edema.
Back: Abscess site is without drainage or significant erythema.
Neuro: Appropriately oriented. No focal motor deficits.
Pertinent Results:
ADMISSION LABS
================
___ 02:50AM BLOOD WBC-32.8*# RBC-2.84* Hgb-8.2* Hct-24.1*
MCV-85 MCH-28.9 MCHC-34.2 RDW-14.1 Plt ___
___ 02:50AM BLOOD Neuts-87.6* Lymphs-3.1* Monos-6.3 Eos-2.8
Baso-0.2
___ 02:50AM BLOOD Plt ___
___ 02:50AM BLOOD Glucose-186* UreaN-90* Creat-8.8* Na-125*
K-3.0* Cl-92* HCO3-12* AnGap-24*
___ 07:30AM BLOOD CK(CPK)-80
___ 07:30AM BLOOD Albumin-3.2* Calcium-7.5* Phos-4.5
Mg-1.3*
___ 10:00AM BLOOD Vanco-12.1
___ 07:39AM BLOOD ___ pO2-114* pCO2-25* pH-7.26*
calTCO2-12* Base XS--13 Comment-GREEN TOP
DISCHARGE LABS
===============
___ 02:43AM BLOOD WBC-9.9 RBC-2.56* Hgb-7.1* Hct-21.7*
MCV-85 MCH-27.9 MCHC-32.8 RDW-14.6 Plt ___
___ 02:43AM BLOOD Neuts-72.3* Lymphs-15.3* Monos-6.6
Eos-5.3* Baso-0.4
___ 02:43AM BLOOD Plt ___
___ 02:43AM BLOOD Glucose-135* UreaN-82* Creat-7.8* Na-142
K-2.9* Cl-105 HCO3-25 AnGap-15
___ 02:43AM BLOOD Calcium-8.0* Phos-5.6* Mg-2.3
___ 04:00AM BLOOD Vanco-23.0*
RADIOLOGY
==========
TEE ___
No echocardiographic evidence of endocarditis. Symmetric left
ventricular hypertrophy with normal biventricular function. Mild
mitral regurgitation.
CT CHEST W/O CONTRAST Study Date of ___ 5:15 AM
1. 4.6 x 2.4 cm focal area of subcutaneous stranding and edema
with overlying skin defect and packing material. No undrained
fluid collection. The muscle plane and deeper structures of the
back are not involved.
2. Mild generalized subcutaneous edema throughout the
subcutaneous fat of the back.
3. Gynecomastia.
CXR ___
Right PICC ends in the proximal right atrium and can be pulled
back
approximately 2.0 - 2.5 cm. No pneumothorax.
MICROBIOLOGY
=============
___ 5:00 am BLOOD CULTURE
Blood Culture, Routine (Preliminary):
STAPH AUREUS COAG +.
Consultations with ID are recommended for all blood
cultures
positive for Staphylococcus aureus, yeast or other
fungi.
FINAL SENSITIVITIES.
Staphylococcus species may develop resistance during
prolonged
therapy with quinolones. Therefore, isolates that are
initially
susceptible may become resistant within three to four
days after
initiation of therapy. Testing of repeat isolates may
be
warranted.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN----------<=0.25 S
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- 0.25 S
OXACILLIN------------- 0.5 S
TRIMETHOPRIM/SULFA---- <=0.5 S
Anaerobic Bottle Gram Stain (Final ___:
GRAM POSITIVE COCCI IN CLUSTERS.
Reported to and read back by ___. ___ (___)
___ @ 10:48
AM.
___ 5:00 am SWAB Source: right upper back.
**FINAL REPORT ___
WOUND CULTURE (Final ___:
STAPH AUREUS COAG +. HEAVY GROWTH.
Staphylococcus species may develop resistance during
prolonged
therapy with quinolones. Therefore, isolates that are
initially
susceptible may become resistant within three to four
days after
initiation of therapy. Testing of repeat isolates may
be
warranted.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN----------<=0.25 S
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- 0.25 S
OXACILLIN------------- 0.5 S
TETRACYCLINE---------- <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
___ 3:05 am STOOL CONSISTENCY: SOFT Source: Stool.
**FINAL REPORT ___
C. difficile DNA amplification assay (Final ___:
Negative for toxigenic C. difficile by the Illumigene DNA
amplification assay.
(Reference Range-Negative).
Brief Hospital Course:
___ yo M with a history of DMII, stage V CKD and HTN, presenting
with right back abscess and worsening renal function with
metabolic acidosis.
ACTIVE ISSUES
==============
# Sepsis/Back Abscess
Patient initially met SIRS criteria with leukocytosis and
tachycardia. Sources of infection likely back abscess now s/p
drainage in the ED.
CT shows no extension into muscular tissue. Area was drained and
packed in ER. Initially there was concern for UTI but urine
culture grew only skin flora. Cdiff negative. Blood and wound
cultures now growing gram positive cocci/staph aureus, now have
sensitivities and vanc has been narrowed to nafcillin (day ___-
___. Patient sent home on Nafcillin and will followup with
OPAT to determine length of course.
# Diarrhea
Patient now with perfuse diarrhea. Was Cdiff negative on
___. Restarted home dose lomitil for diarrhea.
# Hypertension
Home meds were initially held in the setting of sepsis. Home
dose metoprolol and minoxidil were restarted. Home dose
amlodipine was restarted and uptitrated to 10mg PO daily. Home
dose lisinopril was stopped per renal recs.
# Anemia
No active bleeding, likely has basline anemia due to CKD.
# Stage V CKD
Progressively worsening kidney disease over the last several
years, followed by Dr. ___. It appears that patient has
missed many recent outpatient appointments to discuss renal
replacement therapy. Worsening creatinine combined with
significant electrolyte abnormalities are concerning future need
for dialysis, though patient did not meet criteria for needing
urgent dialysis during admission. Patient was started on sodium
bicarbonate tabs.
# Diabetes mellitus
Patient was on humalog ___ 20 units BID at home. ___ was
consulted and recommended 70/30 insulin 14 units BID with
breakfast/dinner. Patient was set up
# Metabolic acidosis
Patient presented with low bicarbonate, and acidosis of 7.25
consistent with metabolic acidosis with appropriate
compensation. He has a delt-delta of slightly less than one
(___), indicating an additional non-anion gap metabolic
acidosis which could be due to renal disease or patient's report
of diarrhea. Blood sugar has been <300, and there is no glucose
or ketones in urine so this is not due to ketoacidosis. In
addition, lactate is normal. It is odd that his potassium is low
and phosphate is normal, but otherwise, picture is most
consistent with worsening renal function. Initially upon
arrival, received bicarb infusion. Improved and was stable
prior to discharge.
TRANSITIONAL ISSUES
====================
- wound and blood cultures grew Staph Aureus, patient to remain
on Nafcillin 2g q4hrs and will followup outpatient with
infectious disease regarding length of course of antibiotics
- patient with progressive kidney disease and will require close
renal followup for discussions about dialysis initiation
- ___ consult obtained to aid in sugar control, recommended
Insulin 70/30, 14 units twice a day with breakfast and dinner
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amlodipine 5 mg PO DAILY
2. Atorvastatin 20 mg PO DAILY
3. Calcitriol 0.25 mcg PO 3X/WEEK (___)
4. Fluticasone Propionate NASAL 2 SPRY NU BID
5. Furosemide 80 mg PO QAM
6. Lisinopril 40 mg PO DAILY
7. Metoprolol Succinate XL 100 mg PO DAILY
8. Minoxidil 2.5 mg PO DAILY
9. Aspirin 81 mg PO DAILY
10. Humalog ___ 32 Units Breakfast
Humalog ___ 32 Units Dinner
11. Furosemide 40 mg PO HS
12. PrednisoLONE Acetate 1% Ophth. Susp. 1 DROP LEFT EYE QID
13. Latanoprost 0.005% Ophth. Soln. 1 DROP LEFT EYE BID
14. Brimonidine Tartrate 0.15% Ophth. 1 DROP LEFT EYE BID
15. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP LEFT EYE QHS
Discharge Medications:
1. Amlodipine 10 mg PO DAILY
RX *amlodipine 10 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*2
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 20 mg PO DAILY
4. Brimonidine Tartrate 0.15% Ophth. 1 DROP LEFT EYE BID
5. Calcitriol 0.25 mcg PO 3X/WEEK (___)
6. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP LEFT EYE QHS
7. Furosemide 80 mg PO QAM
8. Minoxidil 2.5 mg PO DAILY
9. PrednisoLONE Acetate 1% Ophth. Susp. 1 DROP LEFT EYE QID
10. Latanoprost 0.005% Ophth. Soln. 1 DROP LEFT EYE HS
11. Metoprolol Succinate XL 100 mg PO DAILY
12. Fluticasone Propionate NASAL 2 SPRY NU BID
13. Nafcillin 2 g IV Q4H
RX *nafcillin in dextrose iso-osm 2 gram/100 mL 2 g IV q4hrs
Disp #*28 Intravenous Bag Refills:*0
14. Sodium Bicarbonate ___ mg PO TID
RX *sodium bicarbonate 650 mg 3 tablet(s) by mouth three times a
day Disp #*270 Tablet Refills:*1
15. Outpatient Lab Work
Labs: ___
LFTs, CBC, Chem-10, ESR/CRP
ICD-9: 790.7
Fax to ___, Attention: OPAT
16. Insulin SC
Sliding Scale
Insulin SC Sliding Scale using HUM Insulin
17. HumaLOG Mix ___ (insulin lispro protam-lispro) 100 unit/mL
(75-25) subcutaneous BID
___ Units BID following sliding scale (Breakfast and Dinner)
RX *insulin lispro protam-lispro [Humalog Mix 75-25] 100 unit/mL
(75-25) ___ Units SQ twice a day Disp #*1 Vial Refills:*3
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY
Abscess
Staph Bacteremia
Diabetes
Chronic Renal Failure
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you at ___. You
were admitted due to an infection in your back. You were
treated with IV antibiotics and you started to feel better.
You will go home with an IV line and receive IV antibiotics at
home. It is very important that you continue to take these
antibiotics, continue to take insulin for your diabetes and make
sure you attend your followup appointments.
Followup Instructions:
___
|
19714547-DS-9
| 19,714,547 | 29,658,686 |
DS
| 9 |
2185-08-27 00:00:00
|
2185-08-28 22:37:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
ESRD
Major Surgical or Invasive Procedure:
Hemodialysis
Multiple pRBC transfusions during this admission (5 units total)
History of Present Illness:
___ w/ hx stage V CKD ___ type 1 DM and hypertensive
nephrosclerosis, legally blind ___ retinal detachment, and
sickle cell trait, admitted to start hemodialysis.
Patient was seen in ___ clinic yesterday ___ with cough
x1 month (s/p abx?). Patient reports mild itching but otherwise
minimal uremic symptoms (no anorexia/nausea/vomiting, no
fatigue, no SOP/CP, no muscle weakness, pain or cramping). CXR
suggested new cardiomegaly, possible pericardial effusion, and
patient was directed to ED for cardiac eval before he starts
dialysis. Regarding his ESRD, he has been on kidney transplant
list (followed by ___ and found out on ___
that his foster nephew is a match and will be his living donor.
In the ED, patients vitals were T 98.4, BP 129/70, HR 66, RR 18,
SpO2 90% RA. Initial exam was generally well appearing, notable
for 1+ bilateral ___ edema. No effusion on bedside US.
Past Medical History:
Stage V chronic kidney disease
LUE AVFistula since ___
DM- insulin dependent
Hypertension
Diabetic retinopathy
h/o imperforate anus s/p repair
Sickle cell trait
Congenital radial abnormality of left arm s/p multiple surgeries
Retinal detachment s/p repair ___ and ___ (bilateral)
Social History:
___
Family History:
Mother: DM, HTN, deceased d/t MI
Father: DM, HTN
Brother: died at ___ of MI
Uncle: lung ca
Strongly positive family history for diabetes with multiple
family members on dialysis. Two paternal cousins with sickle
cell.
Physical Exam:
=======================
ADMISSION PHYSICAL EXAM:
=======================
Vitals: T 97.5, BP 127/69, HR 71, RR 18, SpO2 98% RA.
General: Alert, oriented, no acute distress
HEENT: Sclerae anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated
Lungs: CTAB no crackles/wheezes
CV: RRR, S1/S2, III/VI crescendo/decrescendo systolic murmur w/o
radiation
Abdomen: soft, NT/ND, BS+, no rebound tenderness or guarding
Ext: Warm, well perfused. No wounds/ulcers on feet, significant
lower extremity pitting edema up to knees, no cyanosis. L upper
extremity with congenital malformation (no thumb, shortened).
AVFistula of LUE with palpable thrill.
Neuro: AOx3. No vision in R eye (cannot see light/dark). L eye
able to see light/dark but no acuity. Cranial nerves otherwise
intact.
=======================
DISCHARGE PHYSICAL EXAM:
=======================
Vitals: Tm 98.7 122/70, BP 76, RR 18 100% RA
General: Alert, oriented, no acute distress
HEENT: Sclerae anicteric, MMM, oropharynx clear
Neck: supple
Lungs: CTAB no crackles/wheezes
CV: RRR, S1/S2, III/VI crescendo/decrescendo systolic murmur w/o
radiation. No rubs.
Abdomen: soft, NT/ND, BS+, no rebound tenderness or guarding
Ext: Warm, well perfused. No wounds/ulcers on feet, minimal
lower extremity pitting edema up to knees, no cyanosis. L upper
extremity with congenital club hand malformation (no thumb,
shortened forearm). AVFistula of LUE with palpable thrill. LUE
is swollen from upper arm to hand is edematous, with intact
sensation and radial pulse. No palpable mass or fluctuance.
Neuro: AOx3. No vision in R eye (cannot see light/dark). L eye
able to see light/dark but no acuity. Cranial nerves otherwise
intact.
Pertinent Results:
===============
ADMISSION LABS:
===============
___ 11:40AM BLOOD WBC-7.3 RBC-2.33* Hgb-6.8* Hct-21.7*
MCV-93 MCH-29.2 MCHC-31.3* RDW-17.3* RDWSD-59.3* Plt ___
___ 11:40AM BLOOD Neuts-73.5* Lymphs-10.0* Monos-9.1
Eos-5.5 Baso-0.7 Im ___ AbsNeut-5.36 AbsLymp-0.73*
AbsMono-0.66 AbsEos-0.40 AbsBaso-0.05
___ 11:40AM BLOOD Plt ___
___ 11:40AM BLOOD Glucose-124* UreaN-181* Creat-20.3*
Na-141 K-4.7 Cl-89* HCO3-27 AnGap-30*
___ 11:40AM BLOOD Calcium-9.6 Phos-9.3* Mg-2.7*
___ 03:15PM BLOOD HBsAg-Negative HBsAb-Negative
HBcAb-Negative
___ 03:15PM BLOOD HCV Ab-Negative
___ 11:53AM BLOOD K-4.5
===============
DISCHARGE LABS:
===============
___ 10:45AM BLOOD WBC-9.8 RBC-2.90* Hgb-8.5* Hct-25.8*
MCV-89 MCH-29.3 MCHC-32.9 RDW-15.7* RDWSD-50.5* Plt ___
___ 10:45AM BLOOD Glucose-150* UreaN-67* Creat-9.7* Na-137
K-4.6 Cl-92* HCO3-29 AnGap-21*
___ 10:45AM BLOOD Calcium-9.7 Phos-4.8* Mg-2.1
========
IMAGING:
========
CXR ___:
Vascular congestion and bilateral small pleural effusions
consistent with
heart failure. Increasing cardiac silhouette may suggest new
cardiomegaly or pericardial effusion given patient's history of
end-stage renal disease
requiring dialysis.
LUE US ___:
1. No evidence of deep vein thrombosis in the left upper
extremity.
2. Patent arteriovenous fistula. A 1.0 x 0.5 cm hypoechoic
region adjacent to the fistula is of indeterminate age and may
represent a hematoma.
Fistulogram ___:
Conclusions: The patient has a left upper arm straight graft.
The central axillary vein is completely occluded. The occlusion
could not be recanalized with a wire. The graft outflow drains
via large collateral with multiple draining veins to the
subclavian vein. Percutaneous angioplasty of the 50% venous
anastamosis stenosis with no residual stenosis. The outflow vein
does remain smaller in caliber compared to the dilated axillary
vein. Mild arterial limb stenosis was not treated at this time
and is noncontributory to LUE swelling.
Brief Hospital Course:
BRIEF SUMMARY
============
Mr. ___ is a ___ year old man with history of stage V CKD ___
type 1 DM and hypertensive nephrosclerosis, legally blind ___
diabetic retinopathy & retinal detachment, chronic anemia, and
sickle cell trait, admitted to start hemodialysis.
ACTIVE ISSUES
===============
#ESRD on HD via LUE AV Fistula: Patient started HD on ___
and AV Fistula functioned well. However, LUE developed edema
after first HD session. Ultrasound ruled out DVT, confirmed
patent fistula and 1cm hypoechoic region adjacent to the fistula
that might represent a hematoma. Fistulogram showed complete
occlusion of axillary vein that could not be re-canalized.
However, graft drains via large cephalic collateral to
subclavian vein. Percutaneous angioplasty was performed for 50%
stenosis of venous anastamosis with no residual stenosis.
Arrangements and coordination for out-patient hemodialysis
included TB screen (PPD was negative) and hepatitis serologies
(also negative), and patient was set up to continue hemodialysis
in an outpatient basis at ___. His home Lasix,
sodium bicarb, and sevelemer were discontinued.
# Cardiomegaly: Work-up of the increased cardiac silhouette on
CXR included a TTE, which showed normal LVEF, mild RV dilation,
mild pulmonary HTN, and very small pericardial effusion, but
overall no change from previous TTE in ___. Patient's
mild dyspnea and slight oxygen requirement resolved after
several session of hemodialysis. Likely related to his
hypervolemic state on admission.
#C hronic anemia ___ ESRD: Receives Aranesp every other week in
outpatient setting. Required multiple pRBC transfusions during
the admission as well as epo. Hb on discharge is 8.5.
CHRONIC ISSUES:
================
# Type 1 DM: Most recent A1c was 5.7% in ___.
# Hyperparathyroidism ___ ESRD: Continued on home calcitriol.
TRANSITIONAL ISSUES:
======================
# Patient set up with outpatient HD at ___
# Home Lasix, sevelemer, and bicarb were discontinued in the
setting of improved volume status and electrolyte abnormalities.
# He has follow-up arranged with transplant team in ___s appointment in ___are to follow up on
fistulogram.
# Please continue to monitor left upper extremity arm swelling,
as it is anticipated to improve over time.
# CODE STATUS: Full Code (confirmed)
# CONTACT: ___ (brother, ___, ___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. Aranesp (in polysorbate) (darbepoetin alfa in polysorbat) 200
mcg/mL injection EVERY 2 WEEKS
2. amLODIPine 10 mg PO DAILY
3. Atorvastatin 20 mg PO QPM
4. Calcitriol 0.5 mcg PO DAILY
5. Cephalexin 250 mg PO Q24H
6. Furosemide 160 mg PO QAM
7. Furosemide 80 mg PO QPM
8. LOPERamide 2 mg PO QID:PRN diarrhea
9. Metoprolol Succinate XL 100 mg PO DAILY
10. Minoxidil 2.5 mg PO BID
11. sevelamer CARBONATE 4000 mg PO TID W/MEALS
12. Sodium Bicarbonate 2 tabs PO BID
13. Aspirin 81 mg PO DAILY
14. Artificial Tears ___ DROP BOTH EYES PRN dry eyes
15. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP LEFT EYE BID
16. Latanoprost 0.005% Ophth. Soln. 1 DROP LEFT EYE QHS
17. PrednisoLONE Acetate 1% Ophth. Susp. 1 DROP LEFT EYE QID
Discharge Medications:
1. amLODIPine 10 mg PO DAILY
2. Aranesp (in polysorbate) (darbepoetin alfa in polysorbat)
200 mcg/mL injection EVERY 2 WEEKS
3. Artificial Tears ___ DROP BOTH EYES PRN dry eyes
4. Aspirin 81 mg PO DAILY
5. Atorvastatin 20 mg PO QPM
6. Calcitriol 0.5 mcg PO DAILY
7. Cephalexin 250 mg PO Q24H
8. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP LEFT EYE BID
9. Latanoprost 0.005% Ophth. Soln. 1 DROP LEFT EYE QHS
10. LOPERamide 2 mg PO QID:PRN diarrhea
11. Metoprolol Succinate XL 100 mg PO DAILY
12. Minoxidil 2.5 mg PO BID
13. PrednisoLONE Acetate 1% Ophth. Susp. 1 DROP LEFT EYE QID
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
==================
ESRD (starting HD this admission)
Type 1 diabetes complicated by diabetic nephropathy
Hyperparathyroidism ___ ESRD (and hyperphosphatemia)
Anemia
SECONDARY DIAGNOSIS:
===================
Hypertensive nephrosclerosis
Legally blind, s/p retinal detachment and laser therapy
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
We saw you in the hospital to initiate hemodialysis for your
kidney disease. You were also more short of breath than
previously and required extra oxygen. Echocardiogram imaging of
your heart showed some enlargement of your heart, but normal
contraction, and minimal extra fluid around your heart. Overall,
it looked very similar to your previous one in ___.
You had multiple sessions of hemodialysis during your stay at
the ___, which helped remove a significant amount of the
excess fluid in your body. During these sessions, you received
numerous blood transfusions to help with your chronic anemia
that is caused by your renal disease. When your left arm swelled
up after the first hemodialysis session, we did several tests to
rule out a clot in the arm and to check how well your fistula
was working. You received a procedure called a fistulogram,
which showed that there was a narrowing of the veins, which was
then fixed.
You will need to continue hemodialysis sessions regularly after
leaving the hospital. As part of your work-up to receive
hemodialysis in the out-patient setting, we screened you for TB
and for hepatitis viruses and your results were negative. We
have also stopped some of your home medications.
It was a pleasure to take part in your care!
Regards,
Your ___ Team
Followup Instructions:
___
|
19714853-DS-13
| 19,714,853 | 28,487,322 |
DS
| 13 |
2155-09-28 00:00:00
|
2155-09-28 20:21:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
fever
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ yo male with history of diverticulitis, CAD s/p CABG, and AVR
on aspirin/plavix who was transferred from an OSH with two days
of fever, N/V and abdominal pain. He had a cataract repair on
___. On ___, he started to feel unwell. He felt
"woozy" and reports poor PO intake with nausea and vomiting.
Also noted to have abdominal pain that was worse when driving
over bumps in the road. Denies dysuria, frequency, or urgency.
He denies foley catheter placement during surgery. He denies
prior UTI's. He has not had prior abdominal surgery. He reports
a colonoscopy a few years ago and notes normal daily bowel
movements. His last BM was on ___. His BP's are typically
greater than 100.
At the OSH, he was febrile, and persistently hypotensive despite
3L fluid. He was exquisitely tender to palpation abdominal exam
with guarding most notably in right lower quadrant. Non-con CT
abd did not reveal any acute abdominal issue. There was concern
for ischemic bowel, so he was given 1 dose zosyn and
transferred.
In the ED, initial VS: 5 98.8 114 98/57 20 94% on RA.
- Labs were notable for lactate 1.5, trop 0.13, and Cr 2.6
- UA w/ UTI
- portable CXR w/o obvious pneumonia; possible mild bibasilar
atelectasis/effusion
- gen surg consult: no need for OR
- noncon CT from OSH: stone, AAA without extravastation, no wall
thickening about gall bladder, no free air or fluid
- blood pressures dipping into 80-90s systolic with HR around
100, sat 96% on 3L O2, afebrile
- Total 5L NS received (3 @OSH, 2 here)
- 20g in right AC, 22g in left AC both from OSH
- Abdominal exam still with severe tenderness to palpation
throughout stay, no rebound or guarding
- foley new from OSH
Vitals prior to transfer were: ___ 20 95% on 2L.
On arrival to the MICU, he is currently nauseated but passing
gas. He reports ___ squeezing abdominal pain that was initially
over the right side of the abdomen but is now moving to the left
side. He is thirsty but denies any lightheadedness or dizziness.
Review of systems:
(+) Per HPI, cough, weight loss, occaisional exertional chest
pain
(-) Denies fever, chills, night sweats, recent weight gain.
Denies headache, sinus tenderness, rhinorrhea or congestion.
Denies shortness of breath, or wheezing. Denies chest pressure,
palpitations, or weakness. Denies diarrhea. Denies arthralgias
or myalgias. Denies rashes or skin changes.
Past Medical History:
CAD s/p MI ___ years ago, CABG with AVR in ___iverticulitis
Pancreatitis
GERD
s/p bilateral TKR
Glaucoma in right eye
s/p cataract repair in left eye
Social History:
___
Family History:
No family history of heart disease
Physical Exam:
ADMISSION EXAM:
Vitals: 98.4 93 ___ 16 99% on 2L
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP at 8, no LAD
CV: Tachycardic, normal S1 + S2, no murmurs, rubs, gallops
Lungs: decreased breath sounds throughout but mostly at left
base, crackles at right base
Abdomen: +BS, soft, exquisitely tender to palpation and
percussion, distended, no rebound, mild guarding
Back: no CVA tenderness
Ext: warm, well perfused, 2+ pulses, 1+ bilateral ___ edema
Neuro: CNII-XII intact, ___ strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred, finger-to-nose intact
.
DISCHARGE EXAM:
Vitals: T 98.6 BP 146/68 RR 20 O2 sat 96%
Physical Exam
Gen: sitting up in bed appears comfortable in NAD
HEENT- EOMI, MMM
Neck - supple, no JVD, no LAD
Chest- nl S1 S2 no M/R/G
LUNGS- CTAB NO W/R/R
ABDOMEN-soft NTND, no rebound
Neuro- AOx3
Pertinent Results:
ADMISSION LABS:
___ 09:35PM BLOOD WBC-14.1* RBC-3.28* Hgb-10.3* Hct-32.0*
MCV-98 MCH-31.3 MCHC-32.1 RDW-14.0 Plt Ct-67*
___ 09:35PM BLOOD Neuts-91.5* Lymphs-5.1* Monos-3.2 Eos-0.1
Baso-0.1
___ 06:40AM BLOOD Hypochr-1+ Anisocy-1+ Poiklo-1+
Macrocy-2+ Microcy-NORMAL Polychr-NORMAL Ovalocy-1+ Tear Dr-1+
___ 09:35PM BLOOD ___ PTT-28.0 ___
___ 09:35PM BLOOD Glucose-102* UreaN-49* Creat-2.6* Na-139
K-4.1 Cl-106 HCO3-20* AnGap-17
___ 09:35PM BLOOD ALT-101* AST-132* CK(CPK)-43* AlkPhos-66
TotBili-0.6
___ 09:35PM BLOOD Lipase-19
___ 09:35PM BLOOD Albumin-3.0* Calcium-7.7* Phos-3.1 Mg-1.6
OTHER LABS:
___ 06:40AM BLOOD VitB12-1270*
___ 02:30PM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE
HBcAb-NEGATIVE
___ 06:40AM BLOOD PEP-NO SPECIFI IgG-716 IgA-195 IgM-36*
IFE-NO MONOCLO
___ 05:00AM BLOOD Vanco-8.6*
___ 02:30PM BLOOD HCV Ab-NEGATIVE
___ 09:47PM BLOOD Lactate-1.5
___ 09:35PM BLOOD cTropnT-0.13*
___ 06:40AM BLOOD CK-MB-5 cTropnT-0.15*
___ 03:01PM BLOOD CK-MB-5 cTropnT-0.16*
___ 03:28AM BLOOD CK-MB-4 cTropnT-0.16*
___ 02:30PM BLOOD CK-MB-4 cTropnT-0.16*
REPORTS:
CXR: 1. Vascular congestion could be due to volume overload
(particularly if the patient is receiving volume support). 2.
New left base pneumonia or atelectasis.
ECHO: The left atrium is mildly dilated. The estimated right
atrial pressure is ___ mmHg. There is mild symmetric left
ventricular hypertrophy with normal cavity size. There is mild
regional left ventricular systolic dysfunction with hypokinesis
of the septum and inferior wall. The remaining segments contract
normally (LVEF = 40 %). Right ventricular chamber size and free
wall motion are normal. A bioprosthetic aortic valve prosthesis
is present. The aortic valve prosthesis appears well seated,
with normal leaflet motion and transvalvular gradients. No
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. Mild (1+) mitral regurgitation is seen.There
is mild pulmonary artery systolic hypertension. There is
moderate tricuspid regurgitation. There is no pericardial
effusion.
IMPRESSION: Suboptimal image quality. Well seated, normal
functioning aortic valve bioprosthesis. Mild symmetric left
ventricular hypertrophy with regional systolic dysfunction c/w
CAD. Puilmonary artery hypertension. Moderate tricuspid
regurgitation. .
KUB: Nonspecific bowel gas pattern with no evidence of bowel
obstruction or perforation.
RUQ U/S: 1. Ill-defined hypoechoic area in segment III of the
liver is indeterminate. This finding would be better evaluated
with cross-sectional imaging such as CT/MRI. 2. Cholelithiasis
without sonographic evidence of acute cholecystitis. 3.
Echogenic and atrophic kidneys most likely related to chronic
renal disease. Bilateral simple renal cysts and non-obstructing
left-sided nephrolithiasis. 4. Fusiform infrarenal abdominal
aortic aneurysm appears stable to prior exam, however, is better
evaluated on prior CT abdomen.
CXR: Increase in mild bibasilar atelectasis. The rest of the
exam is unchanged
Brief Hospital Course:
BRIEF CLINICAL HISTORY:
___ year old male with HTN, HLD, CAD s/p CABG who presents with
four days of fatigue along with two days of fever and abdominal
pain to outside hospital with course complicated by ___ on CKD,
hypotension, and acute GIB.
ACTIVE ISSUES:
#GIB: Patient had moderate volume (~300cc) of coffee ground
emesis on the afternoon of ___. Hemodynamically stable with
SBPs in 130's, HR in 80's, clinically stable. The patient was
bolused a liter of fluid, placed on a PPI, made NPO, had his
antibiotics switched to IV, and GI was consulted. They
attempted to take the patient for an EGD on ___ to the ___
___ to have anesthesia oversee his care, but his procedure
was postponed until ___. Per the endoscopy report
"Esophagitis in the lower third of the esophagus and
gastroesophageal junction, Erythema in the antrum consistent
with mild gastritis, Otherwise normal EGD to third part of the
duodenum." Given this information and a stabilization in the
patient's hemoglobin and hematocrit, he was placed on PO
pantoprazole 40mg BID, and allowed to resume his diet as
tolerated. On ___, we resumed his ASA and the patient
remained asymptomatic throughout the evening and morning. His
AM labs on ___ revealed a drop in his hemoglobin and
hematocrit and we again halted his ASA. He was given 2 units of
pRBC on ___ and his hct increased appropriately. It was
stable over the next ___ hours and he had no evidence of bleeding
at the time of discharge on ___. His ASA and BB were
restarted the day prior to discharge.
# Hypotension: differential is septic shock with undetermined
infectious source vs NSTEMI four days prior to admission.
Evidence for sepsis was Fever, leukocytosis, hypotension and
tachycardia. Potential sources included positive UA, but patient
also reported cough and there was PNA vs atelectasis on CXR. GI
source was also considered in setting of abdominal pain but work
up for that was negative as below. Unfortunately Zosyn was given
at OSH without BC or urine culture drawn so we do not know what
to make of our negative UA. He does have toxic granulation which
points towards infectious etiology though a major cardiac event
could not be excluded. TTE showed inferior and septal wall
hypokinesis which is new compared to TTE in ___. Troponin
mildly elevated but CK-MB normal and trop remained stable. CT
abdomen reviewed with radiology did not show any acute process
to explain pain or elucidate source of infection. Treated
empirically with Vanc/Zosyn. Blood and urine cx obtained which
showed no growth. Medically managed empirically for MI with
aspirin/plavix/statin. The patient was normotensive on continued
to show no signs of sepsis. Vanc was discontinued and pt
remained on Zosyn for 2 additional days. He continued to remain
stable and af and antibiotic course was tranistioned to
Cipro/Flagyl as it was thought primary SIRS event was most
likely of GI etiology.
# Abdominal pain: Likely this was due to constipation. CT
abdomen only showed fecal loading. KUB showed constipation. RUQ
US showed No cholecystis. ACS consulted on admission and said
not surgical. No concern for obstruction. LFTs mildly elevated
so obtained hepatitis serologies, which were all negative.
Recommended serial abd exams. Pt received enema and had several
large BM and improvement in symptoms. He did not complain of
abdominal pain over the weekend ___ - ___.
#Hypoxemia: pt was stable on 2L NC in MICU with some prominent
pulm vasculature and atelectasis. Given reduced EF, and slightly
elevated JVD hypoxemia was thought to be ___ mild pulm edema,
especially in setting of fluid resuscitation and new reduction
in EF. No signs of PE. Received small dose of lasix in MICU and
SOB improved. There was a concern for aspiration on the floor
and speech and swallow evaluated patient. They recommended he
remain NPO until strength and mental status improved. He was
transitioned to a puree diet after several days.
# ___ on CKD: creatinine elevated to 2.6 on admission from
baseline creatinine of 1.5. Urine lytes on admission c/w pre
renal with fena of 0.59%. Pt ___ had low UOP. Given IVF. Cr
trended up throughout hospital course despite fluids so renal
was consulted and urine spun, showing muddy brown casts c/w ATN.
ATN was thought to be ___ prolonged prerenal state given
prerenal findings and hypotension on admission. SPEP and UPEP
were also ordered and were negative. Cr peaked at 4.4 and
thereafter trended down.
#Hypernatremia: Pt's ATN was complicated by hypernatremia.
Sodium peaked at 149 on ___ and pt was started on D5W. Renal
was consulted and free water replacement was calculated consider
free water clearance. The patients hypernatremia improved after
___ Liters of D5W. Sodium has remained stable for the rest of
admission.
# Thrombocytopenia: Per records, Plt have been in low 100s in
PCP's office. Plats below baseline on admission and trended down
with no signs of bleeding. No schistocytes on smear so TTP /HUS
thought to be less likely. Held SC heparin once plats dropped
below 50. We trended platelets and they were in the 200s at the
time of discharge.
# HTN: held home antihypertensives on admission. His home meds
were restarted started with metoprolol once BP stabilized above
140/90, but metoprolol was held in the setting of GIB. Blood
pressures remained stable. His BB was restarted the day prior
to discharge. His ramipril was also continued at the time of
discharge.
# Gout: renally dosed allopurinol
# Recent cataract surgery: continued prednisolone, ketorlac
# Med rec: continued vit D, MVI, timolol, ranitidine.held iron
# CAD: Stable angina at home. trended troponins and checked EKG
as above. continued aspirin, plavix, pravastatin until GIB.
Imdur, metoprolol, ramipril held at first but reintroduced when
patient stabilized.
.
-
Medications on Admission:
Preadmissions medications listed are incomplete and require
futher investigation. Information was obtained from OSH
records.
1. Allopurinol ___ mg PO DAILY
2. Doxazosin 8 mg PO HS
3. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
4. Pravastatin 40 mg PO DAILY
5. Timolol Maleate 0.5% 1 DROP BOTH EYES BID
6. Vitamin D 1000 UNIT PO DAILY
7. Centrum Silver *NF* (multivitamin-minerals-lutein;<br>mv with
min-lycopene-lutein;<br>mv-min-folic acid-lutein) 0.4-300-250
mg-mcg-mcg Oral daily
8. Ferrous Sulfate 325 mg PO DAILY
9. Aspirin 81 mg PO DAILY
10. Metoprolol Succinate XL 50 mg PO DAILY
11. Ranitidine 300 mg PO DAILY
12. Clopidogrel 75 mg PO DAILY
13. Ramipril 5 mg PO DAILY
14. ketorolac *NF* 0.5 % OS qid
15. PrednisoLONE Acetate 1% Ophth. Susp. 1 DROP LEFT EYE QID
Discharge Medications:
1. Allopurinol ___ mg PO DAILY
renally dosed
2. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
3. Pravastatin 40 mg PO DAILY
4. PrednisoLONE Acetate 1% Ophth. Susp. 1 DROP LEFT EYE QID
5. Ramipril 5 mg PO DAILY
6. Timolol Maleate 0.5% 1 DROP BOTH EYES BID
7. Simethicone 40-80 mg PO QID
8. Pantoprazole 40 mg PO Q12H
9. Acetaminophen 325-650 mg PO Q6H:PRN pain
do not exceed more than 2 gram per day
RX *acetaminophen 325 mg 1 tablet(s) by mouth every 6 hours Disp
#*60 Tablet Refills:*0
10. Centrum Silver *NF* (multivitamin-minerals-lutein;<br>mv
with min-lycopene-lutein;<br>mv-min-folic acid-lutein)
0.4-300-250 mg-mcg-mcg Oral daily
11. Doxazosin 8 mg PO HS
12. Ferrous Sulfate 325 mg PO DAILY
13. Ranitidine 300 mg PO DAILY
14. Vitamin D 1000 UNIT PO DAILY
15. Metoprolol Succinate XL 50 mg PO DAILY
16. Aspirin 81 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary:
Hypotension secondary to NSTEMI and SIRS
GI bleed
esophagitis
CAD
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you during your admission to
___. You were transferred here due to low blood pressure and
trouble with your kidneys. You were started on antibiotics
because we believed there was an infection in your blood. You
may have also had a minor heart attack contributing to your low
blood pressure as well. Your blood pressure returned to normal
and your kidneys improved, but you began to bleed into your
gastrointestinal tract. You were given fluids, blood, and
placed on medications to protect your stomach. You were seen by
the GI doctors and had a procedure done to look for any areas of
bleeding. Your procedure revealed some minor tears in your
esophagus that were healing. Your blood counts stabilized and
you continued to improve until discharge.
Followup Instructions:
___
|
19715664-DS-7
| 19,715,664 | 29,713,954 |
DS
| 7 |
2152-09-08 00:00:00
|
2152-09-08 20:27:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Procardia XL
Attending: ___.
Chief Complaint:
progressive SOB
Major Surgical or Invasive Procedure:
___ Cardioversion
History of Present Illness:
___ w/ hx of pacemaker placement and CHF, HTN, HLD, p/w
generalized weakness and increased SOB.
Patient reports progressive SOB over the past week and a half
and generalized weakness. She took an extra pill of furosemide
2 days last at the directionof her ___, but bp was low 100s at
home so she has been taking only her regular dose for the past
few days. She denies any fevers, sick contacts, cough, PND,
increased swelling, adding pillows( baseline 3 pillows), CP,
SOB, abdominal pain, pain on urination, nausea, vomiting,
changed bowel habits. She does endorse a mild headache that has
come and gone but denies diziness. No recent plane travel,
opperations. At adult daycare today she was feeling weak and
the nurse there checked her vitals found her to be tachycardic
sent her in to the ED.
In the ED, initial vital signs were: T 98.2 P ___ B146/99 R 18
O2 sat 98% RA. Exam notable for tachycardia, clear lungs, b/l
edea to b/l legs.
Labs were notable for troponin <.01, h/h 11.7/36.4 (at baseline)
WBC 7.3 70% neutrophils, UA with moderate leukocytes , negative
nitrites, BUN/Cr ___ (at baseline) proBNP 2602 ___ 209)
Patient was given CeftriaXONE 1 g IV sent to the floor.
On Transfer Vitals were: 98.2 128/91 114 18 98%
Past Medical History:
Hypertensive heart disease, Chronic diastolic heart failure.
S/p dual-chamber pacemaker - implanted at the ___
___ ___ likely for sick sinus syndrome
HTN
HLD
Glucose intolerance.
Status post hernia repair.
Status post CCY.
Status post shoulder surgery
Social History:
___
Family History:
non contributory
Physical Exam:
ADMISSION PHYSICAL EXAM:
PHYSICAL EXAM:
Vitals: 98.2 128/91 114 18 98%
General: well appearing sitting in bed, speaking in full
sentances, NAD
HEENT: moist mucous membranes, JVP to midneck
CV: tachycardic
Lungs: CTA b/l with crackes at bases, no wheezes
Abdomen: soft, nontender,
Ext: WWP, 1+ pulses b/l, 1+ swelling to midcalf.
Neuro: CN II-XII grossly intact, no pronator drift, can lift
both legs off without much effort,
Skin: large hyperpigmented macule on R abdomen clear boarders
(this has been there for a long time, per patient)
==============================================================
DISCHARGE PHYSICAL EXAM:
Vitals: 97.9 131/57 59 18 97%
tele: a paced v sensed in ___
General: well appearing sitting in chair breathing comfortably
HEENT: moist mucous membranes, JVP 6cm at clavical,
Lungs: CTA-B
CV: RRR no m/r/g appreciated
Abdomen: soft, nontender, no rebound/ guarding.
Ext: warm and well perfused 1+ to ankles
Neuro: grossly intact
Skin: rectangular rash with well defined erythematous boarder on
midchest.
Pertinent Results:
INITIAL LABS:
___ 12:20PM URINE MUCOUS-RARE
___ 12:20PM URINE RBC-0 WBC-8* BACTERIA-NONE YEAST-NONE
EPI-1 TRANS EPI-<1
___ 12:20PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-MOD
___ 12:20PM URINE COLOR-Straw APPEAR-Clear SP ___
___ 12:20PM PLT COUNT-280
___ 12:20PM NEUTS-70.0 ___ MONOS-4.5 EOS-4.6*
BASOS-0.5
___ 12:20PM WBC-7.3 RBC-4.69 HGB-11.7* HCT-36.4 MCV-78*
MCH-24.9* MCHC-32.0 RDW-14.8
___ 12:20PM URINE GR HOLD-HOLD
___ 12:20PM URINE UHOLD-HOLD
___ 12:20PM URINE HOURS-RANDOM
___ 12:20PM URINE HOURS-RANDOM
___ 12:20PM CALCIUM-9.4 PHOSPHATE-3.7 MAGNESIUM-2.1
___ 12:20PM proBNP-2602*
___ 12:20PM cTropnT-<0.01
___ 12:20PM estGFR-Using this
___ 12:20PM GLUCOSE-119* UREA N-28* CREAT-1.7* SODIUM-138
POTASSIUM-4.4 CHLORIDE-103 TOTAL CO2-22 ANION GAP-17
___ 12:27PM LACTATE-2.6*
___ 12:27PM ___ COMMENTS-GREEN TOP
___ 09:00PM CK-MB-1 cTropnT-<0.01
___ 09:47PM LACTATE-2.3*
INTERIM LABS:
___ 07:30AM BLOOD WBC-6.4 RBC-4.40 Hgb-11.4* Hct-34.4*
MCV-78* MCH-25.9* MCHC-33.2 RDW-14.7 Plt ___
___ 07:45AM BLOOD WBC-6.7 RBC-4.46 Hgb-11.3* Hct-35.8*
MCV-81* MCH-25.3* MCHC-31.4 RDW-14.7 Plt ___
___ 06:50AM BLOOD WBC-7.4 RBC-4.41 Hgb-11.0* Hct-33.9*
MCV-77* MCH-24.9* MCHC-32.4 RDW-15.0 Plt ___
___ 05:14PM BLOOD WBC-8.1 RBC-4.52 Hgb-11.5* Hct-35.0*
MCV-78* MCH-25.5* MCHC-32.9 RDW-14.9 Plt ___
___ 07:00AM BLOOD WBC-7.9 RBC-4.62 Hgb-11.8* Hct-36.4
MCV-79* MCH-25.5* MCHC-32.5 RDW-14.8 Plt ___
___ 07:30AM BLOOD Glucose-99 UreaN-28* Creat-1.9* Na-142
K-4.2 Cl-102 HCO3-25 AnGap-19
___ 07:45AM BLOOD Glucose-97 UreaN-36* Creat-2.1* Na-140
K-5.1 Cl-104 HCO3-18* AnGap-23*
___ 06:50AM BLOOD Glucose-98 UreaN-35* Creat-1.7* Na-138
K-4.1 Cl-102 HCO3-26 AnGap-14
___ 05:14PM BLOOD Glucose-103* UreaN-35* Creat-1.7* Na-137
K-4.3 Cl-102 HCO3-23 AnGap-16
___ 07:00AM BLOOD Glucose-103* UreaN-32* Creat-1.7* Na-140
K-4.1 Cl-102 HCO3-24 AnGap-18
___ 12:20PM BLOOD cTropnT-<0.01
___ 09:00PM BLOOD CK-MB-1 cTropnT-<0.01
___ 05:00PM BLOOD CK-MB-1 cTropnT-<0.01
___ 07:30AM BLOOD Calcium-9.9 Phos-4.6* Mg-2.2
___ 07:45AM BLOOD Calcium-8.9 Phos-5.0* Mg-2.2
___ 06:50AM BLOOD Calcium-8.8 Phos-4.2 Mg-2.4
___ 05:14PM BLOOD Calcium-9.3 Phos-4.4 Mg-2.4
___ 07:00AM BLOOD Calcium-9.7 Phos-4.2 Mg-2.5
___ 07:30AM BLOOD TSH-1.2
DISCHARGE LABS:
___ 12:55PM BLOOD WBC-8.1 RBC-4.23 Hgb-11.1* Hct-33.1*
MCV-78* MCH-26.3* MCHC-33.6 RDW-14.7 Plt ___
___ 12:55PM BLOOD Glucose-107* UreaN-38* Creat-1.9* Na-135
K-4.3 Cl-99 HCO3-22 AnGap-18
___ 12:55PM BLOOD Calcium-9.6 Phos-4.5 Mg-2.6
___ CXR
Left-sided dual-chamber pacemaker device is noted with leads
terminating in the right atrium and right ventricle, unchanged.
Lung volumes are low which accentuate the size of the cardiac
silhouette which appears moderately enlarged. Aorta remains
tortuous and calcified. There is crowding of the bronchovascular
structures with probable mild pulmonary vascular congestion.
Patchy opacities in the lung bases likely reflect areas of
atelectasis. A small left pleural effusion may be present. No
pneumothorax is demonstrated. Multilevel degenerative changes
are seen in the thoracic spine. IMPRESSION: Low lung volumes
with patchy bibasilar airspace opacities, likely atelectasis.
Possible mild pulmonary vascular congestion and small left
pleural effusion.
___ echo The left atrium is moderately dilated. No atrial
septal defect is seen by 2D or color Doppler. There is mild
symmetric left ventricular hypertrophy with normal cavity size
and regional/global systolic function (LVEF>55%). There is no
ventricular septal defect. Right ventricular chamber size and
free wall motion are normal. The 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. Mild to moderate
(___) mitral regurgitation is seen. The tricuspid valve
leaflets are mildly thickened. There is mild pulmonary artery
systolic hypertension. ICAEL Accredited Electronically signed by
___, MD, Interpreting physician ___ ___ 13:47
___ ECG Probable atrial flutter with a 2:1 conduction. Left
axis deviation. Left anterior fascicular block. Non-specific
ST-T wave changes. TRACING ___ ECHO No spontaneous echo contrast or thrombus is seen in
the body of the left atrium/left atrial appendage or the body of
the right atrium/right atrial appendage. 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 descending thoracic aorta. The aortic valve
leaflets (3) appear structurally normal with good leaflet
excursion. Mild (1+) aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. Moderate (2+) mitral
regurgitation is seen ___ 0.2 cm2, regurgitant volume 32 mL).
There is no pericardial effusion.
IMPRESSION: No spontaneous echo contrast or thrombus seen in the
___. Normal biventricular systolic function. Moderate
mitral regurgitation. Mild aortic regurgitation.
Brief Hospital Course:
___ year old female with Chronic diastolic heart failure s/p
dual-chamber pacemaker placement presents with progressive SOB
and generalized weakness found to be tachycardic in new onset
atrial flutter. Patient was cardioverted and started on
anticoagulation and rate controlled with metoprolol. At
discharge patients SOB was much improved.
#atrial flutter: Patient was found to be in new onset aflutter,
thought to likely driving symptoms. Labetaolol was discontinued
in favor of metoprolol. Given CHADS2 score = 3 patient was
started on coumadin with a heparin bridge. Patient had
successful DCCV cardioversion on ___. After procedure
patient experienced significant symptomatic relief. INR on
discharge = 2.2
#CHF exacerbation: Patient appeared volume up on admission with
elevated JVP and crackles on exam likely due to new onset
aflutter causing CHF exacerbation. Initially diuresed with
double home dose of IV lasix with good effect. She resumed her
home dose of lasix and remained euvolemic for the remainder of
her hospitalization.
#HTN: Patient was found to be hypotensive on admission. Home
labetalol discontinued in favor of metoprolol. After the
procedure her blood pressure improved significantly to 140s
systolic. She was sent home on a reduced dose of Valsartan to
be uptitrated by outpatient doctors.
#GERD: replace home esomeprazole with Omeprazole 40 mg PO DAILY
#HLD- Not on statin given age
# Code: full (confirmed)
# Emergency Contact: daughter ___ (HCP) ___ (cell)/
___
***TRANSITIONAL ISSUES***
-Patient will need INR monitoring as an outpatient
-INR goal ___
-INR on discharge 2.2
-Patient developed contact dermatitis after cardioversion. She
is being treated with hydrocortisone cream. Please ensure
resolution.
-Labetalol was discontinued.
-Patient started on metoprolol. discharged on metoprolol XL 75mg
daily.
-Valsartan dose reduced to 80mg BID please continue to titrate
to outpatient bps.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Furosemide 20 mg PO DAILY
2. esomeprazole magnesium 40 mg oral daily
3. Labetalol 150 mg PO BID
4. Valsartan 80 mg PO QAM
5. Valsartan 160 mg PO QPM
6. Aspirin 81 mg PO DAILY
7. Cyanocobalamin 1000 mcg IM/SC MONTHLY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Furosemide 20 mg PO DAILY
3. Valsartan 80 mg PO BID
RX *valsartan [Diovan] 80 mg 1 tablet(s) by mouth twice a day
Disp #*56 Tablet Refills:*0
4. Hydrocortisone Cream 1% 1 Appl TP QID
RX *hydrocortisone 1 % please apply up to 4 times a day QID: PRN
as needed Refills:*0
5. Cyanocobalamin 1000 mcg IM/SC MONTHLY
6. esomeprazole magnesium 40 mg oral daily
7. Metoprolol Succinate XL 75 mg PO DAILY
RX *metoprolol succinate 25 mg 3 tablet(s) by mouth daily Disp
#*105 Tablet Refills:*0
8. Warfarin 4 mg PO DAILY16
RX *warfarin 1 mg 4 tablet(s) by mouth daily Disp #*112 Tablet
Refills:*1
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Final diagnosis:
atrial flutter
diastolic CHF exacerbation acute on chronic
Secondary Diagnosis:
HTN
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 after you were found to have a
fast heart rate and more shortness of breath. You were found to
have a fast and irregular heart rate called atrial flutter. To
treat you we put you on a medication called metoprolol and you
had a procedure called cardioversion to restore a normal rhythm.
Because this heart rate puts you at a high risk of stroke you
were started on a blood thinner called coumadin. You will need
to have your blood tests checked very frequently and monitored
by your primary care doctor to make sure you are taking the
right amount of medication.
-Please stop taking labetalol at home as it is no longer needed
-Losartan dose was decreased to 80 mg twice daily.
Followup Instructions:
___
|
19715664-DS-8
| 19,715,664 | 28,113,132 |
DS
| 8 |
2154-04-28 00:00:00
|
2154-04-30 18:29:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Procardia XL
Attending: ___.
Chief Complaint:
Left elbow cellulitis
Gout
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ with PMx atrial fibrillation s/p DCCV on Coumadin, ___,
SSS s/p biV pacer, HTN, who presents with L elbow swelling and
erythema. Per her daughter this was noted 48 hours ago. There
was no witnessed trauma, but she had a bruise earlier last week
on the elbow. Since ___, elbow became painful, red, swollen.
The pain has resolved. There has been no fever. The patient has
not been eating since onset, and also complained of chest
discomfort, initially described as discomfort with swallowing.
In the ED, initial vitals were: 98.3 66 137/52 16 94% RA
Exam notable for: On exam pleasant and not toxic-appearing,
erythema and swelling from above L elbow to mid L forearm, no
pain with palpation of skin or ROM
Labs notable for: WBC 11.9 (increased from baseline), Hgb 10.4,
INR 2.0, lactate 1.2, trop <0.01, Cr 1.7 (baseline)
Imaging notable for:
Left elbow film: IMPRESSION:
1. No fracture or dislocation.
2. No joint effusion.
ECG: SR @ 60, borderline LAD, borderline LBBB, TWI III,
equivocal STD V4-V6, overall CWP
Patient was given:
___ 00:01 IV Vancomycin 1000 mg
___ 00:01 PO Acetaminophen 650 mg
On the floor, the patient has no complaints. ROS notable for
absence of nausea/emesis, weight gain, orthopnea, ___ edema,
dysuria, cough. 'Chest pain' as above. Of note, patient has had
nausea/epigastric discomfort as outpatient concerning for angina
equivalent. ROS notable also for feeling "off balance" since
poor PO intake/L elbow pain started.
Past Medical History:
Hypertensive heart disease, Chronic diastolic heart failure.
S/p dual-chamber pacemaker - implanted at the ___
___ ___ likely for sick sinus syndrome
HTN
HLD
Glucose intolerance.
Status post hernia repair.
Status post CCY.
Status post shoulder surgery
Multinodular toxic goiter
Elongated, unfolding aortic arch causing rightward deviation of
trachea
Social History:
___
Family History:
non contributory
Physical Exam:
ON ADMISSION:
VS 98.0 PO 139 / 55 61 18 95% on RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL,
neck supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, ___ systolic murmur
loudest at LUSB.
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
GU: No foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis,
trace edema in bilateral lower extremities.
MSK: Dorsal aspect of R elbow joint
edematous/erythematous/indurated, but non-tender. Surrounding
erythema over forearm and upper arm demarcated with marker. No
pain with active/passive elbow flexion/extension.
Neuro: CNII-XII intact, ___ strength upper/lower extremities,
grossly normal sensation, gait deferred.
ON DISCHARGE:
Vitals: 98.7 122/54 60 17 97% RA
General: lying in bed, knows she's at ___, comfortable
HEENT: sclera anicteric, moist mucous membranes, CN intact.
Neck: unable to visualize JVP
Lungs: few rhonchi bilaterally
CV: Regular rate and rhythm, normal S1 + S2, ___ systolic murmur
loudest at ___.
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding
Ext: L elbow with resolution of erythema, mild swelling.
Non-tender and full ROM. BLE warm, well perfused, trace edema.
No inflamed joints. Bilaterally ankles non-tender.
Neuro: motor function grossly normal. Good strength in BUE.
Pertinent Results:
ADMISSION LABS:
___ 10:30PM BLOOD WBC-11.9*# RBC-4.20 Hgb-10.4* Hct-33.1*
MCV-79* MCH-24.8* MCHC-31.4* RDW-15.0 RDWSD-42.8 Plt ___
___ 10:30PM BLOOD Neuts-77.7* Lymphs-12.2* Monos-7.8
Eos-1.4 Baso-0.4 Im ___ AbsNeut-9.22*# AbsLymp-1.44
AbsMono-0.92* AbsEos-0.16 AbsBaso-0.05
___ 10:30PM BLOOD ___ PTT-38.4* ___
___ 10:30PM BLOOD Plt ___
___ 10:30PM BLOOD Glucose-117* UreaN-20 Creat-1.7* Na-135
K-3.9 Cl-96 HCO3-25 AnGap-18
___ 10:30PM BLOOD cTropnT-<0.01
___ 09:16PM BLOOD CK-MB-<1 cTropnT-<0.01
___ 10:30PM BLOOD Calcium-9.2 Phos-3.6 Mg-2.3
___ 10:30PM BLOOD TSH-0.47
___ 10:36PM BLOOD Lactate-1.2
DISCHARGE LABS:
___ 07:50AM BLOOD WBC-6.8 RBC-3.88* Hgb-9.6* Hct-30.3*
MCV-78* MCH-24.7* MCHC-31.7* RDW-14.5 RDWSD-40.7 Plt ___
___ 07:50AM BLOOD ___
___ 07:50AM BLOOD Glucose-123* UreaN-32* Creat-1.7* Na-137
K-4.4 Cl-98 HCO3-25 AnGap-18
___ 07:50AM BLOOD Calcium-9.1 Phos-4.2 Mg-2.6
___ 07:50AM BLOOD TotProt-5.7* Calcium-8.8 Phos-4.1 Mg-2.3
IMAGING:
ELBOW (AP, LAT & Oblique) ___:
IMPRESSION:
1. No fracture or dislocation.
2. No joint effusion.
CHEST (PORTABLE AP) ___:
IMPRESSION:
Comparison to ___. Improved inspiration. A density
in the right lung apex is caused by a calcified costosternal
junction of the first right rib. Currently there is no evidence
of pneumonia. No pulmonary edema. Minimal atelectasis in the
retrocardiac lung areas. Borderline size of the cardiac
silhouette. Mild elongation of the descending aorta.
ANKLE (AP, MORTISE & LA) ___:
IMPRESSION:
No acute fracture is seen.
CHEST (PORTABLE AP) ___:
IMPRESSION:
1. Superior portion of trachea appears shifted to the right
side when
compared to ___ chest radiograph; this could be
secondary to low lung volumes or patient's rotated position when
image was taken. However, cannot rule out a comparison mass.
Recommend repeat chest x-ray with adequate inspiration for
further evaluation.
TRANSTHORACIC ECHOCARDIOGRAM ___:
Conclusions
There is mild symmetric left ventricular hypertrophy with
normal cavity size and global systolic function (LVEF>55%). Due
to suboptimal technical quality, a focal wall motion abnormality
cannot be fully excluded. Right ventricular chamber size is
normal There is an anterior space which most likely represents a
prominent fat pad.
CT CHEST W/O CONTRAST ___:
IMPRESSION:
Multinodular goiter with mild attenuation of the trachea.
The rightward displacement of the trachea at the level of the
superior
mediastinum is due to an elongated, unfolding aortic arch. No
significant
attenuation of the trachea at this level.
No mediastinal masses.
Multiple pulmonary nodules the largest in the left upper lobe
measuring 7 mm and the right upper lobe measuring 6 mm.
Follow-up should be determined in the clinical context of the
patient.
MICROBIOLOGY:
___ 10:30 pm BLOOD CULTURE
Blood Culture, Routine (Pending):
___ 11:05 pm BLOOD CULTURE
Blood Culture, Routine (Pending):
Brief Hospital Course:
___ yo F with PMHx atrial fibrillation s/p DCCV on Coumadin,
___, SSS s/p biV pacer, HTN, who presents with L elbow swelling
and erythema and occasional chest discomfort; course as below:
# Left elbow cellulitis: Non-purulent cellulitis with possible
inciting incident mild trauma with possible skin break. She has
an elevated white count but no fevers, tachycardia. Low concern
for septic joint/hematoma; no pain or joint effusion on XRay. No
risk factors or history of MRSA infection. Clinically improved
with Keflex, will complete 7 day course.
# Polyarthralgias: Per daughter, had shoulder, ankle pain for
the last several months. Elevated ESR 106, CRP 211, uric acid
11. Per rheumatology, concerning for gout. Globulin gap normal.
RF 18 (mild elevation), ___, ANCA negative. SPEP, UPEP pending.
Started on prednisone 20 mg with taper for 8 day course, in
addition to allopurinol 50 mg daily, with plan to follow up in
___ clinic in 1 week.
She was continued on home vitamin D and started on calcium.
# Chest discomfort - EKGs unchanged, troponin negative, no e/o
CHF exacerbation. Recently seen as outpatient for fatigue with
concern for ?angina/ hypotension/bradycardia contributing.
Cardiac medications adjusted (amlodipine increased, diovan
decreased, metoprolol decreased) with reported good effect. TSH
0.47. No events on telemetry, pacemaker interrogation with no
arrhythmias. She may benefit from outpatient stress test and/or
esophageal evaluation. She was continued on ranitidine and
esomeprazole for GERD.
# L ankle pain: ?unwitnessed injury during hospitalization with
strain vs. sprain. Xray with no e/o fracture. Could be related
to gout. She was seen by ___ who recommended rehab given acute on
chronic ankle pain and weakness. Treatment of gout, as above.
CHRONIC ISSUES:
# Atrial fib s/p DCCV: CHADS-Vasc 5, on warfarin. Continue
metoprolol & warfarin
# Chronic diastolic heart failure: Appeared compensated.
Continued on home metoprolol, lasix, valsartan. Evening dose
Lasix 20 mg was held due to poor PO intake and hypovolemia.
# HTN: Continued home amlodipine, metoprolol, valsartan
# Sick sinus syndrome s/p s/p dual-chamber pacemaker placement:
Pacemaker interrogated, as above.
# CKD: Cr at baseline. Medications were renally-dosed.
# Iron-deficiency anemia: At baseline hgb. She was continued on
ferrous sulfate
# Toxic multinodular goiter: Found on CT which was done for
tracheal deviation (see below). TSH normal, goiter not impinging
on trachea.
# FEN: IVF PRN, replete electrolytes, regular diet
# PPX: systemic anti-coagulation, Senna/Colace, analgesics prn
# ACCESS: PIVs
# CODE: Full, confirmed
# CONTACT: Daughter ___ ___
# DISPO: Medicine for now
--------------
Transitional issues:
# L elbow cellulitis: Keflex ___ mg q8H ___
# Chest discomfort: EKGs unchanged, pacemaker with no events.
___ benefit from outpatient stress test. ___ benefit from
esophageal eval as outpatient.
# Gout: Started on prednisone with following taper:
___ - 20mg ; ___ mg; ___ mg; ___ -
10 mg
___ mg; ___ mg; ___ mg. Started on allopurinol 50
mg daily. ___ benefit from colchicine 0.6 every other day, given
CKD, after completion of prednisone taper. Started on calcium,
in addition to home medication Vitamin D, for osteoporosis
protection.
# Evening dose furosemide 20 mg held due to volume depletion
secondary to poor PO intake. Can restart if develops dyspnea,
volume overload, or weight gain of 3 lbs or more.
# CXR showed tracheal deviation with no evidence of
pneumothorax. Chest CT was done for further eval and showed
anatomical variant elongated aorta causing rightward shift of
trachea, toxic multinodular goiter (TSH normal), and pulmonary
nodules. No impingement on trachea. Follow up CT in ___ months
for monitoring pulmonary nodules.
# Will need follow up in ___ clinic (at ___ ___ within 1
week of discharge.
# CODE: Full, confirmed
# CONTACT: Daughter ___ ___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. Valsartan 80 mg PO QPM
2. Metoprolol Succinate XL 50 mg PO DAILY
3. Warfarin 4 mg PO DAILY16
4. amLODIPine 5 mg PO DAILY
5. Ranitidine 150 mg PO QHS
6. Ferrous Sulfate 325 mg PO DAILY
7. Furosemide 40 mg PO QAM
8. Furosemide 20 mg PO QPM
9. esomeprazole magnesium 40 mg oral DAILY
10. Aspirin 81 mg PO DAILY
11. Cyanocobalamin 1000 mcg IM/SC QMONTHLY
12. Vitamin D 3000 UNIT PO DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
2. Allopurinol 50 mg PO DAILY
3. Calcium Carbonate 500 mg PO TID
4. Cephalexin 250 mg PO Q8H
5. Ipratropium-Albuterol Neb 1 NEB NEB Q6H:PRN wheezing
6. amLODIPine 5 mg PO DAILY
7. Aspirin 81 mg PO DAILY
8. esomeprazole magnesium 40 mg oral DAILY
9. Ferrous Sulfate 325 mg PO DAILY
10. Metoprolol Succinate XL 50 mg PO DAILY
11. Ranitidine 150 mg PO QHS
12. Valsartan 80 mg PO QPM
13. Vitamin D 3000 UNIT PO DAILY
14. Warfarin 2.5 mg PO 2X/WEEK (MO,FR)
15. Warfarin 2 mg PO 5X/WEEK (___)
16. HELD- Furosemide 40 mg PO QAM This medication was held. Do
not restart Furosemide until pending clinical evaluation at
rehab, will restart in ___ days or sooner if gain 3 or more
pounds
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSES:
Left elbow cellulitis
Gout
SECONDARY DIAGNOSES:
Atrial fibrillation
Sick sinus syndrome with pacemaker
Diastolic heart failure
Chronic kidney disease
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Ms. ___,
You were admitted to ___ from ___ for left elbow and
forearm infection (cellulitis). We treated you with antibiotics
(Keflex). Your last day on this medication will be ___.
Your daughter also told us about your history of joint pains.
Our rheumatology team evaluated you further and found that you
may have gout. You were started on prednisone for an 8 day
course (doses outlined below) and allopurinol, which you will
need on an ongoing basis. Prednisone can increase risk of
osteoporosis so we started you on calcium, in addition, to the
Vitamin D you were taking, for bone protection. We scheduled you
for a follow up appointment in ___ clinic in ___ weeks.
You also had vague chest discomfort a couple times in the
hospital. We did not think there was dangerous cause of this.
Our cardiology team interrogated your pacemaker and there was no
evidence of an abnormal heart rhythm. You should follow up with
a cardiologist in ___ weeks, as they might want to do additional
testing.
While you were in the hospital, we held your evening dose of
furosemide 20 mg, because you weren't drinking as much as you
normally would. You should check your weight daily and if it
goes up by 3 lbs or more, you should restart this medicine.
You will also need to follow up within 1 week to check your INR
level for Coumadin.
Thank you for allowing us to take part in your care!
-Your entire ___ team
Followup Instructions:
___
|
19715664-DS-9
| 19,715,664 | 21,615,543 |
DS
| 9 |
2155-04-13 00:00:00
|
2155-04-17 20:54:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Procardia XL
Attending: ___.
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ year old woman with a past medical
history of atrial fibrillation s/p DCCV on Coumadin, HFpEF, SSS
s/p biV pacer, HTN, gout, and dementia who presents with
dyspnea.
The patient's daughter provides history as the patient is
___ speaking.
The patient began having symptoms three days prior to admission.
She is having shortness of breath with moving a few steps. At
baseline she can walk about 100 feet with a walker. The daughter
also noted that the patient's heart rate was elevated to 100
transiently at rest three times over the past three days. This
is associated with a mild chest pressure in the substernal
region. Overall, she is feeling more weakness, fatigue, and
lightheadedness.
The patient denies cough, fevers, chills. She has two pillow
orthopnea at baseline and this has not changed. No PND. Lower
extremity edema is more notable than at baseline. No change in
the diet.
Denies chest pain and shortness of breath at the time of
presentation to the ED.
ED Course:
Initial vitals
98.5 56 113/61 24 97% RA
Exam: Normal heart and lung exam. Mild pitting edema. Bowel
sounds present, abdomen soft, no rebound, no guarding.
Labs notable for:
Na 133 K 5 Cl 95 HCO3 19 BUN 48 Cr 1.9 Glucose 148 AG 19
CK 67 MB 1 Trop <0.01
NT-proBNP 4802
CBC: 10.2>10.6/33.6<270
INR 2.7
UA 2WBC, few ___
Patient was given
___ 17:15 IV Furosemide 40 mg
Imaging with:
CXR showing Mild interstitial pulmonary edema and mild bibasilar
atelectasis.
EKG shows paced with rate 60, new TWI in V2, No ischemic ST-T
changes, T waves appear slightly more peaked than prior EKG.
Vitals at the time of transfer
98.3 69 117/82 18 96% RA
Upon arrival to the floor, the patient reports no shortness of
breath or chest pain. She is comfortable at rest. She reports ___
edema is mildly improving since furosemide given. The patient's
daughter reports that they dry weight is 215 lb.
REVIEW OF SYSTEMS:
General: no weight loss, fevers, sweats.
Eyes: no vision changes.
ENT: no odynophagia, dysphagia, neck stiffness.
Cardiac: See HPI
Resp: See HPI
GI: no nausea, vomiting, diarrhea.
GU: no dysuria, frequency, urgency.
Neuro: no unilateral weakness, numbness, headache.
MSK: no myalgia or arthralgia.
Heme: no bleeding or easy bruising.
Lymph: no swollen lymph nodes.
Integumentary: no new skin rashes or lesions.
Psych: no mood changes
Past Medical History:
Chronic diastolic heart failure
Atrial fibrillation s/p DCCV in ___
S/p dual-chamber pacemaker - implanted at the ___
___ ___ likely for sick sinus syndrome
HTN
HLD
chronic recurrent tophaceous gout
Glucose intolerance.
Status post hernia repair.
Status post CCY.
Status post shoulder surgery
Multinodular toxic goiter
Elongated, unfolding aortic arch causing rightward deviation of
trachea
Social History:
___
Family History:
non contributory
Physical Exam:
ADMISSION PHYSICAL EXAM:
VITALS: 98.3 135/74 103 21 91 RA
WEIGHT ON ADMISSION: 98.7 kg
DRY WEIGHT: 97.5kg (per pt daughter)
GEN: Well appearing and appears stated age. No acute distress.
HEENT: PERRL, EOMI, Oropharynx clear with moist mucous
membranes.
NECK: JVP at 12cm
PULM: Mild bibasilar crackles. No wheezes, rales, or rhonchi.
Good air movement bilaterally
CV: RRR normal S1 S2. No murmurs rubs or gallops. Radial pulses
2+ symmetric.
ABD: Soft, nontender, nondistended. Bowel sounds present.
EXTR: Warm, well perfused. No cyanosis, clubbing. Trace pedal
edema. Full ROM in bilateral MTP. No warmth or erythema noted.
NEURO: Alert and oriented. Strength ___ in upper and lower
extremities. Sensation to light touch intact and symmetric.
SKIN: No visible ecchymoses or rash.
DISCHARGE PHYSICAL EXAM:
97.6 153 / 78 51 20 95 Ra
General: sleeping comfortably, nad, easily awaken
HEENT: moist mucus membranes, sclera nonicteric
Neck: supple
CV: irregular rhythm, no murmurs, 2+ radial pulse
Lungs: clear to auscultation bilaterally, no crackles or
wheezes, no use of accessory muscles
Abdomen: obese abdomen, soft, nontender
Ext: 1+ edema in bilateral lower extremities
Neuro: oriented to self and place, grossly moving all
extremities
Pertinent Results:
ADMISSION LABS
___ 09:30PM CK-MB-1 cTropnT-<0.01
___ 02:05PM URINE HOURS-RANDOM
___ 02:05PM URINE HOURS-RANDOM
___ 02:05PM URINE UHOLD-HOLD
___ 02:05PM URINE GR HOLD-HOLD
___ 02:05PM URINE COLOR-Straw APPEAR-Clear SP ___
___ 02:05PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-SM*
___ 02:05PM URINE RBC-2 WBC-2 BACTERIA-FEW* YEAST-NONE
EPI-1 TRANS EPI-<1
___ 01:10PM GLUCOSE-128* UREA N-48* CREAT-1.9* SODIUM-133
POTASSIUM-5.0 CHLORIDE-95* TOTAL CO2-19* ANION GAP-24*
___ 01:10PM CK(CPK)-67
___ 01:10PM cTropnT-<0.01
___ 01:10PM CK-MB-1 proBNP-4802*
___ 01:10PM WBC-10.2* RBC-3.84* HGB-10.6* HCT-33.6*
MCV-88 MCH-27.6 MCHC-31.5* RDW-16.6* RDWSD-52.4*
___ 01:10PM NEUTS-81.1* LYMPHS-10.9* MONOS-4.4* EOS-2.2
BASOS-0.5 IM ___ AbsNeut-8.30* AbsLymp-1.11* AbsMono-0.45
AbsEos-0.22 AbsBaso-0.05
___ 01:10PM PLT COUNT-270
___ 01:10PM ___ PTT-40.9* ___
DISCHARGE LABS
___ 07:00AM BLOOD WBC-9.1 RBC-3.55* Hgb-9.7* Hct-31.2*
MCV-88 MCH-27.3 MCHC-31.1* RDW-16.0* RDWSD-50.5* Plt ___
___ 07:00AM BLOOD Plt ___
___ 07:00AM BLOOD ___ PTT-36.2 ___
___ 07:00AM BLOOD Glucose-98 UreaN-30* Creat-1.6* Na-140
K-3.8 Cl-100 HCO3-25 AnGap-15
___ 07:00AM BLOOD Calcium-9.2 Phos-3.4 Mg-2.3
PERTINENT IMAGING
ECHO ___
The left atrial volume index is moderately increased. No atrial
septal defect is seen by 2D or color Doppler. The estimated
right atrial pressure is ___ mmHg. Left ventricular wall
thicknesses are normal. The left ventricular cavity size is top
normal/borderline dilated. Regional left ventricular wall motion
is normal. Overall left ventricular systolic function is normal
(LVEF>55%). Doppler parameters are indeterminate for 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 aortic valve
leaflets (3) are mildly thickened but aortic stenosis is not
present. No aortic regurgitation is seen. The mitral valve
leaflets are structurally normal. There is no mitral valve
prolapse. Mild (1+) mitral regurgitation is seen. There is
moderate pulmonary artery systolic hypertension. There is no
pericardial effusion.
IMPRESSION: Mild left ventricular dilatation with preserved and
regional/global systolic function. Mild mitral regurgitation.
Pulmonary artery systolic hypertension.
Compared with the prior study (images reviewed) of ___,
estimated pulmonary artery pressures are higher; the technically
suboptimal nature of the prior study precludes definitive
comparison
Brief Hospital Course:
Ms. ___ is a ___ year old woman with a past medical
history of atrial fibrillation s/p DCCV on Coumadin, HFpEF, SSS
s/p dual chamber PPM pacer, HTN, chronic tophaceous gout, and
dementia who presents with palpitations and reported dyspnea
with evidence of mild pulmonary edema and an elevated BNP
consistent with heart failure exacerbation. On pacemaker
interrogation, patient also noted to have pacer dysfunction with
RA lead fracture that likely precipitated diastolic heart
failure exacerbation. Pacer was evaluated by EP and changed to
VVI 50bpm with no further atrial arrhythmic events.
ACTIVE ISSUES
# Dyspnea
# Acute on chronic diastolic CHF exacerbation - LVEF >55%
# Atrial Lead Fracture
Patient reported palpitations and dyspnea on exertion without
significant change in orthopnea. Admission CXR showed evidence
of mild pulmonary edema and NT-proBNP 4802 from baseline of 165
in ___. Patient was diuresed with additional IV Lasix and was
subsequently continued on her home dose. She was seen by EP for
pacemaker interrogation, which revealed a RA lead fracture which
likely resulted in the absence of atrial sensing/pacing function
resulting in A-V dysynchrony and high RV pacing burden. Lead
fracture was suspected to be ___ which correlated with the onset
of reported dyspnea and clinical heart failure. Echo again
revealed mild LV dilatation with preserved and regional/global
systolic function (LVEF >55%) and mild MR.
# Atrial fibrillation
# SSS s/p dual chamber pacemaker
CHADS2VASC=5. Patient previously underwent successful ___ in
___. Well controlled since that time. Patient was continued on
2mg warfarin daily and metoprolol for rate control. She was
monitored on telemetry with pacemaker interrogation as above.
Predominant rhythm was recorded as SR with infrequent V pacing.
# Acute Renal Failure on CKD
CKD with Baseline around 1.6. Patient tolerated diuresis well
with Cr downtrending from 1.9 on admission to 1.6 at discharge.
Home valsartan was held.
CHRONIC ISSUES
==============
# HTN
Stable. Patient was continued on amlodipine. Valsartan was held
in the setting of acute renal failure.
# Chronic recurrent tophaceous gout
Stable. Patient followed by rheumatology as an outpatient.
Continued on prednisone 5mg daily. Allopurinol initially held in
the setting of acute renal failure, but restarted with improved
renal function. Clinical exam showed no signs of acute flare.
# GERD
Stable. Patient continued on pantoprazole daily.
TRANSITIONAL ISSUES
===================
[]Patient was noted to have RA lead fracture causing an erratic
ventricular pacing that likely precipitated diastolic heart
failure exacerbation. Switched to VVI 50bmp with predominately
NS rhythm and infrequent V pacing. Patient should have close
follow up with cardiology. Please consider further pacing
adjustment as needed.
[]Home valsartan was held in the setting of acute kidney injury.
Patient remained normotensive. Consider restarting in the
outpatient setting.
[]Please check her electrolytes within ___ days of discharge
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Allopurinol ___ mg PO DAILY
2. amLODIPine 5 mg PO DAILY
3. Cyanocobalamin 1000 mcg IM/SC EVERY 4 WEEKS (___)
4. Esomeprazole 40 mg Other DAILY
5. Furosemide 40 mg PO QAM
6. Furosemide 20 mg PO QPM
7. Metoprolol Succinate XL 50 mg PO DAILY
8. PredniSONE 5 mg PO DAILY
9. Valsartan 80 mg PO BID
10. Warfarin 4 mg PO DAILY16
11. Ferrous Sulfate 325 mg PO DAILY
12. Vitamin D 4000 UNIT PO DAILY
Discharge Medications:
1. Metoprolol Succinate XL 50 mg PO DAILY
2. Warfarin 2 mg PO DAILY16
3. Allopurinol ___ mg PO DAILY
4. amLODIPine 5 mg PO DAILY
5. Cyanocobalamin 1000 mcg IM/SC EVERY 4 WEEKS (___)
6. Esomeprazole 40 mg Other DAILY
7. Ferrous Sulfate 325 mg PO DAILY
8. Furosemide 20 mg PO QPM
9. Furosemide 40 mg PO QAM
10. PredniSONE 5 mg PO DAILY
11. Vitamin D 4000 UNIT PO DAILY
12. HELD- Valsartan 80 mg PO BID This medication was held. Do
not restart Valsartan until your primary care physician
instructs you to do so.
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Diastolic Heart Failure with Acute Exacerbation
Atrial Fibrillation
RA Lead 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:
Dear Ms. ___,
Why were you admitted to the hospital?
-You were feeling short of breath and were experiencing
occasional palpitations in your chest
What happened while you were here?
-You were given IV Lasix to help remove some of the fluid around
your lungs that were making it hard to breath
-The Electrophysiology Team (cardiology) looked at your
pacemaker and found that one of the leads was broken. They
changed the setting on your pacemaker to help with this. This
reprogramming fixed some of the abnormal heart rhythms you were
experiencing. They were likely contributing to your shortness of
breath.
What should you do when you go home?
-Continue to take your home Lasix
-You should follow up with your outpatient cardiologist, Dr.
___.
It was a pleasure taking care of you,
Your ___ Care Team
Followup Instructions:
___
|
19716166-DS-16
| 19,716,166 | 21,471,585 |
DS
| 16 |
2153-08-07 00:00:00
|
2153-08-07 19:44:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Chest Pressure
Major Surgical or Invasive Procedure:
Cardiac Catheterization (___)
History of Present Illness:
Mr. ___ is a ___ year old man with stage 4 lung
adenocarcinoma on chemotherapy who presents with 2.5 weeks of
progressive, intermittent chest tightness.
About 2.5 weeks ago he was working on a ___ and
doing some minor manual labor and felt central chest pressure
and
a tightness in his neck. He subsequently felt very unwell
including fevers and fatigue, but his symptoms mostly resolved
by
the next day. Over the course of the next week he felt
intermittent chest pressure and neck tightness with activity.
This past ___, he again felt tightness in his chest and
throat along with dyspnea. He also felt aching in his arms, legs
along with headaches and dry heaves. He spoke to an oncologist
on
call and eventually was seen in urgent care later that day. At
that point, his symptoms had significantly improved.
However, over the past two days he had significant chest
pressure
with exertion and called his oncologist on ___ night. She
ordered him for an EKG/CXR which he had early ___ and was read
as abnormal. He was sent to the ___ ED.
Review of systems in positive for pain in the right calf after
walking for 15 minutes that is present for several years. Rare
sensation of palpitations. No abdominal pain, bloody stool,
diarrhea.
EMERGENCY DEPARTMENT COURSE
Initial vital signs were notable for:
T 97.4, HR 113, BP 131/59, RR 16, O2 98% RA
Labs were notable for:
- proBNP 740
- Hemoglobin 9.5
- Troponin 1.34 -> 1.48
- MB 4 -> 3
Patient was given:
- Heparin gtt
- Atorvastatin 80mg
- Metoprolol tartrate 6.25mg
- Aspirin 324mg
Consults:
STEMI Consult:
- Cancel code STEMI. Patient is chest pain free and comfortable.
- Please check serial troponin
- Please obtain posterior ECG
- Please trend ECG q30 minutes x3
- TTE in AM
- Admit to ___ Cardiology
- NPO for cath in AM
- Atorvastatin 80mg PO daily, metoprolol tartrate 6.25 mg PO
Q6H,
heparin GTT ACS protocol, ASA 81 mg PO daily (already got 324
today so next dose ___
Vital signs prior to transfer:
- T 98.8, HR 103, BP 113/62, RR 21, O2 93%RA
Upon arrival to the floor: He reported being chest pain free.
Past Medical History:
- HTN
- HLD
- OSA
- GERD
- hypogonadism
Social History:
___
Family History:
Father with COPD
Physical Exam:
=======================
ADMISSION PHYSICAL EXAM
=======================
VITALS: T 98.6, BP 139/74, HR 114, RR 16, O2 96RA
GENERAL: Comfortable appearing, sitting up in a chair.
Accompanied by his wife.
___ equal and reactive, no scleral icterus or
injection. Moist mucous membranes.
NECK: No JVD
CARDIAC: S1/S2 regular with no murmurs, rubs or S3/S4.
CHEST: Port-a-cath in R upper chest with mild surrounding
erythema.
LUNGS: Clear bilaterally with diminished lung sounds.
ABDOMEN: Soft, non-tender, non-distended.
EXTREMITIES: Warm extremities. Faintly palpable DP pulse on R
foot, ___ pulse not palpable.
SKIN: Warm and dry
NEUROLOGIC: Grossly normal strength in upper and lower
extremities
=======================
DISCHARGE PHYSICAL EXAM
=======================
GENERAL: WDWN adult man sitting in bed in NAD
___: NCAT, sclerae anicteric
NECK: Supple, JVP not elevated
CARDIAC: RRR, normal S1/S2, no m/r/g
CHEST: Port-a-cath in R upper chest with mild surrounding
erythema, dressing clean. Lungs CTAB, no increased work of
breathing
ABDOMEN: Soft, non-tender, non-distended, normoactive BS
EXTREMITIES: Warm extremities. Faintly palpable DP pulse on R
foot. No edema.
Pertinent Results:
ADMISSION LABS
=============
___ 03:51PM BLOOD WBC-6.2 RBC-3.39* Hgb-9.5* Hct-28.6*
MCV-84 MCH-28.0 MCHC-33.2 RDW-16.8* RDWSD-51.1* Plt ___
___ 03:51PM BLOOD Neuts-78.9* Lymphs-10.5* Monos-9.8
Eos-0.3* Baso-0.2 Im ___ AbsNeut-4.89 AbsLymp-0.65*
AbsMono-0.61 AbsEos-0.02* AbsBaso-0.01
___ 03:51PM BLOOD Plt ___
___ 03:51PM BLOOD Glucose-147* UreaN-16 Creat-0.8 Na-137
K-3.5 Cl-96 HCO3-24 AnGap-17
___ 03:51PM BLOOD CK-MB-4 proBNP-740*
___ 03:51PM BLOOD cTropnT-1.34*
PERTINENT LABS
=============
___ 03:51PM BLOOD cTropnT-1.34*
___ 03:51PM BLOOD CK-MB-4 proBNP-740*
___ 06:31PM BLOOD CK-MB-3
___ 06:31PM BLOOD cTropnT-1.48*
___ 02:31AM BLOOD CK-MB-3 cTropnT-1.27*
___ 06:59AM BLOOD CK-MB-3 cTropnT-1.17*
___ 07:55AM BLOOD %HbA1c-5.8 eAG-120
___ 06:59AM BLOOD Triglyc-112 HDL-37* CHOL/HD-3.6
LDLcalc-75
___ 06:59AM BLOOD TSH-6.2*
___ 06:59AM BLOOD Free T4-1.0
DISCHARGE LABS
=============
___ 05:08AM BLOOD WBC-5.3 RBC-3.47* Hgb-9.5* Hct-29.6*
MCV-85 MCH-27.4 MCHC-32.1 RDW-17.1* RDWSD-52.2* Plt ___
___ 05:08AM BLOOD Plt ___
___ 05:08AM BLOOD ___ PTT-24.2* ___
___ 05:08AM BLOOD Glucose-110* UreaN-11 Creat-0.7 Na-136
K-4.2 Cl-98 HCO3-25 AnGap-13
___ 05:08AM BLOOD Calcium-8.8 Phos-3.1 Mg-1.7
IMAGING/PROCEDURES
==================
CHEST X RAY (___)
FINDINGS:
PA and lateral views of the chest provided.
Opacity seen in the left lower lobe which may represent
atelectasis or
developing pneumonia. A Port-A-Cath is seen along the right
anterior chest
wall with the tip terminating in the right atrium. There is no
effusion, or
pneumothorax. There are no signs of congestion or edema. The
cardiomediastinal silhouette is normal. Imaged osseous
structures are intact.
Surgical anchors are noted in the right humeral head.
IMPRESSION:
Left lower lobe opacity, which may represent atelectasis or
developing
pneumonia.
TTE (___)
CONCLUSION:
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 normal left ventricular
wall thickness with a normal cavity size. There is mild regional
left ventricular systolic dysfunction with hypokinesis of the
mid-distal inferolateral, anterolateral, and anterior walls (see
schematic). The visually estimated left ventricular ejection
fraction is 45-50%. There is no resting left ventricular outflow
tract gradient. No ventricular septal
defect is seen. Diastolic parameters are indeterminate. Normal
right ventricular cavity size with normal free wall motion. The
aortic sinus diameter is normal for gender with normal ascending
aorta diameter for gender. The aortic valve leaflets are
moderately thickened. There is no aortic valve stenosis. There
is trace aortic regurgitation. The mitral valve leaflets are
mildly thickened with no mitral valve prolapse. There is mild
[1+]
mitral regurgitation. The tricuspid valve leaflets appear
structurally normal. There is physiologic tricuspid
regurgitation. The estimated pulmonary artery systolic pressure
is normal. There is a trivial pericardial effusion.
IMPRESSION: Mild regional systolic dysfunction with hypokinesis
of the mid-distal inferolateral, anterolateral, and anterior
walls consistent with multivessel coronary artery disease. Mild
mitral regurgitation. Normal pulmonary pressure.
CARDIAC CATHETERIZATION (___)
Coronary Description
The coronary circulation is right dominant.
LM: The Left Main, arising from the left cusp, is a large
caliber vessel and is normal. This vessel trifurcates into the
Left Anterior Descending, Left Circumflex, and Ramus
Intermedius.
LAD: The Left Anterior Descending artery, which arises from the
LM, is a large caliber vessel. There is a 50% tubular stenosis
in the proximal segment. There is a 30% diffuse stenosis in the
mid segment. The Septal Perforator, arising from the proximal
segment, is a small caliber vessel.
Cx: The Circumflex artery, which arises from the LM, is a large
caliber vessel with mild luminal irregularities. The ___ Obtuse
Marginal, arising from the proximal segment, is a medium caliber
vessel. There is a 70% stenosis in the ostium. The ___ Obtuse
Marginal, arising from the mid segment, is a medium caliber
vessel.
RI: The Ramus Intermedius, which arises from the LM, is a medium
caliber vessel. There is a 100% stenosis in the proximal
segment. There are collaterals from the distal RCA.
RCA: The Right Coronary Artery, arising from the right cusp, is
a large caliber vessel. There is a 95% stenosis in the proximal
and mid segments. There is a 95% stenosis in the mid and distal
segments. The Acute Marginal, arising from the proximal segment,
is a small caliber vessel. The Right Posterior Descending
Artery, arising from the distal segment, is a medium caliber
vessel. The Right Posterolateral Artery, arising from the distal
segment, is a medium caliber vessel.
Interventional Details
Percutaneous Coronary Intervention: Percutaneous coronary
intervention (PCI) was performed on an ad hoc basis based on the
coronary angiographic findings from the diagnostic portion of
this procedure. A ___ AL 0.75 guiding catheter provided excellent
support. After crossing with a wire all stenoses were dilated
using a 2.0 mm NC balloon. Unsuccessful attempt to pass a 2.5mm
x 38mm stent, so did further dilations using a 2.5mm NC balloon
at high pressure. The balloon at this point became stuck to the
wire
and pulled wire out of vessel as removed. Tried unsuccessfully
to recross all stenoses using a Sion wire and then a Prowater
wire but unsuccessful because of passage into dissection flaps..
Since there is only mild stenosis (approx 40%) and normal flow
and patient free of chest pain, decided that risks outweigh
benefits of more aggressive attempts.
Complications: There were no clinically significant
complications.
Findings
Three vessel coronary artery disease.
PTCA alone (POBA) of RCA.
MICROBIOLOGY
============
None
Brief Hospital Course:
Mr. ___ is a ___ year old man with stage 4 lung
adenocarcinoma on chemotherapy who presentsed with 2.5 weeks of
progressive, intermittent chest tightness and found to have
likely subacute STEMI. Underwent cardiac cath with POBA,
deferred stenting given small dissection.
============
ACUTE ISSUES
============
#Subacute STEMI
Presented with 2.5 weeks of worsening intermittent chest and
neck pressure and found to have ST elevations in aVL, V1 with ST
depressions in II, III, aVF, V3-V6, Q waves in I and aVL.
Troponins and CK-MB downtrending. Overall given duration of
symptoms concern for subacute/missed MI. While admitted, on ASA,
heparin, beta blockade, high-intensity statin. Cardiac cath
revealed 95% RCA lesion, TIMI 3 flow after POBA. Stenting
deferred due to small dissection, plan for PCI in 6 weeks.
Post-procedure remaining chest pain-free, no anginal equivalents
or symptoms with ambulation. Noted to have sinus tachycardia to
low 100s, transitioned to PO metoprolol succinate 50. TTE
notable for regional systolic dysfunction with EF 45-50%
consistent with multivessel CAD. While admitted no evidence
clinical HF on history or exam. Given new systolic dysfunction
in setting of ACS started spironolactone, should re-check BMP in
2 weeks. Plan for PCI and repeat TTE in six weeks.
#Anemia
On admission noted to have Hgb 9.5, decreased from 14.5 in
___. Denied black, bloody stool. Guaiac negative, brown
stool. Likely in setting of active malignancy treated with
chemotherapy and radiation. Patient remained hemodynamically
stable without overt bleeding. Hgb stable while admitted.
#Hypertension
Held home HCTZ and ACEI. Started spironolactone. Holding HCTZ
and ACEI on discharge, can re-assess at follow-up.
#Stage IV Lung CA
Patient status post radiation/chemo and immunotherapy with
further progression of
disease. On Carboplatin/Pemetrexed/Pembrolizumab q3w x 4 cycles
as first line treatment for stage IV adenocarcinoma of lung. C1
___, C2 ___, C3 planned for ___. While admitted,
continued folic acid 1mg daily, multivitamin 1 tab daily,
guaifenesen PRN cough, zofran PRN for nausea (QTc<450). Given
subacute STEMI, consider discussion with cardiology prior to
initiating C3.
#GERD
Continued omeprazole 20mg daily.
#Peripheral Artery Disease
Was planned to have non-invasive vascular studies. Continued
ASA, statin as above.
TRANSITIONAL ISSUES
========================
[ ] Assess heart rate, consider increasing metoprolol succinate
dose
[ ] Cath in 6 weeks for stenting
[ ] Consider repeat TTE in 3 months
[ ] Consider referral to cardiac rehab
[ ] Re-check BMP one to two weeks post-discharge (started
spironolactone this admission)
[ ] Holding lisinopril, HCTZ on discharge
[ ] Re-check Hgb, consider need for further work-up, management
of anemia
[ ] Needs ABI/PVR for PAD
New Meds:
Aspirin 81 MG daily
Clopidogrel 75MG daily
Spironolactone 4X per week (MWFS)
Changed Meds:
Atorvastatin 80MG daily (from 40MG)
Held/Stopped Meds:
Lisinopril
Hydrochlorothiazide
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lisinopril 30 mg PO DAILY
2. Dexamethasone 4 mg PO PRN FOR NAUSEA Look below for
instructions
3. Ondansetron 8 mg PO Q8H:PRN Nausea/Vomiting - Second Line
4. Prochlorperazine 10 mg PO Q6H:PRN Nausea/Vomiting - First
Line
5. FoLIC Acid 1 mg PO DAILY
6. LORazepam 0.5-1 mg PO Q6H:PRN anxiety or insomnia
7. Atorvastatin 40 mg PO QPM
8. Hydrochlorothiazide 25 mg PO DAILY
9. Metoprolol Succinate XL 50 mg PO DAILY
10. Omeprazole 20 mg PO DAILY
11. testosterone cypionate 200 mg/mL injection 1X/WEEK
12. GuaiFENesin ER 600 mg PO Q12H
13. Guaifenesin-CODEINE Phosphate ___ mL PO Q6H:PRN cough
14. tadalafil 10 mg oral DAILY:PRN
15. Multivitamins 1 TAB PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
RX *aspirin 81 mg 1 tablet(s) by mouth Daily Disp #*90 Tablet
Refills:*0
2. Clopidogrel 75 mg PO DAILY to prevent stent thrombosis
RX *clopidogrel 75 mg 1 tablet(s) by mouth Daily Disp #*90
Tablet Refills:*0
3. Spironolactone 25 mg PO 4X/WEEK (___)
RX *spironolactone 25 mg 1 tablet(s) by mouth Four days a week
Disp #*30 Tablet Refills:*0
4. Atorvastatin 80 mg PO QPM
RX *atorvastatin 80 mg 1 tablet(s) by mouth Daily at bedtime
Disp #*90 Tablet Refills:*0
5. Dexamethasone 4 mg PO PRN FOR NAUSEA Look below for
instructions
6. FoLIC Acid 1 mg PO DAILY
7. GuaiFENesin ER 600 mg PO Q12H
8. Guaifenesin-CODEINE Phosphate ___ mL PO Q6H:PRN cough
9. LORazepam 0.5-1 mg PO Q6H:PRN anxiety or insomnia
10. Metoprolol Succinate XL 50 mg PO DAILY
11. Multivitamins 1 TAB PO DAILY
12. Omeprazole 20 mg PO DAILY
13. Ondansetron 8 mg PO Q8H:PRN Nausea/Vomiting - Second Line
14. Prochlorperazine 10 mg PO Q6H:PRN Nausea/Vomiting - First
Line
15. tadalafil 10 mg oral DAILY:PRN
16. testosterone cypionate 200 mg/mL injection 1X/WEEK
Discharge Disposition:
Home
Discharge Diagnosis:
ST-Elevation Myocardial Infarction
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you at ___
___.
WHY WAS I ADMITTED TO THE HOSPITAL?
- You were admitted to the hospital for a heart attack.
WHAT HAPPENED WHILE I WAS IN THE HOSPITAL?
- You underwent a procedure (cardiac catheterization) that
revealed a blockage in one of the blood vessels of the heart.
- The blockage was opened during the procedure and blood flow
was restored. A stent was not placed at this time due to a small
tear (dissection) in the wall of the blood vessel. You will be
scheduled in approximately 6 weeks for a repeat procedure and
stent placement at that time.
- You were started on new medications for your heart disease and
to prevent future heart attacks or heart failure.
WHAT SHOULD I DO WHEN I GO HOME?
- You should continue to take your medications as prescribed. It
is important you take all the medications to reduce further
damage to your heart.
- You should attend the appointments listed below.
We wish you the best!
Your ___ Care Team
Followup Instructions:
___
|
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DS
| 17 |
2153-11-12 00:00:00
|
2153-11-12 21:23:00
|
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:
endotracheal intubation ___
Comprehensive EP evaluation w induction or attempt ___
ICD placement ___
History of Present Illness:
___ is a ___ year old man with recurrent stage IV NSCLC
along with CAD on ASA/Plavix who is admitted from the ED with
syncope.
At approximately 330pm yesterday patient developed acute
dizziness while walking; the senstation lasted about one minute
before resolving. He had approximately four more similar
episodes
throughout the afternoon. At dinner that night he got up to get
glass of water. He again felt a wave of severe dizziness and he
sat down before passing out. His wife caught him and reported he
was out for about 3 minutes. He also had generalized shaking,
and "turned blue." When he woke up he was incontinent of urine
and confused for approximately 5 minutes. He did not bite his
tongue. EMS was activated and he was sent to the ___ ED.
Patient otherwise denies recent fevers or chills. No headaches.
No mucositis. No dysphagia or odynophagia. No CP or palpitation.
He has chronic dyspnea with exertion, primarily walking up
stairs. No orthopnea. He has a chronic cough, which had gotten
better but returned about 3 weeks ago. No N/V. Appetite is fair,
but he has lost abou 10 pounds in 6 weeks. No diarrhea. No
dysuria. No new leg pain or swelling.
In the ED, initial VS were pain 0, T 98.5, HR 106, BP 162/108,
RR
12, O2 96%RA. Initial labs notable for Na 140, K 3.7, HCO3 23,
Cr
0.7, WBC 9.9, HCT 34.3, PLT 225, Trop <0.01, INR 1.2. CT head
showed no acute process. CTA chest showed no evidence of PE,
left
hilar soft tissue mass and left lung opacities, mild pulmonary
edema, and moderate left pleural effusion. Patient was given IV
NS and atorvastatin. VS prior to transfer were T 98.3, HR 101,
BP 145/89, RR 18, O2 95%RA.
REVIEW OF SYSTEMS:
A complete 10-point review of systems was performed and was
negative unless otherwise noted in the HPI.
PAST ONCOLOGIC HISTORY:
Please see Dr. ___ note from ___ for full history.
Briefly, non-small cell cancer of left lung, poorly
differentiated adenocarcinoma, mucin producing, previously stage
IIIB (cT1N3M0) s/p concurrent chemo/radiation with Cisplatin and
etoposide, completed treatment ___ with partial response,
followed by Durvalumab q2w started ___ PET/CT ___
showed
progressive disease. Biopsy of pleura based tumor confirmed
recurrent adenocarcinoma, stage IV, PD-L1 50%; no actionable
gene
mutation. PET/CT after 4 cycles of
Carboplatin/Pemetrexed/Pembrolizumab q3w showed progressive
disease. Started Abraxane/Avastin on ___.
Past Medical History:
- HTN
- HLD
- OSA
- GERD
- hypogonadism
Social History:
___
Family History:
Father with COPD
Physical Exam:
ADMISSION EXAM:
===============
VS: T 98.3 HR 108 BP 135/96 RR 16 SAT 96% O2 on RA
GENERAL: Pleasant and generally well appearing man in no
distress
EYES: Anicteric sclerea, PERLL, EOMI;
ENT: Oropharynx clear without lesion, JVD not elevated
CARDIOVASCULAR: Regular rate and rhythm, no murmurs, rubs, or
gallops
RESPIRATORY: Appears in no respiratory distress, decreased BS
left base and halfway up, right lung is clear
GASTROINTESTINAL: Normal bowel sounds; nondistended; soft,
nontender without rebound or guarding; no hepatomegaly, no
splenomegaly
MUSKULOSKELATAL: Warm, well perfused extremities without lower
extremity edema; Normal bulk
NEURO: Alert, oriented, CN II-XII intact, motor and sensory
function grossly intact
SKIN: No significant rashes
DISCHARGE EXAM:
===============
VS: 24 HR Data (last updated ___ @ 550)
Temp: 97.3 (Tm 98.0), BP: 102/65 (100-102/61-65), HR: 78
(78-81), RR: 16, O2 sat: 97% (93-97), O2 delivery: 2L, Wt: 162.7
lb/73.8 kg
Fluid Balance (last updated ___ @ 450)
Last 8 hours Total cumulative -185ml
IN: Total 240ml, PO Amt 240ml
OUT: Total 425ml, Urine Amt 425ml
Last 24 hours Total cumulative -185ml
IN: Total 240ml, PO Amt 240ml
OUT: Total 425ml, Urine Amt 425ml
GENERAL: Sitting comfortably in chair in no acute distress
HEENT: Oropharynx clear. Sclerae anicteric.
CHEST: ICD site mildly nontender, nonerythematous. No area of
fluctuance.
NECK: Supple. JVP not elevated
CARDIAC: Normal rate and rhythm. Normal S1 and S2. No murmurs,
rubs, or gallops.
LUNGS: Clear to auscultation bilaterally.
ABDOMEN: Soft, non-tender, non-distended. No palpable
hepatomegaly or splenomegaly.
EXTREMITIES: Warm, well perfused. 2+ pedal pulses.
Neuro: AAOx3. No focal deficits.
Pertinent Results:
ADMISSION LABS:
===============
___ 08:28PM BLOOD WBC: 9.9 RBC: 3.82* Hgb: 10.3* Hct: 34.3*
MCV: 90 MCH: 27.0 MCHC: 30.0* RDW: 19.2* RDWSD: 63.1* Plt Ct:
335
___ 08:28PM BLOOD Neuts: 82.7* Lymphs: 5.7* Monos: 9.7 Eos:
1.0 Baso: 0.5 Im ___: 0.4 AbsNeut: 8.21* AbsLymp: 0.57*
AbsMono:
0.96* AbsEos: 0.10 AbsBaso: 0.05
___ 11:19PM BLOOD ___: 12.6* PTT: 25.9 ___: 1.2*
___ 08:28PM BLOOD Glucose: 125* UreaN: 11 Creat: 0.7 Na:
140
K: 3.7 Cl: 104 HCO3: 23 AnGap: 13
___ 08:28PM BLOOD cTropnT: <0.01
MICROBIOLOGY:
=============
None
IMAGING/DIAGNOSITICS:
=====================
___ CXR:
Stable examination. No pneumothorax identified.
___ CXR:
Interval improvement of pulmonary vascular congestion. Lucency
in the left apex may suggest a pneumothorax however no
definitive pleural line is seen.
___ CXR
IMPRESSION:
In comparison with the study of ___, the monitoring and
support devices are essentially unchanged. Cardiac silhouette
remains at the upper limits of normal or mildly enlarged and
there is moderate pulmonary edema and substantial volume loss in
the left lower lobe. Increased opacification in the perihilar
and suprahilar region on the left would suggests superimposed
aspiration/pneumonia in the appropriate clinical setting.
___ Cardiac Catheterization
Findings
Stable LAD and LCx disease comapred to prior.
Moderate residual RCA disease after prior POBA with normal
flow and intact RI collaterals
___ TTE
Conclusion:
The left atrium is mildly dilated. There is no evidence for an
atrial septal defect by 2D/color Doppler. The estimated right
atrial pressure is ___ mmHg. There is normal left ventricular
wall thickness with a normal cavity size. There is normal
regional and global left ventricular systolic function.
Quantitative 3D volumetric left ventricular ejection fraction is
67 %. Left ventricular cardiac index is low normal (2.0-2.5
L/min/m2). There is no resting left ventricular outflow tract
gradient. Tissue Doppler suggests an increased left ventricular
filling pressure (PCWP greater than 18 mmHg). Normal right
ventricular cavity size with normal free wall motion. Tricuspid
annular plane systolic excursion (TAPSE) is normal. 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 (?#) are mildly thickened. 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 mild [1+] mitral regurgitation. The pulmonic
valve leaflets are not well seen. The tricuspid valve leaflets
appear structurally normal. There is physiologic tricuspid
regurgitation. There is moderate pulmonary artery systolic
hypertension. There is a small loculated pericardial effusion
primarily anterior to the right atrium and basal right
ventricle.
IMPRESSION: Normal left ventricular wall thickness and
biventricular cavity sizes and regional/global systolic
function. Moderate pulmonary artery systolic hypertension. Mild
mitral regurgitation with normal valve morphology.
___ CXR
IMPRESSION:
The endotracheal tube is been advanced now terminates 2.7 cm
above the carina. There is slightly increased left lower lobe
atelectasis. Otherwise, no significant interval change compared
to most recent prior study from earlier today.
___ Imaging CTA CHEST
1. No evidence of pulmonary embolism or aortic abnormality.
2. Left hilar soft tissue has grown from PET-CT in ___
narrowing numerous bronchi. Left lung opacities may represent
post obstructive pneumonia or atelectasis. Scattered right lung
opacities likely reflect ongoing infectious/inflammatory
process.
3. Mild pulmonary edema in the lung apices.
4. Moderate left pleural of effusion has grown from ___.
5. Left-sided soft tissue pleural based masses appear overall
similar to prior PET-CT on ___.
___ Imaging CT HEAD W/O CONTRAST
There is no evidence of infarction, hemorrhage, edema, or mass.
There is prominence of the ventricles and sulci suggestive of
involutional changes. There is no evidence of fracture. There is
severe calcification
of the left V4 artery (2:4). There is mild mucosal thickening of
the right maxillary sinus and bilateral anterior and posterior
ethmoid air cells. The remainder of the visualized portions of
the paranasal sinuses, mastoid air cells, and middle ear
cavities
are clear. The visualized portion of the orbits are
unremarkable.
___ Imaging FDG TUMOR IMAGING (PET-
1. Worsening disease in the left lung base with increased uptake
in the left pleural effusion.
2. Interval increase in the size and metabolic activity of the
left adrenal gland, compatible with disease progression.
3. Treated left upper lobe mass demonstrate background activity.
EK: Sinus tachycardia at 103 with occasional PAC. TWI in AVL,
flattening in II. No other ischemic changes.
DISCHARGE LABS:
===============
___ 05:30AM BLOOD WBC-8.0 RBC-3.57* Hgb-9.7* Hct-32.5*
MCV-91 MCH-27.2 MCHC-29.8* RDW-19.0* RDWSD-62.8* Plt ___
___ 05:30AM BLOOD Plt ___
___ 05:30AM BLOOD Glucose-101* UreaN-12 Creat-0.6 Na-139
K-4.7 Cl-103 HCO3-25 AnGap-11
___ 05:30AM BLOOD Calcium-9.2 Phos-4.1 Mg-1.9
Brief Hospital Course:
Outpatient Providers: Mr. ___ is a ___ yo M with PMH
significant for recurrent stage IV NSCLC, CAD s/p NSTEMI s/p RCA
angioplasty admitted for syncope, subsequently intubated in the
setting of VT storm, received 1 shock, transferred to CCU,
subsequently stabilized and extubated
ACTIVE ISSUES:
===============
#Polymorphic Ventricular Tachycardia
#Syncope
Patient presenting with syncopal event in setting of
lightheadedness with frequent NSVT. CT head negative. Two
troponins negative. CT chest neg for PE or not suggestive of
infection. Patient ultimately progressed to unstable polymorphic
VT for which he was shocked and maintained on Lidocaine gtt with
repletion of K and Mg. No evidence of acute ischemia on cardiac
catheterization. Etiology for polymorphic VT likely ___ R on T
phenomenon in setting of known cardiac disease and prolonged
QTc. Patient had been taking Zofran and Chlorpromazine in the
past for nausea associated with chemo though reportedly had not
used in weeks to family's knowledge. Recently started Trazodone
which he had been taking the past ___ nights prior to admission
and recently prescribed Azithromycin. No evidence of long-QTc
syndrome to family's knowledge or sudden cardiac death. He was
recently started on Abraxane/Avastin on ___ with Abraxane
(paclitaxel) known to cause tachyarrhythmias and
bradyarrhythmias, though most commonly associated with sinus
bradycardia. Also with tumor burden in lung with encroachment on
pulmonary arteries. Patient was started on metoprolol and
verapamil with good response and decrease in ectopy burden. He
underwent an EP study on ___ which was unable to find a
specific focus for ablation. He then underwent ICD placement on
___. Procedure was uncomplicated and device was interrogated
prior to discharge.
#Elevated Transaminases, improving
Patient with uptrending LFTs as outpatient, initially with
concern for possible DILI. Recently started on chemotherapeutic
regimen as above. LFTs downtrended through admission without
intervention.
CHRONIC ISSUES:
===============
#Stage IV NSCLC
#Secondary malignancy of pleura
#Secondary malignancy of lung
#Pleural Effusion
Patient s/p concurrent chemo/radiation with Cisplatin and
etoposide, completed treatment ___ with partial response,
followed by Durvalumab q2w started ___ PET/CT ___
showed progressive disease. Biopsy of pleura based tumor
confirmed
recurrent adenocarcinoma, stage IV, PD-L1 50%; no actionable
gene mutation. PET/CT after 4 cycles of
Carboplatin/Pemetrexed/Pembrolizumab q3w showed progressive
disease. Started Abraxane/Avastin on ___. Next cycle was due
___ but held while inpatient. Held Compazine and lorazepam
in setting of NSVT.
#CAD s/p NSTEMI ___ s/p RCA angioplasty
Continued home ASA, Plavix, spironolactone, metoprolol,
atorvastatin.
#GERD
#Hx PUD
Continued home omeprazole
#Hypoxemic Respiratory Failure, resolved
Patient hypoxemic during initial episode of VT for which he was
intubated. Most likely precipitated by arrhythmia. No evidence
of PE or concern for pneumonia. Patient passed SBT and extubated
on ___
#___
Refused hospital-provided CPAP during admission
TRANSITIONAL ISSUES:
====================
[ ] Given polymorphic VT, please avoid QTc prolonging
medications. Would recommend alternative antiemetics for
chemotherapy (e.g. Aloxi, if available, or Ativan to prevent QT
prolongation)
[ ] No lifting heavy objects greater than gallon of milk in left
hand for 10 days
[ ] No golf or swimming for 6 months
[ ] No driving for 6 months
[ ] Care connect with ___ in ___ clinic
prior to discharge.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Atorvastatin 80 mg PO QPM
2. FoLIC Acid 1 mg PO DAILY
3. LORazepam 0.5-1 mg PO Q6H:PRN anxiety or insomnia
4. Metoprolol Succinate XL 50 mg PO DAILY
5. Multivitamins 1 TAB PO DAILY
6. Omeprazole 20 mg PO DAILY
7. Ondansetron 8 mg PO Q8H:PRN Nausea/Vomiting - Second Line
8. Aspirin 81 mg PO DAILY
9. Clopidogrel 75 mg PO DAILY to prevent stent thrombosis
10. Spironolactone 25 mg PO 4X/WEEK (___)
11. Prochlorperazine 10 mg PO Q6H:PRN Nausea/Vomiting - First
Line
12. Dexamethasone 4 mg PO ASDIR
13. TraZODone 50 mg PO QHS:PRN insomnia
14. Chlorpheniramine-Hydrocodone 5 mL PO Q12H:PRN mouth pain
Discharge Medications:
1. Magnesium Oxide 400 mg PO DAILY Duration: 2 Doses
RX *magnesium oxide 400 mg 1 (One) capsule(s) by mouth once a
day Disp #*30 Capsule Refills:*0
2. Spironolactone 25 mg PO 4X/WEEK (___)
RX *spironolactone 25 mg 1 (One) tablet(s) by mouth 4 times per
week Disp #*30 Tablet Refills:*0
3. Verapamil SR 480 mg PO Q24H
RX *verapamil 240 mg 2 (Two) tablet(s) by mouth once a day Disp
#*60 Tablet Refills:*0
4. Metoprolol Succinate XL 25 mg PO QHS
RX *metoprolol succinate 25 mg 1 (One) tablet(s) by mouth once a
day Disp #*30 Tablet Refills:*0
5. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild/Fever
6. Aspirin 81 mg PO DAILY
7. Atorvastatin 80 mg PO QPM
8. Clopidogrel 75 mg PO DAILY to prevent stent thrombosis
9. Dexamethasone 4 mg PO ASDIR
10. Multivitamins 1 TAB PO DAILY
11. Omeprazole 20 mg PO DAILY
12. HELD- Ondansetron 8 mg PO Q8H:PRN Nausea/Vomiting - Second
Line This medication was held. Do not restart Ondansetron until
talking to your oncologist
13. HELD- Prochlorperazine 10 mg PO Q6H:PRN Nausea/Vomiting -
First Line This medication was held. Do not restart
Prochlorperazine until talking with your oncologist
14. HELD- TraZODone 50 mg PO QHS:PRN insomnia This medication
was held. Do not restart TraZODone until talking with your
oncologist
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
==================
Polymorphic Ventricular Tachycardia s/p ICD placement
SECONDARY DIAGNOSIS:
====================
Stage IV Non-Small Cell Lung Cancer
Secondary malignancy of pleura
Secondary malignancy of lung
Pleural Effusion
Coronary artery disease
Gastroesophageal Reflux Disease
Hypoxemic Respiratory Failure
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear. Mr. ___,
You were admitted because:
- You passed out and were found to have a dangerously abnormal
heart rhythm. You received an electric shock.
During your stay:
- Your breathing was initially supported with a breathing tube.
You improved and no longer needed the breathing tube so it was
removed.
- You underwent cardiac catheterization to examine the arteries
around your heart.
- You underwent an electrophysiologic study to examine your
abnormal heart rhythms.
- You had an ICD placed to prevent future dangerous abnormal
heart rhythms.
- Your chemotherapy was held during this hospital admission in
case these drugs made it more likely for your heart to return to
the dangerous abnormal rhythm.
After you leave:
- Please take your medications as prescribed.
- Please attend any outpatient follow-up appointments you have
- Please weigh yourself every morning, call MD if weight goes up
more than 3 lbs in 1 day or 5lb in 1 week.
- Please avoid driving for 6 months
- Please do not hold anything heavier than a gallon of milk for
a month. Please avoid motions (such as golfing) that involve
lifting your arm above your head for a month. Please also avoid
swimming while the wound from your ICD procedure is healing.
It was a pleasure participating in your care! We wish you the
very best!
Sincerely,
Your ___ HealthCare Team
Followup Instructions:
___
|
19716166-DS-18
| 19,716,166 | 27,704,745 |
DS
| 18 |
2154-01-25 00:00:00
|
2154-01-25 20:01:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Fatigue and Dyspnea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ year old male with recurrent metastatic
NSCLC,
CAD s/p NSTEMI and VT storm s/p ICD who presents with
progressive
dyspnea.
Of note, the patient was recently admitted at ___ from
___ with syncope and was admitted to the oncology service
where he developed unstable VT thought to be from R on T
phenomenon due to his cardiac disease and QTc prolonging
medications. He responded responded to defibrillation and was
transferred to the CCU where he underwent ICD placement on ___
and was started on metoprolol and verapamil.
Since discharge, the patient had been feeling well until 2 weeks
ago when he noticed the onset of cough and dyspnea. He was
diagnosed with PNA by his PCP and treated with amoxicillin and
doxycycline x7 days. Over the last week, the patient has noted
progressive fatigue with dizziness and presyncope upon standing.
He has had no fevers or chills. No decreased PO intake and no
diarrhea. Then, over the last 2 days, he has had progressive
dyspnea on exertion, worse that his baseline, so he presented to
the ___ ED for further evaluation.
Of note, he has had no chest pain and only occasional
palpitations. He has had no shocks from his ICD. He denies abd
pain or dysuria.
In the ED, the initial vital signs were:
T 98.6 HR 81 BP 132/61 R 18 SpO2 97% RA
Laboratory data was notable for:
Trop <0.01
Normal Chem10
BNP 830
WBC 8.8 Hgb 9.1 Plt 209
INR 1.1
The patient received:
___ 20:26 PO Omeprazole 20 mg
___ 20:26 PO Metoprolol Succinate XL 25 mg
Imaging demonstrated:
___ 18:04 Chest (Pa & Lat)
IMPRESSION:
There is persisting and progressed small to moderate left
pleural
effusion, with left upper and lower atelectasis/consolidation,
presumably due to known small cell lung cancer.
ECG: SNR Rate 77. Normal axis and intervals. No Q waves or ST-T
wave changes
Upon arrival to 11R, the patient feels well and endorses the
above history. He is without dyspnea at rest or chest pain.
Past Medical History:
ONCOLOGIC HISTORY:
He had been healthy with hypertension and GERD, has had
persistent dry cough since ___ weeks before hospitalization. He
did not respond to supportive care and empirical antibiotics.
He
developed chills, high fevers night sweat and profuse diarrhea
___ after shoveling snow. The symptoms continued the following
day. He was referred to the hospital on ___
8. He vomited a few times on the day of admission. He received
empirical antibiotics for possible pneumonia and underwent the
following workup. During admission, he was noted to have
leukopenia and thrombocytopenia as well as elevated
transaminases, alkaline phosphatases and LDH. The cytopenia
improved spontaneously but liver function remained abnormal
throughout the hospital course. His fever gradually subsided,
cough and diarrhea decreased and he was discharged home on ___.
___, CT of chest and abdomen:
1. Ill-defined left hilar mass with associated nodularity and
opacification along the left major fissure and extension into
the
superolateral left aspect of the mediastinum. Mass encases the
left main pulmonary artery,
as well as the left lingular, lower lobar, and upper lobar
pulmonary arteries.
2. Notably, the mass also causes significant narrowing of the
left upper lobar bronchus.
3. Associated enlarged left para-aortic, right upper
paratracheal, and subcarinal mediastinal lymph nodes.
4. Incidentally noted 3.5 x 3.2 cm hypodense mass involving the
appendix, without adjacent fat stranding. This
is worrisome for a separate neoplasm. Less likely metastasis,
but this possibility is not excluded.
___ brain MRI: no evidence of metastasis.
___ Bronchoscopy and the transbronchial biopsy of the left
upper lobe of lung showed: Poorly differentiated adenocarcinoma
with mucinous features, predominantly present in submucosal
lymphatic spaces. The carcinoma is strongly positive for CK 7,
and shows only focal CK 20 positivity. It is negative for TTF-1,
Napsin, p40, and CDX-2. Attempt of FOUNDATION ONE CDx was
unsuccessful due to inadequate tissue.
___ Colonoscopy: The appendiceal orifice was examined
carefully. A pair of large-cap forceps were used to retract the
appendix through the AO, and the mucosa appeared normal without
any masses. Due to inadequate prep, small to medium sized
lesions may have been missed. Colonic biopsy showed normal
mucosa.
___: began XRT for stage IIIB NSCLC
___ - ___: cycle 1 cisplatin/etoposide.
___ - ___ - ___: cycle 2 cisplatin/etoposide
anticipated.
___: completion of radiation.
___: began Durvalumab q2w
___: port-a-cath placement due to difficulty with venous
access.
___: CT guided left pleural mass biopsy - Poorly
differentiated adenocarcinoma with focal mucin production and
papillary features, similar to the previous left upper lobe
tumor.
___: C1 Carboplatin/Pemetrexede/Pembrolizumab
___: C2 Carboplatin/Pemetrexede/Pembrolizumab
___ - ___: admitted to ___ for subacute MI. S/p
angioplasty for RCA stenosis. Felt dramatic improvement of
symptoms of chest pressure and dyspnea after the procedure.
___ echocardiogram - Mild regional systolic dysfunction
with
hypokinesis of the mid-distal inferolateral, anterolateral, and
anterior walls consistent with multivessel coronary artery
disease. Mild mitral regurgitation. Normal pulmonary pressure.
Estimated LVEF 45-50%
___: coronary angiogram and angioplasty - Three vessel
coronary artery disease.
PTCA alone (POBA) of RCA.
___: C3 Carboplatin/Pemetrexede/Pembrolizumab
___: C4 Carboplatin/Pemetrexede/Pembrolizumab
___: C1 Abraxane and
___: C2 Abraxane and Avastin anticipated.
___: noted abnormal liver function of unclear reason.
___ - ___: admitted to ___ following a syncopal
episode. Was diagnosed unstable polymorphic ventricular
tachycardia, r/o secondary to R on T phenomenon in the setting
of
known cardiac disease and prolonged QTc. PE and CNS metastases
were excluded.
Endotracheal intubation ___ Comprehensive EP
evaluation w induction or attempt ___ ICD placement ___
Liver function worsened at first, felt to be cardiogenic,
improved towards the latter part of hospitalization.
___: office follow up visit; worsening of LFT noted;
atorvastatin was held.
___: C1W1 gemcitabine, 3 weeks on 1 week off.
___: C2W1 gemcitabine
PAST MEDICAL HISTORY:
Metastatic Lung Cancer
L adrenal Metastasis
CAD s/p NSTEMI in ___: Coronary angiogram ___ with normal
LMCA; LAD proximal 50% and mid 30% stenoses; LCx with 70%
stenosis in the ostium of OM1; ramus with 100% proximal stenosis
and collaterals from the distal RCA; RCA large vessel with 95%
disease throughout. PCI was attempted to the right coronary but
a
stent could not be placed. Stenoses could not be crossed and
wire
passed into dissection flaps. Given normal flow and the absence
of chest pain, POBA alone was performed. Disease was noted to be
stable on re-look in ___.
Polymorphic VT s/p ICD ___
HTN
HLD
OSA
GERD
Social History:
___
Family History:
Father with COPD
Identical twin with HCM
Physical Exam:
ADMISSION
GENERAL: Tired, NAD, sitting comfortably in bed
HEENT: Clear OP, no lesions or thrush
EYES: PERRL, anicteric
NECK: supple
RESP: No increased WOB, decreased breath sounds L side with
mild
crackles. No rhonchi or wheezing
___: Regular, no MRG. ICD over L anterior chest c/d/I without
errythema
GI: soft, NTND no rebound or guarding
EXT: warm, no edema
SKIN: dry, no obvious rashes
NEURO: CN II-XII intact
ACCESS: POC c/d/i
DISCHARGE
GENERAL: NAD, sitting comfortably in bed
HEENT: Clear OP, no lesions or thrush
EYES: PERRL, anicteric
NECK: supple
RESP: No increased WOB, decreased breath sounds on left. No
rhonchi or wheezing
___: Regular, no MRG. ICD over L anterior chest c/d/I without
errythema
GI: soft, NTND no rebound or guarding
EXT: warm, no edema
SKIN: dry, no obvious rashes
NEURO: CN II-XII intact
Pertinent Results:
ADMISSION
___ 06:30PM BLOOD WBC-8.8 RBC-3.26* Hgb-9.1* Hct-29.3*
MCV-90 MCH-27.9 MCHC-31.1* RDW-22.5* RDWSD-68.8* Plt ___
___ 06:30PM BLOOD Neuts-74.5* Lymphs-9.5* Monos-12.7
Eos-1.1 Baso-0.3 Im ___ AbsNeut-6.52* AbsLymp-0.83*
AbsMono-1.11* AbsEos-0.10 AbsBaso-0.03
___ 06:30PM BLOOD ___ PTT-26.9 ___
___ 06:30PM BLOOD Glucose-140* UreaN-13 Creat-0.8 Na-137
K-3.9 Cl-98 HCO3-25 AnGap-14
___ 07:20AM BLOOD ALT-24 AST-20 AlkPhos-109 TotBili-0.3
___ 06:30PM BLOOD proBNP-830*
___ 06:30PM BLOOD cTropnT-<0.01
___ 10:40PM BLOOD cTropnT-<0.01
___ 06:30PM BLOOD Calcium-9.1 Phos-3.4 Mg-1.9
___ 07:20AM BLOOD Cortsol-12.6
___ 06:37PM BLOOD Lactate-1.2
DISCHARGE
___ 05:25AM BLOOD WBC-7.9 RBC-3.46* Hgb-9.7* Hct-30.6*
MCV-88 MCH-28.0 MCHC-31.7* RDW-22.1* RDWSD-67.8* Plt ___
___ 05:25AM BLOOD Glucose-96 UreaN-9 Creat-0.7 Na-139 K-4.3
Cl-100 HCO3-25 AnGap-14
REPORTS
___ (PA & LAT)
There is persisting and progressed small to moderate left
pleural effusion,
with left upper and lower atelectasis/consolidation, presumably
due to known lung cancer.
___ (PA & LAT)
Compared to chest radiographs, DIS since ___ most
recently ___ through ___.
Marked elevation of the left lung base is due in part to
moderate subpulmonic
left pleural effusion. Left suprahilar mass is noted. No
pneumothorax.
Right lung clear. Heart borderline enlarged unchanged.
Right transjugular central venous infusion catheter ends close
to the superior
cavoatrial junction. Transvenous right atrial pacer
defibrillator lead in
standard position.
RECOMMENDATION(S): If there is concern about the specific
nature of these
radiographic findings, chest CT scan, with intravenous contrast
if tolerated, would be helpful to compare with most recent chest
CT, performed on ___.
Brief Hospital Course:
Mr. ___ is a ___ year old man with metastatic lung cancer on
gemcitabine, CAD s/p NSTEMI and recent VT storm s/p ICD presents
from home with progressive fatigue and dyspnea with progressive
left sided pleural effusion found on CXR.
#FATIGUE
#DYSPNEA:
Patient presented with progressive dyspnea, fatigue and
lightheadedness with standing. He was recently treated as an
outpatient for community acquired pneumonia. He was initially
improving, but subsequently developed progressive dyspnea and
fatigue. He had one episode of presyncope upon standing, which
prompted him to present to the ED. Workup showed progressive
left-sided pleural effusion found on CXR. He had no hypoxemia on
exam at rest or with ambulation. No evidence of ischemia. He
received one liter of IVF in the ED and his symptoms resolved.
His pleural effusion was thought to be contributing to his
dyspnea though his symptoms improved without intervention.
Adrenal insufficiency was considered given his adrenal
metastasis and fatigue; however, he was without hypotension or
electrolyte abnormalities and AM cortisol WNL. Lastly, it was
though his fatigue and pre-syncope could also be exacerbated by
his metoprolol and verapamil, which were started during his last
hospitalization. His blood pressures remained stable and the
doses weren't reduced. IP consult for thoracentesis was deferred
to outpatient setting.
#LUNG CANCER
#SECONDARY MALIGNACY OF PLEURA
#SECONDARY MALIGNANCY OF ADRENAL GLAND:
C2D1 of Gemcitabine was on ___.
#CORONARY ARTERY DISEASE
#S/P ICD:
No need to interrogate device at this time given other, more
likely cause for his symptoms. No chest pain. Negative trop x2.
Continued home ASA. Atorvastatin on hold due to elevated LFTs.
Continued home verapamil, metoprolol, and spironolactone.
#OSA: ordered CPAP while in house
#GERD: continued home omeprazole while in house
Name of health care proxy: ___
Phone number: ___
#CODE STATUS: full, presumed
TRANSITIONAL ISSSUES:
[] Repeat CXR within 1 month to monitor resolution of pleural
effusion
[] consider therapeutic/diagnostic thoracentesis in outpatient
setting, IP follow up currently being arranged.
[] Consider outpatient echocardiogram to assess for new valvular
abnormalities of systolic dysfunction that could explain his
symptoms.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Metoprolol Succinate XL 25 mg PO QHS
3. Omeprazole 20 mg PO DAILY
4. Magnesium Oxide 400 mg PO DAILY
5. Spironolactone 25 mg PO 4X/WEEK (___)
6. Verapamil SR 480 mg PO Q24H
7. TraZODone 50 mg PO QHS:PRN insomnia
8. Prochlorperazine 10 mg PO Q6H:PRN Nausea/Vomiting - First
Line
9. Ondansetron 8 mg PO Q8H:PRN Nausea/Vomiting - Second Line
10. Multivitamins 1 TAB PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Magnesium Oxide 400 mg PO DAILY
3. Metoprolol Succinate XL 25 mg PO QHS
4. Multivitamins 1 TAB PO DAILY
5. Omeprazole 20 mg PO DAILY
6. Ondansetron 8 mg PO Q8H:PRN Nausea/Vomiting - Second Line
7. Prochlorperazine 10 mg PO Q6H:PRN Nausea/Vomiting - First
Line
8. Spironolactone 25 mg PO 4X/WEEK (___)
9. TraZODone 50 mg PO QHS:PRN insomnia
10. Verapamil SR 480 mg PO Q24H
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
==================
Dyspnea
Orthostatic hypotension
SECONDARY DIAGNOSIS:
====================
Polymorphic Ventricular Tachycardia s/p ICD placement
Stage IV Non-Small Cell Lung Cancer
Secondary malignancy of pleura
Secondary malignancy of lung
Pleural Effusion
Coronary artery disease
Gastroesophageal Reflux Disease
Hypoxemic Respiratory Failure
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear. Mr. ___,
You were admitted because:
- You were feelings lightheaded and short of breath.
During your stay:
- You were given fluids through and IV.
- You had a chest x ray, which showed fluid around your lung.
Your symptoms improved and there was no urgency to remove this
fluid during your hospitalization.
After you leave:
- Please take your medications as prescribed.
- Please attend any outpatient follow-up appointments you have.
Be sure to follow up with interventional pulmonology to follow
up the fluid around your lung.
- Please weigh yourself every morning, call your doctor if
weight goes up more than 3 lbs in 1 day or 5lb in 1 week.
- Please continue to avoid driving until instructed by your
doctor.
- Please do not hold anything heavier than a gallon of milk for
a month.
It was a pleasure participating in your care! We wish you the
very best!
Sincerely,
Your ___ HealthCare Team
Followup Instructions:
___
|
19716166-DS-19
| 19,716,166 | 20,934,658 |
DS
| 19 |
2154-02-12 00:00:00
|
2154-02-12 13:33:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Dizziness, Presyncope
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
Mr. ___ is a ___ yo M with PMH significant for CAD s/p RCA
POBA ___ (pLAD 50%, mLAD 30%, 70% OM1, 100% RI w/collaterals
from distal RCA, stable coronary disease ___, infarct
related cardiomyopathy (LVEF previously 40%, most recently 67%)
with PVC (likely from anterolateral papillary muscle), PMVT s/p
single chamber ___ ICD ___, recurrent Stage IV NSCLC on
Gemzar presenting with presyncope found to be in polymorphic VT.
Patient was in his normal state of health until earlier on the
day of admission when he developed dyspnea and palpitations
while ascending a flight of stairs. This occurred after
receiving chemotherapy earlier this morning. The episode lasted
a few seconds and resolved with rest. At 1715, patient was
watching TV and took a deep breath, after which he again
developed dizziness and lightheadedness, with symptoms similar
to prior VT. He subsequently presented to ___ ED for further
work-up.
On arrival, patient denied any CP, SOB, hemoptysis, leg
swelling, history of blood clots, fevers/chills, URI sx, n/v,
abdominal pain. While in the ED, he experienced 3 similar
episodes of lightheadedness with "warm sensation" and
palpitations lasting ___ seconds found to be in polymorphic VT.
During the second episode, patient syncopized while in bed and
received a shock by his AICD. Patient reportedly had eyes rolled
back and regained consciousness after the shock. EP evaluated
the patient and performed ICD interrogation which confirmed
polymorphic VT. Patient subsequently experienced another episode
of lightheadedness/palpitations lasting ___ seconds with episode
of polymorphic VT which subsequently resolved on its own. He
received IV Lidocaine and was started on Lidocaine prior to
arrival.
Of note, patient presented with syncope and lightheadedness on
___ and progressed to unstable polymorphic VT for which he
was intubated and shocked. At that time, concern for precipitant
of prolonged QTC in setting of Zofran, Chlorpromazine,
Trazodone, and Azithromycin. He was started on Metoprolol and
Verapamil with decrease in ectopy burden. He ultimately
underwent an EP study on ___, though unable to find specific
focus for ablation. Patient underwent ICD placement on ___.
In the ED, - Initial vitals were: T97.1, HR 105, BP 148/70, RR
16, 96% RA - Exam notable for: no JVD, Lungs CTA b/l - Labs
notable for: Hgb 11. BNP 1394. Mg 1.8, K 4.4. Troponin <0.01 -
Studies notable for: CXR with left basilar opacity concerning
for small left pleural effusion, compressive atelectasis and
pleural based mets, though infection difficult to exclude.
Grossly similar left suprahilar mass
Bedside TTE without pericardial effusion
- Patient was given: IV Mg 4gm, Metoprolol succinate 25mg,
Verapamil 240mg, Lidocaine 100mg IV bolus followed by Lidocaine
1mg/min IV gtt
On arrival to the CCU, patient currently denies any chest pain,
palpitations, shortness of breath, dizziness/lightheadedness. He
explained that over the past few months, he has noted
progressive dyspnea on exertion associated with palpitations, as
well as orthopnea requiring him to wake up in the middle of the
night and sleep on the cough with multiple pillows. He denies
any chest pain at rest or on exertion. In light of these
symptoms, he was evaluated by wife's PCP toward end of ___ and
was prescribed 7 day course of Augmentin/Doxycycline with mild
improvement in his symptoms. Given ongoing fatigue and
lightheadedness with standing, he presented again to the ED on
___ with CXR showing progressive left sided pleural effusion
and was discharged with outpatient IP f/u for thoracentesis. ICD
was not interrogated at that time.
As above, patient presented for scheduled chemotherapy earlier
on day of presentation. He has not been taking any antiemetics
(Chlorpromazine, Zofran) at home, though did receive dose of
Chlorpromazine earlier today while receiving treatment.
Past Medical History:
Cardiac History:
- HTN
- HLD
- CAD s/p POBA RCA ___ (noted 70% stenosis ostium OM1, 100%
stenosis proximal segment ramus intermedius, 95% stenosis
proximal, mid and distal RCA)
- Heart failure with recovered EF
- Hx VT storm s/p ICD
Other PMH:
-NSCLC Regimen: Previously on cisplatin and etoposide, Day 1, 8,
29, 36, etoposide day ___. x 2 Cycles and Imfinzi 10
mg/kg Q 2 weeks x 7 Cycles/ Carboplatin/Pemetrexed/Pembrolizumab
q3w x 4 cycles. Abraxane 260 mg/m2 and Avastin 15 mg/m2 Q 3
weeks
x 4 cycles. Current Treatment: Gemzar 1000 mg/m2 week ___ week
4
off
- OSA
- GERD
- Hypogonadism
Social History:
___
Family History:
Mother with CAD s/p CABG (___), HTN; Father with CAD s/p CABG
(___), HTN, Diabetes; Brother with HTN, and ?heart condition.
Says heart disease runs in maternal aunts/uncles, though could
not provide specifics. No history of arrhythmias or sudden
unexplained cardiac death at young age.
Physical Exam:
ADMISSION EXAM
====================
VS: REVIEWED IN METAVISION
GENERAL: Well developed, well nourished in NAD. Oriented x3.
Mood, affect appropriate.
HEENT: Normocephalic, atraumatic. Sclera anicteric. PERRL. EOMI.
NECK: Supple. JVP not elevated.
CARDIAC: Tachycardic, regular rhythm. No murmurs, rubs, or
gallops.
LUNGS: No chest wall deformities or tenderness. Respiration is
unlabored with no accessory muscle use. Decreased breath sounds
LLL. No crackles or rhonchi
ABDOMEN: Soft, non-tender, non-distended. No palpable
hepatomegaly or splenomegaly.
EXTREMITIES: Warm, well perfused. No clubbing, cyanosis, or
peripheral edema.
SKIN: No significant lesions or rashes.
PULSES: Distal pulses palpable and symmetric.
NEURO: AAOx3, no focal deficits
DISCHARGE EXAM
==============
24 HR Data (last updated ___ @ 749)
Temp: 98.2 (Tm 98.8), BP: 132/66 (100-132/58-69), HR: 73
(55-89), RR: 20 (___), O2 sat: 94% (93-97), O2 delivery: RA,
Wt: 157.19 lb/71.3 kg
GENERAL: Well developed, well nourished in NAD. Oriented x3.
Mood, affect appropriate.
HEENT: Normocephalic, atraumatic. Sclera anicteric. EOMI.
NECK: Supple. JVP not elevated.
CARDIAC: Normal rate, regular rhythm. No murmurs, rubs, or
gallops.
LUNGS: No chest wall deformities or tenderness. Respiration is
unlabored with no accessory muscle use. Decreased breath sounds
LLL. No crackles or rhonchi.
ABDOMEN: Soft, non-tender, non-distended. No palpable
hepatomegaly or splenomegaly.
EXTREMITIES: Warm, well perfused. No clubbing, cyanosis, or
peripheral edema.
SKIN: No significant lesions or rashes.
PULSES: Distal pulses palpable and symmetric.
NEURO: AAOx3, no focal deficits
Pertinent Results:
ADMISSION LABS
===================
___ 07:51PM BLOOD WBC-6.4 RBC-3.87* Hgb-11.0* Hct-34.1*
MCV-88 MCH-28.4 MCHC-32.3 RDW-20.8* RDWSD-63.7* Plt ___
___ 07:51PM BLOOD Glucose-146* UreaN-10 Creat-0.7 Na-137
K-4.4 Cl-101 HCO3-21* AnGap-15
___ 07:51PM BLOOD ___ PTT-29.7 ___
___ 07:51PM BLOOD cTropnT-<0.01
___ 01:18AM BLOOD cTropnT-<0.01
___ 07:51PM BLOOD proBNP-139___*
RELEVANT STUDIES
===================
___ CXR PORTABLE AP:
Left basilar opacification likely reflects a combination of a
small left
pleural effusion, compressive atelectasis, and known pleural
based metastases though infection is difficult to exclude in the
correct clinical setting. Grossly similar left suprahilar mass.
TTE ___: CONCLUSION: The left atrial volume index is mildly
increased. The estimated right atrial pressure is ___ mmHg.
There is normal left ventricular wall thickness with a normal
cavity size. Overall left ventricular systolic function is
moderately depressed secondary to hypokinesis of the anterior
septum, anterior free wall, and apex. The visually estimated
left ventricular ejection fraction is 35%. There is no resting
left ventricular outflow tract gradient. Tissue Doppler suggests
an increased left ventricular filling pressure (PCWP greater
than 18 mmHg). Normal right ventricular cavity size with normal
free wall motion. Tricuspid annular plane systolic excursion
(TAPSE) is normal. The aortic sinus diameter is normal for
gender with normal ascending aorta diameter for gender. The
aortic arch diameter is normal with a normal descending aorta
diameter. There is no evidence for an aortic arch coarctation.
There is trace aortic regurgitation. The mitral valve leaflets
appear structurally normal 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 tricuspid regurgitation present (could not be
qualified). Due to acoustic shadowing, the severity of tricuspid
regurgitation may be UNDERestimated. The estimated pulmonary
artery systolic pressure is normal. There is a small pericardial
effusion subtending the right heart. There are no 2D or Doppler
echocardiographic evidence of tamponade. IMPRESSION: extensive
anteroapical hypokinesis Compared with the prior TTE (images
reviewed) of ___ , the left ventricualr ejection fraction
is reduced.
PREVIOUS CARDIAC STUDIES
=========================
___ echocardiogram - Mild regional systolic dysfunction
with
hypokinesis of the mid-distal inferolateral, anterolateral, and
anterior walls consistent with multivessel coronary artery
disease. Mild mitral regurgitation. Normal pulmonary pressure.
Estimated LVEF 45-50%
___: coronary angiogram and angioplasty - Three vessel
coronary artery disease.
PTCA alone (POBA) of RCA.
___ Cardiac Catheterization
Findings
Stable LAD and LCx disease comapred to prior.
Moderate residual RCA disease after prior POBA with normal
flow and intact RI collaterals
___ TTE
Conclusion:
The left atrium is mildly dilated. There is no evidence for an
atrial septal defect by 2D/color Doppler. The estimated right
atrial pressure is ___ mmHg. There is normal left ventricular
wall thickness with a normal cavity size. There is normal
regional and global left ventricular systolic function.
Quantitative 3D volumetric left ventricular ejection fraction is
67 %. Left ventricular cardiac index is low normal (2.0-2.5
L/min/m2). There is no resting left ventricular outflow tract
gradient. Tissue Doppler suggests an increased left ventricular
filling pressure (PCWP greater than 18 mmHg). Normal right
ventricular cavity size with normal free wall motion. Tricuspid
annular plane systolic excursion (TAPSE) is normal. 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 (?#) are mildly thickened. 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 mild [1+] mitral regurgitation. The pulmonic
valve leaflets are not well seen. The tricuspid valve leaflets
appear structurally normal. There is physiologic tricuspid
regurgitation. There is moderate pulmonary artery systolic
hypertension. There is a small loculated pericardial effusion
primarily anterior to the right atrium and basal right
ventricle.
IMPRESSION: Normal left ventricular wall thickness and
biventricular cavity sizes and regional/global systolic
function. Moderate pulmonary artery systolic hypertension. Mild
mitral regurgitation with normal valve morphology.
TTE (___)
CONCLUSION:
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 normal left ventricular
wall thickness with a normal cavity size. There is mild regional
left ventricular systolic dysfunction with hypokinesis of the
mid-distal inferolateral, anterolateral, and anterior walls (see
schematic). The visually estimated left ventricular ejection
fraction is 45-50%. There is no resting left ventricular outflow
tract gradient. No ventricular septal
defect is seen. Diastolic parameters are indeterminate. Normal
right ventricular cavity size with normal free wall motion. The
aortic sinus diameter is normal for gender with normal ascending
aorta diameter for gender. The aortic valve leaflets are
moderately thickened. There is no aortic valve stenosis. There
is trace aortic regurgitation. The mitral valve leaflets are
mildly thickened with no mitral valve prolapse. There is mild
[1+]
mitral regurgitation. The tricuspid valve leaflets appear
structurally normal. There is physiologic tricuspid
regurgitation. The estimated pulmonary artery systolic pressure
is normal. There is a trivial pericardial effusion.
IMPRESSION: Mild regional systolic dysfunction with hypokinesis
of the mid-distal inferolateral, anterolateral, and anterior
walls consistent with multivessel coronary artery disease. Mild
mitral regurgitation. Normal pulmonary pressure.
CARDIAC CATHETERIZATION (___)
Coronary Description
The coronary circulation is right dominant.
LM: The Left Main, arising from the left cusp, is a large
caliber vessel and is normal. This vessel trifurcates into the
Left Anterior Descending, Left Circumflex, and Ramus
Intermedius.
LAD: The Left Anterior Descending artery, which arises from the
LM, is a large caliber vessel. There is a 50% tubular stenosis
in the proximal segment. There is a 30% diffuse stenosis in the
mid segment. The Septal Perforator, arising from the proximal
segment, is a small caliber vessel.
Cx: The Circumflex artery, which arises from the LM, is a large
caliber vessel with mild luminal irregularities. The ___ Obtuse
Marginal, arising from the proximal segment, is a medium caliber
vessel. There is a 70% stenosis in the ostium. The ___ Obtuse
Marginal, arising from the mid segment, is a medium caliber
vessel.
RI: The Ramus Intermedius, which arises from the LM, is a medium
caliber vessel. There is a 100% stenosis in the proximal
segment. There are collaterals from the distal RCA.
RCA: The Right Coronary Artery, arising from the right cusp, is
a large caliber vessel. There is a 95% stenosis in the proximal
and mid segments. There is a 95% stenosis in the mid and distal
segments. The Acute Marginal, arising from the proximal segment,
is a small caliber vessel. The Right Posterior Descending
Artery, arising from the distal segment, is a medium caliber
vessel. The Right Posterolateral Artery, arising from the distal
segment, is a medium caliber vessel.
Interventional Details
Percutaneous Coronary Intervention: Percutaneous coronary
intervention (PCI) was performed on an ad hoc basis based on the
coronary angiographic findings from the diagnostic portion of
this procedure. A ___ AL 0.75 guiding catheter provided excellent
support. After crossing with a wire all stenoses were dilated
using a 2.0 mm NC balloon. Unsuccessful attempt to pass a 2.5mm
x 38mm stent, so did further dilations using a 2.5mm NC balloon
at high pressure. The balloon at this point became stuck to the
wire
and pulled wire out of vessel as removed. Tried unsuccessfully
to recross all stenoses using a Sion wire and then a Prowater
wire but unsuccessful because of passage into dissection flaps..
Since there is only mild stenosis (approx 40%) and normal flow
and patient free of chest pain, decided that risks outweigh
benefits of more aggressive attempts.
Complications: There were no clinically significant
complications.
Findings
Three vessel coronary artery disease.
PTCA alone (POBA) of RCA.
DISCHARGE LABS
==============
___ 08:33AM BLOOD Glucose-95 UreaN-12 Creat-1.0 Na-138
K-4.5 Cl-99 HCO3-23 AnGap-16
Brief Hospital Course:
SUMMARY:
=========
___ yo M with PMH significant for CAD s/p RCA POBA ___ (pLAD
50%, mLAD 30%, 70% OM1, 100% RI w/collaterals from distal RCA,
stable coronary disease ___, infarct related cardiomyopathy
(LVEF previously 40%, most recently 67%) with PVC (likely from
anterolateral papillary muscle), PMVT s/p single chamber ___.
___ ICD ___, recurrent Stage IV NSCLC on Gemzar presenting
with presyncope found to be in polymorphic VT.
#CORONARIES: LAD with 50% tubular stenosis proximal segment, 30%
diffuse stenosis in mid-segment. ___ OM with 70-80% stenosis .
Ramus Intermedius 100% stenosis in proximal segment with robust
collaterals from distal RCA. RCA with diffuse mild-moderate
disease throughout with 50% focal stenosis in distal segment
#PUMP: EF 67% (previous 45-50% ___, mild MR, moderate PASP
#RHYTHM: Sinus
ACUTE ISSUES:
============
#Polymorphic VT
Patient with history of PMVT now s/p ICD placement presenting
with recurrent symptomatic PMVT. Previous etiology concerning
for medication-induced prolonged QTC. Had been controlled on
Metoprolol, Verapamil with previous EP study without focus
amenable to ablation. ICD interrogation consistent with acute
sustained PMVT appropriately shock-terminated by ICD, as well as
8 episodes of NSVT since ___. QTc notably more prolonged than
prior in setting of hypomagnesemia with early after
depolarizations after receiving Chlorpromazine. Patient with
known ischemic cardiomyopathy (EF previously recovered, now
reduced), no evidence of acute ischemic event. Possible
contribution of scar from prior XRT therapy to the chest. EP was
consulted who recommended starting a lidocaine drip and
amiodarone drip, which was later changed to PO amiodarone. He
continued to have brief episodes of non-sustained VT without
receiving shocks. The decision was made to hold off on further
ischemic workup given patient's prognosis from a lung cancer
perspective, as he would not be a surgical candidate and further
ischemic work up would be of limited benefit. Lidocaine gtt was
downtitrated, however, patient developed recurrent NSVT and PO
mexilitine was started. After initiation of mexilitine,
lidocaine gtt was titrated off and patient was maintained on PO
regimen of metoprolol succinate 50mg daily, amiodarone 400mg TID
and mexiletine 200mg q8h with adequate suppression of VT.
Discontinued Verapamil, though given recurrent frequent NSVT,
restarted prior to discharge. Patient triggered for junctional
escape rhythm on ___, though was asymptomatic and
hemodynamically stable. No further medication adjustments were
made.
Discharge medications: Metoprolol succinate XL 50 mg PO daily,
Verapamil 240 mg PO BID, Mexiletine 200 mg PO q8h, amiodarone
400 mg PO TID.
# Acute HFrEF
Had previous reduced EF with recovery, most recent TTE showing
EF reduced again to 35%. Differential includes myocardial
stunning from recent ICD shocks vs. ischemic etiology, although
EKG and troponins not concerning for this. Patient does have
history of CAD, however, due to life expectancy with comorbid
stage IV NSCLC, coronary angiography not pursued.
- PRELOAD: maintaining euvolemia without diuretics
- AFTERLOAD: lisinopril 2.5mg
- NHBK: Continued home spironolactone 25mg 4x/week and
metoprolol succinate as above
CHRONIC ISSUES:
===============
#NSCLC
#Pleural Effusions
Per outpatient oncologist, currently on third line therapy with
plan to repeat chest CT as an outpatient to assess disease
burden. Will also be considered for clinical trials based on
adequate performance status. On Gemzar 1000 mg/m2 week ___ week
4 off. Pleural effusion with malignant cells giving evidence of
metastatic adenocarcinoma.
#Hypertension
Mgmt of hypertension as above (see HFrEF)
#CAD
Continue ASA and increased Metoprolol as above. Outpatient
physician was considering ___, although he had a
transaminitis on a statin before.
TRANSITIONAL ISSUES:
==================
[] Avoid QT prolonging agents
[] Repeat TTE in ___ weeks, if EF still low, send further w/u
for non-ischemic cardiomyopathy
[] Follow-up pleural fluid analysis
[] Repeat LFTs at outpatient follow-up. Had mild transaminitis
(AST 71, ALT 118) on ___. Thought to possibly be due to
amiodarone.
ADVANCED CARE PLANNING:
======================
#CODE: Full, confirmed
#CONTACT/HCP: ___ (wife) ___ ___ (daughter)
___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Magnesium Oxide 400 mg PO DAILY
3. Metoprolol Succinate XL 25 mg PO QHS
4. Multivitamins 1 TAB PO DAILY
5. Spironolactone 25 mg PO 4X/WEEK (___)
6. Prochlorperazine 10 mg PO Q6H:PRN Nausea/Vomiting - First
Line
7. Omeprazole 20 mg PO DAILY
8. Verapamil 240 mg PO Q12H
9. GuaiFENesin-CODEINE Phosphate ___ mL PO QHS:PRN cough
Discharge Medications:
1. Amiodarone 400 mg PO TID
RX *amiodarone 400 mg 1 tablet(s) by mouth three times a day
Disp #*90 Tablet Refills:*0
2. Lisinopril 2.5 mg PO DAILY
RX *lisinopril 2.5 mg 1 tablet(s) by mouth once a day Disp #*90
Tablet Refills:*0
3. Mexiletine 200 mg PO Q8H
RX *mexiletine 200 mg 1 capsule(s) by mouth every eight (8)
hours Disp #*90 Capsule Refills:*0
4. Metoprolol Succinate XL 50 mg PO DAILY
RX *metoprolol succinate 50 mg 1 tablet(s) by mouth once a day
Disp #*90 Tablet Refills:*0
5. Verapamil 240 mg PO Q12H
6. Aspirin 81 mg PO DAILY
7. GuaiFENesin-CODEINE Phosphate ___ mL PO QHS:PRN cough
8. Magnesium Oxide 400 mg PO DAILY
9. Multivitamins 1 TAB PO DAILY
10. Omeprazole 20 mg PO DAILY
11. Spironolactone 25 mg PO 4X/WEEK (___)
12.Outpatient Lab Work
Labs: Chem10, LFTs
Date: ___
ICD-9: E942.0
Please fax to ___ S., MD ___
Discharge Disposition:
Home
Discharge Diagnosis:
Polymorphic ventricular tachycardia
Heart failure with reduced ejection fraction
Non small cell lung cancer
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
WHY WERE YOU ADMITTED TO THE HOSPITAL?
- You were admitted to the hospital because you were you were
having an abnormal heart rhythm which caused your ICD to shock
you.
WHAT WAS DONE WHILE YOU WERE IN THE HOSPITAL?
- You were given IV medication to normalize your heart rhythm.
You were started on new oral medications to control your heart
rhythm.
WHAT DO YOU NEED TO DO WHEN YOU LEAVE THE HOSPITAL?
- Take all of your medications as prescribed (listed below)
- Follow up with your doctors as listed below
- Weigh yourself every morning, seek medical attention if your
weight goes up more than 3 lbs.
- Seek medical attention if you have new or concerning symptoms
or you develop swelling in your legs, abdominal distention, or
shortness of breath at night.
Please see below for more information on your hospitalization.
It was a pleasure taking part in your care here at ___!
We wish you all the best!
- Your ___ Care Team
Followup Instructions:
___
|
19716166-DS-20
| 19,716,166 | 27,532,827 |
DS
| 20 |
2154-02-21 00:00:00
|
2154-02-22 11:25:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
syncope
Major Surgical or Invasive Procedure:
ICD Interrogation
Ventricular Tachycardia Ablation
History of Present Illness:
Mr. ___ is a ___ yo M with PMH significant for CAD s/p RCA
POBA ___ (pLAD 50%, mLAD 30%, 70% OM1, 100% RI w/collaterals
from distal RCA, stable coronary disease ___, infarct
related cardiomyopathy (LVEF previously 40%, most recently 67%)
with PVC (likely from anterolateral papillary muscle), PMVT s/p
single chamber ___ ICD ___, recurrent Stage IV NSCLC on
Gemzar presenting with presenting with syncope found to be in
polymorphic VT.
Of note, he was admitted to ___ on ___ with syncope and was
noted to have recurrent polymorphic VT. He was thought to have
PVC triggering polymorphic VT originating from somewhere in the
anterolateral LV. EPS was performed without focus amenable to
ablation. An ICD was implanted given the fact that his prognosis
from his lung cancer may still be at least one year. He was sent
home on metoprolol and verapamil
He was then readmitted from ___ for presyncope ___
polymorphic VT. He was still on metop/verapamil at that time.
ICD interrogation was consistent with acute sustained PMVT
appropriately shock-terminated by ICD. He was initially on a
Lidocaine drip which was transitioned to mexilitine. PO amio was
also started. He was discharged on a regimen of metoprolol
succinate 50mg daily, amiodarone 400mg TID and mexiletine 200mg
q8h. Discontinued Verapamil, though given recurrent frequent
NSVT, restarted prior to discharge. Patient triggered for
junctional escape rhythm on ___, though was asymptomatic and
hemodynamically stable. No further medication adjustments were
made.
He was discharged yesterday ___. This morning he woke up
feeling dizzy, however was steady on his feet. While watching TV
he felt a non-painful sensation arise from his chest to his head
prior to losing consciousness. This was similar to prior
episodes. He was oriented upon waking, and denies any shock,
nausea, vomiting, headache, chest pain, shortness of breath,
palpitations, or incontinence. The event lasted several seconds,
and resulting in EMS transport to ___.
In the ED he was noted to be normotensive with normal RR and
oxygen saturation on room air. His labs were notable for a mild
leukocytosis and a normal K and Mag. EP was consulted and noted
a single episode of VT terminated after ATP with no shock
delivered. He was not given any medications in the ED, and was
admitted for further monitoring and evaluation.
On arrival to the floor he endorses the above HPI and is
currently asymptomatic. He notes having taken all of his
medications as prescribed.
Past Medical History:
Cardiac History:
- HTN
- HLD
- CAD s/p POBA RCA ___ (noted 70% stenosis ostium OM1, 100%
stenosis proximal segment ramus intermedius, 95% stenosis
proximal, mid and distal RCA)
- Heart failure with recovered EF
- Hx VT storm s/p ICD
Other PMH:
-NSCLC Regimen: Previously on cisplatin and etoposide, Day 1, 8,
29, 36, etoposide day ___. x 2 Cycles and Imfinzi 10
mg/kg Q 2 weeks x 7 Cycles/ Carboplatin/Pemetrexed/Pembrolizumab
q3w x 4 cycles. Abraxane 260 mg/m2 and Avastin 15 mg/m2 Q 3
weeks
x 4 cycles. Current Treatment: Gemzar 1000 mg/m2 week ___ week
4
off
- OSA
- GERD
- Hypogonadism
Social History:
___
Family History:
Mother with CAD s/p CABG (___), HTN; Father with CAD s/p CABG
(___), HTN, Diabetes; Brother with HTN, and ?heart condition.
Says heart disease runs in maternal aunts/uncles, though could
not provide specifics. No history of arrhythmias or sudden
unexplained cardiac death at young age.
Physical Exam:
ADMISSION EXAM:
===============
___ 1158 Temp: 98.0 PO BP: 108/56 R Lying HR: 60 RR: 20
O2 sat: 94% O2 delivery: RA
GENERAL: Well developed, well nourished in NAD. Oriented x3.
Mood, affect appropriate.
HEENT: Normocephalic, atraumatic. Sclera anicteric. EOMI.
NECK: Supple. JVP not elevated.
CARDIAC: Normal rate, regular rhythm. No murmurs, rubs, or
gallops.
LUNGS: No chest wall deformities or tenderness. Respiration is
unlabored with no accessory muscle use. Decreased breath sounds
LLL. No crackles or rhonchi.
ABDOMEN: Soft, non-tender, non-distended. No palpable
hepatomegaly or splenomegaly.
EXTREMITIES: Warm, well perfused. No clubbing, cyanosis, or
peripheral edema.
SKIN: No significant lesions or rashes.
PULSES: Distal pulses palpable and symmetric.
NEURO: AAOx3, no focal deficits
DISCHARGE EXAM:
===============
VS: 24 HR Data (last updated ___ @ ___
Temp: 98.3 (Tm 98.3), BP: 101/58 (90-124/51-71), HR: 58
(54-67), RR: 18 (___), O2 sat: 91% (90-97)
GENERAL: Well developed, well nourished in NAD. Oriented x3.
Mood, affect appropriate.
HEENT: Normocephalic, atraumatic. Sclera anicteric. EOMI.
NECK: Supple. JVP not elevated.
CARDIAC: Normal rate, regular rhythm. No murmurs, rubs, or
gallops.
LUNGS: No chest wall deformities or tenderness. Respiration is
unlabored with no accessory muscle use. Decreased breath sounds
LLL. No crackles or rhonchi.
ABDOMEN: Soft, non-tender, non-distended. No palpable
hepatomegaly or splenomegaly.
EXTREMITIES: Warm, well perfused. No clubbing, cyanosis, or
peripheral edema.
SKIN: No significant lesions or rashes.
PULSES: Distal pulses palpable and symmetric.
NEURO: AAOx3, no focal deficits
Pertinent Results:
ADMISSION LABS:
==============
___ 10:55AM BLOOD WBC-12.1* RBC-3.34* Hgb-9.6* Hct-30.8*
MCV-92 MCH-28.7 MCHC-31.2* RDW-22.8* RDWSD-72.8* Plt ___
___ 10:55AM BLOOD Neuts-79.3* Lymphs-5.6* Monos-11.9
Eos-0.2* Baso-0.4 Im ___ AbsNeut-9.59* AbsLymp-0.68*
AbsMono-1.44* AbsEos-0.02* AbsBaso-0.05
___ 11:25AM BLOOD ___ PTT-28.7 ___
___ 08:33AM BLOOD Glucose-95 UreaN-12 Creat-1.0 Na-138
K-4.5 Cl-99 HCO3-23 AnGap-16
___ 10:55AM BLOOD ALT-121* AST-53* AlkPhos-139* TotBili-0.3
___ 08:33AM BLOOD Calcium-9.4 Phos-3.8 Mg-2.0
PERTINENT LABS:
===============
___ 06:07AM BLOOD ALT-98* AST-36 AlkPhos-140*
DISCHARGE LABS:
===============
___ 06:00AM BLOOD WBC-9.1 RBC-3.26* Hgb-9.4* Hct-29.9*
MCV-92 MCH-28.8 MCHC-31.4* RDW-21.2* RDWSD-70.4* Plt ___
___ 06:00AM BLOOD Glucose-106* UreaN-16 Creat-0.9 Na-138
K-4.0 Cl-102 HCO3-21* AnGap-15
___ 06:00AM BLOOD Calcium-9.3 Phos-3.7 Mg-2.0
IMAGING/STUDIES:
=================
___ CHEST (PORTABLE AP)
IMPRESSION:
Left-sided pacemaker and right-sided Port-A-Cath are unchanged.
Small left
pleural effusion unchanged. Cardiomediastinal silhouette is
stable. No
pneumothorax. There is stable subsegmental atelectasis in the
left lower
lobe.
___ ICD Interrogation
Interrogation:
Battery voltage/time to ERI: ___ years, 12uA
Charge Time: 7.8 sec
Presenting rhythm: VS
Underlying rhythm: SR ___
Mode, base and upper track rate: VVI 40
ICD Configuration:
VT1 171: monitor only
VT2 190: ATPx2, 30Jx1, 36Jx3
VF 250: ATPx1, 30Jx1, 36Jx5
Lead Testing
R waves: 11.7 mV RV thresh: 0.75 V @ 0.5 ms RV imp: 460 ohms
DF impedance: 61 ohms (RV to can)
Diagnostics:
VP: 0%
Events:
___ 0940: VT-2 ATP (successful per ICD, but there were 7
beats of polymorphic VT before resuming sinus rhythm
Summary:
1. 1 episode of sustained monomorphic VT, self-terminated after
ATP and no shock delivered
2. ICD function normal with acceptable lead measurements and
battery status
3. Programming changes: none
4. Follow-up: Inpatient admission under Dr. ___, EP
attending
___ ICD Interrogation
Diagnostics:
VP: 0%
Events:
___ 0940: VT-2 ATP (successful per ICD, but there were 7
beats of polymorphic VT before resuming sinus rhythm
Brief Hospital Course:
Outpatient Providers: SUMMARY:
___ yo M with PMH significant for CAD s/p RCA POBA ___ (pLAD
50%, mLAD 30%, 70% OM1, 100% RI w/collaterals from distal RCA,
stable coronary disease ___, infarct related cardiomyopathy
(LVEF previously 40%, most recently 67%) with PVC (likely from
anterolateral papillary muscle), PMVT s/p single chamber ___.
___ ICD ___, recurrent Stage IV NSCLC on ___ presenting
with presyncope found to be in polymorphic VT now maintained on
Amiodarone and Verapamil and s/p VT ablation on ___.
ACTIVE ISSUES:
# Polymorphic VT
Patient has a history of PMVT now s/p ICD placement presenting
with recurrent symptomatic PMVT. Previous etiology concerning
for
medication-induced prolonged QTC (currently 523). Had been
controlled on Metoprolol, Verapamil during prior EP study
without focus amenable to ablation. ICD interrogation consistent
with acute sustained PMVT appropriately self-terminated after
ATP and no shock delivered. Patient with known ischemic
cardiomyopathy (EF previously recovered, now reduced), though no
evidence of acute ischemic event. Possible contribution of scar
from prior XRT to the chest. Patient on verapamil, amid,
metoprolol and mexiletine with little room for maximizing doses.
He complicated an amiodarone load and transitioned to 400mg QD
prior to discharge. As he was not a great candidate for surgery
given comorbidities, and PVCs appeared predominantly unifocal,
decision to VT ablate was made and performed on ___. His
mexiletine was also discontinued prior to discharge. He was sent
home on amiodarone and verapamil.
# HFrEF
Had previous reduced EF with recovery, most recent TTE showing
EF reduced again to 35%. Differential included myocardial
stunning from recent ICD shocks vs. ischemic vs. non-ischemic
etiologies. Patient does have history of CAD, however, due to
life expectancy with comorbid stage IV NSCLC, coronary
angiography was not pursued. There was no role for ischemic
work-up for now and can repeat TTE as an outpatient and pursue
further workup if EF continues to be depressed, as current
decline in systolic function likely ___ episodes of VT and ICD
discharges. Patient was continued on metoprolol and
spironolactone throughout.
#Elevated Transaminases
Possibly ___ recent Amiodarone. No RUQ pain. Mildly elevated
INR. AST downtrended to WNL. ALT remained mildly elevated at 98
on discharge.
CHRONIC ISSUES:
===============
#___
#Pleural Effusions
Per outpatient oncologist, currently on third line therapy with
plan to repeat chest CT as an outpatient to assess disease
burden. Will also be considered for clinical trials based on
adequate performance status. Cytology with metastatic
adenocarcinoma. Patient is on Gemzar 1000 ___ week 4 off.
#Hypertension
Patient with history of hypertension. Continued on
spironolactone, metoprolol and lisinopril during course.
#CAD
Unikely that patient would have undergone coronary angiogram
given comorbidities so was not worked up as possible contributor
to dysrrhythmia.
TRANSITIONAL ISSUES:
DISCHARGE WEIGHT: 72.6kg (160.05 lbs)
DISCHARGE Cr/BUN: 0.9
MEDICATION CHANGES:
- NEW:
None
- STOPPED:
Mexiletine
- CHANGED:
Amiodarone 400mg TID to ___ QD
Metoprolol succinate 50mg QD to 50mg BID
[] QTc was prolonged to 524 prior to discharge. Please avoid QT
prolonging meds
[] No ischemic evaluation was conducted this admission given
that he would not be candidate for CABG and already had
complicated PCI in the past
[] Please consider repeat TTE as an outpatient
[] He did not receive ___ this admission and he will
follow-up with outpatient oncologist Dr. ___
___ status: Full ___
Contact/HCP: ___ (wife) ___ ___ (daughter)
___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Metoprolol Succinate XL 50 mg PO DAILY
3. Multivitamins 1 TAB PO DAILY
4. Omeprazole 20 mg PO DAILY
5. Spironolactone 25 mg PO 4X/WEEK (___)
6. Amiodarone 400 mg PO TID
7. Lisinopril 2.5 mg PO DAILY
8. Mexiletine 200 mg PO Q8H
9. GuaiFENesin-CODEINE Phosphate ___ mL PO QHS:PRN cough
10. Magnesium Oxide 400 mg PO DAILY
11. Verapamil 240 mg PO Q12H
Discharge Medications:
1. Metoprolol Succinate XL 50 mg PO Q12H
2. Amiodarone 400 mg PO TID
3. Aspirin 81 mg PO DAILY
4. GuaiFENesin-CODEINE Phosphate ___ mL PO QHS:PRN cough
5. Lisinopril 2.5 mg PO DAILY
6. Magnesium Oxide 400 mg PO DAILY
7. Mexiletine 200 mg PO Q8H
8. Multivitamins 1 TAB PO DAILY
9. Omeprazole 20 mg PO DAILY
10. Spironolactone 25 mg PO 4X/WEEK (___)
11. Verapamil SR 240 mg PO Q12H
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY:
--------------------
Polymorphic Ventricular Tachycardia
SECONDARY:
--------------------
Heart failure with reduced ejection fraction
Non Small Cell Lung Cancer
Hypertension
Coronary Artery Disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
WHY WERE YOU ADMITTED TO THE HOSPITAL?
- You were admitted to the hospital because you were having an
abnormal heart rhythm which caused you to lose consciousness.
WHAT WAS DONE WHILE YOU WERE IN THE HOSPITAL?
- Your heart rhythm medications were optimized and you underwent
a ventricular tachycardia ablation on ___.
WHAT DO YOU NEED TO DO WHEN YOU LEAVE THE HOSPITAL?
- Take all of your medications as prescribed (listed below)
- Follow up with your doctors as listed below
- Weigh yourself every morning, seek medical attention if your
weight goes up more than 3 lbs.
- Seek medical attention if you have new or concerning symptoms
or you develop swelling in your legs, abdominal distention, or
shortness of breath at night.
- Seek medical attention if you are having worsening
ilghtheadedness and dizziness.
Please see below for more information on your hospitalization.
It was a pleasure taking part in your care here at ___!
We wish you all the best!
- Your ___ Care Team
Followup Instructions:
___
|
19716166-DS-21
| 19,716,166 | 21,255,294 |
DS
| 21 |
2154-02-27 00:00:00
|
2154-03-04 14:02:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Chest Pain/ Pre-syncope
Major Surgical or Invasive Procedure:
cardiac cateterization
History of Present Illness:
HISTORY OF PRESENTING ILLNESS:
Mr. ___ is a ___ yo M with PMH significant for CAD s/p RCA
POBA ___ (pLAD 50%, mLAD 30%, 70% OM1, 100% RI w/collaterals
from distal RCA, stable coronary disease ___, infarct
related cardiomyopathy (LVEF 35 % on ___, VT s/p ICD and
VT ablation (___), recurrent Stage IV NSCLC on Gemzar
presenting with presenting with progressive DOE and presyncopal
episode.
Mr. ___ was recently admitted here from ___ for syncope
___ polymorphic VT. He ended up getting a VT ablation during
that
admission. He states that since discharge he hasn't felt like
himself. He states he has had progressive DOE, increasing ___
edema, orthopnea, and nausea without vomiting. The DOE got to
the
point where he could not make it up one flight of stairs. He did
not have SOB with rest. He had a presyncopal episode earlier
today which prompted him to seek care at the ED. During this
episode he felt SOB, lightheadedness, palpitations, and a brief
discomfort in his chest for less than 1 min that he has trouble
characterizing.
In the ED...
- Initial vitals: 24 HR Data (last updated ___ @ 1536)
Temp: 99.4 (Tm 99.4), BP: 129/80, HR: 66, RR: 18, O2 sat:
92%, O2 delivery: Ra
- EKG: No changes from prior EKG. NSR no ST changes
- Labs/studies notable for: troponin elevated to 0.23 proBNP
1351
- Patient was given: Lasix IV 40 mg good response. was able to
be weaned of O2.
On the floor the patient states SOB is much improved. Denies CP
atm. Currently euvolemic and off supplemental O2.
Mr. ___ has not had a recent stress test. He had a recent
cath
which showed CAD (see below for full report). His last TTE
showed
EF 35%.
REVIEW OF SYSTEMS:
remainder of 10 point ROS negative.
Past Medical History:
Cardiac History:
- HTN
- HLD
- CAD s/p POBA RCA ___ (noted 70% stenosis ostium OM1, 100%
stenosis proximal segment ramus intermedius, 95% stenosis
proximal, mid and distal RCA)
- Heart failure with recovered EF
- Hx VT storm s/p ICD
Other PMH:
-NSCLC Regimen: Previously on cisplatin and etoposide, Day 1, 8,
29, 36, etoposide day ___. x 2 Cycles and Imfinzi 10
mg/kg Q 2 weeks x 7 Cycles/ Carboplatin/Pemetrexed/Pembrolizumab
q3w x 4 cycles. Abraxane 260 mg/m2 and Avastin 15 mg/m2 Q 3
weeks
x 4 cycles. Current Treatment: Gemzar 1000 mg/m2 week ___ week
4
off
- OSA
- GERD
- Hypogonadism
Social History:
___
Family History:
Mother with CAD s/p CABG (___), HTN; Father with CAD s/p CABG
(___), HTN, Diabetes; Brother with HTN, and ?heart condition.
Says heart disease runs in maternal aunts/uncles, though could
not provide specifics. No history of arrhythmias or sudden
unexplained cardiac death at young age.
Physical Exam:
Admission Physical Exam:
================================
GENERAL: Well-developed, well-nourished. NAD. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva pink, no
pallor or cyanosis of the oral mucosa. No xanthelasma.
NECK: No JVD
CARDIAC: RRR, normal S1, S2. No extra heart sounds. No
murmurs/rubs. No thrills, lifts.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. No crackles, wheezes or
rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES: Distal pulses palpable and symmetric
Discharge Physical Exam:
=============================
GENERAL: Well-developed, well-nourished. NAD. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva pink, no
pallor or cyanosis of the oral mucosa. No xanthelasma.
NECK: No JVD
CARDIAC: RRR, normal S1, S2. No extra heart sounds. No
murmurs/rubs. No thrills, lifts.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. No crackles, wheezes or
rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES: Distal pulses palpable and symmetric
Pertinent Results:
Admission Labs:
========================
___ 09:01AM BLOOD WBC-10.5* RBC-3.41* Hgb-9.7* Hct-31.1*
MCV-91 MCH-28.4 MCHC-31.2* RDW-20.3* RDWSD-67.9* Plt ___
___ 09:01AM BLOOD Plt ___
___ 09:01AM BLOOD Glucose-105* UreaN-12 Creat-0.8 Na-134*
K-4.7 Cl-97 HCO3-21* AnGap-16
___ 09:01AM BLOOD ALT-25 AST-26 CK(CPK)-59 AlkPhos-124
TotBili-0.3
___ 09:01AM BLOOD CK-MB-2 proBNP-1351*
___ 09:01AM BLOOD cTropnT-0.23*
___ 01:30PM BLOOD cTropnT-0.23*
___ 07:46PM BLOOD CK-MB-1 cTropnT-0.20*
___ 02:51AM BLOOD Calcium-9.5 Phos-5.0* Mg-2.2
Discharge Labs:
==========================
___ 04:56AM BLOOD WBC-12.9* RBC-3.37* Hgb-9.7* Hct-31.0*
MCV-92 MCH-28.8 MCHC-31.3* RDW-20.1* RDWSD-67.9* Plt ___
___ 04:56AM BLOOD Glucose-112* UreaN-18 Creat-1.0 Na-137
K-4.5 Cl-98 HCO3-26 AnGap-13
___ 04:56AM BLOOD Plt ___
___ 07:46PM BLOOD CK-MB-1 cTropnT-0.20*
___ 04:56AM BLOOD Calcium-9.6 Phos-4.8* Mg-2.0
Imaging:
==========================
Cardiac Cath ___
Two vessel CAD. Recommendations:
Had extensive discussions with patient and referring
cardiologist around findings and options for
management. No clear culprit for current presentation, and
comparing angiographic images there
has been no significant change compared to prior cath ___.
Decided maximize medical
therapy, and consider MIBI to evaluate for ischemic territory.
ICD interrogation report ___
Battery function normal. No episodes of VT or evidence of other
malignant arrhythmias.
Brief Hospital Course:
PATIENT SUMMARY:
====================
Mr. ___ is a ___ yo M with PMHx significant for CAD s/p RCA
POBA ___ (pLAD 50%, mLAD 30%, 70% OM1, 100% RI w/collaterals
from distal RCA, stable coronary disease ___, infarct
related cardiomyopathy (LVEF 35 % on ___, VT s/p ICD and
VT ablation (___), recurrent Stage IV NSCLC on Gemzar
presenting with progressive DOE and presyncopal episode. He was
found to have acute decompensated CHF. He was diuresed with IV
Lasix and was euvolemic at discharge. He was also found to have
an NSTEMI and underwent cardiac catheterization which revealed
stable coronary artery disease. He was medically optimized for
CAD and discharged.
====================
ACUTE ISSUES:
====================
#Acute on chronic HFrEF: Patient presented clinically volume
overloaded with orthopnea, DOE, and increasing ___ edema. CXR
showed pulmonary edema. He has a history of ischemic and
nonischemic CM. Most recent EF 35% (___). Patient is NYHA
class I at baseline. Patient reports compliance with
medidcations, no changes in diet, no alcohol/drugs. s/p cath ___
without any new obstructive disease. Unclear precipitating
factor. He was diuresed to euvolemia with IV Lasix and had
symptomatic relief. He was dishcharged on his home medications.
#NSTEMI: The patient had atypical chest pain briefly before a
presyncopal
episode prior to admission. He has known stable CAD on medical
management. Trops were initially negative and rose to 0.23 on
admission. TIMI score of 4. Of note, due to life expectancy with
comorbid stage IV NSCLC, coronary angiography was not pursued on
previous admission. s/p cardiac cath on ___ which revealed
stable 2 vessel coronary artery disease. Possibly type II NSTEMI
in the setting of decompensated CHF vs. recent VT ablation,
rather than an acute plaque rupture.
====================
CHRONIC ISSUES:
====================
#Stage IV lung cancer:
Per outpatient oncologist, currently on third line therapy with
plan to repeat chest CT as an outpatient to assess disease
burden. Will also be considered for clinical trials based on
adequate performance status. Cytology with metastatic
adenocarcinoma. The patient did not receive Gemzar during this
hospitalization after discussions with his outpatient
oncologist, Dr. ___.
#HTN
The patient was continued on home BP regimen. No changes were
made and the patient remained normotensive thorughout admission.
====================
TRANSITIONAL ISSUES:
====================
-Discharge Weight: 154.8 lbs
-Discharge Cr: 1.0
[ ]Consider MIBI to evaluate for ischemic territory
[ ]Patient is due for next chemotherapy cycle of Gemzar. Please
coordinate with patient's oncologist, Dr. ___
[ ]FYI the patient had episodes of junctional bradycardia during
his stay. He demonstrated chronotropic competence however and
was otherwise asymptomatic. His PPM was interrogated and was
working appropriately
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Aspirin 81 mg PO DAILY
2. GuaiFENesin-CODEINE Phosphate ___ mL PO QHS:PRN cough
3. Lisinopril 2.5 mg PO DAILY
4. Magnesium Oxide 400 mg PO DAILY
5. Metoprolol Succinate XL 50 mg PO Q12H
6. Multivitamins 1 TAB PO DAILY
7. Omeprazole 20 mg PO DAILY
8. Spironolactone 25 mg PO 4X/WEEK (___)
9. Verapamil SR 240 mg PO Q12H
10. Amiodarone 400 mg PO DAILY
Discharge Medications:
1. Atorvastatin 80 mg PO QPM
RX *atorvastatin 80 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
2. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
RX *isosorbide mononitrate 30 mg 1 tablet(s) by mouth once a day
Disp #*30 Tablet Refills:*0
3. Amiodarone 400 mg PO DAILY
4. Aspirin 81 mg PO DAILY
5. GuaiFENesin-CODEINE Phosphate ___ mL PO QHS:PRN cough
6. Lisinopril 2.5 mg PO DAILY
7. Magnesium Oxide 400 mg PO DAILY
8. Multivitamins 1 TAB PO DAILY
9. Omeprazole 20 mg PO DAILY
10. Spironolactone 25 mg PO 4X/WEEK (___)
11. Verapamil SR 240 mg PO Q12H
12. HELD- Metoprolol Succinate XL 50 mg PO Q12H This medication
was held. Do not restart Metoprolol Succinate XL until you see
your cardiologist
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary diagnoses:
==================
1) NSTEMI
2) Acute on chronic heart failure with reduced EF
3) Ventricular Tachycardia
SECONDARY DIAGNOSES:
===================
1) Junctional Bradycardia
2) Non small cell lung cancer
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you at ___
___.
WHY WAS I ADMITTED TO THE HOSPITAL?
- You were admitted to the hospital because you had chest pain
and almost fainted
- You were also becoming more short of breath a few days prior
to your admission
WHAT HAPPENED WHILE I WAS IN THE HOSPITAL?
- You were treated with medications called diuretics (Lasix) to
remove extra fluid from your lungs. Your shortness of breath
improved.
- You received a cardiac catheterization which showed that you
did not have any worsening blockages in your arteries
- You were given medications to protect your heart which you
tolerated well
- You had episodes where your heart rate became slow, but you
were not symptomatic. This slow heart rate is not dangerous.
WHAT SHOULD I DO WHEN I GO HOME?
- Your discharge weight is 154.8 lbs. Please weigh yourself
daily. Call your doctor if you gain more than 3 lbs.
- You should continue to take your medications as prescribed.
- You should attend the appointments listed below.
- Seek medical attention if you have new or concerning symptoms
or you develop swelling in your legs, abdominal distention, or
shortness of breath at night.
We wish you the best!
Your ___ Care Team
Followup Instructions:
___
|
19716166-DS-22
| 19,716,166 | 29,255,705 |
DS
| 22 |
2154-04-28 00:00:00
|
2154-04-28 12:12:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Major Surgical or Invasive Procedure:
Radiation therapy -- ___
attach
Pertinent Results:
LABORATORY RESULTS:
___ 06:20AM BLOOD WBC-2.8* RBC-3.09* Hgb-9.0* Hct-28.0*
MCV-91 MCH-29.1 MCHC-32.1 RDW-18.9* RDWSD-61.1* Plt ___
___ 05:17AM BLOOD WBC-1.3* RBC-2.97* Hgb-8.6* Hct-26.5*
MCV-89 MCH-29.0 MCHC-32.5 RDW-18.8* RDWSD-59.7* Plt ___
___ 05:14AM BLOOD WBC-1.7* RBC-2.45* Hgb-6.9* Hct-21.9*
MCV-89 MCH-28.2 MCHC-31.5* RDW-20.1* RDWSD-64.1* Plt ___
___ 05:17AM BLOOD Neuts-94* Bands-2 Lymphs-3* Monos-1*
Eos-0* Baso-0 AbsNeut-1.25* AbsLymp-0.04* AbsMono-0.01*
AbsEos-0.00* AbsBaso-0.00*
___ 04:34PM BLOOD Glucose-113* UreaN-18 Creat-0.6 Na-139
K-3.9 Cl-100 HCO3-25 AnGap-14
___ 02:33AM BLOOD Glucose-105* UreaN-15 Creat-0.5 Na-138
K-3.7 Cl-98 HCO3-26 AnGap-14
___ 06:12AM BLOOD Glucose-120* UreaN-15 Creat-0.5 Na-138
K-4.2 Cl-97 HCO3-26 AnGap-15
___ 05:14AM BLOOD Glucose-114* UreaN-25* Creat-0.6 Na-139
K-3.3* Cl-97 HCO3-28 AnGap-14
___ 05:17AM BLOOD Glucose-113* UreaN-25* Creat-0.6 Na-136
K-4.3 Cl-93* HCO3-30 AnGap-13
___ 02:33AM BLOOD cTropnT-0.05* proBNP-3115*
___ 07:15PM BLOOD cTropnT-0.09* proBNP-2908*
___ 06:12AM BLOOD cTropnT-0.03*
___ 02:33AM BLOOD Calcium-8.7 Phos-3.7 Mg-1.7
___ 04:36PM BLOOD Lactate-1.8
TTE: LVEF 35%. Findings similar to previous.
CXR:
Single lead left chest wall AICD unchanged. Right chest wall
Port-A-Cath tip overlying the SVC. Stable mediastinal contour.
Bilateral pulmonary
opacifications worse at the left lung base than the right.
Stable left
pleural effusion. No pneumothorax.
Brief Hospital Course:
On admission, there was initial concern for a transfusion
reaction. The unit of blood was tested by the blood bank, and
testing was NEGATIVE for a transfusion reaction. Taking
additional history, his presentation was more consistent with an
acute exacerbation of his CHFrEF, and he was grossly volume
overloaded on exam. He was diuresed with IV furosemide with
improvement in his symptoms. His dry weight was 138.7 lbs, and
he is being discharged home with furosemide 80 mg daily and a
potassium supplement. He was examined on day of discharge; no
lower extremity edema, lungs without crackles, S1, S2, RRR, no
m/r/g, and JVP flat. He will follow up with his PCP and his
cardiologist; he should have his heart failure medications
titrated as possible (adding BB, complicated with his history of
VT, increase of ACE-I, possible restarting spironolactone).
HOSPITAL COURSE BY PROBLEMS:
1. Acute exacerbation of CHF
- dry weight 138.7
- furosemide 80 mg daily, KCL 40 mEq daily, close outpatient
follow up
- lisinopril 2.5 mg daily
2. Anemia.
- received 1 unit PRBCs with no problems
- work up for transfusion reaction negative.
3. Leukopenia. The patient's navelbine administration had been
complicated by leukopenia in the past. After discussion with
Atrius oncology, he received a dose of filgrastim 300 mg with
improvement in his counts.
4. Elevated troponin. Likely due to volume overload.
Downtreneded with diuresis.
5. History of VT storm
- continue amiodarone
- continue verapamil
6. Metastatic NSCLC
- continue dexamethasone PRN
- continue oxycodone PRN
- outpatient follow up with Dr. ___
7. Prolonged QTc 501 msec
- held QTc prolonging meds
8. OSA. Home CPAP.
TRANSITIONAL ISSUES:
[ ] patient needs to weighed daily, dry weight was 138.7. Will
likely need adjustment of his diuretics
[ ] consider increase ACE-I, BB, spironolactone, given recurrent
hospitalizations for heart failure
[ ] will follow up with Dr. ___ navelbine therapy. ___
require additional filgrastim and transfusions of PRBCs.
> 30 minutes spent on discharge activities.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amiodarone 400 mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Lisinopril 2.5 mg PO DAILY
4. Multivitamins 1 TAB PO DAILY
5. Omeprazole 20 mg PO DAILY
6. Verapamil SR 240 mg PO Q24H
7. Atorvastatin 80 mg PO QPM
8. Magnesium Oxide 400 mg PO DAILY
9. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
10. OxyCODONE (Immediate Release) 5 mg PO QHS
11. Dexamethasone 4 mg PO BID:PRN nausea/as appetite stimulant
as needed
12. Senna 17.2 mg PO BID
13. Lactulose 15 mL PO Q4H:PRN constipation
Discharge Medications:
1. Furosemide 80 mg PO DAILY
RX *furosemide 80 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*2
2. Potassium Chloride 40 mEq PO DAILY
RX *potassium chloride 20 mEq 2 tablets by mouth once a day Disp
#*60 Tablet Refills:*0
3. Amiodarone 400 mg PO DAILY
4. Aspirin 81 mg PO DAILY
5. Atorvastatin 80 mg PO QPM
6. Dexamethasone 4 mg PO BID:PRN nausea/as appetite stimulant
as needed
7. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
8. Lactulose 15 mL PO Q4H:PRN constipation
9. Lisinopril 2.5 mg PO DAILY
10. Magnesium Oxide 400 mg PO DAILY
11. Multivitamins 1 TAB PO DAILY
12. Omeprazole 20 mg PO DAILY
13. OxyCODONE (Immediate Release) 5 mg PO QHS
14. Senna 17.2 mg PO BID
15. Verapamil SR 240 mg PO Q24H
Discharge Disposition:
Home with Service
Discharge Diagnosis:
Acute exacerbation of heart failure with reduced ejection
fraction.
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 heart failure
exacerbation. You received furosemide (Lasix), which removed the
extra fluid. You were able to walk without needing any oxygen.
You are being sent home on a water pill at home (furosemide 80
mg once daily). Please continue to take this daily. Your weight
in the hospital prior to discharge was 138.7. When you get home,
make sure to weigh yourself on your home scale. This is your DRY
WEIGHT. If your weight ever goes 3 lbs above your home dry
weight, please call your primary care or your cardiologist; you
will need an extra dose of furosemide.
Otherwise, you had a blood transfusion and a dose of filgrastim.
You did NOT have a transfusion reaction. All of your work up was
negative. Your shortness of breath was from your heart failure
exacerbation.
In the long run, you will need to follow up with your outpatient
cardiologist to maximize your heart failure medications to
prevent readmissions.
Followup Instructions:
___
|
19716199-DS-11
| 19,716,199 | 21,596,391 |
DS
| 11 |
2195-07-22 00:00:00
|
2195-07-22 21:07:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Positive Blood Cultures in ED
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ yo woman no significant PMH who was recently
seen in the ED for fever, chills, myalgias. She was given
anti-inflammatories and IVF and symptoms improved. Flu swab and
U/A were negative and the patient was discharged with
recommendations for anti-inflammatories and PO hydration. Blood
cultures subsequently grew GNRs and GPCs and the patient was
called back to the ED. She reports improving symptoms.
In the ED, initial vital signs were: 97.8 107 114/69 18 100% RA
Labs were notable for WCC 5.3, normal chemistry panel, normal
LFTs
Patient was given 1gram Tylenol, 1L NS, ibuprofen 600mg,
vancomycin 1 gram, zosyn 4.5mg
On Transfer Vitals were: 97.8 101 ___ 99% RA
On the floor, patient reports she feels great. She reports her
son has been sick with similar illness but has gotten better.
Past Medical History:
POB:
FT SVD x 1
C/S x 1 for NRFRHT per patient
SAB x 1, TAB x 3
PGyn: Denies
PMed: Denies - has had urine infections in prior pregnancies
PSurg: C/S
Social History:
___
Family History:
NC
Physical Exam:
ADMISSION PHYSICAL EXAM:
=========================
Vitals: T98.4 BP 122/70 HR 92 RR 18 O2 100 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,
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: No cuts/rashes
NEURO: Power ___ in all four limbs. Sensation intact. Mentating
well
DISCHARGE PHYSICAL EXAM:
=========================
Vitals: T98.2 BP 128/70-143/77 HR ___ RR 18 O2 100 RA
GENERAL: Alert, oriented ___ speaking female 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: No cuts/rashes
NEURO: Power ___ in all four limbs. Sensation intact. Mentating
well
Pertinent Results:
ADMISSION LABS:
================
___ 04:55PM BLOOD WBC-5.3 RBC-4.28 Hgb-13.0 Hct-38.5 MCV-90
MCH-30.4 MCHC-33.8 RDW-12.8 RDWSD-42.2 Plt ___
___ 04:55PM BLOOD Neuts-45.5 ___ Monos-13.2*
Eos-1.1 Baso-0.6 Im ___ AbsNeut-2.41 AbsLymp-2.09
AbsMono-0.70 AbsEos-0.06 AbsBaso-0.03
___ 04:55PM BLOOD ___ PTT-30.5 ___
___ 04:55PM BLOOD Glucose-83 UreaN-8 Creat-0.6 Na-139 K-4.5
Cl-106 HCO3-21* AnGap-17
___ 04:55PM BLOOD ALT-25 AST-29 AlkPhos-80 TotBili-0.2
___ 04:55PM BLOOD Albumin-4.0
___ 05:24PM BLOOD Lactate-1.4
PERTINENT FINDINGS:
URINE CULTURE (Final ___: <10,000 organisms/ml.
Blood Cultures:
___ x2 - Negative to date at discharge
___ x 2 - Negative to date at discharge
___ x1 - Negative to date at discharge
***Blood Culture ___ FROM ED:****
ENTEROBACTER CLOACAE COMPLEX. FINAL SENSITIVITIES.
This organism may develop resistance to third
generation
cephalosporins during prolonged therapy. Therefore,
isolates that
are initially susceptible may become resistant within
three to
four days after initiation of therapy. For serious
infections,
repeat culture and sensitivity testing may therefore be
warranted
if third generation cephalosporins were used.
ENTEROBACTER CLOACAE COMPLEX. SECOND MORPHOLOGY.
FINAL SENSITIVITIES.
This organism may develop resistance to third
generation
cephalosporins during prolonged therapy. Therefore,
isolates that are initially susceptible may become resistant
within three to
four days after initiation of therapy. For serious
infections,
repeat culture and sensitivity testing may therefore be
warranted if third generation cephalosporins were used.
ESCHERICHIA COLI. FINAL SENSITIVITIES.
ENTEROCOCCUS FAECALIS. FINAL SENSITIVITIES.
HIGH LEVEL GENTAMICIN SCREEN: Susceptible to 500 mcg/ml
of
gentamicin. Screen predicts possible synergy with
selected
penicillins or vancomycin. Consult ID for details.
HIGH LEVEL STREPTOMYCIN SCREEN: Susceptible to
1000mcg/ml of
streptomycin. Screen predicts possible synergy with
selected
penicillins or vancomycin. Consult ID for details..
Daptomycin MIC=3.0MCG/ML Sensitivity testing performed
by Etest.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROBACTER CLOACAE COMPLEX
| ENTEROBACTER CLOACAE
COMPLEX
| | ESCHERICHIA
COLI
| | |
ENTEROCOCCUS FAE
| | | |
AMPICILLIN------------ =>32 R <=2 S
AMPICILLIN/SULBACTAM-- =>32 R
CEFAZOLIN------------- =>64 R
CEFEPIME-------------- <=1 S <=1 S <=1 S
CEFTAZIDIME----------- <=1 S <=1 S 2 S
CEFTRIAXONE----------- <=1 S <=1 S <=1 S
CIPROFLOXACIN---------<=0.25 S <=0.25 S <=0.25 S
DAPTOMYCIN------------ S
GENTAMICIN------------ <=1 S <=1 S <=1 S
MEROPENEM-------------<=0.25 S <=0.25 S <=0.25 S
PENICILLIN G---------- 2 S
PIPERACILLIN/TAZO----- <=4 S <=4 S 8 S
TOBRAMYCIN------------ <=1 S <=1 S <=1 S
TRIMETHOPRIM/SULFA---- <=1 S <=1 S <=1 S
VANCOMYCIN------------ 2 S
Anaerobic Bottle Gram Stain (Final ___:
GRAM NEGATIVE ROD(S).
Reported to and read back by ___ (EW) ___ AT
1136.
GRAM POSITIVE COCCI IN PAIRS.
Reported to and read back by ___ 10:30AM
___.
Aerobic Bottle Gram Stain (Final ___: GRAM NEGATIVE
ROD(S).
CXR ___:
PA and lateral views of the chest provided. New from prior, is
consolidation in the left lower lobe which is concerning for
pneumonia. No large effusion or pneumothorax. Right lung is
clear. Cardiomediastinal silhouette is normal. Bony structures
are intact.
IMPRESSION: Left lower lobe pneumonia.
DISCHARGE LABS:
=================
___ 06:45AM BLOOD WBC-6.4 RBC-4.03 Hgb-12.0 Hct-35.7 MCV-89
MCH-29.8 MCHC-33.6 RDW-12.8 RDWSD-41.8 Plt ___
___ 06:45AM BLOOD Glucose-84 UreaN-6 Creat-0.5 Na-140 K-3.5
Cl-109* HCO3-22 AnGap-13
___ 06:45AM BLOOD Calcium-8.9 Phos-3.4 Mg-1.8
Brief Hospital Course:
Ms. ___ is a ___ with no significant PMH who was admitted for
positive blood cultures from previous ED visit on ___ for
further evaluation.
#Positive Blood Cultures: Cultures grew ENTEROBACTER CLOACAE, E.
Coli, and ENTEROCOCCUS FAE as well as Gram Positive Cocci in
Pairs. She was given IVF and initially started on
Vancomycin/Cefepime/Flagyl for broad coverage. However, she had
no leukocytosis and remained afebrile, hemodynamically stable,
with no respiratory or abdominal symptoms. Infectious disease
was consulted and it was decided that iven her lack of symptoms
and multiple bacteria in only 1 blood culture, this was thought
to be contaminant. Other sources considered included UTI (Urine
culture negative), gut translocation (no abdominal symptoms),
and no respiratory symptoms. CXR was read as LLL pneumonia, but
patient had no symptoms and once it was determined blood
cultures were likely spurious, further antibiotic treatment was
discontinued. Initial symptoms thought to have been viral in
nature given short duration and similar symptoms from other
family members that also quickly resolved.
#Vaginal Itching: Patient complained of new vaginal itching,
consistent with previous yeast infections. She was discharged on
Micanozole cream
TRANSITIONAL ISSUES:
=====================
# Patient's home has no heat and has an insect infestation: she
met with social work, and was given the phone number for ___
___ Services
# She intermittently complained of lower quadrant pain, but had
a benign exam: consider U/S as outpatient if this persists
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Ibuprofen 600 mg PO Q6H:PRN Pain
Discharge Medications:
1. Miconazole Nitrate Vag Cream 2% 1 Appl VG QHS Duration: 6
Days
RX *miconazole nitrate [Miconazole 7] 100 mg at bedtime Disp
#*1 Suppository Refills:*0
2. Ibuprofen 600 mg PO Q6H:PRN Pain
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
- contaminated blood culture
- cough
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 ___ due to
a positive blood culture. In the emergency department on your
previous visit, your blood was found to have bacteria. You were
initially given antibiotics, but we then realized that this
blood culture was most likely contaminated, and you did not have
a blood infection. We did give you some medications to improve
you cough symptoms, which are most likely from a virus (and
would not be helped with antibiotics).
It was a pleasure taking care of you during your stay at ___.
If you have any questions about the care you received, please do
not hesitate to ask.
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
19716465-DS-3
| 19,716,465 | 23,330,062 |
DS
| 3 |
2175-06-23 00:00:00
|
2175-06-23 17:09:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
codeine / Demerol
Attending: ___.
Chief Complaint:
Mechanical fall
C1 and T1 fractures
Alcohol use disorder
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ female with a history of dementia and alcoholism
(s/p multiple failed detox) presents as OSH transfer with
chronic C1 and T1 fracture after an unwitnessed fall while
intoxicated.
Patient is poor historian with inattention and poor
understanding capacity but endorses bilateral ankle, feet, knee,
shoulder, back and neck pain. She does not remember how she fell
but was on the ground for about 1 hour. Endorses chronic urinary
incontinence over the last year, as she soils herself nightly.
No tingling or numbness. Endorses BLE weakness due to all of her
falls.
She drinks daily. There was concern for SI as patient stated she
wanted to die, but on further questioning, patient denied. She
was also thought to be going into benzo withdrawal. She was
waiting a rehab bed but was able to be placed so was admitted to
medicine.
In the ED, initial VS:
97.2 84 134/82 14 95% RA
Exam notable for:
anxious
Labs notable for:
CBC: WBC 6.2, HGb 11.2, plt 260
Chem: Na 135, K 4.5, Cl 84, BUN 6, Cr 0.7
Ca 8.5, Mg 1.8, P 3.6
UA: large leuks, negative nitrites, 91 WBC, no bacteria
Bld cx x2 pending
Imaging notable for:
CT scan demonstrated chronic C1 fracture and possible small,
chronic T1 compression fracture.
CXR:
1. No pneumothorax or acute pulmonary disease.
2. Distal right clavicular deformity and focal defect which may
be chronic, but correlation with physical examination is
recommended as there are no prior studies with which to compare.
Consults:
Orthopaedic surgery: c collar given neck pain as well as spine
clinic follow up in 2 week.
Vitals prior to transfer:
98.0 86 121/73 18 98% RA
On arrival to the floor, patient confirms much of the above
story. Regarding her fall, she was drunk on the day of her
admission and believes that she just "tipped over." Regarding
her alcohol intake, she drinks about a half a gallon of wine per
day. She used to drink about ___ gallon of vodka, but has
recently cut back to just wine. Her last drink was on ___,
prior to presentation at the ED. Currently, she has about ___
out of 10 pain in her hips, as well as her neck, which has been
stable since arrival to the ED. She is hoping to get her
Ambien,
as well as some benzodiazepine to help her get some sleep.
REVIEW OF SYSTEMS:
A complete 10-point review of systems was performed and was
negative less otherwise noted in the HPI.
Past Medical History:
Dementia
Alcohol use disorder
Social History:
___
Family History:
Patient has a long family history of alcohol use
disorder. Her mother and father both drank heavily. She was
told her mother died of a heart attack, but she believes that
both her mother and father died from alcohol-related
complications. She has 2 brothers, 1 older who drinks daily but
is still alive, and one younger who died after a liver
transplant
for alcoholic cirrhosis. She has 2 sisters both of whom drink,
one who passed away from alcohol-related complications as well.
Physical Exam:
ADMISSION PHYSICAL EXAM:
==========================
VS: ___ 2208 Temp: 97.8 PO BP: 133/80 HR: 78 RR: 18 O2 sat:
96% O2 delivery: RA
GENERAL: Pleasant, lying in bed comfortably, c-collar in place.
Lying flat in bed speaking in full sentences.
HEENT: Pupils equal round and reactive, extraocular motions
intact. Cervical collar in place.
CARDIAC: Regular rate and rhythm, no murmurs, rubs, or gallops
LUNG: Appears in no respiratory distress, clear to auscultation
bilaterally, no crackles, wheezes, or rhonchi
ABD: Normal bowel sounds, soft, nontender, nondistended, no
hepatomegaly, no splenomegaly
EXT: Warm, well perfused, no lower extremity edema
PULSES: 2+ radial pulses, 2+ ___ pulses, 2+ DP pulses
NEURO: Alert, oriented, CN II-XII intact, motor and sensory
function grossly intact
DISCHARGE PHYSICAL EXAM:
==========================
24 HR Data (last updated ___ @ 234)
Temp: 97.7 (Tm 97.8), BP: 114/71 (114-133/71-80), HR: 82
(78-82), RR: 18, O2 sat: 95% (95-96), O2 delivery: Ra
GENERAL: Pleasant, lying in bed comfortably, c-collar in place.
Teary at times during the interview
HEENT: Pupils equal round and reactive. Cervical collar in
place.
EXT: Warm, well perfused, no lower extremity edema. R shoulder
with mild tenderness to palpation but no surrounding erythema
NEURO: Alert, oriented x3, hand grip ___, dorsiflexion and
plantar flexion ___
Pertinent Results:
ADMISSION LABS:
====================
___ 02:10PM URINE COLOR-Straw APPEAR-Hazy* SP ___
___ 02:10PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-8.0
LEUK-LG*
___ 02:10PM URINE RBC-4* WBC-91* BACTERIA-NONE YEAST-NONE
EPI-4
___ 09:42AM GLUCOSE-76 UREA N-6 CREAT-0.7 SODIUM-135
POTASSIUM-4.5 CHLORIDE-94* TOTAL CO2-29 ANION GAP-12
___ 09:42AM WBC-6.2 RBC-4.50 HGB-11.2 HCT-37.0 MCV-82
MCH-24.9* MCHC-30.3* RDW-16.6* RDWSD-48.6*
___ 09:42AM NEUTS-68.9 LYMPHS-16.2* MONOS-12.4 EOS-1.1
BASOS-1.1* IM ___ AbsNeut-4.29 AbsLymp-1.01* AbsMono-0.77
AbsEos-0.07 AbsBaso-0.07
___ 09:42AM PLT COUNT-360
DISCHARGE LABS:
====================
___ 06:10AM BLOOD WBC-4.2 RBC-3.76* Hgb-9.5* Hct-31.6*
MCV-84 MCH-25.3* MCHC-30.1* RDW-16.9* RDWSD-51.6* Plt ___
___ 06:10AM BLOOD Plt ___
___ 06:10AM BLOOD Glucose-83 UreaN-13 Creat-0.6 Na-139
K-4.2 Cl-102 HCO3-26 AnGap-11
___ 06:10AM BLOOD Calcium-9.0 Phos-4.0 Mg-1.8
IMAGING:
====================
___ PELVIC AND HIP XR
IMPRESSION:
Minimal degenerative change of the left hip without fracture.
Mild-to-moderate change of the right hip
___ CHEST XR
IMPRESSION:
1. No pneumothorax or acute pulmonary disease.
2. Distal right clavicular deformity and focal defect which may
be chronic, but correlation with physical examination is
recommended as there are no prior studies with which to compare.
Brief Hospital Course:
___ is a ___ female with a history of
alcoholism, who presents to the hospital after a fall likely
related to alcohol intoxication with chronic C1 and possible
small T1 compression fracture now in a C-spine collar with
planned follow-up with orthopedics in 2 weeks.
====================
ACUTE/ACTIVE ISSUES:
====================
# Mechanical fall
# C1 and T1 fracture
Patient presented with an unwitnessed fall after intoxication.
She had a CT cervical spine on ___ at ___ that showed likely
chronic C1 and possible small T1 compression fractures. Other
imaging negative for acute injury or bleed. No symptoms or exam
findings concerning for cord compression. Orthopedics consulted
and felt that nothing to do at this moment. They recommended
C-spine immobilization with ___ J collar with ortho follow-up
in 2 weeks. Given vertebral compression fracture, patient also
meets criteria for osteoporosis. She will begin calcium and
vitamin D supplementation, as well as consideration for
bisphosphonate therapy as an outpatient.
# Alcohol use disorder
Patient drinks about ___ gallon of wine daily. Her last drink
was on ___, and as such she was out of the window for
withdrawal seizures. She had no signs or symptoms of withdrawal,
nor has she ever undergone withdrawal, or alcohol withdrawal
related seizures. The patient reported taking lorazepam nightly
to help with sleep, and we continued this to avoid
benzodiazepine withdrawal. She is motivated to work towards
sobriety again. Patient was seen by social work and she is
already connected with ___, who reports
that patient is involved with their ___ services team. She has
___ CM and RN through MVES. They are active with her and will
continue to follow her throughout her rehab stay at ___
___. Patient was also given thiamine and folate during this
admission.
# Suicidal ideation
Reportedly, the patient noted some passive suicidal ideation
while in the ED. She denied any suicidal ideation subsequently,
and felt that she was still intoxicated, and feeling overwhelmed
in that moment.
# Assymptomatic bacteruria
E coli in urine with no symptoms. Patient was treated with
nitrofurantoin while in the ED. She was asymptomatic on the day
of discharge.
# Insomnia
Patient reports that she takes Ambien and lorazepam nightly for
sleep. Trazodone is in her fill list but she states that she
does not use this any more. She was continued on Ativan QHS:PRN.
Please consider discontinuing some of these medications in light
of her recent fall and alcohol use.
======================
CHRONIC/STABLE ISSUES:
======================
# Hypothyroidism
Continued levothyroxine 50 mcg daily
====================
TRANSITIONAL ISSUES:
====================
Medication changes
- Patient was started on calcium and vitamin D supplementation
[] Please consider bisphosphonate therapy in light of her T1
compression fracture
[] Patient reports takes Ativan 1mg QHS. There was a different
fill history for Ativan 0.5 mg Q6H for anxiety which was
continued on discharge
[] Patient reports motivation to quit drinking. She will look
into joining AA. Please consider pharmacological treatment for
alcohol use disorder if patient feels she may benefit from same.
[] Patient to wear ___ collar for the next 2 weeks and
follow-up with orthopedics afterwards
======================================
# CODE: full confirmed
# CONTACT: ___ (husband) ___
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Levothyroxine Sodium 50 mcg PO DAILY
2. Pantoprazole 40 mg PO Q24H
3. Gabapentin 200 mg PO TID
4. Meclizine 12.5 mg PO DAILY:PRN Nausea
5. Multivitamins 1 TAB PO DAILY
6. Thiamine 200 mg PO DAILY
7. LORazepam 0.5 mg PO Q6H:PRN anxiety
8. Zolpidem Tartrate 5 mg PO QHS
Discharge Medications:
1. Calcium Carbonate 500 mg PO DAILY osteoporosis Duration: 30
Days
2. FoLIC Acid 1 mg PO DAILY
3. Vitamin D 800 UNIT PO DAILY
4. Gabapentin 200 mg PO TID
5. Levothyroxine Sodium 50 mcg PO DAILY
6. LORazepam 0.5 mg PO Q6H:PRN anxiety
7. Meclizine 12.5 mg PO DAILY:PRN Nausea
8. Multivitamins 1 TAB PO DAILY
9. Pantoprazole 40 mg PO Q24H
10. Thiamine 200 mg PO DAILY
11. Zolpidem Tartrate 5 mg PO QHS
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
==================
PRIMARY DIAGNOSES:
==================
Mechanical fall
C1 and T1 fractures
Alcohol use disorder
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking care of you at the ___
___.
Why did you come to the hospital?
- You came to the hospital as you had a fall.
What did you receive in the hospital?
- You had imaging studies of the head and spine. We saw a
fracture in your spine that could be new or chronic. Our
orthopedics doctors saw ___ and wanted you to be in a C-spine
collar for 2 weeks.
- Our physiotherapist also evaluated you. They think you would
benefit from going to rehab after discharge from hospital.
What should you do once you leave the hospital?
- Please follow-up with orthopedic doctors as below.
- Per our discussion this morning, please consider joining a
program to help with quitting alcohol; your PCP should be able
to help with this.
We wish you all the best!
Your ___ Care Team
Followup Instructions:
___
|
19716704-DS-10
| 19,716,704 | 22,564,837 |
DS
| 10 |
2119-06-20 00:00:00
|
2119-06-21 03:08:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
Keflex / cefprozil
Attending: ___.
Chief Complaint:
Fall from motorcycle
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ male with bipolar disorder recently on lithium
presenting after motor vehicle accident. Patient was going 80
miles an hour, helmeted, when he hit a ___, slid and fell onto
his right side with head strike but no LOC. Patient was seen at
an outside hospital where his imaging was notable for a right
ulnar contusion, right rib fracture. On arrival, reports pain in
his right shoulder and right rib cage and right knee. Denies any
nausea, vomiting, chest pain, vision changes, headaches, or
dizziness.
Past Medical History:
Bipolar Disorder
Alcohol use Disorder
Social History:
___
Family History:
Non-contributory
Physical Exam:
Vitals: T 98.6, BP 104 / 57, HR 68, RR 18, O2 97 Ra
GEN: A&O, NAD
HEENT: No scleral icterus, mucus membranes moist
CHEST: Right ribs and flank tender to touch
CV: RRR, No M/G/R
PULM: Clear to auscultation b/l, No W/R/R
ABD: Soft, nondistended, nontender, no rebound or guarding,
normoactive bowel sounds, no palpable masses, scattered
abrasions over left flank
Ext: No ___ edema, ___ warm and well perfused, right deltoid
tender to touch
Pertinent Results:
___ 12:45AM BLOOD WBC-14.3* RBC-4.51* Hgb-13.6* Hct-39.5*
MCV-88 MCH-30.2 MCHC-34.4 RDW-12.8 RDWSD-41.1 Plt ___
___ 12:45AM BLOOD ___ PTT-25.9 ___
___ 12:45AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 12:45AM BLOOD Lipase-13
___ R shoulder XR:No right shoulder fracture or dislocation
identified.
Brief Hospital Course:
At the OSH, he was Pan scanned, which demonstrated a right
pulmonary contusion, right shoulder ac sprain, and left knee
punctate injury. He was admitted to ACS for pain management and
monitoring given high impact trauma on ___. Throughout the day,
his pain medication was adjusted to allow for adequate control.
He was tolerating a regular diet and he was moving around the
halls with minimal pain - improving throughout the day.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet, ambulating, voiding without assistance, and pain was well
controlled. The patient was discharged home without services.
The patient received discharge teaching and follow-up
instructions with understanding verbalized and agreement with
the discharge plan.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acamprosate 333 mg PO TID
2. Lithium Carbonate CR (Eskalith) 300 mg PO BID
3. Gabapentin 600 mg PO TID
Discharge Medications:
1. Acetaminophen 650 mg PO Q4H
2. Ibuprofen 400 mg PO Q8H
3. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - Severe
RX *oxycodone 5 mg ___ tablet(s) by mouth every six (6) hours
Disp #*30 Tablet Refills:*0
4. Acamprosate 333 mg PO TID
5. Gabapentin 600 mg PO TID
6. Lithium Carbonate CR (Eskalith) 300 mg PO BID
Discharge Disposition:
Home
Discharge Diagnosis:
Fall
Right lower Lobe contusion
Right shoulder AC sprain
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 ___ after you sustained a fall on a
motorcycle that caused a Right lower lobe lung contusion and
Right shoulder joint sprain. Your pain was improved and better
controlled and it was felt safe to discharge you from the
hospital
* You should take your pain medication as directed to stay ahead
of the pain otherwise you won't be able to take deep breaths. If
the pain medication is too sedating take half the dose and
notify your physician.
* Symptomatic relief with ice packs or heating pads for short
periods may ease the pain.
* Narcotic pain medication can cause constipation therefore you
should take a stool softener twice daily and increase your fluid
and fiber intake if possible.
* Do NOT smoke
* If your doctor allows, non-steroidal ___ drugs
are very effective in controlling pain ( ie, Ibuprofen, Motrin,
Advil, Aleve, Naprosyn) but they have their own set of side
effects so make sure your doctor approves.
* Return to the Emergency Room right away for any acute
shortness of breath, increased pain or crackling sensation
around your ribs (crepitus).
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.
Avoid driving or operating heavy machinery while taking pain
medications.
Followup Instructions:
___
|
19716747-DS-14
| 19,716,747 | 25,019,093 |
DS
| 14 |
2158-05-02 00:00:00
|
2158-05-02 15:35:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
left shoulder dislocation w/ associated greater tuberosity
fracture
Major Surgical or Invasive Procedure:
Closed reduction under general anesthesia and closed treatment
of proximal tuberosity fracture with manipulation ___, Dr.
___
History of Present Illness:
___ LHD p/w the above fracture s/p mechanical fall when she
tripped over new flooring. Landed on left side, denies HS/LOC.
Happened at 8pm ___. Tx from OSH after failed closed redxn
attempt under conscious sedation. Denies paresthesias, denies
antecedent L shoulder pain.
Past Medical History:
none
Social History:
___
Family History:
Non-contributory
Physical Exam:
Vitals: AFVSS
General: A&Ox3, NAD
Heart: Regular rate and rhythm peripherally
Lungs: Breathing comfortably on room air.
Left upper extremity:
- Skin intact. Arm in sling.
- ecchymosis around the anterior shoulder and arm.
- Soft, non-tender arm and forearm
- Full, painless active/passive ROM of elbow, wrist, and digits.
ROM around shoulder lmited
- EPL/FPL/DIO (index) fire
- Sensation intact to light touch in
axillary/radial/median/ulnar nerve distributions
- 2+ radial pulse, fingers warm and well perfused
Pertinent Results:
___ 07:24PM GLUCOSE-97 UREA N-23* CREAT-1.0 SODIUM-139
POTASSIUM-4.8 CHLORIDE-106 TOTAL CO2-22 ANION GAP-11
___ 07:24PM WBC-9.4 RBC-3.89* HGB-11.6 HCT-36.3 MCV-93
MCH-29.8 MCHC-32.0 RDW-13.5 RDWSD-46.5*
Brief Hospital Course:
The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have a left shoulder dislocation w/ associated greater
tuberosity fracture and was admitted to the orthopedic surgery
service. The patient was treated nonoperatively under general
anesthesia with a closed reduction approach and worked with
physical therapy who determined that discharge to home was
appropriate. The patient was given anticoagulation per routine,
and the patient's home medications were continued throughout
this hospitalization. The ___ hospital course was
otherwise unremarkable.
At the time of discharge the patient's pain was well controlled
with oral medications, and the patient was voiding/moving bowels
spontaneously. The patient is NWB in the left upper extremity,
and will be discharged on no pharmacological medications for DVT
prophylaxis but is encouraged to ambulate. The patient will
follow up with Dr. ___ routine. A thorough discussion
was had with the patient regarding the diagnosis and expected
post-discharge course including reasons to call the office or
return to the hospital, and all questions were answered. The
patient was also given written instructions concerning
precautionary instructions and the appropriate follow-up care.
The patient expressed readiness for discharge.
Medications on Admission:
none
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H
2. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*10 Capsule Refills:*1
3. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN pain
RX *oxycodone 5 mg 1 tablet(s) by mouth every eight (8) hours
Disp #*10 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
left shoulder dislocation w/ associated greater tuberosity
fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
AVSS
NAD, A&Ox3
left UE: Fires EPL/FPL/FDP/FDS/EDC/DIO. SILT radial/median/ulnar
n distributions. 1+ radial pulse, wwp distally.
Discharge Instructions:
- Resume your regular activities as tolerated, but please follow
your weight bearing precautions strictly at all times.
ACTIVITY AND WEIGHT BEARING:
- Remain in your sling at all times. Do not bear any weight on
your left shoulder. Light passive range of motion around your
left shoulder is okay. No external rotation or abduction of
shoulder.
MEDICATIONS:
1) Take Tylenol ___ every 6 hours around the clock. This is
an over the counter medication.
2) Add Oxycodone as needed for increased pain. Aim to wean
off this medication in 1 week or sooner. This is an example on
how to wean down:
Take 1 tablet every 3 hours as needed x 1 day,
then 1 tablet every 4 hours as needed x 1 day,
then 1 tablet every 6 hours as needed x 1 day,
then 1 tablet every 8 hours as needed x 2 days,
then 1 tablet every 12 hours as needed x 1 day,
then 1 tablet every before bedtime as needed x 1 day.
Then continue with Tylenol for pain.
3) Do not stop the Tylenol until you are off of the narcotic
medication.
4) Per state regulations, we are limited in the amount of
narcotics we can prescribe. If you require more, you must
contact the office to set up an appointment because we cannot
refill this type of pain medication over the phone.
5) Narcotic pain relievers can cause constipation, so you
should drink eight 8oz glasses of water daily and continue
following the bowel regimen as stated on your medication
prescription list. These meds (senna, colace, miralax) are over
the counter and may be obtained at any pharmacy.
6) Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
7) Please take all medications as prescribed by your
physicians at discharge.
8) Continue all home medications unless specifically
instructed to stop by your surgeon.
ANTICOAGULATION:
- Please continue to ambulate throughout the day.
Physical Therapy:
Activity: Activity: Activity as tolerated Activity: Ambulate
twice daily if patient able
Left upper extremity: Non weight bearing
Sling: At all times
Encourage turn, cough and deep breathe q2h when awake
Treatments Frequency:
Call your surgeon's office with any questions.
Followup Instructions:
___
|
19716849-DS-4
| 19,716,849 | 25,162,458 |
DS
| 4 |
2153-08-29 00:00:00
|
2153-08-29 18:06:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
abdominal pain, vaginal bleeding
Major Surgical or Invasive Procedure:
None
History of Present Illness:
The patient is a ___ y/o lady with a PMHx significant for DM and
uterine fibroids and dysmenorrhea is s/p UAE by ___ on ___
presents with recurrent vaginal bleeding post-procedure.
Briefly the patient initially presented with increased uterine
bleeding for the past 6 mo. Imaging demonstrated multiple large
fibroids. Endometrial bx was neg. She is now s/p bilateral
uterine artery embolization by INR. She was observed overnight
and discharged the following day.
Since discharge she reports persistent vaginal bleeding
requiring sanity pads every 3 hours. She has associated
shortness of breath, painful right and lower abdominal quadrant
pain, nausea. She denies chest pain, fevers, chills. She
presented to ___ where she had a CT abdomen and
pelvis which did not show any active proceses. Her CBC was
stable (___). She was given 16mg morphine and 8mg of zofran
prior to transfer from ___ for ___ evaluation.
In the ___ ED:
Initial Vitals: 98.5 76 132/78 15 95%
Labs were significant for: 10.9/34.4 ___ on ___.
No further imaging was performed.
___ was consulted who reviewed the imaging and recommended pain
control and bedside evaluation in the morning.
Vitals on transfer: 98.5 96 136/90 24 95% RA
On arrival to the floor vitals were: 98.8 133/57 84 20 100% RA.
She is in obvious discomfort. Has not achieved pain control at
all since arriving. Notes bleeding has slowed considerably.
Past Medical History:
constipation
costrochondritis
obesity
headache
pre-diabetes
Social History:
___
Family History:
Noncontributory
Physical Exam:
ADMISSION PHYSICAL EXAM
Vitals - 98.8 133/57 84 20 100% RA.
GENERAL: Very kind, in obvious distress and pain, uncomfortable
posturing in bed
HEENT:EOMI, anicteric sclera, pink conjunctiva, MMM
CARDIAC: RRR, S1/S2
LUNG: CTAB
ABDOMEN: soft, obese, tender to deep palpation in the bilateraly
lower quadrants without rebound.
MSK: There is also bilateral low back pain to percussion of the
flanks. No bruising noted.
EXTREMITIES: no cyanosis, clubbing or edema, moving all 4
extremities with purpose
PULSES: 2+ DP pulses bilaterally
DISCHARGE PHYSICAL EXAM
VS: Tm 99.9 Tc 98.8 123/54 73 18 96% RA
GENERAL: appears more comfortable lying in bed
HEENT:EOMI, anicteric sclera, pink conjunctiva, MMM
CARDIAC: RRR, S1/S2
LUNG: CTAB
ABDOMEN: soft, obese, tender to deep palpation in the bilateral
lower quadrants without rebound.
EXTREMITIES: no cyanosis, clubbing or edema
PULSES: 2+ DP pulses bilaterally
Pertinent Results:
ADMISSION LABS
___ 01:00AM URINE RBC-13* WBC-9* BACTERIA-NONE YEAST-NONE
EPI-7
___ 01:00AM URINE BLOOD-MOD NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-SM
___ 01:00AM URINE COLOR-Straw APPEAR-Clear SP ___
___ 01:15AM WBC-11.6*# RBC-4.02* HGB-10.9* HCT-34.4*
MCV-86 MCH-27.0 MCHC-31.6 RDW-17.6*
___ 01:15AM NEUTS-78.9* LYMPHS-14.1* MONOS-3.5 EOS-3.4
BASOS-0.1
___ 01:15AM CALCIUM-8.5 PHOSPHATE-3.5 MAGNESIUM-1.8
___ 01:15AM GLUCOSE-133* UREA N-7 CREAT-0.6 SODIUM-137
POTASSIUM-3.5 CHLORIDE-100 TOTAL CO2-25 ANION GAP-16
___ 01:22AM LACTATE-1.5
DISCHARGE LABS
___ 06:40AM BLOOD WBC-10.3 RBC-3.89* Hgb-10.2* Hct-32.3*
MCV-83 MCH-26.2* MCHC-31.5 RDW-16.7* Plt ___
IMAGING
UTERINE EMBO ___
1. Left uterine artery supplying a large fibroid. No
arteriovenous shunting, stenosis, vesical, vaginal or ovarian
branches noted.
2. Right uterine artery supplying a large fibroid. No
arteriovenous shunting, stenosis, vesical, vaginal or ovarian
branches noted.
3. No evidence of ovarian arterial supply to the fibroids.
4. Post-procedure fibroid staining and near stasis confirming
successful imaging end point
Brief Hospital Course:
___ w/DM, uterine fibroids and dysmenorrhea now s/p UAE by ___
on ___ presenting with recurrent vaginal bleeding and pain
post-procedure.
ACTIVE ISSUES
# Vaginal Bleeding s/p Uterine Artery Embolization: Bleeding was
already slowing on arrival to ___ with low level bleeding by
time of discharge. Patient was hemodynamically stable and H/H
remained stable throughout admission.
# Abdominal Pain: CT abdomen/pelvis from ___
showed no acute process; this was reviewed by ___ here. There
were no acute findings on exam, and pain was secondary to
changes following UAE. Started on IV morphine initially but
weaned off to oxycodone, and tolerated this. Discharged home
with 1 week supply of oxycodone, and will follow up in HCA in 3
days to ensure pain is controlled.
# Constipation: due to opiate use, started on aggressive bowel
regimen, and had bowel movement on day of discharge.
# Borderline UA: 17 WBC but 4 epis, no leuk esterase or nitrite,
and patient not symptomatic, so not treated. Will f/u culture
and contact patient if positive.
CHRONIC ISSUES
# Diabetes: Continued home metformin.
TRANSITIONAL ISSUES
None.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. MetFORMIN (Glucophage) 500 mg PO BID
2. Ibuprofen 600 mg PO Q6H:PRN pain
3. Oxycodone-Acetaminophen (5mg-325mg) 1 TAB PO Q6H:PRN pain
Discharge Medications:
1. MetFORMIN (Glucophage) 500 mg PO BID
2. Docusate Sodium 100 mg PO BID constipation
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*30 Capsule Refills:*0
3. OxycoDONE (Immediate Release) ___ mg PO Q6H:PRN pain
RX *oxycodone 5 mg ___ tablet(s) by mouth every six (6) hours
Disp #*56 Tablet Refills:*0
4. Polyethylene Glycol 17 g PO DAILY constipation
RX *polyethylene glycol 3350 17 gram 1 packet by mouth daily
Disp #*15 Packet Refills:*0
5. Senna 17.2 mg PO BID constipation
RX *sennosides [senna] 8.6 mg 2 tabs by mouth twice a day Disp
#*30 Tablet Refills:*0
6. Acetaminophen 650 mg PO Q6H:PRN pain
Do not exceed 3000mg per day
Discharge Disposition:
Home
Discharge Diagnosis:
Primary
1. Uterine fibroids
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Ms. ___,
It was a pleasure taking care of you while you were admitted to
___. You were admitted due to pain and vaginal bleeding
related to your uterine artery embolization. The pain is an
expected side effect of the uterine artery embolization, and
should ease over time. You were started on IV pain medications
and then were switched to oral pain medications. Your vaginal
bleeding slowed on its own, and your blood counts were stable.
You were given three new medications for constipation. They
should be taken every day while you are taking the oxycodone,
but stop if you are having loose stools.
You have appointments to follow up with your primary care
doctor's office.
Followup Instructions:
___
|
19716849-DS-5
| 19,716,849 | 20,023,835 |
DS
| 5 |
2154-11-04 00:00:00
|
2154-11-07 16:29:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Pt interviewed without aid of interviewer at her request.
___ female with h/o non-insulin dependent DM, known LBBB, hernia
repair, with complaint of recurrent abdominal pain after recent
hospital admission in ___ for diverticulitis (___).
She has had intermittent abdominal pain since ___. At that
time CT ordered by ___ with diverticulosis without
diverticulitis, managed with miralax, although pt unable to
tolerate increased frequency of stooling.
In brief, pt presented to ___ with ___ sharp
intermittent lower Abd pain ass w N/V no f/c/ns, CT with
persistent sigmoid diverticulosis and interval development of
proximal sigmoid diverticulitis is seen with signs of
perforation or abscess formation. She was treated with IV
cipro/metronidazole and per pt completed 7 day course of on
___.
She states that her abdominal pain has been persistent since
discharge. It worsened two days prior to presentation, primarily
on the right side. Continues to have bowel movment with streaks
of blood. Last BM day prior to admission. No fever or chills,
Denies dysuria on my interview, but with dysuria per her PCP.
In the ED, initial vital signs were: 98.9 97 136/84 16 98% RA
- Exam was notable for: There is tenderness to palpation in the
right lower quadrant without evidence of rebound or guarding
- Labs were notable for: WBC 11.1 (N 76.9), LFTs WNL, Lipase
62, lytes WNL. Lactate 2.3. U/A WNL, slightly concentrated spec
1.013 without ketones
- Imaging: CT Abd/Pelv: 1. Mild pericolonic stranding and
sigmoid diverticula is consistent with provided history of
recent diverticulitis. A lobulated focus of air is present in
this region, unclear if this is within a diverticula or
alternatively extraluminal. No fluid collection or abscess
formation.
2. Fibroid uterus, some of which are rim calcified.
- The patient was given: 1 L NS, morphine 4mg IV, Zofran 4mg
IV, flagyl IV 500
- Consults: none
Vitals prior to transfer were: 98.5 82 138/66 18 99% RA
Upon arrival to the floor, endorses above history. Endorses
chest pain, that has been intermittent since day prior to
presentation. First occurred at work (works as ___) with
substernal chest pain, radiating down L arm, numb hand, not asso
with exertion, not relievd with rest. Occurred for 40 min after
putting hand on ice. No asso with N/V/diaphoresis. (Has been
having ongoing nausea from abdominal pain). ASA 325 and SLN
given on floor, no improvement or change, but does say that cp
improved with morphine in ED.
ROS of symptoms positive for hoarse voice and URI sx in last
two days (nasal congestion, rhinorrhea, and sore throat.)
Past Medical History:
constipation
costrochondritis
obesity
headache
pre-diabetes
Social History:
___
Family History:
Noncontributory
Physical Exam:
ADMISSION PHYSICAL EXAM:
GENERAL - pleasant, well-appearing, in no apparent distress
HEENT - normocephalic, atraumatic, no conjunctival pallor or
scleral icterus, PERRLA, EOMI, OP clear
NECK - supple, no LAD, no thyromegaly, JVP flat
CARDIAC - regular rate & rhythm, normal S1/S2, no murmurs rubs
or gallops
PULMONARY - clear to auscultation bilaterally, without wheezes
or rhonchi
ABDOMEN - NABS. Mild to mod tenderness at umbilicus, no masses
palpated ++voluntary guarding. No rebound.
EXTREMITIES - warm, well-perfused, no cyanosis, clubbing or
edema
SKIN - without rash
NEUROLOGIC - A&Ox3, CN II-XII grossly normal, normal sensation,
with strength ___ throughout. Gait assessment deferred
PSYCHIATRIC - listen & responds to questions appropriately,
pleasant
DISCHARGE PHYSICAL EXAM:
VS - 98.6 123/68 74 20 96 r/a
General: Obese female laying in hospital bed
HEENT: PERRL, EOMI
CV: RRR, s1 and s2 heard, no m/r/g
Lungs: CTABL, no wheezes, rhonci or crackles
Abdomen: Obese, soft, mildly tender in the RUQ and RLQ, no
rebound or guarding
Ext: NO ___ edema
Pertinent Results:
LABS upon admission:
___ 05:10PM BLOOD WBC-11.1*# RBC-4.16 Hgb-12.5 Hct-38.4
MCV-92 MCH-30.0 MCHC-32.6 RDW-14.3 RDWSD-48.5* Plt ___
___ 05:10PM BLOOD Glucose-128* UreaN-20 Creat-0.9 Na-142
K-4.0 Cl-102 HCO3-28 AnGap-16
___ 05:10PM BLOOD ALT-18 AST-19 CK(CPK)-74 AlkPhos-66
TotBili-0.3
___ 05:10PM BLOOD Lipase-62*
___ 05:10PM BLOOD CK-MB-1 cTropnT-<0.01
___ 06:03AM BLOOD CK-MB-1 cTropnT-<0.01
___ 06:23PM BLOOD Lactate-2.3*
LABS upon discharge:
___ 06:03AM BLOOD WBC-8.1 RBC-3.91 Hgb-11.8 Hct-36.1 MCV-92
MCH-30.2 MCHC-32.7 RDW-14.3 RDWSD-48.7* Plt ___
___ 06:03AM BLOOD Glucose-97 UreaN-9 Creat-0.7 Na-138 K-3.3
Cl-102 HCO3-24 AnGap-15
___ 06:03AM BLOOD CK(CPK)-58
___ 06:25AM BLOOD Lactate-0.9
IMAGING:
___:
IMPRESSION:
1. Minimal pericolonic stranding and sigmoid diverticula is
consistent with provided history of recent diverticulitis. A
lobulated focus of air is present in this region, unclear if
this is within a diverticulum or alternatively extraluminal. No
fluid collection or abscess formation.
2. Fibroid uterus, some of which are rim calcified.
Brief Hospital Course:
___ female with h/o non-insulin dependent DM, known LBBB, hernia
repair, recent episode of diverticulitis p/w recurrent abdominal
pain
# DIVERTICULITIS:
Pt has recent history of diverticulitis and current. CT of the
abdomen revealed minimal stranding and sigmoid diverticula c/w
diverticulitis. Per radiology, CT scan demonstrates very mild
diverticulitis and may be consistent with resolving
inflammation. Pt did initially report blood in stools but then
reported constipation with her last BM several days ago. Pt
endorsing minimal abdominal pain upon discharge. Pt was
initially treated with ceftriaxone and flagyl upon admission.
Cipro was not used because of QTC of 500. Pt will be discharged
on five day course of augmentin. Pt thought to have incompletely
treated diverticulitis and pain was minimal upon d/c.
# Chest pain: OSH received from ___ and ___. Known LBBB,
no Sgarbossa criteria. Chest pain substernal, but constant since
day before, not asso with exertion or improved with rest or SLN,
improved with morphine. Notable family history. Previous cath in
___ at ___ with minimal CAD. Received aspirin but trops
negative x2 and MB flat thought to be non cardiac in etiology.
**TRANSITIONAL ISSUES***
-QTC of 484 upon discharge. Please f/u as an outpatient. Please
consider cardiology consult if QTC prolonged.
-Augmentin upon discharge for five days (end date ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. MetFORMIN XR (Glucophage XR) 500 mg PO DAILY
Discharge Medications:
1. MetFORMIN XR (Glucophage XR) 500 mg PO DAILY
2. Amoxicillin-Clavulanic Acid ___ mg PO Q12H
RX *amoxicillin-pot clavulanate 1,000 mg-62.5 mg 2 tablets by
mouth twice per day Disp #*20 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis:
Diverticulitis, uncomplicated
Prolonged QTC
Secondary diagnoses:
Diabetes Mellitus
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms ___,
Why was I admitted to the hospital?
--you were admitted with abdominal pain
What happened while I was in the hospital?
--We took a picture of your abdomen, which shows mild
inflammation
What should I do when I go home?
--You should continue taking your medicines
--You should take the antibiotic that we are giving you
(augmentin) for five days. You should start taking it tomorrow
(___).
--You should also call Health Care Associates (___) and
follow up with your primary care doctor, ___
___,
Your ___
Followup Instructions:
___
|
19717200-DS-15
| 19,717,200 | 23,241,611 |
DS
| 15 |
2141-07-20 00:00:00
|
2141-07-23 14:57:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
fall, alcohol withdrawal
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with EtOH abuse, h/o EtOH withdrawal seizures who presents
s/p fall and with concern for EtOH withdrawal. Patient reports
he was walking to a ___ restaurant around midnight on ___
when he fell on some rocks. He believes he lost consciousness
for approximately 5 minutes after the fall. A friend who was
walking with him reportedly witness the fall and did not
appreciate any seizure activity. Patient denies any palpatations
prior to the fall, denies bowel or bladder incontinence. Does
think he was confused for approximately 10minutes after fall. Of
note, patient insists he hit the back of his head in the fall,
but was found to be bleeding from his nose and has trauma to his
face. Patient thinks he may have been intoxicated at time of the
fall, but then reports his last drink was at 9am ___ morning.
Patiently typically drinks 1 pint vodka daily. Reports history
of withdrawal seizure in police station one year ago, but cannot
elaborate. Denies history of hallucinations.
In the ED, vital T 97.6, HR 66 BP 138/87 RR 22 O2 100% RA.
Patient found to be inattentive, unkempt with diffusely tender
abdomen and voluntary guarding, no rebound. Neuro exam was
notable for intention tremor. Labs significant WBC 2.2, Hb 12.5,
Serum ETOH 97, K 3.2, Mg 1.4. AST 277, ALT 102, Alk Phos 240,
Tbili 1.4, INR 1.2. Serum tox positive for benzos. CT head
showed no acute intracranial process, but did reveal small R
frontal scalp hematoma and small displaced fracture of R orbit.
CXR negative for acute cardiopulmonary process. EKG showed
normal sinus rhythm.Plastic surgery evaluated patient in ED and
determined entrapment. Patient given 2L IVF, KCl, Mg, Lorazepam,
thiamine, folic acid and MV in ED and was transferred to
medicine for further evaluation and treatment.
On the floor, patient markedly tremulous. Reports mild head
pain, nausea, vomiting w/one episode of hematemesis in ED
(teaspoon of brb), diarrhea, RUQ abdominal pain, chills. Denies
chest pain, sob, auditory or visual hallucinations, cough,
dysuria, numbness, weakness or tingling.
Review of systems:
(+) Per HPI. Remainder of 10 point ROS negative.
Past Medical History:
HTN
Alcohol dependence
Seizure
GERD
Social History:
___
Family History:
Mother with DM
Father reformed alcoholic
Physical Exam:
Admission Labs
================
Vital Signs: T 98.8 BP 127/76 P 76 RR 18 O2 100% RA
General: Visibly tremulous, alert, oriented to self, ___,
___. Thinks month is ___.
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL,
neck supple, JVP not elevated, no LAD. + lateral nystagmus
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, non-distended, bowel sounds present. TTP in RUQ,
+rebound, no guarding. No HSM.
GU: No foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema. No palmar erythema.
Skin: No jaundice or rashes
Neuro: CN2-12 intact. No asterixis. Gait deferred given fall
risk.
Discharge Exam
=================
Vitals: Tm:98.5 BP:103/67 P:75 R:18 O2:98% RA
General: appears comfortable; lying in bed; alert and
cooperative.
HEENT: Sclera anicteric, MMM, oropharynx clear, PERRL, neck
supple, JVP not elevated, no LAD, no nystagmus.
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, non-distended, bowel sounds present. Mild TTP in
RUQ, no rebound, no guarding, no appreciable organomegaly.
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema. No palmar erythema.
Skin: No jaundice or rashes, no spider angioma
Neuro: No asterixis. Grossly intact.
Pertinent Results:
Admission Labs
==================
___ 05:07AM BLOOD WBC-2.2*# RBC-3.93* Hgb-12.5* Hct-35.7*
MCV-91 MCH-31.8 MCHC-35.0 RDW-15.5 RDWSD-51.8* Plt Ct-58*#
___ 05:07AM BLOOD Neuts-59.9 ___ Monos-10.2 Eos-1.9
Baso-1.4* Im ___ AbsNeut-1.29* AbsLymp-0.53* AbsMono-0.22
AbsEos-0.04 AbsBaso-0.03
___ 05:07AM BLOOD ___ PTT-30.6 ___
___ 05:07AM BLOOD Plt Ct-58*#
___ 05:07AM BLOOD Glucose-109* UreaN-9 Creat-0.4* Na-138
K-3.2* Cl-97 HCO3-25 AnGap-19
___ 07:49PM BLOOD Glucose-105* UreaN-6 Creat-0.5 Na-135
K-3.5 Cl-99 HCO3-24 AnGap-16
___ 05:07AM BLOOD ALT-102* AST-277* AlkPhos-240*
TotBili-1.4
___ 05:07AM BLOOD Albumin-4.1 Calcium-8.4 Phos-3.1 Mg-1.4*
___ 07:49PM BLOOD Calcium-8.7 Phos-2.4* Mg-1.8
___ 07:49PM BLOOD VitB12-822 Folate-15.2
___ 05:07AM BLOOD ASA-NEG Ethanol-97* Acetmnp-NEG
Bnzodzp-POS Barbitr-NEG Tricycl-NEG
Significant Interim Labs
=========================
___ 05:45AM BLOOD ALT-80* AST-179* LD(LDH)-323*
AlkPhos-204* TotBili-2.3*
___ 05:34AM BLOOD ALT-83* AST-181* AlkPhos-222*
TotBili-1.9*
___ 05:42AM BLOOD ALT-84* AST-145* AlkPhos-203* TotBili-1.3
___ 05:42AM BLOOD calTIBC-246* Ferritn-172 TRF-189*
___ 05:45AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE IgM
HBc-NEGATIVE IgM HAV-NEGATIVE
___ 05:34AM BLOOD AFP-7.1
___ 05:34AM BLOOD HIV Ab-Negative
___ 05:45AM BLOOD HCV Ab-NEGATIVE
Discharge Labs
===================
___ 04:50AM BLOOD WBC-2.8* RBC-3.98* Hgb-12.7* Hct-37.5*
MCV-94 MCH-31.9 MCHC-33.9 RDW-15.6* RDWSD-54.2* Plt Ct-80*
___ 04:50AM BLOOD Neuts-46.5 ___ Monos-15.2*
Eos-3.6 Baso-1.1* Im ___ AbsNeut-1.29* AbsLymp-0.92*
AbsMono-0.42 AbsEos-0.10 AbsBaso-0.03
___ 04:50AM BLOOD Plt Ct-80*
___ 04:50AM BLOOD Glucose-84 UreaN-12 Creat-0.5 Na-136
K-3.2* Cl-100 HCO3-24 AnGap-15
___ 04:50AM BLOOD ALT-79* AST-119* AlkPhos-200* TotBili-1.2
___ 04:50AM BLOOD Calcium-9.0 Phos-4.0 Mg-2.0
Microbiology
==============
Blood cultures ___: No growth to date (pending at discharge).
Imaging
===============
CXR ___
IMPRESSION:
No rib fracture is identified. If there are focal areas of pain
dedicated views of those areas are recommended.
Head CT ___
IMPRESSION:
1. No acute intracranial process.
2. Small right frontal scalp hematoma.
3. There is a small displaced fracture of the right orbital rim
(series 3
images 17 and 18).
Abdominal US ___
IMPRESSION:
1. Echogenic and coarsened liver consistent with steatosis.
Other forms of liver disease including hepatic fibrosis or
cirrhosis or steatohepatitis cannot be excluded on the basis of
this examination.
2. 9 mm hypoechoic lesion in the right lobe full which a MRI of
the abdomen is recommended for further evaluation given
suspected underlying liver disease.
MRI abdomen/pelvis ___
IMPRESSION:
1. Cirrhotic appearing liver with innumerable regenerative
nodules. No
lesion meeting OPTN-5 criteria for ___.
2. Evidence of portal hypertension with mild splenomegaly and
varices. No ascites.
3. Abnormal enhancement along the left paraspinal muscles, which
is most
likely traumatic, given the history of a recent fall. Likely
nondisplaced fractures of the L1, L2, and possibly L3 transverse
processes.
Brief Hospital Course:
Mr. ___ is a ___ year old man with EtOH abuse, h/o EtOH
withdrawal seizures who presents s/p fall with abdominal pain
and concern for EtOH withdrawal.
#Fall w/head strike: Thought to be mechanical in nature, as
patient intoxicated and reported no dizziness or palpatations
prior to the fall. No report of seizure activity surrounding the
fall, no bowel or bladder incontinence. EKG normal, no
arrythmias. Patient likely fell on face, as he presented with R
orbital fracture and frontal scalp hematoma. Head CT negative
for intracranial bleed. No focal deficits on neuro exam. Patient
seen by plastic surgery and determined no entrapment, no
surgical intervention needed. Evaluated by opthalmology, who
determined to damage to eye or changes in vision. No falls while
inpatient. Patient to follow up with ophtalmology and plastic
surgery as outpatient
# Abdominal pain: Patient presented with abdominal pain, with
TTP in RUQ on exam and elevated LFT's. Patient also reports
episode of hemoptysis in ED. Concern for pancreatitis vs.
alcoholic hepatitis, versus cholecystitis, vs gastritis/duodenal
ulcer. Patient's lipase 85, so pancreatitis unlikely. No fevers
on exam, no leukocytosis, so cholecystitis is less likely.
AST/ALT 2:1 ratio, consistent with long standing alcohol abuse,
patient extremely tender to palpation in RUQ, so alcoholic
hepatitis was a consideration. Discriminant factor: 5, so no
role for steroids. Finally, patient reported episode of
hemoptysis, recent dark stools, so duodenal ulcer, gastritis a
concern. RUQ revealed small 9mm mass in liver (f/u MRI
recommended), but was otherwise unremarkable. Follow up MRI
showed evidence of cirrhosis, but no HCC. Patient's abdominal
pain improved without intervention and he was discharged with GI
follow up.
#Cirrhosis: MRI revealed multinodular liver consistent with
cirrhosis. Patient also thrombocytopenic (platelets 58 on
admission). INR 1.2. Likely secondary to chronic alcohol abuse,
as hepatitis panel negative. Patient had no stigmata of
cirrhosis on exam and no evidence of decompensation. The primary
team educated the patient on cirrhosis and counselded him to
stop drinking. Patient discharged with GI follow up.
#Alcohol withdrawal and abuse: Patient's ethanol elevated on
arrival to ED, reported drinking 1 pint of vodka daily. Patient
reports last drink was day prior to presentation at 9AM, but
unlikely, as patient appeared intoxicated on presentation to ED.
Reported history of seizure, no DT's. Patient placed on CIWA and
required Lorzepam for withdrawal symptoms. Also treated with
multivitamin, thiamine and folate. Patient's symptoms improved
and he was no longer requiring benzos at discharge. He expressed
desire to stop drinking and planned to enroll in AA upon
discharge.
#Hemoptysis/Melena: Patient reported episode of hemoptysis in ED
in setting of nausea, several episodes of vomiting. Also
reported recent "dark stools". Most likely ___ tear in
setting of vomiting, unlikely acute UGIB as H/H remained stable
and guiac negative. No further episodes during admission.
#Leukopenia, thrombocytopenia: Stable. Likely secondary to bone
marrow suppression in setting of chronic alcohol use. Infection
was also a consideration, although patient afebrile. UA, urine
culture negative. Primary bone marrow process a possibility, but
unlikely. Blood cultures still pending at discharge, but no
growth to date.
Transitional Issues:
===========================
-Patient found to have cirrhotic liver by MRI with evidence of
portal hypertension, splenomegaly and varices. Patient should be
followed closely by GI.
-Patient reports episodes of melena prior to admission. Stool
guiaic negative. Consider EGD by GI.
-Patient has no immunity to Hepatitis B. Start vaccination
series as outpatient.
-Patient has R orbital fracture from recent fall. Seen by Optho
and Plastics during admission and should follow up with both
services as outpatient.
-Patient has long history of alcohol abuse. Should consider
enrollment in AA or equivalent program to help maintain
sobriety, particularly in setting of cirrhosis.
-MRI on ___ showed likely nondisplaced
fractures of the L1, L2, and possibly L3 transverse processes.
Patient asymptomatic. Please follow up as outpatient (consider
back imaging in ___ weeks if patient has persistent back pain).
Patient neurologically intact with no FNDs during hospital stay
and no spinous process tenderness.
CODE: Full (confirmed)
CONTACT: ___ ___
Medications on Admission:
None
Discharge Medications:
1. FoLIC Acid 1 mg PO DAILY
RX *folic acid 1 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*1
2. Multivitamins 1 TAB PO DAILY
RX *multivitamin 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*1
3. Thiamine 100 mg PO DAILY
RX *thiamine HCl 100 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*1
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnoses:
R orbital fracture
Alcohol Withdrawal
Cirrhosis of Liver
Secondary Diagnoses:
Leukopenia
Thrombocytopenia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure caring for you at ___
___. You were admitted after a fall. You were found
to have a fracture in the bone around your right eye. You were
seen by plastic surgery and opthalmology and they determined
that there was no damage to your eye or vision. You were found
to be withdrawing from alcohol, so you were treated with
medication and your sympmtoms improved. You had a scan of your
abdomen which revealed cirrhosis of your liver, likely due to
longstanding alcohol use. You should enroll in a detox program
to aid in your sobriety and follow up with Gastrointestinal
doctors for your liver. As we discussed in the hospital, please
abstain from alcohol. Given the damage already done to your
liver, continued alcohol drinking will result in irreparable
harm and death. Do not hesitate to reach out to your physician
below or the hospital if you start to feel the urge to drink.
You should also follow up with Opthalmology, Plastic surgery and
your PCP (see appointments below).
It was wonderful meeting you and we wish you all the best in
your recovery.
Sincerely,
Your Medical Team
Followup Instructions:
___
|
19717260-DS-11
| 19,717,260 | 26,747,548 |
DS
| 11 |
2120-08-09 00:00:00
|
2120-08-09 12:06:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
nickel / latex
Attending: ___.
Chief Complaint:
R hip fracture
Major Surgical or Invasive Procedure:
ORIF R periprosthetic femur fracture
History of Present Illness:
___ female presents with the above fracture s/p mechanical fall.
She was in her usual health until this morning, when she arose
from bed, was making her bed, and tripped over her blankets. She
fell onto her right hip and had instant pain. Denies HS, no LOC,
no blood thinners. No other apparent injuries. Initially
presented to ___, where she was diagnosed with
periprosthetic R hip fracture and transferred here for further
evaluation.
Patient is very active at baseline. She lives in independent
living, uses a walker sometimes in her apartment, and goes out
with a cane. She performs all ADL/IADL independently. She still
drives.
Past Medical History:
PMH: Afib, CHF, COPD, atrial fibrillation on ASA,
hypertension, hypothyroidism, cardiomyopathy
PSH: Cholecystectomy, Vein stripping b/l ___
Social History:
___
Family History:
NC
Physical Exam:
___ 0402 Temp: 98.1 PO BP: 142/77 HR: 93 RR: 18 O2 sat: 90%
O2 delivery: Ra
General: Well-appearing, breathing comfortably
MSK, RLE:
- Dressing c/d/I, no drainage or erythema
- Ecchymosis along groin, non-TTP
- Thigh and calf soft and compressible
- Full, painless ROM at knee, and ankle
- Fires ___
- SILT S/S/SP/DP/T distributions
- Palpable ___ pulses, foot WWP
Pertinent Results:
See OMR
Brief Hospital Course:
The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have a right periprosthetic femur fracture and was admitted
to the orthopedic surgery service. The patient was taken to the
operating room on ___ for open reduction and internal
fixation of the fracture, which the patient tolerated well. For
full details of the procedure please see the separately dictated
operative report. The patient was taken from the OR to the PACU
in stable condition and after satisfactory recovery from
anesthesia was transferred to the floor. The patient was
initially given IV fluids and IV pain medications, and
progressed to a regular diet and oral medications by POD#1. The
patient was given ___ antibiotics and anticoagulation
per routine.
#Anemia:
The patient was hypotensive and noted to have a Hct of 20.7
post-operatively. She received 2u of pRBCs and her Hct responded
appropriately. The patient was noted to have swelling and
ecchymosis of the thigh post-operatively, the likely source of
bleeding given the extent of her revision procedure. She was
also resuscitated with fluid boluses in the context of her
congestive heart failure. Her Hct was stable at the time of her
discharge at 26.
[ ] restart iron at discharge - dosing recommendation once every
other day
#Hyponatremia:
The patient was noted to have a downtrending sodium to 123
post-operatively. Her home dose of Lasix was held, and urine
electrolytes revealed an etiology of likely hypovolemic
hyponatremia. The patient responded to intravenous fluid and a
free water restriction. Sodium at discharge was measured to be
135. Her Lasix was restarted at the time of discharge.
[ ] Encourage high solute intake, 2L restriction
#Hypotension
The patient's SBP was low post-operatively, responding well to
boluses of fluid and blood transfusion. The patient's blood
pressure was noted to be SBPs 110s at the time of her discharge;
the patient Lisinopril was given hold parameters in the context
of recent surgery and risk of orthostasis/falls while recovering
at rehab.
[ ] restart Lisinopril when medically appropriate given morality
benefit in CHF
#Afib
Rate controlled with metoprolol. Transitioned to metoprolol XL
at discharge per medicine recommendations given HR controlled in
house, plus once-daily dosing.
#Osteoporosis
- Continue Vitamin D + Calcium supplementation
- Recommend discussion re: bisphosphate in future
The patient worked with ___ who determined that discharge to
rehab was appropriate. The ___ hospital course was
otherwise unremarkable.
At the time of discharge the patient's pain was well controlled
with oral medications, incisions were clean/dry/intact, and the
patient was voiding/moving bowels spontaneously. The patient is
weight bearing as tolerated in the left lower extremity, and
will be discharged on enoxaparin 40mg daily for DVT prophylaxis.
The patient will follow up with Dr. ___ routine. A
thorough discussion was had with the patient regarding the
diagnosis and expected post-discharge course including reasons
to call the office or return to the hospital, and all questions
were answered. The patient was also given written instructions
concerning precautionary instructions and the appropriate
follow-up care. The patient expressed readiness for discharge.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN dyspnea wheeze
2. Levothyroxine Sodium 137 mcg PO DAILY
3. Atorvastatin 10 mg PO QPM
4. Lisinopril 2.5 mg PO DAILY
5. Furosemide 20 mg PO DAILY
6. Multivitamins 1 TAB PO DAILY
7. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 500 mg PO
DAILY
8. Aspirin 81 mg PO DAILY
9. Digoxin 0.125 mg PO DAILY
10. Metoprolol Succinate XL 100 mg PO DAILY
11. Docusate Sodium 250 mg PO DAILY
12. Fiber Laxative (methylcellulo) (methylcellulose (laxative))
500 mg oral DAILY
13. Ferrous Sulfate Dose is Unknown PO BID
14. B-12 Compliance (cyanocobalamin (vitamin B-12)) 2500 mcg
injection monthly
Discharge Medications:
1. Acetaminophen 650 mg PO 5X/DAY
2. Calcium Carbonate 500 mg PO DAILY
3. Enoxaparin Sodium 40 mg SC QPM
RX *enoxaparin 40 mg/0.4 mL 40 mg SC daily Disp #*27 Syringe
Refills:*0
4. OxyCODONE (Immediate Release) 2.5-5 mg PO Q4H:PRN pain
RX *oxycodone 5 mg ___ tablet(s) by mouth every ___ hours as
needed Disp #*10 Tablet Refills:*0
5. Senna 17.2 mg PO BID
6. Vitamin D 1000 UNIT PO DAILY
7. Ferrous Sulfate 325 mg PO BID
8. Metoprolol Succinate XL 50 mg PO DAILY
9. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN dyspnea wheeze
10. Aspirin 81 mg PO DAILY
11. Atorvastatin 10 mg PO QPM
12. B-12 Compliance (cyanocobalamin (vitamin B-12)) 2500 mcg
injection monthly
13. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 500 mg PO
DAILY
14. Digoxin 0.125 mg PO DAILY
15. Docusate Sodium 250 mg PO DAILY
16. Fiber Laxative (methylcellulo) (methylcellulose (laxative))
500 mg oral DAILY
17. Furosemide 20 mg PO DAILY
18. Levothyroxine Sodium 137 mcg PO DAILY
19. Lisinopril 2.5 mg PO DAILY
Hold for SBP < 140, may consider restarting in one week
20. Multivitamins 1 TAB PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Periprosthetic femur fracture
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:
INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY:
- You were in the hospital for orthopedic surgery. It is normal
to feel tired or "washed out" after surgery, and this feeling
should improve over the first few days to week.
- Resume your regular activities as tolerated, but please follow
your weight bearing precautions strictly at all times.
ACTIVITY AND WEIGHT BEARING:
- Weight bearing as tolerated, right lower extremity
MEDICATIONS:
1) Take Tylenol ___ every 6 hours around the clock. This is
an over the counter medication.
2) Add oxycodone as needed for increased pain. Aim to wean
off this medication in 1 week or sooner. Then continue with
Tylenol for pain.
3) Do not stop the Tylenol until you are off of the narcotic
medication.
4) Per state regulations, we are limited in the amount of
narcotics we can prescribe. If you require more, you must
contact the office to set up an appointment because we cannot
refill this type of pain medication over the phone.
5) Narcotic pain relievers can cause constipation, so you
should drink eight 8oz glasses of water daily and continue
following the bowel regimen as stated on your medication
prescription list. These meds (senna, colace, miralax) are over
the counter and may be obtained at any pharmacy.
6) Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
7) Please take all medications as prescribed by your
physicians at discharge.
8) Continue all home medications unless specifically
instructed to stop by your surgeon.
ANTICOAGULATION:
- Please take enoxaparin daily for 4 weeks
WOUND CARE:
- You may shower. No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- Incision may be left open to air unless actively draining. If
draining, you may apply a gauze dressing secured with paper
tape.
DANGER SIGNS:
Please call your PCP or surgeon's office and/or return to the
emergency department if you experience any of the following:
- Increasing pain that is not controlled with pain medications
- Increasing redness, swelling, drainage, or other concerning
changes in your incision
- Persistent or increasing numbness, tingling, or loss of
sensation
- Fever > 101.4
- Shaking chills
- Chest pain
- Shortness of breath
- Nausea or vomiting with an inability to keep food, liquid,
medications down
- Any other medical concerns
THIS PATIENT IS EXPECTED TO REQUIRE <30 DAYS OF REHAB
Heart Failure:
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs.
Physical Therapy:
WBAT BLE
No splint or braces needed
ROMAT
Treatments Frequency:
Any staples or superficial sutures you have are to remain in
place for at least 2 weeks postoperatively. Incision may be
left open to air unless actively draining. If draining, you may
apply a gauze dressing secured with paper tape. You may shower
and allow water to run over the wound, but please refrain from
bathing for at least 4 weeks postoperatively.
Followup Instructions:
___
|
19717536-DS-13
| 19,717,536 | 27,027,575 |
DS
| 13 |
2201-02-17 00:00:00
|
2201-02-19 20:49:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Conray / Citalopram / Vicodin / atorvastatin
Attending: ___.
Chief Complaint:
Respiratory failure
Major Surgical or Invasive Procedure:
Intubation
History of Present Illness:
Ms. ___ is a ___ w/ PMH notable for baseline
dementia, HF, COPD & SSS s/p PPM who presents as a transfer from
___ w/ dyspnea. The patient initially presented to
OSH from her rehab facility w/ AMS & dyspnea and was found to be
in respiratory distress requiring non-invasive ventilation. A
CXR was concerning for a RML infiltrate & she was started on
levofloxacin for empiric PNA coverage.
She was transferred to ___ for further care. En route, she
developed a narrow-complex tachycardia requiring adenosine.
Upon presentation to ___ ED, she remained in respiratory
distress w/ hypoxia to the ___ & required intubation for acute
hypoxic respiratory failure. She remained intermittently
tachycardic w/ intermittent AF w/ RVR to 150s-180s. She was
broadened to vancomycin & ceftazadime. She was admitted to the
MICU for further support.
In ED:
-Initial VS & exam:
99.0 177 128/73 42 100% BiPAP
"Appears in distress, tachypnea w/ coarse breath sounds & poor
air movement bilaterally."
-Labs significant for:
148 | 104 | 44 /
---------------- 81
4.9 | 26 | 2.3 \
\ 11.8 /
28.7 ------ 86
/ 37.2 \
Lactate 3.6
VBG 7.29/33/61/31
Troponin 0.02
-Patient was given:
___ 20:35 IV Etomidate 20 mg
___ 20:46 IV Succinylcholine 120 mg
___ 21:01 IV DRIP Propofol ___ mcg/kg/min ordered)
___ 21:24 IV CefTAZidime 1 g
___ 21:27 IV DRIP Propofol
___ 21:32 IV DRIP Propofol
___ 21:32 IV Morphine Sulfate 4 mg
___ 21:32 IV BOLUS Midazolam 2 mg
___ 21:32 IV DRIP Midazolam (0.5-2 mg/hr ordered)
-Imaging notable for:
CXR:
1. The endotracheal tube terminates approximately 3.4 cm above
the carina.
2. Re-demonstration of diffuse hazy opacity in the right
hemithorax most consistent with pneumonia, not significantly
changed compared to prior radiograph.
On arrival to the MICU, the patient remained intubated and
sedated and was unable to provide further history.
Past Medical History:
unspecified dementia
GERD
HFpEF
OSA
SSS w/ PPM
Chronic diastolic heart failure
Hypertension.
Obesity.
Dyslipidemia.
Tachybrady syndrome, status post pacemaker.
Chronic kidney disease.
Polymyalgia rheumatica, on chronic corticosteroid therapy.
COPD.
Atrial fibrillation, on Xarelto.
Obstructive sleep apnea, currently not using CPAP because
equipment has been lost.
Memory Loss: MOCA ___ on ___
Depression
CKD
Osteopenia
Glaucoma
Hyperparathyroidism
Social History:
___
Family History:
Sister with hypertension. Mother with unknown cardiovascular
disease.
Physical Exam:
ADMISSION:
============
Vitals reviewed in OMR.
GENERAL: Intubated, sedated.
HEAD: NC/AT, ETT, OG in place.
CARDIAC: NSR on monitor.
RESPIRATORY: No wheezing anteriorly.
ABDOMEN: Obese, soft.
EXTREMITIES: 3+ ___ edema to knees bilaterally.
DISCHARGE:
===========
Vitals: ___ ___ Temp: 97.9 PediatricAxillary BP: 115/72
HR: 66 RR: 20 O2 sat: 92% O2 delivery: Ra
General: Asleep, withdraws to pain and to attempts to open eyes
Eyes: Sclera anicteric
HEENT: MMM, oropharynx clear, resists opening eyes
Neck: supple, JVP not elevated
Resp: CTAB
CV: regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
GI: soft NT DD
GU: Foley draining clear urine
MSK: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNs2-12 unable to assess, R-sided facial droop (chronic)
Pertinent Results:
ADMISSION:
==========
___ 08:23PM BLOOD WBC-28.7* RBC-4.34 Hgb-11.8 Hct-37.2
MCV-86 MCH-27.2 MCHC-31.7* RDW-16.6* RDWSD-51.7* Plt ___
___ 08:23PM BLOOD Neuts-91* Bands-4 Lymphs-4* Monos-1*
Eos-0 Baso-0 ___ Myelos-0 AbsNeut-27.27*
AbsLymp-1.15* AbsMono-0.29 AbsEos-0.00* AbsBaso-0.00*
___ 08:23PM BLOOD Hypochr-NORMAL Anisocy-1+* Poiklo-NORMAL
Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL Ovalocy-1+* Tear
Dr-1+*
___ 08:23PM BLOOD ___ PTT-30.1 ___
___ 08:23PM BLOOD Glucose-81 UreaN-44* Creat-2.3* Na-148*
K-4.9 Cl-104 HCO3-26 AnGap-18
___ 08:23PM BLOOD ALT-13 AST-26 AlkPhos-43 TotBili-0.8
___ 08:23PM BLOOD proBNP-2422*
___ 08:23PM BLOOD cTropnT-0.02*
___ 08:23PM BLOOD Calcium-8.3* Phos-4.8* Mg-1.4*
___ 08:36PM BLOOD ___ pO2-33* pCO2-61* pH-7.29*
calTCO2-31* Base XS-0
___ 08:36PM BLOOD Lactate-3.6*
MICROBIOLOGY:
=============
___ URINEURINE CULTURE-FINAL
NO GROWTH.
___ SPUTUM GRAM STAIN-FINAL; RESPIRATORY CULTURE-FINAL
GRAM STAIN (Final ___:
>25 PMNs and <10 epithelial cells/100X field.
1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S).
SMEAR REVIEWED; RESULTS CONFIRMED.
RESPIRATORY CULTURE (Final ___: NO GROWTH.
___ MRSA SCREENMRSA SCREEN-FINAL
No MRSA isolated.
___ URINELegionella Urinary Antigen -FINAL
NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN.
___ Rapid Respiratory Viral Screen & CultureRespiratory
Viral Culture-FINAL; Respiratory Viral Antigen Screen-FINAL
No respiratory viruses isolated.
Culture screened for Adenovirus, Influenza A & B,
Parainfluenza type
1,2 & 3, and Respiratory Syncytial Virus.
___ BLOOD CULTUREBlood Culture, Routine-FINAL
NO GROWTH.
___ URINEURINE CULTURE-FINAL
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN
AND/OR GENITAL CONTAMINATION.
___ BLOOD CULTUREBlood Culture, Routine-FINAL
NO GROWTH.
IMAGING:
========
CXR CHEST (PORTABLE AP) ___ 7:59 ___
IMPRESSION:
Diffuse hazy opacity in the right hemithorax most consistent
with pneumonia.
Probable small parapneumonic effusion.
CXR CHEST (PORTABLE AP) ___ 8:40 ___
1. The endotracheal tube terminates approximately 3.4 cm above
the carina.
2. Re-demonstration of diffuse hazy opacity in the right
hemithorax most
consistent with pneumonia, not significantly changed compared to
prior
radiograph.
CT Chest w/o contrast ___
IMPRESSION:
-Extensive pneumonia, possibly due to aspiration involving the
dependent
portions of all 3 right lobes, with small focus of necrotizing
pneumonia in
the right lower lobe.
-In the left partially imaged kidney possible solid round lesion
is partially
imaged.
CT HEAD W/O CONTRAST ___ 12:31 AM
IMPRESSION:
1. On slightly motion degraded examination, no evidence of acute
large
territory infarct or intracranial hemorrhage on noncontrast head
CT. No
intracranial mass effect.
2. If there are no contraindications, MRI would be more
sensitive for sequela
and etiology of seizure.
3. Aerosolized mucous in the left maxillary sinus, potentially
representing
acute sinusitis. Clinical correlation is recommended.
UNILAT UP EXT VEINS US ___ 7:56 AM
IMPRESSION:
No evidence of deep vein thrombosis in the right upper
extremity.
CHEST (PORTABLE AP) ___ 3:22 AM
IMPRESSION:
Compared to chest radiographs ___
through
___.
Severe pneumonia in the right lung, particularly upper lobe,
improved from
___ through ___, and has decreased subsequently.
Previous small
bilateral pleural effusions are smaller. Moderate cardiomegaly,
pulmonary and
mediastinal vascular engorgement are stable. No pneumothorax.
Right PIC line ends close to the superior cavoatrial junction.
Transvenous
right atrial and right ventricular pacer leads are unchanged in
course from
the left pectoral generator.
CHEST (PORTABLE AP) ___ 11:53 AM
IMPRESSION:
In comparison with the earlier study of this date, the
cardiomediastinal
silhouette is stable. The pulmonary vascular congestion appears
increased.
There is increased opacification at the right base silhouetting
hemidiaphragm,
consistent with pleural effusion and underlying compressive
atelectasis. Less
prominent changes are seen on the left. Dual channel pacer is
unchanged.
In the appropriate clinical setting, it would be very difficult
to exclude
superimposed aspiration/pneumonia, especially in the absence of
a lateral
view.
DISCHARGE LABS:
==============
___ 06:04AM BLOOD WBC-8.6 RBC-3.32* Hgb-9.2* Hct-28.2*
MCV-85 MCH-27.7 MCHC-32.6 RDW-17.2* RDWSD-51.2* Plt ___
___ 06:04AM BLOOD Plt ___
___ 06:04AM BLOOD Glucose-97 UreaN-44* Creat-1.3* Na-143
K-3.8 Cl-101 HCO3-30 AnGap-12
___ 05:50AM BLOOD UreaN-41* Creat-1.4* K-3.9
___ 05:50AM BLOOD Mg-1.8
Brief Hospital Course:
Ms. ___ is a ___ w/ PMH notable for baseline dementia, HFpEF,
COPD & SSS s/p PPM, who p/w SOB, found a significant R-sided
PNA, requiring intubation, admitted initially to MICU.
Transferred back to the MICU for respiratory distress I/s/o
SVTs, re-transferred to floor for continued tx of COPD
exacerbation and likely pulmonary edema.
#Acute hypoxic respiratory failure
#Pneumonia
#COPD exacerbation
The patient's initial respiratory failure was thought to be
likely related to her large right sided pneumonia demonstrated
on CT scan. Was thought less likely to be related to a CHF
exacerbation or COPD exacerbation as her exam and imaging were
not consistent with considerable fluid overload nor was her VBG
consistent with significant hypercarbia.
She was initially admitted to the MICU and started on
broad-spectrum antibiotics with vanc/ceftaz. Sputum gram stain
was positive for GNRs, but did not grow anything in cultures. S.
pneumo antigen and MRSA screen returned negative. She was
narrowed to CTX to complete an 8-day course. The patient was
diuresed with boluses of Lasix IV and treated with IV steroids
as well. She demonstrated significant respiratory improvement
and was extubated without event on ___. Patient was called out
to the floor on ___, but re-transferred to ICU for acute
pulmonary edema in the setting of tachycardia (discussed below).
The patient was maintained on Advair BID, montelukast, and q6h
duonebs. She completed a taper of prednisone, starting at 40mg
and decreasing by 10mg every two days; she was taking 10mg
prednisone on discharge, with a plan for the following taper:
5mg on ___, 5mg on ___.
# Acute on chronic diastolic heart failure
# SVTs
She was called out to the floor on ___. Overnight on ___, she
triggered for tachycardia to 150s (?SVT vs Afib) that required
diltiazem to break after multiple rounds of metoprolol. She had
a similar episode the day prior in the MICU that self-resolved.
While on the floor, patient was also felt to have increased work
of breathing. O2 requirement increased to 2L NC from RA. Given
concern for respiratory status, she was transferred back to the
MICU.
While in the MICU the second time, patient had no recurrent SVT.
CXR showed worsening pulmonary vascular congestion and pleural
effusions without new infiltrate. Flash pulmonary edema in
setting of SVT was suspected. The patient appeared volume
overloaded on exam and had not consistently been receiving
diuretics. Following second transfer to the floor, she improved
significantly with diuresis with boluses of IV lasix and was
weaned to RA. She was continued on her home dose of carvedilol,
and home torsemide (80mg qd) was restarted prior to discharge.
# Myoclonus
MICU course was also complicated by myoclonus on L side of her
body. Neuro was consulted, and EEG did not show seizure. She was
started on keppra and symptoms resolved. Keppra was discontinued
on ___. No further myoclonus was observed.
# ___:
Baseline unclear though 2.0 @ OSH before transfer. MICU
admission Cr was 2.3. BUN/creatinine 19.13, consistent with
pre-renal etiology likely ___ sepsis and dehydration. Patient
was hydrated with IVF in the MICU. Discharge Cr of 1.4.
# Hypernatremia:
Na on arrival was 148. Likely secondary to free water loss
likely representing dehydration. Patient remained hypernatremic
during her stay despite hydration with hypotonic fluids. No D5
available; had been getting FW with ___ NS, but appeared
mildly fluid overloaded so this was discontinued. PO intake was
encouraged, and hypernatremia resolved spontaneously.
# Afib:
Rate controlled. Apixaban briefly held on ___ due to concern of
GIB, but subsequently restarted. Continued home carvedilol.
# Hyperglycemia
No history of DM, hyperglycemia felt likely transient and
related to prednisone. Controlled on sliding scale while
hospitalized, requiring ___ Humalog off sliding scale daily
towards end of hospital course.
#Anemia
#Melena
Single hard bowel movement with bright blood noted after first
floor transfer. Apixaban was briefly held, continued on home
omeprazole. No melena noted afterwards, with subsequent stools
consistently loose, brown. Guaiac negative. H/H at baseline,
stable. Labs notable for elevated ferritin, low TIBC, normal
iron, normal LFTs, inappriately low reticulocyte index, most
consistent with anemia of chronic disease. Possibly component of
iron deficiency.
# GERD - Continued home omeprazole.
# HLD - Continued home pravastatin.
# Unspecified dementia - Continued home donepezil & sertraline.
# Hypothyroidism - Continued home levothyroxine.
TRANSITIONAL ISSUES
===================
[ ] Recommend Chem 7 + Mg on ___ to follow up electrolytes and
Cr on torsemide and K dosing.
[ ] Cardiology clinic follow-up as outpatient on ___.
[ ] Please weigh daily and consider increasing torsemide vs
adding metolazone if gaining weight.
[ ] Continue to assess volume status and weight and adjust
diuretics as needed.
[ ] Consider further anemia work up and iron as outpatient if
not already done.
MEDICATIONS:
- NEW: Complete rednisone taper: 5mg on ___ and ___.
- NEW: Insulin sliding scale. ___ discontinue at end of
prednisone taper.
- NEW: Multivitamin daily.
- CHANGED: Potassium decreased to 10mEq daily from 20mEq.
# Discharge Cr: 1.4
# Discharge weight: 247.5 lbs
Communication: HCP: ___ ___
Code: DNR/DNI
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Levothyroxine Sodium 75 mcg PO DAILY
3. Pravastatin 80 mg PO QPM
4. Apixaban 2.5 mg PO BID
5. Carvedilol 6.25 mg PO BID
6. Donepezil 5 mg PO QHS
7. Sertraline 50 mg PO DAILY
8. Omeprazole 20 mg PO DAILY
9. budesonide-formoterol 80-4.5 mcg/actuation inhalation BID
10. ipratropium-albuterol 0.5 mg-3 mg(2.5 mg base)/3 mL
inhalation Q6H:PRN
11. Polyethylene Glycol 17 g PO DAILY:PRN constipation
12. Senna 17.2 mg PO BID
13. Montelukast 10 mg PO DAILY
14. Tiotropium Bromide 1 CAP IH DAILY
15. Torsemide 80 mg PO DAILY
16. Ventolin HFA (albuterol sulfate) 90 mcg/actuation inhalation
Q4H:PRN
17. Potassium Chloride 20 mEq PO DAILY
18. PredniSONE 20 mg PO DAILY
Discharge Medications:
1. Insulin SC
Sliding Scale
Fingerstick QACHS
Insulin SC Sliding Scale using HUM Insulin
2. Multivitamins W/minerals 1 TAB PO DAILY
3. PredniSONE 5 mg PO DAILY Duration: 2 Days
4. Potassium Chloride 10 mEq PO DAILY
5. Albuterol Inhaler 2 PUFF IH Q4H:PRN dyspnea
6. Apixaban 2.5 mg PO BID
7. Carvedilol 12.5 mg PO BID
8. Donepezil 5 mg PO QHS
9. Ipratropium Bromide Neb 1 NEB IH Q6H
10. Metolazone 2.5 mg PO 2X/WEEK (___) PRN for weight >255
lbs
11. Montelukast 10 mg PO DAILY
12. Omeprazole 20 mg PO DAILY
13. Polyethylene Glycol 17 g PO DAILY:PRN constipation
14. Pravastatin 80 mg PO QPM
15. Senna 8.6 mg PO BID:PRN constipatin
16. Sertraline 50 mg PO DAILY
17. Symbicort (budesonide-formoterol) 80-4.5 mcg/actuation
inhalation BID
18. Tiotropium Bromide 1 CAP IH DAILY
19. Torsemide 80 mg PO DAILY
20. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Respiratory failure
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear ___,
___ was a pleasure taking care of you at ___. Please see below
for information on your time in the hospital.
WHY WAS I IN THE HOSPITAL?
- You presented to the hospital with respiratory failure
requiring intubation.
- We believe this was related to a pneumonia and possible a COPD
exacerbation, as well as having fluid in your lungs.
WHAT HAPPENED IN THE HOSPITAL?
-You were initially admitted to the MICU because you required a
ventilator to support your breathing.
-You were treated with antibiotics for your pneumonia.
-You were treated with steroids and nebulizer breathing
treatments for a COPD exacerbation.
-You were transferred to the MICU a second time because you were
having difficulty breathing again, this time because of a fast
heart rate, which likely caused fluid to accumulate in your
lungs.
-You improved with treatment with diuretics to remove the excess
fluid.
-Your blood sugars were somewhat high because of the prednisone
you were taking, so you were given some insulin.
WHAT SHOULD I DO WHEN I GO HOME?
-Please continue to take the prednisone as prescribed.
-Please check your blood sugars and take insulin as needed until
the prednisone is stopped. Your care team can help with this.
-Please weigh yourself daily, and take your metolazone if your
weight is greater than 255 lbs.
-Please also tell your doctor if you gain more than 2 pounds in
1 day, or 5 pounds in 1 week.
-Please limit your daily sodium intake to less than 2 grams per
day.
-Your medications and follow up appointments are below.
We wish you the best!
-Your Care Team at ___
Followup Instructions:
___
|
19717536-DS-15
| 19,717,536 | 22,142,531 |
DS
| 15 |
2202-04-16 00:00:00
|
2202-07-05 12:29:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
Conray / Citalopram / Vicodin / atorvastatin
Attending: ___.
Chief Complaint:
Left ankle pain
Major Surgical or Invasive Procedure:
Open reduction internal fixation of left ankle
History of Present Illness:
Patient is a pleasant ___ female who sustained an
ankle fracture that was initially nondisplaced and is being
treated by Dr. ___ at ___ unfortunately it is
lost the alignment and she presents to us for definitive
management given her medical comorbidities.
Past Medical History:
- paroxysmal afib on anticoagulation
- COPD
- HFpEF
- dementia
- depression
- insomnia
- CKD stage III
- sick sinus syndrome s/p PPM
- hypertension
- osteopenia
- pre-diabetes
- osteoarthritis
- low back pain
- valvular heart disease
- OSA
- polymyalgia rheumatica
- pulmonary nodule
- thyroid nodule
- hemorrhoids
- gastric polyps
- glaucoma
- hyperparathyriodsim
- s/p knee surgery
- s/p cataract surgery
Social History:
___
Family History:
Sister with hypertension. Mother with unknown cardiovascular
disease.
Physical Exam:
___ 0704 Temp: 98.5 PO BP: 146/70 L Lying HR: 67 RR: 18 O2
sat: 97% O2 delivery: Ra
General: Sleeping comfortably this AM
MSK:
RLE, splinted, wwp.
remainder of exam deferred ___ geriatric protocol
Pertinent Results:
See omr
Brief Hospital Course:
The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have a left ankle fracture and was admitted to the orthopedic
surgery service. The patient was taken to the operating room on
___ for open reduction internal fixation of the left ankle,
which the patient tolerated well. For full details of the
procedure please see the separately dictated operative report.
The patient was taken from the OR to the PACU in stable
condition and after satisfactory recovery from anesthesia was
transferred to the floor. The patient was initially given IV
fluids and IV pain medications, and progressed to a regular diet
and oral medications by POD#1. The patient was given
___ antibiotics and anticoagulation per routine. The
patient's home medications were continued throughout this
hospitalization. The patient worked with ___ who determined that
discharge to rehab was appropriate. The patient was followed by
geriatrics throughout her admission (see note below). She was
more lethargic post-operatively, which was thought to be due to
retaining CO2. Strict adherence to bipap while napping or
sleeping was encouraged. This will need to be closely monitored
at rehab. The ___ hospital course was otherwise
unremarkable.
At the time of discharge the patient's pain was well controlled
with oral medications, incisions were clean/dry/intact, and the
patient was voiding/moving bowels spontaneously. The patient is
nonweightbearing in the left lower extremity, and will be
discharged on home apixaban for DVT prophylaxis. The patient
will follow up with Dr. ___ routine. A thorough
discussion was had with the patient regarding the diagnosis and
expected post-discharge course including reasons to call the
office or return to the hospital, and all questions were
answered. The patient was also given written instructions
concerning precautionary instructions and the appropriate
follow-up care. The patient expressed readiness for discharge.
Please see below for geriatric note prior to discharge:
Note contains an addendum. See bottom.
Note Date: ___ Time: 1639
Note Type: Progress note
Note Title: Geriatric ___ Progress Note
Electronically signed by ___, MD on ___ at 4:42
pm Affiliation: ___
Electronically cosigned by ___, MD on ___ at 1:06
am
======================================
GERIATRIC CONSULT PROGRESS NOTE:
======================================
PCP: ___ ___
Primary Service: Surgery - Orthopedics
Geriatric attending: Dr. ___
___ of information: Patient, OMR
Admission date: ___
======================================
REASON FOR CONSULTATION: co-management of care
HISTORY OF PRESENT ILLNESS:
Ms. ___ is a an ___ woman with past medical history
of
dementia, CKD stage III, A. fib on apixaban, COPD, HFpEF, PMR,
SSS s/p PPM who presents on ___ for ORIF of left ankle
fracture.
INTERVAL HISTORY
-patient tired this AM
-wore CPAP intermittently throughout night
-says she has pain in her ankle
-eating well
CARDIAC HISTORY:
Atrial Fibrillation on Apixaban
Heart Failure with preserved Ejection fraction
Hypertension
Mild TR
Sick Sinus Syndrome s/p PPM
OTHER PAST MEDICAL HISTORY:
- COPD
- dementia
- depression
- insomnia
- CKD stage III
- sick sinus syndrome s/p PPM
- hypertension
- osteopenia
- pre-diabetes
- osteoarthritis
- low back pain
- valvular heart disease
- OSA
- polymyalgia rheumatica
- pulmonary nodule
- thyroid nodule
- hemorrhoids
- gastric polyps
- glaucoma
- hyperparathyriodsim
- s/p knee surgery
- s/p cataract surgery
INPATIENT MEDICATIONS:
--------------- --------------- --------------- ---------------
Active Inpatient Medication list as of ___ at 1639:
Medications - Standing
Donepezil 5 mg PO/NG QHS
Sertraline 50 mg PO/NG DAILY
Sodium Chloride 0.9% Flush ___ mL IV Q8H and PRN, line flush
Docusate Sodium 100 mg PO BID
CARVedilol 12.5 mg PO/NG BID
Montelukast 10 mg PO/NG DAILY
Pravastatin 80 mg PO QPM
PredniSONE 8 mg PO/NG DAILY
Torsemide 80 mg PO/NG DAILY
Tiotropium Bromide 1 CAP IH DAILY
Ipratropium-Albuterol Neb 1 NEB IH TID
Acetaminophen 1000 mg PO/NG Q8H
Polyethylene Glycol 17 g PO/NG DAILY
Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
Omeprazole 20 mg PO DAILY
Senna 8.6 mg PO/NG BID
Apixaban 2.5 mg PO/NG BID
Medications - PRN
Bisacodyl 10 mg PR QHS:PRN Constipation - Second Line
OxyCODONE (Immediate Release) 2.5-5 mg PO Q4H:PRN Pain
Bisacodyl 10 mg PR QHS:PRN Constipation - Second Line
--------------- --------------- --------------- ---------------
ALLERGIES:
Allergies (Last Verified ___ by ___:
atorvastatin
Citalopram
Conray
Vicodin (Hydrocodone Bitartrate/Acetaminophen)
PHYSICAL EXAM:
___ 1539 Temp: 98.3 PO BP: 114/67 R Sitting HR: 66 RR: 18
O2
sat: 99% O2 delivery: Ra
___ Urine Amt: large inc Bowel Mvmt: liquid BM
Gen: NAD, A/O x2 (hospital)
HEENT: Anicteric, PER, EOM intact, MMM, oropharynx without
erythema or exudate
Neck: no JVD
CV: irregular rhythm
Pulm: coarse breath sounds, unchanged - baseline COPD
GI: +BS, NT, ND, no organomegaly
Skin: no lesions
MSK: Warm, no edema, 2+ pedal pulses , left ankle in cast
Neuro: no focal deficits, gait not assessed
Psych: Alert, oriented to person/place, pleasant.
CAM:
1) Acute onset and fluctuating course: +
2) Inattention: +
3) Disorganized thinking: -
4) Altered level of consciousness: +
If yes to criteria 1 and 2 AND either 3 or 4, then positive for
delirium
Patient appears to have hypoactive delirium. She has baseline
dementia.
LABS/IMAGING:
___ 08:00AM BLOOD WBC: 7.9 RBC: 3.89* Hgb: 11.3 Hct: 38.2
MCV: 98 MCH: 29.0 MCHC: 29.6* RDW: 14.4 RDWSD: 51.2* Plt Ct: 241
___ 08:00AM BLOOD Glucose: 88 UreaN: 34* Creat: 1.7* Na:
148* K: 4.3 Cl: 106 HCO3: 27 AnGap: 15
___ 08:00AM BLOOD Calcium: 9.8 Phos: 4.3 Mg: 1.9
EKG: Atrial paced, no acute ST changes
___ ankle XR
IMPRESSION:
Intraoperative images were obtained during open reduction
internal fixation of
the left ankle. Please refer to the operative note for details
of the
procedure.
CXR ___: Hypoinflated lungs with bronchovascular crowding.
No
focal consolidation concerning for pneumonia.
PFTs ___: Mild obstructive ventilatory defect with a
moderate
gas exchange defect. Compared to the prior study
of ___ the DLCO has decreased by 8.48 ml/min/mmHg (-52%).
This decrease is greater than would
be expected for the change in age. Compared to the prior study
of
___ there has been no
significant change in FVC and FEV1.
ECHO ___:
Suboptimal image quality. Normal LV systolic function. Mildly
dilated RV, function difficult to assess. Mild mitral
regurgitation. Mild aortic regurgitation. Elevated PCWP.
Moderate tricuspid regurgitation. Moderate pulmonary
hypertension.
ASSESSMENT&RECOMMENDATIONS:
Ms. ___ is a an ___ woman with past medical history
of
dementia, CKD stage III, A. fib on apixaban, COPD, HFpEF, PMR,
SSS s/p PPM who presents for ORIF.
***SUMMARY OF RECOMMENDATIONS***
#Hypoactive delirium
-patient usually more energetic but today falling asleep mid
conversation
-history of dementia
-no evidence of infection
-pain improved with regimen
-having BM
-intermittently compliant with CPAP machine and has known OSA
Recommend:
-VBG to assess for hypercarbia
-encourage CPAP use throughout night
#L Ankle fracture s/p ORIF on ___
-surgery delayed because of need to hold anticoagulation for
epidural for anaesthesia
Recommend:
-resume torsemide daily
-resumed apixaban
-Tylenol 1 g tid scheduled
-continue oxycodone 2.5 mg q4h prn for moderate to
severe pain
-senna 1 tab daily, miralax daily (hold both for loose stools,
bisacodyl suppository prn
#COPD
-provided patient with incentive spirometer today and taught her
how to use it. She demonstrated use with success.
Recommend:
-continue incentive spirometer, every hr do 10 breaths
-continue duo-nebs tid
-continue Montelukast 10 mg daily
-continue tiotropium daily inh
#HFpEF
-continue carvedilol 12.5 mg bid
-continue torsemide 80 mg daily
#OSA
-she had recent sleep study and she was recommended to wear a
CPAP
-she has been refusing at home and while admitted
#CKD III
-hold nephrotoxic agents
#Dementia
-continue donepezil but change to qAM as can disrupt sleep
#PMR
-continue daily prednisone
#HLD
-continue pravastatin 80 qhs
#GERD
-continue omeprazole
#Depression
-continue sertraline 50 mg daily
#Advanced care planning
-MOLST in chart from ___ is DNR/DNI
-Daughter, ___ is HCP
The plan was discussed with the primary team in detail.
These recommendations are preliminary until reviewed by an
attending and cosigned below. Please page geriatric ___
with
questions.
To be staffed with attending Dr. ___
___, MD
___ Fellow
Pager ___
Addendum by ___, MD on ___ at 1:06 am:
On ___ I have seen, examined and was physically present
with Dr. ___ key portions of the services provided. I
agree with Dr. ___ and notes. I would add the
following remarks:
The patient was not discharged to rehab because of her lethargy.
Today she was less interactive than how she was before surgery.
She did not have any fever, chills, chest pain, SOB, GI
symptoms,
or vital sign abnormalities. During the exam, she was falling
asleep, consistent with delirium. Cardiopulmonary exam
unremarkable. Abdomen soft, BS+, nontender. Able to move her
toes and feel light touch in both legs. Given her COPD history,
we think it is important to rule out CO2 retention. Continue to
monitor her for another day.
___, MD, MPH, ___
Staff Geriatrician
Division of Gerontology, Department of ___
Tel: ___
Fax: ___
Medications on Admission:
See OMR
Discharge Medications:
1. Acetaminophen 1000 mg PO TID
for pain
2. Docusate Sodium 100 mg PO BID
3. OxyCODONE (Immediate Release) 2.5-5 mg PO Q4H:PRN Pain
RX *oxycodone [Oxaydo] 5 mg ___ tablet(s) by mouth every four
(4) hours Disp #*20 Tablet Refills:*0
4. Polyethylene Glycol 17 g PO DAILY
5. Senna 8.6 mg PO BID:PRN Constipation - First Line
6. Apixaban 2.5 mg PO/NG DAILY
7. CARVedilol 12.5 mg PO BID
8. Donepezil 5 mg PO QHS
9. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
10. Montelukast 10 mg PO DAILY
11. Omeprazole 20 mg PO DAILY
12. Pravastatin 80 mg PO QPM
13. PredniSONE 8 mg PO DAILY
14. Sertraline 50 mg PO DAILY
15. Tiotropium Bromide 1 CAP IH DAILY
16. Torsemide 80 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Left ankle fracture
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs.
Physical Therapy:
Activity: Activity: Activity as tolerated
Left lower extremity: Non weight bearing
Encourage turn, cough and deep breathe q2h when awake
Treatments Frequency:
Any staples or superficial sutures you have are to remain in
place for at least 2 weeks postoperatively. Incision may be
left open to air unless actively draining. If draining, you may
apply a gauze dressing secured with paper tape. You may shower
and allow water to run over the wound, but please refrain from
bathing for at least 4 weeks postoperatively.
Followup Instructions:
___
|
19717536-DS-6
| 19,717,536 | 23,365,032 |
DS
| 6 |
2199-08-24 00:00:00
|
2199-08-28 22:01:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Conray / Citalopram / Vicodin / atorvastatin
Attending: ___.
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ PMHx atrial fibrillation on xarelto, tachy-brady syndrome
s/p PPM, CKD, HTN, COPD (FEV1 67% in ___, and moderate
dementia who presented with dyspnea.
She has had a runny nose and productive cough x 1 week. She also
had subjective fevers at home. Per family, she's also has sweats
for several weeks to months. This morning, she was brought to
the hospital due to increasing dyspnea. She has no symptoms of
orthopnea per her family. They deny any edema or weight loss or
gain. She was born in the ___ and has never traveled
abroad.
Of note, she was admitted to ___ in late ___ for
community acquired PNA. Blood cultures were negative, no sputum
culture was done.
In the ED, initial vitals: 98.9 66 149/57 20 100% Nasal Cannula.
Tmax was 100.0. Labs were significant for leukocytosis to 18.0,
troponin < 0.01, creatinine at 1.5 (near baseline), lactate 2.1,
proBNP: 794 (prior 453).
CXR showed patchy airspace opacities in the left lung base may
reflect atelectasis but infection is not excluded. Mild
pulmonary vascular congestion.
In the ED, she received 1g IV ceftriaxone, 500mg IV
azithromycin, 125mg IV solumedrol, and 324mg PO aspirin
Vitals prior to transfer: T 99.9, HR 67, BP 134/63, RR 22, 96%
Nasal Cannula
ROS:
No fevers, chills, or weight changes. No changes in vision or
hearing, no changes in balance. 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:
Memory Loss: MOCA ___ on ___
Depression: on sertraline since ___, dose increased
___
Insomnia
CKD
Rotator Cuff Tear
Atrial Fibrillation on warfarin
HLD
COPD
Diastolic CHF: on torsemide
HTN
Osteopenia: Last DEXA ___
Pre-DM
Osteoarthritis
Lumbago
Valvular Heart Disase: TR and diastolic dysfunction
OSA: CPAP use periodically
Sick Sinus Syndrome s/p PPM
Gait disorder
PMR on prednisone
Elevated CK
Pulmonary Nodule: no further f/u needed
Thyroid Nodule: followed by endocrine
Hemorrhoids
Gastric Polyps
Glaucoma
Hyperparathyroidism
Social History:
___
Family History:
Sister with HTN
Physical Exam:
PHYSICAL EXAM ON ADMISSION:
=====================================
VS: T 98.9 BP 162/75 HR 69 RR 25 02 sat: 100% 2L
GEN: Alert, diaphoretic, tachypneic,
HEENT: Moist MM, anicteric sclerae, no conjunctival pallor
NECK: Supple without LAD, JVP difficult to assess
PULM: Diffusely rhoncorous, no crackles.
COR: RRR (+)S1/S2 no m/r/g
ABD: Soft, non-tender, non-distended
EXTREM: Warm, well-perfused, no edema
NEURO: CN II-XII grossly intact, motor function grossly normal
PHYSICAL EXAM ON DISCHARGE:
=========================================
Vitals: 97.9 134/47 66 20 97 RA
I/O: ___
General: alert, knows she's at ___.
HEENT: pinpoint pupils, sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP flat
PULM: good air movement, minimal wheezing bilaterally
COR: RRR (+)S1/S2, soft holosystolic murmur heard over apex
ABD: Soft, non-tender, non-distended. no ttp over epigastrium.
EXTREM: Warm, well-perfused, pitting edema to ankles. R arm with
mild redness at PIV site, but soft to touch.
NEURO: CN II-XII grossly intact, motor function grossly normal
Pertinent Results:
LABS ON ADMISSION:
================================
___ 01:50PM BLOOD WBC-18.0*# RBC-4.17 Hgb-12.1 Hct-37.2
MCV-89 MCH-29.0 MCHC-32.5 RDW-14.1 RDWSD-45.5 Plt ___
___ 01:50PM BLOOD Plt ___
___ 01:50PM BLOOD Glucose-95 UreaN-19 Creat-1.5* Na-142
K-5.1 Cl-102 HCO3-29 AnGap-16
___ 01:50PM BLOOD ALT-12 AST-36 LD(LDH)-639* AlkPhos-58
TotBili-0.8
___ 01:50PM BLOOD cTropnT-<0.01 proBNP-794*
___ 01:50PM BLOOD Albumin-3.4*
___ 01:50PM BLOOD TSH-0.71
___ 08:25AM BLOOD Calcium-9.4 Phos-3.9 Mg-2.2 UricAcd-8.6*
___ 12:11AM BLOOD ___ pO2-62* pCO2-52* pH-7.32*
calTCO2-28 Base XS-0
___ 08:25AM BLOOD CRP-176.0*
LABS ON DISCHARGE:
=================================
___ 09:20AM BLOOD LD(LDH)-347*
___ 09:20AM BLOOD PEP-TRACE ABNO IgG-1260 IgA-297 IgM-67
IFE-MONOCLONAL
___ 08:25AM BLOOD WBC-11.1* RBC-3.68* Hgb-10.8* Hct-33.0*
MCV-90 MCH-29.3 MCHC-32.7 RDW-14.6 RDWSD-47.5* Plt ___
___ 08:25AM BLOOD Plt ___
___ 08:25AM BLOOD Glucose-94 UreaN-43* Creat-1.5* Na-145
K-4.6 Cl-105 HCO3-30 AnGap-15
___ 08:25AM BLOOD Calcium-9.3 Phos-4.3 Mg-2.4
___ 06:50AM BLOOD Hapto-216*
Brief Hospital Course:
**THIS PATIENT WILL NEED LESS THAN 30 DAYS OF REHAB**
Ms. ___ is a ___ PMHx atrial fibrillation on xarelto,
tachy-brady syndrome s/p PPM, CKD, HTN, COPD, who presented with
productive cough and dyspnea concerning for COPD exacerbation
superimposed with pneumonia. Her course was complicated by
transient episodes of SVT, likely atrial tachycardia and
hyperkalemia.
#Dyspnea, COPD exacerbation: Presented with cough, dyspnea x 1
week. In ED, her O2 sat was 100% NC, Tmax 100. Exam was notable
for diffusely rhoncorous lungs. VBG 7.32/62/52/28. Initial CXR
with possible consolidation. BNP was 794. Initially there was
concern for HCAP (hospitalization w/n 90 days for pneumonia) and
she was treated with Vancomycin/Cefepime. On hospital day 2, she
had minimal cough and significant wheezing and her exam was more
consistent with COPD exacerbation. She was weaned off oxygen.
She was treated with frequent duonebs, advair, montelukast (home
medication). She received a 5-day burst of prednisone
(40-40-60-60-60mg) from ___. She also received levaquin
from ___, which was stopped due to low concern for
pneumonia. Her exam showed interval improvement in wheezing and
she was discharged to pulmonary rehab for further recovery. Her
outpatient pulmonologist recently did a CT trachea which raised
concern for upper airway disease. She is scheduled to follow in
___ clinic for further evaluation.
___: Her Cr was 3.2 on ___ and downtrended to 1.5 on discharge
(1.5 is her baseline). She had good urine output throughout. Per
urine lytes on ___ showed FeNa <1% suggestive of pre-renal
etiology. It was thought that her ___ was secondary to low
effective circulating volume in setting of fluid losses while
being on valsartan. She had no evidence on physical exam for
worsening heart failure. Bladder scan and PVR showed complete
emptying, so her ___ was unlikely to be post-renal. In addition,
there could have been a contribution from vancomycin which she
received on admission. Her Cr improved with IV fluids and
holding home Torsemide. Given her changing kidney function,
xarelto was briefly stopped and she was anticoagulated with
heparin. On ___, she was restarted on xarelto 15 mg. Her
xarelto dose can be uptitrated by primary care provider, as
needed, based on kidney function. She was re-started on home
dose Torsemide 10 mg PO daily on ___. Valsartan dose was
decreased from 320 mg to 160 mg given ___ and hyperkalemia.
# Hyperkalemia: K 5.5 on ___ and 5.7 on ___. Improved with
insulin 10 u x1 and kayexelate. Thought to be elevated in
setting of ___. She'd had elevated LDH, uric acid however, H&H
stable. Haptoglobin 216. On discharge, her K was 4.8. She should
have chem7 checked on ___, to make sure her potassium
is stable.
#Elevated LDH, uric acid: unclear etiology. H&H stable and
haptoglobin is not low, so doesn't appear to be hemolysis. Given
her subacute symptoms of night sweats, occult malignancy is on
our differential. CT Trachea done recently didn't show any
mediastinal or hilar LAD. SPEP with trace abnormal band seen in
gamma region based on IFE. UPEP neg. Consider CT Abd/Pel as
outpatient
#SVT: now resolved, seen on tele on ___, likely i/s/o more
frequent albuterol nebs. Per Cards, appears to be atrial
tachycardia. Pt notes occasional palpitations, but no other
symptoms. No further events on tele, HRs in ___. Metoprolol
succinate was discontinued and she was placed on carvedilol
6.25mg BID.
# Atrial Fibrillation: CHADS of 3. Restarted on xarelto 15mg on
___. Carvedilol 6.25mg BID for rate control.
# CHF: history of diastolic CHF, on 10mg torsemide at home. Does
not endorse orthopnea, no evidence of significant volume
overload on exam. BNP 794. Restarted on Torsemide 10 mg on ___.
# HTN:
- continue amlodipine, valsartan dose decreased to 160 mg. Also
started on carvedilol 6.25mg BID during this admission.
# HLD: continued on home dose pravastatin
# PMR: Came in on 6mg prednisone, which was supposed to be
tapered down. However, she required higher dose prednisone x5
days for COPD exacerbation. She was discharged on 6mg prednisone
and can follow up in ___ clinic for continued taper.
# Iron Deficiency Anemia: Continue ferrous sulfate
# OSA: prescribed for CPAP at home.
========
Transitional issues:
1. Needs chem7 checked on ___, to check her K+ level.
2. Resumed on xarelto 15 mg
3. Decreased valsartan dose from 320mg to 160 mg daily
4. Discontinued metroprolol succinate and restarted on
carvedilol 6.25mg BID.
5. Taking prednisone 6mg for PMR at time of admission. She was
supposed to be on taper. She got 5-day burst of prednisone
(40-40-60-60-60mg) in the hospital. She is being discharged on
6mg and will need to follow up in ___ clinic for
tapering.
7. She has had night sweats for the past few months. Labs showed
elevated LDH (639) and uric acid (10.0). Hematocrit was stable.
CT Trachea done recently didn't show mediastinal or hilar LAD.
Please SPEP trace abnormal band seen in gamma region. UPEP was
negative for protein. She should get a CT Abd/Pel as an
outpatient within ___ months (discussed with Dr. ___
PCP).
8. CT Trachea prior to admission showed narrowed upper airway.
She has ___ clinic follow up for further evaluation.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler 2 PUFF IH Q6H:PRN shortness of breath
2. amLODIPine 10 mg PO DAILY
3. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation
inhalation BID
4. Montelukast 10 mg PO DAILY
5. Pravastatin 80 mg PO QPM
6. PredniSONE 6 mg PO DAILY
Tapered dose - DOWN
7. Sertraline 50 mg PO DAILY
8. Torsemide 10 mg PO DAILY
9. Valsartan 320 mg PO DAILY
10. Calcitrate-Vitamin D (calcium citrate-vitamin D3) 315mg-200u
oral DAILY
11. Vitamin D 1000 UNIT PO DAILY
12. Ferrous Sulfate Dose is Unknown PO DAILY
13. melatonin 5 mg oral DAILY
14. Rivaroxaban 15 mg PO DAILY
15. Metoprolol Succinate XL 50 mg PO DAILY
Discharge Medications:
1. Carvedilol 6.25 mg PO BID
2. Polyethylene Glycol 17 g PO DAILY:PRN Constipation
3. Ferrous Sulfate 325 mg PO DAILY
4. Valsartan 160 mg PO DAILY
5. Albuterol Inhaler 2 PUFF IH Q6H:PRN shortness of breath
6. amLODIPine 10 mg PO DAILY
7. Calcitrate-Vitamin D (calcium citrate-vitamin D3) 315mg-200u
oral DAILY
8. melatonin 5 mg oral DAILY
9. Montelukast 10 mg PO DAILY
10. Pravastatin 80 mg PO QPM
11. PredniSONE 6 mg PO DAILY
Tapered dose - DOWN
12. Rivaroxaban 15 mg PO DAILY
13. Sertraline 50 mg PO DAILY
14. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation
INHALATION BID
15. Torsemide 10 mg PO DAILY
16. Vitamin D 1000 UNIT PO DAILY
17.CPAP Precription
CPAP Prescription: ICD-9 CODE 490 COPD. Autoset CPAP: Minimum 4
Maximum 20.
Discharge Disposition:
Extended Care
Facility:
___
___ Rehabilitation and Sub-Acute Care)
Discharge Diagnosis:
PRIMARY DIAGNOSES:
COPD exacerbation
Acute kidney injury
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Ms. ___,
You were admitted to ___ from ___ for difficulty
breathing. We diagnosed you with a COPD flare. You were treated
with oxygen, inhalers, and steroids. At first, there was concern
that you may have a lung infection as well, so you got
antibiotics. During the admission, your kidney function got
worse because you were dehydrated. We treated this with IV
fluids. We stopped xarelto, your blood thinning medicine, for a
while until your kidney function improved. You were then
re-started on xarelto before leaving the hospital. It is very
important to take this medicine. You should also continue to
take your COPD inhalers.
As a separate issue, we also noted that you've been having night
sweats for a couple months. You will need to see your primary
doctor (___) for further work up.
For better blood pressure and heart rate control, we
discontinued metoprolol and started you on a new medicine called
carvedilol. We also halved your valsartan dose to 160mg daily.
We are also sending you home on prednisone 6 mg for polymyalgia
rheumatica (PMR). You will need to see your doctor who will
decrease the dose over time.
Thank you for letting us be a part of your care!
-Your ___ Team
Followup Instructions:
___
|
19717773-DS-12
| 19,717,773 | 28,922,574 |
DS
| 12 |
2185-05-11 00:00:00
|
2185-05-12 10:08:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
Codeine / Percocet / Pollen/Hayfever / Soap / adhesive tape /
prednisone
Attending: ___.
Chief Complaint:
retro-orbital headache
Major Surgical or Invasive Procedure:
N/A
History of Present Illness:
___ is a ___ year-old female with history of
diverticulitis and migraine who presents with retro-orbital
headache and was found to have a right superior ophthalmic vein
thrombosis.
She initially presented to ___ on ___ with incoherent
speech and left frontal headache. Reportedly, her symptoms
resolved in about 5 minutes. She had a CT scan that was
unremarkable and was scheduled to get an outpatient MRI of the
brain outpatient, and this was also largely unrevealing.
She presented again to ___ on ___ with vague
complaints
after spending some time in a hot house with no air
conditioning.
She said that "I just feel sick". She had a repeat noncontrast
CT had, which showed enlargement of the right superior
ophthalmic
vein. CTA was obtained, which confirmed this abnormality. She
was then transferred to ___ for additional
management.
Patient is a very poor historian; however, she states that she
has been having headaches for at least 3 to 7 days. She is
unsure if initially her headache was more consistent with her
previous migraines. However, she now believes her headaches are
different. She initially had right retro-orbital throbbing pain
that was slightly worse with eye movement. She is now started
to
have pain behind the left eye as well. She denies auras. She
is
unsure about photophobia or phonophobia. She denies visual loss
and photopsia, but she does note intermittent floaters.
On neurologic ROS, the pt denies headache, loss of vision,
blurred vision, diplopia, dysarthria, dysphagia,
lightheadedness,
vertigo, tinnitus or hearing difficulty. Denies difficulties
producing or comprehending speech. Denies focal weakness,
numbness, parasthesiae. No bowel or bladder incontinence or
retention. Denies difficulty with gait.
On general review of systems, the pt denies recent fever or
chills. No night sweats or recent weight loss or gain. Denies
cough, shortness of breath. Denies chest pain or tightness,
palpitations. Denies nausea, vomiting, diarrhea, constipation
or
abdominal pain. No recent change in bowel or bladder habits.
No
dysuria. Denies arthralgias or myalgias. Denies rash.
Past Medical History:
AWB DONATION
Social History:
___
Family History:
No pertinent family history of neurological disorders.
Physical Exam:
ADMISSION EXAM:
===============
Vitals: Stable
General: Awake, cooperative, NAD.
HEENT: Right conjunctive injected with left nasal inferior
portion of conjunctive a suffused with a small amount
hemorrhage.
Neck: Supple, no nuchal rigidity
Pulmonary: Non-labored breathing on ambient air
Cardiac: RRR, no MRG.
Abdomen: Soft, NT/ND, no masses or organomegaly noted.
Extremities: Warm, well-perfused, no cyanosis, clubbing or edema
bilaterally
Skin: no rashes or lesions noted.
NEUROLOGIC:
-----------
-Mental Status:
Appears alert, but subjectively drowsy. Language is fluent
without errors. Patient has difficulty recounting her medical
history. She forgets many details and does not give a linear
account she has no difficulty with months of the year backwards.
Is right eye ___
-Cranial Nerves:
I: Olfaction not tested.
II: OD 3 to 2 mm; ___. OS 4 to 3 mm ___. VFF to
confrontation
with finger counting. Fundoscopic exam performed, revealed crisp
disc margins with no papilledema, exudates, or hemorrhages.
III, IV, VI: Full range, conjugate gaze, no nystagmus. Normal
saccades.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor:
Normal bulk, tone throughout. No pronator drift bilaterally.
No adventitious movements, such as tremor, noted. No asterixis
noted.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 5 ___ 5 ___ 5 5 5 5 5
R 5 ___ 5 ___ 5 5 5 5 5
-Sensory:
No deficits to light touch, pinprick, cold sensation,
proprioception throughout. No extinction to DSS.
-Reflexes:
Bi Tri ___ Pat Ach
L 2 2 2 2 1
R 2 2 2 2 1
Plantar response was flexor bilaterally.
-Coordination:
No intention tremor, no dysdiadochokinesia noted. No dysmetria
on
FNF or HKS bilaterally.
-Gait:
Good initiation. Narrow-based, normal stride and arm swing.
Able
to walk in tandem without difficulty. Romberg absent.
DISCHARGE EXAM:
===============
General: Awake, lying comfortably in bed. NAD
HEENT: No conjunctival injection
Pulmonary: Non-labored breathing on ambient air
Cardiac: Warm and well-perfused
Neurologic:
-Mental Status:
Alert and oriented to self, location, and date. Attentive to
interview. Language is fluent without paraphrasic errors.
-Cranial Nerves:
II, III, IV, VI: PERRL, 3 --> 2mm. VFF, EOMI with no nystagmus.
Bilateral acuity ___ that corrects to ___ with pinhole.
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.
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally.
-Sensory: No deficits to light touch throughout. No extinction
to
DSS.
-Reflexes: Deferred
-Coordination: Deferred
-Gait: Deferred
Pertinent Results:
ADMISSION LABS:
___ 04:20AM BLOOD WBC-6.6 RBC-4.31 Hgb-11.8 Hct-37.4 MCV-87
MCH-27.4 MCHC-31.6* RDW-15.1 RDWSD-48.0* Plt ___
___ 04:20AM BLOOD Neuts-63.1 ___ Monos-14.7*
Eos-1.5 Baso-0.3 Im ___ AbsNeut-4.16 AbsLymp-1.33
AbsMono-0.97* AbsEos-0.10 AbsBaso-0.02
___ 04:20AM BLOOD Plt ___
___ 06:40AM BLOOD ___ PTT-27.3 ___
___ 04:20AM BLOOD Glucose-94 UreaN-17 Creat-1.1 Na-142
K-4.4 Cl-108 HCO3-21* AnGap-13
HYPERCOAG LAB WORKUP:
___ 02:25PM BLOOD Lupus-NOTDETECTE dRVVT-S-0.96 SCT-S-0.74
___ 02:25PM BLOOD ProtCFn-PND ProtSFn-PND
___ 04:20AM BLOOD ___ CRP-3.5
___ 04:43PM BLOOD SED RATE-Test
___ 02:25PM BLOOD BETA-2-GLYCOPROTEIN 1 ANTIBODIES (IGA,
IGM, IGG)-PND
___ 02:25PM BLOOD CARDIOLIPIN ANTIBODIES (IGG, IGM)-PND
___ 02:25PM BLOOD ANTITHROMBIN ANTIGEN-PND
DISCHARGE LABS:
___ 05:10AM BLOOD WBC-5.9 RBC-4.21 Hgb-11.5 Hct-36.1 MCV-86
MCH-27.3 MCHC-31.9* RDW-15.0 RDWSD-46.8* Plt ___
___ 05:10AM BLOOD Plt ___
___ 05:10AM BLOOD ___ PTT-62.1* ___
___ 05:10AM BLOOD Glucose-129* UreaN-19 Creat-1.0 Na-145
K-4.4 Cl-107 HCO3-23 AnGap-15
___ 05:10AM BLOOD Calcium-9.1 Phos-4.2 Mg-2.1
MR HEAD W&W/O:
1. Dilated right superior ophthalmic vein with a large filling
defect
compatible with thrombosis.
2. Diminished enhancement of the right cavernous sinus lateral
to the
cavernous portions of the internal carotid arteries with a
questionable
filling defect lateral and superior to the right ICA, possibly
representing extension of thrombosis into the right cavernous
sinus.
3. Questionable central filling defect in the left superior
ophthalmic vein. Small thrombus is not excluded.
4. Paranasal sinus disease as detailed above.
CT A/P:
1. No specific evidence of malignancy in the abdomen or pelvis.
2. Few scattered high subcentimeter hypodense lesions in the
liver are too
small to characterize, but statistically likely represent cysts
or biliary hamartomas.
3. Please refer to the separate report of CT chest performed on
the same day for description of the thoracic findings.
CT CHEST:
1. Multiple pulmonary nodules measuring up to 5 mm, are
indeterminate.
2. No evidence of intrathoracic lymphadenopathy.
3. Multinodular thyroid gland with the largest thyroid nodule
measuring up to 1.6 cm.
RECOMMENDATION(S): A follow-up chest CT in 3 months is
recommended.
Thyroid nodule. Follow up recommended.
Absent suspicious imaging features, unless there is additional
clinical
concern, ___ College of Radiology guidelines do not
recommend further
evaluation for incidental thyroid nodules less than 1.0 cm in
patients under age ___ or less than 1.5 cm in patients age ___ or
___.
Brief Hospital Course:
TRANSITIONAL ISSUES
=======
[] Requires follow-up for hypercoagulable labs. See pending
above. Also will need prothrombin gene mutation, Factor V Leiden
and homocysteine.
[] Requires ongoing follow-up for INR monitoring and warfarin
dosing. Goal INR ___.
[] Requires follow-up chest-CT in 3 months due to multiple
pulmonary nodules up to 5mm and a multinodular thyroid gland
with a thyroid nodule.
SUMMARY
=======
Ms. ___ is an ___ woman with history of migraine and
diverticulitis who presented with a progressively worsening
retro-orbital headache and was found to have a right superior
ophthalmic vein thrombosis.
#Superior ophthalmic vein thrombosis
Ms. ___ presented with a right retro-orbital headache and
right eye pain worsened by extra-ocular eye movements. She was
found to have a right superior ophthalmic vein thrombosis on CTA
and MRI. Initial neurological exam was notable for anisocoria
with intact pupillary light reflex, and right conjunctival
injection with small amount of hemorrhage. CT-CHEST and
CT-ABDOMEN showed no evidence of malignancy. Hypercoagulability
labs (APLS, antithrombin antigen) are still pending. Improvement
was noted after initiation of heparin. She was discharged with a
lovenox bridge to warfarin, with goal INR ___. She had no
headache on discharge. Exam was notable for pupils 3->2, full
eye movements, full gross fields to digits and visual acuity: ___
___ -> ___ with correction. Optho follow-up scheduled for 2
days within discharge. Anticoagulation and follow-up arranged
with her PCP ___.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. ALPRAZolam 0.25-0.5 mg PO QHS:PRN insomnia
2. Atorvastatin 10 mg PO QPM
3. Betamethasone Dipro 0.05% Cream 1 Appl TP DAILY
4. Celecoxib 200 mg oral BID:PRN knee pain
5. Levothyroxine Sodium 75 mcg PO DAILY
6. Omeprazole 20 mg PO DAILY
7. Chlorpheniramine Maleate 8 mg PO BID
Discharge Medications:
1. Enoxaparin Sodium 60 mg SC BID
Start: ___, First Dose: Next Routine Administration Time
RX *enoxaparin 80 mg/0.8 mL 0.7 mL subcutaneous once a day Disp
#*14 Syringe Refills:*0
RX *enoxaparin 60 mg/0.6 mL 0.6 mL subcutaneous twice a day Disp
#*14 Syringe Refills:*0
2. Warfarin 5 mg PO DAILY16
RX *warfarin 5 mg 1 tablet(s) by mouth once a day Disp #*14
Tablet Refills:*0
3. Atorvastatin 10 mg PO QPM
4. Omeprazole 20 mg PO DAILY
5. ALPRAZolam 0.25-0.5 mg PO QHS:PRN insomnia
6. Betamethasone Dipro 0.05% Cream 1 Appl TP DAILY
7. Celecoxib 200 mg oral BID:PRN knee pain
8. Chlorpheniramine Maleate 8 mg PO BID
9. Levothyroxine Sodium 75 mcg PO DAILY
10.Outpatient Lab Work
INR
ICD-10: ___
___, MD: FAX ___
11.Outpatient Lab Work
Homocysteine, Factor V Leiden, Prothrombin Gene Mutation
ICD-10: ___.___
___, MD: FAX ___
Discharge Disposition:
Home With Service
Facility:
___
___ Address: ___ischarge Diagnosis:
Superior ophthalmic vein thrombosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were hospitalized due to symptoms of right-sided headache
and eye pain resulting from a SUPERIOR OPHTHALMIC VEIN
THROMBOSIS, a condition where a blood vessel behind your eye was
blocked by a clot.
Thrombosis can have many different causes, so we assessed you
for medical conditions that may raise your risk of having a
clot. In order to prevent future clots, we plan to modify those
risk factors by giving you a blood-thinner called warfarin
(Coumadin).
We are changing your medications as follows:
- START Warfarin (Coumadin) 5mg daily (for blood thinning)
- START Enoxaparin (Lovenox) 70mg daily (for blood thinning)
until your INR blood test is at the correct level.
Please take your other medications as prescribed.
Please follow up with Neurology and your primary care physician
as listed below.
You need to have your INR checked (blood test) tomorrow,
___. Please come to the ___ lab (or a lab of your choice)
to have your blood checked. The result will be faxed to Dr. ___
___ will advise you regarding warfarin dosing.
If you experience any of the symptoms below, please seek
emergency medical attention by calling Emergency Medical
Services (dialing 911). In particular, since stroke can recur,
please pay attention to the sudden onset and persistence of
these symptoms:
- Sudden partial or complete loss of vision
- Sudden loss of the ability to speak words from your mouth
- Sudden loss of the ability to understand others speaking to
you
- Sudden weakness of one side of the body
- Sudden drooping of one side of the face
- Sudden loss of sensation of one side of the body
Sincerely,
Your ___ Neurology Team
Followup Instructions:
___
|
19718654-DS-9
| 19,718,654 | 24,146,921 |
DS
| 9 |
2188-01-24 00:00:00
|
2188-01-24 15:01:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Shortness of breath.
Major Surgical or Invasive Procedure:
1. T5, T6, T7 posterior laminectomy, medial facetectomy,
and foraminotomy for intraspinal extradural lesion.
2. Biopsy, intraspinal extradural lesion, T6.
3. Open treatment, fracture-dislocation T5-6 and T6-7.
4. Posterior instrumentation, T4-T9.
5. Posterior arthrodesis, T4-T9.
6. Application of allograft and autograft.
7. Spinal cord monitoring.
History of Present Illness:
Mr ___ is a ___ year-old gentleman with severe back pain since
yesterday. He was seen by PCP who took an X-Ray of his thoracic
spine which demonstrated a T6 compression fracture. He was given
pain medication for conservative management but had a sudden
onset of leg weakness while navigating stairs at home. He fell
and was subsequently sent to ___ with new onset of
lower extremity weakness and paresthesias in both of his lower
extremities and retention of urine. He was transferred to ___
for urgent Orthopaedic Surgery evaluation due to concern for
cauda equina syndrome.
Past Medical History:
1. Severe COPD on 3L of home oxygen and steroid dependent
followed by Dr. ___.
2. Recurrent aspiration pneumonia in the setting of GERD and
poor diet compliance.
3. Diastolic congestive heart failure with an ejection fraction
of 65%, 3+ tricuspid regurgitation, elevated pulmonary artery
pressures on his echo from ___. Dry weight approximately
213lb
4. Hypertension.
5. Hyperlipidemia.
6. A complex psychiatric history that includes insomnia from
coughing on high doses of trazodone and sertraline.
7. Neuropathy on gabapentin.
8. GERD. Most recent workup for aspiration was done ___
where a modified barium swallow was overall unremarkable.
9. History of paroxysmal atrial fibrillation, but was never
confirmed on EKG or telemetry.
11. Hyperglycemia while on steroids.
12. Lumbar decompression and fusion in ___
Social History:
___
Family History:
not obtained
Physical Exam:
Physical Exam on Presentation:
AVSS
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: normal EOMs
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Motor:
D B T WE WF IP Q H AT ___ G
R ___ 4 4
L ___ 3 3
Sensation: Decreased Sensation in entire left lower extremity
with nospecific distribution. Decreased senstation on lasteral
aspect of thigh on right lower extremity.
Decreased perianal sensation.
Reflexes: B T Br Pa Ac
Right absent
Left absent
Propioception diminished
Toes mute billaterally
Rectal exam decreased sphincter control
Physical Exam on Discharge:
VS: T98.2, HR101, BP126/77, RR20, O2sat 95% 3LNC
Lungs: Coarse breath sounds and wheeze intermittantly throughout
lung fields
Heart: Irregular Rhythm, no M/R/G
Neuro: strength ___ bilateral lower extremities, proximally and
distally, sensation to light touch intact
Exam otherwise unchanged from admission.
Pertinent Results:
Lab Results on Presentation:
___ 09:24AM BLOOD WBC-5.4 RBC-3.82* Hgb-10.4* Hct-34.4*
MCV-90 MCH-27.2 MCHC-30.1* RDW-15.8* Plt ___
___ 09:24AM BLOOD Neuts-79.5* Lymphs-13.3* Monos-5.8
Eos-0.6 Baso-0.8
___ 12:18PM BLOOD ___ PTT-24.4* ___
___ 09:24AM BLOOD Glucose-115* UreaN-28* Creat-0.9 Na-144
K-4.1 Cl-103 HCO3-34* AnGap-11
___ 05:10AM BLOOD Calcium-7.9* Phos-2.8 Mg-1.9
___ 08:40PM BLOOD Type-ART pO2-348* pCO2-48* pH-7.45
calTCO2-34* Base XS-8 Intubat-INTUBATED Vent-CONTROLLED
___ 08:40PM BLOOD Glucose-76 Lactate-1.0 Na-141 K-3.9
Cl-102
___ 08:40PM BLOOD Hgb-10.3* calcHCT-31 O2 Sat-98
___ 08:40PM BLOOD freeCa-1.13
___ 09:24AM URINE Color-Yellow Appear-Clear Sp ___
___ 09:24AM URINE Blood-NEG Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
___ 09:24AM URINE RBC-0 WBC-0 Bacteri-NONE Yeast-NONE
Epi-<1
Pathology:
Date of Procedure: ___ ___ #: ___
Date Specimen(s) Received: Patient Location: OR ___
___
Date Reported: ___ Ordering Provider: ___,
___
Responsible Provider: ___
___, ___
Assigned Pathologist: ___
___,
___
SURGICAL PATHOLOGY REPORT - Final
PATHOLOGIC DIAGNOSIS:
Epidural tissue, T6, removal (A):
Adipose tissue and dense connective tissue; bone fragments.
Imaging:
Radiology Report MR ___ SPINE W/O CONTRAST Study Date of
___ 7:14 AM
Radiology Report MR THORACIC SPINE W/O CONTRAST Study Date of
___ 7:14 AM
IMPRESSION:
1. No cord signal abnormality throughout.
2. Acute T6 compression deformity with mild retropulsion
deforming the
underlying cord. Contact is increased greater than expected by
mild
retropulsion due to anterior displacement of cord by multilevel
epidural
lipomatosis which is focally pronounced. Focality of fat at this
level is
unusual, and cannot rule out a small fatty herniation into the
thecal sac or
possibly a small epidural hematoma.
3. T8 compression deformity, age indeterminate, but likely
remote with mild
retropulsion. again, though milder, focal epidural fat pushes
the cord
anteriorly increasing the degree of contact
4. L3-L5 posterior fusion w/ laminectomy with fluid signal in L4
disc
suggesting discetomy. edema w/in surgical bed suggests surgery
was recent.
5. multilevel degenerative change as detailed above
Radiology Report CT T-SPINE W/O CONTRAST Study Date of
___ 2:00 ___
FINDINGS:
1. Mild compression fracture of the T6 vertebral body with
minimal
retropulsion and central canal narrowing, new from ___, but likely
present on ___ radiographs suggesting that this is
subacute.
2. Mild to moderate compression deformities of T5 and T8,
unchanged from
___.
3. Severe emphysema and pulmonary arterial hypertension.
Radiology Report CT L-SPINE W/O CONTRAST Study Date of
___ 2:01 ___
IMPRESSION: Status post posterior fusion from L3 to L5. No
evidence of acute fracture, subluxation, or hardware
complications. Paraspinal soft tissue edema at L4 level, as seen
on the MRI from today.
Radiology Report MR CERVICAL SPINE W/O CONTRAST Study Date of
___ 3:13 ___
IMPRESSION:
1. No evidence of cord compression or abnormal cord signal.
2. Multilevel degenerative changes of the cervical spine with
disc bulges, neural foraminal narrowing, and ligamentum flavum
thickening as described above.
Radiology Report LUMBAR SP,SINGLE FILM IN O.R. Study Date of
___ 8:03 ___
REPORT:
Multiple images were obtained without radiologist present.
These show an existing posterior fusion at L3 through L5.
There is a compression fracture at approximately T8 through
which some spinal markings and posterior transpedicular screws
are placed and ultimately multilevel mid thoracic posterior
transpedicular screws have been placed, probably in anticipation
of laminectomy, although it is uncertain whether this has been
performed. For further details, please refer to the operative
note.
Radiology Report CHEST (PORTABLE AP) Study Date of ___
1:19 AM
IMPRESSION: AP chest compared to ___:
In the interim, patient has had spinal stabilization. New
intended left
internal jugular line passes behind the left clavicle and
surgical device, out of view. Tip probably does not enter the
transverse portion of the left brachiocephalic vein.
ET tube is in standard placement ending at the thoracic inlet.
Lung volumes are very low, but left lung appears clear aside
from mild basilar atelectasis. On the right, atelectasis is
much more severe and there is probably lower lobe collapse,
perhaps middle lobe collapse as well, and if they are
accompanied by small right pleural effusion that would be
unremarkable. There is no pneumothorax. Heart size is
indeterminate but not substantially enlarged.
Radiology Report CHEST (PORTABLE AP) Study Date of ___
5:17 AM
FINDINGS: Comparison is made to prior study from ___.
Spinal hardware is seen in the thoracic spine. There is
improved aeration of the right middle lobe. There remains some
atelectasis at the lung bases. There is unchanged cardiomegaly.
No focal consolidation or pleural effusions are seen.
Radiology Report CTA CHEST W&W/O C&RECONS, NON-CORONARY Study
Date of ___ 2:29 ___
IMPRESSION:
1. No acute pulmonary embolus seen.
2. Dilated pulmonary arteries consistent with pulmonary
arterial
hypertension, unchanged compared to the prior study.
3. Right lower lobe consolidation concerning for pneumonia,
potentially
aspiration pneumonia in the appropriate clinical circumstances.
ECG:
Cardiovascular Report ECG Study Date of ___ 4:24:58 ___
Baseline artifact. Probable sinus tachycardia with premature
atrial
contractions. Compared to the previous tracing of ___
ectopy is new.
TRACING #1
Cardiovascular Report ECG Study Date of ___ 10:35:06 AM
Sinus tachycardia. Arm lead reversal. Occasional premature
atrial
contractions. Compared to the previous tracing no clear change.
TRACING #2
Lab Results on Discharge:
___ 09:08AM BLOOD WBC-9.1 RBC-3.37* Hgb-9.3* Hct-30.4*
MCV-90 MCH-27.7 MCHC-30.8* RDW-15.5 Plt ___
___ 05:00AM BLOOD Glucose-147* UreaN-25* Creat-0.6 Na-144
K-4.4 Cl-104 HCO3-34* AnGap-10
___ 06:51PM BLOOD cTropnT-<0.01
___ 11:37AM BLOOD CK-MB-2 cTropnT-<0.01
___ 05:00AM BLOOD Calcium-8.4 Phos-2.9 Mg-2.3
___ 08:14AM BLOOD Type-ART Temp-37.1 pO2-95 pCO2-51*
pH-7.45 calTCO2-37* Base XS-9 Intubat-NOT INTUBA
___ 08:14AM BLOOD Lactate-1.2
___ 10:22PM BLOOD Hgb-8.7* calcHCT-26
___ 04:33PM BLOOD freeCa-1.05*
Brief Hospital Course:
PRIMARY REASON FOR HOSPITALIZATION:
Mr. ___ is a ___ male with PMH of COPD on home O2, chronic
prednisone, and azithromycin, dCHF, recurrent aspiration
pneumonias, and COPD on nightly Bipap who is ___ s/p T4-T9
decompression and fusion for acute T6 compression fracture with
significant neurologic compromise. He initially had a prolonged
PACU stay for post-op respiratory decompensation and was
transferred to medicine for ongoing managment of COPD in the
post-op setting once stable. On the medicine service, he was
given a pulse dose of steroids and returned to his home COPD
regiment. He clinically improved and was transferred to rehab to
complete recovery.
ACUTE CARE
#T6 acute Compression Fracture: Mr. ___ experienced a day of
severe low back pain and his PCP discovered ___ T6 compression
fracture on CXR without neurologic compromise. He later
developed onset of lower extremity weakness and paresthesias in
both of his lower extremities and retention of urine. He
presented to the ED. Spine MRI revealed no abnormal spinal cord
signal, but did show slight retropulsion of the vertebrae
coupled with epidural lipomatosis, causing deformity of the
cord. He was taken for urgent decompression procedure. Following
the procedure, he was fitted for a TLSO brace and evaluated by
___. He was able to stand with heavy assistance and tolerates the
TLSO brace out of bed. His wound was followed daily by the
orthopedic service. He was able to void on his own. He was
discharged to rehab to complete his recovery. He needs to wear
the TLOS brace at all times when out of bed until further
instructed by the spine surgeons.
#Pneumonia: Found on CT ___. Was intubated for procedure and
has been hospitalized. ___ be consistent with aspiration. He was
given a day of vancomycin and cefepime and transitioned to
levofloxacin with continued improvement. He will complete a
7-day treatment course on discharge.
#Tachycardia: Irregular rhythm is noted on tele and ECG to be
from multiple atrial foci and organized, not afib. This is
consistent with increased albuterol use. He is noted to be more
tachycardic sitting upright and when anxious or straining. There
is likely a component of deconditioning as well. Theophylline
was initially held for concern of toxicity, but tachycardia
remained. The patient was assymptomatic and felt well. He was
discharged to rehab back on theophylline with plan to check a
level in 3 days and adjust as needed.
#Chest Discomfort: Mr. ___ experienced bilateral chest
discomfort that was worse with inspiration during the admission.
On initial evaluation troponin was negativex2, there were no ECG
changes, and CTA was negative for PE but did show RLE pneumonia.
Pain is felt likely chest wall/musculoskeletal given recent
respiratory distress and immobilization. Would advise
reconsidering CAD if the pain recurs in a different fashion or
with other signs and symptoms of cardiac ischemia such as
diaphoresis, nausea, radiation.
#COPD on home O2:
Mr. ___ had intermittent respiratory distress initially
requiring standing nebulizer therapy. He had lung collapse
following surgery and had disruption in his home medication
regiment in hospitalization. The lung re-expanded but was found
to have pneumonia (see above). He received a 3-day pulse of
increased steroids. He was transitioned back to his home COPD
medications and supplemental oxygen with goal oxygen saturations
88-92%. His breathing improved and he was brought back to his
home dose of steorids. Theophylling was initially held, then
restarted on discharge (see above).
CHRONIC CARE:
#Chronic Diastolic CHF: At dry weight 200lb confirmed from PCP
___. Continued home furosemide.
#OSA: Continued nightly BIPAP, home settings
#Hypertension
Stable, continued amlodipine.
#GERD: Transitioned to PRN famotidine. ___ consider restarting
PPI as outpatient as needed.
#Neuropathy: Continued gabapentin
TRANSITIONS IN CARE:
# CODE STATUS: Presumed Full
# He will require followup with Orho-spine and with PCP
___ was held for a few days and restarted on
discharge. Level should be checked in 3 days time as outlined on
Page1.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Tiotropium Bromide 1 CAP IH DAILY
2. Furosemide 40 mg PO DAILY
3. Amlodipine 10 mg PO DAILY
4. TraZODone 350 mg PO HS
5. ClonazePAM 0.5 mg PO QHS
6. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation
inhalation 2 puffs BID
7. Sertraline 50 mg PO BID
8. Sertraline 50 mg PO QAM
9. Potassium Chloride 10 mEq PO 3X/WEEK (___)
10. PredniSONE 15 mg PO DAILY
11. Gabapentin 300 mg PO TID
12. Azithromycin 250 mg PO DAILY
13. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN shortness of
breath, wheeze
14. budesonide 0.25 mg/2 mL inhalation BID
15. Theophylline SR 100 mg PO BID
Discharge Medications:
1. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN shortness of
breath, wheeze
2. Amlodipine 10 mg PO DAILY
3. Azithromycin 250 mg PO DAILY
4. ClonazePAM 0.5 mg PO QHS
RX *clonazepam 0.5 mg 1 tablet(s) by mouth at bedtime Disp #*4
Tablet Refills:*0
5. Furosemide 40 mg PO DAILY
6. Gabapentin 300 mg PO TID
7. PredniSONE 15 mg PO DAILY
8. Sertraline 50 mg PO BID
see other sertaline order.
Total morning dose=100mg
9. Sertraline 50 mg PO QAM
see other sertaline order.
Total morning dose=100mg
10. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation
INHALATION 2 PUFFS BID
11. Tiotropium Bromide 1 CAP IH DAILY
12. TraZODone 350 mg PO HS
13. Acetaminophen 1000 mg PO Q8H
14. Docusate Sodium 100 mg PO BID
15. Heparin 5000 UNIT SC TID
16. Levofloxacin 750 mg PO DAILY Duration: 3 Days
17. Milk of Magnesia 30 mL PO Q6H:PRN constipation
18. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
RX *oxycodone 5 mg ___ tablet(s) by mouth Q4H:PRN Disp #*20
Tablet Refills:*0
19. Budesonide 0.25 mg/2 mL INHALATION BID
20. Potassium Chloride 10 mEq PO 3X/WEEK (___)
21. Senna 1 TAB PO QHS
22. Theophylline SR 100 mg PO BID
measure theophylline level on ___ and may need to adjust.
23. Insulin SC
Sliding Scale
Fingerstick Q6H
Insulin SC Sliding Scale using HUM Insulin
24. Famotidine 20 mg PO Q12H:PRN acid reflux
Discharge Disposition:
Extended Care
Facility:
___
___ Diagnosis:
Primary: T6 Vertebral Body Fracture, Epidural Lipomatosis
Secondary: Exacerbatiobn of Chronic Obstructive Pulmonary
Disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Mr. ___,
You were admitted to the hospital following a vertbral body
fracture that was affecting your nerves. You had surgery to
repair this fracture and decompress the nerves and the surgery
was successful. You also experienced an exacerbation of your
COPD following surgery, along with pneumonia. While in the
hospital we treated your COPD exacerbation and pneumonia, and
your lung function improved. You are being discharged to a rehab
hospital to complete your recovery.
Please adhere to the recommended medications, and please keep
all discharge appointments.
It was a pleasure taking part in your care.
Followup Instructions:
___
|
19718930-DS-5
| 19,718,930 | 24,882,516 |
DS
| 5 |
2115-01-30 00:00:00
|
2115-01-30 19:20:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Weakness, aphasia
Major Surgical or Invasive Procedure:
Thrombectomy
History of Present Illness:
___ is a ___ year old woman with a past medical
history of hypertension, HFpEF, recent lung cancer diagnosis
(unknown details, no biopsy) with multiple subsequent thrombotic
events including R MCA distribution infarct on ___ while
on
apixaban, NSTEMI ___, with recent hospitalization for CHF
exacerbation complicated by thrombocytopenia with platelets of
28
for which apixiban was held on ___ patient transferred to
___
for L MCA syndrome with L ICA occlusion with LKW 5AM ___ for
thrombectomy.
___ was hospitalized at ___ for a CHF exacerbation
on
___, detailed below. On ___, patient was seen normal at 5
am (per report her baseline is left arm weakness ___, right arm
and bilateral legs full strength per recent OT note). At 6:30 AM
she was seen to have new right arm plegia, aphasia, and left
gaze
deviation. CT/CTA revealed a left distal internal carotid
occlusion. Patient was transferred to ___ for thrombectomy.
Patient arrived at 11:54 AM, CTH showed a few small areas of
possible hemorrhagic transformation vs contrast extravasation in
areas of encephalomalacia. CTP revealed left MCA distribution
increased tmax. Patient taken for thrombectomy, unable to obtain
distal reperfusion TICI I.
To review patient's recent history, patient had exploratory
laparotomy with rectosigmoid resection and end colostomy for
diverticulitis in ___. She was discharged and
subsequently
developed a PE in ___, which was considered to be provoked in
the
post op period and started on apixiban. She was also diagnosed
with lung cancer "recently" per chart review but there are no
other details about this in ___ notes. Verbal report
from
___ - patient was found to have a lung mass in ___
with
no biopsy pursued. On repeat imaging in ___ there was
mediastinal involvement of mass. On ___ she had acute
onset left sided weakness and was found to have a right MCA
stroke (as far as I know she was on apixiban at this time).
Apixiban was held for a period of time post stroke and then
restarted prior to discharge to rehab on ___. She was
readmitted
to ___ on ___ for hypoxia and NSTEMI, she had a
cardiac cath which was negative. This hospitalization was
complicated by a new onset thrombocytopenia; platelets were 180
on ___ and had dropped to 71 on ___. HIT studies were reportedly
sent (except not a serotonin release assay) and she was
discharged to ___. She presented to ___ on ___ with SOB,
found to have T wave inversions in V3, V4 with a troponin
elevation to 0.21. Cardiology was consulted, and they were
concerned for takotsubo stress cardiomyopathy (attributed
positive trops to recent NSTEMI). Therefore, most likely
etiology
was thought to be CHF exacerbation and was treated with
aggressive IV diuresis. There was verbal report of repeat chest
imaging that showed a PE at this time, and it was unclear if
this
was left over from prior PE or a new process; however there is
no
documentation of this imaging in records available at this time.
Her platelets on presentation were 35, and trended down over the
ensuing days to 25, then 21, then 28 (repeat on the ___,
and ___ respectively). Tick studies and and serotonin release
assay were sent. Apixiban was held on ___
because of the low platelets. She was noted to have a
leukocytosis on ___ to 13 and was started on vancomycin and
meropenem (though no documented fevers there was high clinical
suspicion for pneumonia).
Per collateral from her son, she has been losing weight recently
as she has had no appetite. She went from 140 pounds to 126
pounds, and continues to lose weight. She was a former smoker,
quit about 6 months ago. She has not had any coughing up blood
or
any blood in the stool. He denies any knowledge of cancer,
however her records state that she has a history of lung cancer.
Unable to obtain ROS due to clinical conditions.
Past Medical History:
- HTN
- HLD
- DVT/PE on ___ ___
- Right MCA stroke ___
- Diverticulitis with exploratory laparotomy with rectosigmoid
resection and end colostomy ___
- NSTEMI, clean cardiac cath ___
- Lung cancer diagnosis, no known details
Social History:
___
Family History:
Unknown
Physical Exam:
Vitals: vitals in the field per report HR ___, BP 130s/80s, SaO2
96% RA
General: Awake, thin woman, left gaze deviation, not speaking
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple
Pulmonary: Normal work of breathing
Cardiac: RRR, warm, well-perfused
Abdomen: soft, non-distended
Extremities: 1+ ___ edema.
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Awake eyes open, left gaze deviation. No speech
output. No commands.
CN:
Decreased BTT on the right. Pupils 3-->2 reactive. Left gaze
deviation unable to overcome with dolls. Left facial droop.
Sensorimotor:
LUE drifts to bed when raised manually
RUE plegic
LLE withdraws to noxious in plane of bed
RLE TF to noxious
Pertinent Results:
___ 12:00PM BLOOD WBC-11.5* RBC-2.95* Hgb-8.2* Hct-26.5*
MCV-90 MCH-27.8 MCHC-30.9* RDW-15.9* RDWSD-51.8* Plt Ct-28*
___ 12:00PM BLOOD Neuts-73.8* Lymphs-9.5* Monos-7.8 Eos-6.7
Baso-0.5 Im ___ AbsNeut-8.47* AbsLymp-1.09* AbsMono-0.89*
AbsEos-0.77* AbsBaso-0.06
___ 03:20PM BLOOD ___ PTT-29.4 ___
___ 03:20PM BLOOD ___
___ 03:20PM BLOOD Glucose-118* UreaN-15 Creat-0.7 Na-143
K-3.8 Cl-108 HCO3-19* AnGap-16
___ 03:20PM BLOOD ALT-10 AST-26 LD(LDH)-960* CK(CPK)-43
AlkPhos-100 TotBili-0.9 DirBili-0.2 IndBili-0.7
___ 03:20PM BLOOD CK-MB-2 cTropnT-0.06*
___ 12:00PM BLOOD cTropnT-0.03*
___ 03:20PM BLOOD Albumin-3.4* Calcium-8.7 Phos-3.9 Mg-2.0
Cholest-104
___ 03:20PM BLOOD Hapto-<10*
___ 03:20PM BLOOD %HbA1c-4.8 eAG-91
___ 03:20PM BLOOD Triglyc-188* HDL-34* CHOL/HD-3.1
LDLcalc-32
___ 03:20PM BLOOD TSH-0.56
___ 12:00PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Tricycl-NEG
___ 12:20PM BLOOD Glucose-90 Creat-0.6 Na-142 K-2.9*
Cl-113* calHCO3-20*
___ Imaging CODE STROKE
1. Acute left MCA infarction with increased mismatch volume.
2. Multiple hyperintense foci may represent hemorrhage or
underlying mass and MR is recommended for further evaluation.
Additionally, areas of low
attenuation may suggest ischemic small vessel disease or
vasogenic edema from underlying mass.
Neurointervention ___
Ultrasound of the right groin demonstrates a pulsatile
single-lumennon-compressible vessel over the femoral head. There
is evidence
of needle access into the arterial lumen.
Left internal carotid artery: Reveals a complete occlusion at
the left ICA
terminus consistent with TICI 0. After 5 passes of stent suction
catheter
there is unsuccessful recanalization to TICI 1.
Right common femoral artery: Arteriotomy is above the
bifurcation. There is
good distal runoff. There is no evidence of dissection. Vascular
caliber is
appropriate for closure device.
IMPRESSION:
Large vessel occlusion stroke with left ICA T occlusion status
post
unsuccessful recanalization to TICI 1.
Brief Hospital Course:
___ with HTN, HpEF, recent dx lung CA, thrombocytopenia (unclear
etiology), prior R MCA stroke ___ w/ residual LUE ___
weakness), and NSTEMI on ___, who presented with L MCA syndrome
and found to have a L distal ICA occlusion s/p unsuccessful EVT
(TICI I after 4 passes). Transitioned to CMO.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Ondansetron 4 mg PO Q6H:PRN Nausea/Vomiting - First Line
2. Meropenem 500 mg IV Q8H
3. Furosemide 40 mg IV BID
4. Cyanocobalamin 1000 mcg PO DAILY
5. Magnesium Oxide 400 mg PO BID
6. Vitamin D 400 UNIT PO DAILY
7. Ferrous Sulfate 325 mg PO DAILY
8. LORazepam 0.5 mg PO BID:PRN anxiety
9. amLODIPine 2.5 mg PO BID
10. Escitalopram Oxalate 10 mg PO DAILY
11. Lisinopril 30 mg PO DAILY
12. Metoprolol Tartrate 25 mg PO BID
13. Atorvastatin 80 mg PO QPM
14. BusPIRone 5 mg PO BID
Discharge Medications:
1. Acetaminophen IV 1000 mg IV Q6H:PRN Pain - Mild
2. Glycopyrrolate 0.1-0.2 mg IV Q4H:PRN excess secretions
3. LORazepam 2 mg IV Q4H
4. LORazepam 2 mg IV Q2H:PRN anxiety, seizures
5. Morphine Sulfate ___ mg IV Q15MIN:PRN moderate-severe pain
or respiratory distress
6. Sodium Chloride 0.9% Flush ___ mL IV Q8H and PRN, line
flush
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Acute ischemic stroke
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Lethargic and not arousable.
Activity Status: Bedbound.
Discharge Instructions:
Dear Ms. ___ and family,
You were admitted after you developed sudden weakness and
problems with speech. You were found to have a large stroke. We
attempted to remove the clot from your brain, but unfortunately,
this was not successful. After discussion with your family, we
decided to focus on making you as comfortable as possible. You
were transitioned to hospice care.
It was a pleasure taking care of you,
Your ___ care team
Followup Instructions:
___
|
19718991-DS-24
| 19,718,991 | 20,492,199 |
DS
| 24 |
2135-03-02 00:00:00
|
2135-03-31 10:30:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
Penicillins
Attending: ___
Chief Complaint:
___
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ s/p high speed head-on MVC vs ___ barrier, GCS 15 but
confused, found to have sm IPH, L 3rd rib fx, L shoulder AC
separation; INR 2.4. incidentally found R pharyngeal mass.
Past Medical History:
VASCULAR HISTORY: Lower Extremity Bypass Graft: Aortobifem.
Hypertension, dyslipidemia, coronary artery disease, s/p MI, h/o
SBO s/p LOA
PAST SURGICAL HISTORY: PSH: Aortobifemoral bypass ___, exlap,
LOA ___, ORIF/internal fixation of L wrist fx, s/p PCA to RCA
in ___ and LCx in ___, LAD stent (DES) ___
Social History:
___
Family History:
Mother - ___. Father - DM2, CAD, MI in his ___, died
from cardiac arrest.
Physical Exam:
PE on discharge
AVSS
RRR
CTA b/l
s/nt/nd
Pertinent Results:
___ 02:24AM BLOOD WBC-6.9# RBC-4.83 Hgb-14.2 Hct-42.5
MCV-88 MCH-29.3 MCHC-33.4 RDW-14.5 Plt ___
___ 07:52AM BLOOD WBC-18.5* RBC-4.78 Hgb-14.2 Hct-42.4
MCV-89 MCH-29.6 MCHC-33.4 RDW-14.8 Plt ___
___ 02:34AM BLOOD WBC-12.9* RBC-5.14 Hgb-15.2 Hct-45.6
MCV-89 MCH-29.7 MCHC-33.4 RDW-14.6 Plt ___
___ 02:24AM BLOOD ___
___ 07:52AM BLOOD ___ PTT-31.2 ___
___ 02:34AM BLOOD ___ PTT-34.2 ___
___ 07:52AM BLOOD Glucose-126* UreaN-17 Creat-1.1 Na-136
K-4.1 Cl-101 HCO3-25 AnGap-14
CTH: Small focus of parafalcine hemorrhage with probable
intraparenchymal/subarachnoid extension seen in the left vertex,
in a
paramedian location in the left frontal lobe. A small focus of
hypodensity in the left corona radiata is compatible with
infarct.
CT-C-spine: No evidence of fracture or malalignment. Moderate
degenerative changes of the cervical spine, as described above.
Asymmetry of the pharyngeal tonsillar tissue with an enlarged
right
tonsil. No cervical lymphadenopathy.
CT torso:
Minimally displaced fracture of the lateral aspect of the left
third rib.
No other fracture is identified. No evidence of mediastinal or
pulmonary
injury. No evidence of laceration of the abdominal solid organs
or intestinal injury. Large thyroid nodule in the lower aspect
of the thyroid gland has heterogeneous enhancement and should be
further assessed with ultrasound. Other hypodense nodules within
the gland can be assessed at that time.
Dependent bilateral pulmonary consolidation may represent
atelectasis
although aspiration cannot be excluded.
Complete occlusion of the right subclavian-femoral bypass graft
and left aorto-femoral bypass graft. Patent left
subclavian-femoral bypass graft and right aorto-femoral bypass
graft.
Upper lobe predominant emphysema, coronary artery
calcifications, and
atherosclerotic disease of the aorta are chronic condition.
X-ray shoulder: No evidence of fracture. Findings compatible
with a mild likely type 2 AC joint separation.
Repeat head CT: No change in the tiny left parieto-occipital
subarachnoid and left parafalcine subdural hemorrhage, compared
to the study of 10 hours earlier. Significant bifrontal cortical
atrophy, greater than expected for patient's age.
Brief Hospital Course:
Patient was admitted to ___ because of his small IPH and his
rib fractures. By the morning of his admission he was sitting up
in a chair and oriented x3. He was brought down for repeat head
CT scan that showed no interval increase. This was done because
he was on coumadin.
On day of discharge he was tolerating a regular diet, ambulating
without assistance and safe for discharge home.
Medications on Admission:
Coumadin
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H
RX *acetaminophen 650 mg 1 tablet extended release(s) by mouth
every six (6) hours Disp #*40 Tablet Refills:*0
2. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 tablet(s) by mouth twice a day Disp
#*60 Capsule Refills:*0
3. 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
4. Senna 1 TAB PO BID
RX *sennosides [senna] 8.6 mg 1 tablet by mouth twice a day Disp
#*60 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Motor Vehicle Crash
Intraparenchymal Hemorrhage
Rib 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:
Mr. ___,
You were admitted to the ___ department of Acute Care Surgery
(___) following your car accident. You were evaluated in the
Emergency Department for your numerous injuries. Your head
injury was serious enough to warrant an admission to the
Intensive Care Unit for observation. The neurosurgery service
monitored your injury and felt it was safe for you to be
transferred to the general patient floors. Once there, you
worked with occupational therapy for any upper extremity
weakness. Now that you aer eating a regular diet and your pain
is well controlled, you can return home for the remainder of
your recovery. Please pay close attention to your discharge
instructions.
*Diet*
You may eat a regular diet.
*Activity*
You may resume your regulard daily activities as you can
tolerate. Please be sure to follow up with occupational therapy
as an outpatient if instructed to do so. If you require
narcotics for pain control, avoid operating motor vehicles.
*Medications*
Please take all medications as prescribed. Because of a small
bleed in your brain, your coumadin has been discontinued. It is
very important that you make all of your follow up appointments
regarding this medication as you will likely need to resume this
at some point. Narcotics may cause constipation. You may take
stool softeners to help alleviate this.
We wish you the best of luck and are hopeful for a speedy
recovery.
*Warning Signs*
If you experience any of the symptoms listed below, please
notify your physician or go to your nearest emergency department
for prompt evaluation.
Followup Instructions:
___
|
19719384-DS-16
| 19,719,384 | 25,844,792 |
DS
| 16 |
2133-09-18 00:00:00
|
2133-09-18 16:51:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
tamsulosin
Attending: ___.
Chief Complaint:
Difficulty with speech and remembering names.
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ right-handed man presenting with
expressive aphasia and alexia on a background of autonomic
dysfunction with labile blood pressure, paroxysmal atrial
fibrillation, on Coumadin, chronic renal insufficiency
(nephrectomy for renal cell).
Mr. ___ was with his wife, walking in the park. He stopped to
practice tennis moves, miming them like a shadow boxer. They
both
then walked home. This was around 4 ___. Earlier in the day he
had
seen his acupuncturist who had given him some powder to drink,
dissolved, for his orthostatic hypotension. He took this and no
other remedies at about 1 ___. It is not clear what this
substance
was.
He arrived home and they sat down to a cup of tea. He went
upstairs. Soon afterward, he called our to his wife "I'm in
trouble." She asked what he meant and he said, "I can't talk".
She went up to find him scarce of words and a little
exacerbated,
sitting on the side of the bed. She noted that he was also
unable
to read. She called Dr. ___ PCP, and he recommended
coming to ___. They drove here. On arriving, he was still
having some difficulty communicating. He noted that his right
hand felt mildly clumsy and that he signed his name ___ at
registration, but the next attempt produced a normal signature.
He has ongoing orthostasis, but denies lightheadedness during
the
event. He has had gradually worsening difficulties with
arithmetic and memory. There is no headache, no unusual
smells/tastes/emotions. He started to clear over about an hour
and now feels essentially back to normal. There were no other
neurologic symptoms such as visual difficulties, hearing
difficulties, numbness, clumsiness. He is not using CPAP
equipment. He states that he needs his sleep and was concerned
to
be admitted.
There were three recent significant events. He had two minor
automobile collisions, inappropriately, with ___
indifference, going to the gym after one. He "nose dived into
the
pavement" in ___ this year, injuring his head. He recalls
falling
and getting up, but did not trip - thought to be arrhythmia
related. Work-up included seeing a neurologist at ___ at ___ and MRI at ___ (normal per patient). No incontinence,
confusion afterward. States not recalling very much of
automobile
incidents above, however.
Past Medical History:
Paroxysmal atrial fibrillation
Orthostatic hypotension diagnosed on autonomic testing in ___
Chronic fatigue syndrome
Renal cell carcinoma status post nephrectomy in ___.
Chronic renal insufficiency with a baseline creatinine of 1.3
Chronic Pelvic Pain, dx as chronic prostatitis
Social History:
___
Family History:
Sister with atrial fibrillation.
Mother lived to her ___.
Physical Exam:
Vitals: 98.2 60 198/72 16 100%
General Appearance: Comfortable, no apparent distress.
HEENT: NC, OP clear, MMM.
Neck: Supple. No bruits.
Lungs: CTA bilaterally (fine crackles in upper part of left
lower
lobe cleared).
Cardiac: RRR. Normal S1/S2. No M/R/G.
Abdominal: Soft, NT, BS+
Extremities: Warm and well-perfused.
Neurologic:
Mental status:
Awake and alert, cooperative with exam, normal affect. Able to
perform months of the year backwards. Orientation: Oriented to
person, place, date ___, but took some time to think of
year, likely away from baseline) and context.
Language: Normal fluency, comprehension, repetition, naming. No
paraphasic errors. Writing messy on first signing name at
registration, but then normal. Able to read.
Registration of three words at one trial and recall of two at
five minutes without hints. Declines to subtract 19 from 34,
states had a lot of difficulty with arithmetic over the last
couple of years.
Fund of knowledge for recent events within normal limits.
Cranial Nerves:
I: Not tested.
II: Pupils equally round and reactive to light, to
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 symmetric.
XI: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Posture normal and no truncal ataxia.
Tone normal throughout.
Power
D B T WE WF FF FAb | IP Q H AT G/S ___ TF
R ___ ___ 5 | ___ ___ 5
L ___ ___ 5 | ___ ___ 5
Reflexes: B T Br Pa Ac
Right ___ 2 1
Left ___ 2 1
Toes downgoing bilaterally
Sensation intact to light touch, vibration, joint position,
pinprick bilaterally. Romberg negative.
Normal finger nose, great toe finger, RAM's bilaterally.
Gait:
Normal initiation, cessation, turn, armswing, base. Able to
tandem a few steps.
Pertinent Results:
___ 10:45PM %HbA1c-5.7 eAG-117
___ 07:20PM ___ PTT-52.1* ___
___ 07:20PM WBC-6.5 RBC-4.77 HGB-13.9* HCT-40.6 MCV-85
MCH-29.2 MCHC-34.3 RDW-13.5
___ 07:20PM TSH-3.0
___ 07:20PM ALBUMIN-4.4 CALCIUM-9.2 PHOSPHATE-2.7
MAGNESIUM-2.3 CHOLEST-194
___ 07:20PM CK-MB-5 cTropnT-<0.01
___ 07:20PM ALT(SGPT)-21 AST(SGOT)-30 LD(LDH)-222
CK(CPK)-231 ALK PHOS-113 TOT BILI-0.5
___ 08:10PM URINE RBC-2 WBC-1 BACTERIA-NONE YEAST-NONE
EPI-0
Provisional Findings Impression: HBcb MON ___ 12:09 ___
PFI: No evidence of acute ischemic infarct or other acute
intracranial
abnormality such as hemorrhage or mass.
Age-related volume loss as well as sequela of chronic small
vessel ischemic
disease.
Normal MRA of the head and neck.
Brief Hospital Course:
Mr. ___ was admitted to the neurology service on ___. A
code stroke was called upon his arrival to the ED. Given that
his NIHSS was 0 and his INR was 2.8 he was not a candidate for
tPA.
Neuro:
MRI showed no evidence of stroke. MRA was unremarkable with no
significant stenosis or occlusion. EEG showed no evidence of
seizure activity. By the next day transient speech difficulties
had resolved and his neurologic exam revealed no deficits. His
prior neuro-imaging reports were obtained from ___. ___ and
were read as normal.
He was continued on coumadin and his INR remained therapeutic.
CV:
Pt was maintained on telemetry monitoring. Cardiac enzymes were
negative. His home Losartan was decreased to 25mg BID and
reincreased to his home dose upon discharge.
Endocrine
HbA1c was 5.7. TSH was 3.0.
Respiratory
CXR was clear. Patient refused CPAP while in house.
Dispo
Pt was seen by ___ and OT and determined to be safe to return
home upon discharge. He was discharged on ___ in good
condition. He will follow up with Dr. ___ in clinic.
Medications on Admission:
Medications:
- Losartan 100 mg QD
- Flonase
- Warfarin 5 mg QD
Discharge Medications:
1. warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
___.
2. trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed for insomnia.
3. losartan 100 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Temporary word finding difficulties of undetermined etiology
(possible TIA)
Discharge Condition:
Mental Status: Clear and coherent.
Activity Status: Ambulatory - Independent.
Level of Consciousness: Alert and interactive.
Discharge Instructions:
Dear Mr. ___,
You were seen and evaluated at ___ Department of Neurology due
to difficulty speaking. An MRI and MRA of your brain did not
show any findings consistent with a stroke. An EEG showed no
evidence of seizure activity. Your symptoms may have been
related to a TIA (transient ischemic attack) that did not show
up on the MRI, or to a transient decrease in blood flow to your
brain.
-Please resume your normal home medications.
-Please continue to follow up with your PCP/Cardiologist for
management of your INR and other general health issues.
We made no changes to your medications.
If you experience any of the below listed danger signs, please
call your doctor or go to the nearest emergency department.
Followup Instructions:
___
|
19719472-DS-16
| 19,719,472 | 29,203,371 |
DS
| 16 |
2124-09-25 00:00:00
|
2124-09-25 11:33:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
Aspirin / IV Dye, Iodine Containing Contrast Media
Attending: ___
Chief Complaint:
Headache
Major Surgical or Invasive Procedure:
Cerebral angiogram
History of Present Illness:
___ with a PMH of right parietal IPH in ___ no microbleeds to
suggest amyloid on recent MRI ___ and felt to be related to
hypertension, 1x GTC seizure in ___ on lamotrigine, lung cancer
s/p right lobectomy ___ years ago with chemotherapy with radiation
and radiation pneumonitis and periodic bronchospasm now
seemingly
in remission, Paroxysmal AF not on anticoagulation, CRF, HTN,
COPD presented with a 2 day history of right temporal headache
followed by acute onset on ___ evaluation ___ of left
hemiparesis and difficulty speaking at 7pm with head CT at
___ showing a roughly 3.2x2.9cm right temporal IPH
with minimal edema and mass effect and is being admitted to the
neuro-ICU.
Patient notes being previously assessed at ___ ___
weesk ago where he apparently had a 4 day hospitalisation for
headaches where CT head was normal and discharged. He was then
at
his baseline until 2 days ago when he noted a relatively sudden
onset of right temporal headache which was sharp and at times
severe.He hadno nausea, vomiting and no visual changes. Thsi
worsened ovver this time but the patient was stoical. He was
visiting ___ for an unrelated reason where his
wife
felt he did not look himself. She then took him to the ___ to
evaluate his headaches where at just after 6pm he had a CT which
showed a right temporal IPH as above. Importantly, per his wife,
apparently AFTER this at roughly 7pm he then had onset of left
weakness and speech difficulties where initilly he could not
move
the right side at all. Unfortunately we do not have notes of his
current admission from ___ but perreport given to
___, he was loaded with fosphenytoin and given IV ondansetron and
fentanyl and transferred to ___ for further evaluation.
Since transfer his symptoms have improved. He is now antigravity
in both left arm and leg although the arm is weaker than the
leg.
He also described some numbness and tingling in his left hand
and
this seemingly subsided. He also felt light-headed and noted
cough, SOB and some chest tightness with wheezing while in
___ (has COPD).
He still has a fairly significant headache and was given
morphine
for this in the ___. He is somewhat inattentive and has a right
gaze preference but is verbalising well and shows insight into
his situation.
On neuro ROS, the pt denies loss of vision, blurred vision,
diplopia, dysphagia, vertigo, tinnitus or hearing difficulty.
Denies difficulties producing or comprehending speech. No bowel
or bladder incontinence or retention.
On general review of systems, the pt denies recent fever or
chills. No night sweats or recent weight loss or gain. Denies
chest pain or tightness, palpitations. Denies nausea, vomiting,
diarrhea, constipation or abdominal pain. No recent change in
bowel or bladder habits. No dysuria. Denies arthralgias or
myalgias. Denies rash.
Past Medical History:
PMH:
- Lung cancer s/p right lobectomy ___ years ago with chemotherapy
with radiation and radiation pneumonitis and
periodicbronchospasm
now seemingly in remission
- Right parietal IPH in ___ in ___ admitted to the ICU and
started on phenytoin for seizure prophylaxis and treated for a
week with mannitol as well and went to rehab. Felt to be
hypertensive in origin.
- Paroxysmal AF not on anticoagulation
- CRF - OSH documentation shows previous Cr 1.8
- Seizure disorder since ___ apparently 1x GTC seizure and
started on lamotrigine for this
- HTN
- GERD
- Squamous cell carcinoma
- COPD and ? asthma
PSurgHx:
Other than right lobectomy above had an appendectomy
Social History:
___
Family History:
Mother - died ___ of ICH no associated dementia
Father - CAD s/p CABGx3 died ___ after 3xMIs
Sibs - brother and sister are well
Children - None
There is no history of seizures, developmental disability,
learning disorders, migraine headaches, strokes less than 50,
neuromuscular disorders, or movement disorders.
Physical Exam:
ADMISSION Physical Exam:
Vitals: T:97.4 P:74 R:18 BP:152/87 SaO2:92% 2L
General: Awake, some difficulties following commands but
generally does well, complains of headache.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: Some decreased BS right base and otherwise with
prolonged expiratory phase and wheeze
Cardiac: RRR, nl. S1S2, no M/R/G noted. Regular also on monitor.
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted.
Extremities: ___ pitting edema to upper shin on left and lower
shin on right which is less significant, 2+ radial, DP pulses
bilaterally.
Skin: no rashes or lesions noted.
Neurologic:
___ Stroke Scale score was ___. Level of Consciousness: 0
1b. LOC Question: 0
1c. LOC Commands: 0
2. Best gaze: 1 but mild right gaze preference
3. Visual fields: 1
4. Facial palsy: 2
5a. Motor arm, left: 1
5b. Motor arm, right: 0
6a. Motor leg, left: 0
6b. Motor leg, right: 0
7. Limb Ataxia: 0
8. Sensory: 1
9. Language: 0
10. Dysarthria: 1
11. Extinction and Neglect: ___ - essentially 2 modalities
(visual and sensory inattention) but not severe
-Mental Status:
ORIENTATION - Alert, oriented x 3 but had to think about the
month at length
The pt. had good knowledge of current events knew current
president is ___ and previous was ___.
SPEECH
Able to relate history with some difficulty but helped by wife.
Language is fluent with intact repetition and comprehension.
Normal prosody. There were no paraphasic errors.
Speech was dysarthric but easily able to understand.
NAMING Pt. was able to name both high and low frequency objects
on stroke card.
READING - Able to read without difficulty on stroke card
examples.
ATTENTION - Inattentive, able to name ___ forward with pauses
and
significant difficulty.
REGISTRATION and RECALL
Pt. was able to register 3 objects and recall 0/ 3 at 5
minutes.
COMPREHENSION
Able to follow both midline and appendicular commands including
2
step commands.
There was no evidence of apraxia but had visual and sensory
neglect which was not profound.
Patient had intermittent chewing motion which was interruptable
and very brief right mentalis twitching with ___ episode of
left
UE low amplitude jerking.
-Cranial Nerves:
I: Olfaction not tested.
II: Mild anisocoria right pupil1.5mm and left 2mm and brisk.
VFF
show possible left incongrous homonymous hemianopia essentially
in the left eye field to confrontation but may be related to
neglect and did not seem to have a field defect on assessment of
the right eye field. Funduscopic exam revealed no papilledema,
exudates, or hemorrhages but technically challenging and only
got
brife glimpses of disc.
III, IV, VI: Full range of eye movement but non-sustained
nystagmus 10 beats on left gaze and 3 beats on right gaze.
Saccadic intrusions. Left gaze preference but coyld fully ___ to
the left and this was subtle.
V: Facial sensation intact to light touch.
VII: Left lower facial weakness. Dysarthria.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM on right and 4+/5 on left.
XII: Tongue protrudes in midline with noraml movement.
-Motor: Normal bulk reduced tone left arm>leg. Left pronator
drift.
No adventitious movements, such as tremor, noted. No asterixis
noted.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 4 ___ 4+ ___ 4+ 4 5 4+ 4+
R 5 ___ ___ 5 5 5 5 5 5
-Sensory: No deficits to light touch, pinprick, cold sensation,
proprioception on right. On left seemingly normal light touch
but
noted decreased pinprick whole left side. Decreased vibration to
knee on left and ankle on right and decreased proprioception to
ankle on left. Left sensory inattention.
-DTRs:
Bi Tri ___ Pat Ach
L 1 1 1 2+ 2
R 1 1 1 2+ 0
Plantar response was flexor on right extensor on left.
-Coordination: No intention tremor noted. No dysmetria on FNF or
HKS bilaterally in context of significant weakness on left.
-Gait: Deferred
Pertinent Results:
ON ADMISSION:
-------------
___ 08:10PM BLOOD WBC-7.7 RBC-4.88 Hgb-13.9* Hct-42.7
MCV-88 MCH-28.5 MCHC-32.6 RDW-14.4 Plt ___
___ 08:10PM BLOOD Neuts-75.4* ___ Monos-3.6 Eos-1.1
Baso-0.5
___ 08:10PM BLOOD ___ PTT-31.2 ___
___ 08:10PM BLOOD Glucose-123* UreaN-23* Creat-1.7* Na-140
K-4.3 Cl-103 HCO3-29 AnGap-12
___ 08:10PM BLOOD ALT-17 AST-16 AlkPhos-74 TotBili-0.2
___ 08:10PM BLOOD Albumin-4.9
___ 08:10PM BLOOD Phenyto-13.5
IMAGING & STUDIES:
-----------------
CT HEAD ___ New right temporoparietal intraparenchymal
hemorrhage with no clear subarachnoid or intraventricular
extension. Minimal associated mass effect without evidence of
herniation or shift of midline structures. Encephalomalacia
related to prior right frontoparietal intraparenchymal
hemorrhage.
CT HEAD ___ Unchanged exam with stable right
temporoparietal intraparenchymal hemorrhage with surrounding
vasogenic edema and minimally associated mass effect. Further
workup to exclude underlying vascular/neopalstic etiology;
correlate clinically for coagulopathy/amyloid angiopathy.
MR HEAD ___ Noncontrast study Right parietal
intraparenchymal hemorrhage with no significant change compared
to same day CT. Underlying lesion cannot be excluded. Followup
is recommended.
CXR ___ Status post right thoracic surgery, most likely
lobectomy,
recording rib defects and clips in situ. Elevation of the right
hemidiaphragm. The cardiac silhouette is of normal size. The
left hemithorax is normal. At the site of resection on the
right, there is no evidence of recurrence. However, CT should be
performed given the substantially higher sensitivity of this
technique.
EKG ___ Sinus rhythm. Non-specific ST-T wave changes,
probably normal variant. Compared to the previous tracing of
___ no change.
Rate PR QRS QT/QTc P QRS T
76 176 88 364/392 58 12 55
Cerebral angiogram ___: ___ underwent cerebral
angiography which revealed that there were no vascular sources
for his right hemispheric hemorrhages, specifically no AVM,
arteriovenous fistula or vasculitis was identified. He does have
an occlusion of his right common iliac artery just beyond the
aortic bifurcation.
Hip Film ___ Three views show the bony structures and joint
spaces to be within normal limits and symmetric with the
opposite side. If there is serious clinical concern for occult
fracture, cross-sectional imaging could be considered.
MRI L Spine ___: There is normal lumbar vertebral body
height and alignment. There is a small hemangioma at L1
vertebral body. The conus medullaris is normal in morphology and
intrinsic signal intensity and terminates at the L1-2 level.
There is a normal distribution of cauda equine nerve roots. The
paravertebral and limited included retroperitoneal soft tissues
are grossly unremarkable. At L1-L2 and L2-3 there are mild disc
bulges but no spinal canal stenosis or neuroforaminal narrowing.
At L3-L4, there is a disc bulge with a left annular tear
touching the left L3
nerve root in the left neural foramen. At L4-L5, there is a disc
bulge with an annular tear on the left. There is also bilateral
facet arthrosis which in combination with the disc bulge is
causing compression of the right L4 nerve root and also
contacting the left L4 nerve root. There is ligamentum flavum
thickening but no spinal canal stenosis. At L5-S1, there is a
disc bulge with an annular tear but no spinal canal stenosis or
neural foraminal narrowing.
Brief Hospital Course:
The patient is a ___ yo RHM h/o prior right parietal IPH (___)
c/b seizures, lung cancer (s/p right lobectomy, chemotherapy,
radiation), PAF, CKD, HTN, COPD p/w severe right
periorbital/temporal headache and subsequently sudden onset
aphasia and left hemiparesis. He was transferred from an OSH
with a finding of a 3.2 x 2.9 cm right temporal IPH and was
admitted to the Neuro ICU for close monitoring and blood
pressure control. His deficits quickly improved but overnight on
___ he did have some worsening of LLE weakness which had
resolved by the morning. Repeat ___ showed no change in size
or extent of the hemorrhage. He was continued on lamotrigine at
a slightly higher dose (175 mg/150 mg from 150 mg BID)
concerning the possibility of increased seizure activity related
to the hemorrhage. Given concerns regarding the nature of his
hemorrhage, he had an MRI Brain with contrast which (other than
the hemorrhage) showed no underlying obvious mass or vascular
malformation. Given his stable neurological examinations and
hemodynamic stability, he was transferred to the floor wards of
the Neurology unit.
Neurosurgery was consulted to perform a diagnostic cerebral
angiogram to identify a possible arteriovenous dural fistula or
other cerebral vascular malformation as a possible etiology of
his two hemorrhages. This was done following the administration
of steroids, H1 and H2 blockers as well as a bicarbonate
preparation given his 1) chronic kidney disease with Cr 1.7-1.8,
and 2) history of iodine contrast allergy. This also
unfortunately did not identify an etiology of his
intraparenchymal hemorrhages. This procedure was complicated a
small groin hematoma that was not noticeable the next day. His
peripheral pulses remained constant.
He did complain of some local right sided hip pain which was
limiting motion of his right lower extremity. We obtained hip
films and a lumbar spine MRI which showed no acute injury,
fracture or radicular/plexus lesion, which was reassuring. He
also reassured us that he has had problems with hip pain in the
past.
On the day of his discharge, he was able to ambulate with one
assist. His foley catheter was discontinued. His pain was well
controlled with PO analgesics and he obtained good relief from
his pain following one dose of IV toradol.
TRANSITIONAL ISSUES:
- Please be sure to have Mr. ___ follow up with Dr. ___
Dr. ___ at the dates/times listed below. He has been
ordered for an outpatient MRI/MRA for follow up. The date for
this test has not been scheduled. Please call ___ to
clarify date/time of this appointment.
Medications on Admission:
Lamotrigine 150mg bid
Metoprolol 50mg bid
Simvastatin 10mg HS
Omeprazole 40mg qd
Lisinopril 10mg qd
Combivent inhaler qid
Acetaminophen 650mg qid PRN
Discharge Medications:
1. lamotrigine 150 mg Tablet Sig: One (1) Tablet PO QAM (once a
day (in the morning)).
Disp:*30 Tablet(s)* Refills:*2*
2. lamotrigine 25 mg Tablet Sig: One (1) Tablet PO QAM.
Disp:*30 Tablet(s)* Refills:*2*
3. lamotrigine 150 mg Tablet Sig: One (1) Tablet PO QPM (once a
day (in the evening)).
Disp:*30 Tablet(s)* Refills:*2*
4. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
6. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
7. oxycodone 5 mg Tablet Sig: Two (2) Tablet PO Q3H (every 3
hours) as needed for headache.
Disp:*40 Tablet(s)* Refills:*0*
8. benzonatate 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day) as needed for cough.
Disp:*30 Capsule(s)* Refills:*0*
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Main Diagnosis: Intraparenchymal hemorrhage
Paroxysmal atrial fibrillation
History of lung cancer s/p pneumonectomy
Chronic kidney disease
Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
.
Neuro exam on discharge: Normal mental status without focal
weakness or sensory deficits. No cranial nerve findings save for
mild old left ptosis.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you during this
hospitalization. You were admitted to the ICU after you were
found to have an area of bleeding in your brain. We performed a
number of neuroimaging tests as well as an angiogram to
understand the cause for this bleeding. These tests all showed
that the size of your bleed remained stable, which is
reassuring. We were able to organize a rehabilitation location
for you so that you can spend a few days/weeks building your
strength and balance. We have set up follow up appointments for
you to see your primary care physician as well as Dr. ___
___ the division of Stroke Neurology.
- We ask that you take all your medications as prescribed below.
- Please see the doctors ___ below for ___.
- Do not hesitate to contact us should you have any questions or
concerns.
Followup Instructions:
___
|
19720007-DS-9
| 19,720,007 | 29,113,438 |
DS
| 9 |
2130-06-19 00:00:00
|
2130-06-19 16:34:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Penicillins / codeine
Attending: ___.
Chief Complaint:
Fall from standing
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ DM, afib on Coumadin s/p fall from standing p/w isolated R
displaced proximal humerus fracture.
Past Medical History:
DM, afib on Coumadin, neuropathy, hypothyroid
Social History:
___
Family History:
Non-contributory
Physical Exam:
Admission Physical Exam:
Temp: 98.5; P:104; BP:132/77; RR: 18; O2: 985RA
General: alert, oriented X3; in no acute distress
HEENT: atraumatic, normocephalic, in no acute distress
Resp: clear breath sounds bilaterally
CV: chronic a fib; no murmurs, rubs or gallops
Abd: soft, non-distended, non-tender
Extr: R displaced proximal humerus fx, splinted; in sling
Discharge Physical Exam:
VS:98.9, 100/68, 98, 18, 97% RA
General: alert, sitting up in chair.
HEENT: no deformity. PERRL. EOMI. mucus membranes pink/moist.
trachea midline. neck supple.
CV: Irregular rhythm, normal rate.
Resp: Clear to auscultation bilaterally.
Abd: Soft, non-distended, non-tender, normo-active bowel sounds.
Ext: Right upper extremity in splint. Ecchymosis to right bicep.
pulses intact 2+, sensation intact. 1+ edema bilateral lower
extremity. calves soft/non-tender.
Pertinent Results:
___ 04:47AM GLUCOSE-385* UREA N-24* CREAT-0.8 SODIUM-136
POTASSIUM-4.7 CHLORIDE-100 TOTAL CO2-22 ANION GAP-19
___ 04:47AM CALCIUM-8.5 PHOSPHATE-4.4 MAGNESIUM-1.6
___ 04:47AM WBC-13.4* RBC-3.58* HGB-11.5 HCT-35.1 MCV-98
MCH-32.1* MCHC-32.8 RDW-13.4 RDWSD-48.4*
___ 04:47AM PLT COUNT-250
___ 04:47AM ___ PTT-33.0 ___
___ 02:06AM GLUCOSE-459* UREA N-24* CREAT-0.9 SODIUM-133
POTASSIUM-5.2* CHLORIDE-98 TOTAL CO2-20* ANION GAP-20
___ 02:06AM PHOSPHATE-4.6* MAGNESIUM-1.6
___ 02:06AM ___ PO2-140* PCO2-38 PH-7.36 TOTAL
CO2-22 BASE XS--3
___ 02:06AM LACTATE-3.6*
___ 10:23PM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 10:23PM URINE BLOOD-NEG NITRITE-POS PROTEIN-TR
GLUCOSE-1000 KETONE-40 BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-TR
___ 10:23PM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 10:23PM URINE BLOOD-NEG NITRITE-POS PROTEIN-TR
GLUCOSE-1000 KETONE-40 BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-TR
___ 10:23PM URINE RBC-2 WBC-9* BACTERIA-MOD YEAST-NONE
EPI-1
___ 09:50PM GLUCOSE-421* UREA N-22* CREAT-0.8 SODIUM-133
POTASSIUM-4.5 CHLORIDE-96 TOTAL CO2-19* ANION GAP-23*
___ 09:50PM estGFR-Using this
___ 09:50PM DIGOXIN-1.2
___ 09:50PM WBC-18.8* RBC-3.93 HGB-12.8 HCT-38.1 MCV-97
MCH-32.6* MCHC-33.6 RDW-13.3 RDWSD-47.8*
___ 09:50PM NEUTS-86.6* LYMPHS-7.2* MONOS-4.8* EOS-0.0*
BASOS-0.2 IM ___ AbsNeut-16.31* AbsLymp-1.35 AbsMono-0.91*
AbsEos-0.00* AbsBaso-0.04
___ 09:50PM PLT COUNT-278
___ 09:50PM ___ PTT-35.2 ___
___
DX SHOULDER & HUMERUS
IMPRESSION:
Obliquely oriented fracture through the proximal right humeral
diaphysis, with lateral displacement of the distal fracture
fragment and approximately 1-2 cm of foreshortening. Extension
of fracture line to involve the right greater tuberosity.
Suspected extension through through the surgical neck.
___ CT AB/PELVIS
No evidence of traumatic injury in the abdomen or pelvis. Fatty
liver.
___ Right Knee xray
Degenerative changes without acute fracture
___ ECG: Atrial fibrillation with a rapid ventricular
response. Diffuse ST-T wave abnormalities. No previous tracing
available for comparison.
Brief Hospital Course:
Ms. ___ is a ___ year old female admitted to the Acute Care
Trauma surgical service with right arm pain. An Xray showed a
right humerus fracture. The orthopedic surgery team was
consulted and recommended a brace, non-weight bearing, and out
patent follow up in clinic. Upon admission her blood glucose was
elevated in the 400's, ketones in her urine, and hyperkalemia.
She was admitted to the ICU for further medical management
related to elevated blood glucose.
___ Diabetes specialist was consulted for diabetic
management. The patient was placed on insulin drip and
resuscitated in the ICU. On HD2, the patient was discharged from
the ICU after being transitioned to insulin therapy.
The patient has been followed by physical and occupation therapy
who recommend acute rehabilitation post discharge.
The remainder of the hospital course is as follows:
Neuro: The patient was alert and oriented throughout
hospitalization; pain was initially managed with a IV dilaudid
and then transitioned to oral Tylenol and oxycodone once
tolerating a diet.
CV: The patient remained stable from a cardiovascular
standpoint; vital signs were routinely monitored. Coumdin was
held in the setting of potential surgical intervention for her
fracture.
Pulmonary: The patient remained stable from a pulmonary
standpoint; vital signs were routinely monitored. Good pulmonary
toilet, early ambulation and incentive spirometry were
encouraged throughout hospitalization.
GI/GU/FEN: The patient tolerated a regular diabetic diet. Intake
and output were closely monitored. She was found to have a
urinary tract infection and prescribed a 3 day course of
ciprofloxacin.
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 with assistance, voiding, and pain was well
controlled. The patient received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with the discharge plan. Follow up appointments were
scheduled with the orthopedic surgery team. She should follow up
with her primary care to address her diabetic management. Her
Coumadin can be restarted ___ after her course of
ciprofloxacin is complete.
Medications on Admission:
Coumadin 7.5mg ___, 5mg ___
Levothyroxine 112mcg daily
Atenolol 25mg daily
Digoxin 0.25mg daily
Lisinopril 10mg daily
Metformin 1000mg BID
Glimepiride 4mg BID
Januvia 1mg daily
HCTZ 25mg 3x/wk
Discharge Medications:
1. Atenolol 25 mg PO DAILY
2. Digoxin 0.25 mg PO DAILY
3. Hydrochlorothiazide 25 mg PO 3X/WEEK (___)
4. Levothyroxine Sodium 112 mcg PO DAILY
5. Lisinopril 10 mg PO DAILY
6. Warfarin 7.5 mg PO 4X/WEEK (___)
Please resume on ___.
7. Warfarin 5 mg PO 3X/WEEK (___)
Please resume on ___.
8. Acetaminophen 650 mg PO Q6H:PRN pain
9. Docusate Sodium 100 mg PO BID
hold for diarrhea
10. Senna 8.6 mg PO BID:PRN constipation
11. sitaGLIPtin 100 mg oral DAILY
12. MetFORMIN (Glucophage) ___ mg PO BID
13. glimepiride 4 mg ORAL BID
14. Ciprofloxacin HCl 500 mg PO Q12H
RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth every twelve
(12) hours Disp #*2 Tablet Refills:*0
15. Heparin 5000 UNIT SC BID
until INR therapeutic on Coumadin.
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Right humerus 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:
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 driving or operating heavy machinery while taking pain
medications.
Followup Instructions:
___
|
19720119-DS-7
| 19,720,119 | 28,060,710 |
DS
| 7 |
2180-12-20 00:00:00
|
2180-12-20 18:58:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Augmentin
Attending: ___.
Chief Complaint:
cough
Major Surgical or Invasive Procedure:
intubation ___
extubation ___
ICP bolt placement ___
ICP bolt removed ___
Lumbar puncture ___
History of Present Illness:
Ms. ___ is a ___ year old female with uncertain PMHx who
presents as a transfer from ___ for multi-organ failure.
By ED report, she was recently treated for a pneumonia. Based on
a medication history review she was prescribed Augmentin x 7
days. She was doing better but remained slightly dyspneic, which
began worsening the day prior to admission. She went to ___.
___ and was found to have grossly abnormal labs
prompting transfer to ___.
According to their records, she had new onset bilateral
peripheral edema.
In our ED, her initial vitals were: T 100, HR 112, BP 120/91, RR
28, O2 100% RA. She had progressively increased work of
breathing and was intubated. After intubation she was started on
norepinephrine for hypotension.
Her labs were notable for:
131 | 90 | 33
---------------< 63 AG = 33
4.4 | 12 | 1.7
23.7 > 5.2/18.4 < 188 MCV 76, N 86.8
INR 3.1, PTT 33.3, Fibrinogen 130
BNP 28409, Trop-T 0.60
AST ___ ALT 8270 AP 116 TBili 1.6 Lip 61 Alb 3.5
Negative serum tox screen. Urine tox positive for
benzodiazepines. Negative HCG.
VBG: ___ with lactate 7.3
POCUS: "no effusion, LVEF ~45%, no noted RWMA, RV dilatation
(1:1) with hypokinesis, plethoric IVC. c/w toxic-metabolic biV
dysfunction, less so PE"
She was given:
___ 00:54 IV DRIP Acetylcysteine (IV) (3000 mg ordered)
Started 62.5 mL/hr
___ 01:24 IV Ketamine (For Intubation) 100 mg
___ 01:24 IV Succinylcholine 100 mg
___ 01:24 IV DRIP Midazolam ___ mg/hr ordered) Started 2
mg/hr
___ 01:57 IV Dextrose 50% 25 gm
___ 02:22 IVF D5NS ( 1000 mL ordered) Started 125 mL/hr
___ 02:35 IV Vecuronium Bromide 10 mg
___ 02:39 IV DRIP Midazolam Confirmed Rate Changed to 4
mg/hr
___ 02:39 IV DRIP Fentanyl Citrate (100-200 mcg/hr
ordered)Started 100 mcg/hr
___ 02:39 IVF NS ( 500 mL ordered)
___ 02:39 IV DRIP NORepinephrine (0.03-0.25 mcg/kg/min
ordered) Started 0.12 mcg/kg/min
On arrival to the MICU, the patient was intubated and sedated.
Review of systems: See HPI. Otherwise unable to obtain.
Past Medical History:
-allergies
-asthma
-depression
-history of hospitalizations: anorexia as a teenager
-anorexia with laxative use
-no history of drug overdose
-no history of alcohol abuse
Social History:
___
Family History:
-mom: breast cancer
-father: healthy
no know family history of hepatitis, cirrhosis, need for
transplantation, gastrointestinal or liver malignancies
Physical Exam:
ADMISSION EXAM
==============
Vitals: T: 100.7 BP: 116/80 P: 107 R: 28 O2: 100% on ventilator
GENERAL: Intubated and sedated
HEENT: Sclera anicteric, PERRL, MMM, oropharynx clear
NECK: R IJ CVL in place
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
EXT: Warm, well perfused, 2+ edema bilaterally
SKIN: No rashes or bruising
DISCHARGE EXAM
==============
Pertinent Results:
ADMISSION LABS
==============
___ 12:16AM BLOOD WBC-23.7* RBC-2.42* Hgb-5.2* Hct-18.4*
MCV-76* MCH-21.5* MCHC-28.3* RDW-19.9* RDWSD-54.3* Plt ___
___ 12:16AM BLOOD ___ PTT-33.3 ___
___ 12:16AM BLOOD ___
___ 01:50PM BLOOD Fibrino-97*
___ 12:56PM BLOOD Parst S-NEGATIVE
___ 12:16AM BLOOD Glucose-63* UreaN-33* Creat-1.7* Na-131*
K-4.4 Cl-90* HCO3-12* AnGap-33*
___ 12:16AM BLOOD ALT-8270* ___ AlkPhos-116*
TotBili-1.6*
___ 12:16AM BLOOD Lipase-61*
___ 12:16AM BLOOD ___
___ 02:15AM BLOOD UricAcd-16.9* Iron-24*
___ 02:15AM BLOOD HBsAg-Negative HBsAb-Negative HAV
Ab-Negative IgM HBc-Negative IgM HAV-Negative
___ 12:16AM BLOOD HCG-<5
___ 04:49AM BLOOD AMA-NEGATIVE Smooth-NEGATIVE
___ 11:51AM BLOOD CEA-2.0 AFP-2.3
___ 04:49AM BLOOD ___
___ 12:56PM BLOOD HIV Ab-Negative
___ 02:15AM BLOOD HCV Ab-Negative
___ 02:15AM BLOOD HBV VL-NOT DETECT HCV VL-NOT DETECT
___ 12:22AM BLOOD Type-CENTRAL VE Temp-37.8 pO2-33*
pCO2-25* pH-7.37 calTCO2-15* Base XS--9 Intubat-NOT INTUBA
___ 12:22AM BLOOD Lactate-7.3* K-4.2
IMAGING
=======
RUQ US ___. Patent hepatic vasculature and IVC.
2. Slightly echogenic liver and gallbladder wall edema without
gallbladder
distention are compatible with provided history of liver
failure.
CT CHEST ___. Mild cardiomegaly without pericardial effusion. Suggestion
of anemia.
2. Suggestion of pulmonary hypertension.
3. Moderate bibasilar atelectasis and mild mucous plugging,
right greater than left. An underlying infection or aspiration
cannot be excluded in the proper clinical setting.
4. Subpleural posterior consolidation in the left upper lobe
could reflect
atelectasis but warrants follow-up in 3 months to exclude an
underlying
malignancy.
5. No acute abnormality in the abdomen. Nondistended
gallbladder with
gallbladder wall thickening likely related to to clinical
history of liver
disease, or systemic causes ; cholecystitis is unlikely.
ECHO ___
The left atrium is elongated. No atrial septal defect is seen by
2D or color Doppler. Left ventricular wall thicknesses and
cavity size are normal. Overall left ventricular systolic
function is moderately depressed (LVEF= 35 %). There is no
ventricular septal defect. The right ventricular free wall is
hypertrophied. The right ventricular cavity is mildly dilated
with moderate global free wall hypokinesis (fractional area
change = 25%). There is abnormal diastolic septal
motion/position consistent with right ventricular volume
overload. The number of aortic valve leaflets cannot be
determined. There is no aortic valve stenosis. Trace aortic
regurgitation is seen. The mitral valve leaflets are
structurally normal. Mild to moderate (___) mitral
regurgitation is seen. Moderate [2+] tricuspid regurgitation is
seen (may be underestimated due to suboptimal imaging). There is
mild pulmonary artery systolic hypertension. There is a
trivial/physiologic pericardial effusion. There are no
echocardiographic signs of tamponade.
ECHO ___
The left atrium is elongated. Left ventricular wall thicknesses
are normal. The left ventricular cavity size is normal. Overall
left ventricular systolic function is severely depressed (LVEF=
20 %). The right ventricular free wall thickness is normal.
Right ventricular chamber size is normal with depressed free
wall contractility. The diameters of aorta at the sinus,
ascending and arch levels are normal. The aortic valve leaflets
(3) appear structurally normal with good leaflet excursion and
no aortic stenosis or aortic regurgitation. The mitral valve
leaflets are structurally normal. Moderate (2+) mitral
regurgitation is seen. Moderate [2+] tricuspid regurgitation is
seen. There is moderate pulmonary artery systolic hypertension.
There is no pericardial effusion.
ECHO ___
Left ventricular wall thicknesses and cavity size are normal.
There is moderate global left ventricular hypokinesis (biplane
LVEF = 33 %). The right ventricular cavity size is milldy
increased with low normal free wall motino. The mitral valve
leaflets are structurally normal. There is no mitral valve
prolapse. Mild to moderate (___) mitral regurgitation is seen.
There is mild pulmonary artery systolic hypertension. There is a
trivial/physiologic pericardial effusion.
IMPRESSION: Normal left ventricular cavity size with moderate
global hypokinesis in a pattern most c/w a non-ischemic
cardiomyopathy. Mild-moderate mitral regurgitation. Mild
pulmonary artery systolic hypertension.
Compared with the prior study (images reviewed) of ___,
global left ventricular systolic function has improved. The
severity of mitral regurgitation, tricuspid regurgitation and
the estimated PA systolic pressure are now slightly lower. The
heart rate is also now lower.
VQ Scan ___. Low likelihood ratio for pulmonary embolism.
NCCT Head ___. Suggestion of early global cerebral swelling. No evidence of
hemorrhage or infarction.
NCCT HEAD ___
No acute intracranial process.
CT Abd/pelvis ___
Suggestion of acute pancreatitis involving pancreatic tail.
Diffuse soft tissue edema.
CT Chest
1. Proximal right mainstem bronchus intubation, endotracheal
tube should be pulled back.
2. Consolidation, adjacent nodularity in the posterior left
upper lobe is
unchanged, is indeterminate, follow-up exam is recommended.
3. Improvement in bibasilar atelectasis ; residual ground-glass
opacities may be sequela of re-expansion; infection is less
likely. .
4. No new acute abnormality in the chest.
RECOMMENDATION(S): Follow-up of left upper lobe consolidation
with CT in 3 months time.
CSF:
NEGATIVE FOR MALIGNANT CELLS.
Lymphocytes and monocytes.
MRI HEAD ___
There is no evidence of intracranial hemorrhage, mass, mass
effect or shifting of the normally midline structures. The
ventricles and sulci are normal in size and configuration for
the patient's age. No diffusion abnormalities are detected.
Small subependymal hyperintense areas are noted adjacent to the
left ventricular horns (for example image 14, series 10), which
are nonspecific and may represent some gliotic areas and of
doubtful clinical significance. The major vascular flow voids
are present and demonstrate normal distribution. The orbits are
unremarkable, the paranasal sinuses are notable for mucosal
thickening in the maxillary sinuses, more significant on the
right, frontoethmoidal recesses, frontal sinus, sphenoid sinus.
Bilateral mucosal thickening is present mastoid air cells, more
significant on the left.
___ U/S ABD/PELVIS
1. Patent hepatic vasculature. Pulsatile waveforms within the
portal veins could be due to right heart failure.
2. Small stones and sludge noted in the gallbladder. There is
no sonographic sign of cholecystitis and there is no biliary
dilation.
3. Scant trace ascites seen only in the perihepatic space.
4. Normal sonographic appearance of the pancreas with no
evidence of secondary sequelae of acute pancreatitis.
OTHER LABS/STUDIES
==================
HIV-Ab: Negative
RPR: Negative
FluAPCR: Negative
FluBPCR: Negative
Hepatitis B Surface Antigen Negative
Hepatitis B Surface Antibody Negative
Hepatitis A Virus Antibody Negative
Hepatitis B Core Antibody, IgM Negative
Hepatitis A Virus IgM Antibody Negative
Hepatitis C Virus Antibody Negative
HBV VL undetectable
HCV VL undetectable
immunogloblulins relatively normal
tox neg
___ VIRUS: RESULTS INDICATIVE OF PAST EBV INFECTION.
CA ___: 20 (<34)
Anti-Mitochondrial Antibody NEG
Anti-Smooth Muscle Antibody NEG
Anti-Nuclear Antibody NEG
Herpesvirus 6 Antibody, IgG and IgM: PAST INFECTION
Hepatitis E Antibody (IgG) NEG
Parvovirus B19 Antibodies: IgG positive, IgM NEG
CMV IgG ANTIBODY: Neg
CMV IgM ANTIBODY: Neg
VARICELLA-ZOSTER IgG SEROLOGY: Neg
___: negative
Paraneoplastic panel: negative
DISCHARGE LABS
==============
___ 07:26AM BLOOD WBC-8.4 RBC-3.23* Hgb-8.3* Hct-28.2*
MCV-87 MCH-25.7* MCHC-29.4* RDW-30.2* RDWSD-92.0* Plt ___
___ 08:06AM BLOOD ___ PTT-28.4 ___
___ 07:26AM BLOOD Plt ___
___ 03:02AM BLOOD ___
___ 03:24AM BLOOD QG6PD->19.5*
___ 05:21AM BLOOD Ret Aut-5.0* Abs Ret-0.16*
___ 07:26AM BLOOD Glucose-80 UreaN-9 Creat-1.1 Na-139 K-4.4
Cl-100 HCO3-23 AnGap-20
___ 07:26AM BLOOD ALT-69*
___ 07:26AM BLOOD Calcium-9.0 Phos-4.7* Mg-1.5*
Brief Hospital Course:
Ms ___ is a ___ with h/o asthma, depression, anorexia w/
laxative abuse who was recently treated for PNA with Augmentin
initially went to her PCP and then an outside hospital for
shortness of breath and new peripheral edema. Her work up at the
OSH showed a Troponin of 7, BNP of 30000, Creat of 1.35, and a
marked transaminitis concerning for acute liver failure. She was
transferred to ___ for further care and eval for liver
transplant.
Tox screen negative, but she was empirically given NAC given
abnormal LFTs and concern for drug toxicity. She also had an
ECHO which showed an EF of 35% consistent with new systolic
heart failure. She was also found to have ATN, with Cr peaking
at 7.2; ALT/AST 8000s/12000s. She was intubated ___ mental
status change thought to be due to hepatic encephalopathy. A
head CT was obtained which demonstrated early global cerebral
swelling. Pt was started on EEG and neurology was consulted. EEG
showed irritability but no frank seizures; she was started on
keppra. LP done on ___ which showed elevated opening pressure,
but negative otherwise. Patient was extubated ___ with
improved mental status. She was transferred to the floor. LFTs,
renal function improved. Repeat echos with nadir at 25%, though
EF improved to 33% prior to DC. Patient worked with ___. She
was seen by psych in the setting of significant h/o depression,
anorexia and laxative abuse. They did not feel she was SI/HI or
had a purposeful ingestion.
Pt's mental status continued to improve prior to discharge,
A+Ox3, without asterixis. She was on rifaximin and lactulose per
Hepatology, but this was discontinued once her LFTs and mental
status normalized. Heme-Onc was consulted for severe anemia on
presentation, along with questionable hyper-coaguable state, pt
will f/u with Hematology as outpatient. She will also follow-up
with cardiology upon discharge for her new heart failure with
systolic dysfunction.
#Acute respiratory failure:
Patient was intubated x 2 during MICU course. Initial intubation
was in ED for unclear reasons, and patient weaned off ventilator
in a few days. Patient then became increasingly altered and
tachypneic, with sustained RR in ___. Imaging showed possible
evidence of pneumonia and she was treated with antibiotics. Also
attributed to possible encephalopathy. As mental status improved
she was able to be weaned from the vent and was extubated on
___.
#Acute liver failure:
Her initial lab work showed AST > 12k and ALT > 8k with elevated
INR and Tbili. ALT/LDH ratio <1.5 and rapid rise of LDH with
associated ATN point to possible ischemic etiology. Serum
acetaminophen and ETOH negative. Broad workup initiated which
was mostly unremarkable for causes of acute liver failure.
Patient does have known history of laxative abuse and was
reportedly taking "handfuls" of bisacodyl which could have
contributed. She was treated with NAC until INR downtrended
below 2. She did have evidence of cerebral edema on CT Head and
patient had altered mental status and was treated with
lactulose/rifaximin. LFTs trended down during hospital course
and coags normalized. Her lactulose/rifaximin were discontinued
after her mental status and LFTs normalized.
#Acute renal failure, acute tubular necrosis:
Her creatinine peaked in the 7's, though patient never lost the
ability to make urine. Consideration was given for dialysis for
uremia/altered mental status but deferred as UOP picked up and
encephalopathy improved. Cr 1.1 on discharge.
#Toxic metabolic encephalopathy:
After initial extubation, patient became increasingly altered
and would not follow commands and would not speak. With
concomitant tachypnea, she was intubated. CT Head showed
possible early global cerebral edema. LP performed had elevated
opening pressure to 34. CSF studies unremarkable. EEG with
generalized cortical irritability, and neurology recommended
starting her on Keppra. Neurosurgery placed an intracranial bolt
for ICP monitoring and this was normal. Lactulose/rifaximin
continued in case hepatic encephalopathy. Abx given at
meningitic doses, with ___ompleted. Her
encephalopathy improved throughout hospital course and she
became more responsive and oriented. She had some asterixis, but
upon discharge this was gone and she was A+Ox3 and able to say
days of week backwards.
#Acute systolic CHF:
Patient's initial echo showed EF 35% with global hypokinesis.
As patient worsened, repeat echo showed EF 20% with again global
hypokinesis. Cardiology consulted for questionable cardiac
biopsy but deferred as thought to be low-yield in terms of
providing info for overall picture of patient and in setting of
___. Patient will have follow-up with heart failure specialist
who can consider MR vs. biopsy. Repeat echo prior to d/c with EF
33%. Patient was started on coreg 12.5 mg BID and lisinopril 2.5
mg qd.
#Microcytic Anemia:
From collateral from PCP prior labs ___/ MCV 83, H&H ___
(normocytic anemia). No Fe studies per outpt PCP. RI on ___
with RI<2% likely rep of underproduction. However, repeat RI >
2% w/ normal hapto and no evidence of acute blood loss. Fe snl,
TIBC wnl and ferritin normal. Fe/TIBC 21% which is not c/w Fe
def anemia. Fe/TIBC 21% could be c/w anemia of chronic
inflammation, but ferritin nrm and Fe and TIBC wnl. Started Fe
supplement per heme-onc.
# h/o Depression
# h/o Anorexia/bulimia w/ laxative use
On disability for depression and anorexia. Collateral from
family indicates she may have been using at home. Unclear if
possible ingestion contributed to presentation and multi-organ
failure. Patient denies SI/HI prior to hospitalization. Does
report large ingestions of laxatives. Psych consulted and
strongly advises patient to have psych/SW follow-up for rehab.
She also recs DMH referral. Held home mirtazapine,
amitriptyline, alprazolam, venlafaxine, sertraline per
psychiatry.
# h/o anorexia w/ laxative abuse and depression. Per her
parents/patient, was abusing bisacodyl prior to presentation
# Pancreatitis: Unknown etiology. Abdomen has remained
non-tender.
# Nutrition
continued S/S eval as patient transitions to rehab and consider
DMP as part of dc planning.
# Elevated intracranial pressure- resolved: Discovered on LP w/
some evidence of cerebral edema on CT head. Initially had ICP
monitoring w/ normal pressures. D/c bolt on ___.
CHRONIC ISSUES:
================
# Migraine
Patient with migraines for many years. She responded well w/ po
tylenol and hot packs.
# Asthma: continued Albuterol Q4H PRN and Advair BID
TRANSITIONAL ISSUES:
===================
#NEW MEDICATIONS: Carvedilol 12.5 mg BID, Lisinopril 2.5 mg qd,
Ferrous Sulfate 325mg qd, Keppra 500mg BID
# HELD MEDICATIONS: Pravastatin 20mg qhs, OCP
# STOPPED MEDICATIONS: Xanax 1mg tid, Amitryptiline 75mg
qhs:prn, Mirtazipine 45mg qhs, Montelukast 10mg qd, Omeprazole
20mg qd, Potassium 10 mEq BID, Promethazine 25mg q6h:prn,
Sertraline 200mg qd, Venlafaxine 300mg qd
-Incidental Finding on CT-Chest: Subpleural posterior
consolidation in the left upper lobe could reflect atelectasis
but warrants follow-up in ___ weeks per Heme-Onc to exclude an
underlying malignancy. (___)
[] per neurology, AMS most likely ___ toxic metabolic
encephalopathy ___ overall picture. EEG ___ discharges,
but c/w 500mg keppra bid. Will f/u as outpatient ___ EEG,
if wnl, can d/c keppra at that time. ___ mo from discharge)
[] Recommend rifaximin/lactulose if she develops signs or
symptoms of hepatic encephalopathy, was previously on these meds
over admission though ended prior to DC with encephalopathy
improvement, will f/u with Hepatology as outpatient
[] pt with new cardiomyopathy, unclear etiology, improved prior
to DC. Pt was started on Carvedilol 12.5 mg BID, lisinopril 2.5
mg qd and will f/u with Heart Failure Cardiology clinic and
likely repeat TTE (as her EF was improving)
[] pt will require pysch f/u-- Psychiatry team recommended
SW/psych follow-up. Psychiatry also recommended discontinuing
all prior home psych meds until psych f/u apt. Patient given a
list of mental health providers in her area by SW.
[] would recommend weekly labs to check electrolytes (sodium, K,
BUN/Cr), CBC, and Liver Function tests to confirm continued
downtrend/normalization
[] pt started on PO iron per Heme-Onc as has mixed iron
deficiency anemia with chronic disease picture. pt will f/u with
Hematology to f/u anemia, started on Ferrous Sulfate. Heme-Onc
consult did not recommend hyper-coaguable ___ while inpatient
[] pt will f/u with ___ clinic as outpatient for ATN. Cr
peaked >7, though was resolving prior to DC
-DC WEIGHT: 69.4 kg (153 lb)
#Communication: ___ (Brother) ___, ___ (mom)
___ or ___
#Code: Full
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. ALPRAZolam 1 mg PO TID
2. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheezing
3. Amitriptyline 75 mg PO QHS:PRN per instruction
4. Mirtazapine 45 mg PO QHS
5. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
6. Omeprazole 20 mg PO DAILY
7. Montelukast 10 mg PO DAILY
8. Pravastatin 20 mg PO QPM
9. Venlafaxine XR 300 mg PO DAILY
Discharge Medications:
1. Carvedilol 12.5 mg PO BID
RX *carvedilol 12.5 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*0
2. Ferrous Sulfate 325 mg PO DAILY
RX *ferrous sulfate 325 mg (65 mg iron) 1 tablet(s) by mouth
daily Disp #*30 Tablet Refills:*0
3. LevETIRAcetam 500 mg PO BID
RX *levetiracetam 500 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*0
4. Lisinopril 2.5 mg PO DAILY
RX *lisinopril 2.5 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
5. Acetaminophen 500 mg PO Q6H:PRN Pain - Mild
6. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheezing
7. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
8. HELD- Montelukast 10 mg PO DAILY This medication was held.
Do not restart Montelukast until told to do so by your doctor
9. HELD- Trivora (28) (levonorg-eth estrad triphasic) ___
(6)/75-40 (5)/125-30(10) oral daily This medication was held.
Do not restart Trivora (28) until told to do so by your doctor
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS
==================
acute systolic CHF
acute liver failure
acute tubular necrosis
toxic metabolic encephalopathy
SECONDARY DIAGNOSIS
===================
depression
anorexia
microcytic anemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Lethargic but arousable.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. ___,
You were in the hospital because you developed failure of
multiple organs. While you were in the hospital you had blood
work and tests to determine what caused the organ failure.
You were seen by multiple specialists including a liver doctor,
___, brain doctor and blood doctor. Many
tests were done to determine what caused your organ failures.
The tests came back negative for infection, blood clots, and
autoimmune disease. At this point, the cause of your organ
failure is now known. However, your organs began to recover
during your hospitalization. We have put a list of mental health
workers in your area that we would like you to contact and visit
as soon as possible at home. The information is below.
Please follow-up at the appointments below.
We wish you the best,
- Your ___ Team
___, ___
___ Counseling
___
___ Counseling ___
Phone: ___
Followup Instructions:
___
|
19720832-DS-11
| 19,720,832 | 23,036,537 |
DS
| 11 |
2139-10-08 00:00:00
|
2139-10-08 18:00:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / acetaminophen
Attending: ___
___ Complaint:
Oxygen desaturation
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ year old female with a history of left
pontine stroke with residual right sided weakness and recent
admission to ___ from ___ to ___ who presents from
rehab with fever to 101 and desaturation to 89% on 2.5L NC at
rehab. She had a left lower lobe opacity on her CXR in our ED
and was started on hospital acquired pneumonia coverage,
receiving cefepime/levofloxacin in the ED and vancomycin when
she came up to the floor.
.
Her admission from ___ to ___ was for hypoxemia. She
was treated empirically for heart failure with iv diuresis. She
was also treated for community acquired pneumonia at that time
and was discharged on levofloxacin, which she was to take
through ___ at rehab. She was getting levofoxacin daily per
the ___ records.
.
She has not had shaking chills or subjective fevers. She has a
stable productive cough that has persisted since her prior
admission.
.
In the ED 97.3 ___ 100% 15L Non-Rebreather. Above abx
given. Vitals on transfer: t 97, p98, 95/39 94% 6L NC.
Currently, she has no acute complaints.
Past Medical History:
- CVAs in ___, with residual R-hand and arm weakness for ___ year
afterwards
- Left-sided progressive weakness
- Meningioma
- Hyperlipidemia
Social History:
___
Family History:
daughter had NHL, now in remission ___, mother died
from breast ca, father from colon ca
Physical Exam:
ADMISSION EXAM:
General Appearance: Well nourished, No acute distress
HEENT: PERRL
Cardiovascular: RR, nml S1/S2, no murmurs
Respiratory: Decreased BS at bases, no wheezes
Abdominal: Soft, Non-tender, Bowel sounds present, no
organomegaly
Extremities: WWP, no ___ edema
Neurologic: A&Ox3, mild chronic right facial droop, unable to
move right hand, ___ strength in the right shoulder, sensation
grossly intact
.
DISCHARGE EXAM:
Pertinent Results:
ADMISSION LABS:
___ 04:52AM BLOOD WBC-7.1 RBC-3.60* Hgb-10.8* Hct-31.8*
MCV-89 MCH-29.9 MCHC-33.8 RDW-14.2 Plt ___
___ 04:52AM BLOOD Neuts-75.3* Lymphs-12.7* Monos-10.9
Eos-0.6 Baso-0.4
___ 04:52AM BLOOD Glucose-151* UreaN-21* Creat-0.8 Na-132*
K-3.5 Cl-97 HCO3-23 AnGap-16
___ 04:59AM BLOOD Lactate-1.3
.
DISCHARGE LABS:
.
MICRO:
___ Blood cultures: no growth to date
.
IMAGING:
___ CXR: Portable upright view of the chest demonstrates
ill-defined opacity in the lateral right lung base, slightly
more conspicuous since ___. Similar opacities seen in the
left lung base, has progressed since prior. Prominence of
interstitial markings persists. Hilar and mediastinal
silhouettes are unremarkable. The descending aorta is mildly
tortuous. Heart size is normal. There is no pneumothorax.
Healing remote left-sided rib fracture is noted.
IMPRESSION: Ill-defined opacities in bilateral lung bases, more
conspicuous since ___ exam, could be atypical infection.
.
___ ECHO: The left atrium is normal in size. No atrial
septal defect is seen by 2D or color Doppler. The estimated
right atrial pressure is ___ mmHg. Left ventricular wall
thicknesses and cavity size are normal. Left ventricular
systolic function is hyperdynamic (EF>75%) with normal regional
left ventricular wall motion. The estimated cardiac index is
normal (>=2.5L/min/m2). Right ventricular chamber size and free
wall motion are normal. The diameters of aorta at the sinus,
ascending and arch levels are normal. The aortic valve leaflets
(3) appear structurally normal with good leaflet excursion and
no aortic stenosis. Trace aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. Physiologic mitral
regurgitation is seen (within normal limits). There is a very
small pericardial effusion.
IMPRESSION: Normal biventricular cavity sizes with preserved
global and regional biventricular systolic function.
.
___ CT Chest w/o con:
1. Moderately severe emphysema with an inflammatory interstitial
component.
2. Scattered areas of alveolar opacification, have not worsened
since recent conventional radiographs, could have been due to
aspiration or no longer active infection. Alternatively, if the
patient continues to smoke, the findings could be due to
desquamative interstitial pneumonia or drug reaction.
3. Widespread atherosclerosis, including large plaques in head
and neck vessels, left main coronary artery and branches, and
minimally aneurysmal upper abdominal aorta.
4. Diffuse esophageal wall thickening could be due to reflux or
other causes of esophagitis
Brief Hospital Course:
___ year old female with a history of left pontine stroke with
residual right sided weakness and recent admission to ___ from
___ to ___ for ?CHF and pneumonia, who presents from
rehab with fever and hypoxia.
.
# Fever/Hypoxia: Patient had no fevers documented during this
admission. Her initial CXR showed diffuse interstitial
abnormalities bilaterally and a questionable right base opacity
suggesting pneumonia. We continued the levofloxacin which she
had been taking and added vancomycin/cefepime for possible HCAP.
A CT chest showed moderately severe emphysema with an
inflammatory interstitial component, also scattered areas of
alveolar opacification which could be due to desquamative
interstitial pneumonia or drug reaction. Given this, and her
lack of fevers/leukocytosis, and lack of improvement on the
levofloxacin, this was felt unlikely to be a bacterial pneumonia
so the antibiotics were stopped on ___. A respiratory viral
swab was ordered and a bronch was done with BAL, which did not
grow any organisms and revealed pale airways suggesting an
interstitial process. The cell differential on the bronchoscopy
indicated a possible inflammatory process such as AIP. She was
started on methylprednisolone 1000mg daily for 3 days (day one
recieved in the MICU on ___ and will require a slow taper over
the period of a month if her shortness of breath is improving.
.
# H/o left pontine stroke: Patient has residual right upper and
lower extremity weakness which remained stable with no new focal
findings on neuro exam. We continued aspirin 325mg and
atorvastatin 80mg.
.
# Right frontotemporal mass: Likely meningioma. Stable neuro
exam. Continued keppra for seizure prophylaxis.
.
# Hyperlipidemia: Continued atorvastatin.
.
# Restless Leg Syndrome: Continued carbidopa-levodopa.
# Goals of care: Ms. ___ and ___ family are currently
leaning towards ___ care going further. They were
amenable to PICC placement for IV steroids in case this will
improve Ms. ___ respiratory symptoms, but overall are
interested in measures to make Ms. ___ more comfortable.
___ from ___ worked with the patient and her
family while she was here, and will email the ___ care
department at her ___ nursing facility to update them as to
her progress. It may prudent to transition to comfort measures
only in the coming days depending on her response to steroids.
Transitional Issues:
- Ms. ___ was started on IV methylprednisolone 1gm x 3
days(day ___, and she will start prednisone 60mg daily on
___. She will likely need a long (1 month) taper to be
predicated by her respiratory response to the steroids.
- Goals of care will need to be re-addressed pending the
response to the steroids. The family is currently amenable to
___ focused care, but this will need to be re-confirmed.
Medications on Admission:
1. Aspirin 325 mg PO DAILY
2. Atorvastatin 80 mg PO HS
3. Bisacodyl ___AILY:PRN constipation
4. Carbidopa-Levodopa (___) 0.5 TAB PO TID
for restless leg syndrome
5. Dexamethasone 1 mg PO Q12H Duration: 2 Days
Continue through ___
Tapered dose - DOWN
6. Docusate Sodium 100 mg PO BID
7. NPH 3 Units Breakfast
NPH 3 Units Dinner
Insulin SC Sliding Scale using REG Insulin
8. LeVETiracetam 500 mg PO BID
9. Omeprazole 20 mg PO DAILY
10. Polyethylene Glycol 17 g PO BID:PRN constipation
11. Senna 2 TAB PO BID:PRN constipation
12. Sodium Chloride 1 gm PO TID
chronic hyponatremia
13. traZODONE 50 mg PO HS:PRN insomnia
14. dalteparin (porcine) *NF* 5,000 unit/0.2 mL Subcutaneous
daily
DVT prophylaxis
15. magnesium hydroxide *NF* 2400 mg Oral daily:PRN reflux
2400 mg/30ml
16. Nystatin Powder *NF* 15 GM Mucous Membrane qshift
17. polyvinyl alcohol *NF* 1.4 % ___
6 drops
18. Levofloxacin 750 mg PO DAILY Duration: 7 Days
End ___
Discharge Medications:
1. Aspirin 325 mg PO DAILY
2. Atorvastatin 80 mg PO DAILY
3. Bisacodyl 10 mg PR HS:PRN constipation
4. Carbidopa-Levodopa (___) 0.5 TAB PO TID
5. Docusate Sodium 100 mg PO BID
6. NPH 3 Units Breakfast
NPH 3 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
7. LeVETiracetam 500 mg PO BID
8. Omeprazole 20 mg PO DAILY
9. Polyethylene Glycol 17 g PO DAILY:PRN constipation
10. Senna 2 TAB PO BID:PRN constipation
11. Sodium Chloride 1 gm PO TID chronic hyponatremia
12. traZODONE 50 mg PO HS:PRN insomnia
13. dalteparin (porcine) *NF* 5000 Subcutaneous daily
14. magnesium hydroxide *NF* 2,400 mg/10 mL Oral daily reflux
symptoms
15. polyvinyl alcohol *NF* 1.4 % ___ 6 drops ___
16. MethylPREDNISolone Sodium Succ 1000 mg IV Q24H Duration: 2
Days
Total of 3 day course, recieved day 1 dose on ___ at ___
17. PredniSONE 60 mg PO DAILY
start on ___ after IV methylpred has been completed. Taper as
respiratory status improves.
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Interstitial Lung Disease of unknown cause
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking care of you at ___. You were
admitted with shortness of breath which is likely due to an
inflammatory disease involving your lungs. We started you on a
course of steroids which will hopefully improve your symptoms.
The following medication changes have been made:
STOP Dexamethasone and levofloxacin as these medications are no
longer necessary
START methylprednisolone 1000mg IV daily for a total of 3 days.
You will require 2 more days, as you recieved 1 of 3 days in the
ICU at ___
START Prednisone 60mg daily. This dose will need to be tapered
by your doctors at rehab.
Followup Instructions:
___
|
19720832-DS-12
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| 12 |
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|
2140-01-08 16:39:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / acetaminophen
Attending: ___.
Chief Complaint:
weakness and confusion
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms. ___ is a ___ year old female with a history of left
pontine stroke with residual right sided weakness, DM, Htn,
urinary retention and recent admission to ___ from ___ -
___ ___s admission to OSH ___ who
presents from ___ with increased lethargy and weakness
and inability to take PO meds. Per records she has been
feeling more weak and confused for several days. Also, per chart
she noted R arm pain and swelling for several days although she
says the pain only begain today once her arm was put in a cast.
She has mild abdominal pain, nausea and vomiting. She denies any
diarrhea, constipation, chest pain, shortness of breath, or
headache. She says she has had a dry cough for a while, not
sure exactly how long. Her most recent admission at OSH she was
diagnosed with urosepsis, acute on chronic blood loss anemia
(was transfused one unit for Hgb of 7.6), etiology unknown. She
has a foley in place for urinary retention.
In the ED, initial vs were 98.0 po, po, 99, 16, 110/51, 100% RA.
Her exam was notable for bilateral rhonchi and crackles, mildly
ttp diffusely, RUE w/swelling and eccymosis especially at wrist,
R side +1 strength and L +4 strength, AAOx3. Because of her
right wrist pain, xrays were obtained which were negative for
any acute fracture, however her R arm was put in a cast. Her CXR
was unchanged from prior but commented on interstitial lung
disease with small pleural effusions, no focal consolidation.
Her EKG was notable for new deep T waves and troponins were 0.02
(baseline <0.01). UA was negative with blood and urine cultures
pending. Of note, pt also had an outpatient brain MRI on ___
which noted interval multifocal subacute left cerebellar and
right occipital infarcts, likely emboli in etiology given the
distribution; Interval evolution of the known left paramedian
pontine infarct. No evidence of intracranial hemorrhage; Large
right frontal meningioma with similar mass effect and vasogenic
edema on to the adjacent parenchyma.
On arrival to the floor, patient reports pain all over her body,
weakness of the R side of her body which is not new. She says
"there is something wrong with my head", is tearful, and did not
fully cooperate with exam or interview.
Past Medical History:
-OSH admission ___ for sepsis of urologic origin, also
noted to have bilateral lower lobe infiltrates on CT abd/pelvis
with no clinical pneumonia, as well as bilateral hydronephrosis
which resolved after foley placement, discharged on levofloxacin
for 5 days.
-meningioma
-urinary retention with foley in place since last
hospitalization
- CVAs in ___, with residual R-hand and arm weakness for ___ year
afterwards
- left paramedian pontine infarct ___ with current R sided
weakness, numbness and tingling
- Left-sided progressive weakness
- right frontotemporal meningioma
- Hyperlipidemia
- COPD
- DM controlled
- Acute on chronic blood loss anemia, etiology unknown,
transfused one unit RBC's on last admission
-dysuria
-h/o alcohol abuse
-"other malignant lymphomas" per ___ record
-diverticulosis
-generalized abdominal pain
Social History:
___
Family History:
daughter had NHL, now in remission ___, mother died
from breast ca, father from colon ca
Physical Exam:
VS T: 97, HR 93, BP 109/50, RR16, O2 99% on 2L
GEN Alert and oriented x3, tearful, refusing to answer some
questions, "everything hurts"
HEENT NCAT MMM EOMI sclera anicteric, OP clear, R sided facial
droop
NECK supple, no JVD, no LAD
PULM Coarse crackles throughout lungs
CV RRR normal S1/S2, no mrg
ABD soft NT ND normoactive bowel sounds, no r/g, foley in place
EXT WWP 2+ pulses palpable bilaterally, no c/c/e
NEURO: AOx3, naming intact, dysarthric but speech fluent. Gait
could not be assessed. ___ strength in R arm and leg. Facial
droop on R. 3+ strength in L arm and leg. Hyperactive DTR's
R>L. Several beats of clonus at R achilles. Sensation decreased
on R side of body, intact on left. RAM intact in L hand.
Patient would not attempt FTN. EOMI, PERRL. Visual acuity
grossly intact. Visual fields intact. Hearing intact. Normal
elevation of soft palate.
SKIN no ulcers or lesions
Discharge Exam
VS T: 97.9, HR 80, 137/56, RR18, O2 96% on RA
GEN awake, alert, NAD
HEENT NCAT MMM EOMI sclera anicteric, OP clear, R sided facial
droop
PULM clear to auscultation anteriorly
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
Ext: R wrist in splint. R hand very swollen (3+ edema) and red.
L hand normal.
Pertinent Results:
Admission Labs:
___ 02:41PM BLOOD WBC-7.5 RBC-4.00* Hgb-12.0 Hct-37.1
MCV-93 MCH-30.1 MCHC-32.4 RDW-13.3 Plt ___
___ 02:41PM BLOOD Neuts-68.1 Lymphs-17.7* Monos-12.5*
Eos-1.2 Baso-0.4
___ 02:41PM BLOOD Glucose-89 UreaN-6 Creat-0.4 Na-139 K-3.6
Cl-104 HCO3-24 AnGap-15
___ 02:41PM BLOOD ALT-8 AST-21 CK(CPK)-31 AlkPhos-49
TotBili-0.3
___ 09:45PM BLOOD CK(CPK)-16*
___ 02:41PM BLOOD CK-MB-2
___ 02:41PM BLOOD cTropnT-0.02*
___ 09:45PM BLOOD CK-MB-2 cTropnT-0.02*
___ 08:20AM BLOOD cTropnT-0.02*
___ 02:41PM BLOOD Albumin-3.2* Calcium-8.6 Phos-3.6 Mg-1.5*
___ 02:49PM BLOOD Lactate-1.2 K-3.1*
___ 03:55PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.5 Leuks-NEG
___ 3:55 pm URINE **FINAL REPORT
___
URINE CULTURE (Final ___: NO GROWTH.
Video Speech and Swallow: (preliminary report)
Video fluoroscopic oropharyngeal swallowing exam was performed
in
Preliminary Reportconjunction with speech and swallow division.
Multiple consistencies of
Preliminary Reportbarium were administered, demonstrating
aspiration with crackers and nectar
Preliminary Reportconsistency. There is also penetration with
nectar consistency. For further
Preliminary Reportdetails, please refer to speech and swallow
report in the OMR.
Preliminary ReportIMPRESSION: Aspiration and penetration with
nectar consistency. Aspiration
Preliminary Reportwith solid consistency.
EKG Sinus rhythm. Anterolateral ST segment depressions and T
wave inversions raise concern for anterolateral ischemia.
Clinical correlation is suggested. Compared to the previous
tracing of ___ the anterolateral ST-T wave changes are new
and the heart rate is decreased.
TRACING #1
Read ___.
IntervalsAxes
___
___
Sinus rhythm. Anterolateral ST segment depression and T wave
inversions
suggest myocardial ischemia. Compared to tracing #2 the T wave
inversions are
deeper.
TRACING #3
Read ___.
IntervalsAxes
___
___
CXR ___
IMPRESSION: Interstitial lung disease, similar to prior, with
new small
pleural effusions. No focal consolidation.
Xrays of R shoulder, elbow, forearm, wrist and hand all negative
for fracture.
Brain MRI ___
IMPRESSION:
1. Interval multifocal subacute left cerebellar and right
occipital infarcts,
likely emboli in etiology given the distribution.
2. Interval evolution of the known left paramedian pontine
infarct. No
evidence of intracranial hemorrhage.
3. Large right frontal meningioma with similar mass effect and
vasogenic
edema on to the adjacent parenchyma.
Discharge Labs:
___ 10:20AM BLOOD WBC-5.2 RBC-3.36* Hgb-9.8* Hct-31.3*
MCV-93 MCH-29.2 MCHC-31.4 RDW-13.2 Plt ___
___ 05:10PM BLOOD Glucose-88 UreaN-4* Creat-0.3* Na-130*
K-4.0 Cl-103 HCO3-20* AnGap-11
___ 05:10PM BLOOD Calcium-7.1* Phos-2.3* Mg-1.6
___ 02:24PM URINE Color-Straw Appear-Clear Sp ___
___ 02:24PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.5 Leuks-SM
___ 02:24PM URINE RBC-<1 WBC-3 Bacteri-FEW Yeast-NONE Epi-0
___ 02:24PM URINE Hours-RANDOM Creat-19 Na-158 K-17 Cl-150
___ 02:24PM URINE Osmo___-___
Brief Hospital Course:
Summary: ___ yo female with complicated past medical history and
numerous recent hospitalizations who was admitted from rehab for
decreased alertness and inability to take PO. Mental status
improved when holding sedating medications, patient eventually
decided to focus her care on comfort and does not want to be
readmitted to a hospital.
Active Issues:
# Goals of care: At last hospitalization here in ___,
documented that patient and her family were leaning towards
comfort care. In further conversation with ___ PA
at ___ it appears that she was leaning towards
palliative care while at ___. ___ the attending,
Dr. ___ spoke with the patient and she clearly stated the
following:
-she does not want to be anticoagulated
-she understands that eating and drinking may lead to pneumonia
and death but she does not want a feeding tube or PEG and wants
to continue eating and drinking
-she wants her pain controlled with morphine even if it makes
her sedated
-she wants to focus her care on comfort and does not want to be
rehospitalized
She remains DNR/DNI
She was also seen by palliative care and confirmed the above
information. She also confirmed that she wanted to make these
decisions for herself. She refused most oral medications during
her stay.
# lethargy: Patient was progressively lethargic before discharge
per records from her facility. Since holding sedating meds she
improved and then became lethargic after receiving morphine.
Sedating medications likely contributing. Urine cx negative. CXR
unrevealing.
#Electrolyte Abnormalities: Electrolytes morning of ___
while on ___ as she has been were abnormal with Na of 129, Ca
of 6.8, Phos 2.5, Mg 1.5 and patient is not taking good PO.
Urine lytes showed FeNa of approximately 2%, consistent with
SIADH. IVF discontinued per patient's wishes to focus on
comfort care.
#Dsyphagia and Nausea: Patient reports difficulty swallowing and
nausea after swallowing. Bedside speech and swallow performed,
patient refused barium swallow study and wanted to continue to
take PO despite risks which were explained to her. However,
___ she agreed to go for video swallow study and she aspirated
everything including ___ crackers. The only safe solution
for her given her stroke would be to become permanently NPO with
a g-tube, however the patient does not want this even after we
discussed the risks of continuing to eat and drink. She was
switched to a regular diet and thin liquids per her request and
goals of care as she has expressed them.
# TWI: New TWI on EKG since ___ with trop 0.02 (baseline
<0.01). Pt denies any chest pain and MB has been flat, Troponin
stable at .02. Repeat EKG's unchanged.
T wave changes in anterolateral leads possibly consistent with
myocardial ischemia, although also possibly due to stroke.
Patient has stated she would not want to be anticoagulated, and
if she was cathed she would require anticoagulation.
Intervention would not be in line with her goals of care.
# R upper extremity pain: Patient unable to provide history of
trauma. No fx in shoulder, forearm, wrist or hand on plain
films. When I tried to remove splint morning of ___ it was
exquisitely painful - she points to anatomical snuff box and ___
and ___ metacarpals in particular and was seen by ortho who
provided a new splint for comfort, and recommended treating her
for a presumed scaphoid fracture by leaving the thumb ___
splint in place. She may desire follow up with ortho in ___
weeks and repeat an xray in 1 week. Pain was ultimately
controlled with liquid morphine despite sedating the patient (as
above). No discharge appointment was set up given her goals of
care.
#Subacute embolic stroke: Pt had thorough work up at admission
in ___, which included stroke workup including CTA of the head
and neck showed some minor atherosclerotic disease in the aortic
arch as well as intracranial atherosclerosis involving bilateral
posterior cerebral arteries and middle cerebral arteries. Her
cardiac echo did not reveal any embolic source. She has been on
an enteric-coated
aspirin as well as high doses of statin. On neuro exam, her
strength seems to correlate more with alertness than anything
else. Reflexes were hyperactive on admission, and hypoactive by
discharge. No anticoagulation per patient's wishes (as above).
Chronic Issues:
#History of acute blood loss anemia on previous hospitalization:
pt has recent hospitalization for acute blood loss, etiology
never determined. Hct currently stable and increased from
previous hospitalization when she was transfused 1 unit RBC's
for HgB of 7.6. FOB negative while in ___, active type and
screen maintained but HCT was stable and she was not transfused.
# H/o left pontine stroke: Patient has residual right upper and
lower extremity weakness which seems to be stable on exam. She
was continued on ASA 325mg and Atorvastatin
# Right frontotemporal meningioma: Pt had been planned for
surgery in ___ but had stroke day prior to surgery so this has
been postponed. She does not want to have surgery at this time.
# Hyperlipidemia: Continued atorvastatin.
# diabetes, controlled
Transitional Issues:
#Possible scaphoid fracture - if desired by patient, may follow
up with ortho in ___ weeks and repeat xray of R wrist in 1 week
- appointment not set up given goals of care.
#Comfort - follow up with hospice and palliative care already
involved at ___
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from chart from ___.
1. Atorvastatin 20 mg PO DAILY
2. LeVETiracetam 250 mg PO BID
3. Lorazepam 0.5 mg PO HS:PRN insomnia
4. Ondansetron 4 mg PO Q8H:PRN nausea
5. Potassium Chloride 10 mEq PO DAILY Duration: 24 Hours
Hold for K >
6. Prochlorperazine 10 mg PO Q8H:PRN nausea and vomiting
7. Aspirin 81 mg PO DAILY
8. Bisacodyl 10 mg PO DAILY
9. Artificial Tears ___ DROP BOTH EYES PRN dry eyes
10. Docusate Sodium 100 mg PO BID
11. Insulin SC
Sliding Scale
Insulin SC Sliding Scale using REG Insulin
12. Mirtazapine 7.5 mg PO HS
13. Morphine Sulfate (Concentrated Oral Soln) 5 mg PO Q4H:PRN
pain
14. TraMADOL (Ultram) 50 mg PO Q4H:PRN pain
15. Aspirin 325 mg PO DAILY:PRN pain
16. Calcium Carbonate 500 mg PO QID:PRN GI distress
17. Milk of Magnesia 30 mL PO DAILY:PRN constipation
18. Polyethylene Glycol 17 g PO DAILY:PRN constipation
19. Senna 1 TAB PO BID:PRN constipation
20. Ranitidine 150 mg PO HS
Discharge Medications:
1. Artificial Tears ___ DROP BOTH EYES PRN dry eyes
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 20 mg PO DAILY
4. Bisacodyl 10 mg PO DAILY
5. Calcium Carbonate 500 mg PO QID:PRN GI distress
6. Docusate Sodium 100 mg PO BID
7. Polyethylene Glycol 17 g PO DAILY:PRN constipation
8. Ranitidine 150 mg PO HS
9. Senna 1 TAB PO BID:PRN constipation
10. TraMADOL (Ultram) 50 mg PO Q4H:PRN pain
11. Aspirin 325 mg PO DAILY:PRN pain
12. Lorazepam 0.5 mg PO HS:PRN insomnia
13. Milk of Magnesia 30 mL PO DAILY:PRN constipation
14. Ondansetron 4 mg PO Q8H:PRN nausea
15. Potassium Chloride 10 mEq PO DAILY Duration: 24 Hours
Hold for K >
16. Prochlorperazine 10 mg PO Q8H:PRN nausea and vomiting
17. LeVETiracetam 250 mg PO BID
18. Mirtazapine 7.5 mg PO HS
19. Morphine Sulfate (Oral Soln.) 0.5-1 mg PO Q4H:PRN pain
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary Diagnosis: lethargy, secondary diagnoses: subacute
embolic stroke, aspiration, possible scaphoid fracture
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: waxing and waning, depending on morphine
administration
Activity Status: Bedbound.
Discharge Instructions:
Ms. ___,
It was a pleasure taking care of you at ___
___.
You were admitted with increased sleepiness.
In the hospital we held all medications that can make you sleepy
(morphine, benzodiazepenes) and you became more alert.
While here, you had trouble swallowing. A swallow study showed
that you were aspirating (food going into your lungs instead of
your stomach). We explained that if you continue to eat and
drink that you may get pneumonia and die; however, you expressed
that you would like to continue eating and drinking as opposed
to having a permanent feeding tube or tube directly inserted
into your stomach.
During your stay you also had pain in your arm and wanted
morphine to control the pain. The morphine made you sleepy
(which is why you came to the hospital), but you told us that
this was okay, that you wanted to focus on being comfortable.
Images of your brain showed that you were having continued
strokes; you could be anticoagulated to help prevent future
strokes but this would cause a risk of bleeding and require
frequent blood draws and you said you would rather not do this.
You were found to have bruising and pain in your arm. X-rays
were negative for fracture, but given your tenderness you are
being treated with a splint for comfort.
You also told us that you did not want to come back to a
hospital again, but would prefer to spend the rest of your time
trying to be comfortable. You will continue to get care at
___ and work with ___ care who saw you while you
were here in the hospital.
Followup Instructions:
___
|
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