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19720832-DS-8
| 19,720,832 | 25,508,423 |
DS
| 8 |
2139-09-04 00:00:00
|
2139-09-04 12:52:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROSURGERY
Allergies:
Penicillins / acetaminophen
Attending: ___
Chief Complaint:
Left facial droop
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ is a ___ RH woman with PMHx of alcoholism,
tobacco abuse and ___ years of progressive L sided weakness
requiring a cane, who presents from ___ after a sudden
onset of L facial droop and slurred speech and was found to have
a large R sided frontal/temporal mass with 5mm of midline shift.
Patient and her family note that over the last ___ years, patient
has had some mild L-sided weakness that has worsened, but
particularly since ___, when she needed a cane to
walk.
Also starting in ___ she started to c/o nausea and some
occasional vomiting with frequent headaches. She did not seek
medical attention for these issues. Over the last 3 days she
started to complain that she "had the flu" because she was
vomiting more frequently than previously and her headaches
worsened. Today (___) around noon her son stopped by her house
to check on her, noted that the newspaper was still on the front
steps, and that the water was running in the sink once he got
inside. The pt was laying on the couch, and c/o numbness in her
L arm. When the son tried to get her up, she "felt limp", but
he
didn't notice any specific weakness. Her speech was slurred,
but
fluent, although he mentioned that she seemed "odd". He called
EMS, and when they got there, the pt got up and walk to "prove
she didn't need to go to the hospital", but EMS still took her
to
___. There, it was noted that she had a L sided facial
droop. A CT head was done which showed a 7.5x2.9cm likely
meningioma in the R frontal and temporal lobes with edema in the
R cerebral hemisphere with effacement of the R lateral ventricle
and shift of the midline structures from L->R by approximately
5mm. She was sent to ___ for neurosurgical evaluation.
Past Medical History:
- CVAs in ___, with residual R-hand and arm weakness for ___ year
afterwards
- Left-sided progressive weakness
Social History:
___
Family History:
daughter had NHL, now in remission ___, mother died
from breast ca, father from colon ca
Physical Exam:
ADMISSION PHYSICAL EXAM:
O: T: 98.4 BP: 135/66 HR: 90 R 16 O2Sats 96% on 2L
Gen: WD/WN, comfortable, NAD.
HEENT: OP clear; ___ in R eye, ___ in L eye
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 and place, but insisted it was
___ the ___ (it is actually ___, knew
the president
Language: Speech fluent with good comprehension and repetition,
but impaired naming, got many of the NIHSS words wrong, but
reading was intact, speech mildly dysarthric but no paraphasic
errors with spontaneous speech.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 1.5 to 1
mm bilaterally. Visual fields are full to confrontation except
for decreased vision in L lateral field on visual field testing.
Unable to complete fundoscopic exam ___ pinpoint pupils.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial sensation intact with a L facial droop.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
XI: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. No pronator drift.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 4 ___ 4+ ___ 5 4 5- 5- 4+ 5-
R 5- ___ ___ 5- 5 5 5 5 5 5
Sensation: Intact to light touch, propioception, pinprick and
vibration bilaterally, but pt with somehyperesthesia to
vibratory
sensation in LLE.
Reflexes: B T Br Pa Ac
Right ___ 1 0
Left ___ 1 0
Toes upgoing bilaterally
Coordination: normal on finger-nose-finger and rapid alternating
movements
Gait: slow, unsteady without L sided assistance, Romberg
negative
Upon discharge:
Awake, alert, walking independently, MAE full, follows commands
Pertinent Results:
ADMISSION LABS:
___ 06:50PM BLOOD WBC-6.9 RBC-4.23 Hgb-12.3 Hct-38.6 MCV-91
MCH-29.1 MCHC-31.9 RDW-12.7 Plt ___
___ 06:50PM BLOOD Neuts-61.0 ___ Monos-13.3*
Eos-0.5 Baso-0.3
___ 08:15PM BLOOD ___ PTT-29.2 ___
___ 06:50PM BLOOD Glucose-136* UreaN-19 Creat-0.7 Na-136
K-3.9 Cl-101 HCO3-19* AnGap-20
___ 06:50PM BLOOD ALT-14 AST-19 AlkPhos-46 TotBili-0.8
___ 06:50PM BLOOD Albumin-4.7 Calcium-9.3 Phos-3.1 Mg-1.8
REPORTS:
CXR ___: IMPRESSION: No acute cardiopulmonary abnormality.
___ MRI: IMPRESSION: The study is limited as only a few
pre-contrast images of the head could be obtained and MRV head
images are degraded by motion artifact. 1. A T1 isointense
extra-axial lesion along the right frontal and temporal
convexity causing mass effect on the underlying brain parenchyma
and shift of midline structures to the left. Further evaluation
is needed with contrast-enhanced MRI.
2. The MRA is negative for focal stenosis or occlusion in the
intracranial circulation.
3. Limited MRV head examination, however, no obvious evidence
of venous sinus thrombosis.
___ MRI MRA/MRV Brain (incomplete study): IMPRESSION: The
study is limited as only few of the precontrast images could be
obtained of the brain. The images are degraded by motion
artifact.
1. A T2/FLAIR mildly hyperintense extra-axial lesion along the
right frontal and temporal convexity causing mass effect on the
underlying brain parenchyma and shift of midline structures to
the left. This likely represents a meningioma.
2. No acute infarct or hemorrhage.
___ MRI Brain:
IMPRESSION: The study is limited as only few of the precontrast
images could be obtained of the brain. The images are degraded
by motion artifact.
1. A T2/FLAIR mildly hyperintense extra-axial lesion along the
right frontal and temporal convexity causing mass effect on the
underlying brain parenchyma and shift of
midline structures to the left. This likely represents a
meningioma.
2. No acute infarct or hemorrhage.
Brief Hospital Course:
___ is a ___ RH woman with PMHx of alcoholism,
tobacco abuse and ___ years of progressive L sided weakness
requiring a cane, who presented from ___ after a sudden
onset of L facial droop and slurred speech and was found
to have a large R sided frontal/temporal mass with 5mm of
midline shift. She was admitted to the neurosurgical service
for pre-surgical evaluation. She was put on keppra 1000mg BID,
dexamethasone 4mg Q6H. She was noted to be increasingly
confused on ___ but then woke up and was ambulating. As as
result keppra was increased to 1250mg bid. Psych was consulted
for competency. They deemed she is not competetant to make her
own decisions. On ___ an MRI was attempted but aborted
before the contrast could be administered due to patient
agitation. The study attempt was repeated on ___
overnight but again aborted secondary to agitation. On ___ she
was monitored while awaiting a ___ attempt with more sedation.
She was discharged home with 24hr supervision on ___ with plans
to return on ___ for surgery with Dr ___.
Medications on Admission:
ASA 81mg QD
Discharge Medications:
1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. dexamethasone 4 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours).
Disp:*30 Tablet(s)* Refills:*0*
3. levetiracetam 1,000 mg Tablet Sig: One (1) Tablet PO BID (2
times a day): Take total of 1250mg BID.
Disp:*60 Tablet(s)* Refills:*2*
4. levetiracetam 250 mg Tablet Sig: One (1) Tablet PO twice a
day: Take total of 1250mg BID.
Disp:*60 Tablet(s)* Refills:*2*
5. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Discharge Disposition:
Home
Discharge Diagnosis:
right frontal mass
Confusion
dysarthria
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Take your pain medicine as prescribed if needed. You do not
need to take it if you do not have pain.
Exercise should be limited to walking; no lifting >10lbs,
straining, or excessive bending.
Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
DO not take any anti-inflammatory medicines such as Motrin,
Aspirin, Advil, or Ibuprofen etc.
You have been discharged on Keppra (Levetiracetam) for
anti-seizure medicine; continue until follow-up
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
New onset of tremors or seizures.
Any confusion, lethargy or change in mental status.
Any numbness, tingling, weakness in your extremities.
Pain or headache that is continually increasing, or not
relieved by pain medication.
New onset of the loss of function, or decrease of function on
one whole side of your body.
Followup Instructions:
___
|
19721001-DS-13
| 19,721,001 | 25,488,433 |
DS
| 13 |
2118-10-20 00:00:00
|
2118-10-26 09:13:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Confusion
Major Surgical or Invasive Procedure:
None
History of Present Illness:
The patient is aka ___ (___) and is a ___
PMHx polysubstance abuse and otherwise unknown who presented
with
acute onset R sided weakness and dysarthria.
Pt was at his ___ clinic when he had sudden onset of R
sided weakness and dysarthria at 16:00. His BP in the field was
200/114. He was brought to an OSH.
He arrived to the OSH at ~16:17, VS: 98.3 185/125 (peaked at
204/138) 112 20 94% RA. He was apparently alert and trying to
get
off the stretcher per records. He was "paralyzed on the right"
with a right sided facial droop and dysarthria. He was given
labetalol 20 IV x1. He was intubated for transport due to
presence of bleed on NCHCT and agitation. He was also given
phenytoin 1g for unclear reasons - there was no verbal report of
or documentation of a seizure.
Past Medical History:
Insomnia
Polysubstance abuse
*Otherwise unknown
Social History:
___
Family History:
Unknown
Physical Exam:
ADMISSION PHYSICAL EXAMINATION:
PHYSICAL EXAMINATION
Vitals: HR ___ SBP ___ ventilated saturating well
General: Critically ill-appearing
HEENT: NCAT, no oropharyngeal lesions, moist mucous membranes,
sclerae anicteric, +ETT
Neck: Supple
___: RRR
Pulmonary: CTAB
Abdomen: Soft, NT, ND
Extremities: Warm, no edema
Skin: No rashes or lesions, +tattoos
Examined after 10 minutes off propofol.
Neurologic Examination:
- Mental Status - Awake, grabbing at ETT and Foley catheter.
Does
not follow commands. Purposefully moving LUE, no movement in
RUE.
Will briefly track examiner on left side.
- Cranial Nerves - PERRL 1.5->1 sluggish. Does not BTT. +corneal
reflexes bilaterally. EOMI with tracking to the left, unable to
check EOMI to R and coughs/doesn't comply with checking VOR. R
NLFF over ETT. +cough/gag.
- Sensori-motor - Normal bulk and tone throughout. Moves LUE/LLE
antigravity and provides full strength to resist examiner
(trying
to pull at tubes and get OOB). RUE plegic. About to briefly move
RLE antigravity but unable to resist examiner. Does not withdraw
to noxious in any extremity.
- DTRs: ___ throughout and toes mute.
- Coordination - Unable to be assessed.
- Gait - Deferred.
===============================
DISCHARGE PHYSICAL EXAMINATION
Vitals: T:98.2F BP:135-158/80-89 HR:65-70 RR:16 SaO2:98% RA
General: lying in bed, NAD
HEENT: normocephalic, atraumatic
Lungs: breathing comfortably on RA
Abdomen: soft, nondistended
Ext: symmetric, no edema. Stage II pressure ulcer R lateral
malleolus. 3-4mm area of central skin breakdown with surrounding
2cm erythema. No purulence, no fluctuance. The area is
immediately over ankle fusion hardware, which is easily palpable
under the skin. There are only approx. 3mm of tissue between the
skin and the hardware.
Neurologic:
-Mental Status: Awake, alert. Oriented to self, ___
___ oriented to medical situation nor date. Follows
simple appendicular commands,
-Cranial Nerves: Anisocoria w/ R pupil 2.5->2, L 2->1.5. EOMI
without nystagmus. R facial droop. Moderate dysarthria.
-Sensorimotor: RUE no movement to noxious with significant
spasticity. RLE occ spontaneous 2 at IP/hamstring. LUE/LLE
moving spontaneously briskly antigravity.
- Coordination- coordination intact in LUE.
Pertinent Results:
___ 06:14PM BLOOD WBC-15.7* RBC-4.19* Hgb-12.6* Hct-38.5*
MCV-92 MCH-30.1 MCHC-32.7 RDW-13.3 RDWSD-45.5 Plt ___
___ 06:14PM BLOOD ___ PTT-27.7 ___
___ 06:14PM BLOOD ___
___ 01:50AM BLOOD Glucose-85 UreaN-15 Creat-1.3* Na-140
K-3.9 Cl-101 HCO3-26 AnGap-17
___ 01:50AM BLOOD ALT-18 AST-17 LD(LDH)-195 AlkPhos-65
TotBili-0.2
___ 06:14PM BLOOD Lipase-19
___ 05:30PM BLOOD CK-MB-2 cTropnT-<0.01
___ 01:50AM BLOOD CK-MB-2 cTropnT-<0.01
___ 01:50AM BLOOD Albumin-3.4* Calcium-8.2* Phos-4.0 Mg-2.2
___ 06:14PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 08:04PM BLOOD Type-ART ___ Tidal V-430 PEEP-8
FiO2-100 pO2-324* pCO2-48* pH-7.36 calTCO2-28 Base XS-1
AADO2-334 REQ O2-61 Intubat-INTUBATED
___ 06:22PM BLOOD Glucose-157* Lactate-1.6 Na-140 K-4.1
Cl-102 calHCO3-27
___ 05:30AM BLOOD freeCa-1.08*
___ 10:59PM URINE Blood-LG Nitrite-NEG Protein-100
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG
___ 10:59PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG oxycodn-NEG mthdone-NEG
___ Sputum Cx: MORAXELLA CATARRHALIS. HEAVY GROWTH.
HAEMOPHILUS INFLUENZAE, BETA-LACTAMASE POSITIVE. HEAVY
GROWTH.
BETA-LACTAMASE POSITIVE: RESISTANT TO AMPICILLIN.
___ 05:51AM BLOOD WBC-7.5 RBC-4.59* Hgb-13.5* Hct-41.9
MCV-91 MCH-29.4 MCHC-32.2 RDW-14.1 RDWSD-47.1* Plt ___
___ 07:10AM BLOOD ___ PTT-28.5 ___
___ 06:14PM BLOOD ___
___ 05:30AM BLOOD Glucose-98 UreaN-24* Creat-1.0 Na-138
K-4.5 Cl-101 HCO3-24 AnGap-18
___ 05:00AM BLOOD estGFR-Using this
___ 01:50AM BLOOD CK(CPK)-243
___ 05:30PM BLOOD CK(CPK)-330*
___ 01:50AM BLOOD ALT-18 AST-17 LD(LDH)-195 AlkPhos-65
TotBili-0.2
___ 01:50AM BLOOD CK-MB-2 cTropnT-<0.01
___ 05:51AM BLOOD Calcium-9.4 Phos-4.8* Mg-2.1
___ 06:14PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 05:30AM BLOOD Type-ART Rates-/___ Tidal V-555 PEEP-5
FiO2-50 pO2-171* pCO2-44 pH-7.41 calTCO2-29 Base XS-3
Intubat-INTUBATED Vent-SPONTANEOU
___ 05:30AM BLOOD Lactate-0.8
___ 05:30AM BLOOD freeCa-1.08*
Imaging:
___ CT/CTA: PRELIM READ: No interval change in 2.3 x 2.1 cm
left BG hemorrhage with left lateral IVE and mild adjacent mass
effect. Patent basal cistern. No new hemorrhage. CTA: Internal
carotid arteries, vertebral arteries, and their major vessels
are patent. No flow-limiting stenosis, aneurysm greater than 3
mm, or evidence of dissection. Mild oropharyngeal secretions.
Mild paraseptal emphysema. Bilateral subcentimeter cervical
lymph nodes do not meet CT criteria for enlargement.
___ CXR: Low-lying ET tube, tip position 1.3 cm above the
carina. Mild left basal atelectasis.
___ CXR: Rib fracture of one of the lateral thoracic ribs, not
previously seen on chest radiograph ___, and
increased opacification the left hemithorax, also new. These
findings raise the possibility of a left-sided pleural effusion
or even hemothorax
___ CT chest: Small posteriorly layering L pleural effusion,
not frank hemothorax. Small amount of intramuscular hematoma and
minimal extrapleural bleeding are due to the mildly displaced
fracture through the lateral aspect of the left 7th rib
___ CT spine: no fracture or traumatic malalignment
___ NCHCT: Grossly stable left basal ganglia hemorrhage with
left lateral intraventricular extension and 3 mm right to left
midline shift. Stable left frontal periventricular hypodensity
may represent edema associated with the hemorrhage, or sequela
of chronic infarct
Brief Hospital Course:
Mr. ___ was admitted and arrived at the ICU intubated. He was
subsequently extubated on the day after admission. He was
diagnosed with a pna, and his sputum grew moraxella and H. flu.
He completed a 7 day course of azithromycin 500 mg q24h x7 days
___.
He was subsequently stabilized and transferred to the floor
___.
Following transfer to floor, his blood pressure medications were
titrated and he was subsequently stabilized with SBP below his
goal of <150 on his discharge regimen.
Depakote was started for mood stabilization. He required prn
Haldol approx. 3 times during his month-long hospitalization.
His hospitalization was prolonged due to guardianship and
placement difficulties.
Late in his hospitalization he began to develop a pressure ulcer
on his L lateral malleolus, Stage II at the time of discharge.
He does not comprehend that he needs to keep pressure off of
this area. Dressing applied to area, waffle boots importance
reinforced multiple times per day and he was transitioned to air
bed. This pressure ulcer is directly over L ankle fusion
hardware. He would be at very high risk for bone infection if
this pressure ulcer gets worse. This was communicated to the
patient.
He developed significant spasticity of RUE>RLE, but was
noncompliant with bracing devices. These were reattempted
multiple times.
Hospital course by system:
Neurologic: L basal ganglia 6cc hemorrhage with IVH
- repeat NCHCT ___ stable hemorrhage with edema and 3mm MLS
- Continued home suboxone 8mg-2mg 1.5 tabs daily
- continued thiamine, folate, MVI
- spasticity in RUE is concerning for developing contracture,
patient continues to refuse bracing by OT.
Psych:
- Per Psychiatry, he has capacity to sign in at rehab, but not
capacity to appoint a health care proxy. ___ obtained
___
- continued home citalopram, 20 mg daily.
- Continued valproic acid for agitation/irritability 500mg qam,
250mg pm.
MSK:
R lateral malleolus stage II pressure ulcer in the setting of
subcutaneous hardware: Patient does not understand importance of
keeping pressure off of this area despite multiple discussions
with RN/MD and patient about the consequences of a bone
infection if this pressure ulcer progresses. He repeatedly
refuses waffle boots. He keeps leg in external rotation nearly
100% of the time.
- mepilex dressing
- air bed
- continued to reinforce importance of keeping weight off
of this area, though Mr. ___ does not demonstrate
understanding of this.
Cardio:
- SBP goal<150
- continued carvedilol 50 bid, Lisinopril 40mg, Amlodipine 10 mg
daily, clonidine 0.1mg tid
- Hydralazine prn was ordered inpatient prn SBP>150
FEN/GI: Repleted lytes prn, had bedside swallow -> reg diet with
thin liquids
Ppx: Pneumoboots, Bowel regimen
Code status: Presumed Full
Dispo: To ___ Rehab
==========================
Transitional Issues:
[ ] SBP goal <150
[ ] continue aggressive wound care and pressure offloading of L
lateral malleolus
[ ] hold ASA and NSAIDs because patient had brain bleed
==============================
AHA/ASA Core Measures for Intracerebral Hemorrhage
1. Dysphagia screening before any PO intake? (x) Yes - () No
2. DVT Prophylaxis administered? (x) Yes - () No
3. Smoking cessation counseling given? (x) Yes - () No [reason
() non-smoker - () unable to participate]
4. Stroke education (personal modifiable risk factors, how to
activate EMS for stroke, stroke warning signs and symptoms,
prescribed medications, need for followup) given (verbally or
written)? (x) Yes - () No
5. Assessment for rehabilitation and/or rehab services
considered? (x) Yes - () No
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. ClonazePAM 1 mg PO DAILY 1 and a half tablet
2. CloNIDine 0.3 mg PO DAILY
3. Gabapentin 800 mg PO QID
4. MetFORMIN XR (Glucophage XR) 500 mg PO QPM with evening meal
Discharge Medications:
1. amLODIPine 10 mg PO DAILY
2. Buprenorphine-Naloxone (8mg-2mg) 1.5 TAB SL DAILY
3. Carvedilol 50 mg PO BID
4. Citalopram 20 mg PO DAILY
5. Docusate Sodium 100 mg PO BID constipation
6. FoLIC Acid 1 mg PO DAILY
7. Lisinopril 40 mg PO DAILY
8. Multivitamins W/minerals 1 TAB PO DAILY
9. Polyethylene Glycol 17 g PO DAILY
10. Senna 8.6 mg PO QHS constipation
11. Thiamine 100 mg PO DAILY
12. Valproic Acid ___ mg PO QAM
13. Valproic Acid ___ mg PO QPM Daily at ___
14. CloNIDine 0.1 mg PO TID
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
L basal ganglia hemorrhage
Hypertension
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Mr. ___,
You were hospitalized due to symptoms of right-sided weakness
resulting from an ACUTE HEMORRHAGIC STROKE, a condition where a
blood vessel providing oxygen and nutrients to the brain breaks
open and bleeds. The brain is the part of your body that
controls and directs all the other parts of your body, so damage
to the brain from being deprived of its blood supply can result
in a variety of symptoms.
Stroke can have many different causes, so we assessed you for
medical conditions that might raise your risk of having stroke.
In order to prevent future strokes, we plan to modify those risk
factors. Your risk factors are:
High blood pressure
High cholesterol
Please take your other medications as prescribed.
Please follow up with Neurology and your primary care physician
as listed below.
If you experience any of the symptoms below, please seek
emergency medical attention by calling Emergency Medical
Services (dialing 911). In particular, since stroke can recur,
please pay attention to the sudden onset and persistence of
these symptoms:
- Sudden partial or complete loss of vision
- Sudden loss of the ability to speak words from your mouth
- Sudden loss of the ability to understand others speaking to
you
- Sudden weakness of one side of the body
- Sudden drooping of one side of the face
- Sudden loss of sensation of one side of the body
Sincerely,
Your ___ Neurology Team
Followup Instructions:
___
|
19721002-DS-20
| 19,721,002 | 25,894,834 |
DS
| 20 |
2155-10-18 00:00:00
|
2155-10-19 19:53:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Air leaking from prior chest tube site
Major Surgical or Invasive Procedure:
___: s/p left chest tube placement (___) and chemical
pleurodesis (talc)
History of Present Illness:
Mr. ___ is a ___ with h/o severe smoking-related interstitial
lung disease recently admitted ___ for decompression of
spontaneous L PTX. A left chest tube was placed in the ED and
was
subsequently removed after confirming absence of air leak and
resolution of PTX. Post pull film also failed to show recurrent
PTX and patient was discharged home on ___ ___. He contacted
Thoracic Surgery Clinic this AM with concerns for sensation of
air leaking from his prior CT site. He was instructed to return
to clinic with repeat CXR showing recurrent L PTX and mild R
mediastinal shifting. He reports some increased fatigue/DOE on
baseline home O2 requirement of 2L NC, but has otherwise
remained
hemodynamically stable and denies significant SOB/CP,
fevers/chills, worsening cough.
Past Medical History:
- Smoking Related Interstitial lung disease
- Depression
- H/O suicidal ideation while taking Chantix
Social History:
___
Family History:
- Negative for rheumatologic or lung diseases
Physical Exam:
VITALS: 97.8 77 123/79 15 97% NC
GENERAL
[x] WN/WD [x] NAD [x] AAO [ ] abnormal findings:
HEENT
[x] NC/AT [x] EOMI [x] PERRL/A [x] Anicteric
[x] OP/NP mucosa normal [x] Tongue midline
[x] Palate symmetric [x] Neck supple/NT/without mass
[x] Trachea midline [x] Thyroid nl size/contour
[ ] Abnormal findings:
RESPIRATORY
[ ] CTA/P [x] Excursion normal [x] No fremitus
[x] No egophony [x] No spine/CVAT
[x] Abnormal findings: mildly diminished L sided breath sounds;
prior L CT site w/ intact occlusive dressing w/ mild SS drainage
CARDIOVASCULAR
[x] RRR [x] No m/r/g [x] No JVD [x] PMI nl [x] No edema
[x] Peripheral pulses nl [x] No abd/carotid bruit
[ ] Abnormal findings:
GI
[x] Soft [x] NT [x] ND [x] No mass/HSM [x] No hernia
[ ] Abnormal findings:
GU [x] Deferred
[ ] Nl genitalia [ ] Nl pelvic/testicular exam [ ] Nl DRE
[ ] Abnormal findings:
NEURO
[x] Strength intact/symmetric [x] Sensation intact/ symmetric
[x] Reflexes nl [x] No facial asymmetry [x] Cognition intact
[x] Cranial nerves intact [ ] Abnormal findings:
MS
[x] No clubbing [x] No cyanosis [x] No edema [x] Gait nl
[x] No tenderness [x] Tone/align/ROM nl [x] Palpation nl
[x] Nails nl [ ] Abnormal findings:
LYMPH NODES
[x] Cervical nl [x] Supraclavicular nl [x] Axillary nl
[x] Inguinal nl [ ] Abnormal findings:
SKIN
[x] No rashes/lesions/ulcers
[x] No induration/nodules/tightening [ ] Abnormal findings:
PSYCHIATRIC
[x] Nl judgment/insight [x] Nl memory [x] Nl mood/affect
[ ] Abnormal findings:
DISCHARGE PHYSICAL EXAM
=====================
VS: T 98.2 BP 109/68 HR 68 RR 20 O2 90% 2L
General: alert, oriented, no acute distress, breathing
comfortably on NC
HEENT: sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: fine inspiratory crackles diffusely without wheezing or
rhonchi
CV: regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no ebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, motor function grossly normal
Pertinent Results:
ADMISSION LABS
=====================
___ 11:35AM WBC-14.1* RBC-4.44* HGB-14.4 HCT-42.4 MCV-96
MCH-32.4* MCHC-34.0 RDW-15.7* RDWSD-55.6*
___ 11:35AM NEUTS-74.8* LYMPHS-15.3* MONOS-6.1 EOS-2.7
BASOS-0.2 IM ___ AbsNeut-10.55* AbsLymp-2.16 AbsMono-0.86*
AbsEos-0.38 AbsBaso-0.03
___ 11:35AM PLT COUNT-151
___ 11:35AM GLUCOSE-85 UREA N-38* CREAT-1.3* SODIUM-137
POTASSIUM-4.4 CHLORIDE-99 TOTAL CO2-24 ANION GAP-18
DISCHARGE LABS
=====================
___ 07:15AM BLOOD WBC-8.1 RBC-4.18* Hgb-13.6* Hct-41.2
MCV-99* MCH-32.5* MCHC-33.0 RDW-14.7 RDWSD-53.8* Plt ___
___ 07:15AM BLOOD Glucose-87 UreaN-32* Creat-0.9 Na-138
K-4.7 Cl-99 HCO3-26 AnGap-18
___ 07:15AM BLOOD Calcium-9.1 Phos-2.8 Mg-2.1
IMAGING
=====================
___ CXR :
1. Compared to ___, new moderate-sized left
pneumothorax with
rightward shift of the trachea and mediastinum suggesting a
degree of tension.
2. Interval increase in left-sided subcutaneous gas, which now
extends to the left neck.
___ CXR :
Interval placement of left-sided chest tube. Left pneumothorax
has decreased in size and is now barely visible.
___ CXR :
In comparison with the study of ___, the left chest tube
remains in place and there is no evidence of pneumothorax.
Extensive subcutaneous gas is again seen along the left lateral
chest wall extending into the neck. Pneumomediastinum is
clearing.
Little overall change in the appearance of the heart and lungs
except for some mild increased opacification at the left base.
Brief Hospital Course:
Mr. ___ was evaluated in the Thoracic Clinic and a chest xray
demonstrated a recurrent left pneumothorax. He was sent to the
Emergency Room for urgent placement of a chest tube. He
tolerated the procedure well and initially had a large air leak.
A subsequent chest xray confirmed placement of the tube at the
left apex and a tiny residual apical pneumothorax. he was
transferred to the Surgical floor for further management.
Later that day he underwent talc pleurodesis with 4 Grams of
sterile talc. Towards the end of the procedure he had some
burning pain which was relieved with IV Dilaudid. The tube was
placed above the level of his heart for 2 hours post pleurodesis
and he repositioned himself frequently to coat the lung then the
tube was placed on -20 cm suction for 48 hours. About 6 hours
later he developed sinus tachycardia to 130 and desaturated to
the low 80's eventually requiring a non rebreather.
He was transferred to the SICU for further management of what
seemed to be talc related SIRS. He was never intubated but
required high flow O2 to maintain sats > 88%. His chest xray
showed no pneumothorax and his pain was controlled with oral
Dilaudid. He spent time in ICU for weaning off of high flow
oxygen and his chest tube was eventually removed on ___.
His post pull film showed no evidence of PTX and he remained
hemodynamically stable without need for repeat CT placement.
He was evaluated by the Pulmonary service and recommendations
were made for reducing his Prednisone to 10 mg daily from 20 mg
daily during this acute phase to allow for appropriate
inflammation and ensure adequate pleurodesis. Given that his
surgical problems had resolved (no recurrence of PTX following
pleurodesis), the deicision was made to transfer patient to
Medicine Service for continued O2 wean and medical management of
his known ILD.
On medicine service, O2 requirement rapidly decreased without
intervention. On DC, satting in low ___ on 2L O2, which is home
O2 requirement. Course also complicated by urinary retention
requiring foley catheter, which had resolved on discharge.
Transitional Issues:
[] Prednisone decreased to 10 mg daily to aid in pleurodesis
scarring. Should be increased back to 20 mg daily ~10 days after
pleurodesis, on ___
[] Tamsulosin 0.8 mg qHS started during admission for urinary
retention.
[] Patient needs follow-up in ___ clinic to monitor for
pneumothorax re-accumulation.
[] Continue to encourage smoking cessation.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO TID
2. ClonazePAM 1 mg PO TID
3. Docusate Sodium 100 mg PO BID
4. Ipratropium-Albuterol Neb 1 NEB NEB Q6H:PRN SOB, wheezing
5. Nicotine Patch 14 mg TD DAILY
6. OxyCODONE (Immediate Release) ___ mg PO Q3H:PRN Pain -
Moderate
7. PredniSONE 20 mg PO DAILY
8. RisperiDONE 1 mg PO QHS
9. Sertraline 200 mg PO DAILY
10. Sulfameth/Trimethoprim DS 1 TAB PO/NG DAILY
11. Tiotropium Bromide 1 CAP IH DAILY
12. alfuzosin 10 mg oral DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO TID
2. Docusate Sodium 100 mg PO BID
3. OxyCODONE (Immediate Release) ___ mg PO Q3H:PRN Pain -
Moderate
4. Senna 8.6 mg PO BID
5. Tamsulosin 0.8 mg PO QHS
6. PredniSONE 10 mg PO DAILY
take 10 mg daily until ___, and then increase to 20 mg daily
7. alfuzosin 10 mg oral DAILY
8. ClonazePAM 1 mg PO TID
9. Ipratropium-Albuterol Neb 1 NEB NEB Q6H:PRN SOB, wheezing
10. Nicotine Patch 14 mg TD DAILY
11. RisperiDONE 1 mg PO QHS
12. Sertraline 200 mg PO DAILY
13. Sulfameth/Trimethoprim DS 1 TAB PO DAILY
14. Tiotropium Bromide 1 CAP IH DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
recurrent spontaneous left pneumothorax
urinary retention
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
* You were admitted to the hospital for a recurrent episode of
collapsed lung. You underwent decompression with chest tube
placement and had a chemical pleurodesis (purposeful
inflammation of your lung lining to prevent recurrent lung
collapse) and you've recovered well. You are now ready for
discharge.
* It is crucial for your health that you stop smoking.
* Continue to use your incentive spirometer 10 times an hour
while awake.
*Check your incisions daily and report any increased redness or
drainage. Cover the area with a gauze pad if it is draining.
* Your chest tube dressing may be removed in 48 hours. If it
starts to drain, cover it with a clean dry dressing and change
it as needed to keep site clean and dry.
* You will continue to need pain medication once you are home
but you can wean it over a few weeks as the discomfort resolves.
Make sure that you have regular bowel movements while on
narcotic pain medications as they are constipating which can
cause more problems. Use a stool softener or gentle laxative to
stay regular.
* No driving while taking narcotic pain medication.
* Take Tylenol ___ mg every 6 hours in between your narcotic.
If your doctor allows you may also take Ibuprofen to help
relieve the pain.
* Continue to stay well hydrated and eat well to heal your
incisions
* Shower daily. Wash incision with mild soap & water, rinse,
pat dry
* No tub bathing, swimming or hot tubs until incision healed
* No lotions or creams to incision site
* Walk ___ times a day and gradually increase your activity as
you can tolerate.
Call Dr. ___ office at ___ if you experience
-Temp > 101, chills, increased shortness of breath, chest pain
or any other symptoms that concern you.
Thank you for allowing us to participate in your care! Our hope
is that you will have a quick return to your life and usual
activities.
Followup Instructions:
___
|
19721002-DS-21
| 19,721,002 | 23,465,596 |
DS
| 21 |
2157-01-22 00:00:00
|
2157-01-23 16:52:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Syncope
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Patient is a ___ with history of smoking related interstitial
lung disease c/b prior recurrent PTX (on chronic
glucocorticoids)/COPD on home O2 2L, anxiety/depression with
some
paranoid thinking, and likely BPH who presents with recurrent
syncopal episodes.
Patient says that for the past ___ he has been awaking in
the
AM and feeling lightheaded. His symptoms predictably occur
within 90min of getting up. Patient describes walking down the
hall in his apartment when he will feel 'faint and weak,'
immediately falling to the floor, his legs giving out. Patient
seems to think that he does not lose consciousness. No reported
headstrikes. It takes him ~5min to gather the strength to get
up, which he is able to do by himself. Patient denies any
concomitant/preceding symptoms including SOB/nausea/chest
pain/palpitations/sense of dread. No bowel/bladder
incontinence.
When trying to cross ___ at ___ this past ___ in
the
hot sun, patient felt immediately weak and fell to the asphalt.
Passersby helped him up and called an ambulance. Patient
refused
transfer to an ED and was eventually able to get himself home
independently. Of note, patient presented to our ED ___
after
having a 'black out' at home and dislocating his L shoulder. He
ultimately left AMA without any additional work-up.
Of note, patient was admitted to ___ ___
after presenting with recurrent L PTX with rightward mediastinal
shift after having had a chest tube placed/removed for PTX
during
the week prior. He underwent talc pleurodesis which was
complicated by talc related SIRS requiring admission to the
SICU.
Patient never required intubation. Prednisone 20mg was
decreased
to 10mg after evaluation by pulmonary. His hospitalization was
further complicated by transient urinary obstruction requiring
foley placement. Patient was satting in the low ___ on 2L at
time of discharge.
In the ED, initial vitals: 97.4 95 ___ 95% 2L NC
- Labs were notable for:
CBC 8.7>13.4/38.2<105 (MCV 89, 81.6% PMNs)
BMP ___ (AG 20)
K 4.8
Ca 9.5, Mg 2.0, Phos 3.3
Troponin-T <.01
Ddimer 419
ABG 7.43/___
Urinalysis notable for 1000 glucose, no ketones
- Imaging:
NCCTH
No acute intracranial process
CXR
IMPRESSION:
No pneumothorax. Similar appearance of previously seen right
upper lobe opacity, though evaluation slightly limited by
overlying EKG sticker. If clinically indicated, further
evaluation is opacity should be performed by CT.
- Patient was given:
___ 09:05 IVF NS (500 mL ordered)
___ 10:34 IVF NS (1000 mL ordered)
___ 11:00 SC Insulin Lispro 10 UNIT
- Vitals prior to transfer were: 98.1 62 132/83 17 95% 2L NC
On arrival to the floor, patient recounts the history as above.
He denies any acute lightheadedness/dizziness. No
cardiovascular
symptoms, patient feels comfortable breathing on his home O2 2L.
No missed prednisone doses recently. Patient denies any
worsening polyuria/nocturia recently, he says that he sometimes
urinates 1x during the night. He does endorse 'prostate' issues
for the past ___, which have caused some urinary frequency. No
fevers/chills.
REVIEW OF SYSTEMS:
A complete 10-point review of systems was performed and was
negative less otherwise noted in the HPI.
Past Medical History:
- Smoking Related Interstitial lung disease
- Depression
- H/O suicidal ideation while taking Chantix
Social History:
___
Family History:
- Father and brother DM2
- Father died of complications of colon cancer
- Brother died of complications of DM2 at age ___
- Mother with unknown 'heart related problems,' currently age ___
- Negative for rheumatologic or lung diseases
Physical Exam:
ADMISSION PHYSICAL EXAM
========================
VS: 97.7 129/70 70 16 89 2L NC
GENERAL: Pleasant, lying in bed comfortably
HEENT: PERRL, no scleral icterus. OP clear with MMM, no tongue
lacerations.
CARDIAC: Regular rate and rhythm, ___ systolic murmur at the L
sternal border, no rubs or gallops.
LUNG: Diffuse, dry inspiratory crackles predominantly in the
lower lung fields bilaterally.
ABD: Normal bowel sounds, soft, nontender, nondistended, no
hepatomegaly, no splenomegaly.
EXT: Warm, well perfused, no lower extremity edema.
PULSES: 2+ radial pulses, 2+ DP pulses.
NEURO: Alert, oriented, CN II-XII intact, motor and sensory
function grossly intact.
SKIN: No significant rashes.
DISCHARGE PHYSICAL EXAM
========================
VS: ___ 0356 Temp: 98.0 PO BP: 107/72 L Lying HR: 70 RR: 18
O2 sat: 92% O2 delivery: 2L
GENERAL: No acute distress, pleasant and conversant
HEENT: PERRL, no scleral icterus. OP clear with MMM, no tongue
lacerations.
CARDIAC: Regular rate and rhythm, ___ systolic murmur at the L
sternal border, no rubs or gallops.
LUNG: Diffuse, dry inspiratory crackles predominantly in the
lower lung fields bilaterally.
ABD: Normal bowel sounds, soft, nontender, nondistended, no
hepatomegaly, no splenomegaly.
EXT: Warm, well perfused, no lower extremity edema.
PULSES: 2+ radial pulses, 2+ DP pulses.
NEURO: Alert, oriented, CN II-XII intact, motor and sensory
function grossly intact.
SKIN: No significant rashes.
Pertinent Results:
ADMISSION LABS
===============
___ 07:52AM BLOOD WBC-8.7 RBC-4.29* Hgb-13.4* Hct-38.2*
MCV-89 MCH-31.2 MCHC-35.1 RDW-15.2 RDWSD-50.0* Plt ___
___ 07:52AM BLOOD Neuts-81.6* Lymphs-11.9* Monos-3.9*
Eos-0.5* Baso-0.5 Im ___ AbsNeut-7.08* AbsLymp-1.03*
AbsMono-0.34 AbsEos-0.04 AbsBaso-0.04
___ 07:52AM BLOOD Plt ___
___ 07:52AM BLOOD ___ PTT-26.7 ___
___ 07:52AM BLOOD Glucose-425* UreaN-25* Creat-1.1 Na-134*
K-5.5* Cl-97 HCO3-17* AnGap-20*
___ 07:52AM BLOOD ALT-18 AST-24 LD(LDH)-356* AlkPhos-68
TotBili-0.8
___ 02:00PM BLOOD cTropnT-<0.01
___ 07:52AM BLOOD cTropnT-<0.01
___ 07:52AM BLOOD Calcium-9.5 Phos-3.3 Mg-2.0 Iron-137
___ 08:05AM BLOOD D-Dimer-419
___ 07:52AM BLOOD calTIBC-337 Ferritn-235 TRF-259
___ 08:05AM BLOOD %HbA1c-11.6* eAG-286*
___ 07:52AM BLOOD HCV Ab-NEG
___ 10:29AM BLOOD Type-ART pO2-59* pCO2-38 pH-7.43
calTCO2-26 Base XS-0
___ 09:49AM BLOOD K-4.8
DISCHARGE LABS
================
___ 07:05AM BLOOD WBC-7.6 RBC-4.02* Hgb-12.6* Hct-36.6*
MCV-91 MCH-31.3 MCHC-34.4 RDW-15.3 RDWSD-51.0* Plt ___
___ 07:05AM BLOOD Plt ___
___ 07:05AM BLOOD Glucose-201* UreaN-21* Creat-1.0 Na-138
K-4.3 Cl-100 HCO3-27 AnGap-11
___ 07:05AM BLOOD Calcium-8.7 Phos-2.9 Mg-2.0
MICRO:
======
URINE CULTURE (Final ___: NO GROWTH.
IMAGING
==========
___ CXR
FINDINGS:
Re-demonstration of diffuse reticular opacities in bilateral
lungs consistent with chronic interstitial lung disease, overall
stable since prior chest radiograph. There is similar
appearance of previously seen right upper lobe opacity, however
evaluation slightly limited by overlying EKG sticker. No
pleural effusion or pneumothorax is seen. The cardiac and
mediastinal silhouettes are unchanged.
IMPRESSION:
No pneumothorax. Similar appearance of previously seen right
upper lobe
opacity, though evaluation slightly limited by overlying EKG
sticker. If
clinically indicated, further evaluation is opacity should be
performed by CT.
___ CT Head Noncon
IMPRESSION:
1. No acute intracranial abnormality on noncontrast head CT.
Specifically no intracranial hemorrhage or large territory
infarct.
2. Additional findings as described above.
___ TTE
The left atrium is elongated. The right atrium is mildly
enlarged. There is no evidence for an atrial septal defect by
2D/color Doppler. The estimated right atrial pressure is ___
mmHg. There is mild symmetric
left ventricular hypertrophy with a normal cavity size. There is
normal regional left ventricular systolic function. Global left
ventricular systolic function is normal. Quantitative biplane
left ventricular ejection
fraction is 56 %. There is no left ventricular outflow tract
gradient at rest or with Valsalva. Mildly dilated right
ventricular cavity with normal free wall motion. The aortic
sinus diameter is normal for
gender with mildly dilated ascending aorta. The aortic arch
diameter is normal. There is no evidence for an aortic arch
coarctation. The aortic valve leaflets (3) are mildly thickened.
There is no aortic valve
stenosis. There is no aortic regurgitation. The mitral leaflets
are mildly thickened with no mitral valve prolapse. There is
trivial mitral regurgitation. The tricuspid valve leaflets
appear structurally normal.
There is mild [1+] tricuspid regurgitation. The pulmonary artery
systolic pressure could not be estimated. There is a trivial
pericardial effusion.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
normal cavity size and regional/global systolic function. Mild
right ventricular dilation with normal systolic function. Mild
tricuspid
regurgitation. Compared with the prior TTE (images reviewed) of
___ , the right ventricle is now more dilated. The
estimated pulmonary artery systolic pressure is less well
assessed on the current study.
Brief Hospital Course:
SUMMARY STATEMENT
==================
Mr. ___ is a ___ year old man with a past medical history of
smoking-related interstitial lung disease complicated by prior
recurrent PTX (on chronic glucocorticoids) and COPD on home O2
2L who presents with recurrent presyncopal episodes, found to be
hyperglycemic. Problems addressed during his hospitalization are
as follows:
#Preyncope:
Presenting with episodes of lightheadedness and feeling "faint,
weak" increasing in frequency over several weeks. Sometimes
associated with falls. Denies loss of consciousness, no
concomitant or preceding symptoms, no bowel or bladder
incontinence. Most recently had episode 2 days prior to
admission resulting in fall to the ground without head strike,
resulted in no residual pain. Saw PCP the following day who
recommended ED for evaluation. It remains unclear if symptoms
represent discrete episodes of presyncope or if he merely
becomes faint, lightheaded. The etiology of these episodes may
be from volume depletion in the setting of worsening
hyperglycemia causing an osmotic diuresis. This is supported by
an elevated BUN/Cr on admission. Although reports positional
component to these episodes at times, his orthostatic vitals
were normal. Low suspicion of cardiac etiology given
unremarkable telemetry and TTE. ___ still consider arrhythmia.
Low suspicion for seizures, adrenal insufficiency (on chronic
steroids). At the time of discharge, reported good PO intake,
was able to ambulate independently without any symptoms.
#Hyperglycemia:
Patient does not have any known history of T2DM, has been on
chronic prednisone in the setting of interstitial lung disease.
There was a concern for HHS in the ED, blood sugars rapidly
improved with 10U lispro. His anion gap was elevated, though no
ketonuria or acidemia to suggest DKA. HbA1C 11.6. Initiated
metformin 500 mg BID.
#Normocytic anemia:
Most likely anemia of chronic disease. Iron studies
unremarkable.
#Thrombocytopenia:
Patient has been thrombocytopenic in the past, nadirs around
120. No known history of chronic liver disease. HIV NEG ___.
HCV Ab pending at discharge.
#Dyslipidemia:
Continued home atorvastatin.
#Urinary retention
Tamsulosin in place of home alfluzosin given formulary.
#Smoking related ILD
#COPD:
Remained on 2L NC, which is baseline requirement. Initiated
ranitidine for ulcer prophylaxis. Continued home prednisone,
Bactrim, tiotropium. Held home varenicline, endorsed remote
history of potentially associated SI.
#Anxiety
#Depression:
Continue home clonazepam, risperidone, sertraline.
TRANSITIONAL ISSUES:
======================
[] initiated metformin (A1C 11.6), continue to monitor need for
titration or additional agents
[] initiated ranitidine for ulcer prophylaxis
[] continue to monitor thrombocytopenia, f/u HCV Ab, consider
repeat HIV if risk factors present
[] continue to monitor anemia, likely chronic disease
[] due for repeat colonoscopy (last done ___
[] consider nonurgent outpatient CT chest for better evaluation
of RUL opacity on CXR (previously seen, no interval change)
[] consider osteoporosis testing given steroid use and falls
[] consider outpatient holter monitor
[] continue to encourage smoking cessation, reported remote
history of SI possibly associated with varenicline, consider
discontinuing.
# CONTACT: ___ (mother) ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. ClonazePAM 1 mg PO TID
2. RisperiDONE 1 mg PO QHS
3. Sertraline 200 mg PO QAM
4. Sulfameth/Trimethoprim DS 1 TAB PO DAILY
5. Tiotropium Bromide 1 CAP IH DAILY
6. alfuzosin 10 mg oral DAILY
7. PredniSONE 20 mg PO DAILY
8. Atorvastatin 20 mg PO QPM
9. varenicline 1 mg oral BID
Discharge Medications:
1. MetFORMIN (Glucophage) 500 mg PO BID
RX *metformin 500 mg 1 (One) tablet(s) by mouth twice a day Disp
#*30 Tablet Refills:*0
2. Ranitidine 150 mg PO BID
RX *ranitidine HCl 150 mg 1 (One) capsule(s) by mouth twice a
day Disp #*60 Capsule Refills:*0
3. ClonazePAM 2 mg PO DAILY
4. PredniSONE 20 mg PO DAILY
5. alfuzosin 10 mg oral DAILY
6. Atorvastatin 20 mg PO QPM
7. ClonazePAM 1 mg PO TID
8. ClonazePAM 1 mg PO QHS
9. RisperiDONE 1 mg PO QHS
10. Sertraline 200 mg PO QAM
11. Sulfameth/Trimethoprim DS 1 TAB PO DAILY
12. Tiotropium Bromide 1 CAP IH DAILY
13. HELD- varenicline 1 mg oral BID This medication was held.
Do not restart varenicline until discussing with your PCP
___:
Home
Discharge Diagnosis:
#Presyncope
#Hyperglycemia
#Normocytic anemia
#Thrombocytopenia
#Dyslipidemia
#Urinary retention
#Smoking related ILD
#COPD
#Anxiety
#Depression
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 the ___
___! You came to the hospital because you fainted
multiple times. We believe your fainting may be related to high
levels of sugar in your blood. You were started on a new
medication called "metformin" to better control your blood sugar
levels. Your outpatient doctors ___ monitor ___ on this new
medication.
Please continue to take your medications as prescribed and to
follow-up with your doctors as ___.
We wish you all the best!
Your ___ care team
Followup Instructions:
___
|
19721002-DS-23
| 19,721,002 | 22,134,009 |
DS
| 23 |
2158-03-21 00:00:00
|
2158-03-21 19:20:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
dyspnea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is a ___ male with end-stage COPD on 5 L at home
who
presents with shortness of breath. Patient developed gradual
shortness of breath today and called ___. He was treated for
hypoxia in the ___. He was placed on his 5 L nasal cannula and
was only satting in the ___. He denies chest pain, fever,
abdominal pain, dysuria, diarrhea. He states he wants to be
admitted to the hospital. He is DNR and DNI.
In the ED, patient was placed on a non-rebreather, but was
still
saturating in the high ___. He was switched to Bipap with
improvements in his saturation. A CXR showed evidence of
pneumonia and he was started on broad spectrum antibiotics.
Past Medical History:
CKD, DM2, interstitial lung dx / COPD on hospice, chronic pain,
urinary retention
Social History:
___
Family History:
- Father and brother DM2
- Father died of complications of colon cancer
- Brother died of complications of DM2 at age ___
- Mother with unknown 'heart related problems,' currently age ___
- Negative for rheumatologic or lung diseases
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
VS: reviewed in metavision
GEN: NAD, sitting up comfortably on oxymizer. Wearing unclean
clothing
HEENT: NCAT, NAD. Mildly cyanotic lips
NECK: No LAD, JVP not elevated
CV: RRR, no murmurs or gallops
RESP: Diffuse coarse rhonchi at the bases, no wheezes.
Unlabored
breathing.
GI: soft, non-distended
MSK: Warm, well-perfused, no edema or cyanosis
SKIN: Ecchymoses over right knee.
NEURO: AOx3, moving all extremities
DISCHARGE PHYSICAL EXAM:
========================
GEN: NAD, sitting in bed comfortably on 3L NC
HEENT: NCAT, NAD. Cyanotic lips.
CV: RRR, S1/S2, no m/r/g
RESP: bibasilar crackles with mild wheezes. Breathing
comfortably on 3L NC
GI: soft, non-distended, non-tender to palpation
MSK: warm, well-perfused, no edema or cyanosis
SKIN: ecchymoses over right knee
NEURO: AOx3, moving all extremities purposefully
Pertinent Results:
ADMISSION LABS
============
___ 11:00AM BLOOD WBC-8.7 RBC-3.93* Hgb-11.9* Hct-37.9*
MCV-96 MCH-30.3 MCHC-31.4* RDW-16.6* RDWSD-59.5* Plt ___
___ 11:00AM BLOOD Neuts-74.7* Lymphs-13.8* Monos-6.0
Eos-3.2 Baso-0.6 Im ___ AbsNeut-6.50* AbsLymp-1.20
AbsMono-0.52 AbsEos-0.28 AbsBaso-0.05
___ 11:00AM BLOOD ___ PTT-28.4 ___
___ 11:00AM BLOOD Glucose-273* UreaN-39* Creat-1.4* Na-141
K-4.3 Cl-99 HCO3-18* AnGap-24*
___ 11:00AM BLOOD proBNP-7678*
___ 11:00AM BLOOD cTropnT-<0.01
___ 11:00AM BLOOD Calcium-8.9 Phos-5.0* Mg-1.9
___ 11:12AM BLOOD ___ pO2-36* pCO2-34* pH-7.38
calTCO2-21 Base XS--3
___ 11:12AM BLOOD Lactate-6.1*
___ 02:29PM BLOOD Lactate-1.0
___ 11:12AM BLOOD O2 Sat-59
DISCHARGE LABS
==============
___ 07:18AM BLOOD WBC-9.5 RBC-4.28* Hgb-12.7* Hct-39.5*
MCV-92 MCH-29.7 MCHC-32.2 RDW-16.5* RDWSD-55.8* Plt ___
___ 07:18AM BLOOD Glucose-87 UreaN-35* Creat-1.1 Na-143
K-4.0 Cl-103 HCO3-25 AnGap-15
___ 07:18AM BLOOD Calcium-9.2 Phos-3.6 Mg-2.1
Brief Hospital Course:
Mr. ___ is a ___ w CKD, DM, interstitial lung dx / COPD on
chronic pred, on hospice, chronic pain, recently admitted for
left shoulder dislocation, who presents with acute hypoxic
respiratory failure, suspected secondary to progression of his
underlying lung disease. He was initially started on BiPAP, but
was titrated down to oxymizer. He was empirically treated for a
pneumonia, as well as started on high dose steroids. Though his
oxygen requirement improved with rest, he still had significant
oxygen requirement with activity. After extensive conversation
with both the hospice group, the primary team, and the patient,
he continued to express a wish to be discharged to home despite
the extensive risks.
ACUTE ISSUES
===============
#. GOC
#. Home Safety
Throughout hospitalization, patient had significant concerns and
discussions regarding his disposition. It was not felt safe that
he could return home with such a large oxygen requirement, and
given his multiple recurrent falls at home. There was extensive
discussion between the team, patient, hospice, social work, and
case management regarding his disposition options. Ultimately,
despite extensively reviewing the risks of him returning home,
and his other options, including a trial period at ___ to
gain more time to help arrange services at home, patient
continued to express desire to go home. Given that patient was
able to reiterate the risks of going home, understood his
alternatives, and overall expressed capacity to make this
decision, he was discharged home in accordance with his wishes.
[] Unfortunately, given the perceived risks of patient going
home without more support, his current hospice company, ___
___, does not feel comfortable supporting an unsafe
discharge plan, and thus will no longer be able to follow him
and provide him care. He will need to establish care with
another hospice company if he wishes to continue to receive
their services. A homecare company is planning on coming to
evaluate the patient tomorrow morning (___).
[] There is significant concern for patient's safety at home. In
the setting of his significant oxygen requirement and history of
multiple falls at home, there is significant concern that
another fall at home may be catastrophic for him. These concerns
were extensively discussed with the patient, who remained
adamant that he would like to be discharged home.
#. Acute on chronic hypoxic respiratory failure
#. Suspected Pneumonia
#. Smoking related ILD
#. COPD
End stage COPD and smoking related ILD, baseline 5L home O2
requirement and baseline O2 saturation 88-93%. Etiology of
patient's respiratory distress is unclear, but suspect likely
secondary to chronic progression of his underlying lung disease.
CXR on admission with some evidence of pneumonia, but without
leukocytosis, fevers, or other symptoms, but empirically
initiated on treatment with Cefpodoxime and doxycycline (given
prolonged Qtc). He completed this course of abx on ___. Also
initiated on high dose steroids, as well as inhaler therapy. O2
requirement improved from BiPAP requirement on presentation,
back to nasal cannula at time of discharge.
[] Patient is being discharged on a course of prednisone: 30mg
for 7 days ___ followed by a return to his regular
home dose of 20mg daily (___)
[] The appropriateness of PJP and PPI prophylaxis should be
extensively discussed with the patient in regards to his goals
of care and utility given his prognosis.
[] Patient is being discharged on new inhaler therapy: Anoro
Ellipta
[] It is strongly recommended patient discontinues his tobacco
use.
#. Fall
#. Orthostatic hypotension
Patient is s/p mechanical fall while attempting to unlock door
for EMS. No trauma noted by EMS. CXR without evidence fracture.
Neurologically intact. Etiology is likely due to hypoxia and
decompensation in the setting of his lung disease. Difficulty
working with ___ here given significant O2 requirement with
activity.
#. Cigarette use
Continued nicotine patch, lozenges while in house
#. Acute on Chronic Kidney Injury
On presentation elevated to 1.4 above baseline 1.1. Suspect
pre-renal, iso poor PO intake at home. Returned to baseline at
time of discharge.
CHRONIC ISSUES
===============
# T2DM
Held home metformin, placed on Humalog insulin sliding scale
while inpatient
# BPH
Tamsulosin while inpatient as home alpha blocker nonformulary
# Chronic Pain
Continue home morphine regimen
# Anxiety
# Depression
Continued home clonazepam, risperidone, and sertraline
TRANSITIONAL ISSUES
===================
[] Unfortunately, given the perceived risks of patient going
home without more support, his current hospice company, ___
___, does not feel comfortable supporting an unsafe
discharge plan, and thus will no longer be able to follow him
and provide him care. He will need to establish care with
another hospice company if he wishes to continue to receive
their services. A homecare company is planning on coming to
evaluate the patient tomorrow morning (___).
[] There is significant concern for patient's safety at home. In
the setting of his significant oxygen requirement and history of
multiple falls at home, there is significant concern that
another fall at home may be catastrophic for him. These concerns
were extensively discussed with the patient, who remained
adamant that he would like to be discharged home.
[] Patient is being discharged on a course of prednisone: 30mg
for 7 days ___ followed by a return to his regular
home dose of 20mg daily (___)
[] The appropriateness of PJP and PPI prophylaxis should be
extensively discussed with the patient in regards to his goals
of care and utility given his prognosis.
[] Patient is being discharged on new inhaler therapy: Anoro
Ellipta
[] It is strongly recommended patient discontinues his tobacco
use.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. ClonazePAM 1 mg PO DAILY PRN anxiety
2. Morphine SR (MS ___ 15 mg PO Q12H
3. PredniSONE 20 mg PO DAILY
4. RisperiDONE 1 mg PO QHS
5. Sertraline 200 mg PO DAILY
6. alfuzosin 10 mg oral QHS
7. MetFORMIN (Glucophage) 1000 mg PO BID
8. Morphine Sulfate (Concentrated Oral Solution) 20 mg/mL 10 mg
PO Q4: PRN SOB
9. Midodrine 10 mg PO TID
Discharge Medications:
1. Anoro Ellipta (umeclidinium-vilanterol) 62.5-25
mcg/actuation inhalation DAILY
RX *umeclidinium-vilanterol [Anoro Ellipta] 62.5 mcg-25
mcg/actuation 1 puff IH once a day Disp #*1 Disk Refills:*0
2. Nicotine Lozenge 2 mg PO Q4H:PRN cravings
RX *nicotine (polacrilex) 2 mg every 4 hrs as needed Disp #*30
Lozenge Refills:*0
3. Nicotine Patch 14 mg/day TD DAILY
RX *nicotine 14 mg/24 hour once a day Disp #*30 Patch
Refills:*0
4. Pantoprazole 40 mg PO Q24H
RX *pantoprazole 40 mg 40 mg by mouth once a day Disp #*30
Tablet Refills:*0
5. ClonazePAM 1 mg PO QHS:PRN anxiety
6. ClonazePAM 2 mg PO DAILY:PRN anxiety
7. PredniSONE 30 mg PO DAILY Duration: 7 Days
Tapered dose - DOWN
RX *prednisone 10 mg 3 tablet(s) by mouth once a day Disp #*15
Tablet Refills:*0
8. alfuzosin 10 mg oral QHS
9. MetFORMIN (Glucophage) 1000 mg PO BID
10. Midodrine 10 mg PO TID
11. Morphine SR (MS ___ 15 mg PO Q12H
12. Morphine Sulfate (Concentrated Oral Solution) 20 mg/mL 10
mg PO Q4: PRN SOB
13. RisperiDONE 1 mg PO QHS
14. Sertraline 200 mg PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY
=======
Acute Hypoxic Respiratory Failure
COPD/ILD
___
Fall
SECONDARY
=========
BPH
DMII
Chronic Pain
Depression
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
======================
DISCHARGE INSTRUCTIONS
======================
Dear Mr. ___,
It was a pleasure caring for you at ___
___.
WHY WAS I IN THE HOSPITAL?
- You were brought in to the hospital due to concerns for
increasing oxygen needs.
WHAT HAPPENED TO ME IN THE HOSPITAL?
- While here, we evaluated you for possible causes of your
oxygen needs, but unfortunately did not find a specific cause.
- We also started treatment for a pneumonia, to see if this
helped.
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
- Continue to take all your medicines and keep your
appointments.
- We would strongly recommend you discontinue your tobacco use.
We wish you the best!
Sincerely,
Your ___ Team
Followup Instructions:
___
|
19721002-DS-24
| 19,721,002 | 28,352,958 |
DS
| 24 |
2158-03-30 00:00:00
|
2158-03-30 15:58:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
fall
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is a ___ male with a history of COPD and ILD who
presents after 3 or 4 syncopal events this morning resulting in
a
fall with head strike, laceration to his forehead and left
shoulder dislocation. He denies any prodromal symptoms regarding
his syncope. Specifically, no chest pain, shortness of breath,
palpitations, diaphoresis, nausea or vomiting. He states he is
no
prior cardiac history. For his COPD, he was on hospice care
until
recently when he was admitted to the hospital after a fall.
Because the patient wanted to return home and had had many
recent
falls, his hospice company felt this was an unsafe plan and
could
no longer provide services. He was instructed to find a new
hospice provider. He is on ___ L nasal cannula at baseline.
In the ED, initial VS were 96 102/64 20 100% 4L.
Left Shoulder was obviously dislocated
Labs showed WBC of 13.1, Plt of 135, BUN/Cr of 45/1.3. Tropon
negative. LFTS WNL.
CT Spine was negative for acute fracture.
CT Head showed midline frontal laceration and soft tissue
swelling without underlying acute fracture.
He received IV LR and IV fentanyl. He underwent reduction of his
left shoulder dislocation.
I have reviewed the patient's most recent admission as follows:
He was admitted from ___ to ___ for acute hypoxic
respiratory failure, thought to be secondary to progression of
his underlying lung disease. He was treated empirically for a
pneumonia nand started on high dose steroids. His
hospitalization
was notable for extensive goals of care. It was felt that the
patient was not safe to return home due to high oxygen
requirement and multiple falls. Because of the high risk, his
previous hospice company Care ___ did not feel they could
provide care for him.
Upon arrival to the floor, the patient tells the story as
follows. He reports he woke up this morning and was rising from
a
chair to go to the bathroom. On his way, he felt lightheaded,
with dizziness, as if "a cloud came over." He hit his head on
the
edge of a table and a lamp. He then tried to decide what to do.
He got up and fell in the kitchen. He got up again and fell a
third time. He reports one of these episodes was associated by
urinary incontinence, but only because he had to urinate nad was
unable to make it to the bathroom. He denies chest pain. He is
unsure if he had worsening shortness of breath during this
episodes. At one point, he increased his home O2 from 3L to 4L
to
see if it would help. He otherwise denies fevers, chills, cough,
diarrhea.
We spoke about his recent admission. He reports that he felt he
received "a lot of bullying" on the last admission from his
previous hospice provider. He was very upset with his
conversation with ___. He was considering inpatient
hospice, but then, felt that the hospice retaliated by saying
they would no longer see him as an outpatient. He states that
"many people were trying to convince me to go to a safer place
other than home." He says he "should have listened" and that
his
plan to go home "didn't work out." He reports a visiting nurse
visited him at home and arranged for ___ to come to his house.
The
physical therapist that came to his house told him "You can not
stay here by yourself." The ___ threatened to call an ambulance
if
the patient existing on staying home. Ultimately, the patient
kicked the ___ out of his house and the ambulance did come and
question him. He states that "My wish now is not to be a floater
- going from ___ nursing facility to ___." He would like to find a hospice center that has a
bed.
ROS: Pertinent positives and negatives as noted in the HPI. All
other systems were reviewed and are negative.
Past Medical History:
- CKD
- DM2
- Interstitial lung disase/COPD
- Chronic pain
- Urinary retention
Social History:
___
Family History:
- Father and brother DM2
- Father died of complications of colon cancer
- Brother died of complications of DM2 at age ___
- Mother with unknown 'heart related problems,' currently age ___
- Negative for rheumatologic or lung diseases
Physical Exam:
VITALS: 97.7 PO 122/81 R Lying 88 16 94% 5L Nc
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
Mucous membranes dry
CV: Heart regular, no murmur
RESP: Lungs clear to auscultation anteriorly (can not auscultate
posteriorly as patient is on bed rest)
GI: Abdomen soft, non-distended, non-tender to palpation
MSK: Neck supple, left arm/shoulder in wrap, moves
EXT: warm, no edema
SKIN: +4 cm vertical laceration of the forehead
NEURO: Alert, oriented, face symmetric, gaze conjugate with
EOMI,
speech fluent, moves all limbs
PSYCH: pleasant, appropriate affect
Pertinent Results:
___ 03:36PM BLOOD WBC-13.1* RBC-4.71 Hgb-14.1 Hct-42.9
MCV-91 MCH-29.9 MCHC-32.9 RDW-15.9* RDWSD-53.1* Plt ___
___ 07:15AM BLOOD ___ PTT-28.6 ___
___ 03:36PM BLOOD Glucose-135* UreaN-45* Creat-1.3* Na-139
K-4.3 Cl-99 HCO3-23 AnGap-17
___ 03:36PM BLOOD ALT-21 AST-23 AlkPhos-69 TotBili-0.9
___ 06:15AM BLOOD Calcium-9.1 Phos-3.6 Mg-1.9
___ 03:47PM BLOOD Lactate-1.0
CT HEAD:
IMPRESSION:
1. Midline frontal laceration and soft tissue swelling without
underlying
acute fracture.
2. No acute intracranial abnormality.
CT C SPINE:
IMPRESSION:
1. No acute fracture or traumatic malalignment.
2. Moderate cervical spondylosis with mild to moderate central
canal and
severe bilateral neural foraminal stenosis at C5-6 and C6-7.
CXR:
FINDINGS:
Lung volumes are low with chronic fibrosing interstitial changes
again
demonstrated diffusely in the lungs. More focal opacity in the
periphery of
the right upper lobe is minimally improved from ___.
Cardiac and
mediastinal contours are unchanged with the heart size appearing
normal. No
pulmonary edema, new focal consolidation, pleural effusion, or
pneumothorax.
No acute osseous abnormality.
IMPRESSION:
Minimal improvement in right upper lobe focal opacity suggestive
of improving
pneumonia. Background of chronic fibrosing interstitial lung
disease.
FINDINGS:
Previously noted left anterior glenohumeral joint dislocation
has been reduced
with the humeral head articulating normally with the glenoid.
Chronic
___ fracture deformity of the humeral head is
re-demonstrated. No new
fracture. Acromioclavicular joint remains preserved. Imaged
left lung
demonstrates chronic interstitial abnormality.
IMPRESSION:
Interval reduction of previously noted left anterior
glenohumeral joint
dislocation. Chronic appearing ___ fracture deformity of
the left
humeral head without new fracture.
Brief Hospital Course:
This is a ___ man with a history of severe COPD and ILD
who presented after 3 or 4 syncopal events resulting in a fall
with head strike, laceration to his forehead and left shoulder
dislocation.
# Acute on chronic hypoxic respiratory failure
# Smoking related ILD
# COPD
End stage COPD and smoking related ILD, baseline 5L home O2
requirement and baseline O2 saturation 88-93%. Per report, the
patient changes his O2 from ___ at home, and perhaps should be
instructed to keep his nasal cannula at a higher setting. He
had no evidence of new pneumonia (CXR improving from prior
hospitalization). He was currently at his baseline. He
completed a previously scheduled prednisone taper back to his
home 20mg daily. His inhalers were continued as able by
formulary. He continued his 02 at his baseline
# Recurrent L shoulder dislocation now s/p closed reduction:
# Forehead laceration
Patient was noted to be grossly unstable and at extremely high
risk of re-dislocating, however he was not an optimal surgical
candidate given his chronic respiratory failure and hospice
status.
- Appreciate orthopedic surgery recommendations
- Nonweightbearing left upper extremity with activities of daily
living as tolerated.
- Arm in sling
- Patient is not a surgical candidate and should adhere to range
of motion parameters. He should not externally rotate greater
than 90 degrees, not flex the shoulder forward greater than 90
degrees. He should not lift items that are greater than 10
pounds.
- Pain control with home MS ___ and morphine and scheduled
Tylenol
- OT consulted
- Forehead laceration sutured. PLEASE REMOVE forehead sutures
on ___
# Syncope:
# Orthostasis
Patient presenting with multiple syncopal events with some
prodome syndrome. Similar to prior episodes prior to last
hospitalization. His fall resulted in a head strike, requiring
sutures for a forehead laceration. CT head and Cspine otherwise
negative. Neuro-vascularly intact. This was likely due to his
chronic orthostasis. HE was continued on midodrine with ___
consult and fall precautions.
# Acute Renal failure: Admission Cr of 1.4, above baseline of
1.1. Given hypovolemia and dehydration, expect this to be
prerenal in etiology. Resolved
# Goals of Care, concern for home safety:
The patient has had significant concerns regarding his
disposition and verbalizes understanding that he is not safe to
return home. He now verbalizes that he would like to pursue
inpatient hospice options where he can "spend whatever time he
has left." Due to an extensive conversation on admission, and
the need for multi-team involvement (case management, social
work, primary team, and possibly palliative care). I reviewed
with him in detail: he wishes to be DNR/DNI and understands the
terminal nature of his condition
- MOLST completed
- Social work consult
- Transition to hospice
CHRONIC/STABLE PROBLEMS:
# T2DM
- Resume metformin on DC
# Tobacco Abuse:
- Nicotine Patch 14 mg/day TD DAILY
- Nicotine Lozenge 2 mg PO Q4H:PRN cravings
# BPH
- alpha blocker
# Chronic Pain
- Morphine SR (MS ___ 15 mg PO Q12H
- Morphine Sulfate (Concentrated Oral Solution) 20 mg/mL 10 mg
PO Q4: PRN SOB
# Anxiety
# Depression
Continued home clonazepam, risperidone, and sertraline
- ClonazePAM 2 mg PO QPM
- RisperiDONE 1 mg PO QHS
- Sertraline 200 mg PO DAILY
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Anoro Ellipta (umeclidinium-vilanterol) 62.5-25 mcg/actuation
inhalation DAILY
2. ClonazePAM 2 mg PO QPM
3. ClonazePAM 1 mg PO DAILY:PRN anxiety
4. Midodrine 10 mg PO TID
5. Morphine SR (MS ___ 15 mg PO Q12H
6. Morphine Sulfate (Concentrated Oral Solution) 20 mg/mL 10 mg
PO Q4: PRN SOB
7. PredniSONE 30 mg PO DAILY
Tapered dose - DOWN
8. RisperiDONE 1 mg PO QHS
9. Sertraline 200 mg PO DAILY
10. alfuzosin 10 mg oral QHS
11. MetFORMIN (Glucophage) 1000 mg PO BID
12. Pantoprazole 40 mg PO Q24H
13. Nicotine Patch 14 mg/day TD DAILY
14. Nicotine Lozenge 2 mg PO Q4H:PRN cravings
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
2. PredniSONE 20 mg PO DAILY
3. alfuzosin 10 mg oral QHS
4. Anoro Ellipta (umeclidinium-vilanterol) 62.5-25
mcg/actuation inhalation DAILY
5. ClonazePAM 2 mg PO QPM
6. ClonazePAM 1 mg PO DAILY:PRN anxiety
RX *clonazepam 1 mg ___ tablet(s) by mouth twice a day Disp #*12
Tablet Refills:*0
7. MetFORMIN (Glucophage) 1000 mg PO BID
8. Midodrine 10 mg PO TID
9. Morphine SR (MS ___ 15 mg PO Q12H
RX *morphine [MS ___ 15 mg 1 tablet(s) by mouth every twelve
(12) hours Disp #*6 Tablet Refills:*0
10. Morphine Sulfate (Concentrated Oral Solution) 20 mg/mL 10
mg PO Q4: PRN SOB
RX *morphine concentrate 100 mg/5 mL (20 mg/mL) 0.5 (One half)
ml by mouth every four (4) hours Disp ___ Milliliter Milliliter
Refills:*0
11. Nicotine Lozenge 2 mg PO Q4H:PRN cravings
12. Nicotine Patch 14 mg/day TD DAILY
13. Pantoprazole 40 mg PO Q24H
14. RisperiDONE 1 mg PO QHS
15. Sertraline 200 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY
=======
Acute Hypoxic Respiratory Failure
COPD/ILD
___
Fall - forehead laceration
Left shoulder dislocation
SECONDARY
=========
BPH
DMII
Chronic Pain
Depression
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
You were admitted after a fall resulting in a forehead
laceration and dislocated left shoulder. You were hospitalized
for safe discharge planning. Please take all medications as
prescribed. We recommend ongoing hospice care
Followup Instructions:
___
|
19721002-DS-25
| 19,721,002 | 28,371,171 |
DS
| 25 |
2158-04-24 00:00:00
|
2158-04-24 18:54:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
fall
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ M with hx end-stage COPD, smoking-related ILD, CKD, DM2,
and urinary retention who presents with left shoulder pain after
a fall.
Patient reports that he started declining about 2 months ago,
both from a breathing perspective and stability. He started
becoming more hypoxic, and having more falls after getting dizzy
and falling to the floor or passing out. Reports falling/losing
consciousness at least ___ times over the last 4 months.
Before passing out, he reports fogginess and dizziness with no
associated chest pain, palpitations, diaphoresis, nausea,
feeling of impending doom. Falls always while standing or with
standing, never while sitting. Uses rolling walker at home.
No recent fevers, chills, night sweats, cough, sore throat,
headaches, vision changes, nausea, vomiting, abdominal pain,
diarrhea, constipation, bloody stools, melena, dysuria,
hematuria, myalgias, joint pains, wheezing. Did have diarrhea
for 1 week at rehab last week. Resolved now.
Of note patient was admitted and discharged from BI ___nd went home for 3 days instead of going to rehab. He
then fell again and got eadmitted ___. Went to rehab from
there. Was there 3 weeks and wanted to go home again so checked
out AMA two days prior to admission. The morning after at 6:30
AM he was leaning over to get water from the fridge, reports
stumbling
backwards and falling on his left elbow and experiencing left
shoulder pain. Was dizzy during this episode but didn't pass
out. He has had a history of multiple shoulder dislocations in
the past, particular on the left side, last one being 2 to 3
months ago. He reports being on the ground sitting for about 2
hours, also he was able to get a neighbor to come help him up.
About an
hour later, he was standing and going to the bathroom, denies
any preceding lightheadedness or loss of consciousness but he
does report falling down, landed in a seated position. This time
he was on the ground for about an hour before he was able to
call for help. Denied any chest pain or trouble
breathing/shortness of breath, headache, abdominal or back pain,
focal weakness. Denied changes in urination or bowel movements.
At baseline 3L home O2 requirement and baseline O2 saturation
88-93%. Per report, the patient changes his O2 from ___ at
home, and perhaps should be instructed to keep his nasal cannula
at a higher setting.
Past Medical History:
- CKD
- DM2
- Interstitial lung disase/COPD
- Chronic pain
- Urinary retention
Social History:
___
Family History:
- Father and brother DM2
- Father died of complications of colon cancer
- Brother died of complications of DM2 at age ___
- Mother with unknown 'heart related problems,' currently age ___
- Negative for rheumatologic or lung diseases
Physical Exam:
ADMISSION EXAM
=================================
VITALS: T 97.9, BP 147/88, HR 70, RR 18, ___ NC
GENERAL: Alert and interactive. In no acute distress.
EYES: NCAT. PERRL, EOMI. Sclera anicteric and without injection.
ENT: MMM. No cervical lymphadenopathy. No JVD.
CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No
murmurs/rubs/gallops.
RESP: Clear to auscultation bilaterally. Crackles at bases,
higher up on the right side
ABDOMEN: Normal bowels sounds, non distended, non-tender to deep
palpation in all four quadrants. No organomegaly.
MSK: No spinous process tenderness. No CVA tenderness. No
clubbing, cyanosis, or edema. Pulses DP/Radial 2+ bilaterally. L
arm in sling
SKIN: Warm. Cap refill <2s. No rash.
NEUROLOGIC: no focal deficits
PSYCH: appropriate mood and affect
DISCHARGE EXAM
=================================
VITALS: Temp: 97.6 PO BP: 114/75 HR: 78 RR: 20 O2 sat: 94% O2
delivery: 2L
GENERAL: Well appearing man in no acute distress. Comfortable.
NEURO: AAOx3. Moving all four extremities with purpose.
HEENT: NCAT. EOMI. MMM.
CARDIOVASCULAR: Regular rate & rhythm. Normal S1/S2. No murmurs,
rubs, or gallops.
PULMONARY: Diffuse fine crackles bilaterally.
ABDOMEN: Soft, non-tender, non-distended. No hepatosplenomegaly.
EXTREMITIES: Left shoulder in sling, able to move extremity with
purpose.
SKIN: No significant rashes.
Pertinent Results:
ADMISSION LABS
=================================
___ 01:40PM BLOOD WBC-10.1* RBC-3.70* Hgb-11.2* Hct-33.7*
MCV-91 MCH-30.3 MCHC-33.2 RDW-16.1* RDWSD-53.2* Plt ___
___ 01:40PM BLOOD Neuts-88.4* Lymphs-6.6* Monos-3.7*
Eos-0.0* Baso-0.3 Im ___ AbsNeut-8.95* AbsLymp-0.67*
AbsMono-0.37 AbsEos-0.00* AbsBaso-0.03
___ 01:40PM BLOOD Glucose-203* UreaN-47* Creat-1.1 Na-139
K-4.8 Cl-99 HCO3-22 AnGap-18
___ 01:40PM BLOOD CK(CPK)-105
___ 01:40PM BLOOD CK-MB-8 cTropnT-0.21*
___ 01:40PM BLOOD Calcium-8.9 Phos-3.0 Mg-1.6
___ 01:45PM BLOOD Lactate-3.9*
PERTINENT LABS
=================================
___ 05:09AM BLOOD CK-MB-5 cTropnT-0.21*
___ 03:14PM BLOOD CK-MB-4 cTropnT-0.14*
___ 05:09AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Tricycl-NEG
___ 05:12AM BLOOD Lactate-1.3
DISCHARGE LABS
=================================
___ 05:59AM BLOOD WBC-9.8 RBC-4.32* Hgb-13.0* Hct-39.6*
MCV-92 MCH-30.1 MCHC-32.8 RDW-16.7* RDWSD-55.7* Plt ___
___ 04:35AM BLOOD Glucose-114* UreaN-26* Creat-1.0 Na-140
K-4.4 Cl-99 HCO3-29 AnGap-12
___ 04:35AM BLOOD Calcium-9.4 Phos-4.5 Mg-1.9
PERTINENT STUDIES
=================================
CHEST (PA & LAT) (___)
1. Left anterior glenohumeral joint dislocation.
2. Patchy right upper lobe opacity does not appear substantially
changed from the prior radiograph from ___ and may
reflect residual pneumonia.
3. Chronic interstitial lung disease with probable left basilar
atelectasis.
GLENO-HUMERAL SHOULDER (___)
Anterior glenohumeral joint dislocation.
CT HEAD W/O CONTRAST (___)
No acute intracranial process.
CT C-SPINE W/O CONTRAST (___)
1. No acute fractures or traumatic subluxation.
2. Mild-to-moderate cervical spondylosis with mild moderate
central canal
narrowing and moderate to severe foraminal stenosis secondary to
degenerative changes, as detailed above.
SHOULDER (AP, NEUTRAL &) (___)
Interval reduction in previously seen left shoulder dislocation.
The left
humeral head appears mildly high riding in relation to the
glenoid which could relate to rotator cuff disease, also
suggested, similar in appearance on prior study from ___.
Brief Hospital Course:
___ with history of end-stage COPD, smoking-related interstitial
lung disease, CKD, and DM2 who was admitted for fall complicated
by left anterior shoulder dislocation.
# FALL
# ORTHOSTATIC HYPOTENSION
Falls most likely due to orthostatic hypotension in setting of
chronic lung disease and multiple other co-morbidities.
Extensively evaluated in the past without clear cardiogenic
etiology. No events on telemetry. Overall inconsistent with
neurogenic causes and EEG (as below) was normal. Did have
positive orthostatic vital signs in the setting of poor PO
intake as well as alpha blocker use (discontinued). Continued
midodrine 10 mg PO TID. Overall stable at time of discharge.
# LEFT SHOULDER DISLOCATION
Evaluated by orthopedic surgery who reduced shoulder upon a
arrival. Recommended non-weightbearing left upper extremity with
activities of daily living as tolerated, wrapped in adduction to
prevent re-dislocation. He will follow up as an outpatient.
# TRANSIENT LOSS OF CONSCIOUSNESS
Experienced transient loss of consciousness while in radiology
CT suite. Unclear if had convulsions but reported post ictal
period for ___ minutes with urinary incontinence. Has never
had a seizure before. No focal deficits and remained HDS.
Patient did not recall dizziness or any other prodromal
symptoms. Could be related to overmedication (benzos and
opiates). Underwent 24 hour EEG to r/o seizure, which was
unrevealing.
# CHRONIC HYPOXEMIC RESPIRATORY FAILURE
Due to severe COPD and smoking-related ILD. Currently on ___ O2
at baseline. Easily desaturates with minimal activity consistent
with end-stage illness. Continued chronic, high-dose prednisone
and inhaler regimen.
# TYPE II NSTEMI
Noted to have mildly elevated troponin (peak of 0.2) likely
demand ischemia in setting of poor PO intake and failure to
thrive at home leading up to admission. ECG with stable T-wave
inversions in V1-V4. No anginal symptoms.
# H/O URINARY RETENTION
Alfuzosin was held given orthostatic hypotension likely
contributing to falls. He did not have significant issues with
urinary retention while admitted.
# CHRONIC KIDNEY DISEASE
Stable; baseline Cr 1.1-1.3.
# TYPE II DIABETES
Continued metformin at discharge.
# ANXIETY
Continue clonazepam.
# TOBACCO USE DISORDER
Continued nicotine replacement therapy.
# DEPRESSION
Continued home risperidone and sertraline.
TRANSITIONAL ISSUES
=================================
[ ] Has severe hypoxia secondary to COPD/ILD requiring ___ L at
baseline and overall consistent with end-stage disease. He will
desaturate easily with minimal exertion.
[ ] Monitor orthostatic vital signs as outpatient and up-titrate
midodrine if needed. If refractory could consider autonomics
evaluation
[ ] Monitor for recurrent urinary retention though would use
caution prior initiating vasodilatory medications given
orthostatic hypotension with falls. Could consider finasteride.
[ ] Will need ongoing goals of care discussions given end-stage
COPD/ILD with significant baseline O2 requirement.
#CODE STATUS: DNR/DNI
#CONTACT: ___ (friend: ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. ClonazePAM 2 mg PO QPM
2. ClonazePAM 1 mg PO DAILY:PRN anxiety
3. Midodrine 10 mg PO TID
4. Morphine SR (MS ___ 15 mg PO Q12H
5. Morphine Sulfate (Concentrated Oral Solution) 20 mg/mL 10 mg
PO Q4: PRN SOB
6. Nicotine Lozenge 2 mg PO Q4H:PRN cravings
7. Nicotine Patch 14 mg/day TD DAILY
8. Pantoprazole 40 mg PO Q24H
9. PredniSONE 20 mg PO DAILY
10. RisperiDONE 1 mg PO QHS
11. Sertraline 200 mg PO DAILY
12. alfuzosin 10 mg oral QHS
13. Anoro Ellipta (umeclidinium-vilanterol) 62.5-25
mcg/actuation inhalation DAILY
14. MetFORMIN (Glucophage) 1000 mg PO BID
15. Acetaminophen 1000 mg PO Q8H
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
2. Anoro Ellipta (umeclidinium-vilanterol) 62.5-25
mcg/actuation inhalation DAILY
3. ClonazePAM 2 mg PO QPM
RX *clonazepam 2 mg 1 tablet(s) by mouth qPM Disp #*7 Tablet
Refills:*0
4. ClonazePAM 1 mg PO DAILY:PRN anxiety
RX *clonazepam 1 mg 1 tablet(s) by mouth once a day Disp #*7
Tablet Refills:*0
5. MetFORMIN (Glucophage) 1000 mg PO BID
6. Midodrine 10 mg PO TID
7. Morphine SR (MS ___ 15 mg PO Q12H
RX *morphine [MS ___ 15 mg 1 tablet(s) by mouth q12 hours
Disp #*14 Tablet Refills:*0
8. Morphine Sulfate (Concentrated Oral Solution) 20 mg/mL 10 mg
PO Q4: PRN SOB
RX *morphine concentrate 20 mg/mL 0.5 (One half) ml by mouth
every four (4) hours Disp #*30 Syringe Refills:*0
9. Nicotine Lozenge 2 mg PO Q4H:PRN cravings
10. Nicotine Patch 14 mg/day TD DAILY
11. Pantoprazole 40 mg PO Q24H
12. PredniSONE 20 mg PO DAILY
13. RisperiDONE 1 mg PO QHS
14. Sertraline 200 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
___ Diagnosis:
PRIMARY DIAGNOSIS:
# FALL
SECONDARY DIAGNOSIS:
# ORTHOSTATIC HYPOTENSION
# LEFT SHOULDER DISLOCATION
# TRANSIENT LOSS OF CONSCIOUSNESS
# TYPE II NSTEMI
# H/O URINARY RETENTION
# CHRONIC KIDNEY DISEASE
# TYPE II DIABETES
# ANXIETY
# TOBACCO USE DISORDER
# DEPRESSION
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you at ___.
Why you were in the hospital:
- fall
- shoulder dislocation
What was done for you in the hospital:
- You were evaluated by orthopedic surgery who were able to
repair your shoulder dislocation. We stopped medications which
may be contributing to your falls. We monitored you and
discharged you to a SNF given your difficulties staying at home.
What you should do after you leave the hospital:
- Please take your medications as detailed in the discharge
papers. If you have questions about which medications to take,
please contact your regular doctor to discuss.
- Please go to your follow up appointments as scheduled in the
discharge papers. Most of them already have a specific date &
time set. If there is no specific time specified, and you do not
hear from their office in ___ business days, please contact the
office to schedule an appointment.
- Please monitor for worsening symptoms. If you do not feel like
you are getting better or have any other concerns, please call
your doctor to discuss or return to the emergency room.
We wish you the best!
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
19721023-DS-7
| 19,721,023 | 27,895,475 |
DS
| 7 |
2186-12-04 00:00:00
|
2186-12-04 15:01:00
|
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
Sulfa (Sulfonamide Antibiotics)
Attending: ___.
Chief Complaint:
R knee pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ was taking out her trash when she caught her
foot in a mat and fell down ___ stairs taking to fall onto her
right lower extremity. She tried to ambulate however had
significant pain in her RLE and was unable to do so and called
for help from her daughter and was then brought to our ED. In
our
ED x-rays reveal a right tibial plateau fracture and large knee
effusion. she denies LOC, striking her head, chest pain, neck
pain or pain elsewhere in her body.
Past Medical History:
c-section
rotator cuff tear
torn meniscus in R knee tx'd non-operatively with ___
approximately ___ year ago
DM II
HTN
HLD
Social History:
___
Family History:
Non contributory
Physical Exam:
On Exam upon consultation in the ED:
PE:
Vitals:
HR 98, BP 144.90 RR 20 O2 sat 96% RA
GEN: Calm and comfortable
Neuro: A&O x 3
CV: Regular
CHEST: No distress, no audible wheezes
Pelvis: stable to ap and lateral compression. non-tender
RLE skin clean and intact
right femur non-tender to palpation along diaphysis and right
hip, tender at joint line
significant effusion right knee. tender to palpation of right
joint line
No pain with passive motion of foot or ankle.
Saph Sural DPN SPN SILT
___ FHL ___ TA intact
2+ ___ and DP pulses
Brief Hospital Course:
The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have right tibial plateau fracture and was admitted to the
orthopedic surgery service overnight for pain control, she was
managed non operatively.
The patients home medications were continued throughout this
hospitalization. The patient worked with ___ who determined that
discharge to home was appropriate. The ___ hospital course
was otherwise unremarkable.
At the time of discharge the patient was afebrile with stable
vital signs that were within normal limits, pain was well
controlled with oral medications, incisions were
clean/dry/intact, and the patient was voiding/moving bowels
spontaneously. The patient is touch down weight bearing in the
right lower extremity, and will be discharged on lovenox for DVT
prophylaxis. The patient will follow up in two weeks per
routine. A thorough discussion was had with the patient
regarding the diagnosis and expected post-discharge course, and
all questions were answered prior to discharge.
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H
2. Docusate Sodium 100 mg PO BID
3. Enoxaparin Sodium 40 mg SC DAILY
RX *enoxaparin 40 mg/0.4 mL 40 mg syringe daily Disp #*14
Syringe Refills:*0
4. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN pain
RX *hydromorphone 2 mg ___ tablet(s) by mouth q4-6 hours Disp
#*50 Tablet Refills:*0
5. Lorazepam 0.5 mg PO Q8H:PRN Anxiety
6. Losartan Potassium 50 mg PO DAILY
7. Multivitamins 1 CAP PO DAILY
8. OLANZapine 2.5 mg PO DAILY
9. Omeprazole 20 mg PO DAILY
10. Simvastatin 40 mg PO DAILY
11. Vitamin D 400 UNIT PO DAILY
12. Zolpidem Tartrate 2.5-5 mg PO QHS:PRN Insomnia
Discharge Disposition:
Home
Discharge Diagnosis:
R tibial plateau fracture.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
MEDICATIONS:
- Please take all medications as prescribed by your physicians
at discharge.
- Continue all home medications unless specifically instructed
to stop by your surgeon.
- Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
- Narcotic pain relievers can cause constipation, so you should
drink eight 8oz glasses of water daily and take a stool softener
(colace) to prevent this side effect.
ANTICOAGULATION:
- Please take lovenox 40mg daily for 2 weeks
ACTIVITY AND WEIGHT BEARING:
- TDWB. Unlocked ___.
Followup Instructions:
___
|
19721567-DS-20
| 19,721,567 | 23,368,391 |
DS
| 20 |
2117-03-25 00:00:00
|
2117-03-25 20:05:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
DOE
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with hx of tobacco use disorder, htn presenting with
acute onset DOE.
Pt reports that he was in his USOH on ___, then on
___ noted mild DOE, which he observed after climbing stairs
from the basement. Then on ___, he was talking to his Dr.
___, and RN on the phone was asking for information
which required him to run up and back downstairs. When he got
back on the phone, he felt urgent need to urinate, ended call,
and had significant SOB. He was able to go to the bathroom, then
used albuterol inhaler x5 puffs, with transient and modest
improvement. That night, he went to bed, fell asleep around 11
am, then awoke at midnight with increased SOB. He moved
downstairs to inclined sofa, which allowed him to sleep until 3
am. Breathing again woke him. Wife came downstairs (she is an
ultrasonographer at ___ in fetal medicine) on her way to work,
brought him to ED for further evaluation. He endorses a mild dry
cough which is not baseline for him. He denies F/C, chest pain,
sore throat. He does recall a rhinorrhea 3 days prior, and has
had sick contacts at work, but colleagues' illness was
GI-related. He has never had acute exacerbations of COPD in the
past, and does not carry a diagnosis of COPD. Denies recent
travel or long car rides. Bilateral ___ edema is at baseline.
He has previously tried to quit with nicotine TD, wellbutrin,
both unsuccessful. Longest period of not smoking was 2 days. He
has decreased from 2 ppd, to 1 ppd, and does not carry a
diagnosis of COPD, although did recently have a screening CT
chest given his smoking history.
In the ___ ED:
VS 97.6, 82, 145/98, 95% RA
Exam notable for poor air movement, expiratory wheeze
bilaterally, baseline mild bilateral ___ edema to shins
Labs notable for WBC 8.1, Hb 11.5, plt 331
BUN 22, Cr 1.4
TnT <0.01
BNP 1881
Imaging:
CXR with patchy opacities in the lung bases, cannot exclude
infection or aspiration
Received:
Albuterol nebs x3
Ipratropium nebs x3
Methylprednisolone 125 mg IV x1
Ceftriaxone
Azithromycin
Furosemide 20 mg IV x1
Nicotine TD
On arrival to the floor, he feels that his breathing is back to
baseline. Denies cough, chest pain. He has chronic bilateral ___
edema, just at the ankles.
ROS: 10 point review of system reviewed and negative except as
otherwise described in HPI
Past Medical History:
tobacco use disorder, htn
Social History:
___
Family History:
Reviewed and found to be not
relevant to this hospitalization/illness
Physical Exam:
ADMISSION
VS: ___ Temp: 97.9 PO BP: 176/92 R Sitting HR: 94 RR:
20 O2 sat: 97% O2 delivery: 2L Nc
___ 2149 BP: 179/91 HR: 93 RR: 16 O2 sat: 100% O2 delivery:
RA
GEN: alert and interactive, comfortable, no acute distress
HEENT: +facial plethora, PERRL, anicteric, conjunctiva pink,
oropharynx without lesion or exudate, moist mucus membranes,
ears
without lesions or apparent trauma
LYMPH: no anterior/posterior cervical, supraclavicular
adenopathy
CARDIOVASCULAR: Regular rate and rhythm with ___ systolic murmur
at RUSB
LUNGS: clear to auscultation bilaterally without rhonchi,
wheezes, or crackles
GI: soft, nontender, without rebounding or guarding,
nondistended
with normal active bowel
sounds. Large ventral hernia. + hepatomegaly, with liver edge
3-4
cm below costal margin, smooth, nontender.
EXTREMITIES: trace bilateral pitting edema
GU: no foley
SKIN: no rashes, petechia, lesions, or echymoses; warm to
palpation
NEURO: Alert and interactive, cranial nerves II-XII grossly
intact, strength and sensation grossly intact
PSYCH: normal mood and affect
DISCHARGE
___ 2317 Temp: 97.8 PO BP: 173/88 R Sitting HR: 78 RR: 20
O2
sat: 97% O2 delivery: Ra
___ 2349 BP: 168/90 R Sitting
Gen - sitting up in bed, comfortable
Eyes - EOMI
ENT - OP clear, MMM
Heart - RRR no mrg
Lungs - CTA bilaterally
Abd - soft nontender, normal bowel sounds, no flank pain
Ext - no edema
Skin - no rashes
Vasc - 2+ DP/radial pulses
Neuro - AOx3, moving all extremities
Psych - appropriate
Pertinent Results:
ADMISSION
___ 08:43AM BLOOD WBC-8.1 RBC-3.59* Hgb-11.5* Hct-32.7*
MCV-91 MCH-32.0 MCHC-35.2 RDW-13.2 RDWSD-43.6 Plt ___
___ 08:43AM BLOOD Glucose-108* UreaN-22* Creat-1.4* Na-136
K-3.9 Cl-93* HCO3-25 AnGap-18
___
___ 08:43AM BLOOD Glucose-108* UreaN-22* Creat-1.4* Na-136
K-3.9 Cl-93* HCO3-25 AnGap-18
___ 06:07AM BLOOD Glucose-119* UreaN-24* Creat-1.6* Na-134*
K-3.3* Cl-92* HCO3-23 AnGap-19*
___ 06:10AM BLOOD Glucose-97 UreaN-22* Creat-1.5* Na-138
K-3.1* Cl-96 HCO3-26 AnGap-16
___ 12:40PM BLOOD UreaN-24* Creat-1.7*
___ 05:09AM BLOOD Glucose-101* UreaN-24* Creat-1.5* Na-139
K-3.5 Cl-101 HCO3-22 AnGap-16
___ 08:57AM URINE Blood-NEG Nitrite-NEG Protein-30*
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG
___ 08:57AM URINE RBC-0 WBC-0 Bacteri-NONE Yeast-NONE Epi-0
___ 03:41PM URINE Hours-RANDOM Creat-30 Na-<20
DISCHARGE
___ 05:09AM BLOOD WBC-10.3* RBC-3.26* Hgb-10.4* Hct-30.1*
MCV-92 MCH-31.9 MCHC-34.6 RDW-13.2 RDWSD-45.0 Plt ___
___ 05:09AM BLOOD Glucose-101* UreaN-24* Creat-1.5* Na-139
K-3.5 Cl-101 HCO3-22 AnGap-16
CXR - ___
Patchy opacities in the lung bases, which may reflect
atelectasis, though
infection or aspiration certainly cannot be excluded in the
correct clinical setting.
Brief Hospital Course:
This is a ___ year old male with reported history of asthma,
poorly controlled hypertension, admitted ___ with acute
asthma exacerbation, also found to have ___, thought to be
pre-renal in etiology in setting of recent Lasix initiation,
treated with IV fluids and discontinuation of Lasix, with
subsequent slow improvement in renal function, course notable
poorly controlled blood pressure, able to be discharged home
# Mild intermittent asthma with acute exacerbation
Patient with reported history of asthma who presented with
increased wheezing and dyspnea on exertion in the setting of a
recent upper respiratory illness. Clinical picture was felt to
be consistent with asthma exacerbation. Patient was started on
prednisone, bronchodilators, azithromycin with rapid improvement
to baseline within 24 hours. Given rapid improvement, patient
was de-escalated to bronchodilators and inhaled fluticasone with
continued stability. Of note, admission CXR showed patchy
infiltrate thought to be atelectasis; would repeat CXR in ___ to
ensure resolution. Course was complicated by ___ as below.
# ___
Patient with baseline Cr 1.0, admitted with Cr 1.4, peaking to
1.7 therafter. Patient reported decreased PO intake in setting
of illness, as well as recent initiation of Lasix as 2 weeks
prior. Concern was for dehydration. UA showed mild
proteinuria, negative blood; sediment analysis was without muddy
brown casts. Urine electrolytes supported pre-renal state.
Patient was treated with IV fluids and holding home Lasix and
lisinopril. Cr improved to 1.5 and patient was euvolemic and
able to demonstrate ability to maintain own hydration status via
oral intake. Residual ___ was felt to have likely represented
injury that occurred in setting of dehydration that might take
___ weeks to fully resolve. Given ___, instructed patient to
hold Lasix, metformin, lisinopril. Changed atenolol to
labetalol. Given proteinuria and risk factors for CKD (chronic
poorly controlled hypertension), arranged for patient to
establish with outpatient nephrologist. Transitional issues as
below.
# Hypertension
Patient with chronic poorly controlled hypertension (he reported
a baseline SBP range 160-180mmHg at prior PCP ___. In
setting ___ with above medication changes, he had variable
blood pressures. As above, discharge regimen was amlodipine and
labetalol. Transitional issues as below.
# GERD
Continued PPI
# CAD
Continued statin
# Depression
Continued OLANZapine, Nortriptyline
# Diabetes type ___
Metformin was held during this admission without significant
hyperglycemia. In setting of ___, held metformin at discharge
pending outpatient follow-up.
Transitional issues
- Discharged home
- Provided with new prescription for albuterol inhaler and
fluticasone inhaler
- Cr at discharge was 1.5 after peak at 1.7; would consider
repeat check at follow-up to ensure normalization
- Given ___ and poorly controlled hypertension, made the
following changes: discontinued Lasix, held Lisinopril, changed
atenolol to labetalol; would reassess for Lisinopril restarting
at follow-up visit
- Would consider PFTs for better characterization of lung
process
- Noted to have protineuria this admission on UA; would consider
repeat as outpatient and additional workup and management
- Noted to have cardiac systolic murmur on exam; if new compared
to prior and no prior TTE done, would consider TTE as outpatient
- Exam notable for mild hepatomegaly; could consider outpatient
imaging
- Given ___, held metformin at discharge; would consider
assessment of renal function at follow-up to inform if metformin
can be restarted;
> 30 minutes spent on this discharge
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. amLODIPine 10 mg PO DAILY
2. OLANZapine 15 mg PO DAILY
3. Lisinopril 40 mg PO DAILY
4. Omeprazole 20 mg PO DAILY
5. Cialis (tadalafil) 20 mg oral DAILY:PRN
6. Furosemide 20 mg PO DAILY
7. Klor-Con 10 (potassium chloride) 10 mEq oral DAILY
8. Atenolol 50 mg PO BID
9. MetFORMIN (Glucophage) 850 mg PO DAILY
10. Simvastatin 10 mg PO QPM
11. Nortriptyline 100 mg PO QHS
12. Albuterol Inhaler 1 PUFF IH Q6H:PRN cough
Discharge Medications:
1. Fluticasone Propionate 110mcg 1 PUFF IH BID Duration: 1 Week
RX *fluticasone [Flovent HFA] 110 mcg/actuation 1 puff INH twice
a day Disp #*1 Inhaler Refills:*0
2. Labetalol 400 mg PO BID
RX *labetalol 200 mg 2 tablet(s) by mouth twice a day Disp #*56
Tablet Refills:*0
3. Albuterol Inhaler 1 PUFF IH Q6H:PRN cough
RX *albuterol sulfate [ProAir HFA] 90 mcg 1 puff INH every six
(6) hours Disp #*1 Inhaler Refills:*0
4. amLODIPine 10 mg PO DAILY
5. Cialis (tadalafil) 20 mg oral DAILY:PRN
6. Nortriptyline 100 mg PO QHS
7. OLANZapine 15 mg PO DAILY
8. Omeprazole 20 mg PO DAILY
9. Simvastatin 10 mg PO QPM
10. HELD- Klor-Con 10 (potassium chloride) 10 mEq oral DAILY
This medication was held. Do not restart Klor-Con 10 until ___
see your primary care doctor
11. HELD- Lisinopril 40 mg PO DAILY This medication was held.
Do not restart Lisinopril until ___ see your primary care doctor
12. HELD- MetFORMIN (Glucophage) 850 mg PO DAILY This
medication was held. Do not restart MetFORMIN (Glucophage) until
___ see your primary care doctor
Discharge Disposition:
Home
Discharge Diagnosis:
# Mild intermittent asthma with acute exacerbation
# ___
# Hypertension
# GERD
# CAD
# Depression
# Diabetes type 2
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr. ___:
It was a pleasure caring for ___ at ___. ___
were admitted with an asthma exacerbation.
While ___ were here ___ were also found to have an elevated
kidney test (Creatinine). We think this is from dehydration
from your new Lasix (furosemide) medication.
___ were treated with fluids. Your kidney numbers improved.
___ are now ready for discharge home. At your request we have
arranged for a new primary care doctor for ___, here at ___
___.
It will be very important for ___ to discuss whether or not ___
may need several tests with your new primary care doctor,
including pulmonary function tests, liver tests, an
echocardiogram, and repeat kidney tests. We will communicate
this information to them.
Followup Instructions:
___
|
19721672-DS-19
| 19,721,672 | 25,850,007 |
DS
| 19 |
2187-11-20 00:00:00
|
2187-11-29 17:00:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
ibuprofen / metoclopramide
Attending: ___.
Chief Complaint:
hypoxia
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr ___ is a ___ with sick sinus syndrome s/p pacemaker
transferred from outside hospital for evaluation of hypoxia in
in the setting of multilobar pneumonia.
.
Per report, patient presented to the OSH with weakness and cough
x4-5 days. Awoke morning of admit with rigors per wife and
presented to ___. On arrival patient was noted to be
hypoxic the ___. CXR was notable for multilobar PNA and patient
received vancomycin. He was placed on BiPAP with improvement to
___ and decision made to transport to ___.
.
On arrival to ED, VS: 98.8 86 147/64 24 98% on BiPAP. Patient
was quickly weaned off BiPAP to 3L. Labs notable for WBC 6;
9%bands, creatinine 1.3; lactate 2.6. Patient received
CTX/azithromycin. In setting of tachypnea decision made to
transfer to the ICU. VS prior to transfer Tm 100.6, Tc 99.8 72
144/68 24 100% on 3L.
.
On arrival to the MICU, patient comfortable; feeling more
relaxed, RR: ___, saturating >98%3L. Did note left sided
chest wall pain as well as mild abdominal pain. Prior to
admission notes nausea with one episode of vomiting; no loose
stools. Additionally denies mylagias, arthralgias, high fever,
sick contacts, recent travel, recent hospitalizations/nursing
home trips.
.
In the ICU he received dexamethasone in addition to
azithromycin,ceftriaxone. His breathing improved, his abdominal
and chest pain completely resolved and he was very shortly after
transferred to the regular floor.
REVIEW OF SYSTEMS:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies shortness of breath, or wheezing. Denies
chest pain, chest pressure, palpitations Denies diarrhea,
constipation, abdominal pain, or changes in bowel habits. Denies
dysuria, frequency, or urgency. Denies arthralgias or myalgias.
Denies rashes or skin changes
Past Medical History:
PAST MEDICAL HISTORY:
Cardiac:
+ Hypertension + Hyperlipidemia
Cath: ___ mid-LAD disease (no intervention)
PPM secondary to sick sinus syndrome
BPH
.
Social History:
___
Family History:
Non-contributory
Physical Exam:
Vitals: T: 99 BP: 143/65 P: 90-100 R: ___ 18 O2: 98%3L
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, dry MM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Chest: pacer pocket palpated
Lungs: Poor effort, but overall decreased breath sounds
throughout left; improved aeration on right no wheezes,
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, ___ strength upper/lower extremities,
grossly normal sensation,gait deferred
.
Vitals: Tc: 98.0 BP: 130/60 HR: 70 RR; 14 02: 98% RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, dry MM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Chest: pacer pocket palpated
Lungs: improved aeration, breath sounds, right and left lung
fields, no accessory muscle use.
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, ___ strength upper/lower extremities,
grossly normal sensation,gait deferred
Pertinent Results:
ADMISSION LABS:
___ 01:30PM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 01:30PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5
LEUK-NEG
___ 01:30PM URINE RBC-1 WBC-1 BACTERIA-NONE YEAST-NONE
EPI-0
___ 01:30PM URINE MUCOUS-RARE
___ 08:55AM LACTATE-2.6*
___ 08:45AM GLUCOSE-144* UREA N-13 CREAT-1.3* SODIUM-141
POTASSIUM-3.3 CHLORIDE-105 TOTAL CO2-25 ANION GAP-14
___ 08:45AM estGFR-Using this
___ 08:45AM ALT(SGPT)-12 AST(SGOT)-14 LD(LDH)-219 ALK
PHOS-76 TOT BILI-0.9
___ 08:45AM WBC-6.0 RBC-4.83 HGB-14.3 HCT-45.1 MCV-93
MCH-29.6 MCHC-31.7 RDW-14.4
___ 08:45AM NEUTS-78* BANDS-9* LYMPHS-9* MONOS-4 EOS-0
BASOS-0 ___ MYELOS-0
___ 08:45AM HYPOCHROM-OCCASIONAL ANISOCYT-NORMAL
POIKILOCY-NORMAL MACROCYT-1+ MICROCYT-NORMAL POLYCHROM-NORMAL
___ 08:45AM PLT SMR-NORMAL PLT COUNT-184
MICRO:
___ legionella antigen negative
___ blood cultures negative
DISCHARGE LABS:
___ 07:45AM BLOOD WBC-14.0* RBC-3.89* Hgb-11.6* Hct-36.4*
MCV-94 MCH-29.9 MCHC-32.0 RDW-14.4 Plt ___
___ 09:36AM BLOOD Neuts-65 Bands-18* Lymphs-3* Monos-13*
Eos-0 Baso-0 ___ Metas-1* Myelos-0
___ 07:45AM BLOOD Plt ___
___ 07:45AM BLOOD
___ 07:45AM BLOOD Glucose-162* UreaN-22* Creat-1.2 Na-138
K-4.1 Cl-105 HCO3-23 AnGap-14
___ 07:45AM BLOOD Calcium-8.7 Phos-4.2 Mg-2.0
CXR ___:
Portable AP upright view of the chest was reviewed and compared
to the prior study. Bowel gas extends from the right abdomen
through the mediastinum and into the thoracic inlet and
represents a colonic conduit from prior esophagectomy.
Extensive bilateral parenchymal opacities located predominantly
in the right upper lung and lingula are relatively unchanged.
There is no pulmonary edema, abscess, pleural effusion or
pneumothorax. Right and left calcified pleural plaques located
over the hemidiaphragms are from prior asbestos or talc
pleuradesis. A left pectoral bi-electrode pacer's leads end in
the right atrium and right ventricular apex respectively.
IMPRESSION:
1. Relatively unchanged extensive bilateral pneumonia.
2. Colonic conduit from prior esophageal resection.
Brief Hospital Course:
SSESSMENT AND PLAN: Mr ___ is a ___ transferred from outside
hospital for evaluation of hypoxia in in the setting of
multilobar pneumonia.
.
#) Hypoxia/Multifocal Pneumonia. His Curb 65 score was 2 (age
and RR). Patient had evidence of multilobar PNA on CXR and
leukocytosis. Blood cultures were negative. Urine legionella was
negative and his presentation was not consistent with flu. He
was treated initially with ceftriaxone and azithromycin for
community acquired pneumonia, with dexamethasone 4 day course
given the severity of his pneumonia and he improved. He was
weaned off supplemental oxygen back to room air and maintained
his sats with ambulation. His antibiotics were transitioned to
levoquin for an anticipated total antibiotic course of 8 days.
He will follow up with his PCP, Dr ___ as an outpatient.
.
#) ___. Creatinine was 1.3 on admission, with ___ likely
prerenal in etiology in the setting of infection with
hypoperfusion/hypovolemia. He received intravenous fluids and
was eventually able to take good oral hydration. His Cr was 1.2
on discharge.
.
#) CAD. Evidence of disease in mid-LAD during ___ cath; no
intervention performed at this time. Per cards, no history of
CHF though no TTE in the system. his EKG was unchanged and his
chest pain quickly resolved as was thought to be pleurtic chest
pain secondary to pneumonia. He continued aspirin, metoprolol
and statin.
.
#) Hyperlipidemia: Continued atorvastatin
.
#) DMII. Insulin sliding scale inhouse, discharged on home
glipizide.
.
#) GERD. Continued home ranitidine
.
#) BPH: continued finasteride, tamsulosin
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. GlipiZIDE XL 2.5 mg PO DAILY
2. Atorvastatin 40 mg PO DAILY
3. tamsuLOSIN *NF* 0.4 mg Oral bedtime
4. Finasteride 5 mg PO DAILY
5. ranitidine HCl *NF* 150 mg Oral BID
6. Acetaminophen 325-650 mg PO Q6H:PRN fever, pain
7. Metoprolol Succinate XL 50 mg PO DAILY
8. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN fever, pain
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 40 mg PO DAILY
4. Finasteride 5 mg PO DAILY
5. tamsuLOSIN *NF* 0.4 mg Oral bedtime
6. Levofloxacin 750 mg PO Q24H CAP
RX *levofloxacin 750 mg 1 tablet(s) by mouth daily Disp #*4
Tablet Refills:*0
7. GlipiZIDE XL 2.5 mg PO DAILY
8. Metoprolol Succinate XL 50 mg PO DAILY
9. ranitidine HCl *NF* 150 mg ORAL BID
Discharge Disposition:
Home
Discharge Diagnosis:
multilobar community acquired pneumonia
hypoxia
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 because you were having
difficulty breathing. You were found to have a pneumonia and
were treated with antibiotic and steroids and you improved. You
will need to continue taking antibiotics for 4 days.
Followup Instructions:
___
|
19721864-DS-5
| 19,721,864 | 28,205,009 |
DS
| 5 |
2184-12-26 00:00:00
|
2184-12-26 19:18:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
ARF
Major Surgical or Invasive Procedure:
Bone Marrow Biopsy ___
History of Present Illness:
Mr. ___ is a ___ male with history of severe
COPD not dependent on O2, HTN, depression, prior herpes zoster
ophthalmicus who was transferred from ___ for renal
failure. Patient presented there due to hyperkalemia to 6.2 and
Cr 4.16 on ___ routine PCP ___.
ATRIUS labs:
K 6.2 on ___ (was WNL on ___
Cr 4.16 on ___ (was 1.10 on ___
Hgb was 9.7 on ___ (was 12.9 on ___
MCV was 106.4 on ___ (was 107.5 on ___
PTH was 44 on ___
___ interventions: 3L NS, 10u insulin/D50 there
___ ___: 50meq bicarb amp x 3, 1L NS, 10u insulin /D50 here
On interview, patient states he was in USOH without any pain
until before ___ of last year, he began to experience
increase in anxiety attacks, and constant migrating dull aching
pain in his bilateral chest, back and flanks. He had no fever.
He
has however experienced weight loss of 20 pounds over a year.
For the back pain, he has been taking ibuprofen 3 times a day.
He
has been compliant with his Lasix. He states he was never told
he
had hypercalcemia in the past (though it was seen on ___
labs)
or past renal failure.
He does not take antacids, vitamin supplements including vit D
or
calcium supplements.
He denies family history of bone or blood cancers or other
malignancies.
He reports his pains have gone since he got IVF in the ___.
He otherwise denies SOB, chest pain today, dysuria, headache,
abdominal pain, N/V/D.
Past Medical History:
-COPD (chronic obstructive pulmonary disease)
Severe obstuction on spirometry with polycythemia and CO2
retention. Improved significantly with quitting smoking and with
meds.Gained weight. Started Spiriva ___ with improvement. Seen
by pulmonary. Has emergency supply of prednisone and erythro at
home. Pulmonary rehab ___
-Depressive disorder
On Bupropion. On ___ had tapered dose to QOD. In ___ still
taking QOD. In ___ 1 QD
-Hematuria
Microscopic for yrs since Dr ___
-___ zoster ophthalmicus
___. Followed by Dr ___. Tried low dose nortriptyline for
discomfort but didn't help. Has plugs which dissolve. Very low
dose steroid eye drops. Still using once per week ___
-Hypertension, essential, benign
-Impotence due to erectile dysfunction
PAST SURGICAL HISTORY:
Tobacco Use: Quit
Packs/Day: ___
Years: ___
Quit date: ___
Alcohol Use: Yes 3.5 - 5 oz/week
grandson just turned one, wife wants to retire
Social History:
___
Family History:
FAMILY HISTORY:
Mult. Sclerosis [OTHER]
Mother
___
Brother
___ - Type II
Paternal Grandmother
___
Father
___
Father
CAD/PVD
Maternal Grandfather
Physical ___:
ADMISSION PHYSCIAL:
VITALS: Afebrile and vital signs stable (see eFlowsheet)
GENERAL: Alert and in no apparent distress
EYES: Anicteric, pupils equally round
ENT: Ears and nose without visible erythema, masses, or trauma.
Oropharynx without visible lesion, erythema or exudate
CV: Heart regular, no murmur
RESP: Lungs clear to auscultation with good air movement
bilaterally. Breathing is non-labored
GI: Abdomen soft, non-distended, non-tender to palpation. No
splenomegaly.
GU: No suprapubic fullness or tenderness to palpation
MSK: Neck supple, moves all extremities, strength grossly full
and symmetric bilaterally in all limbs
PSYCH: pleasant, appropriate affect
NEUROLOGIC:
MENTATION: alert and cooperative. Oriented to person and place
and time.
DISCHARGE PHYSICAL:
98.2 140/64 104 16 95
GENERAL: Pleasant, sitting up in bed
HEENT: Bilateral cataract changes, EOMI, oropharynx clear,
dentition adequate
CARDIAC: Regular rate and rhythm, no murmurs, rubs, or gallops
LUNG: Pursed lip breathing, adequate air movement, fine crackles
posterior lung fields > superior lung fields.
ABD: Normal bowel sounds, soft, nontender, nondistended.
EXT: Warm, well perfused, no lower extremity edema
GU: Foley removed
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
Pertinent Results:
___ 07:00AM BLOOD WBC-8.7 RBC-2.80* Hgb-9.2* Hct-28.4*
MCV-101*# MCH-32.9* MCHC-32.4 RDW-16.1* RDWSD-60.4* Plt ___
___ 05:11AM BLOOD WBC-9.2 RBC-2.02* Hgb-7.0* Hct-22.2*
MCV-110* MCH-34.7* MCHC-31.5* RDW-12.3 RDWSD-49.2* Plt ___
___ 07:00AM BLOOD Glucose-92 UreaN-31* Creat-2.7* Na-142
K-5.1 Cl-106 HCO3-24 AnGap-12
___ 02:53AM BLOOD Glucose-125* UreaN-47* Creat-3.7* Na-137
K-6.3* Cl-109* HCO3-16* AnGap-12
___ 05:11AM BLOOD Glucose-83 UreaN-36* Creat-3.0* Na-142
K-5.2* Cl-109* HCO3-25 AnGap-8*
DISCHARGE LABS:
___ 06:45AM BLOOD WBC-11.0* RBC-2.77* Hgb-9.1* Hct-28.1*
MCV-101* MCH-32.9* MCHC-32.4 RDW-15.0 RDWSD-56.2* Plt ___
___ 07:00AM BLOOD Neuts-77.6* Lymphs-11.8* Monos-8.1
Eos-1.4 Baso-0.2 Im ___ AbsNeut-6.74* AbsLymp-1.02*
AbsMono-0.70 AbsEos-0.12 AbsBaso-0.02
___ 06:45AM BLOOD Plt ___
___ 06:45AM BLOOD Glucose-110* UreaN-53* Creat-2.4* Na-138
K-5.1 Cl-103 HCO3-22 AnGap-13
___ 06:45AM BLOOD Calcium-10.2 Phos-4.3 Mg-1.8
IMAGING:
___ Skeletal survey:
1. Single well-circumscribed 12 mm lytic lesion in the right
proximal femoral shaft. No other definite lytic lesions are
identified though evaluation of the spine is limited by bony
demineralization.
2. Age-indeterminate moderate compression deformity of the T12
vertebral body.
CT Chest ___ contrast ___
IMPRESSION:
-Extensive skeletal myelomatous disease. The larger lytic
lesion at the level
of the left transverse process and costovertebral junction of
T7, possibly
invading the spinal canal, for further evaluation by MRI as
clinically
indicated.
-Panlobular emphysema with concurrent mild bronchitis.
MICRO:
___ Blood Cx: PND
___ 3:02 am URINE
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
Brief Hospital Course:
___ with PMHx of severe COPD, HTN, MDD and prior herpes zoster
ophthalmicus who presented to ___ on ___ after
routine
labs from ___ office demonstrated acute renal failure and
hyperkalemia (Cr 4.16 and K 6.2), found to have predominant
monoclonal kappa light chain spike, in the setting of lytic
spinal bone lesions overall concerning for new diagnosis of MM,
transferred to the OMED service for consideration of
chemotherapy initiation.
ACUTE ISSUES
# Plasma cell dyscrasias, Multiple Myeloma:
Clinally suggested based on ARF, hypercalcemia, anemia,
unintentional weight loss and skeletal pain, diagnosis now based
on monoclonal kappa light chain spike, elevated B2 microglobulin
and skeletal lytic bone
lesions seen on CT Chest. S/p bone marrow biopsy on ___ with
pathology and cytogenetics pending. He was placed on
dexamethasone 40mg PO daily for 3 days (___), PPI while
on steroids. He obtained a bone marrow biopsy ___, awaiting
pathology and cytogenetics. He was initiated on Bortezomib ___, 4, 8, and 11), as well as VZV suppression with Acyclovir
800mg BID, and planning for PCP prophylaxis ___/ Bactrim 3x/week.
# ARF
# Hyperkalemia
Likely multifactorial in the setting of multiple myeloma,
hypercalcemia, and lisinopril/NSAID use. Home lisinopril and
NSAIDs held. Cr continued to improved with hydration, avoidance
of nephrotoxic agents and tx of MM. Followed by renal consult
service.
# Hypercalcemia:
Likely in the setting of MM. Ca ___, stable with IVF. No mental
status changes.
# Anemia, macrocytic:
Likely in the setting of MM. s/p 2U pRBC on ___ with
appropriate increase. No s/s bleeding.
# Vit D Deficiency:
Vit D level 7. Continued 1,000U daily repletion.
CHRONIC ISSUES:
# COPD, severe. Continued home tiopropium, albuterol, symbicort
# HTN. Held home lisinopril/NSAIDs in the setting of ARF and
hyperkalemia.
# Depression: Continued buproprion, lorazepam
TRANSITIONAL ISSUES:
New medications:
-Acyclovir 800 mg PO Q12H
-Pantoprazole 40 mg PO Q24H
-Sulfameth/Trimethoprim DS 1 TAB PO 3X/WEEK (___)
-Prochlorperazine 10 mg PO Q8H:PRN nausea
Stopped medications:
-Ibuprofen 600 mg PO Q6H:PRN Pain - Moderate
-Lisinopril 20 mg PO DAILY
[]Please draw labs on ___ for monitoring of CBC,
BMP, potassium
[]Please f/u with Dr. ___ in clinic on ___ at
11:45pm at ___, ___ floor oncology
#HCP/Contact: ___, Wife, ___
#Code: Full
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. BuPROPion XL (Once Daily) 300 mg PO DAILY
2. Ibuprofen 600 mg PO Q6H:PRN Pain - Moderate
3. Symbicort (budesonide-formoterol) 80-4.5 mcg/actuation
inhalation BID
4. LORazepam 0.5 mg PO BID:PRN anxiety
5. Lisinopril 20 mg PO DAILY
6. Albuterol Inhaler 2 PUFF IH Q4H:PRN SOB
7. Tiotropium Bromide 1 CAP IH DAILY
Discharge Medications:
1. Acyclovir 800 mg PO Q12H
RX *acyclovir 800 mg 1 tablet(s) by mouth every 12 hours Disp
#*28 Tablet Refills:*0
2. Pantoprazole 40 mg PO Q24H
RX *pantoprazole 40 mg 1 tablet(s) by mouth once a day Disp #*14
Tablet Refills:*0
3. Prochlorperazine 10 mg PO Q8H:PRN nausea
RX *prochlorperazine maleate 10 mg 1 tablet(s) by mouth up to
every 8 hours as needed Disp #*21 Tablet Refills:*0
4. Sulfameth/Trimethoprim DS 1 TAB PO 3X/WEEK (___)
RX *sulfamethoxazole-trimethoprim 800 mg-160 mg 1 tablet(s) by
mouth once every ___ Disp #*6 Tablet Refills:*0
5. Albuterol Inhaler 2 PUFF IH Q4H:PRN SOB
6. BuPROPion XL (Once Daily) 300 mg PO DAILY
7. LORazepam 0.5 mg PO BID:PRN anxiety
8. Symbicort (budesonide-formoterol) 80-4.5 mcg/actuation
inhalation BID
9. Tiotropium Bromide 1 CAP IH DAILY
10. HELD- Ibuprofen 600 mg PO Q6H:PRN Pain - Moderate This
medication was held. Do not restart Ibuprofen until cleared to
restart by your doctor
11. HELD- Lisinopril 20 mg PO DAILY This medication was held.
Do not restart Lisinopril until cleared by your doctor
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY:
Multiple myeloma
Acute kidney injury
Hypercalcemia
Hyperkalemia
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 in the hospital?
- You were hospitalized because your lab work returned in
severe derangements of your blood chemistry as well as low red
blood cell counts.
What was done while I was in the hospital?
- Pictures and blood lab work were taken that showed you had
excessive disease of the bones in your body as well as problems
with your red blood cell, calcium levels and kidney function.
This picture overall fits the disease of multiple myeloma which
you diagnosed with.
- You were started on the treatment of multiple myeloma as
well as medications to help treat the problems with your blood
and chemistries associated with this disease.
- You were placed on medications to prevent the development of
further diseases or infections since both this disease and its
therapy can put you at greater risk for some consequences.
What should I do when I go home?
- It is very important that you take your medications as
prescribed.
- Please go to your scheduled appointment with your primary
doctor.
- If you have any fractures, severe abdominal pains, changes
in your mental status or bleeding, please tell your primary
doctor or go to the emergency room.
Best wishes,
Your ___ team
Followup Instructions:
___
|
19721908-DS-13
| 19,721,908 | 29,402,638 |
DS
| 13 |
2151-06-11 00:00:00
|
2151-06-11 11:52:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Left ankle fracture
Major Surgical or Invasive Procedure:
ORIF left ankle fracture
History of Present Illness:
___ year old male with PMH HLD, low back pain, sleep apnea, and
hypogonadism who presents after a fall with left ankle pain. He
was participating in a super-hero day and jumped off of a ~6
foot object landing on uneven ground. He believes he rolled his
ankle. Immediate pain in the ankle and at the proximal fibula.
Denies back pain.
Past Medical History:
HLD
Low back pain
Sleep apnea
Hypogonadism
Seasonal allergies
Asthma
Atypical chest pain
Social History:
___
Family History:
Non-contributory
Physical Exam:
In general, the patient is a well-appearing gentleman in NAD
resting comfortably on the stretcher
Vitals: T 96.3, HR 101, BP 126/91, RR 16, SpO2 96% RA
Left lower extremity:
Skin intact
TTP proximal fibula without swelling or ecchymosis
Swelling over lateral ankle
Tenderness over medial malleolus
Full, painless AROM/PROM of hip, knee
___ fire
+SILT SPN/DPN/TN/saphenous/sural distributions
___ pulses, foot warm and well-perfused
Pertinent Results:
___ XRAY LEFT ANKLE
There is a obliquely oriented fracture of the medial malleolus
exiting at the talar articular surface with minimal medial soft
tissue swelling. There does not appear to be any widening of
the ankle mortise. The syndesmosis is intact. No fibular
fracture is identified, although there is mild soft tissue
swelling at the lateral malleolus. A small talar ankle joint
effusion may be present. Remainder of the visualized bones are
within normal limits.
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 left ankle
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 progressed to a regular
diet and oral medications without difficulty. The patient was
given ___ antibiotics and anticoagulation per
routine. 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, incisions were clean/dry/intact, and the
patient was voiding/moving bowels spontaneously. The patient is
non-weight-bearing in the left lower extremity, and will be
discharged on aspirin for DVT prophylaxis. The patient will
follow up with Dr. ___ routine. A thorough discussion
was had with the patient regarding the diagnosis and expected
post-discharge course including reasons to call the office or
return to the hospital, and all questions were answered. The
patient was also given written instructions concerning
precautionary instructions and the appropriate follow-up care.
The patient expressed readiness for discharge.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. carisoprodol 350 mg oral TID:PRN Back spasm
2. Fluticasone Propionate NASAL 2 SPRY NU DAILY
3. Simvastatin 40 mg PO QPM
4. Montelukast 10 mg PO DAILY
5. Aspirin 81 mg PO DAILY
6. Cetirizine 10 mg PO DAILY
7. testosterone 75 mg implant ASDIR
Discharge Medications:
1. Montelukast 10 mg PO DAILY
2. Simvastatin 40 mg PO QPM
3. carisoprodol 350 mg oral TID:PRN Back spasm
4. Cetirizine 10 mg PO DAILY
5. Fluticasone Propionate NASAL 2 SPRY NU DAILY
6. testosterone 75 mg implant ASDIR
7. OxycoDONE (Immediate Release) ___ mg PO Q3H:PRN pain
8. Aspirin 325 mg PO BID Duration: 14 Days
Discharge Disposition:
Home
Discharge Diagnosis:
Left ankle fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY:
- You were in the hospital for orthopedic surgery. It is normal
to feel tired or "washed out" after surgery, and this feeling
should improve over the first few days to week.
- Resume your regular activities as tolerated, but please follow
your weight bearing precautions strictly at all times.
ACTIVITY AND WEIGHT BEARING:
- Non weight bearing on the left lower extremity in splint
MEDICATIONS:
- Please take all medications as prescribed by your physicians
at discharge.
- Continue all home medications unless specifically instructed
to stop by your surgeon.
- Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
- Narcotic pain relievers can cause constipation, so you should
drink eight 8oz glasses of water daily and take a stool softener
(colace) to prevent this side effect.
ANTICOAGULATION:
- Please take aspirin 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
Followup Instructions:
___
|
19722050-DS-5
| 19,722,050 | 27,090,251 |
DS
| 5 |
2176-08-12 00:00:00
|
2176-08-12 16:48:00
|
Name: ___ ___ No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
right leg weakness
Major Surgical or Invasive Procedure:
N/A
History of Present Illness:
Mr. ___ is a ___ ___ speaking man with a PMHx
significant for primary progressive MS who presents to ___ ED
with new right-sided leg weakness and stiffness. Mr. ___ has
limited ___, so much of the history is obtained from his
close friend ___ ___. They relate that Mr. ___
has long-standing right sided weakness and requires an electric
wheelchair for ambulation. Last night, however, ___ noticed that
his left leg felt "stiff" and "slow". Now ___ can barely lift it
off the bed and is unable to bend at the knee. This represents a
significant change from his baseline.
On ROS, ___ reports some baseline urinary urgency and admits to
not drinking very much water so that ___ doesn't have to go to
the bathroom a lot. ___ also complains of significant
pseudobulbar affect. ___ reports having "the common cold" 3 days
ago.
On repeat history with phone interpreter (___), ___
reports 2 discrete episodes of transient right leg greater than
hand weakness occurring the day of presentation. The spells each
came on suddenly and lasted for ___ minutes before returning to
his usual function. ___ noticed the greatest difficulty with the
right leg as it was difficult to get in and out of his chair. ___
does also note that ___ seemed to have some minor difficulty with
the right hand during the spells. ___ also reports that ___ has
had increasing stiffness in the legs for the past few weeks.
Past Medical History:
Primary progressive MS
- onset and diagnosis in ___
- initial symptoms included right sided weakness
Vitiligo
Social History:
___
Family History:
No family history of MS.
___ Exam:
PHYSICAL EXAMINATION
GEN - middle aged M, NAD
HEENT - NC/AT, MMM
NECK - full ROM, no meningismus
CV - RRR
RESP - normal WOB
ABD - soft, NT, ND
EXTR - warm and well perfused, atraumatic
SKIN - extensive vitiligo
NEUROLOGICAL EXAMINATION
MS - Awake, alert, oriented x3. Attentive to examiner.
Comprehension intact, naming intact, speech fluent via telephone
interpreter. Affect is improved and more stable.
CN -
[II] PERRL 3->2 brisk, no RAPD. +BTT
[III, IV, VI] EOMI, no nystagmus.
[V] V1-V3 without deficits to light touch bilaterally.
[VII] No facial movement asymmetry with forced eyelid closure or
volitional smile. [VIII] Hearing intact to voice.
[IX, X] Palate elevation symmetric. [XI] SCM/Trapezius strength
___ bilaterally.
[XII] Tongue midline with full ROM.
MOTOR - Dramatically increased tone over all extremities, RLE >
LLE > BUE. ROM is decreased in bilateral knee flexion/extension,
to about 50 degrees on RLE, 90 degrees on LLE.
=[Delt] [Bic] [Tri] [ECR] [IO] [IP] [Quad] [Ham] [TA] [Gas]
[C5] [C5] [C7] [C6] [T1] [L2] [L3] [L5] [L4] [S1]
L 5 5 5 5 5 * 5 5 5 4
R 5 5 5 5 4+ * 5 5 5 4
*Significant amount of spastic tone limiting evaluation of
strength, however appears at least antigravity
SENSORY - Denies deficits to LT and PP throughout.
REFLEXES -
=[Bic] [Tri] [___] [Quad] [Gastroc]
L 3 3 3 3 2
R 3 3 3 3 2
Plantar response down on the right, up on the left.
COORD - No evidence of appendicular or truncal ataxia.
GAIT - Unable to perform.
Pertinent Results:
___ 08:00PM BLOOD WBC-15.5* RBC-4.61 Hgb-13.8 Hct-41.7
MCV-91 MCH-29.9 MCHC-33.1 RDW-13.2 RDWSD-43.7 Plt ___
___ 08:00PM BLOOD Neuts-78.7* Lymphs-11.8* Monos-6.0
Eos-2.5 Baso-0.6 Im ___ AbsNeut-12.18* AbsLymp-1.83
AbsMono-0.92* AbsEos-0.38 AbsBaso-0.09*
___ 07:50AM BLOOD WBC-10.7* RBC-4.40* Hgb-13.4* Hct-40.0
MCV-91 MCH-30.5 MCHC-33.5 RDW-13.3 RDWSD-44.3 Plt ___
___ 07:45AM BLOOD WBC-8.9 RBC-4.26* Hgb-12.8* Hct-39.1*
MCV-92 MCH-30.0 MCHC-32.7 RDW-13.2 RDWSD-44.4 Plt ___
___ 07:50AM BLOOD ___ PTT-32.0 ___
___ 08:00PM BLOOD Glucose-104* UreaN-16 Creat-0.8 Na-138
K-4.1 Cl-100 HCO3-22 AnGap-20
___ 08:00PM BLOOD ALT-18 AST-23 CK(CPK)-91 AlkPhos-80
TotBili-0.8
___ 07:50AM BLOOD Calcium-9.6 Phos-3.0 Mg-2.0
___ 07:45AM BLOOD CK-MB-3 cTropnT-<0.01
___ 07:45AM BLOOD %HbA1c-5.5 eAG-111
___ 07:45AM BLOOD Triglyc-115 HDL-42 CHOL/HD-3.8 LDLcalc-94
___ 08:00PM URINE Blood-SM Nitrite-NEG Protein-TR
Glucose-NEG Ketone-40 Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG
___ 11:40PM OTHER BODY FLUID FluAPCR-NEGATIVE
FluBPCR-NEGATIVE
MRI brain w/wo ___:
IMPRESSION:
1. Numerous white plaques and associated T1 black holes,
unchanged from prior.
2. No acute infarct or intracranial hemorrhage.
MRI cervical and thoracic spine ___:
IMPRESSION:
1. Small T2 hyperintense lesion in the anterior cervical spinal
cord at the C2 level is compatible with demyelination with no
associated enhancement, either new or more conspicuous since the
prior study.
2. Other intracranial T2 hyperintense white matter plaques in
the pons,
brainstem, and cerebellar hemispheres are better assessed on
prior MRI/ MRA of the brain from ___.
3. No thoracic spinal cord lesions or pathologic postcontrast
enhancement.
4. Multilevel cervical and thoracic spondylosis is mild, as
described above.
5. T2 hyperintense enhancing hepatic mass is potentially a
hemangioma, but
incompletely assessed on this exam.
6. Bilateral maxillary sinus inflammatory disease.
RECOMMENDATION(S): Ultrasound is recommended for further
characterization of partially visualized hepatic mass described
in IMPRESSION #5.
CXR ___:
FINDINGS:
Compared with prior radiographs on ___, there is no
significant change. Again seen are low lung volumes with
crowding at the hila. There is no focal consolidation to
suggest pneumonia. There is no pleural effusion or
pneumothorax. The mediastinal silhouette is unchanged.
IMPRESSION:
No pneumonia.
Brief Hospital Course:
Patient was admitted for episodes of acute on chronic bilateral
leg weakness. MRI imaging of brain, cervical spine, and thoracic
spine showed no acute infarct or demyelinating lesion with
enhancement. ___ underwent a TIA workup including risk factor
stratification with HbA1c and LDL, which were all within normal.
Toxic metabolic workup was also negative. His symptoms were felt
to represent chronic worsening of spasticity from his MS. ___ was
started on valium and baclofen which appeared to improve his
spasticity upon discharge.
___ also had urinary retention to >300cc's on bladder scans. Also
felt to be secondary to his progressive demyelinating disease.
This was managed with intermittent straight catheterization.
___ had some mild rhonchi and had influenza testing and chest
X-ray which were negative for pneumonia.
Transitional issues:
[ ] Please continue valium and baclofen for spasticity; can
uptitrate baclofen as needed to improve symptoms, next
uptitration to 10mg TID
[ ] Patient's friend will attempt to bring his home Copaxone and
Neudexta to continue at rehab, but if unable to do so please
attempt to procure these from Pharmacy.
[ ] Please continue intermittent straight catheterization q8h
for urinary retention. Can consider referral to Urology if this
significantly worsens in the future.
[ ] Please continue social work involvement for patient's
[ ] For the neurology provider: please address whether patient's
current MS regimen is appropriate for his diagnosis
[ ] Needs outpatient hepatic U/S for further characterization of
mass seen on MRI spine, thought to be consistent with hemangioma
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Betamethasone Dipro 0.05% Oint 1 Appl TP BID
2. econazole 1 % topical DAILY
3. Copaxone (glatiramer) 40 mg/mL subcutaneous TIW
4. Ketoconazole 2% 1 Appl TP BID
5. Ketoconazole Shampoo 1 Appl TP ASDIR
6. Polyethylene Glycol 17 g PO DAILY:PRN constipation
7. Vitamin D 4000 UNIT PO DAILY
8. Nuedexta (dextromethorphan-quinidine) ___ mg oral DAILY
9. Modafinil 100 mg PO DAILY
Discharge Medications:
1. Betamethasone Dipro 0.05% Oint 1 Appl TP BID
2. Copaxone (glatiramer) 40 mg/mL subcutaneous TIW
3. Ketoconazole 2% 1 Appl TP BID
4. Polyethylene Glycol 17 g PO DAILY:PRN constipation
5. Vitamin D 4000 UNIT PO DAILY
6. econazole 1 % topical DAILY
7. Ketoconazole Shampoo 1 Appl TP ASDIR
8. Baclofen 5 mg PO TID
9. Bisacodyl 10 mg PR QHS:PRN Constipation
10. Docusate Sodium 100 mg PO BID
11. Senna 8.6 mg PO BID
12. Modafinil 100 mg PO DAILY
13. Nuedexta (dextromethorphan-quinidine) ___ mg oral DAILY
14. Diazepam 5 mg PO QID
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Multiple sclerosis, primary progressive
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear ___,
You were admitted to the hospital because of ongoing leg
weakness and stiffness that prevented you from performing your
usual daily functions. We evaluated you with MRI imaging of your
brain and spinal cord to look for any acute lesions, which we
did not find. We think your symptoms are from chronic worsening
of your MS. ___ started two medications called valium and
baclofen which help with your stiffness and spasticity. We also
had our Physical and Occupational therapists evaluate you, and
they felt you would benefit from an acute rehab stay.
Please take your medications as prescribed and follow up with
your Neurology provider as below. It was a pleasure taking care
of you, and we wish you the best.
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
19722227-DS-4
| 19,722,227 | 24,675,615 |
DS
| 4 |
2155-12-02 00:00:00
|
2155-12-02 16:57:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
rectal bleeding
Major Surgical or Invasive Procedure:
Flexible sigmoidoscopy with thermal coagulation
History of Present Illness:
This patient is a ___ with Afib, on coumadin, who had painless
bright red blood per rectum several times daily since
colonoscopy/triple snare polypectomy on ___.
The pt reported "significant" amounts of pure blood each time
she has used the toilet during that time. Although she had had
no prior GI bleeds, she assumed the bleeding was normal after
colonoscopy, particularly for an anticoagulated patient.
Additionally, she thought the bleeding had begun to improve.
However, the patient was instructed to go to the ED, today,
after a routine INR check in which her Hct was noted to have
dropped from 35 to 28.8.
Of note, Ms. ___ decreased and discontinued her coumadin prior
to colonoscopy, as instructed by Gastroenterology. For several
days surrounding the procedure, she took lovenox instead/in
addition. The pt had restarted her normal coumadin dose prior to
INR testing.
In the ED, Ms. ___ vital signs were: 97.8 94 138/61 16 97%
RA. Hct was 31.9, down from baseline of 35. Pt was typed and
crossmatched for 2u PRBC, and two 18g IVs were placed.
Gastroenterology was consulted. The patient's exam was notable
for bright red blood on rectal exam, without abdominal pain or
tenderness. Ms. ___ denied any fevers, chills, n/v, abd pain,
chest pain, SOB, and lightheadedness.
Past Medical History:
Atrial Fibrillation- on coumadin; followed by Dr. ___.
CABG- ___ years ago. Details unknown.
CHF - on furosemide 20mg/40mg QOD
Colonoscopy (___): Colonic diverticuli (R and L), polyps
(Hepatic polyp 5mm; Sigmoid polyp 9mm; Rectal polyp, 12mm).
Glaucoma - treated with eyedrops.
Cataracts - s/p surgical correction
HTN
HLD
Social History:
___
Family History:
Brother: cancer (type unknown), heart disease
Physical Exam:
Physical Exam on Admission:
Vitals: T: 97.8 147/69 71 18 100% RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP moderately elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: obese, soft, non-tender, non-distended, bowel sounds
present, no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses. 2+ pitting edema. No
clubbing or cyanosis
Neuro: no focal deficits.
Physical Exam on Discharge:
Vitals: 98.1 140/80 70 22 99%RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Soft crackles at bases bilaterally. No rales or ronchi.
No accessory muscle use in breathing.
CV: irregular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: obese, soft, non-tender, non-distended, bowel sounds
present, no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses. No lower extremity edema.
No clubbing or cyanosis
Neuro: no focal deficits.
Pertinent Results:
Blood
___ 02:00PM BLOOD WBC-8.4 RBC-3.59* Hgb-10.1* Hct-31.9*
MCV-89 MCH-28.2 MCHC-31.8 RDW-13.4 Plt ___
___ 07:10PM BLOOD Hct-30.2*
___ 09:25PM BLOOD Hct-29.2*
___ 04:15AM BLOOD WBC-6.7 RBC-3.05* Hgb-8.6* Hct-26.6*
MCV-87 MCH-28.2 MCHC-32.4 RDW-13.6 Plt ___
___ 01:30PM BLOOD Hct-30.0*
___ 05:15PM BLOOD Hct-29.3*
___ 02:29AM BLOOD WBC-15.3*# RBC-3.92*# Hgb-11.2*#
Hct-34.7* MCV-88 MCH-28.6 MCHC-32.4 RDW-13.6 Plt ___
___ 07:00AM BLOOD WBC-19.0* RBC-3.98* Hgb-11.4* Hct-35.0*
MCV-88 MCH-28.7 MCHC-32.6 RDW-14.0 Plt ___
___ 05:20AM BLOOD WBC-7.2# RBC-3.46* Hgb-10.0* Hct-30.3*
MCV-88 MCH-29.0 MCHC-33.0 RDW-14.1 Plt ___
INR
___ 02:25PM BLOOD ___ PTT-46.5* ___
___ 04:15AM BLOOD ___ PTT-40.1* ___
___ 07:00AM BLOOD ___ PTT-35.7 ___
___ 05:20AM BLOOD ___ PTT-36.3 ___
ABG
___ 02:50AM BLOOD Type-ART pO2-59* pCO2-31* pH-7.48*
calTCO2-24 Base XS-0
___: CXR:
Portable AP radiograph of the chest was reviewed in comparison
to ___.
There is interval development of bilateral substantial new
interstitial
opacities with some alveolar opacities, finding consistent with
interval
development of pulmonary edema, moderate. Small amount of
bilateral pleural
effusions is most likely present. There is no pneumothorax.
Post-sternotomy
wires appear unremarkable
___ cxr:
IMPRESSION: Small bilateral pleural effusions, right greater
than left, are
the residua of improved congestive heart failure which is now
minimal. Mild
cardiomegaly is unchanged. There is no evidence for pneumonia.
Brief Hospital Course:
Ms ___ is an ___ F with PMH of CHF, Afib on coumadin, CAD sp
CABG who was admitted for post-polypectomy bleed. Hospital
course complicated with acute on chronic diastolic heart
failure.
# Rectal Bleeding - The pt reported rectal bleeding with bowel
movements, beginning shortly after colonoscopy and triple snare
polypectomy. PCP noted ___ drop from 35 (baseline) to 28, and
referred pt to the ED. During hospitalization, the patient's Hct
dropped further to 26.6, and she was transfused 1u PRBC and 2u
FFP. She underwent a flexible sigmoidoscopy with thermal
coagulation of bleeding post-polypectomy ulcer site. Following
the procedure, the patient's hematocrit stabilized. She reported
no further rectal bleeding. The pt was re-started on her home
dose of coumadin prior to discharge.
# Leukocytosis - One day after flexible sigmoidoscopy, pt
developed a leukocytosis (WBC = 19). The patient remained
afebrile and asymptomatic. Infectious work-up (CXR, U/A) was
negative. Clinical exam reassuring. The patient's WBC count
spontaneously normalized within 24 hours.
# Pulmonary Edema/Acute on chronic diastolic heart failure - The
pt developed pulmonary edema during during her first night in
the hospital. She desatted to 83% on RA, and became tachycardic
to 141. CXR demonstrated diffuse pulmonary infiltrates. The
patient's symptoms responded to supplemental oxygen, metoprolol
25mg, and 40mg lasix IV. The pt subsequently resumed her home
dose of lasix. Repeat CXR demonstrated significant improvement.
Pulmonary edema was likely precipitated by a combination of
volume overload (pt's home furosemide had been "held" in the
setting of Gi bleed) and Afib with RVR. She had no further
episodes while inhouse nad was satting in high ___ on room air
at time of discharge. She was discharged on her home regimen of
lasix.
# Atrial fibrillation/Atrial flutter - the pt was in Afib for
much of her hospital stay. She was also found to be in A flutter
(3:1). She was effectively rate controlled on her home dose of
metoprolol, other than that incident above when she had afib
with RVR with acute pulmonary edema. In that setting, she was
given additional doses of metoprolol. Home dose of coumadin was
restarted after resolution of lower Gi bleed.
Transitional Issues:
-Cardiology: to trend A fib/A flutter, make sure she continues
to be effectively rate controlled.
-Rectal bleeding: resolved, would benefit from CBC check when
visiting PCP
___ on ___:
1. Aspirin 81 mg PO DAILY
2. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP BOTH EYES BID
3. Simvastatin 20 mg PO DAILY
4. Lisinopril 20 mg PO DAILY
5. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES HS
6. Pilocarpine 4% 1 DROP BOTH EYES Q6H
7. Amlodipine 5 mg PO DAILY
8. Metoprolol Tartrate 25 mg PO Q 6 HRS
hold BP<100, HR<50
9. Furosemide 40 mg PO QMOWEFR
10. Furosemide 20 mg PO QTUTHSA (___)
11. Vitamin D 800 UNIT PO DAILY
12. Warfarin 3 mg PO 3X/WEEK (___)
M, W, F
13. Warfarin 4 mg PO 4X/WEEK (___)
___, ___, Sa
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP BOTH EYES BID
3. Lisinopril 20 mg PO DAILY
4. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES HS
5. Pilocarpine 4% 1 DROP BOTH EYES Q6H
6. Amlodipine 5 mg PO DAILY
7. Furosemide 40 mg PO ___, FRI
___ and ___
8. Furosemide 20 mg PO ___, M, W, F, SA
9. Vitamin D 800 UNIT PO DAILY
10. Warfarin 3 mg PO 3X/WEEK (___)
M, W, F
11. Warfarin 4 mg PO 4X/WEEK (___)
___, ___, Sa
12. Metoprolol Succinate XL 100 mg PO DAILY
13. Simvastatin 40 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Post-polypectomy hemorrhage
Acute on chronic diastolic heart failure
Atrial fibrillation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
Thank you for the privilege of participating in your care.
You were admitted to the hospital due to rectal bleeding, which
caused a drop in your red blood cell levels. This bleeding was
due to your recent colonoscopy and polyp removal While in the
hospital, you received a transfusion of blood. You also
underwent a procedure called "flexible sigmoidoscopy," during
which the source of the rectal bleeding was identified, and the
bleeding was stopped.
Also during your admission, you developed high levels of fluid
in your lungs. This caused you to feel short of breath. This
fluid went away when you received medications to help you
urinate more (lasix).
Finally, during your hospitalization you developed a temporary
increase in your white blood cell counts, which can sometimes
indicate infection. However, you had no other signs of
infection, and your white blood cell counts have returned to a
normal level. A chest X-Ray was normal, urine studies normal and
your exam was reassuring.
No medication changes were made during this admission. Please
continue your regular home medications as usual.
Followup Instructions:
___
|
19722358-DS-21
| 19,722,358 | 20,573,175 |
DS
| 21 |
2146-05-21 00:00:00
|
2146-05-21 09:58:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ h/o CABG otherwise healthy with abdominal pain. Pt has had
viral-like symptoms over the past several days, including h/a,
low grade fever, sore throat. Today, patient had sudden onset of
epigastric pain, which has since radiated somewhat to the LUQ.
No previous ab surgeries. Recently started ___ diet with
wife, who he notes also had a similar onset of abdominal pain
today. Denies n/v/d. Denies f/c.
In ED pt found to have lipase 6930. Given 2Lns, tylenol and
dilaudid.
On arrival to the floor pt
ROS: +as above, otherwise reviewed and negative
Past Medical History:
#. Coronary artery disease - CABG in ___ was elected with
LIMA to LAD for proximal aneurysm with stenoses at each end of
aneurysm and D1 + D2 arising from aneurysms. There was mild
diffuse plaqueing in RCA, LCX, and LMCA with no critical
stenoses.
#. Hyperlipidemia
#. Hypertension
Social History:
___
Family History:
Mother with valvular disease and ICD. No history of sudden
cardiac death or premature CAD.
Physical Exam:
Vitals: T:98.1 BP:126/79 P:49 R:18 O2:98%ra
PAIN: 7
General: nad
Lungs: clear
CV: rrr no m/r/g
Abdomen: bowel sounds present, soft, tender periumbilical
Ext: no e/c/c
Skin: no rash
Neuro: alert, follows commands
Pertinent Results:
___ 04:15PM GLUCOSE-140* UREA N-21* CREAT-0.9 SODIUM-144
POTASSIUM-3.7 CHLORIDE-105 TOTAL CO2-30 ANION GAP-13
___ 04:23PM LACTATE-1.8
___ 04:15PM ALT(SGPT)-37 AST(SGOT)-47* ALK PHOS-66 TOT
BILI-0.7
___ 04:15PM LIPASE-6930*
___ 04:15PM ALBUMIN-4.4
___ 04:15PM WBC-10.5 RBC-5.16 HGB-16.1 HCT-47.4 MCV-92
MCH-31.3 MCHC-34.0 RDW-12.0
___ 04:15PM NEUTS-88.8* LYMPHS-6.1* MONOS-4.1 EOS-0.4
BASOS-0.7
___ 04:15PM PLT COUNT-117*
___ 07:16PM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 07:16PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30
GLUCOSE-100 KETONE-NEG BILIRUBIN-NEG UROBILNGN-2* PH-6.5
LEUK-NEG
___ 07:16PM URINE RBC-2 WBC-1 BACTERIA-FEW YEAST-NONE
EPI-<1
___ 07:16PM URINE MUCOUS-OCC
RUQ ultrasound:
FINDINGS:
LIVER: The echogenicity of the liver is homogeneous. The contour
of the liver is smooth. There is no focal liver mass. Main
portal vein is patent with hepatopetal flow. There is no
ascites.
BILE DUCTS: There is no intrahepatic biliary dilation. The CBD
measures 3 mm.
GALLBLADDER: There is no evidence of stones or gallbladder wall
thickening. There is gallbladder sludge present.
PANCREAS: The head of the pancreas is within normal limits. The
tail and body of the pancreas are not visualized due to the
presence of gas.
SPLEEN: Normal echogenicity, measuring 11.7 cm.
KIDNEYS: The right kidney measures 11.6 cm. The left kidney
measures 11.8 cm. Midpole the left kidney there is a simple cyst
which measures 3.4 x 3.5 x 3.4 cm. Normal cortical echogenicity
and corticomedullary differentiation is seen bilaterally. There
is no evidence of masses, stones or hydronephrosis in the
kidneys.
RETROPERITONEUM: Visualized portions of aorta and IVC are within
normal
limits.
IMPRESSION:
1. Gallbladder sludge without evidence of gallstones.
2. Simple cyst in the right kidney.
Brief Hospital Course:
Mr. ___ is a ___ year old male with a history of CAD s/p CABG
who presented with pancreatitis.
Acute Pancreatitis: HE was admitted with acute pancreatitis. No
alcohol consumption noted. RUQ was without stones (sludge
noted). His TGs were 110. He is not on any medications that
routinely cause pancreatitis. His calcium was 8.1. No smoking
since ___. No familial history of pancreatitis. He did have a
prodrome of viral like illness prior to this presentation,
making an infectious etiology possible. He was noted to have
gallbladder sludge, a more likely cause for pancreatitis. He
was given the referral number for the pancreas physicians at the
___ for follow up evaluation, likely MRCP and possible
surgical referral.
He was treated conservatively with fluids, bowel rest, and
analgesia. CAD: continued home meds, though held his statin.
Transitions of care: follow up with gastroenterololgist.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Rosuvastatin Calcium 40 mg PO DAILY
2. Multivitamins 1 TAB PO DAILY
3. Fish Oil (Omega 3) 1000 mg PO BID
4. Clopidogrel 75 mg PO DAILY
5. Aspirin 325 mg PO DAILY
6. Metoprolol Succinate XL 50 mg PO DAILY
Discharge Medications:
1. Clopidogrel 75 mg PO DAILY
2. Metoprolol Succinate XL 50 mg PO DAILY
3. Fish Oil (Omega 3) 1000 mg PO BID
4. Multivitamins 1 TAB PO DAILY
5. Rosuvastatin Calcium 40 mg PO DAILY
6. Aspirin 81 mg PO DAILY
7. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
RX *oxycodone [Oxecta] 5 mg ___ tablet(s) by mouth every 6 hours
Disp #*15 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Acute pancreatitis
CAD
hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr. ___-
You were admitted to ___ with acute pancreatitis. The cause of
this was not readily apparent and work-up with imaging and lab
tests was unrevealing. You were treated conservatively with IV
fluids, pain medication, and bowel rest.
It is possible that your symptoms were caused by gallstones and
you should follow up with a gastroenterologist.
No alcohol, no fatty food for the next 2 weeks.
Use the oxycodone just for severe pain, no alcohol or driving
while taking it. Use over the counter stool softeners.
Followup Instructions:
___
|
19723040-DS-21
| 19,723,040 | 24,273,476 |
DS
| 21 |
2168-03-20 00:00:00
|
2168-04-02 12:28:00
|
Name: ___ Unit ___: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
___ Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
s/p fall
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ y/o F with history of hepatitis and ETOH abuse presents
s/p fall with small right parietal SAH/contusion. Patient
reports that she has been experiencing frequent falls due to
feeling weak becasue of the "flu". She states that she fell on
morning of admission while getting out of bed to use bathroom.
She fell striking her right side of her head and body. She was
seen by her GI specialist who recommended that she go to the ED.
She reports that she has been unable to eat and has ___ strength
and that could be the reason
why she has been falling. She reports headache, n/v, and
dizziness, and poor food intake, but denies any recent ETOH use.
Past Medical History:
Acid reflud, H. pylori s/p antibiotic treatment
PSH: GSV stripping bilat
Social History:
___
Family History:
Noncontributory
Physical Exam:
Upon presentation to ___:
T:99 BP:122/86 HR:118 R:16 O2Sats: 100%
Gen: WD/WN, comfortable, NAD.
HEENT: ecchymosis of R temporal region and R periorbital
ecchymosis
Pupils: PERRL EOMs: intact
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Recall: ___ objects at 5 minutes.
Language: Speech fluent with good comprehension and repetition.
Naming intact. ___ 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. ___ abnormal movements,
tremors. RUE 4+/5 limited by pain from fall, LUE ___, BLE ___.
Sensation: Intact to light touch
Pertinent Results:
___ CT head R parietal SAH
___ CT cervical spine neg
___ CT torso:
IMPRESSION:
1. ___ traumatic injury to the chest, abdomen, or pelvis.
2. Findings consistent with acute pancreatitis, with
peripancreatic
inflammatory changes surrounding the pancreatic tail, and a 2.2
x 2.2-cm fluid collection consistent with a non-necrotic
collection (pseudocyst), and ___ evidence of pancreatic necrosis.
3. Fatty liver.
4. Focally dilated left mid-to-lower abdomen sentinel small
bowel loop. ___ bowel obstruction.
5. Possible mild proctocolitis.
ECHOCARDIOGRAM
Findings
LEFT ATRIUM: Normal LA size. Elongated LA.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. Normal IVC
diameter (<=2.1cm) with >50% decrease with sniff (estimated RA
pressure ___ mmHg).
LEFT VENTRICLE: Normal LV wall thickness, cavity size and
regional/global systolic function (LVEF >55%). ___ resting or
Valsalva inducible LVOT gradient.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal diameter of aorta at the sinus, ascending and arch
levels.
AORTIC VALVE: Normal aortic valve leaflets (3). ___ AS. ___ AR.
MITRAL VALVE: Normal mitral valve leaflets with trivial MR. ___
MVP.
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR. Normal PA systolic pressure.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet.
___ PS. Physiologic PR.
PERICARDIUM: ___ pericardial effusion.
Conclusions
The left atrium is normal in size. The left atrium is elongated.
The estimated right atrial pressure is ___ mmHg. Left
ventricular wall thickness, cavity size and regional/global
systolic function are normal (LVEF >55%). There is ___ left
ventricular outflow obstruction at rest or with Valsalva. 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 ___ aortic stenosis or aortic
regurgitation. The mitral valve appears structurally normal with
trivial mitral regurgitation. There is ___ mitral valve prolapse.
The estimated pulmonary artery systolic pressure is normal.
There is ___ pericardial effusion.
IMPRESSION: ___ structural cardiac cause of syncope identified.
Preserved global and regional biventricular systolic function.
___ significant valvular abnormality seen. ___ resting or
inducible outflow tract obstruction.
Brief Hospital Course:
She was admitted to the Acute Care Surgery team and transferred
to the Trauma ICU for further management of her right parietal
SAH and alcohol withdrawal. Incidentally found on CT of her
torso was pancreatitis with pseudocyst. Her initial labs showed
that her lipase was mildly elevated to 91 and was kept NPO while
following her serial abdominal exams. Her diet was eventually
advanced without any issues.
Neurosurgery consult was obtained; she was given Dilantin to
continue for a total of seven days. Her neurologic status was
monitored closely in the ICU and once stabilized she was
transferred to the floor.
She did have some agitation upon admission and was maintained on
a CIWA scale using Ativan. On HD 2 this was changed to PO
Valium. Given her history of multiple falls, a syncope workup
was initiated. She underwent carotid duplex which demonstrated
___ structural cardiac cause of syncope identified. Preserved
global and regional biventricular systolic function, ___
significant valvular abnormality seen and ___ resting or
inducible outflow tract obstruction with a normal EF >55%.
Occupational therapy was consulted for cognitive evaluation and
safety evaluation.
Social work consult was placed for coping and also due to +blood
alcohol level.
She was discharged to home with appointments scheduled for her
to follow up with her PCP for general physical and for further
evaluation of the pancreatic pseudocyst and with Neurosurgery.
Medications on Admission:
___ meds currently. Spontaneously stopped her zoloft, ativan, and
seroquel approx. a week ago
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H
2. Docusate Sodium 100 mg PO BID
3. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
RX *oxycodone 5 mg ___ tablet(s) by mouth every 4 hours Disp
#*20 Tablet Refills:*0
4. Phenytoin Sodium Extended 100 mg PO TID Seziure prophy
Duration: 7 Days
Stop date: ___
RX *phenytoin sodium extended 100 mg 1 capsule(s) by mouth three
times a day Disp #*21 Capsule Refills:*0
5. Senna 1 TAB PO BID:PRN constipation
6. TraMADOL (Ultram) 50 mg PO QID
RX *Ultram 50 mg 1 tablet(s) by mouth every 6 hours Disp #*42
Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
s/p Fall
Injuries:
Subarachnoid hemorrhage
Seocndary diagnosis:
Pancreatitits
Pancreatic pseudocyst
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital after a fall where you
sustained a small bleeding injury to your brain. You are being
treated with a medication called Dilantin (Phenytoin)which is
used to prevent seizures. Please continue this medication as
directed.
The CT scans that were done when you came into the hospital
showed pancreatitis which is an inflammatory process of your
pancreas and a pancreatic pseudocyst. You will need to follow up
with your primary care doctor ___ the next ___ weeks for
further workup of this.
You should AVOID alcohol and illicit drugs while taking the
narcotic pain medications that were prescribed for you. Take a
stool softener and laxative while on the pain medications to
avoid constipation.
Followup Instructions:
___
|
19723067-DS-19
| 19,723,067 | 28,283,671 |
DS
| 19 |
2180-06-29 00:00:00
|
2180-06-29 13:31:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Left tibia and fibula fracture
Major Surgical or Invasive Procedure:
placement of left tibial IM nail ___
History of Present Illness:
___ is a ___ male with a history of hypertension who
was transferred from an outside hospital with a left tibia and
fibula fracture. He was reduced and splinted at the outside
hospital before being transferred. He was at work when he fell
backwards and a utility pole fell onto his left tibia. No head
strike or LOC. He was transferred here for further management.
He denies any numbness or tingling into the left foot or pain
elsewhere.
Past Medical History:
PMH/PSH:
Hypertension
Social History:
___
Family History:
NC
Physical Exam:
General: Well-appearing, breathing comfortably
MSK:
LLE -
primary DSD/ace thigh to foot ___ edema.
- compartments soft, appropriately tender
- Full, painless PROM of digits, knee, some tenderness with
ankle
PROM
- wiggling toes
- SILT throughout exposed toes
- 2+ distal pulses, brisk cap refill
Pertinent Results:
___ 05:25PM BLOOD WBC-11.1* RBC-4.76 Hgb-14.4 Hct-43.0
MCV-90 MCH-30.3 MCHC-33.5 RDW-15.1 RDWSD-49.2* Plt ___
___ 07:05AM BLOOD WBC-10.2* RBC-3.86* Hgb-11.6* Hct-35.9*
MCV-93 MCH-30.1 MCHC-32.3 RDW-14.7 RDWSD-49.3* Plt ___
___ 05:25PM BLOOD Neuts-65.7 ___ Monos-8.2 Eos-1.4
Baso-0.5 Im ___ AbsNeut-7.28* AbsLymp-2.64 AbsMono-0.91*
AbsEos-0.15 AbsBaso-0.06
___ 07:05AM BLOOD Plt ___
___ 05:25PM BLOOD ___ PTT-28.9 ___
___ 05:25PM BLOOD Plt ___
___ 05:25PM BLOOD Glucose-87 UreaN-7 Creat-0.7 Na-142 K-4.0
Cl-101 HCO3-29 AnGap-12
___ 07:05AM BLOOD Glucose-109* UreaN-10 Creat-0.7 Na-140
K-4.3 Cl-99 HCO3-29 AnGap-12
___ 07:05AM BLOOD Calcium-8.4 Phos-4.3 Mg-1.9
Brief Hospital Course:
The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have left tibia and fibula fracture and was admitted to the
orthopedic surgery service. The patient was taken to the
operating room on ___ for left tibial IM nail, which the
patient tolerated well. For full details of the procedure please
see the separately dictated operative report. The patient was
taken from the OR to the PACU in stable condition and after
satisfactory recovery from anesthesia was transferred to the
floor. The patient was initially given IV fluids and IV pain
medications, and progressed to a regular diet and oral
medications by POD#1. The patient was given ___
antibiotics and anticoagulation per routine. The patient's home
medications were continued throughout this hospitalization. The
patient worked with ___ who determined that discharge to home
without services 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 aspirin 325mg daily for 4 weeks 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:
None
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H
RX *acetaminophen 500 mg 1 to 2 tablet(s) by mouth three times a
day Disp #*60 Tablet Refills:*0
2. Aspirin 325 mg PO DAILY
RX *aspirin 325 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
3. crutch miscellaneous as needed for ambulation
RX *crutch Disp #*1 Each Refills:*0
4. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 tablet(s) by mouth twice a day Disp
#*50 Tablet Refills:*0
5. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain -
Moderate
RX *oxycodone 5 mg 1 tablet(s) by mouth every four (4) hours
Disp #*36 Tablet Refills:*0
6. Senna 8.6 mg PO BID
RX *sennosides [senna] 8.6 mg 1 tab by mouth twice daily Disp
#*50 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
left tibia fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY:
- You were in the hospital for orthopedic surgery. It is normal
to feel tired or "washed out" after surgery, and this feeling
should improve over the first few days to week.
- Resume your regular activities as tolerated, but please follow
your weight bearing precautions strictly at all times.
ACTIVITY AND WEIGHT BEARING:
- weight bearing as tolerated to the left lower extremity
MEDICATIONS:
- Please take all medications as prescribed by your physicians
at discharge.
- Continue all home medications unless specifically instructed
to stop by your surgeon.
- Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
- Narcotic pain relievers can cause constipation, so you should
drink eight 8oz glasses of water daily and take a stool softener
(colace) to prevent this side effect.
ANTICOAGULATION:
- Please take aspirin 325mg daily for 4 weeks
WOUND CARE:
- You may shower. No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- Please remain in your dressing and do not change unless it is
visibly soaked or falling off.
- Splint must be left on until follow up appointment unless
otherwise instructed
- Do NOT get splint wet
DANGER SIGNS:
Please call your PCP or surgeon's office and/or return to the
emergency department if you experience any of the following:
- Increasing pain that is not controlled with pain medications
- Increasing redness, swelling, drainage, or other concerning
changes in your incision
- Persistent or increasing numbness, tingling, or loss of
sensation
- Fever > 101.4
- Shaking chills
- Chest pain
- Shortness of breath
- Nausea or vomiting with an inability to keep food, liquid,
medications down
- Any other medical concerns
THIS PATIENT IS EXPECTED TO REQUIRE <30 DAYS OF REHAB
FOLLOW UP:
Please follow up with your Orthopaedic Surgeon, Dr. ___.
You will have follow up with ___, NP in the
Orthopaedic Trauma Clinic 14 days post-operation for evaluation.
Call ___ to schedule appointment upon discharge.
Please follow up with your primary care doctor regarding this
admission within ___ weeks and for and any new
medications/refills.
Physical Therapy:
weight bearing as tolerated to the left lower extremity
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.
Please remain in the splint until follow-up appointment. Please
keep your splint dry. If you have concerns regarding your
splint, please call the clinic at the number provided.
Followup Instructions:
___
|
19723160-DS-29
| 19,723,160 | 26,967,462 |
DS
| 29 |
2189-01-26 00:00:00
|
2189-01-27 20:40:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
lisinopril
Attending: ___.
Chief Complaint:
sob
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with hx of morbid obesity, asthma, copd p/w worsening
dyspnea on exertion and wheezing. The pt states that ___
she began sneezing, coughing and having increased SOB. She
increased her nebs but was not able to take pulse dose steroids
as she normally does with asthma exacerbations bc she was out of
them. She endorsed DOE, coughing productive of clear sputum,
back and muscle pain, and itching of her nose and running of her
eyes. She also states that both her daughter and son are home
with a viral URI.
In the ED, initial vitals:97.7 179/55 53 18 100%RA. The pt was
found to be alert, mentating well, tachypneic, speaking in ___
sentences, +diffuse wheezes b/l, fair air movement. CXR was c/w
prior. The pt was given albuterol nebs, ipratroprium nebs,
methylpred 125mg IV, azithromycin 500mg IV.
Currently, 98.2 146/46 71 16 94%RA. She states she feels much
better than when she presented, however still has dyspnea with
exertion. Of note, the pt did get a flu shot this year (and
every year).
ROS: per HPI, night sweats, headache, vision changes, sore
throat, chest pain, abdominal pain, nausea, vomiting, diarrhea,
constipation, BRBPR, melena, hematochezia, dysuria, hematuria.
Past Medical History:
1. Diabetes mellitus type 2 controlled with oral hypoglycemic
agents for the last ___ years.
2. Asthma with frequent exacerbations requiring prednisone
treatment, no intubations.
3. Obstructive sleep apnea on CPAP at night for the last ___
years.
4. Hypertension on medications for at least ___ years.
5. H/o CVA ___ years ago with right facial droop, previously
diagnosed as Bell's palsy
6. Morbid obesity with intermittent weight gain with use of
steroids. She has recently been worked up at ___ for possible
gastric bypass, but there has been concern regarding her anemia.
She has managed to lose 25 pounds recently.
7. History of left ophthalmic artery aneurysm (coiled ___,
angiogram ___ suggest residual wedge)
8. CKD stage III with isolated microalbuminuria.
9. Anemia for which she has been evaluated by hematology with a
presumed diagnosis of anemia of chronic disease. In terms of
her
anemia, it is noteworthy that her anemia with hemoglobins as low
as 9 in ___ predate her CKD though over the last several years
it appears that her hemoglobin baseline has trended down
somewhat
reaching as low as 9.1 in ___.
10. Osteoarthritis.
11. GERD.
12. Diverticulosis.
13. Anxiety
14. Depression
15. Restless leg syndrome
16. History of lower extremity cellulitis.
17. status post cholecystectomy in ___
18. history of C-section.
Social History:
___
Family History:
No family history of renal disease. Several of her children
however, have hypertension. Three of her brothers passed away
from various cancers. A sister had colon cancer. Her daughter
had DM when pregnant. Both parents died in the ___, from "old
age"
Physical Exam:
admit exam:
VS - 98.2 146/46 71 16 94%RA
GENERAL - obese, pleasant, NAD
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear
NECK - supple, JVD difficult to assess given habitus
HEART - PMI non-displaced, RRR, nl S1-S2, no MRG
LUNGS - moderate air movement, scattered wheezes, no
crackles/dullness to percussion
ABDOMEN - obese, soft, nontender
EXTREMITIES - obese, no obvious edema, hard to assess
SKIN - fungal rashes in skin folds on back
NEURO - awake, A&Ox3, R sided facial droop, symmetric strength
in upper and lower extremities
discharge exam:
VS - 98.4 152/74 62 20 96%RA, 89-90% with ambulation
GENERAL - obese, pleasant, NAD
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear
NECK - supple, JVD difficult to assess given habitus
HEART - PMI non-displaced, RRR, nl S1-S2, no MRG
LUNGS - good air movement, rhonchorous breath sounds, scattered
wheezes, no crackles/dullness to percussion
ABDOMEN - obese, soft, nontender
EXTREMITIES - obese, no obvious edema, hard to assess
SKIN - fungal rashes in skin folds on back
NEURO - awake, A&Ox3, R sided facial droop, symmetric strength
in upper and lower extremities
Pertinent Results:
___ 11:20AM BLOOD WBC-6.7 RBC-3.47* Hgb-10.4* Hct-32.0*
MCV-92 MCH-30.0 MCHC-32.5 RDW-13.9 Plt ___
___ 09:40AM BLOOD WBC-8.2 RBC-3.53* Hgb-10.8* Hct-32.6*
MCV-93 MCH-30.6 MCHC-33.1 RDW-13.8 Plt ___
___ 11:20AM BLOOD Glucose-141* UreaN-14 Creat-1.1 Na-139
K-4.1 Cl-102 HCO3-27 AnGap-14
___ 09:40AM BLOOD Glucose-246* UreaN-15 Creat-1.0 Na-142
K-3.7 Cl-102 HCO3-30 AnGap-14
___ 11:20AM BLOOD cTropnT-<0.01
___ 12:33AM BLOOD CK-MB-2 cTropnT-<0.01
___ 11:29AM BLOOD Lactate-0.9
___ 3:30 pm Influenza A/B by ___
Source: Nasopharyngeal aspirate.
**FINAL REPORT ___
DIRECT INFLUENZA A ANTIGEN TEST (Final ___:
Reported to and read back by ___. ___ @ ___,
___.
POSITIVE FOR INFLUENZA A VIRAL ANTIGEN.
DIRECT INFLUENZA B ANTIGEN TEST (Final ___:
Negative for Influenza B.
ECG: Sinus bradycardia. Prolonged Q-T interval. Intraventricular
conduction delay.
Compared to the previous tracing of ___ no definite change.
___ CXR:
1. Non resolving bandlike opacity in the right upper lobe may
represent
scarring from prior pneumonia but should be evaluated by
non-urgent CT as
neoplasm cannot be excluded given nonresolution.
2. Mild prominence of the hila is unchanged suggesting benign
etiology though this can be assessed also at time of chest CT.
3. No evidence of pneumonia.
___:
There is mild-to-moderate cardiomegaly. The aorta is tortuous.
Aside from
atelectasis in the left lower lobe, the lungs are clear. There
is no
pneumothorax or pleural effusion.
Brief Hospital Course:
___ with hx of asthma, OSA, obesity p/w increasing dyspnea,
found to have asthma exacerbation ___ influenza.
# Acute Asthma Exacerbation ___ Influenza: The pt presented with
complaints of worsening dyspnea, especially on exertion,
wheezing, myalgias, cough, sneezing and rhinorrhea x5 days, with
close family sick contacts. She attempted treatment with nebs of
increasing frequency without relief. She presented to the ED and
was found to have cxr without pna. Symptoms improved with
methylpred/azithro/nebs however not to her baseline. Influenza A
returned positive however the pt was out of the window for
oseltamivir. The pt was treated with increased nebs,
azithromycin x5 days, and home singulair, (flovent/foradil
switched to advair while inpatient). She was also treated with a
pulse dose of prednisone 60mg daily, and started on a rapid
taper (50mg on the day of discharge, with plans for a daily
decrease of 10mg). Admission was prolonged due to persistent
fatigue and desaturation with ambulation. At time of discharge,
pt was 89-90% on RA with ambulation, but 97-98% with 2L nc.
Given pt has O2 at home, she was discharged with instructions to
use O2 with ambulation, and for ___ to check daily ambulatory
sats.
# DM: Pt with well controlled diabetes (last hga1c 6.7%) one
metformin 500mg daily. During admission, blood sugars were
elevated due to prednisone. The pt was started on lantus for
better glycemic control. Given her plan to continue steroid
usage post-discharge, the pt was discharged with a ___ to
administer 10u lantus daily while on prednisone. She was also
instructed to check her FSG TID and notify her PCP of glucose
readings >350.
# HTN: continued amlodipine, diovan, metoprolol, hctz
# CKD: Cr 1.1, improved from baseline 1.2-1.3
# Anemia: at 32, around baseline. Pt is a Jehovah's witness.
Continued home ferrous sulfate.
# Anxiety/depression: Continued home fluoxetine, xanax
# OSA/CPAP: continued cpap at night
# Fungal infection in back skin folds: pt was treated with
miconazole powder
# cns aneurysm with ___ s/p coil ___: stable
# Morbid obesity: Pt has been trying to find bariatric programs
that will take her given she is a Je___s witness.
# Non resolving bandlike opacity in the right upper lobe may
represent scarring from prior pneumonia but should be evaluated
by non-urgent CT as neoplasm cannot be excluded.
Transitional Issues
- ___ to follow and tx with lantus 10u daily while on predisone
- Pt to use home O2 with ambulation until O2 sats >92%
- f/u Non resolving bandlike opacity in the right upper lobe may
represent scarring from prior pneumonia but should be evaluated
by non-urgent CT as neoplasm cannot be excluded.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Calcium 500 + D (D3) *NF* (calcium carbonate-vitamin D3)
500-125 mg-unit Oral BID
2. Amlodipine 10 mg PO DAILY
3. Valsartan 320 mg PO DAILY
4. Albuterol Inhaler 2 PUFF IH Q4H:PRN sob/wheezing
5. Montelukast Sodium 10 mg PO DAILY
6. Ferrous Sulfate 325 mg PO DAILY
7. Fluoxetine 40 mg PO DAILY
8. Omeprazole 40 mg PO DAILY
9. ALPRAZolam 0.5 mg PO BID:PRN anxiety
10. Flovent HFA *NF* (fluticasone) 220 mcg/actuation Inhalation
BID
11. Metoprolol Succinate XL 50 mg PO DAILY
12. MetFORMIN (Glucophage) 500 mg PO DAILY
13. Lotrisone *NF* (clotrimazole-betamethasone) ___ % Topical
BID
14. Fluticasone Propionate NASAL 1 SPRY NU BID
15. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain
16. Hydrochlorothiazide 25 mg PO DAILY
17. Albuterol 0.083% Neb Soln 1 NEB IH Q4-6H:PRN sob/wheeze
18. Aspirin 81 mg PO DAILY
19. Foradil Aerolizer *NF* (formoterol fumarate) 12 mcg
Inhalation q12h
Discharge Medications:
1. Albuterol 0.083% Neb Soln 1 NEB IH Q4-6H:PRN sob/wheeze
2. ALPRAZolam 0.5 mg PO BID:PRN anxiety
3. Amlodipine 10 mg PO DAILY
4. Ferrous Sulfate 325 mg PO DAILY
5. Fluoxetine 40 mg PO DAILY
6. Fluticasone Propionate NASAL 1 SPRY NU BID
7. Hydrochlorothiazide 25 mg PO DAILY
8. MetFORMIN (Glucophage) 500 mg PO DAILY
9. Metoprolol Succinate XL 50 mg PO DAILY
10. Montelukast Sodium 10 mg PO DAILY
11. Omeprazole 40 mg PO DAILY
12. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain
13. Valsartan 320 mg PO DAILY
14. Dextromethorphan-Guaifenesin (Sugar Free) 5 mL PO Q6H:PRN
cough
RX *dextromethorphan-guaifenesin [Diabetic Tussin DM] 100 mg-10
mg/5 mL 5 ml by mouth q4h:PRN Disp #*1 Bottle Refills:*0
15. PredniSONE 10 mg PO daily Duration: 1 Doses Start: After 20
mg tapered dose.
RX *prednisone 10 mg as directed tablet(s) by mouth as directed
Disp #*10 Tablet Refills:*0
16. Albuterol Inhaler 2 PUFF IH Q4H:PRN sob/wheezing
17. Calcium 500 + D (D3) *NF* (calcium carbonate-vitamin D3)
500-125 mg-unit Oral BID
18. Flovent HFA *NF* (fluticasone) 220 mcg/actuation Inhalation
BID
19. Foradil Aerolizer *NF* (formoterol fumarate) 12 mcg
Inhalation q12h
20. Lotrisone *NF* (clotrimazole-betamethasone) ___ % Topical
BID
21. Glargine 10 Units Bedtime
RX *insulin glargine [Lantus Solostar] 100 unit/mL (3 mL) Please
have ___ administer 10u sc at bedtime Disp #*1 Bottle Refills:*0
22. Aspirin 81 mg PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
primary diagnoses: influenza, asthma exacerbation, type 2
diabetes
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. ___,
It was a pleasure participating in your care. You were admitted
for worsening shortness of breath and found to have the flu. You
were treated with steroids, nebulizers and antibiotics in
addition to your home medications with improvement in your
symptoms. Your oxygenation has been good while at rest, however
you continue to require 2 liters of oxygen while walking around.
Please use your home oxygen when moving around the house until
your visiting nurse tells you your oxygen saturations have
improved.
While on steroids, your blood sugars have been very high, so you
have been treated with insulin. A visiting nurse ___ come to
your house to give you a dose of long acting insulin every day
while you are on steroids. In addition, you should check your
blood sugars three times a day. If your blood sugars are greater
than 300, you should call your doctors at ___ for help with
further management.
Followup Instructions:
___
|
19723160-DS-30
| 19,723,160 | 22,226,068 |
DS
| 30 |
2190-04-18 00:00:00
|
2190-04-20 17:33:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
lisinopril
Attending: ___.
Chief Complaint:
L shoulder pain and dyspnea/cough
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
___ with morbid obesity, T2DM, OSA, asthma, HTN, h/o CVA,
presents with worsening dyspnea and cough.
The patient states that for the last week she has noticed
increased cough with wheezing, not improved with her home
inhalers and nebulizers. She did run out of her inhalers a few
days ago, however was able to get a refill earlier on the day of
admission and despite use of the new inhaler continued to have
cough and wheezing. Her cough has been productive of clear
secretions. Denies fever but endorses some chills and night
sweats. She notes that she has frequent asthma/COPD
exacerbations and was last on prednisone about a month ago. She
notes she had significant side effects from being on steroids
including hard to control hyperglycemia.
She also reports left lateral neck/shoulder pain for the last
three days. She denies any recent trauma. She denies chest pain,
palpitations, dizziness or lightheadedness. She states that this
pain radiates down her left arm and did not significantly
improve with her home oxycodone. It is worse with any movement.
She does have arthritis of the left shoulder, but reports that
this pain is worse than usual. She denies any numbness or
weakness in the arm.
Finally, she reports a burning sensation along the anterior LLE
similar to her prior presentations with cellulitis. She cannot
discern any increased edema or erythema of the LLE. She reports
chills and night sweats but no fevers.
In the ED intial vitals were: ___ 57 213/67 18 95% RA. On
exam, the patient was noted to have diminished breath sounds
with scattering wheezing. She was also noted to have a slightly
warm LLE without erythema and no appreciable calf circumference
difference. The patient was treated for possible COPD
exacerbation with albuterol and ipratropium nebs and
methylprednisolone 125mg IV. Given her should pain, she was
treated with morphine 5mg IV and 1 tablet Percocet. The patient
was admitted for COPD exacerbation, however with concern for ACS
given L shoulder pain. Given the LLE warmth, suggested
monitoring for possible cellulitis.
On the floor, patient reprots she feeling nearly er baseline.
Her SOB has now improved and her shoulder pain is better after
the morphine. She still reports ___ pain with movement of left
shoulder. She voices no further complaints.
Past Medical History:
1. T2DM, most recent A1c 5.9%
2. Asthma with frequent exacerbations requiring prednisone
treatment, no intubations.
3. Obstructive sleep apnea on CPAP at night for the last ___
years.
4. Hypertension
5. H/o CVA ___ years ago with right facial droop, previously
diagnosed as Bell's palsy
6. Morbid obesity
7. h/o left ophthalmic artery aneurysm (coiled ___, angiogram
___ suggest residual wedge)
8. CKD stage III with isolated microalbuminuria (currently
normal Cr)
9. Anemia, presumed anemia of chronic disease
10. Osteoarthritis.
11. GERD.
12. Diverticulosis.
13. Anxiety
14. Depression
15. Restless leg syndrome
16. h/o lower extremity cellulitis.
17. s/p cholecystectomy in ___
18. s/p C-section
19. bilateral knee arthritis
20. h/o severe allergic reaction (rash to ?HCTZ vs.
contact/photosensitivity)
Social History:
___
Family History:
Multiple other family members with asthma. There is no strong
family history of lung cancer or pulmonary emboli. No family
history of renal disease. Several of her children however, have
hypertension. Three of her brothers passed away from various
cancers. A sister had colon cancer. Her daughter had DM when
pregnant. Both parents died in the ___, from "old age".
Physical Exam:
ADMISSION EXAM:
================
Vitals - T:98.0 BP:171/70 HR:70 RR:18 02 sat: 93% FSBG 222
Weight 162.4kg
GENERAL: Morbidly obese female in NAD, pleasant and cooperative,
speaking in full sentences.
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
patent nares, MMM, good dentition, OP crowded. No thrush.
NECK: large supple neck, no LAD, no JVD, Thyroid WNL
CARDIAC: distant heart sounds, normal S1/S2, no murmurs,
gallops, or rubs
LUNG: distant lung sounds CTAB, mild expiratory wheeze, no
rales, rhonchi, breathing comfortably without use of accessory
muscles
ABDOMEN: morbidly obese, nontender, non-distended, +BS, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: moving all extremities well, no cyanosis, clubbing.
She has 1+ edema bilaterally
PULSES: 2+ DP pulses bilaterally
NEURO: Speech coherent, CN II-XII intact except for R sided
facial droop, symmetric strength in upper and lower extremities,
gait not assessed.
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
DISCHARGE EXAM:
=================
Vitals - T:98.0 BP:171/70 HR:70 RR:18 02 sat: 93%RA Weight
165.2kg
GENERAL: Morbidly obese female in NAD, pleasant and cooperative,
speaking in full sentences.
CARDIAC: distant heart sounds, normal S1/S2, no murmurs,
gallops, or rubs
LUNG: distant lung sounds CTAB, mild expiratory wheeze, no
rales, rhonchi, breathing comfortably without use of accessory
muscles
ABDOMEN: morbidly obese, nontender, non-distended, +BS, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: moving all extremities well, no cyanosis, clubbing.
She has 1+ edema bilaterally
Pertinent Results:
LABS:
=========
___ 12:50AM BLOOD WBC-10.5 RBC-3.58* Hgb-10.7* Hct-32.7*
MCV-91 MCH-29.8 MCHC-32.6 RDW-14.5 Plt ___
___ 12:50AM BLOOD Glucose-115* UreaN-16 Creat-1.0 Na-148*
K-4.3 Cl-107 HCO3-29 AnGap-16
___ 12:50AM BLOOD Calcium-9.0 Phos-3.6 Mg-2.
___ 08:05AM BLOOD WBC-11.7* RBC-3.60* Hgb-10.8* Hct-32.8*
MCV-91 MCH-29.9 MCHC-32.8 RDW-14.4 Plt ___
STUDIES:
=========
___ L shoulder x-rays:
IMPRESSION:
Severe osteoarthritic changes of the left glenohumeral joint
with no acute fracture or dislocation.
___ CXR
IMPRESSION:
1. No acute pneumonia.
2. Tubular opacity extending superiorly from the chronically
large hilus is again noted and may be atelectasis in a region of
chronic mucoid impaction, scarring, or an isolanted bronchial
abnormality due to asthma or less likely allegeric
bronchopulmonary aspergillosis.
Brief Hospital Course:
___ with morbid obesity, T2DM, OSA, asthma, HTN, h/o CVA,
presents with worsening dyspnea and cough.
# L shoulder pain: Patient with known history of arthritis. Pain
reproducible on exam. EKG, trops negative x 2 reassuring.
Shoulder XR w/ severe OA, but no fracture. Treat w/ home tylenol
and oxycodone.
# Asthma/COPD exacerbation: Patient with recent exacerbation s/p
treatment with prednisone 1 month ago with re-emergence of
symptoms. Unclear trigger, as no recent travel, sick contacts,
or evidence of URTI. CXR without any e/o pneumonia. She will
complete a five day course of prednisone and azithromycin.
Chronic issues:
# T2DM: Most recent A1c 5.9%, c/b nephropathy. On home metformin
and glargine. Held metformin in house and restarted at
discharge.
# HTN: con't home meds.
# Morbid obesity: Refer for bariatric surgery (had workup at ___
in the past that fell through).
# Anemia: Per history, likely anemia of chronic disease. Hb
___ at baseline. Patient is a ___. Continued
home iron supplmentation.
# Anxiety/depression: continued home fluoxetine and alprazolam.
# OSA/CPAP: continue cpap at night with respiratory c/s
# CNS aneurysm with SAH s/p coil ___: stable
# GERD: continued home omperazole
# Osteopenia: continued calcium and vitamin D supplmenetation
Transitional issues:
- complete 5 days of pred/azithro.
- ?need for BB given underlying lung disease
- Refer for bariatric surgery (had workup at ___ in the past
that fell through)
# Code: DNR/DNI
# Emergency Contact: ___ (daughter and HCP)
___
___ on Admission:
1. Albuterol 0.083% Neb Soln 1 NEB IH Q4-6H:PRN sob/wheeze
2. ALPRAZolam 0.5 mg PO BID:PRN anxiety
3. Amlodipine 10 mg PO DAILY
4. Ferrous Sulfate 325 mg PO DAILY
5. Fluoxetine 40 mg PO DAILY
6. Fluticasone Propionate NASAL 1 SPRY NU BID
7. MetFORMIN (Glucophage) 500 mg PO DAILY
8. Metoprolol Succinate XL 50 mg PO DAILY
9. Montelukast Sodium 10 mg PO DAILY
10. Omeprazole 40 mg PO DAILY
11. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain
12. Valsartan 320 mg PO DAILY
13. Albuterol Inhaler 2 PUFF IH Q4H:PRN sob/wheezing
14. Calcium 500 + D (D3) (calcium carbonate-vitamin D3) 500-125
mg-unit Oral BID
15. Flovent HFA (fluticasone) 220 mcg/actuation Inhalation BID
16. Aspirin 81 mg PO DAILY
17. Flovent Diskus (fluticasone) 50 mcg/actuation inhalation BID
18. Glargine 12 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
19. Hydrocortisone Cream 2.5% 1 Appl TP BID
20. Multivitamins W/minerals 1 TAB PO DAILY
Discharge Medications:
1. Albuterol 0.083% Neb Soln 1 NEB IH Q4-6H:PRN sob/wheeze
2. ALPRAZolam 0.5 mg PO BID:PRN anxiety
3. Amlodipine 10 mg PO DAILY
4. Aspirin 81 mg PO DAILY
5. Ferrous Sulfate 325 mg PO DAILY
6. Flovent Diskus (fluticasone) 50 mcg/actuation inhalation BID
7. Fluoxetine 40 mg PO DAILY
8. Fluticasone Propionate NASAL 1 SPRY NU BID
9. Hydrocortisone Cream 2.5% 1 Appl TP BID
10. Glargine 12 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
11. Montelukast Sodium 10 mg PO DAILY
12. Multivitamins W/minerals 1 TAB PO DAILY
13. Omeprazole 40 mg PO DAILY
14. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain
15. Valsartan 320 mg PO DAILY
16. Azithromycin 250 mg PO Q24H Duration: 4 Days
RX *azithromycin 250 mg 1 tablet(s) by mouth daily Disp #*4
Tablet Refills:*0
17. PredniSONE 40 mg PO DAILY Duration: 5 Days
RX *prednisone 20 mg 2 tablet(s) by mouth daily Disp #*8 Tablet
Refills:*0
18. MetFORMIN (Glucophage) 500 mg PO DAILY
19. Flovent HFA (fluticasone) 220 mcg/actuation Inhalation BID
20. Metoprolol Succinate XL 50 mg PO DAILY
21. Calcium 500 + D (D3) (calcium carbonate-vitamin D3) 500-125
mg-unit Oral BID
22. Albuterol Inhaler 2 PUFF IH Q4H:PRN sob/wheezing
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
L shoulder osteoarthritis
COPD exacerbation
Secondary:
Diabetes mellitus, type II
Hypertension
Morbid obesity
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You came to the hospital for left shoulder pain. An x-ray showed
severe osteoarthritis but no fracture. An evaluation for heart
disease as a cause of this shoulder pain was negative (normal).
You should continue to take your home pain medications for this
pain. You were also found to be short of breath, and should
complete treatment for a COPD exacerbation as below.
Followup Instructions:
___
|
19723160-DS-32
| 19,723,160 | 22,419,408 |
DS
| 32 |
2191-01-18 00:00:00
|
2191-01-18 10:47:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
lisinopril
Attending: ___.
Chief Complaint:
shortness of breath x2 weeks
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ yo female with CKD, OSA, asthma with hx of hospitalization
for asthma exacerbations without intubation presenting with DOE
x2 weeks. Pt reports that she feels that her symptoms never
fully recovered from her hospitalization in ___
(___), at which time a CT chest was negative for PE. She
was treated with steroids, nebs, abx, with prolonged steroid
taper. PFTs performed on ___ were without obstructive or
restrictive deficits. She was seen by Dr. ___, who
advised asthma action plan including advair BID, montelukast 10
mg/day, and albuterol q6h prn. Pt reports a very prolonged
steroid taper as advised by her PCP, which she completed approx
1 week prior to presentation. She reports that she noted
increasing DOE which has progressed over the past 2 weeks, such
that she needs to stop to catch her breath after showering. She
does endorse sore throat and nonproductive cough, but denies
sick contacts at home. Three days prior to presentation, she
decided to reintroduce prednisone with escalating doses up to 30
mg BID on day prior to presentation, without significant
improvement in her symptoms. She endorses chest tightness
radiating to her back associated with her DOE, without radiation
to jaw or arm. She endorses intermittent chills, rhinorrhea. She
presented to ED for persistent DOE and hyperglycemia in setting
of resuming steroids. She does report that she completed a
course of azithromycin in early ___ for similar symptoms,
but does not feel that abx relieved her sxs. She notes that,
until 2 weeks prior to presentation, she was able to go
shoppping and play Bingo.
In ___ ED:
98.5 HR: 85 BP: 193/64 Resp: 18 O(2)Sat: 88 room air
WBC 16.3, Lactate 3.3
Received nebs, solumedrol 125 mg x1, levofloxacin 750 mg
Admitted to medicine
ROS: All else negative
Past Medical History:
1. T2DM
2. Asthma with frequent exacerbations requiring prednisone
treatment, no intubations.
3. Obstructive sleep apnea on CPAP at night for the last ___
years.
4. Hypertension
5. H/o CVA ___ years ago with right facial droop, previously
diagnosed as Bell's palsy
6. Morbid obesity
7. h/o left ophthalmic artery aneurysm (coiled ___, angiogram
___ suggest residual wedge)
8. CKD stage III with isolated microalbuminuria (currently
normal Cr)
9. Anemia, presumed anemia of chronic disease
10. Osteoarthritis.
11. GERD.
12. Diverticulosis.
13. Anxiety
14. Depression
15. Restless leg syndrome
16. h/o lower extremity cellulitis.
17. s/p cholecystectomy in ___
18. s/p C-section
19. bilateral knee arthritis
20. h/o severe allergic reaction (rash to ?HCTZ vs.
contact/photosensitivity)
Social History:
___
Family History:
Multiple other family members with asthma. There is no strong
family history of lung cancer or pulmonary emboli. No family
history of renal disease. Several of her children however, have
hypertension. Three of her brothers passed away from various
cancers. A sister had colon cancer. Her daughter had DM when
pregnant. Both parents died in the ___, from "old age".
Physical Exam:
VS: 99.1, 77, 181/82, 22, SaO2 96% RA
Gen: Morbidly obese, pleasant, NAD
HEENT: PERRL, EOMI, clear oropharynx, no cervical or
supraclavicular LAD
Pulm: Diffuse expiratory wheeze, no crackles
CV: RRR, distant heart sounds, no murmurs or rubs appreciated
Abd: obese, soft, NT, ND, +bowel sounds. Unable to appreciate
organomegaly.
Ext: WWP, no clubbing or cyanosis
Neuro: grossly intact
Skin: No rashes or lesions appreciated
Pertinent Results:
___ 08:10PM URINE HOURS-RANDOM
___ 08:10PM URINE HOURS-RANDOM
___ 08:10PM URINE UHOLD-HOLD
___ 08:10PM URINE GR HOLD-HOLD
___ 08:10PM URINE COLOR-Straw APPEAR-Clear SP ___
___ 08:10PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
___ 05:40PM ___ COMMENTS-GREEN TOP
___ 05:40PM LACTATE-3.3*
___ 05:32PM GLUCOSE-232* UREA N-31* CREAT-1.5* SODIUM-141
POTASSIUM-4.6 CHLORIDE-102 TOTAL CO2-24 ANION GAP-20
___ 05:32PM estGFR-Using this
___ 05:32PM WBC-16.3* RBC-3.71* HGB-11.0* HCT-33.8*
MCV-91 MCH-29.7 MCHC-32.6 RDW-14.4
___ 05:32PM NEUTS-86.7* LYMPHS-11.1* MONOS-1.7* EOS-0.3
BASOS-0.1
___ 05:32PM PLT COUNT-338
EKG: NSR at 67, normal axis, normal intervals, no TWI or ST
segment changes, no Q waves, unchanged compared to ___ (my
read)
Final Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: History: ___ with dyspnea and hypoxia
TECHNIQUE: Portable upright AP view of the chest
COMPARISON: ___ chest CTA and chest radiograph
FINDINGS:
Study is slightly limited by underpenetrated technique. Heart
size remains
mildly to moderately enlarged. The aorta is tortuous with mild
atherosclerotic
calcifications noted at the aortic arch. Enlargement of the
pulmonary arteries
bilaterally is similar and suggestive of underlying pulmonary
arterial
hypertension. Retrocardiac opacity could reflect atelectasis
though infection
is not completely excluded. Right lung is grossly clear. No
pleural effusion
or pneumothorax is identified.
IMPRESSION:
Limited study due to underpenetration. Patchy retrocardiac
opacity, possibly
atelectasis, but infection cannot be excluded.
Brief Hospital Course:
___ with hx of asthma, morbid obesity, OSA, DM2 p/w progressive
dyspnea in setting of recent steroid taper.
# Asthma with acute exacerbation: Similar symptoms in ___
attributed to asthma exacerbation, treated with nebs, steroids
with a slow taper, and abiotics for CAP. She reported chronic
steroid exposure since that time, which seems to have had some -
if not full - improvement in her SOB/DOE, with recurrent
symptoms x2 weeks. Her symptoms of a recent sore throat and
nonproductive cough raise suspicion for a viral URI as a trigger
for this asthma exacerbation. Very difficult to interpret CXR in
setting of morbid obesity and underpenetrated film. No obvious
infiltrates. EKG without changes. She was treated with
steroids, standing nebs with improvement. Her case was discussed
with her pulmonologist and the plan was for a long taper with
follow-up in pulmonary clinic.
# T2DM: Last A1C 5.9% ___. On glargine 18u qAM at home, with
metformin. She was treated with glargine and sliding scale
during admission.
# ___: Admission Cr was 1.5, which was above her baseline of
1.1. This improved with hydration.
# HTN: Hypertensive in setting of asthma exacerbation and
steroid use. She is on max amlodipine, valsartan, HCTZ, and
lesser dosing of metoprolol. She was given one dose of
furosemide for BPs in the 170s-180s with good improvement in her
blood pressure.
# Anxiety/depression: continued home fluoxetine.
# OSA: Continued CPAP.
# GERD: Continued home PPI.
# Morbid obesity: Pt is tearful during admission as she
discusses her desire for bariatric surgery. Per records, has
previously been worked up for gastric bypass at ___, but was
considered high risk given that she is a Je___'s witness. Pt
is strongly requesting further consideration for bariatric
surgery.
Medications on Admission:
1. Albuterol 0.083% Neb Soln 1 NEB IH Q4-6H:PRN sob/wheeze
2. Amlodipine 10 mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. Ferrous Sulfate 325 mg PO DAILY
5. Fluoxetine 40 mg PO DAILY
6. Fluticasone Propionate NASAL 1 SPRY NU BID
7. Metoprolol Succinate XL 50 mg PO DAILY
8. Montelukast Sodium 10 mg PO DAILY
9. Multivitamins W/minerals 1 TAB PO DAILY
10. Omeprazole 40 mg PO DAILY
11. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain
12. Valsartan 320 mg PO DAILY
13. Azithromycin 250 mg PO Q24H Duration: 4 Days
RX *azithromycin 250 mg 1 tablet(s) by mouth daily Disp #*3
Tablet Refills:*0
14. PredniSONE 40 mg PO DAILY
RX *prednisone 10 mg 4 tablet(s) by mouth daily Disp #*25 Tablet
Refills:*0
15. Sulfameth/Trimethoprim DS 1 TAB PO BID Duration: 5 Days
RX *sulfamethoxazole-trimethoprim 800 mg-160 mg 1 tablet(s) by
mouth twice a day Disp #*6 Tablet Refills:*0
16. Albuterol Inhaler 2 PUFF IH Q4H:PRN sob/wheezing
17. ALPRAZolam 0.5 mg PO BID:PRN anxiety
18. Hydrocortisone Cream 2.5% 1 Appl TP BID
19. MetFORMIN (Glucophage) 500 mg PO DAILY
20. Calcium 500 + D (D3) (calcium carbonate-vitamin D3) 500-125
mg-unit Oral BID
21. Glargine 12 Units Bedtime
22. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
RX *fluticasone-salmeterol [Advair Diskus] 500 mcg-50 mcg/Dose 1
puff inhaled twice a day Disp #*2 Disk Refills:*11
23. Fluticasone Propionate 110mcg 2 PUFF IH BID
Discharge Medications:
1. ALPRAZolam 0.5 mg PO BID:PRN anxiety
2. Amlodipine 10 mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. Fluoxetine 40 mg PO DAILY
5. Fluticasone Propionate NASAL 1 SPRY NU BID
6. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
7. Hydrochlorothiazide 25 mg PO DAILY
8. MetFORMIN (Glucophage) 500 mg PO DAILY
9. Metoprolol Succinate XL 50 mg PO DAILY
10. Montelukast Sodium 10 mg PO DAILY
11. Multivitamins W/minerals 1 TAB PO DAILY
12. Omeprazole 40 mg PO DAILY
13. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain
RX *oxycodone 5 mg 1 capsule(s) by mouth three times a day Disp
#*20 Capsule Refills:*0
14. Valsartan 320 mg PO DAILY
15. Albuterol Inhaler 2 PUFF IH Q4H:PRN sob/wheezing
16. Calcium 500 + D (D3) (calcium carbonate-vitamin D3) 500-125
mg-unit Oral BID
17. PredniSONE 60 mg PO DAILY Duration: 1 Dose
Start: Tomorrow - ___, First Dose: First Routine
Administration Time
when at 40 mg/day please follow up with Dr. ___: further
tapering instructions
RX *prednisone 10 mg 1 tablet(s) by mouth as directed Disp #*200
Tablet Refills:*0
18. PredniSONE 50 mg PO DAILY Duration: 7 Doses
Start: After 60 mg tapered dose
when at 40 mg/day please follow up with Dr. ___: further
tapering instructions
19. PredniSONE 40 mg PO DAILY Duration: 7 Doses
Start: After 50 mg tapered dose
when at 40 mg/day please follow up with Dr. ___: further
tapering instructions
20. PredniSONE 30 mg PO DAILY Duration: 7 Doses
Start: After 40 mg tapered dose
when at 40 mg/day please follow up with Dr. ___: further
tapering instructions
21. PredniSONE 20 mg PO DAILY Duration: 7 Doses
Start: After 30 mg tapered dose
when at 40 mg/day please follow up with Dr. ___: further
tapering instructions
22. PredniSONE 10 mg PO DAILY Duration: 7 Doses
Start: After 20 mg tapered dose
when at 40 mg/day please follow up with Dr. ___: further
tapering instructions
23. Glargine 18 Units Breakfast
Insulin SC Sliding Scale using HUM Insulin
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Asthma exacerbation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted with an asthma exacerbation. In the future,
please make sure to call Dr. ___ any time you are
experiencing asthma symptoms, PRIOR to presenting the hospital
(you should only come to the hospital if you are struggling to
breathe or can't get in touch with Dr. ___. You will be
discharged with a prednisone taper, and will see Dr. ___ in
followup.
Followup Instructions:
___
|
19723160-DS-33
| 19,723,160 | 25,665,909 |
DS
| 33 |
2191-04-08 00:00:00
|
2191-04-11 13:27:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
lisinopril / Iodinated Contrast Media - IV Dye
Attending: ___.
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms. ___ is a ___ year old female w/ hx of severe asthma,
obesity, OSA, HTN, T2DM, who presents with increasing dysnea and
wheezing consistent with prior asthma exacerbations. Over the
last ___ days, symptoms have become progressively worse
preventing her from performing ADLs. She is using albuterol nebs
4x day. She was seen by Dr. ___ on ___ who increased her
prednisone from 15mg to 40mg (had been on long taper) and
started azithromycin. She did not have significant improvement
from this. Additionally, she has complained of subjective
fevers, cough, and sore throat over last day. No sputum
production. No associated CP, lh, dizziness, or palpitations. No
recent sick contacts.
In the ED, initial VS were: 89 170/95 26 92% ra. Exam was
notable for diffuse wheezing. Labs were notable for: a VBG with
pH 7.34 pCO2 53 pO2 54 HCO3 30 Lactate:4.0 O2Sat: 82. Blood
chemistry was Na of 138 Cl of 97 BUN of 34 K of 5.5 Bicarb of 22
creatnine of 1.4 CK: 120 HCG:<5, WBC of 14.7 with 82.6%
neutrophils, Hgb of 10.7 and platelets of 32.4 Imaging
included: CXR was unremarkable. Chest CT showed ? areas of
aspiration and pulmonary HTN.
Treatments received: Albuterol/ipratroprium nebs, 2g Mag
sulfate, and 125mg IV solumederol. She was placed on
levofloxacin.
Past Medical History:
1. T2DM
2. Asthma with frequent exacerbations requiring prednisone
treatment, no intubations.
3. Obstructive sleep apnea on CPAP at night for the last ___
years.
4. Hypertension
5. H/o CVA ___ years ago with right facial droop, previously
diagnosed as Bell's palsy
6. Morbid obesity
7. h/o left ophthalmic artery aneurysm (coiled ___, angiogram
___ suggest residual wedge)
8. CKD stage III with isolated microalbuminuria (currently
normal Cr)
9. Anemia, presumed anemia of chronic disease
10. Osteoarthritis.
11. GERD.
12. Diverticulosis.
13. Anxiety
14. Depression
15. Restless leg syndrome
16. h/o lower extremity cellulitis.
17. s/p cholecystectomy in ___
18. s/p C-section
19. bilateral knee arthritis
20. h/o severe allergic reaction (rash to ?HCTZ vs.
contact/photosensitivity)
Social History:
___
Family History:
Multiple other family members with asthma. There is no strong
family history of lung cancer or pulmonary emboli. No family
history of renal disease. Several of her children however, have
hypertension. Three of her brothers passed away from various
cancers. A sister had colon cancer. Her daughter had DM when
pregnant. Both parents died in the ___, from "old age."
Physical Exam:
ADMISSION EXAM:
===================
VITAL SIGNS: 98.2 175/67 P79 RR22 97%RA
GENERAL: Alert, oriented, obese with labored breathing
HEENT: Sclera anicteric, MMM, oropharynx clear
LUNGS: Diffuse wheezing in all long fields, no rales, ronchi
CV: Regular rate and rhythm, no murmurs/rubs/gallops
ABDOMEN: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
EXTR: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
NEURO: Cn ___ intact, no focal deficits
SKIN: warm, dry, no rashes or lesions
DISCHARGE EXAM:
====================
Vitals: 98.2 (98.6) 141/59 (120-160/50-80) 60 (60-70) 20 97%RA
I/O: ___ // 0/BR
Weight: 176.6kg
BS: ___ // 103
General: WD morbidly obese AAF. A&O x 3 in NAD. speaking in full
sentences with no accessory respiratory muscle use.
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, thick-necked. JVP unable to appreciate given body
habitus. wheezing heard over trachea
Lungs: diffuse expiratory wheezes heard anteriorly and
posteriorly in all lung fields (improving). no obvious rhonchi.
no crackles. no accessory muscle use
CV: softened heart sounds however regular, normal S1 + S2, no
murmurs, rubs, gallops
Abdomen: obese, 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: no focal deficits, no asterixis
Pertinent Results:
ADMISSION LABS:
=====================
___ 02:48PM BLOOD WBC-14.7* RBC-3.51* Hgb-10.7* Hct-32.4*
MCV-92 MCH-30.5 MCHC-33.0 RDW-15.6* Plt ___
___ 02:48PM BLOOD Neuts-82.6* Lymphs-13.9* Monos-3.1
Eos-0.3 Baso-0.2
___ 02:48PM BLOOD Glucose-307* UreaN-34* Creat-1.4* Na-138
K-5.5* Cl-97 HCO3-22 AnGap-25*
___ 02:48PM BLOOD CK(CPK)-120
___ 02:48PM BLOOD HCG-<5
___ 02:51PM BLOOD ___ pO2-54* pCO2-53* pH-7.34*
calTCO2-30 Base XS-0 Intubat-NOT INTUBA
___ 02:51PM BLOOD Lactate-4.0*
PERTINENT LABS:
=====================
___ 06:00AM BLOOD Glucose-109* UreaN-48* Creat-1.5* Na-143
K-4.0 Cl-102 HCO3-28 AnGap-17
___ 06:00AM BLOOD proBNP-242
___ 06:00AM BLOOD ANCA-NEGATIVE B
___ 06:00AM BLOOD ___
___ 12:12AM BLOOD Lactate-3.6*
___ 10:12AM BLOOD Lactate-2.5*
___ 01:48PM OTHER BODY FLUID FluAPCR-NEGATIVE
FluBPCR-NEGATIVE
DISCHARGE LABS:
======================
___ 06:00AM BLOOD Hct-30.0*
___ 06:00AM BLOOD Glucose-102* UreaN-52* Creat-1.8* Na-140
K-4.4 Cl-102 HCO3-28 AnGap-14
IMAGING:
======================
ECG (___): Sinus rhythm with baseline artifact. Possible
left atrial abnormality. Possible left ventricular hypertrophy.
Compared to the previous tracing of ___, allowing for lead
placement differences, no diagnostic change.
CXR (___): Limited evaluation secondary to underpenetration
and large body habitus. Single portable upright chest radiograph
demonstrates an enlarged heart though similar in size relative
to prior study dated ___. Hilar contours and
mediastinal silhouette are stable. There is no large pleural
effusion. No evidence of pulmonary edema. No focal consolidation
convincing for pneumonia is present. Right medial basilar
atelectasis.
CT Chest (___):
1. Vertically oriented opacity which extends from the right lung
apex and centrally to the right hilar region surrounding the
bronchovascular structures present on prior study dated ___ and unchanged. This is thought to reflect a
recurrent focus of atelectasis versus scarring given
persistence.
2. Small opacities in the left lung base may reflect small focus
of
aspiration. Consider followup imaging to document resolution.
3. Enlarged pulmonary artery suggesting pulmonary hypertension.
TTE (___):
The left atrium is normal in size. The estimated right atrial
pressure is ___ mmHg. There is mild symmetric left ventricular
hypertrophy. The left ventricular cavity size is normal. Due to
suboptimal technical quality, a focal wall motion abnormality
cannot be fully excluded. Overall left ventricular systolic
function is normal (LVEF = 60%). Right ventricular chamber size
and free wall motion are normal. The ascending aorta is mildly
dilated. The aortic valve leaflets (3) are mildly thickened but
aortic stenosis is not present. No aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. Trivial mitral
regurgitation is seen. The left ventricular inflow pattern
suggests impaired relaxation. There is mild pulmonary artery
systolic hypertension. There is no pericardial effusion.
Compared with the prior study (images reviewed) of ___, the
findings are similar.
CT Trachea (___):
Physiologic collapsibility of the tracheobronchial tree with no
evidence of tracheobronchomalacia. Stable chronic right upper
lobe bronchiectasis and scarring. Mild lower lobe cylindrical
bronchiectasis and mucoid impaction. Stable dilatation of the
main pulmonary artery suggests pulmonary arterial hypertension
in the appropriate clinical setting.
MICROBIOLOGY:
======================
___ 2:50 pm BLOOD CULTURE x 2: NO GROWTH
Brief Hospital Course:
___ with hx of asthma, morbid obesity, OSA, DM2 p/w acute asthma
exacerbation in setting of URI.
# Asthma with acute exacerbation: Her symptoms of a recent sore
throat and nonproductive cough raise suspicion for a viral URI
as a trigger for this asthma exacerbation. No obvious
infiltrates on chest CT, however was treated with levofloxacin
in ED and completed course with azithromycin x 5 days. Volume
status was difficult to appreciate given her body habitus,
however clinically felt better with intermittant diuresis. Her
Flu swab was negative and her initial lactate of 4.0 normalized.
Pulmonary team was consulted and recommended CT of trachea which
showed no evidence of TBM. ___ were also negative. Patient
was continued on a 2-week steroid taper and continued on her
home Advair, montelukast and tiotropium.
# T2DM: Last A1C 5.9% ___. On glargine 25u qAM at home
however fingerstick blood sugars were grossly elevated in
setting of prednisone. Her lantus was increased and she also was
placed on standing mealtime insulin. She will need to have close
f/u of insulin titration in setting of steroid taper.
# ___: Admission Cr was 1.4, slightly above recent baseline in
1.2-1.3 range and thought to be pre-renal given recent
infectious symptoms which improved upon discharge. Her home HCTZ
and PO lasix were held however resumed upon discharge.
# HTN: Continued home valsartan, metoprolol, and amlodipine.
# Anxiety/depression: Continued home fluoxetine.
# OSA: Continued CPAP while in house.
# morbid obesity: Many of patient's comorbidities most likely
stem from her morbid obesity. In the past, she had gone to ___
for consideration of bariatric surgery, however was considered
high risk in setting of being ___ witness. She was
provided information to establish care with the Bariatric
services here at ___.
# GERD: Continued home PPI.
Transitional Issues:
-continue titrating her insulin regimen in setting of steroid
taper
-her Cr on discharge was 1.8; will need ___ function at
next PCP appointment
-___ is interested in pursuing bariatric evaluation here at
___ please assist with facilitating this appointment
-continue steroid taper (40 mg daily until ___ 30 mg daily
until ___ 20 mg daily until ___
-HCTZ held in setting of ___ consider restarting if renal
function improves
-code status: full
-contact: ___ ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. ALPRAZolam 0.5 mg PO BID:PRN anxiety
2. Amlodipine 10 mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. Fluoxetine 40 mg PO DAILY
5. Fluticasone Propionate NASAL 1 SPRY NU BID
6. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
7. Hydrochlorothiazide 25 mg PO DAILY
8. MetFORMIN (Glucophage) 500 mg PO DAILY
9. Metoprolol Succinate XL 50 mg PO DAILY
10. Montelukast Sodium 10 mg PO DAILY
11. Multivitamins W/minerals 1 TAB PO DAILY
12. Omeprazole 40 mg PO DAILY
13. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain
14. Valsartan 320 mg PO DAILY
15. Albuterol Inhaler 2 PUFF IH Q4H:PRN sob/wheezing
16. Calcium 500 + D (D3) (calcium carbonate-vitamin D3) 500-125
mg-unit Oral BID
17. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN shortness of
breath
18. PredniSONE 40 mg PO DAILY
19. Azithromycin 500 mg PO Q24H
20. Furosemide 40 mg PO DAILY
21. Glargine 25 Units Breakfast
Insulin SC Sliding Scale using HUM Insulin
Discharge Medications:
1. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN shortness of
breath
2. ALPRAZolam 0.5 mg PO BID:PRN anxiety
3. Amlodipine 10 mg PO DAILY
4. Aspirin 81 mg PO DAILY
5. Fluoxetine 40 mg PO DAILY
6. Fluticasone Propionate NASAL 1 SPRY NU BID
7. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
8. Glargine 40 Units Breakfast
Humalog 14 Units Breakfast
Humalog 16 Units Lunch
Humalog 16 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
9. Metoprolol Succinate XL 50 mg PO DAILY
10. Montelukast 10 mg PO DAILY
11. Omeprazole 40 mg PO DAILY
12. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain
13. PredniSONE 30 mg PO DAILY Duration: 5 Doses
RX *prednisone 10 mg AS DIRECTED tablet(s) by mouth daily Disp
#*29 Tablet Refills:*0
14. Valsartan 320 mg PO DAILY
15. Benzonatate 100 mg PO TID:PRN cough
RX *benzonatate 100 mg 1 capsule(s) by mouth TID:PRN Disp #*42
Capsule Refills:*0
16. Dextromethorphan-Guaifenesin (Sugar Free) 5 mL PO Q6H:PRN
cough
RX *dextromethorphan-guaifenesin [Diabetic Tussin DM] 100 mg-10
mg/5 mL 5 mL by mouth Q6H:PRN Refills:*0
17. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
RX *sulfamethoxazole-trimethoprim [Bactrim] 400 mg-80 mg 1
tablet(s) by mouth daily Disp #*11 Tablet Refills:*0
18. Albuterol Inhaler 2 PUFF IH Q4H:PRN sob/wheezing
19. Calcium 500 + D (D3) (calcium carbonate-vitamin D3) 500-125
mg-unit Oral BID
20. Furosemide 40 mg PO DAILY
21. MetFORMIN (Glucophage) 500 mg PO DAILY
22. Multivitamins W/minerals 1 TAB PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnosis:
-acute asthma exacerbation
-acute kidney injury
Secondary Diagnosis:
-diabetes mellitus
-hypertension
-obstructive sleep apnea
-morbid obesity
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking care of you at the ___
___. You came to the hospital because of
shortness of breath which was due to an acute asthma
exacerbation in the setting of a recent viral illness. After
giving you medications to help with your breathing (steroids,
nebulizers, oxygen), your shortness of breath improved.
Please continue to monitor your blood sugars closely given that
we have placed you on higher doses of insulin than when you came
in. If your morning blood sugars are low, please be sure to
decrease your Lantus by 5 units and also decrease your
dinnertime insulin by 2 units.
Given your long history of asthma, you will need to be on a long
taper for your steroids. Please follow-up with the appointments
listed below and take your medications as instructed below.
Wishing you the best,
Your ___ team
Followup Instructions:
___
|
19723160-DS-37
| 19,723,160 | 22,731,122 |
DS
| 37 |
2192-02-23 00:00:00
|
2192-02-24 19:33:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
lisinopril / Iodinated Contrast Media - IV Dye /
hydrochlorothiazide
Attending: ___.
Chief Complaint:
Acute Asthma Exacerbation
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Patient seen and examined, agree with house officer admission
note by Dr. ___ ___
___ year old Female with a history of moderate-severe chronic
asthma, who presents with cough and wheezing. She has been
hospitalized but never intubated. The patient states she has a
baseline PEF of 400. The patient notes that starting the week
prior to admission she developed a URI, which was resolving, but
3 days prior to admission she developed worsening dyspnea on
exertion and wheezing. 2 days prior to admission she increased
her chronic prednisone from 10mg to 30mg. In addition she
greatly increased the use of her rescue inhaler. She has some
chills and sweats, but no outright fevers. She denies any sick
contacts. She notes that she does have a cough productive of
white sputum.
She also notes that she ran out of her amlodipine and ___ and
___ not taken them for 2 days prior to admission. In the ED her
initial vitals were 98.2, 109, 167/66, 24, 97%. In total she was
given 60mg of prednisone twice, montelukast, multiple
duonebs/albuterol, torsemide, and azithromycin in addition to
her regular medications. She was observed in the ED but
continued to fail with a low PEF of 250 and is being admitted.
Past Medical History:
1. Type 2 Diabetes
2. Asthma with frequent exacerbations requiring prednisone
treatment, no intubations.
3. Obstructive sleep apnea on CPAP at night for the last ___
years.
4. Hypertension
5. H/o CVA ___ years ago with right facial droop, previously
diagnosed as Bell's palsy
6. Morbid obesity
7. h/o left ophthalmic artery aneurysm (coiled ___, angiogram
___ suggest residual wedge)
8. CKD stage III with isolated microalbuminuria (currently
normal Cr)
9. Anemia, presumed anemia of chronic disease
10. Osteoarthritis.
11. GERD.
12. Diverticulosis.
13. Anxiety
14. Depression
15. Restless leg syndrome
16. h/o lower extremity cellulitis.
17. s/p cholecystectomy in ___
18. s/p C-section
19. bilateral knee arthritis
20. h/o severe allergic reaction (rash to ?HCTZ vs.
contact/photosensitivity)
Social History:
___
Family History:
Multiple other family members with asthma. There is no strong
family history of lung cancer or pulmonary emboli. No family
history of renal disease. Several of her children however, have
hypertension. Three of her brothers passed away from various
cancers. A sister had colon cancer. Her daughter had DM when
pregnant. Both parents died in the ___, from "old age."
Physical Exam:
PHYSICAL EXAM ON ADMISSION
Vitals: 98.5; 140/57, 79, 24 99% RA
General: Morbidly obese female. Alert, oriented, no acute
distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRLA
Neck: Supple, unable to appreciate JVD ___ obesity
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: b/l diffuse expiratory wheezes. No crackles/rhonchi
Abdomen: Obese. BS +. Non-tender. Unable to palpate for HSM.
SKIN: fungal rash right subaxillary area.
GU: No foley
Ext: Warm, well perfused. 1+ edema
Neuro: A&Ox3. Moving all extremities purposefully
PHYSICAL EXAM ON DISCHARGE:
VSS: 98, 164/83, 93, 26, 98%RA
GEN: NAD, Morbidly Obese
Pain: ___
HEENT: EOMI, MMM, - OP Lesions
PUL: B/L EE Wheezes
COR: RRR, S1/S2, - MRG
ABD: NT/ND, +BS, - CVAT
EXT: - CC, 1+ edema
NEURO: CAOx3, Motor ___ ___ Flex/Ext/Finger Spread
Pertinent Results:
LABS ON ADMISSION
___ 08:40PM BLOOD WBC-20.5* RBC-3.42* Hgb-10.0* Hct-32.4*
MCV-95 MCH-29.2 MCHC-30.9* RDW-14.7 RDWSD-51.1* Plt ___
___ 08:40PM BLOOD Neuts-91* Bands-0 Lymphs-8* Monos-1*
Eos-0 Baso-0 ___ Myelos-0 AbsNeut-18.66*
AbsLymp-1.64 AbsMono-0.21 AbsEos-0.00* AbsBaso-0.00*
___ 08:40PM BLOOD Hypochr-NORMAL Anisocy-OCCASIONAL
Poiklo-1+ Macrocy-OCCASIONAL Microcy-NORMAL Polychr-OCCASIONAL
Ovalocy-1+
___ 08:40PM BLOOD Glucose-332* UreaN-47* Creat-1.7* Na-141
K-4.8 Cl-99 HCO3-24 AnGap-23*
___ 08:40PM BLOOD CK(CPK)-136
___ 02:25AM BLOOD CK-MB-2 cTropnT-<0.01
___ 08:40PM BLOOD cTropnT-<0.01
___ 08:40PM BLOOD CK-MB-2 proBNP-171
___ 10:30PM BLOOD ___ pO2-39* pCO2-46* pH-7.40
calTCO2-30 Base XS-2
MICROBIO
___ 11:25 pm BLOOD CULTURE
Blood Culture, Routine (Pending):
IMAGING
CHEST (PA & LAT) Study Date of ___ 5:04 ___
IMPRESSION:
Suboptimal due to overlying soft tissue and underpenetration,
however, cardiac and mediastinal silhouettes are stable. Re-
demonstrated prominence of the central pulmonary vasculature
suggests pulmonary vascular engorgement without overt pulmonary
edema.
LABS ON DISCHARGE
___ 08:52AM BLOOD WBC-21.7* RBC-2.87* Hgb-8.5* Hct-27.2*
MCV-95 MCH-29.6 MCHC-31.3* RDW-15.5 RDWSD-53.8* Plt ___
___ 08:52AM BLOOD Glucose-77 UreaN-57* Creat-1.6* Na-142
K-4.1 Cl-104 HCO3-25 AnGap-17
___ 07:38AM BLOOD Calcium-9.6 Phos-4.6* Mg-2.7*
Brief Hospital Course:
___ y.o. F with a history of morbid obesity, asthma, OSA, T2DM,
and CKD who presents with shortness of breath for the last two
days.
#Acute asthma exacerbation: She had no evidence of pneuomonia on
CXR and no fevers despite having a leukocytosis. Leukocytosis
secondary to chronic prednisone use. She has history of frequent
asthma exacerbations and also has history of volume overload ___
CHF. Current episode secondary to asthma exacerbation as CXR
notable for pulmonary congestion, but not volume overload. She
was given saline nebs PRN, aggressive ipratroprium/albuterol
regimen, azithromycin, levofloxacin and steroids. Pulmonary
followed while patient was in-house. To note, patient has home
O2 (2L/min) for activity.
#Leukocytosis: Patient presented with an elevated WBC count.
Patient has a leukocytosis at baseline, secondary to
chronic steroid use. There was no evidence of infection during
admission (neg CXR and UA). She as also maintained on a high
dose steroid regimen that contributed to acute on chronic
elevation.
___ on CKD: Patient had elevated Cr, likely pre-renal in nature
during her stay. She responded to fluids, and was encouraged to
take more PO fluids.
#Chronic Diastolic HF: She was continued on torsemide and
valsartan until Cr began to increase. She was then taken off
torsemide, and we followed I/Os and weights. Once Cr resolved,
valsartan was restarted
#Hypertension:
Continued Amolodipine 10 mg daily. Continued Valsartan 320 mg
daily as above
#Anxiety:
Continued home medication
#CAD:
Continued Aspirin 81 mg daily
#Depression:
Continued Fluoxetine 40 mg daily and increased to 60 mg daily
prior to discharge. Scored PHQ-9 >20 and expressed struggle with
ongoing depression. No SI. Discussed with PCP ___ and in
agreement to increase fluoxetine from 40mg to 60mg daily.
#Allergies:
Continued on home fluticasone and loratadine
#GERD:
Continued on home Omeprazole 40 mg daily
#DMII:
Patient's blood glucose labile on high dose steroids during her
stay. Her glargine and Humalog ISS needed to UPTITRATED
significantly.
TRANSITIONAL ISSUES
===================
[]Patient had significant hyperglycemia sugars during admission
and lantus/Humalog ISS needed recurring adjustments ___
prednisone burst. She was stabilized on a regimen of increased
ISS and increased Lantus (increased to 75 from 40 but will be
discharging on 60 since already tapering prednisone). Upon
prednisone taper, these values will need careful adjustment to
avoid hypoglycemia.
[]Patient is currently prednisone taper, as directed by her
pulmonologist Dr. ___: she was on 5 days of 60 mg, and will be
on 7 days 40 mg; 7 days 30 mg; 7 days 20 mg and will be
maintained on that dose until patient seen by Dr. ___.
[]Fluoxetine was increased from 40->60mg in agreement with PCP.
___ benefit from talk therapy as well for ongoing depressive
symptoms.
[]She was taken off torsemide when her Cr bumped and her weight
was down. She is being discharged off of it. Please monitor
weight. Restart if gains >3lbs.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. PredniSONE 10 mg PO DAILY
2. phentermine 15 mg oral DAILY
3. Valsartan 320 mg PO DAILY
4. Tiotropium Bromide 1 CAP IH DAILY
5. ALPRAZolam 0.5-1 mg PO QHS:PRN Insomnia
6. Fluticasone Propionate NASAL 2 SPRY NU DAILY
7. Amlodipine 10 mg PO DAILY
8. orlistat 60 mg oral TID
9. Glargine 40 Units Breakfast
Insulin SC Sliding Scale using HUM Insulin
10. Ferrous Sulfate 325 mg PO DAILY
11. Montelukast 10 mg PO DAILY
12. Torsemide 40 mg PO DAILY
13. Multivitamins W/minerals 1 TAB PO DAILY
14. OxycoDONE (Immediate Release) 5 mg PO BID:PRN shoulder/knee
pain
15. Beclomethasone Dipro. AQ (Nasal) ___ puffs Other BID:PRN
asthma
16. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
17. Omeprazole 40 mg PO BID
18. Calcium Carbonate 500 mg PO DAILY
19. Aspirin 81 mg PO DAILY
20. Loratadine-D (loratadine-pseudoephedrine) ___ mg oral
DAILY:PRN nasal congestion
21. albuterol sulfate 90 mcg/actuation inhalation BID
22. Fluoxetine 40 mg PO DAILY
Discharge Medications:
1. ALPRAZolam 0.5-1 mg PO QHS:PRN Insomnia
2. Amlodipine 10 mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. Calcium Carbonate 500 mg PO DAILY
5. Ferrous Sulfate 325 mg PO DAILY
6. Fluticasone Propionate NASAL 2 SPRY NU DAILY
7. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
8. Montelukast 10 mg PO DAILY
9. Multivitamins W/minerals 1 TAB PO DAILY
10. Omeprazole 40 mg PO BID
11. OxycoDONE (Immediate Release) 5 mg PO BID:PRN shoulder/knee
pain
RX *oxycodone 5 mg 1 tablet(s) by mouth twice a day Disp #*6
Tablet Refills:*0
12. PredniSONE 40 mg PO DAILY Duration: 4 Doses
This is dose # 1 of 3 tapered doses
13. PredniSONE 30 mg PO DAILY Duration: 7 Doses
This is dose # 2 of 3 tapered doses
14. PredniSONE 20 mg PO DAILY Duration: 7 Doses
This is dose # 3 of 3 tapered doses
15. Valsartan 320 mg PO DAILY
16. albuterol sulfate 90 mcg/actuation inhalation BID
17. Beclomethasone Dipro. AQ (Nasal) ___ puffs Other BID:PRN
asthma
18. Loratadine-D (loratadine-pseudoephedrine) ___ mg oral
DAILY:PRN nasal congestion
19. orlistat 60 mg oral TID
20. phentermine 15 mg oral DAILY
21. Tiotropium Bromide 1 CAP IH DAILY
22. Fluoxetine 60 mg PO DAILY
23. Glargine 60 Units Breakfast
Insulin SC Sliding Scale using HUM Insulin
24. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN Worsening SOB not
responding to MDI
25. Chloraseptic Throat Spray 1 SPRY PO Q6H:PRN throat pain
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS
=================
Asthma exacerbation
Steroid induced Hyperglycemia
SECONDARY DIAGNOSIS
===================
Diabetes Mellitus Type II
Chronic kidney disease
Chronic Diastolic Heart Failure
Depression
Coronary artery disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Can ambulate with home O2 but is exhausted with
minimal exertion.
Discharge Instructions:
Dear Ms. ___,
You were admitted to ___ for an
asthma exacerbation. You were treated with prednisone, extra
nebulizer treatments and antibiotics. We also had to watch your
blood sugars closely because of the extra prednisone.
It has been a pleasure taking part in your care
Your ___ Team
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs.
Followup Instructions:
___
|
19723160-DS-39
| 19,723,160 | 21,729,359 |
DS
| 39 |
2192-07-23 00:00:00
|
2192-07-23 17:22:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
lisinopril / Iodinated Contrast Media - IV Dye /
hydrochlorothiazide
Attending: ___.
Chief Complaint:
DOE
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ w severely morbid obesity, asthma on chronic prednisone,
restrictive lung disease, CKD, HFpEF p/w DOE. She has had
progressive weight gain for several months. About 2 weeks ago
she saw her pulmonologist (___) for DOE and wheezing. She was
prescribed a Z pack and a pred taper. This led to some
improvement of her breathing but she noticed that breathing got
worse as her prednisone tapered back. She saw her PCP ___ ___
and was found to have an elevated creatining, so her PCP held
her torsemide x1 day and then decreased it to 10mg po BID. She
reports breathing has gotten progressively worse since then. She
reports worsening ___, orthopnea (baseline 3 to now 4 pillows),
PND, abdominal distention, early satiety. She has an
intermittently productive cough and some wheeze. She has chest
tightness without chest pain.
She denies fevers, chills, nausea, vomiting, diarrhea, ___
trauma, recent stasis, recent hospitalization, chest pain,
history of clots, malignancy, asymmetric leg swelling, sick
contacts, URI symptoms, urinary urgency, urinary frequency
(except that which is normal for her when she is on diuretics),
urinary incontinence.
She also reports L hip pain, which is constant and not clearly
with any aggravating or alleviating factors. Pain is lateral hip
and down the side of her leg. No numbness/tingling/weakness. Not
hot/red.
ROS otherwise negative 10 systems.
Presented to ED, 97.2 107 134/61 24 97%RA. Desatted to 79% when
went to bathroom. Cr 2.2 (baseline 1.6-1.8) and K 5.5. AG 15,
lipemic specimen. UA dirty (though asx) so given CTX. 80mg
furosemide, put out 700cc, and then another 800cc on reaching
the floor. CXR without pna, nebs, 30 prednisone, admitted to
medicine.
Pt reports her breathing is better since being in the ED.
Past Medical History:
1. Type 2 Diabetes
2. Asthma with frequent exacerbations requiring prednisone
treatment, no intubations.
3. Obstructive sleep apnea on CPAP at night for the last ___
years.
4. Hypertension
5. H/o CVA ___ years ago with right facial droop, previously
diagnosed as Bell's palsy
6. Morbid obesity
7. h/o left ophthalmic artery aneurysm (coiled ___, angiogram
___ suggest residual wedge)
8. CKD stage III with isolated microalbuminuria (currently
normal Cr)
9. Anemia, presumed anemia of chronic disease
10. Osteoarthritis.
11. GERD.
12. Diverticulosis.
13. Anxiety
14. Depression
15. Restless leg syndrome
16. h/o lower extremity cellulitis.
17. s/p cholecystectomy in ___
18. s/p C-section
19. bilateral knee arthritis
20. h/o severe allergic reaction (rash to ?HCTZ vs.
contact/photosensitivity)
Social History:
___
Family History:
no lung cancer/PE, per chart:
Multiple other family members with asthma. There is no strong
family history of lung cancer or pulmonary emboli. No family
history of renal disease. Several of her children however, have
hypertension. Three of her brothers passed away from various
cancers. A sister had colon cancer. Her daughter had DM when
pregnant. Both parents died in the ___, from "old age."
Physical Exam:
98.3 151/63 90 22 96%RA
very pleasant, obese woman, speaking in full sentences
NCAT
RRR, distant, no mrg audible, JVP not discernible ___ habitus
mild expiratory wheezing, distant, no crackles
obese, limited exam of abdomen ___ habitus but no obviously
pulsatile liver, ntnd
wwp, 2+ ___ to knees bilaterally
A&Ox3, L lateral rectus palsy and mild R facial nerve palsy
(both baseline) otherwise CNII-XII intact, ___ BUE/BLE, SILT
BUE/BLE
L hip with no pain on AROM/PROM, no erythema/induration,
negative SLR, negative crossed SLR, no pain with
internal/external rotation; tenderness over L greater trochanter
no rash
no foley on admission
pleasant affect
Pertinent Results:
___ 03:33PM ___ PO2-185* PCO2-36 PH-7.46* TOTAL
CO2-26 BASE XS-2 COMMENTS-GREEN TOP
___ 03:33PM LACTATE-2.1*
___ 03:25PM GLUCOSE-276* UREA N-56* CREAT-1.7* SODIUM-140
POTASSIUM-4.7 CHLORIDE-101 TOTAL CO2-23 ANION GAP-21*
___ 03:25PM cTropnT-<0.01
___ 03:25PM CALCIUM-9.2 PHOSPHATE-4.0 MAGNESIUM-2.3
___ 02:18PM ___ PO2-106* PCO2-33* PH-7.47* TOTAL
CO2-25 BASE XS-0
___ 02:18PM LACTATE-2.6*
___ 02:00PM GLUCOSE-233* UREA N-56* CREAT-1.7* SODIUM-138
POTASSIUM-6.9* CHLORIDE-99 TOTAL CO2-25 ANION GAP-21*
___ 02:00PM ALT(SGPT)-20 AST(SGOT)-42* ALK PHOS-50 TOT
BILI-0.3
___ 02:00PM cTropnT-<0.01 proBNP-249
___ 02:00PM CALCIUM-9.2 PHOSPHATE-4.4 MAGNESIUM-2.4
___ 10:43PM URINE COLOR-Yellow APPEAR-Hazy SP ___
___ 10:43PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-TR KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5 LEUK-LG
___ 10:43PM URINE RBC-2 WBC-45* BACTERIA-FEW YEAST-NONE
EPI-3
___ 09:00PM GLUCOSE-311* UREA N-59* CREAT-2.2* SODIUM-138
POTASSIUM-5.5* CHLORIDE-101 TOTAL CO2-22 ANION GAP-21*
___ 09:00PM ALT(SGPT)-19 AST(SGOT)-15 ALK PHOS-71 TOT
BILI-0.2
___ 09:00PM cTropnT-<0.01 proBNP-215
___ 09:00PM WBC-19.7* RBC-3.49* HGB-10.2* HCT-33.0*
MCV-95 MCH-29.2 MCHC-30.9* RDW-16.1* RDWSD-55.3*
EKG ST at 105, nl axis, nl intervals, LAE, no Qs, no ST changes,
no peaked Ts; unchanged from baseline
CXR
FINDINGS:
Since prior, there is no relevant interval change. Allowing for
image under penetration the lungs appear clear. Lung volumes
are low. Cardiomegaly is unchanged. Mediastinal contour is
stable. There is no large pleural effusion or pneumothorax.
IMPRESSION:
No relevant change in the appearance of the chest since ___.
Brief Hospital Course:
___ w diastolic heart failure combined obstructive (asthma on
pred, intermittent home O2 w activity) and restrictive lung dz,
possible component of aortic stenosis, morbid obesity, CKD,
recently treated for asthma exacerbation presents with
subacutely decompensated heart failure.
# acute on chronic hypoxemic respiratory failure ___:
# possibly due to volume overload: dry weight is not totally
clear, though is at a relatively stable weight. Nonetheless, her
exam on admission was concerning for volume overload. There is a
question of whether she has a component of AS on previous
sub-optimal echo. Her worsening of sxs/creatinine with
holding/reduction of her diuretic further supports the theory
that she is volume overloaded, as does her improvement with
diuretic (though also with nebs) in the ED. Her improvement in
Cr with diuresis also supports this theory. She denies dietary
indiscretions and seems honest in this. No worsening anemia, and
signs and symptoms point away from PE (and would not challenge
her with IV contrast given her allergy). No pneumonia on CXR.
Given the mild wheezing and course of prednisone/azithro, doubt
this is a longer lingering asthma exacerbation, so would not
uptitrate her downtitrated steroids at this time in order to
prevent worsening volume overload. Recent TSH wnl, no NSAIDs.
She improved with diuresis with IV Lasix and was ultimately
transitioned to her home torsemide dose.
# mixed obstructive and restrictive lung disease: last PFTs were
suboptimal but presume moderately severe asthma and likely
obesity related restriction.
- standing inhalers continued
- continued home Advair
- held home Spiriva while getting standing combivent
- continued home prednisone 10mg po qd
Pt also is deconditioned. During the hospitalization she
improved in that she started out as unable to get from bed to
commode without significant DOE and hypoxemia; by the day of
discharge she was able to walk in the hallway approx. 50-100 ft
without using accessory oxygen, with saturations in the 9295%
range.
# AoCKI: c/b hyperkalemia, baseline cr1.6-1.8, admit 2.2. Likely
cardiorenal, improving to baseline with diuresis. ___ resumed
ultimately with improvement in renal function to baseline.
# DM: blood sugars were quite labile, possibly in the setting of
ongoing steroid use. She is discharged on her prior home dose
of insulin.
# htn:
- cont home amlodipine, valsartan and torsemide.
# other chronic conditions: depression, allergic rhinitis,
insomnia
- continued home meds
Medications on Admission:
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Asthma exacerbation
Urinary tract infection
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You came to the hospital with shortness of breath. We believe
this was mostly because of your asthma. Please be sure to
continue taking your inhalers regularly. Also be sure and use
your CPAP whenever you sleep because of your sleep apnea.
You also had a mild urinary tract infection so we are giving you
an antibiotic (Bactrim), which you will take twice daily.
Followup Instructions:
___
|
19723350-DS-3
| 19,723,350 | 26,638,447 |
DS
| 3 |
2149-04-11 00:00:00
|
2149-04-12 10:13:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Seizure
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ year old right handed man with history of
autism/developmental delay, lumbar stenosis and osteoporosis who
presents with first time seizure. This afternoon, patient went
to an optometrist appointment. He was sitting in the waiting
room where he had a "full body seizure." This lasted
approximately 1 minute. No tongue biting, unsure about urinary
incontinence. When EMS arrived, patient "appeared postictal,"
was oriented to his name only and was agitated. Vitals at this
time were BP 130/80 HR 114 O2 98%. ___ was 187. En route to the
ED, patient became more verbal, but still agitated and somewhat
combative, attempting to get off of gurney. In the ED, patient
was temporarily placed in restraints and received 1 dose of
haldol. Mr. ___ has never had a seizure in the past. He
denies recent fever, cough, rhinorrhea, diarrhea, urinary
frequency/dysuria. No known sick contacts, but lives in a group
home. He has not had any recent head trauma nor any head trauma
in the past. Denies neck pain. No history of CNS infections.
No weight changes, no night sweats, no fevers, no headaches.
Does have autism and developmental delay unspecified. Last
colonoscopy was in ___, polyp was biopsied, unremarkable.
There is no family history of seizures. Per dad and step
mother, Mr. ___ is not quite at his baseline. He is more
sedated than usual and unable to answer questions which he could
normally answer in detail.
At baseline, he lives in a group home where he has been for ___
years, prior to that lived with his parents. He volunteers and
participates in several groups that meet monthly. Mr. ___
finished high school. He is quite functional and travels by
himself around the city. He speaks ___ fluently.
On neuro ROS, the pt denies headache, loss of vision, blurred
vision, diplopia, dysarthria, dysphagia, lightheadedness,
vertigo, tinnitus or hearing difficulty. Denies difficulties
producing or comprehending speech. 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:
Osteoporosis
Osteoarthritis
Lumbar stenosis at L4/5
BPH
Autism/developmental delay
Social History:
___
Family History:
No history of seizures, strokes, developmental delay
Physical Exam:
ADMISSION EXAM
Vitals: T 98.1 HR 89 BP 119/70 19 RR 100% RA
General: Awake, cooperative, NAD.
HEENT: NC/AT
Neck: Supple. No nuchal rigidity
Pulmonary: CTABL
Cardiac: RRR, no murmurs
Abdomen: soft, nontender, nondistended
Extremities: no edema, pulses palpated
Skin: no rashes or lesions noted.
Neurologic: (limited by pt's inability to follow all commands)
-Mental Status: Alert, oriented x 3. Answers questions tersely
but appropriately, does not give detailed history, parents
adding
information. Attentive, able to name ___ backward without
difficulty. Language is fluent with intact repetition and
comprehension. Normal prosody. There were no paraphasic
errors.
Pt. was able to name both high and low frequency objects.
Speech
was not dysarthric. Able to follow both midline and appendicular
commands. Pt. was able to register 3 objects and recall ___ at 5
minutes, ___ with prompting. There was no evidence of apraxia
or
neglect.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 3 to 2mm and brisk. VFF grossly full to
confrontation.
Funduscopic exam revealed no papilledema, exudates, or
hemorrhages.
III, IV, VI: Does not fully abduct to the left or right but not
very cooperative with exam, 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. Does not keep arms up to
check for pronator drift bilaterally. Does not cooperate for
formal strength testing but moves all extremities briskly and
symmetrically.
-Sensory: No deficits to light touch, cold sensation.
-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 bilaterally, unable to cooperate for heel to
shin.
-Gait: deferred
DISCHARGE EXAM
Alert awake and oriented. R esotropia at rest. Speech somewhat
dysarthric, baseline per patient. Naming is intact. Moves all
extremities equally antigravity but does not cooperate with
formal strength testing. Very slight right pronator drift.
Apraxia with rapid alternating movements
Pertinent Results:
___ 02:30PM BLOOD WBC-16.3*# RBC-4.98 Hgb-14.0 Hct-42.9
MCV-86 MCH-28.2 MCHC-32.7 RDW-12.6 Plt ___
___ 02:30PM BLOOD ___ PTT-28.7 ___
___ 02:30PM BLOOD Glucose-181* UreaN-14 Creat-1.2 Na-140
K-4.0 Cl-105 HCO3-21* AnGap-18
___ 02:30PM BLOOD ALT-17 AST-34 AlkPhos-75 TotBili-0.3
___ 02:30PM BLOOD Albumin-4.2 Calcium-9.2 Phos-1.6* Mg-2.4
___ 06:00AM BLOOD Calcium-8.6 Phos-3.0 Mg-2.4 Cholest-179
___ 06:00AM BLOOD %HbA1c-5.6 eAG-114
___ 06:00AM BLOOD Triglyc-62 HDL-53 CHOL/HD-3.4 LDLcalc-114
___ 02:30PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 02:53PM URINE Blood-NEG Nitrite-NEG Protein-30
Glucose-TR Ketone-10 Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
___ 02:53PM URINE Color-Yellow Appear-Clear Sp ___
___ 02:53PM URINE RBC-2 WBC-3 Bacteri-FEW Yeast-NONE Epi-0
___ 02:53PM URINE CastHy-9*
___ 02:53PM URINE Mucous-RARE
NCHCT: No acute intracranial hemorrhage or definite mass seen,
however MRI is more sensitive for the detection of intracerebral
masses. Prominence of the ventricles out of proportion to the
size of sulci however in the absence of prior it is difficult to
establish patient's baseline for ventricular size, given history
of developmental delay. Comparison with prior examinations would
be helpful to assess acuity.
CXR: No acute intrathoracic process.
MRI Brain with and without contrast: No evidence of acute
intracranial process, mass effect or abnormal enhancement.
Prominent lateral ventricles out of proportion to cerebral
sulci, may be related to central predominant cerebral volume
loss versus related/sequela of history of developmental delay.
No evidence of hydrocephalus.
Brief Hospital Course:
___ was admitted to the general neurology service, largely to
observe him and perform serial neurological examinations
following his presumed convulsion that occurred in the field. We
were not able to identify any obvious triggers for this seizure,
such as sleep deprivation, dehydration, infection, etc. He
remained well overnight and the following morning, he was back
to his baseline and he and his father were anxious to leave and
go back home.
We obtained an MRI of his brain to look for any possible seizure
focus, which identified no obvious lesion such as a
dysplasia/tumor/prior stroke, but did identify unusually large
ventricles (particularly the occipital horns), which is of
unclear significance, given his history of autism. An EEG was
done to look for interictal discharges or focal slowing, and the
formal read for this pending at this time. It did not identify
any seizures.
We decided ultimately that it was probably in his best interest
to remain on some anticonvulsant medication to prophylax against
seizures in the future. For him, possible risk factors include
his known autism spectrum diagnosis, age. We initiated therapy
with a starting dose of oxcarbazepine, and he will follow up
with Drs. ___ in the neurology clinics.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. This patient is not taking any preadmission medications
Discharge Medications:
1. Oxcarbazepine 300 mg PO BID
___ twice daily for 1 week, then 300mg twice daily ongoing
RX *oxcarbazepine 300 mg/5 mL 2.5mL suspension(s) by mouth twice
a day Disp #*1 Bottle Refills:*3
Discharge Disposition:
Home
Discharge Diagnosis:
Seizure
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Discharge Instructions:
Dear Mr. ___,
You were admitted to ___ under
the neurology service after having a seizure. We did an MRI of
your brain, which was normal, final read to follow. We also did
an EEG, we are also waiting for the final read on this. We do
think that you are at high risk for having another seizure and
so we have started you on a new medication called Trileptal. We
have also scheduled you for a follow up appointment in neurology
clinic.
Followup Instructions:
___
|
19723751-DS-4
| 19,723,751 | 27,548,820 |
DS
| 4 |
2179-03-06 00:00:00
|
2179-03-06 10:59:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Bactrim
Attending: ___.
Major Surgical or Invasive Procedure:
skin biopsy
attach
Pertinent Results:
Admission Labs:
===============
___ 11:00AM BLOOD WBC-17.9* RBC-4.30 Hgb-13.3 Hct-40.7
MCV-95 MCH-30.9 MCHC-32.7 RDW-12.2 RDWSD-42.4 Plt ___
___ 11:00AM BLOOD Neuts-77.2* Lymphs-13.7* Monos-5.1
Eos-2.9 Baso-0.3 Im ___ AbsNeut-13.79* AbsLymp-2.45
AbsMono-0.92* AbsEos-0.51 AbsBaso-0.06
___ 11:00AM BLOOD Glucose-80 UreaN-9 Creat-0.7 Na-136 K-4.7
Cl-97 HCO3-27 AnGap-12
___ 11:00AM BLOOD ALT-32 AST-40 LD(LDH)-293* AlkPhos-125*
TotBili-0.5
___ 11:00AM BLOOD Albumin-4.3
___ 06:09AM BLOOD Calcium-9.2 Phos-3.4 Mg-2.3
Pertinent Labs:
===============
___ 06:09AM BLOOD HBsAg-NEG HBsAb-POS HBcAb-NEG HAV Ab-POS*
___ 06:09AM BLOOD Trep Ab-NEG
___ 08:30AM BLOOD HIV Ab-NEG
___ 06:09AM BLOOD HCV Ab-POS*
___ 08:30AM BLOOD HCV VL-NOT DETECT
Imaging:
========
CXR:
Lungs are low volume with a parenchymal opacity in the right
middle lobe and lingula which could represent pneumonia. Heart
size is normal. There is no pleural effusion. No pneumothorax
is seen. Incidental note is made of a right-sided cervical rib.
Discharge Labs:
===============
Brief Hospital Course:
___ year old female with a past medical history of IVDU on
methadone and recent hand cellulitis treated with bactrim, who
presented with extensive rash.
# Rash: presented with papulovesicular rash spread throughout
body. She had been taking Bactrim up until a week prior to
admission. She reported no other new medications. She had no
lesions on palms or soles, and no mucous membrane lesions. She
had been taking Bactrim for a few weeks before the rash started.
DRESS syndrome was felt to be unlikely given no eosinophilia,
atypical lymphocytes, normal LFTs, and no fevers or
lymphadenopathy.
RPR and HIV serologies were sent to rule out atypical infectious
presentation and were negative. HCV Ab was positive with
negative VL consistent with her previously treated HCV.
Dermatology was consulted and performed biopsy. Results were
consistent with likely drug reaction, though id reaction was
unable to be fully ruled out. She was treated with topical
clobetasol with significant improvement in the rash. Dermatology
did not recommend systemic steroids given her improvement on
topical steroids alone.
# Pneumonia: found to have RML and lingual opacities on CXR. She
endorsed dyspnea and productive cough. She presented with
leukocytosis to 17, which may have been inflammatory in the
setting of severe rash but may have also been due to
pneumonia/infection. She was started on vancomycin and cefepime
in the ED, due
to recent hospital exposure (in ED). Antibiotics were eventually
narrowed to ceftriaxone and doxycycline (azithromycin avoided
due to concurrent methadone use). She completed 5 days of
antibiotics while hosptialized.
# Leukocytosis: WBC 17 on presentation, could reflect pneumonia
or ongoing rash.
Initially improved but now then again uptrended. She had no
fevers or signs
of new infection. Blood cultures were negative.
Some degree of recurrent leukocytosis may have been due to
systemic absorption of steroids.
# Chest pain: reported chest pain on admission. EKG was
unremarkable and troponin negative. Symptoms resolved
# History of IVDU
# Substance use disorder
Continued methadone at 81mg daily, dose confirmed with clinic.
QTc was monitored on methadone
# Asthma:
Continued home fluticasone and albuterol prn
Transitional Issues:
====================
- needs sutures removed around ___. Suture from derm biopsy and
located over L upper shoulder/back
- bactrim should be listed as an allergy
- per dermatology can continue clobetasol 5% cream BID until
___, then should decrease to BID QOD prn for another 7 days
- needs follow up in ___ clinic (their office will
arrange)
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Methadone 81 mg PO DAILY
2. Excedrin Migraine (aspirin-acetaminophen-caffeine) 250-250-65
mg oral unknown
3. Fluticasone Propionate 110mcg 2 PUFF IH BID
4. Albuterol Inhaler 2 PUFF IH Q4H:PRN dyspnea
Discharge Medications:
1. Clobetasol Propionate 0.05% Cream 1 Appl TP BID
RX *clobetasol 0.05 % apply to rash twice a day, on after ___
decrease to every other day as needed for 7 more days Refills:*0
2. HydrOXYzine 100 mg PO Q6H:PRN pruritus
RX *hydroxyzine HCl 50 mg 2 tablets by mouth every six (6) hours
Disp #*20 Tablet Refills:*0
3. Albuterol Inhaler 2 PUFF IH Q4H:PRN dyspnea
4. Excedrin Migraine (aspirin-acetaminophen-caffeine)
250-250-65 mg oral unknown
5. Fluticasone Propionate 110mcg 2 PUFF IH BID
6. Methadone 81 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Allergic/Drug rash
Pneumonia
Secondary:
History of Opiate use disorder on methadone
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You came in with a severe rash. We found that you had an
allergic reaction, most likely to the antibiotic you had taken
recently (bactrim). You should not take bactrim again in the
future, as this could cause another reaction.
You should continue using the clobetasol at home. You should
apply this cream twice a day every day until ___, ___.
After ___ you should decrease to every other day as needed
(instead of every day) until the rash completely resolved.
We also found that you had a pneumonia. We treated you with
antibiotics and the pneumonia resolved.
You will need your sutures removed (from the biopsy) when you
see Dr. ___ for follow up.
It was a pleasure taking care of you, and we are happy that
you're feeling better!
Followup Instructions:
___
|
19723798-DS-11
| 19,723,798 | 27,240,539 |
DS
| 11 |
2156-02-11 00:00:00
|
2156-02-11 16:16:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Levaquin / Latex / Bactrim / Ciprofloxacin / Statins-Hmg-Coa
Reductase Inhibitors
Attending: ___
Chief Complaint:
Diarrhea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with a history of renal transplant in ___, CABG, IDDM, HTN,
DVT on ASA 81 presenting with black diarrhea for ___ days with
___ episodes of liquid stool per day. The patient was diagnosed
with PNA last week at ___ Urgent Care, 7
days of azithro and cefuroxime. He still has a persistent cough
but has no fevers or weakness. The diarrhea began two days after
starting the cefuroxime and azithromycin and has stopped since
he
missed today's dose. Denies peto-bismol or any other ingestion.
Denies vomiting. Denies nausea, denies sick contact.
The patient denies dyschezia or tenesmus. No abd pain, n/v,
decreased or painful urination, no blood in urine. No HA, visual
changes, sore throat. No CP or SOB or lightheadedness. Of note,
3
weeks ago did have a renal bx with no obvious complications at
the time. At that visit on ___, pt was noted to have rising
creatinine above recent baseline but known collapsing FSGS on
recent biopsy with high risk for rapid disease progression.
Since the time of his admission, he has had no further episodes
of diarrhea.
In the ED, vitals were: 98.1 59 163/100 18 99% RA
Past Medical History:
- Hyperlipideia
- Type 1 diabetes
- Hypertension
- s/p anterior MI (DES to 100% ___ LAD stenosis)
- Ischemic cardiomyopathy (Last EF 40%)
- Chronic transplant nephropathy (baseline creatinine 2.5)
- Depression
- Hypothyroidism
- Erectile dysfunction
- Renal transplant in ___.
- DES to ___ LAD ___ ___.
- R shoulder surgery s/p MVA ___
- R hip labrum tear ___
Social History:
___
Family History:
Dad d. ___, h/o polio, multiple MIs first age ___.
Mom d. ___, Alzheimer's.
1 brother & 1 sister: A&W
1 daughter A&W. 1 son: DM
Physical ___:
========================
ADMISSION PHYSICAL EXAM
========================
GENERAL: WDWN, NAD, Cooperative
HEENT: NCAT, sclerae anicteric, moist mucous membranes
CV: RRR, s1/s2, no s3/s4, no m/r/g, peripheral pulse present,
skin warm and well perfused
PULM: CTAB, no rales/rhonchi/wheezing/stridor, no accessory mm.
use
ABDOMINAL: Nontender, nondistended, no rebound/guarding, no
peritonitic signs
GU: no CVAT
RECTAL: scant guaiac neg stool in vault.
MSK: Full ROM, no joint swelling, no erythema
EXTREMITIES: no c/c/e
NEURO: Alert, appropriate, freely moving all extremities
=========================
DISCHARGE PHYSICAL EXAM
=========================
General: Middle-aged man, well-nourished, in no distress
HEENT: Sclera anicteric, mucous membranes moist
Lungs: some scattered wheezes and bilateral bronchial breath
sounds
CV: Regular rate and rhythm, normal S1 + S2, no murmurs
Abdomen: soft, non-tender to palpation, mildly distended in all
four quadrants
Ext: Warm, well perfused, no edema of the legs
Neuro: Face grossly symmetric. Moving all limbs with purpose
against gravity. Not dysarthric.
Pertinent Results:
========================
ADMISSION LAB RESULTS
========================
___ 03:45PM BLOOD WBC-6.3 RBC-5.12 Hgb-14.9 Hct-48.1 MCV-94
MCH-29.1 MCHC-31.0* RDW-14.1 RDWSD-48.3* Plt ___
___ 03:45PM BLOOD Neuts-58.7 ___ Monos-7.7 Eos-3.3
Baso-0.5 Im ___ AbsNeut-3.68 AbsLymp-1.84 AbsMono-0.48
AbsEos-0.21 AbsBaso-0.03
___ 03:45PM BLOOD Plt ___
___ 03:45PM BLOOD Glucose-176* UreaN-27* Creat-3.4* Na-141
K-4.7 Cl-108 HCO3-19* AnGap-14
___ 03:45PM BLOOD ALT-12 AST-25 AlkPhos-111 TotBili-0.2
___ 03:45PM BLOOD estGFR-Using this
___ 03:45PM BLOOD ALT-12 AST-25 AlkPhos-111 TotBili-0.2
___ 03:45PM BLOOD Albumin-3.4*
=======================
DISCHARGE LAB RESULTS
=======================
___ 04:39AM BLOOD WBC-8.3 RBC-5.30 Hgb-15.5 Hct-50.2 MCV-95
MCH-29.2 MCHC-30.9* RDW-14.3 RDWSD-48.4* Plt ___
___ 06:13AM BLOOD ___ PTT-28.8 ___
___ 04:39AM BLOOD Glucose-67* UreaN-27* Creat-2.9* Na-144
K-4.7 Cl-109* HCO3-21* AnGap-14
___ 06:13AM BLOOD ALT-12 AST-26 LD(LDH)-224 AlkPhos-96
TotBili-0.3
___ 04:39AM BLOOD Calcium-8.8 Phos-3.7 Mg-1.9
___ 11:06AM BLOOD tacroFK-11.5
==============
MICRO DATA
==============
__________________________________________________________
___ 5:58 pm STOOL CONSISTENCY: LOOSE Source:
Stool.
OVA + PARASITES (Pending):
__________________________________________________________
___ 12:45 pm STOOL CONSISTENCY: NOT APPLICABLE
Source: Stool.
OVA + PARASITES (Pending):
__________________________________________________________
Time Taken Not Noted Log-In Date/Time: ___ 8:31 pm
STOOL CONSISTENCY: SOFT Source: Stool.
**FINAL REPORT ___
C. difficile PCR (Final ___:
NEGATIVE.
(Reference Range-Negative).
The C. difficile PCR is highly sensitive for toxigenic
strains of C.
difficile and detects both C. difficile infection (CDI)
and
asymptomatic carriage.
A negative C. diff PCR test indicates a low likelihood of
CDI or
carriage.
__________________________________________________________
___ 6:45 pm BLOOD CULTURE
Blood Culture, Routine (Pending): No growth to date.
__________________________________________________________
___ 5:45 pm BLOOD CULTURE
Blood Culture, Routine (Pending): No growth to date.
__________________________________________________________
___ 3:45 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
======================
IMAGING AND REPORTS
======================
CHEST X-RAY ___
IMPRESSION:
1. Moderate interstitial edema.
2. Hazy opacity in the right mid to lower lung may represent
underlying
infection.
3. New 7 mm nodular opacity in the left upper lung. Recommend
further
evaluation with nonemergent chest CT.
RENAL TRANSPLANT ULTRASOUND ___
IMPRESSION:
Abnormal intrarenal arterial waveforms within the mid and lower
pole of the transplanted kidney without antegrade diastolic
flow, new from prior.
Findings are concerning for transplant dysfunction and
correlation with recent biopsy results advised.
Brief Hospital Course:
PATIENT SUMMARY:
================
___ with a history of renal transplant in ___ with progressive
allograft failure, CAD s/p CABG, HFrEF, IDDM, HTN, DVT on ASA 81
presented with black diarrhea for ___ days with ___ episodes of
liquid stool per day in the setting of recent antibiotic
initiation for community acquired pneumonia and chronic
immunosuppression. Infectious workup was not revealing. Patient
likely experienced diarrhea due to antibiotics or viral
gastroenteritis. He was improving at time of discharge.
ACUTE PROBLEMS:
================
# ESRD s/p LURT ___
# Renal allograft failure
# ___ on CKD
Patient followed by Dr. ___. Per recent clinic note,
failing kidney allograft with multiple late stage findings on
biopsy which are severe including scarring and a collapsing form
of glomerular sclerosis. Patient with heavy proteinuria, and is
planning to be connected to a CKD/ESRD nephrologist for
consideration of HD initiation in the near future. On this
admission, his creatinine was elevated to 3.4 from a baseline of
about 3 in the setting of volume losses from diarrhea. He
improved with IV fluids. A renal transplant ultrasound was
consistent with intra-renal pathology. He was maintained on
Myfortic and tacrolimus. His tacro level was checked and was
still pending at the time of discharge. Creatinine at discharge
was improved to 2.9.
# Diarrhea
Patient presented with ___ days of ___ episodes of loose, black
stool. His hemoglobin was at baseline and stool guaiac was
negative. This diarrhea developed about a day after initiating
antibiotics for community acquired pneumonia (see below). This
was thought to be the most likely etiology, as C
diff/Norovirus/Stool cultures were all negative.
# Community acquired pneumonia
Patient was diagnosed with CAP one week prior to admission and
was on a course of azithromycin and cefuroxime. He subsequently
developed diarrhea. His antibiotics were finished during this
admission and he reported lingering cough but overall
improvement in his symptoms.
# Insulin-dependent diabetes mellitus
Insulin pump was managed by the patient. He is s/p failed islet
transplants over ___ years ago. ___ was consulted and
approved patient self-management of pump.
# HFrEF
# CABG
# S/P MVR
Followed by Dr. ___. Last echo ___ Moderate to severe left
ventricular systolic dysfunction EF 32%, most c/w ischemic
cardiomyopathy. Well-functioning mitral annuloplasty ring.
Trialed metoprolol and carvedilol outpatient but developed
dizziness. He declined trial of fractionated metoprolol while
in-house. He should follow up with Dr. ___ further
discussion.
CHRONIC ISSUES:
===============
# Hypertension
Normotensive here without valsartan or beta blocker.
OK to restart home valsartan at discharge.
# skin cancer
Patient has had multiple non melanoma skin cancers. Cant change
tacrolimus to mTOR inhibitor given that he has proteinuria. He
will continue to see dermatology regularly.
# OSA
Not on CPAP.
=========================
TRANSITIONAL ISSUES
=========================
[ ] New 7 mm nodular opacity in the left upper lung. Recommend
further evaluation with nonemergent chest CT.
[ ] Follow up with renal transplant as planned for further
discussion regarding initiation of dialysis.
[ ] Follow up with cardiology as planned for titration of beta
blockers for heart failure management.
[ ] Antibiotic course for CAP completed during admission
[ ] Follow up with PCP for resolution of diarrhea and
respiratory symptoms
#CODE: full presumed
#CONTACT: ___brother) ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Valsartan 80 mg PO DAILY
2. Ranitidine 150 mg PO DAILY
3. Mycophenolate Sodium ___ 360 mg PO BID
4. Tacrolimus 2 mg PO Q12H
5. Aspirin 81 mg PO DAILY
6. Sertraline 200 mg PO DAILY
7. Levothyroxine Sodium 100 mcg PO DAILY
8. chromium picolinate 200 mcg oral DAILY
9. Calcium Carbonate 1000 mg PO DAILY
10. Vitamin D 1000 UNIT PO DAILY
Discharge Medications:
1. Insulin Pump SC (Self Administering Medication)Insulin
Lispro (Humalog)
Target glucose: 80-180
2. Aspirin 81 mg PO DAILY
3. Calcium Carbonate 1000 mg PO DAILY
4. chromium picolinate 200 mcg oral DAILY
5. Levothyroxine Sodium 100 mcg PO DAILY
6. Mycophenolate Sodium ___ 360 mg PO BID
7. Ranitidine 150 mg PO DAILY
8. Sertraline 200 mg PO DAILY
9. Tacrolimus 2 mg PO Q12H
10. Valsartan 80 mg PO DAILY
11. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY:
-Acute kidney injury
SECONDARY:
-Chronic kidney disease
-Diarrhea secondary to medication
-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:
Dear Mr. ___,
It was a pleasure caring for you at ___
___.
WHY WERE YOU IN THE HOSPITAL?
- You were admitted to the hospital for several days of
diarrhea.
WHAT HAPPENED WHEN YOU WERE IN THE HOSPITAL?
- You were given IV fluids, which improved your kidney function.
- You were checked for infectious causes of diarrhea, but none
were identified.
WHAT SHOULD YOU DO AFTER YOU LEAVE THE HOSPITAL?
- Weigh yourself every morning. Call your doctor if your weight
increases by more than 3 pounds.
- 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:
___
|
19723933-DS-3
| 19,723,933 | 28,101,959 |
DS
| 3 |
2180-12-05 00:00:00
|
2180-12-05 14:02:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Amoxicillin
Attending: ___.
Chief Complaint:
osteomyelitis
Major Surgical or Invasive Procedure:
washout and drainage
bone biopsy
closure
History of Present Illness:
Mr. ___ is a ___ with history of left knee septic arthritis
and left thigh abscess s/p drainage, and type I diabetes
presents from ___ with concern for proximal tibia osteomyelitis,
myofascitis and abscess of the left calf. The patient reports
that he has had increasing left leg pain and swelling for the
past week without fevers, chills or other systemic symptoms.
The patient reports that at the end of ___, he began
experiencing left knee pain which typically was worst ___ the
morning and improved over the course of the day. He presented to
___ ___ early ___ where an x-ray demonstrated "a
chipped bone fracture of my knee". He was prescribed oxycodone
and ibuprofen and was instructed to rest. He developed
increasing erythema, edema, pain, fever to ___, and vomiting
one week later and presented to ___. An MRI was performed which
demonstrated a thigh abscess. An arthrocentesis was performed
which demonstrated septic arthritis. The patient was taken to
the OR for wash-out and drainage. A PICC was placed for
antibiotics. The patient was eventually transferred to ___ for
acute rehab. His physical therapy was limited by pain control.
The patient experienced increased edema of his lower extremity
last week. An ultrasound was performed which did not demonstrate
DVT. He progressively had increased erythema and edema of the
leg for the past week. His course of antiobiotics ended five
days prior to presentation. On ___, the patient underwent
repeat imaging at ___ and was told to proceed to
___ for further evaluation. There he was given vancomycin prior
to trasfer to ___. Reportedly, a 2x3 cm abscess within the
posterior tibialis muscle and surrounding myofasciitis with
evidence of proximal tibia osteomyelitis was demonstrated on
MRI.
The patient reports that his diabetes is moderately
well-controlled. He reports an episode of DKA at ___ a few
months ago, but has been stable since that time.
___ the ED, initial vital signs were 98.8 105 171/80 16 98%.
Initial labs demonstrated no leukocytosis, a mild anemia with
HCT 35% (unknown baseline), an unremarkable chem-7, a lactate
1.0, and a ESR of 35. UA was unremarkable. The patient was
evaluated by Ortho who recommended I&D ___ the morning. He was
given clindamycin and admitted to medicine.
Upon arrival to the floor, initial vital signs were 97.9 140/80
97 100%RA. The patient provided the above history. He was
without additional complaint.
Past Medical History:
Type I diabetes mellitus
Septic arthritis
Thigh abscess
Social History:
___
Family History:
Mother and grandparent with type I diabetes mellitus.
Physical Exam:
ADMISSION EXAM
Vitals: 97.9 140/80 97 100%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,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: Deferred
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema. LLE with edema from ankle to knee with previous surgical
sites healing, diffuse erythema, tenderness and warmth. No
crepitus. RLE unremarkable.
Neuro: CNs2-12 intact, motor function grossly normal
DISCHARGE EXAM
Vitals: 97.9 126-131/61-63 ___ 18 96% RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular 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: LLE wrapped ___ ACE bandage not removed. Toes warm.
Neuro: CNs2-12 intact, motor function grossly normal
Pertinent Results:
ADMISSION EXAM
___ 08:20PM BLOOD WBC-5.6 RBC-4.04* Hgb-11.3* Hct-36.0*
MCV-89 MCH-27.9 MCHC-31.3 RDW-13.6 Plt ___
___ 08:20PM BLOOD Neuts-57.8 ___ Monos-6.4 Eos-1.9
Baso-1.2
___ 08:20PM BLOOD ___ PTT-31.3 ___
___ 08:20PM BLOOD Glucose-255* UreaN-18 Creat-0.8 Na-135
K-4.7 Cl-96 HCO3-29 AnGap-15
___ 06:12AM BLOOD Calcium-8.9 Phos-6.2* Mg-2.0
PERTINENT LABS AND STUDIES
___ 07:40AM BLOOD Vanco-3.4*
___ 08:29PM BLOOD Lactate-1.0
___ 08:20PM BLOOD ESR-35*
___ 06:12AM BLOOD ESR-67*
___ 09:00PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
___ 07:30AM BLOOD HBsAb-POSITIVE
___ 07:05AM BLOOD CRP-160.2*
___ 07:30AM BLOOD HIV Ab-NEGATIVE
___ 07:30AM BLOOD HCV Ab-NEGATIVE
DISCHARGE LABS
___ 07:58AM BLOOD WBC-3.4* RBC-3.56* Hgb-9.8* Hct-30.0*
MCV-84 MCH-27.5 MCHC-32.6 RDW-12.6 Plt ___
___ 07:58AM BLOOD Glucose-299* UreaN-12 Creat-0.7 Na-134
K-4.5 Cl-96 HCO3-30 AnGap-13
STUDIES
TEE ___
No spontaneous echo contrast or thrombus is seen ___ 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 ___
the descending thoracic aorta to 40cm from the incisors. The
aortic valve leaflets (3) appear structurally normal with good
leaflet excursion. No masses or vegetations are seen on the
aortic valve. No aortic valve abscess is seen. No aortic
regurgitation is seen. The mitral valve leaflets are
structurally normal. No mass or vegetation is seen on the mitral
valve. No mitral regurgitation is seen. No vegetation/mass is
seen on the pulmonic valve. There is no pericardial effusion.
IMPRESSION: No valvular vegetations or abscesses appreciated.
Normal biventricular global systolic function. Simple atheroma
___ the descending thoracic aorta.
BONE PATHOLOGY ___
1. Bone, left proximal tibia:
Fragments of bone with reactive changes and marrow fibrosis and
skeletal muscle with focal necrosis; no acute osteomyelitis.
2. Bone, left tibia:
Fragments of bone with reactive changes and marrow fibrosis and
skeletal muscle with focal necrosis; no acute osteomyelitis.
3. Bone, left proximal tibia:
Fragments of bone with reactive changes and marrow fibrosis and
skeletal muscle with focal necrosis; no acute osteomyelitis.
CXR ___
Normal heart, lungs, hila, mediastinum and pleural surfaces. No
radiopaque catheter is seen ___ the chest or included regions of
the upper extremities.
TIB/FIB XRAY ___
Four views of the left lower leg show heterogeneous
demineralization ___ the anterior upper tibia, but no periosteal
thickening, not the pattern of an established osteomyelitis. I
suggest the referring
physician to submit the outside MR scan for re-interpretation by
our
musculoskeletal division
MICRO
__________________________________________________________
___ 12:30 pm TISSUE LEFT TIBIA BONE.
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
TISSUE (Final ___: NO GROWTH.
ANAEROBIC CULTURE (Preliminary): NO GROWTH.
__________________________________________________________
___ 12:25 pm TISSUE LEFT TIBIA BONE (PROXIMAL).
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
TISSUE (Final ___: NO GROWTH.
ANAEROBIC CULTURE (Preliminary): NO GROWTH.
__________________________________________________________
___ 9:35 am ABSCESS LEFT CALF ABCESS.
GRAM STAIN (Final ___:
3+ ___ per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
3+ ___ per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS AND CLUSTERS.
WOUND CULTURE (Final ___:
STAPH AUREUS COAG +. SPARSE GROWTH.
SENSITIVITIES: MIC expressed ___
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN----------<=0.25 S
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- 4 R
OXACILLIN------------- 0.5 S
TETRACYCLINE---------- <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
ACID FAST SMEAR (Final ___:
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
ACID FAST CULTURE (Preliminary):
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
ANAEROBIC CULTURE (Final ___: NO ANAEROBES ISOLATED.
__________________________________________________________
___ 9:20 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
__________________________________________________________
___ 9:00 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
__________________________________________________________
___ 8:20 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
Brief Hospital Course:
___ with history of type I diabetes mellitus and septic
arthritis and thigh abscess now transferred from OSH with
concern for proximal tibia osteomyelitis, myofascitis and
abscess of the left calf, s/p 2 wash outs and subsequent
closure.
ACUTE CARE
#MSSA Osteomyelitis/soft tissue infection: Osteomyelitis seen on
MRI with elevated sed rate and CRP. Previously on cefazolin 1g
TID for MSSA ___. Patient empirically on ___
given vancomycin and clindamycin. His wound culture returned
with MSSA so he was placed back on cefazolin 2g q8h on ___. He
went to the OR with ortho ___ for wash out, ___ for washout
and bone biopsy; ___ close with primary intention. ID directed
management and would like to see patient ___ clinic and have
weekly lab checks during his cefazolin treatment. They will
determine when the course of the antibiotics can be completed
but it will be at least 6 weeks (approximately ___. Due to
the abnormal appearance of the patient's initial MRI, radiology
did recommend repeat MRI once the osteomyelitis has resolved to
be sure that there is no underlying abnormality of the bone.
#MSSA Bacteremia: one positive MSSA blood culture last month at
___ and no evaluation was done for endocarditis. TEE negative on
___. Treatment with cefazolin as for septic joint/abscess.
#Hx of IVDA: HIV, Hep C negative; Hep B immune.
# Pain: Initially on Dilaudid PCA while he was ___
and with wound vac ___ place. Then, transitioned successfully to
oral medications. Of note, despite the patient's history of
IVDA, the patient was very appropriate and considerate. We were
not concerned for pain-seeking and he was amenable to
appropriate decreases ___ his pain medications. He was maintained
on an aggressive bowel regimen and last BM was one day prior to
discharge.
#Diabetes: History of type I diabetes mellitus. HgA1c
approximately 10% at ___ per records. On glargine and humalog
standing at home with HISS as well, but has needed more insulin
recently ___ setting of infection and has been hyperglycemic with
intermittent hypoglycemia while inpatient. Thus, he was on
glargine 55 units at night (glargine was 70U at time of d/c from
___ but baseline prior to infection was 40) and a humalog
sliding scale combined with humalog 20U with meals standing. He
is being transitioned back to Aspart on discharge (Aspart is non
formulary here).
TRANSITIONS ___ CARE
# Code: Full
# Emergency Contact: ___ (fiance) ___
# PENDING STUDIES: tissue and abscess cultures
# ISSUES TO DISCUSS AT FOLLOW UP:
- weekly cbc+Diff, basic metabolic panel, lfts, esr/crp which
should be faxed to ___.
- continue cefazolin for at least 6 weeks (to be discussed with
ID at follow up)
- consider repeat MRI of leg once osteomyelitis has cleared.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Glargine 70 Units Bedtime
aspart 30 Units Breakfast
aspart 30 Units Lunch
aspart 30 Units Dinner
2. Acetaminophen 1000 mg PO Q8H:PRN pain
3. CefazoLIN 1 g IV Q8H
4. DiphenhydrAMINE 25 mg PO HS:PRN itch
5. Docusate Sodium 100 mg PO BID:PRN constipation
6. Ibuprofen 800 mg PO Q8H
7. Lisinopril 40 mg PO DAILY
8. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
Discharge Medications:
1. Outpatient Lab Work
Please check weekly cbc+Diff, basic, lfts, esr/crp and fax to
___.
2. Acetaminophen 1000 mg PO Q6H:PRN pain/fever
3. CefazoLIN 2 g IV Q8H
4. DiphenhydrAMINE 25 mg PO HS:PRN itch
5. Docusate Sodium 100 mg PO BID:PRN constipation
6. Glargine 55 Units Bedtime
aspart 15 Units Breakfast
aspart 15 Units Lunch
aspart 15 Units Dinner
Insulin SC Sliding Scale using aspart Insulin
7. OxycoDONE (Immediate Release) ___ mg PO Q2H:PRN pain
RX *oxycodone 5 mg ___ tablet(s) by mouth every 2 hours Disp
#*30 Tablet Refills:*0
8. Bisacodyl 10 mg PO/PR DAILY:PRN constipation
9. Heparin Flush (10 units/ml) 2 mL IV DAILY and PRN, line flush
10. Nicotine Patch 7 mg TD DAILY
11. Senna 1 TAB PO BID
12. OxyCODONE SR (OxyconTIN) 20 mg PO Q8H
RX *oxycodone [OxyContin] 20 mg 1 tablet extended release 12
hr(s) by mouth every eight (8) hours Disp #*10 Tablet Refills:*0
13. Milk of Magnesia 30 mL PO Q6H:PRN constipation
14. Heparin 5000 UNIT SC TID
15. Lisinopril 40 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
primary diagnosis:
osteomyelitis
abscess
secondary diagnosis:
type 1 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. ___,
You were admitted to ___ with a bone infection of your leg.
You underwent surgeries to treat this problem. You are being
discharged on antibiotics which you should continue and follow
up with the infectious disease doctors.
It was a pleasure taking care of you. We wish you all the best.
Please be sure to follow with your physicians and take your
medications as directed. You do need to get your labs checked
weekly and faxed to the infectious disease doctors ___ are
on antibiotics.
Followup Instructions:
___
|
19724101-DS-10
| 19,724,101 | 20,918,473 |
DS
| 10 |
2122-07-08 00:00:00
|
2122-07-08 17:17:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Hydroxychloroquine
Attending: ___
Chief Complaint:
headache
Major Surgical or Invasive Procedure:
Lumbar puncture ___
History of Present Illness:
___ h/o SLE, occipital neuralgia presents to ED with ___
posterior headache, nausea, anorexia and fever. She was seen in
the ED ___ for chronic headaches; CBC was unrevealing but
UA showed RBC's and WBC's; she may have been menstruating. She
was treated with ketorolac, zofran and IVF and discharged home.
Today she went to ___ clinic with ongoing headache and
came back to the ED this pm ___.
Earlier today she was seen in her student health clinic and had
a temp of 100.3 and she was sent to ___ clinic. In ___
clinic today her biggest complaint was her posterior headache
"like someone punched me in the head"; this was similar to the
pain she had during her ___ lupus admission; at that time she
had associated fevers and mental status changes and responded to
steroids. She noted the headache has been ongoing, but more
severe the last 2 days with increased joint pain despite 15mg
prednisone daily. Previously she has seen neurology and pain
mgmt for her headaches and they did not respond to soft collar
or occipital nerve block; MRV was negative.
In review of her record, her course has been complicated by
probably neuropsychiatric lupus, MSSA bacteremia, possible
endocarditis, splenic infarct (ACL and APL negative, only on
aspirin).
In the ED initial vitals were:
Triage 14:58 7 100.2 96 107/68 18 99% ra
- Labs were significant for
WBC 5.1, Hgb 11.5, plt 202
urine >186 RBC's, 28 WBC's
LP was performed, opening pressure was 23.5cm h2o, protein 27
glu 43, no cells
CXR - no acute process
- Patient was given 1L NS and 5mg morphine
Vitals prior to transfer were: Today 20:48 5 99.3 94 95/53 15
100% RA
On the floor, vitals 99.5 104/57 54 18 98%RA. Patient reports
some ongoing headache with waking up, similar to admission. She
notes that this headache and all of her symptoms had originally
improved following occipital nerve block on ___ but have now
returned with worsening symptoms
Past Medical History:
MSSA bacteremia
SLE
splenic infarct
occipital neuralgia
Social History:
___
Family History:
unknown, adopted
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals - 99.5 104/57 54 18 98%RA
GENERAL: alert, oriented x 3, soft spoken
HEAD: normocephalic, atraumatic, no meningismus
EYES: EOMI, conjunctiva clear, no scleral icterus or injection.
Some pain with looking upward
ENT: oropharynx without ulcers or exudates, mucous membranes
moist, lips and gingiva without lesions.
NECK: no masses, supple.
RESPIRATORY: CTAB
CARDIOVASCULAR: RRR, normal S1 & S2, no murmurs.
GI: soft, non distended, normal bowel sounds. No abdominal
tenderness.
EXTREMITIES: no edema; warm and well perfused; no nail capillary
ectasia
NEUROLOGIC: muscle strength ___ all extremities, mental status
normal.
SKIN: warm and dry, no lesions, no rash.
MUSCULOSKELETAL: No swelling of finger joints, wrist, knees or
ankles, mild ttp over left shin anteriorly
DISCHARGE PHYSCIAL EXAM:
Vitals- T 97.9, BP 95/59 (SBP 89-103), HR 62, RR 18, 100%RA
General- wakes easily to voice, alert and oriented
HEENT- Sclerae anicteric, MMM
Lungs- Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV- Regular rate and rhythm, normal S1 + S2, S2 splits with
inspiration, no murmurs, rubs, gallops
Abdomen- +BS, mild LUQ tenderness to deep palpation, no guarding
or rebound
GU- no foley
Ext- warm, no clubbing, cyanosis or edema. no swelling, warmth
or erythema of the small joints of the hands and feet, good ROM
Skin- no rash
Neuro- CNs2-12 intact, moving all extremities equally, following
commands appropriately, gait observed and is normal
Pertinent Results:
ADMISSION LABS:
___ 06:01PM BLOOD WBC-5.1 RBC-3.88* Hgb-11.5* Hct-35.7*
MCV-92 MCH-29.6 MCHC-32.1 RDW-15.8* Plt ___
___ 06:01PM BLOOD Neuts-86.8* Lymphs-6.2* Monos-6.2 Eos-0.4
Baso-0.4
___ 06:01PM BLOOD Glucose-76 UreaN-12 Creat-0.7 Na-140
K-4.1 Cl-105 HCO3-25 AnGap-14
___ 06:01PM BLOOD Calcium-9.3 Phos-3.9 Mg-2.4
___ 06:07PM BLOOD Lactate-1.0
___ 04:05PM URINE Color-Red Appear-Hazy Sp ___
___ 04:05PM URINE Blood-LG Nitrite-NEG Protein-30
Glucose-NEG Ketone-40 Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-MOD
___ 04:05PM URINE RBC->182* WBC-28* Bacteri-FEW Yeast-NONE
Epi-1
___ 04:05PM URINE UCG-NEGATIVE
___ URINE URINE CULTURE-PENDING INPATIENT
___ BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
___ 06:43PM CEREBROSPINAL FLUID (CSF) WBC-0 RBC-0 Polys-0
___ ___ 06:43PM CEREBROSPINAL FLUID (CSF) TotProt-27 Glucose-43
___ 06:43PM CEREBROSPINAL FLUID (CSF) HERPES SIMPLEX VIRUS
PCR-PND
___ CSF;SPINAL FLUID GRAM STAIN-FINAL NEG; FLUID
CULTURE-PRELIMINARY; Enterovirus Culture-PRELIMINARY
___ 18:43 MULTIPLE SCLEROSIS (MS) PROFILE PND
___ 18:43 ANTI-RIBOSOMAL P PROTEIN PND
___ 18:43 HERPES SIMPLEX VIRUS PCR PND
IMAGING:
CXR ___
There is no focal consolidation, effusion, or pneumothorax. The
cardiomediastinal silhouette is normal. Imaged osseous
structures are intact. No free air below the right
hemidiaphragm is seen.
IMPRESSION: No acute intrathoracic process.
Brief Hospital Course:
___ with SLE presents with acute on chronic headache and low
grade fevers concerning for lupus flare.
#Occipital Headache: patient presented with several days of
acute on chronic occipital headaches and low grade fevers.
Thought to be most likely from mild SLE flare with volume
depletion, less likely SLE with CNS involvement. Medication
effect possible (rare side effect of MTX), or catamenial
migraine, giving concurrence with menstruation. Higher dose of
prednisone started on day of admission by outpatient
rheumatologist was continued, and she was treated with standing
moderate dose acetaminophen with good effect. She was seen by
rheumatology here who agreed with the plan. She will see Dr.
___ again in clinic on ___. CSF cultures and HSV
pending at discharge.
#Systemic lupus erythematosus: Diagnosed by ___, dsDNA, Sm last
year. Clinical manifestations have included hair loss, fever,
weight loss (now gaining on steroids), arthralgias,
leukopenia/anemia, malar rash, and altered mental status in the
setting of MSSA bacteremia and tricuspid valve vegetation, as
well as splenic infarct. No clear inflammatory arthritis on
exam, and CSF was bland with normal protein, arguing against CNS
involvement. Continues to have arthralgias; did not respond to
MTX, NSAIDs or low dose prednisone. UA this admission was with
___'s however she is menstruating. TPMT level normal from
___. Complement levels stable on ___. Increased
prednisone and seen by rheumatology as discussed above. She
underwent head MRI with contrast that showed no abnormalities.
Rheumatology would like her to start Cellcept as an outpatient.
She will follow up in clinic tomorrow.
# Hypotension: Most likely baseline low BP in this young, thin
female. OMR review reveals SBP 90-110 consistently. She is not
tachycardic or orthostatic by syptoms, does not appear septic.
Recieved a total of 3 liters of IVF.
TRANSITIONAL ISSUES:
-Emergency contact: uncle ___ ___
-___, urine, CSF cultures pending at discharge, as well as HSV
pcr from CSF, MULTIPLE SCLEROSIS (MS) PROFILE
-Has follow up with rheum on ___
-Note: Not enough CSF to run Anti-ribosomal P protein
-Rheum is consideringn staring cellcept but needs to be
discussed further with patient in ___ tomorrow
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. PredniSONE 15 mg PO DAILY (changed to 40mg daily on day of
admission)
2. Aspirin 81 mg PO DAILY
3. Gabapentin 900 mg PO HS
4. Pantoprazole 40 mg PO Q24H
5. Ascorbic Acid ___ mg PO DAILY
6. biotin 1 mg oral daily
7. calcium carbonate-vitamin D3 500 mg(1,250mg) -400 unit oral
BID
8. Ferrous Sulfate 325 mg PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Gabapentin 900 mg PO HS
3. Pantoprazole 40 mg PO Q24H
4. PredniSONE 40 mg PO DAILY
RX *prednisone 10 mg 4 tablet(s) by mouth every morning Disp
#*40 Tablet Refills:*0
5. Acetaminophen 650 mg PO Q6H:PRN fever, headache
RX *acetaminophen 325 mg 2 tablet(s) by mouth every 6 hours Disp
#*90 Tablet Refills:*0
6. Ascorbic Acid ___ mg PO DAILY
7. biotin 1 mg oral daily
8. calcium carbonate-vitamin D3 500 mg(1,250mg) -400 unit oral
BID
9. Ferrous Sulfate 325 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: headaches, fevers
Secondary: systemic lupus erythematosus
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure caring for you at ___. As you know, you were
admitted with low fevers and headache. A lumbar puncture (spinal
tap) did not show any signs of infection or inflammation. An MRI
of your head was normal. Your steroids were increased according
to the recommendation of your rheumatologist, and the
rheumatologists here also saw you. Please continue to follow up
with them in clinic tomorrow, and with your kidney doctor as
well.
Followup Instructions:
___
|
19724101-DS-13
| 19,724,101 | 29,774,312 |
DS
| 13 |
2123-12-01 00:00:00
|
2123-12-01 09:46:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Hydroxychloroquine / tacrolimus
Attending: ___.
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ w/SLE presenting with n/v/d, RUQ abd pain, and extremity
swelling. Pt was started on Mycophenolate mofetil 5 days ago.
She developed nausea/vomiting, diarrhea, and RUQ pain after
starting new medication. Nausea persisted despite Zofran,
leading to decreased PO intake. She discussed symptoms with
primary rheum who advised her to stop the myfortic, increase
prednisone and present to ED if symptoms worsened. She began to
feeling lightheaded and GI symptoms persisted prompting her to
present to ED. RUQ pain is intermittent, sharp and
non-radiating. Not associated with eating. She also reports 2
days of mild swelling in her bilateral upper and lower
extremities. No associated pain. Swelling is symmetric. No
history DVT or PE.
In ED pt given 1Lns, tramadol, Tylenol, Zofran, prednisone 20mg.
ROS: +as above, otherwise reviewed and negative
Past Medical History:
SLE with lupus nephritis
Hx of MSSA bacteremia
Hx of splenic infarct
occipital neuralgia
Social History:
___
Family History:
unknown, adopted
Physical Exam:
=================
ADMISSION EXAM:
.
Vitals: T:97.8 BP:118/72 P:69 R:16 O2:10%ra
PAIN: 6
General: nad
EYES: anicteric
Lungs: clear
CV: rrr no m/r/g
Abdomen: bowel sounds present, soft, nt/nd
Ext: no e/c/c
Skin: no rash
Neuro: alert, follows commands
.
=================
DISCHARGE EXAM:
.
Tm - 98.3 Tc - 97.3 BP - 97/63 HR - 70 RR - 15 pOx - 99% on
RA
General: nad
EYES: anicteric, EOMI
ENT: no ___ or oral lesions
Lungs: clear to auscultation and percussion bilaterally
CV: rrr, no m/r/g, s1s2 present
Abdomen: bowel sounds present, soft, and nt/nd in all quadrants
MSK: grossly normal aROM, no joint effusions noted in fingers,
hands, or feet
Ext: no e/c/c
Skin: no rash
Neuro: AAOx3, follows commands
Pertinent Results:
=================
Admission Labs:
.
___ 05:35PM WBC-4.5 RBC-4.22 HGB-12.3 HCT-38.9 MCV-92
MCH-29.1 MCHC-31.6* RDW-12.5 RDWSD-41.4
___ 05:35PM NEUTS-86* BANDS-2 LYMPHS-5* MONOS-5 EOS-0
BASOS-0 ___ METAS-1* MYELOS-1* AbsNeut-3.96 AbsLymp-0.23*
AbsMono-0.23 AbsEos-0.00* AbsBaso-0.00*
___ 05:35PM CRP-0.1
___ 05:35PM GLUCOSE-83 UREA N-11 CREAT-0.6 SODIUM-139
POTASSIUM-5.2* CHLORIDE-105 TOTAL CO2-23 ANION GAP-16
___ 05:35PM ALT(SGPT)-23 AST(SGOT)-37 ALK PHOS-39 TOT
BILI-0.2
___ 05:35PM LIPASE-41
___ 05:35PM ALBUMIN-4.3 CALCIUM-9.7 PHOSPHATE-3.5
MAGNESIUM-2.3
___ 05:00PM URINE UCG-NEGATIVE
___ 05:00PM URINE COLOR-Straw APPEAR-Clear SP ___
___ 05:00PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
___ 05:00PM URINE RBC-1 WBC-2 BACTERIA-FEW YEAST-NONE
EPI-1 TRANS EPI-<1
=================
Other Notable Labs:
.
___ 05:35PM BLOOD CRP-0.1
___ 07:16PM BLOOD dsDNA-POSITIVE *
___ 05:41AM BLOOD C3-48* C4-7*
=================
Discharge LABS:
.
___ 05:41AM BLOOD WBC-4.1 RBC-4.04 Hgb-11.7 Hct-37.1 MCV-92
MCH-29.0 MCHC-31.5* RDW-12.3 RDWSD-41.4 Plt ___
___ 05:41AM BLOOD Glucose-83 UreaN-14 Creat-0.7 Na-140
K-3.5 Cl-104 HCO3-26 AnGap-14
=================
Imaging:
.
___ RUQ u/s
IMPRESSION: Normal right upper abdominal ultrasound. Normal
gallbladder.
___ CXR (PA & lat)
FINDINGS: Heart size is normal. The mediastinal and hilar
contours are normal. The pulmonary vasculature is normal. Lungs
are clear. No pleural effusion or pneumothorax is seen. There
are no acute osseous abnormalities.
IMPRESSION: No acute cardiopulmonary abnormality.
Brief Hospital Course:
Ms. ___ is a ___ w/SLE w/ lupus nephritis who presented with
n/v/d and RUQ pain in setting of recently starting two new home
meds (myfortic and quinacrine). RUQ u/s was wnl. LFTs and
lipase were also wnl. The Rheumatology service was consulted.
Her symptoms improved with conservative therapy, including
holding both myfortic and quinacrine. She was continued on
prednisone 40 mg PO daily per Rheumatology recommendations.
Complement levels were checked and were low. dsDNA was checked
and was positive, with a titer of 1:640, which was higher than
the last titer checked on ___ (which was 1:320). CRP was
wnl at 0.1. Urine Pr/Cr ratio was stable compared to prior
results at 1.8. On the day of discharge she was tolerating a
normal diet with no abdominal pain, nausea, vomiting or
diarrhea. She will continue to follow up in ___
clinic, and her next appointment is later today.
.
.
# Time in care: 35 minutes spent on discharge-related activities
on the day of discharge.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 1000 mg PO TID:PRN pain
2. Ascorbic Acid ___ mg PO DAILY
3. Gabapentin 900 mg PO QHS
4. Pantoprazole 40 mg PO Q24H
5. PredniSONE 40 mg PO DAILY
6. Calcium 500 + D (calcium carbonate-vitamin D3) 500
mg(1,250mg) -400 unit oral BID
7. FeroSul (ferrous sulfate) 325 mg (65 mg iron) oral DAILY
8. TraMADOL (Ultram) 50 mg PO BID:PRN pain
9. Lisinopril 2.5 mg PO DAILY
10. quinacrine (bulk) 100 mg PO DAILY
11. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Acetaminophen 1000 mg PO TID:PRN pain
2. Ascorbic Acid ___ mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. Gabapentin 900 mg PO QHS
5. Lisinopril 2.5 mg PO DAILY
6. Pantoprazole 40 mg PO Q24H
7. PredniSONE 40 mg PO DAILY
8. TraMADOL (Ultram) 50 mg PO BID:PRN pain
9. Calcium 500 + D (calcium carbonate-vitamin D3) 500
mg(1,250mg) -400 unit oral BID
10. FeroSul (ferrous sulfate) 325 mg (65 mg iron) oral DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Abdominal pain
Nausea and vomiting
SLE
Lupus nephritis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were admitted to the hospital with persistent abdominal
pain, nausea, and vomiting, which was thought to be due to one
of your medications. That medication was discontinued, and you
symptoms improved. You will need to continue to follow up with
your primary Rheumatology team regarding continued treatment of
your SLE and lupus nephritis.
Followup Instructions:
___
|
19724101-DS-14
| 19,724,101 | 23,102,109 |
DS
| 14 |
2124-09-15 00:00:00
|
2124-09-16 15:54:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Hydroxychloroquine / tacrolimus / mycophenolate sodium /
Myfortic / quinacrine
Attending: ___
Chief Complaint:
Pain with inspiration, Headache
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ yo woman with SLE on chronic prednisone,
azathioprine, and Belimumab who presents with two days of
progressive pain with inspiration and headache.
She states she has been feeling generally fatigued to the last
month. She has had continued joint pain for which she was
started on Belimumab. Her rheumatologist has been trying to wean
her off prednisone but has been unable to get below 15 mg a day.
Two days ago she felt a gradual worsening of pain with
inspiration. She then began to feel slightly shortness of
breath. She denies ever having these symptoms before. She
endorses mild fevers. She denies any sick contacts.
She has had several lupus flairs over the past ___ years. They
typically present with pain in her joints and severe headache.
She has never had an episode like this one. She denies missing
any of her medications. She denies any new rashes. She called
her rheumatologist who referred her to the ED.
In the Ed vitals were T 97.0, HR 110, BP 154/76, RR18, O2Sat
100% RA. Labs were sent which showed a normal WBC of 6.0,
lactate of 1.2, CXR was without abnormality. Flu swab was
negative. She was given Tylenol, ibuprofen, 1L IVF, and
potassium and sent to the floor for rheumatology consult.
On the floor she states she is already feeling better. Her
headache is improving and the pain with inspiration is now a
___. She feels very tired.
ROS:
Positives on review of systems:
All other systems reviewed and negative.
For further specific detail, pt denies: visual changes,
numbness/weakness, , nausea, vomiting, abdominal pain,
diarrhea, bleeding, rash
Past Medical History:
SLE with lupus nephritis
Hx of MSSA bacteremia
Hx of splenic infarct
occipital neuralgia
Social History:
___
Family History:
Unknown, adopted
Physical Exam:
On Admission
VS: Afebrile and vital signs stable (reviewed in bedside
record)
General Appearance: pleasant, comfortable, no acute distress
Eyes: PERLL, EOMI, no conjuctival injection, anicteric
ENT: no sinus tenderness, MMM, oropharynx without exudate or
lesions, no supraclavicular or cervical lymphadenopathy, no JVD,
no carotid bruits, no thyromegaly or palpable thyroid nodules
Respiratory: CTA b/l with good air movement throughout
Cardiovascular: RR, S1 and S2 wnl, no murmurs, rubs or gallops
Gastrointestinal: nd, +b/s, soft, nt, no masses or HSM
Extremities: no cyanosis, clubbing or edema
Skin: warm, no rashes/no jaundice/no skin ulcerations noted
Neurological: Alert, oriented to self, time, date, reason for
hospitalization. Cn II-XII intact. ___ strength throughout.
No sensory deficits to light touch appreciated. No
pass-pointing on finger to nose. 2+DTR's-patellar and biceps.
No asterixis, no pronator drift, fluent speech.
Psychiatric: pleasant, appropriate affect
GU: no catheter in place
On Discharge
VS: 98.3 98/63 88 18 98% RA
Gen: Lying in bed, watching TV, comfortable appearing
Eyes: EOMI, PERRL
ENT: OP clear, MMM
Heart: RRR no mrg
Lungs: CTA bilaterally
Abdomen: Soft nontender, normoactive bowel sounds
MSK: No tenderness over the sternum
Skin: No rashes
Vasc: 2+ DP/radial pulses
Neuro: AOx3, moving all extremities with purpose
Psych: Calm, euthymic, appropriate
Pertinent Results:
On Admission:
___ 11:40PM URINE HOURS-RANDOM
___ 11:40PM URINE UHOLD-HOLD
___ 11:40PM URINE COLOR-Straw APPEAR-Clear SP ___
___ 11:40PM URINE BLOOD-LG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-SM
___ 11:40PM URINE RBC-162* WBC-24* BACTERIA-FEW YEAST-NONE
EPI-2
___ 11:40PM URINE MUCOUS-RARE
___ 08:21PM GLUCOSE-59* UREA N-7 CREAT-0.3* SODIUM-141
POTASSIUM-2.8* CHLORIDE-112* TOTAL CO2-16* ANION GAP-16
___ 08:21PM estGFR-Using this
___ 08:21PM LIPASE-24
___ 08:21PM ALBUMIN-2.9*
___ 08:21PM CRP-0.5
___ 08:21PM WBC-5.7 RBC-2.82*# HGB-8.8*# HCT-27.4*#
MCV-97 MCH-31.2 MCHC-32.1 RDW-13.2 RDWSD-46.9*
___ 08:21PM NEUTS-87.6* LYMPHS-4.9* MONOS-6.5 EOS-0.0*
BASOS-0.0 IM ___ AbsNeut-5.01 AbsLymp-0.28* AbsMono-0.37
AbsEos-0.00* AbsBaso-0.00*
___ 08:21PM PLT COUNT-211
___ 08:00PM LACTATE-1.2 TCO2-22
___ 05:58PM LACTATE-1.7 TCO2-19*
___ 05:50PM WBC-6.0 RBC-4.37 HGB-13.2 HCT-41.5 MCV-95
MCH-30.2 MCHC-31.8* RDW-13.2 RDWSD-46.0
___ 05:50PM NEUTS-86.1* LYMPHS-4.8* MONOS-8.0 EOS-0.0*
BASOS-0.3 IM ___ AbsNeut-5.15 AbsLymp-0.29* AbsMono-0.48
AbsEos-0.00* AbsBaso-0.02
___ 05:50PM PLT COUNT-336
Imaging:
___ RUQ US
1. Heterogeneous appearance of the liver likely due to steatosis
though more advanced forms liver disease cannot be excluded on
the basis of this
appearance.
2. Normal appearance of the gallbladder
___ CXR
No evidence of pneumonia.
___ ECHO
The left atrium is normal in size. No atrial septal defect is
seen by 2D or color Doppler. Left ventricular wall thickness,
cavity size and regional/global systolic function are normal
(LVEF >55%). 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) appear structurally normal
with good leaflet excursion and no aortic stenosis or aortic
regurgitation. The mitral valve appears structurally normal with
trivial mitral regurgitation. The estimated pulmonary artery
systolic pressure is normal. There is no pericardial effusion.
___ CT Chest
Minimal ground-glass nodularity in the upper lobes is likely
caused by
respiratory bronchiolitis. No evidence of hemorrhage. No
infection. No
fibrosis or other diffuse lung disease.
___ CT A/P
1. No acute intra-abdominal or intrapelvic abnormalities.
2. Linear density in the posterior midpole of the left kidney,
likely a
sequela of prior renal biopsy.
Labs on Discharge:
___ 06:30AM BLOOD WBC-5.2# RBC-3.95 Hgb-12.1 Hct-37.4
MCV-95 MCH-30.6 MCHC-32.4 RDW-13.0 RDWSD-45.1 Plt ___
___ 06:30AM BLOOD Glucose-80 UreaN-11 Creat-0.6 Na-140
K-3.8 Cl-103 HCO___ AnGap-17
Brief Hospital Course:
Ms. ___ is a ___ year old female with past medical history of
SLE on chronic prednisone, azathioprine, recently initiated on
___ ___, admitted ___ with dehydration and
sternal pain of unclear etiology, with negative rheumatologic
workup
# Dehydration / Presyncope Patient presented reported symptoms
of dizziness on ambulation. She reported recent poor PO intake
due to feeling ill. She denies nausea/vomiting or diarrhea.
She had orthostatic vital signs with recurrent of symptoms on
standing. Patient was volume resuscitated with IV fluids.
Symptoms resolved and she was restarted on her home lisinopril
prior to discharge.
# Chest / Sternal Pain Patient presented reporting new onset
chest pain. She described it as nonpleuritic, non-exertional.
On exam, pain was semi-reproducible with palpation. EKG was
unchanged. Given her historically difficult to control lupus,
and a mildly decreased C3 on admission, there was concern
regarding potential auto-immune etiology of her symptoms. She
was seen by rheumatology. She underwent a TTE without signs of
cardiac dysfunction. A CT Torso did not demosntrate notable
findings. No medication changes were recommended by
rheumatology. Symptoms improved prior to discharge. She is
advised to have close rheumatology follow up after discharge.
# SLE - continued azathioprine, prednisone; continued home
tramadol, gabapentin. Held home lisinopril given concern for
dehydration on admission, though was restarted on discharge
given resolution of pre-syncopal symptoms.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. PredniSONE 15 mg PO DAILY
2. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild
3. Lisinopril 2.5 mg PO DAILY
4. alendronate 70 mg oral qWeek
5. AzaTHIOprine 75 mg PO BID
6. Gabapentin 900 mg PO QHS
7. Gabapentin 300 mg PO DAILY
8. TraMADol 50 mg PO TID PRN Pain - Moderate
9. Aspirin 81 mg PO DAILY
10. DiphenhydrAMINE 25 mg PO Q8H:PRN itchy
11. Ferrous Sulfate 325 mg PO DAILY
12. Zolpidem Tartrate 5 mg PO QHS
13. belimumab 400 mg injection q month
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild
2. alendronate 70 mg oral QWEEK
3. Aspirin 81 mg PO DAILY
4. AzaTHIOprine 75 mg PO BID
5. belimumab 400 mg injection q month
6. DiphenhydrAMINE 25 mg PO Q8H:PRN itchy
7. Ferrous Sulfate 325 mg PO DAILY
8. Gabapentin 900 mg PO QHS
9. Gabapentin 300 mg PO DAILY
10. Lisinopril 2.5 mg PO DAILY
11. PredniSONE 15 mg PO DAILY
12. TraMADol 50 mg PO TID PRN Pain - Moderate
13. Zolpidem Tartrate 5 mg PO QHS
Discharge Disposition:
Home
Discharge Diagnosis:
# Sternal Pain
# Presyncope
# SLE
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were admitted with chest pain and dehydration. You underwent
a thorough workup to determine the cause of your pain. The pain
does not appear to be related to complications from your lupus.
Your symptoms improved on their own.
You were also found to be dehydrated when you came in and this
was causing you to feel lightheaded. Your symptoms improved with
fluids, but it is very important for you to drink fluids and
stay hydrated.
** Please call your rheumatologists office on ___ and
schedule an appointment with Dr. ___ the next week **
Followup Instructions:
___
|
19724138-DS-21
| 19,724,138 | 27,360,877 |
DS
| 21 |
2165-12-20 00:00:00
|
2165-12-21 20:44:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
leg pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. ___ is a ___ year old ___ speaking ___ man with a
h/o ALS, HTN, and essential tremor who presents with ___ days of
LLE pain and swelling. He reports swelling and pain over his
calf, popliteal region and the back of his thigh for the past
___ days, with swelling that is starting to improve this AM. He
denies CP/SOB, recent travel or hospitalization. No recent
surgeries. He is ambulatory with the help of a cane at
baseline. He does not think he has ever had a colonoscopy, he
quit smoking ___ years ago. He has been seen recently by OT and
by his neurologist for ALS.
In the ED, initial VS were: 99.2 77 149/79 16. Labs were notable
for normal CBC, Na 132, BUN 21, Crt 0.9, and normal coagulation
panel. LENIS showed DVT in superficial femoral and popliteal
veins. VS upon transfer were 98.6 71 144/86 16 97%. On arrival
to the floor, patient reports feeling okay except for the leg
pain and swelling which is improved considerably this AM. Labs
this AM significant for PTT of >150 and then 141.9
Past Medical History:
- essential tremor
- limb onset ALS (___) - patient report weakness mostly in his
legs
- HTN
- GERD
- HLD
Social History:
___
Family History:
- mother with cancer, but he was not sure what it was, his
mother passed away in her mid ___
Physical Exam:
On admission:
VS - 98.5, 157/87, 71, 18, 97% RA
GENERAL - well-appearing man in NAD, comfortable, appropriate
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear
NECK - supple, no thyromegaly, no JVD, no carotid bruits
LUNGS - CTA bilat, no r/rh/wh, good air movement, resp
unlabored, no accessory muscle use
HEART - PMI non-displaced, RRR, no MRG, nl S1-S2
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - WWP, no c/c/e, 2+ DP bilaterally. 1+ pitting edema
in the LLE below the knee, increase warmth, non-erythematous,
tender over the popliteal area in the LLE.
SKIN - no rashes or lesions
NEURO - awake, A&Ox3, difficult to get DTR, strength is 4 in the
forearm, 4- in the upper arm, LLE is mostly 4.
On discharge:
VS - 98.5, 120/80 (max 190/75 at ___ yesterday), 68, 18, 95%
RA (94-98%)
GENERAL - well-appearing man in NAD, comfortable, appropriate,
speaks limited ___
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear
NECK - supple, no thyromegaly, no JVD, no carotid bruits
LUNGS - CTA bilat, no r/rh/wh, good air movement, resp
unlabored, no accessory muscle use
HEART - PMI non-displaced, RRR, no MRG, nl S1-S2
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - WWP, no c/c/e, 2+ DP bilaterally. 2+ pitting edema
in the LLE below the knee and prominent veins when in dependant
position, non-erythematous, LLE not warmer than right, mildly
tender over the popliteal area in the LLE.
NEURO - awake, A&Ox3, no DTR, strength is 4 in the forearm, 4-
in the L upper arm, LLE is mostly 4. Some increased muscle tone
throughout vs. paratonia. CN II-XII intact. RAM intact.
Negative Romberg. Atrophy of intrinsic muscles of the hand and
some fasciculations apparent in L arm.
SKIN - no rashes or lesions
Pertinent Results:
Labs on Admission:
___ 05:35PM BLOOD WBC-9.8# RBC-4.87 Hgb-14.9 Hct-43.4
MCV-89 MCH-30.5 MCHC-34.3 RDW-13.0 Plt ___
___ 05:35PM BLOOD Neuts-74.7* ___ Monos-3.9 Eos-2.4
Baso-0.6
___ 08:50PM BLOOD ___ PTT-27.3 ___
___ 09:29PM BLOOD ___ PTT-30.0 ___
___ 04:29AM BLOOD ___ PTT-150* ___
___ 05:35PM BLOOD Glucose-99 UreaN-21* Creat-0.9 Na-132*
K-4.2 Cl-99 HCO3-23 AnGap-14
___ 06:00AM BLOOD Calcium-8.5 Phos-4.2 Mg-2.0
Labs On Discharge:
___ 06:15AM BLOOD WBC-7.1 RBC-4.48* Hgb-13.4* Hct-39.0*
MCV-87 MCH-30.1 MCHC-34.5 RDW-13.1 Plt ___
___ 06:15AM BLOOD ___ PTT-35.2 ___
___ 06:15AM BLOOD Glucose-107* UreaN-18 Creat-0.7 Na-137
K-3.9 Cl-101 HCO3-26 AnGap-14
___:
IMPRESSION: Left lower extremity DVT involving the popliteal
and femoral
veins. Left calf veins are not well assessed.
Brief Hospital Course:
Summary:
___ yo ___ speaking ___ with ALS, HTN, essential tremor
presents with 4 days of LLE pain found to have DVT treated
initially with heparin, then lovenox and coumadin
# LLE DVT. Popliteal and superficial femoral. No risk factors
other than age and decreased mobility secondary to ALS. Cancer
screening not clear. No B symptoms. Discharged on lovenox and
coumadin. His home ___ draw labs and his PCP ___
follow up and adjust his coumadin dose on ___. He already
has outpatient ___ in place.
Non-active issues:
# ALS.
- continued home riluzole 50 mg BID
- continued creatine
- will continue existing ___ at home
# Essential tremor
- continued home propranolol
# HTN
- continued lisinopril 20 mg daily
# GERD
- conitnued omeprazole
Transitional Issues:
DVT - His PCP ___ monitor his INR and he will d/c lovenox ___
days after becoming therapeutic on coumadin. His home ___
___ draw labs at his home and send them to his PCP for
monitoring and dose adjustment. I spoke to her on the phone and
confirmed this. He was also given compression stocking and an
RX for additional compression stockings. He will discuss with
his PCP the duration of anticoagulation.
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from
PatientFamily/CaregiverPharmacywebOMR.
1. creatine monohydrate *NF* 15 grams Oral daily
2. Fluticasone Propionate NASAL 1 SPRY NU BID
3. Lisinopril 20 mg PO DAILY
4. Meclizine 12.5 mg PO TID:PRN dizziness
5. Omeprazole 20 mg PO DAILY
6. Propranolol 20 mg PO BID
7. riluzole *NF* 50 mg Oral BID
Discharge Medications:
1. Enoxaparin Sodium 80 mg SC Q12H
RX *enoxaparin 80 mg/0.8 mL inject q12 hours Disp #*20 Syringe
Refills:*0
2. compression socks, medium *NF* 4 socks Miscellaneous daily
DVT
RX *compression socks, medium for your feet daily Disp #*4 Not
Specified Refills:*0
3. Warfarin 1 mg PO DAILY16
Take 5 pills ___ and again on ___ and then ask your
doctor on ___ how ___ to continue taking
RX *warfarin [Coumadin] 1 mg 5 tablet(s) by mouth daily Disp
#*35 Tablet Refills:*0
4. Acetaminophen 325-650 mg PO Q6H:PRN pain or fever
5. Fluticasone Propionate NASAL 1 SPRY NU BID
6. Lisinopril 20 mg PO DAILY
hold if sbp < 100
7. Meclizine 12.5 mg PO Q8H:PRN dizziness
hold if sedated
8. Omeprazole 20 mg PO DAILY
9. Propranolol 20 mg PO BID
hold if SBP < 100 or HR < 60
10. riluzole *NF* 50 mg Oral BID Reason for Ordering: Wish to
maintain preadmission medication while hospitalized, as there is
no acceptable substitute drug product available on formulary.
11. creatine monohydrate *NF* 1.5 gram/15 mL Oral daily
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
DVT
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. ___, you were admitted to the hospital for pain in
your leg and were found to have a DVT (deep venous thrombosis)
in your leg. You were treated here with blood thinners, and you
will continuie on these new medications at home. You will take
lovenox (injections) twice daily and coumadin 5mg (5 pills)
daily. Your nurse, ___, will check bloodwork on you and send
it to your primary care provider, Dr. ___. On ___, Dr.
___ will contact you with an appointment and to tell you how
much coumadin to take and when you can stop the lovenox
injections. You should wear compression stockings to help the
swelling in your leg. If you experience chest pain or shortness
of breath you should call your doctor or go to the emergency
room.
Followup Instructions:
___
|
19724164-DS-17
| 19,724,164 | 27,982,079 |
DS
| 17 |
2182-12-31 00:00:00
|
2183-01-08 10:31:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
codeine / Penicillins
Attending: ___.
Chief Complaint:
Headache/neck stiffness/transfer for MRI
Major Surgical or Invasive Procedure:
TENS unit removal (___)
History of Present Illness:
Mr. ___ is a ___ M with a PMH significant for COPD, HTN, 2
TIAs, anxiety, and chronic low back pain with recent TENS trial
who was transferred to ___ for headache, neck stiffness, and
worsening low back pain.
He states that since his TENS trial unit was placed on ___
of last week, he awoke from anesthesia with a headache. He had
progressive headache, neck stiffness, and then acute-on-chronic
back pain develop over the weekend. He endorses
numbness/tingling in his lower extremities and difficulty
initiating urination. He has experienced chills, but no fever.
He presented to the ___ where he was evaluated by
Anesthesia who felt uncomfortable with managing his TENS unit
and performing LP without MRI. MRI at ___ was not
functioning, and he was transfered to ___ ED. No LP performed
given TENS unit in low back and concern for epidural
abscess/hematoma. He was started on ceftriazone 2gm, vancomycin,
and flagyl and transferred to the ___ ED.
In the ___, his labs were: ___ 22:54)
CBC 8.6>15.5/45.3<248; MCV 88.5; Neuts: 53.9%, Lymph 27.8%
Cr = 1.0
LFTs WNL
In transport, he had BPs of ___, pulse 55-62.
In the ___ ED he endorsed chills and ongoing dizziness. The
headache and dizziness are positional, worse with upright or
seated position. His vitals were unremarkable, his labs were
essentially unchanged and notable for a mild leukocytosis
without neutrophilia or bandemia and normal Cr.
Upon arrival to the floor, he endorses ___ pain in his head and
neck.
REVIEW OF SYSTEMS:
(+) Per HPI
Denies fevers, drenchin sweats. Loss of vision. He denies
diarrhea or bowel in continence. He denies bleeding or bruising.
He denies mouth sores or sore throat. He denies cough, shortness
of breath.
Past Medical History:
Back pain - s/p recent TENS trial placed by Dr. ___ at ___
___ pain ___.
COPD
HTN
Stroke (2 months ago, initial left sided deficits, now no
deficits)
"hole in my heart"
Bradycardia
H/O myocardial infarction (last year)
H/o pneumonia in ___
Anxiety
Depression
H/o orthopedic procedures for broken bones
Brain tumor, pituitary per patient
Social History:
___
Family History:
Mother with lung cancer, Father with lymphoma.
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: 98.1, 126/67, 52, 16, 98% on RA
General: Alert, oriented, moderate distress from pain
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: Supple, no LAD in cervial chains or supraclavicular chains
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, non-tender, non-distended, bowel sounds present
GU: No foley, initially bladder scanned for 850cc, was able to
void ___ after that.
Ext: Warm, well perfused, no edema or cyanosis
Neuro: EOMI, PERRL, facial movement symmetric upper and lower,
decreased sensation in left mandibular distribution. SCM/trap
___ and symmetric. Hand grip, biceps, triceps, plantar and
dorsiflection ___ and symmetric.
DISCHARGE PHYSICAL EXAM:
Vitals: 98.2 (Tm 98.4), 121/82 (121/82-149/82), 77 (56-77), 18
(___), 95% on RA (95-97%)
General: Alert, oriented, NAD but painful when rolls to side
HEENT: Sclera anicteric,
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, non-tender, non-distended, bowel sounds present
GU: No foley, initially bladder scanned for 850cc, was able to
void ___ after that.
Ext: Warm, well perfused, no edema or cyanosis
Neuro: grossly intact
Pertinent Results:
Admission Labs:
___ 03:15AM BLOOD WBC-10.2* RBC-5.23 Hgb-15.6 Hct-47.7
MCV-91 MCH-29.8 MCHC-32.7 RDW-13.4 RDWSD-45.2 Plt ___
___ 03:15AM BLOOD Neuts-48.7 ___ Monos-10.1 Eos-6.7
Baso-1.1* Im ___ AbsNeut-4.94 AbsLymp-3.33 AbsMono-1.03*
AbsEos-0.68* AbsBaso-0.11*
___ 03:15AM BLOOD Plt ___
___ 03:30AM BLOOD ___ PTT-33.1 ___
___ 03:15AM BLOOD Glucose-92 UreaN-13 Creat-1.0 Na-138
K-4.1 Cl-102 HCO3-20* AnGap-20
___ 05:12AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5
LEUK-NEG
Notable Labs/Discharge Labs:
___ 06:32AM BLOOD WBC-7.5 RBC-4.44* Hgb-13.4* Hct-41.5
MCV-94 MCH-30.2 MCHC-32.3 RDW-13.6 RDWSD-46.4* Plt ___
___ 06:32AM BLOOD PTT-38.1*
___ 06:32AM BLOOD Glucose-84 UreaN-22* Creat-1.1 Na-138
K-4.5 Cl-104 HCO3-23 AnGap-16
___ 06:32AM BLOOD Calcium-9.2 Phos-4.6* Mg-2.2
-------
MICRO:
-------
__________________________________________________________
___ 9:00 am FOREIGN BODY Source: lumbar catheter.
**FINAL REPORT ___
WOUND CULTURE (Final ___: NO GROWTH.
__________________________________________________________
___ 3:30 am BLOOD CULTURE
Blood Culture, Routine (Pending):
__________________________________________________________
___ 3:15 am BLOOD CULTURE
Blood Culture, Routine (Pending):
--------
IMAGING:
--------
MR ___ & W/O CONT (___):
IMPRESSION:
1. Lumbar spondylosis, most prominent at L4-L5 where there is
moderate left
neural foraminal narrowing is identified.
2. No prevertebral or paraspinal fluid collections to suggest
abscess or
evidence of discitis/osteomyelitis.
___ (AP & LAT) (___):
IMPRESSION: Multilevel degenerative changes in the lumbar
spine. Metallic density projecting over the right upper
quadrant is not visualized on the lateral view, this may be on
the patient's skin or anteriorly within the abdomen.
-----------
Cardiology
-----------
None
Brief Hospital Course:
Mr. ___ is a ___ M with a PMH significant for COPD, HTN, 2
TIAs, anxiety, and chronic low back pain with recent TENS trial
4 days prior to admission who was transferred to ___ for
headache, neck stiffness, and worsening low back pain.
ACUTE ISSUES:
1. Post dural puncture headach - Initially his neck stiffness
and headache were concerning for meningiis related to recent
TENS unit. Labs (no leukocytosis, bands or neutrophilia) and
physical exam (no fever, minimal neck rigidity, no adenopathy)
were reassuring. Given his symptoms and concern for infection,
the TENS unit was removed on hospital day 1 by the pain service.
The TENS unit and ankle bracelet was removed so that he could
undergo an MRI, as well, see below. His headache improved with
restarting oxycodone (recently discontinued in setting of TENS
trial), lidocaine patch, and contining his home meds. The pain
service recommended minimizing intervention and treating
conservatively with supine position and dietary caffeine. He
was given oxycodone until follow up with his pain doctor.
2. Lower extremity sensory changes and low back pain: On
admission, he endorsed numbness/tingling in his lower
extremities and difficulty initiating urination, however he
could urinate with effort. An MRI lumbar spine was performed,
with no evidence of mass-occupying lesion (hematoma, abscess) on
MRI or pinal cord damage. Most likely worsening of his chronic
LBP with discontinuation of narcotics. Sensory changes
unchanged during hospitalization course, and further history
revealed these were not new as initially reported. He was given
20mg Oxycodone q4hr PRN pain, home Baclofen 20 mg PO/NG TID,
home Gabapentin 800 TID, and Lidocaine 5% patch qday (12hr on,
12hr off). Keterolac 30mg q6hr PRN pain was tried, but he
stopped using it due to ineffectiveness.
CHRONIC ISSUES:
3. COPD - quit smoking 1wk prior to admission, given nicotine
patches.
4. HTN - Normotensive on arrival, restarted amlodipine when
hypertensive. Patient reports taking lisinopril/HCTZ ___ and
amlodipine 10, unable to confirm records. Did not restart
liziopril/HCTZ as he was normotensive with amlodipine.
Recommended follow up with PCP.
5. History of TIA x2: Continued ASA in absence of bleeding on
MRI given patient's TIA history.
6. Anxiety/Depression
Continued home CloniDINE 0.1 mg PO BID:PRN anxiety and home
QUEtiapine Fumarate 300 mg PO/NG QHS.
7. Legal satus
He was on probation with a monitoring ankle bracelet in place on
arrival. This was removed so that an MRI could be performed
urgently. With the patient's permission and assistance the
monitoring company and Probation Officer ___ was contacted.
He was instructed to return the monitoring unit and get in touch
with his P.O. after discharge.
8. CODE STATUS: full, confirmed
TRANSITIONAL ISSUES:
- New meds: restarted oxycodone, lidocaine patch
- Stopped meds: HCTZ/lisinopril
- Ongoing labs: No monitoring needed.
- Security ankle bracelet needs to be returned to probation
officer.
- bp 127/70-149/82 on Amlodipine 10mg. Patient reports takes
lisinopril/hctz ___ at home, Held during admission. Restart
at follow-up if bp elevated.
- Given oxycodone script to follow through pain appointment on
___.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Tamsulosin 0.4 mg PO DAILY
2. Baclofen 20 mg PO TID
3. QUEtiapine Fumarate 300 mg PO QHS
4. CloniDINE 0.1 mg PO BID:PRN anxiety
5. Gabapentin 800 mg PO TID
6. Docusate Sodium 100 mg PO BID
7. Nicotine Patch 21 mg TD DAILY
8. Aspirin 81 mg PO DAILY
9. Amlodipine 10 mg PO DAILY
10. lisinopril-hydrochlorothiazide ___ mg oral DAILY
Discharge Medications:
1. Amlodipine 10 mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Baclofen 20 mg PO TID
4. CloniDINE 0.1 mg PO BID:PRN anxiety
5. Docusate Sodium 100 mg PO BID
6. Gabapentin 800 mg PO TID
7. Nicotine Patch 21 mg TD DAILY
8. QUEtiapine Fumarate 300 mg PO QHS
9. Tamsulosin 0.4 mg PO DAILY
10. Lidocaine 5% Patch 1 PTCH TD QAM
RX *lidocaine 5 % (700 mg/patch) 1 patch q 24 hours Disp #*30
Patch Refills:*0
11. OxycoDONE (Immediate Release) 20 mg PO Q4H:PRN pain
RX *oxycodone 10 mg ___ tablet(s) by mouth q 4:PRN Disp #*84
Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary
------------------
Post-___ puncture headache
Chronic lower back pain
Secondary
------------------
COPD
HTN
stroke
bradycardia
H/O myocardial infarction (last year)
h/o pneumonia in ___
Anxiety
Depression
brain tumor, pituitary per patient
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 being a part of your care at ___
___. You were admitted for headache, neck
and increasing back pain most likely due to the manipulation
required for the TENS unit placement. You underwent an MRI and
blood tests to check for infection and these were all normal.
Recommend laying supine and drinking caffeine to alleviate pain.
Please follow closely with your pain doctor Dr ___ - you have
a follow-up appointment scheduled for ___. You
have prescriptions for pain medications up until this
appointment. Please follow-up with your PCP, Dr ___ on ___,
___ at 11:30 AM.
Your blood pressure was controlled on Amlodipine while in the
hospital. Hold your lisinopril/HCTZ until your follow up
appointment and restart if your PCP/pain doctor recommends.
Also, please make sure to return the security bracelet to your
probation officer. Please call probation officer to re-establish
status.
Sincerely,
Your ___ Team
Followup Instructions:
___
|
19724180-DS-4
| 19,724,180 | 29,818,586 |
DS
| 4 |
2128-02-08 00:00:00
|
2128-02-08 17:34:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Bactrim DS / Atorvastatin Calcium / Fosamax / Pravastatin /
Lovastatin / tramadol / desipramine
Attending: ___.
Chief Complaint:
Vomiting, dizziness
Major Surgical or Invasive Procedure:
ENT scope
History of Present Illness:
___ year old female w/h/o pharyngoesophageal dysphagia s/p ENT
cricopharyngeus balloon dilatation 2 weeks ago, presents
complaining of dizziness. Pt describes one episode of vomiting
the night before presentation; today she woke up and felt dizzy,
sweaty and lightheaded (no vertigo) resolved upon sitting. Pt's
daughter took BP, measured 80/50, rose to 100s. Called EMS.
Denies chest pain, palpitations, cough, abdominal pain. She has
been tolerating POs well and denies further episodes of
vomiting.
In the ED, initial vitals were: T 98.5, HR 71, BP 129/54, RR 18,
O2 96% RA. CXR w/n/l. Labs significant for WBC 15.9, H/H
10.8/33.1 (baseline Hgb ~12). Pt evaluated by ENT, who performed
bedside scope revealing known right vocal fold hypomobility and
bilateral vocal fold atrophy, but widely patent airway without
evidence of infection or acute processes at her surgical site.
Recommended CT to r/o pharyngeal perforation, which showed
thyroid nodules, but no collection or other acute surgical
complication. Pt given 1 g vancomycin empirically, admitted to
medicine for further evaluation and treatment.
On transfer, pt's vitals were T 98.6, HR 72, BP 158/89, O2 98%
RA.
On the floor, pt was comfortable, no acute distress, vital signs
similar to above.
Past Medical History:
HYPERTENSION
AORTIC INSUFFICIENCY/AORTIC STENOSIS
coronary artery disease
s/p quadruple bypass surgery in ___
gouty arthritis
s/p cholecystectomy
Social History:
___
Family History:
Brother w/ CAD, died ___ years ago from MI
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: T 97.9, BP 155/73, HR 69, O2 100 on RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear and
nonerythematous EOMI, PERRL
Neck: Supple, JVP not elevated, no LAD. Prominent carotid
pulsations at clavicles.
CV: Regular rate and rhythm, no murmurs, rubs, gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, non-tender, non-distended, no organomegaly, no
rebound or guarding
GU: No foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
DISCHARGE PHYSICAL EXAM:
Vitals: T 97.5, BP 130/60, HR 80, O2 98 on RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear and
nonerythematous EOMI, PERRL
Neck: Supple, JVP not elevated, no LAD. Prominent carotid
pulsations at clavicles.
CV: Regular rate and rhythm, no murmurs, rubs, gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, non-tender, non-distended, no organomegaly, no
rebound or guarding
GU: No foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
LABS (Admission and discharge combined, as pt here <36 h)
___ 05:20AM BLOOD WBC-7.9# RBC-4.11* Hgb-10.3* Hct-30.4*
MCV-74* MCH-25.0* MCHC-33.8 RDW-16.2* Plt ___
___ 01:34PM BLOOD WBC-15.9*# RBC-4.39 Hgb-10.8* Hct-33.1*
MCV-75*# MCH-24.5*# MCHC-32.5 RDW-16.2* Plt ___
___ 01:34PM BLOOD Neuts-85.6* Lymphs-8.4* Monos-5.7 Eos-0.2
Baso-0.1
___ 02:12PM BLOOD ___ PTT-26.0 ___
___ 05:20AM BLOOD Glucose-87 UreaN-16 Creat-0.7 Na-135
K-3.4 Cl-94* HCO3-32 AnGap-12
___ 01:34PM BLOOD Glucose-107* UreaN-20 Creat-0.5 Na-138
K-3.4 Cl-97 HCO3-30 AnGap-14
___ 05:20AM BLOOD Calcium-9.0 Phos-3.5 Mg-1.4* Iron-PND
___ 01:34PM BLOOD Calcium-8.7 Phos-3.5 Mg-1.4*
___ 03:19PM BLOOD Lactate-2.8*
___ 05:29PM BLOOD Lactate-3.1*
STUDIES:
CXR ___:
IMPRESSION:
No acute cardiopulmonary process.
CT CHEST ___:
IMPRESSION:
1. Status post recent laryngoscopy and esophagoscopy with
cricopharyngeus. Botox injection and balloon dilatation without
evidence of a complication. No mediastinal air or
retropharyngeal collection is identified.
2. Multinodular thyroid again noted. Correlation with labs and
ultrasound on a nonemergent basis can be performed for further
evaluation if clinically indicated.
3. Narrowing of the left brachiocephalic vein as it crosses
posterior to the left clavicular head.
VIDEO SWALLOW ___:
FINDINGS:
Barium passes freely through the oropharynx and esophagus
without evidence of obstruction. There was no gross aspiration
or penetration.
IMPRESSION:
No gross aspiration or penetration. Please refer to the speech
and swallow division note in ___ for full details, assessment,
and recommendations.
Brief Hospital Course:
Pt is ___ yo F with history of progressive dysphagia s/p
extensive workup, now POD ___ s/p cricopharyngeal dilatation by
ENT, presenting w/ vomiting X1, dizziness and leukocytosis to
15. Of note she has a bioprosthetic aortic valve; ENT procedure
was done w/ no abx ppx; pt's family very concerned about this.
Pt underwent evaluation in the ED by ENT, who scoped her and
could see no e/o abscess or other post-surgical complication. CT
neck also revealed no acute process. Video swallow performed on
HD1 showed expected post-procedural changes. Pt w/ negative
blood cultures, leukocytosis resolved on HD1, lactate
downtrending 3.1-->2.8. Pt's outpatient cardiologist contacted
(Dr. ___, who felt pt did not need outpatient
echocardiogram; advised her to call his office or come to the ED
if she experienced fevers. Pt felt well on HD1, was sent home
with close follow up, tolerating a soft diet, thin liquids.
TRANSITIONAL ISSUES
-Pt has progressive microcytic anemia, no e/o bleeding. Has poor
po intake, eats no red meat; iron studies pending at discharge.
-ENT will manage any further studies to evaluate swallowing; pt
currently on soft diet, thin liquids
-Blood cultures pending at discharge
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen w/Codeine 1 TAB PO Q4H:PRN pain
2. Colchicine 0.6 mg PO DAILY
3. Hydrochlorothiazide 37.5 mg PO DAILY
4. Lisinopril 40 mg PO DAILY
5. Metoprolol Tartrate 75 mg PO TID
6. Pantoprazole 20 mg PO Q24H
7. Aspirin 81 mg PO DAILY
8. Niacin SR 250 mg PO QHS
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Colchicine 0.6 mg PO DAILY
3. Lisinopril 40 mg PO DAILY
4. Metoprolol Tartrate 75 mg PO TID
5. Niacin SR 250 mg PO QHS
6. Pantoprazole 20 mg PO Q24H
7. Acetaminophen w/Codeine 1 TAB PO Q4H:PRN pain
8. Hydrochlorothiazide 37.5 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Diagnosis:
Transient dizziness
Vomiting X 1
Secondary diagnoses:
Dysphagia s/p dilatation procedure
CAD s/p CABG
AI s/p bioprosthetic valve
HTN
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking care of you during your stay at ___
___. You were admitted for vomiting
and dizziness, and found to have an elevated white blood cell
count. The ENT doctors ___ and ___ no evidence of
infection or surgical complication. You had no further vomiting
episodes, and a video swallow showed some expected
post-procedure changes. You had no fevers, and your white blood
cell count came down to normal. Your outpatient cardiologist was
consulted, and felt that, given your negative blood cultures
(i.e., your blood grew no bacteria), lack of fever and
normalized white blood cell count, you did not need an
echocardiogram to evaluate your heart valve for infection.
If you have fevers, chest pain, palpitations, or persistent
vomiting, you should return to the Emergency Department.
You should follow up with your PCP and your specialists;
appointments are listed below.
We wish you the very best in your recovery!
Your ___ care team
Followup Instructions:
___
|
19724632-DS-23
| 19,724,632 | 22,994,275 |
DS
| 23 |
2115-01-30 00:00:00
|
2115-01-30 21:49:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Hypotension and hypoglycemia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ yo F with history of DM2, hypothyroidism,
HTN, DVT LLE ___, IBD s/p distant colectomy, abscess ___
___ s/p repeat colectomy and small bowel resection at ___
___ bleed, PICC-associated DVT's and PE's who presented
for hypotension and hypoglycemia.
She was recently admitted to the ___ service from ___ for
purulent drainage from her midline incision, which grew MRSA.
She was transitioned from Vancomycin to Bactrim to Cephalexin
with plan for an additional 11 days of treatment after
discharge. She had urinary retention >600 requiring that
persisted despite straight cath x 2 and she ultimately required
a foley.
During this admission she grew E. coli from the urine on ___,
MSSA from the blood on ___, and mixed bacterial flora and MRSA
from the wound on ___.
Since discharge she has been at ___ at ___.
History is difficult to obtain from the patient. She responds "I
hurt all over" when asked about pain.
___ the ED, initial vitals 97.4, 114, 72/39, 18, 99% RA.
Labs were significant for FSBG 66 on presentation, INR 6.8, K
5.8, UA with >182 WBC with negative nitrites, leukocytosis to
34.
Imaging was significant for: CT abdomen pelvis with 1. Right
lower lobe pneumonia; 2. Interval opening of a abscess ___ the
subcutaneous tissues of the lower anterior abdominal wall, with
no significant residual fluid; 3. Cholelithiasis, with no
evidence of acute cholecystitis; 4. Trace pericardial effusion
is slightly increased from prior; 5. Diffuse anasarca.
Past Medical History:
PMH:
IBD (unclear UC vs. Crohns ___ years ago), DM2, Hypothyroid, HTN
DVT LLE ___
PSH:
___ (OSH) - ___ for large bowel obstruction due to IBD
___ (OSH) - Reanastamosis (ostomy takedown) (OSH)
___ (___) - Sigmoid perforation with abscess,
___
Social History:
___
Family History:
h/o colon ca
Physical Exam:
ADMISSION PHYSICAL
====================
Vitals: T: 97.3 BP:109/78 P:109 R:28 O2:93% on RA
FSBG 44
GENERAL: ___ word answers, appears lethargic. After dextrose,
talks ___ full sentances
HEENT: Sclera anicteric, MM dry, poor oral hygiene
NECK: supple, JVP flat, no LAD
LUNGS: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: tachycardic, normal S1 S2, no murmurs, rubs, gallops
ABD: soft, non-distended, bowel sounds present; large abdominal
incision with defect and packing ___ inferior aspect. No
drainage, or foul odor.
GU: Foley ___ place
EXT: cool feet below ankles, <2 sec cap refill. pulses easily
dopplerable,
SKIN: dry, flaking skin throughout. Diffuse maceration of
buttocks with a ~2cm sacral decub with white slough, no purulent
drainage
NEURO: A&O x2.
MSK: Extreme pain to palpation of left thigh and knee.
ACCESS: PIVs (no central access)
DISCHARGE PHYSICAL
==================
VS: Temp 97.8 BP 155/75 HR 106 RR 18 97%Ra
GENERAL: No acute distress
HEENT: Sclera anicteric, MMs dry
LUNGS: Regular work of breathing
CV: Tachycardic; ___ ejection murmur heard best at L ___
interspace, No murmurs, rubs, or gallops appreciated
ABD: Soft, non-distended, non-tender; Large abdominal incision
with no drainage or foul odor; Ostomy ___ place with watery
stool, erythematous stoma
GU: Foley ___ place draining clear yellow urine
EXT: Warm; No edema; Bilateral swelling of knees--no erythema or
warmth
NEURO: A&Ox3, CN's grossly intact
Skin: Chronic venous stasis discoloration bilaterally over shins
bilaterally. Multiple sacral lesions on buttocks and posterior
thighs with areas of ulceration , purulence and active bleeding
GU: Rectal exam ___ with watered down blood, creamy discharge
Pertinent Results:
ADMISSION LABS:
=====================
___ 04:08PM PLT COUNT-423*
___ 10:00AM GLUCOSE-52* UREA N-42* CREAT-1.9* SODIUM-133
POTASSIUM-4.4 CHLORIDE-101 TOTAL CO2-17* ANION GAP-19
___ 10:00AM CK-MB-19* cTropnT-0.05*
___ 10:00AM CALCIUM-8.0* PHOSPHATE-4.5 MAGNESIUM-1.6
___ 10:00AM TSH-1.6
___ 06:10AM GLUCOSE-68* UREA N-43* CREAT-2.0* SODIUM-133
POTASSIUM-5.2* CHLORIDE-101 TOTAL CO2-15* ANION GAP-22*
___ 04:00AM URINE COLOR-Yellow APPEAR-Cloudy SP ___
___ 04:00AM URINE BLOOD-MOD NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-LG
___ 04:00AM URINE RBC-57* WBC->182* BACTERIA-MANY
YEAST-MOD EPI-6
___ 02:56AM LACTATE-1.8 K+-5.8*
___ 02:50AM ALT(SGPT)-19 AST(SGOT)-41* CK(CPK)-716* ALK
PHOS-127* TOT BILI-0.2
___ 02:50AM LIPASE-16
___ 02:50AM cTropnT-0.07*
___ 02:50AM CK-MB-13* MB INDX-1.8
___ 02:50AM ALBUMIN-2.5* CALCIUM-8.5 PHOSPHATE-4.9*
MAGNESIUM-1.8
___ 02:50AM WBC-34.0*# RBC-2.81* HGB-7.3* HCT-23.1*
MCV-82 MCH-26.0 MCHC-31.6* RDW-19.9* RDWSD-58.8*
___ 02:50AM NEUTS-90* BANDS-0 LYMPHS-1* MONOS-8 EOS-0
BASOS-0 ___ METAS-1* MYELOS-0 AbsNeut-30.60* AbsLymp-0.34*
AbsMono-2.72* AbsEos-0.00* AbsBaso-0.00*
MICROBIOLOGY
============
___ 5:11 am BLOOD CULTURE Source: Line-R midline.
Blood Culture, Routine (Pending):
__________________________________________________________
___ 12:07 am BLOOD CULTURE Source: Line-r midline.
Blood Culture, Routine (Pending):
__________________________________________________________
___ 11:56 am STOOL CONSISTENCY: LOOSE Source:
Stool.
**FINAL REPORT ___
FECAL CULTURE (Final ___: NO SALMONELLA OR SHIGELLA
FOUND.
CAMPYLOBACTER CULTURE (Final ___: NO CAMPYLOBACTER
FOUND.
OVA + PARASITES (Final ___:
NO OVA AND PARASITES SEEN.
This test does not reliably detect Cryptosporidium,
Cyclospora or
Microsporidium. While most cases of Giardia are detected
by routine
O+P, the Giardia antigen test may enhance detection when
organisms
are rare.
__________________________________________________________
___ 11:56 am STOOL CONSISTENCY: LOOSE Source:
Stool.
**FINAL REPORT ___
C. difficile DNA amplification assay (Final ___:
Negative for toxigenic C. difficile by the Cepheid nucleic
acid
amplification assay..
(Reference Range-Negative).
__________________________________________________________
Time Taken Not Noted ___ Date/Time: ___ 4:55 pm
SWAB Source: Vaginal.
**FINAL REPORT ___
SMEAR FOR BACTERIAL VAGINOSIS (Final ___:
GRAM STAIN NEGATIVE FOR BACTERIAL VAGINOSIS.
YEAST VAGINITIS CULTURE (Final ___: NEGATIVE FOR
YEAST.
__________________________________________________________
Time Taken Not Noted ___ Date/Time: ___ 4:55 pm
ANORECTAL/VAGINAL Source: Vaginal.
**FINAL REPORT ___
R/O GROUP B BETA STREP (Final ___:
NEGATIVE FOR GROUP B BETA STREP.
__________________________________________________________
___ 2:43 pm SWAB Source: sacral wound.
**FINAL REPORT ___
VIRAL CULTURE: R/O HERPES SIMPLEX VIRUS (Final ___:
HERPES SIMPLEX VIRUS TYPE 2.
CONFIRMED BY MONOCLONAL FLUORESCENT ANTIBODY..
VARICELLA-ZOSTER CULTURE (Final ___:
Refer to Herpes simplex viral culture for further
information.
__________________________________________________________
___ 2:43 pm DIRECT ANTIGEN TEST FOR VARICELLA-ZOSTER VIRUS
Source: sacral wound.
**FINAL REPORT ___
DIRECT ANTIGEN TEST FOR VARICELLA-ZOSTER VIRUS (Final
___:
UNINTERPRETABLE DUE TO INADEQUATE SPECIMEN.
Refer to culture results for further information.
Reported to and read back by ___ ___ ON ___ @
10:38AM.
__________________________________________________________
___ 11:30 am SWAB Source: Sacrum area.
**FINAL REPORT ___
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS.
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.
PSEUDOMONAS AERUGINOSA.
SPARSE GROWTH OF TWO COLONIAL MORPHOLOGIES.
SENSITIVITIES: MIC expressed ___
MCG/ML
_________________________________________________________
PSEUDOMONAS AERUGINOSA
|
AMIKACIN-------------- 4 S
CEFEPIME-------------- 4 S
CEFTAZIDIME----------- 4 S
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ =>16 R
MEROPENEM------------- 4 I
PIPERACILLIN/TAZO----- 8 S
TOBRAMYCIN------------ =>16 R
ANAEROBIC CULTURE (Final ___: NO ANAEROBES ISOLATED.
__________________________________________________________
___ 4:45 pm URINE Source: Catheter.
**FINAL REPORT ___
URINE CULTURE (Final ___:
YEAST. 10,000-100,000 CFU/mL.
__________________________________________________________
___ 1:00 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
__________________________________________________________
___ 11:30 am URINE Source: Catheter.
**FINAL REPORT ___
URINE CULTURE (Final ___:
YEAST. >100,000 CFU/mL.
__________________________________________________________
___ 10:30 am BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
__________________________________________________________
___ 10:07 am BLOOD CULTURE Source: Venipuncture.
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
__________________________________________________________
___ 9:00 am BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
__________________________________________________________
___ 9:07 am BLOOD CULTURE SET#2.
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
__________________________________________________________
___ 7:25 am BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
__________________________________________________________
___ 9:30 am BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
__________________________________________________________
___ 7:20 am BLOOD CULTURE 1 OF 2.
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
__________________________________________________________
___ 3:41 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
__________________________________________________________
___ 10:45 am BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
__________________________________________________________
___ 10:00 am BLOOD CULTURE Source: Venipuncture #1.
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
__________________________________________________________
___ 3:10 am BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
IMAGING/STUDIES
=====================
MR PELVIS ___
Exam is very limited and was terminated early. Only motion
degraded T2
weighted images were obtained. Of note the bowel wall of the
___ pouch
is not appear to be grossly thickened or edematous
ECG ___
Clinical indication for EKG: I47.1 - Supraventricular
tachycardia
Sinus tachycardia. Diffuse ST-T wave abnormalities. No major
change from
prior.
Read by: ___.
Intervals Axes
Rate PR QRS QT QTc (___) P QRS T
134 ___ 421 37 18 -176
TTE ___
The left atrium is normal ___ size. Left ventricular wall
thickness, cavity size, and global systolic function are normal
(LVEF>55%). Right ventricular chamber size and free wall motion
are normal. There is a small circumferential pericardial
effusion best seen ___ subcostal images.
IMPRESSION: Small circumferential pericardial effusion. Normal
biventricular cavity sizes with preserved global biventricular
systolic function.
Compared with the report of the prior study (images unavailable
for review) of ___, the effusion is slightly larger.
CT A/P with contrast ___
IMPRESSION:
1. No evidence of acute intra-abdominal or intrapelvic process.
2. No evidence of fluid collections, abscess or alternative
source of
infection within the abdomen or pelvis.
3. Post partial colectomy with end colostomy and ___
pouch.
4. Please refer to separate report of CT chest performed on the
same day for
description of the thoracic findings.
TTE ___
The left atrial volume index is normal. The estimated right
atrial pressure is ___ mmHg. Normal left ventricular wall
thickness, cavity size, and regional/global systolic function
(biplane LVEF = 62 %). There is no ventricular septal defect.
Right ventricular chamber size and free wall motion are normal.
The diameters of aorta at the sinus, ascending and arch levels
are normal. The aortic valve leaflets (3) are mildly thickened
but aortic stenosis is not present. No masses or vegetations are
seen on the aortic valve. No aortic regurgitation is seen. The
mitral valve appears structurally normal with trivial mitral
regurgitation. No mass or vegetation is seen on the mitral
valve. There is borderline pulmonary artery systolic
hypertension. There is a very small pericardial effusion.
IMPRESSION: No valvular pathology or pathologic flow
identified.Normal biventricular cavity sizes with preserved
regional and global biventricular systolic function.
CLINICAL IMPLICATIONS:
Based on ___ AHA endocarditis prophylaxis recommendations, the
echo findings indicate prophylaxis is NOT recommended. Clinical
decisions regarding the need for prophylaxis should be based on
clinical and echocardiographic data.
CXR ___
Right lower lobe pneumonia.
CT Abdomen/Pelvis ___
IMPRESSION:
1. Right lower and middle lobe pneumonia.
2. Interval decompression of an abscess ___ the subcutaneous
tissues of the
lower anterior abdominal wall, with no significant residual
fluid.
3. Cholelithiasis, with no evidence of acute cholecystitis.
4. Trace pericardial effusion is slightly increased from prior.
5. Hypoattenuation of the blood pool relative to the myocardium
is suggestive of anemia.
L hip XR ___
No fractures seen on this single AP view
TTE ___
No valvular pathology or pathologic flow identified.Normal
biventricular cavity sizes with preserved regional and global
biventricular systolic function.
NOTABLE LABS
===========
___ 12:45PM BLOOD ZINC-Test
___ 12:45PM BLOOD COPPER (SERUM)-Test
___ 07:20AM BLOOD COPPER (SERUM)-Test
___ 03:57PM BLOOD Lactate-2.5*
___ 01:49PM BLOOD Lactate-2.8*
___ 10:07AM BLOOD calTIBC-90* ___ Ferritn-418*
TRF-69*
___ 10:07AM BLOOD D-Dimer-784*
___ 05:18AM BLOOD Hapto-102
___ 10:00AM BLOOD TSH-1.6
___ 02:50AM BLOOD cTropnT-0.07*
___ 10:00AM BLOOD CK-MB-19* cTropnT-0.05*
___ 02:50AM BLOOD Lipase-16
DISCHARGE LABS
==============
Brief Hospital Course:
Ms. ___ is a very pleasant ___ yo woman with history of NIDDM,
DVT/PEs (on Coumadin), HTN, IBD (s/p distant colectomy c/b
abscess then repeat colectomy and small bowel resection
(___) w/ recent admission for purulent drainage from midline
incision c/b MSSA bacteremia who was admitted to ___ with
sepsis physiology, was initially treated for HAP and then
developed c diff and persistent leukocytosis. Over the course of
her hospital stay, the following issues were addressed:
# Goals of Care. Patient's healthcare proxy and nephew ___
___ expressed
concern that she Ms. ___ has been chronically ill for a long
time and had
reached a point where he was more concerned about her overall
well-being. Ms. ___ expressed being tired of hospitalizations
and invasive diagnostic testing/intervention multiple times
throughout hospital stay. Patient was followed by our palliative
care team and several goals of care discussions were initiated
___. ___ was connected with home hospice liaisons.
Eventually plan was decided to start Hospice at home, and
patient had MOLST filled out stating she was DNR/DNI.
# Sepsis. Hypotensive ___ ED to systolic ___, but fluid
responsive and never required pressor. CXR showed RLL pneumonia.
UA with pyuria, hematuria, and many bacteria though culture
showed polymicrobial growth. Denied respiratory symptoms and was
not hypoxic. Difficult to determine other symptomatology as she
said "I hurt all over." MRSA swab negative. Treated with
Vanc/zosyn and rapidly narrowed to vanc/cefepime (day ___.
Due to lack of symptoms and no improvement ___ leukocytosis with
initiation of abx and the fact that patient was discovered to be
C. Diff positive, the source of her leukocytosis was more
consistent with C. Diff colitis and vancomycin and cefepime were
stopped on ___ after 6 days of antibiotics. Transferred from
MICU to floor on ___.
#C. Diff Colitis. Stool tested positive for C. Diff. Stool
output was variable throughout stay and patient remained
afebrile and hemodynamically stable. However, significant
leukocytosis >15 and serum albumin <3 indicative of severe
disease. She was maintained on PO Vancomycin 125 mg Q6h (start
date ___ IV flagyl was added from ___ due to transient
decrease ___ stool output (with concern for developing ileus) and
persistent leukocytosis as below. Ceftriaxone was administered
___ to ___ and Vancomycin was extended until ___ to cover 7
days after all other antibiotics (start date ___ | projected
end date ___.
# Leukocytosis & intermittent monocytosis. Patient was noted to
have a persistent leukocytosis from ___ for entire length of
hospital stay as well as intermittent monocytosis (15% ___ and
16% ___. No improvement on treatment of c diff as above. UA
with 33 RBC's, 22 WBC's, yeast, but negative for bacteria and
nitrates. No coughing, SOB, fever, and CT does not not show
evidence of pulmonary infiltrate suggestive of pneumonia. No
change ___ collapsed abscess or new abscess formation on repeat
CT. Patient had purulent, beefy red sacral ulcers over back
entire hospital stay which eventually tested positive for HSV 2.
Leukocytosis began downtrending on administration of acyclovir
and rectal hydrocortisone below.
# Sacral Ulcers
# HSV 2. Patient presented with areas of macerated skin over
thighs and sacrum and developed further desquamation with areas
of ulceration on gluteals and posterior thights with exudate.
She was treated with ceftriaxone from ___ to ___ with some
improvement ___ leukocytosis. Eventually grew HSV 2 from wound
swab culture (confirmed with DFA). No discrete ulcers noted on
vaginal exam or vesicles noted over sacrum but certainly
possible that this is contributing to patient's leukocytosis and
even to her urinary retention (rare extravaginal complication).
Started acyclovir 200 mg five times per day for 10 days (start
___ | projected end date ___. She also grew pseudomonas from
these wounds but these were felt to be colonizers.
# Diversion Colitis. Patient with persistent leukocytosis and
oozing blood per rectum noted ___ concerning for diversion
colitis of ___ pouch vs IBD flare ___ rectal stumpy.
Flexible sigmoidoscopy of rectal remnant was attempted but
patient refused. Due to patient's underlying IBD, Hydrocortisone
Acetate 10% Foam ___ID was initiated (start ___. She
will need to be on this medication BID for 2 weeks, and then
every other day for 1 week and then twice a week for 2 weeks and
then stop.
# Bacterial PNA: Patient initially presented with tachycardia,
leukocytosis and hypotension. Found to have right lower and
middle lobe infiltrates on imaging and started empirically on
vancomycin and zosyn for suspected pneumonia, then transitioned
to vancomycin and cefepime(D1= ___. Patient had no respiratory
symptoms and no improvement ___ leukocytosis with initiation of
abx. GPC's ___ clusters on blood culture from ___ were likely
contaminants. MRSA swab negative. ___ light of this, and the fact
that patient was discovered to be C. Diff positive, the source
of her leukocytosis was more consistent with C. Diff colitis and
vancomycin and cefepime were stopped on ___.
# Bilateral knee pain and back pain. Chronic, secondary to
osteoarthritis. Significant cause of pain. Pain regimen was
titrated with aid of pain and palliative consult service. Final
regimen: Lidocaine 5% Patch 2 PTCH TD QAM Please apply 1 patch
to each knee, OxyCODONE (Immediate Release) 2.5 mg PO/NG TID,
Gabapentin 200 mg PO/NG BID, acetaminophen 1 g Q8H, OxyCODONE
(Immediate Release) 2.5 mg PO/NG Q4H:PRN BREAKTHROUGH PAIN.
# History of DVT/PE. Patient had initial LLE DVT at ___
___, placed on lovenox to warfarin bridge with goal INR of
___. Patient represented to ___ ___ with GIB during which
time warfarin and heparin were held. She subsequently developed
right UE PICC-associated DVT and later ___ that hospital stay had
CT angiogram of the chest performed and was found to have
multiple subsegmental PEs. She has thus been on coumadin for 4
continuous months, with all INRs ___ our system ___ the
therapeutic to supratherpeutic range. INR was reversed ___
but was labile and increased above ___ several times during
hospital stay despite administration of both PO and IV vitamin
K. She was first maintained on a heparin drip and then
transitioned to apixaban 2.5 mg BID (originally on 5 mg BID but
dose-reduced to 2.5 mg BID due to patient's weight and concern
for bleeding).
# Severe Malnutrition. Ms. ___ had poor PO intake throughout
hospital stay, with ongoing coagulopathy and poor wound healing.
She was given multivitamin with minerals and nutritional
supplements. Nutrition recommended supplementation with tube
feeds but patient refused placement of Dobhof tube. Zinc and
copper levels were within normal limits.
# Hypoglycemia. Per collateral from ___, FSBS ___ on
metformin and glipizide. Likely due to sepsis and glipizide.
Treated with IV D5W on day 1 and quickly dc'd with stable BS
throughout hospital course.
# ___. Creatinine 2.4 on admission from baseline 0.7. Likely
pre-renal/ATN from sepsis. Improved to baseline with IVF and
antibiotics.
# Type II NSTEMI. Troponin T elevated to 0.07 on admission, and
subsequently downtrended. No chest pain or ischemic EKG changes.
# Anemia: Hypoproliferative, normocytic anemia. Pattern of
down-trending Hgb following pRBC transfusions. Low Fe, low TIBC,
normal haptoglobin, increased ferritin, and decreased
transferrin portray anemia of chronic disease. Consistent with
hx of IBD and multiple bowel resections. Elevated D-dimer and
fibrinogen reassuring that patient was not ___ DIC. Has a hx of
UGI bleed ___ setting of previous supratherapeutic INR and
anastomosis. Less suspicious for current GI bleed given that she
has not had any episodes of hemoptysis, melena from ostomy site,
and is remaining normotensive. Hb was labile and patient
received a total of 4 units pRBCs ___ due to downdrifting
Hb below 7. Only clinical sign of bleeding was scant rectal
bleeding from rectal pouch as described above.
CHRONIC ISSUES:
====================
#) IBD s/p colectomy with history of multiple abscesses and
revisions. Ms. ___ was diagnosed with UC nearly ___ years ago.
Most recently ___ ___ underwent distal descending/sigmoid
resection w/ ___ pouch and colostomy after she was found to
have abscess suggestive of sigmoid colonic perf. Course
complicated by purulent drainage from her midline incision and
MSSA bacteremia. She was treated with vancomycin and pip/tazo
from ___, then transitioned to Bactrim (2 DS tabs BID)
___ and finally to Cephalexin ___ to ___ with plan to
complete an additional 11 days of treatment after discharge. For
her IBD, patient follows with Dr. ___ at ___ but
has not been seen ___ outpatient setting for a while. PCP has
told prior hospital teams that patient should be on
immunosuppressive regimen. Rectal hydrocortisone was
administered as above.
#Tachycardia: HR ___ the ___ when patient is at rest. Tachycardia
associated with episodes of pain/anxiety, and pt with known
history of SVT though EKGs were consistent with sinus
tachycardia ___. There was some concern for PE given hx of
PE's ___ the past and recent INR fluctuations. However, no
dyspnea, SOB, or chest pain to suggest PE and no evidence of RV
dilation on recent echo (___).
TRANSITIONAL ISSUES:
====================
- Apixaban: Patient is on dosing theshold given weight. Was
briefly on apixaban 5 mg BID but then decreased to 2.5 mg given
concern for consistently high INR (thought largely due to
malnutrition) and risk of bleed.
- Holding glipizide at discharge given severe hypoglycemia.
- Ms. ___ grew MIXED BACTERIAL FLORA and sparse growth of 2
colonial morphologies of pseudomonas from wound culture ___.
These were felt to be colonizers.
- Steroid Enema: Hydrocortisone Acetate 10% Foam ___ID
was initiated (start ___. She will need to be on this
medication BID for 2 weeks, and then every other day for 1 week
and then twice a week for 2 weeks and then stop.
- Antibiotics: Continue PO Vanc for 7 days after completing
ceftriaxone (start date ___ | projected end date ___
- Antivirals: Continue acyclovir for a total of 5 days of
therapy (start ___ | projected end date ___
- Pain: Continue oxycodone 2.5 mg tid and oxycodone 2.5 q4h prn.
If she is still uncomfortable, can consider increasing standing
to 5 mg tid. Continue Gabapentin 200 mg PO/NG BID, acetaminophen
1 g Q8H, OxyCODONE (Immediate Release) 2.5 mg PO/NG Q4H:PRN
BREAKTHROUGH PAIN.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 1000 mg PO Q8H
2. Levothyroxine Sodium 100 mcg PO DAILY
3. OxyCODONE (Immediate Release) 2.5 mg PO BID
4. Pantoprazole 40 mg PO Q12H
5. Warfarin 3 mg PO DAILY16
6. Ascorbic Acid ___ mg PO DAILY
7. Gabapentin 100 mg PO BID
8. Zinc Sulfate 220 mg PO DAILY
9. Lisinopril 20 mg PO DAILY
10. GlipiZIDE 5 mg PO DAILY
11. Furosemide 20 mg PO DAILY
12. Tamsulosin 0.4 mg PO QHS
13. Multivitamins W/minerals 1 TAB PO DAILY
14. Mirtazapine 15 mg PO QHS
15. Cephalexin 500 mg PO Q6H
16. Miconazole Powder 2% 1 Appl TP BID:PRN groin rash
17. TraMADol 50 mg PO Q6H:PRN Pain - Moderate
18. Docusate Sodium 100 mg PO BID:PRN constipation
19. Miconazole Nitrate Vag Cream 2% 1 Appl VG QHS
20. Calcium Carbonate 500 mg PO BID
21. Salonpas (camphor-methyl salicyl-menthol;<br>methyl
salicylate-menthol) ___ % topical DAILY
22. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain - Severe
Discharge Medications:
1. Acyclovir 200 mg PO 5X/D Duration: 10 Days
RX *acyclovir 200 mg 1 capsule(s) by mouth five times a day Disp
#*20 Capsule Refills:*0
2. Apixaban 2.5 mg PO BID
RX *apixaban [Eliquis] 2.5 mg 1 tablet(s) by mouth twice daily
Disp #*60 Tablet Refills:*0
3. Hydrocortisone Acetate 10% Foam ___ID
RX *hydrocortisone acetate [Cortifoam] 10 % 1 foam(s) rectally
twice a day Refills:*0
4. Lidocaine 5% Patch 2 PTCH TD QAM Please apply 1 patch to
each knee
RX *lidocaine 5 % apply to both affected knees daily Disp #*60
Patch Refills:*0
5. Psyllium Powder 1 PKT PO BID
RX *psyllium husk (aspartame) [Fiber (with aspartame)] 3.4
gram/5.8 gram 1 powder(s) by mouth twice a day Refills:*0
6. Senna 8.6 mg PO BID:PRN constipation
RX *sennosides 8.6 mg 1 tablet by mouth twice a day Disp #*60
Tablet Refills:*0
7. Vancomycin Oral Liquid ___ mg PO Q6H
RX *vancomycin 125 mg/2.5 mL 1 syringe(s) by mouth every six (6)
hours Disp #*12 Syringe Refills:*0
8. Gabapentin 200 mg PO BID
9. Lisinopril 5 mg PO DAILY
10. OxyCODONE (Immediate Release) 2.5 mg PO TID
RX *oxycodone 5 mg 0.5 (One half) tablet(s) by mouth three times
a day Disp #*3 Tablet Refills:*0
11. OxyCODONE (Immediate Release) 2.5 mg PO Q4H:PRN
BREAKTHROUGH PAIN
RX *oxycodone 5 mg 0.5 (One half) tablet(s) by mouth every 4
hours as needed Disp #*6 Tablet Refills:*0
12. Acetaminophen 1000 mg PO Q8H
13. Ascorbic Acid ___ mg PO DAILY
14. Calcium Carbonate 500 mg PO BID
15. Docusate Sodium 100 mg PO BID:PRN constipation
16. Levothyroxine Sodium 100 mcg PO DAILY
17. Miconazole Nitrate Vag Cream 2% 1 Appl VG QHS
18. Miconazole Powder 2% 1 Appl TP BID:PRN groin rash
19. Mirtazapine 15 mg PO QHS
20. Multivitamins W/minerals 1 TAB PO DAILY
21. Pantoprazole 40 mg PO Q12H
22. Salonpas (camphor-methyl salicyl-menthol;<br>methyl
salicylate-menthol) ___ % topical DAILY
23. HELD- GlipiZIDE 5 mg PO DAILY This medication was held. Do
not restart GlipiZIDE until discussing with your primary care
doctor
24. HELD- Tamsulosin 0.4 mg PO QHS This medication was held. Do
not restart Tamsulosin until discussing with your primary care
doctor
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary
=======
Sepsis
Severe clostridium difficile colitis
Persistent leukocytosis
Sinus tachycardia
Sacral wound herpes simplex 2 infection
Diversion Colitis
Chronic malnutrition
Hypoglycemia
Demand ischemia
Acute kidney injury
Anemia
Secondary
=========
History of pulmonary embolism
Inflammatory bowel 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:
Ms. ___,
It was a pleasure caring for you at ___
___. You came to us with very low blood pressures and
very low blood sugar and were found to have several infections,
including an infection of your colon called Clostridium
difficile colitis and wound infections on your back (HSV 2). We
also switched your blood thinner from Coumadin to a medication
called apixaban because Coumadin was felt to be unsafe for you
with your nutritional deficit.
Please take all of your medications as detailed ___ this
discharge summary. If you experience any of the danger signs
below, please contact your primary care doctor or come to the
emergency department immediately.
Best Wishes,
Your ___ Care Team
Followup Instructions:
___
|
19724930-DS-19
| 19,724,930 | 26,439,242 |
DS
| 19 |
2124-11-06 00:00:00
|
2124-11-06 19:40:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Plasma Protein Fraction / AmLactin
Attending: ___.
Chief Complaint:
dyspnea on exertion
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with h/o paroxysmal afib s/p maze procedure, PV isolation
and atrial appendage resection, chronotropic incompetence,
fibrothorax w/ trapped lung s/p decortication, COPD and sleep
apnea, presents to ED with complaint of DOE and chest pain. At
baseline, patient can climb 4 flights of stairs due to
chronotropic incompetence, but in the last week, has became
increasingly dyspneic on exertion with associated chest
pressure. He reports he can only climb one flight of stairs with
severe dyspnea. Also endorses 6 pound weight gain in one week
and leg swelling. No PND or palpitations.
Past Medical History:
- Atrial fibrillation, status post mini maze and left atrial
appendage ligation in ___, complicated by a trapped lung,
status post decortication. previously treated with warfarin and
metoprolol, but has not required since maze
- History of CVA in ___, which was ultimately
considered related to a cerebellar infarct secondary to an
embolic vertebral artery abnormality.
- History of PFO.
- Chronotropic insufficiency with exercise-induced fatigue and
shortness of breath with extensive evaluation including exercise
spirometry.
- zio patch monitor - showed ventricular ectopy declined
metoprolol treatment
- OSA
- COPD
Social History:
___
Family History:
Father had arrhythmia (unknown etiology)
Physical Exam:
ADMISSION EXAM:
VS: Tm 97.8; 152-156/81-87; 64-72, 18, 98%RA 255 lbs
GENERAL: pleasant man, NAD
HEENT: NCAT. Sclera anicteric. PERRL, EOMI.
NECK: Supple with JVP of 8 cm.
CARDIAC: PMI located in ___ intercostal space, midclavicular
line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or
S4.
LUNGS: diffuse wheezing, bibasilar crackles, L>R, decreased
breath sound at right base.
ABDOMEN: Soft, NT slightly protuberant. No HSM or tenderness.
Abd aorta not enlarged by palpation. No abdominal bruits.
EXTREMITIES: 1+ pitting edema to mid shin,
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
DISCHARGE EXAM:
VS: T 98.3 BP `156/72 HR 65 RR 20 SaO2 95% on RA
255 lbs -> 251 lbs
___ ambulatory sat 94% (started at 94%) HR 71-->91 after 2
flights stairs
GENERAL: pleasant man, NAD
HEENT: EOMI, MMM
NECK: Supple with JVP of 8 cm.
CARDIAC: RRR< no m/r/g.
LUNGS: Good air movement. Faint crackles in left posterior
base. No wheezing.
ABDOMEN: Soft, NT slightly protuberant. No HSM or tenderness.
Abd aorta not enlarged by palpation. No abdominal bruits.
EXTREMITIES: 1+ pitting edema to mid shin,
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
Pertinent Results:
ADMISSION LABS:
___ 01:00AM BLOOD WBC-6.8 RBC-4.44* Hgb-13.6* Hct-41.2
MCV-93 MCH-30.6 MCHC-33.0 RDW-14.8 Plt ___
___ 01:00AM BLOOD Neuts-60.1 ___ Monos-5.2 Eos-4.1*
Baso-1.3
___ 07:00AM BLOOD ___ PTT-32.2 ___
___ 01:00AM BLOOD Glucose-104* UreaN-16 Creat-0.8 Na-140
K-3.8 Cl-106 HCO3-26 AnGap-12
___ 07:00AM BLOOD Calcium-8.7 Phos-3.2 Mg-1.9
___ 02:00AM BLOOD D-Dimer-435
___ 01:08AM BLOOD Lactate-1.1
___ 01:00AM BLOOD cTropnT-0.02*
___ 07:00AM BLOOD CK-MB-2 cTropnT-<0.01
___ 01:00AM BLOOD proBNP-480
IMAGING:
CXR ___:
1. Mild interval increase in heart size may represent incipient
heart
failure.
2. No evidence of acute cardiopulmonary process. Areas of
bilateral pleural thickening are unchanged from prior.
ECHOCARDIOGRAM (___)
The left atrium is moderately dilated. The right atrium is
moderately dilated. Left ventricular wall thickness, cavity
size, and global systolic function are normal (LVEF>55%). Due to
suboptimal technical quality, a focal wall motion abnormality
cannot be fully excluded. 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. There is no
mitral valve prolapse. Mild (1+) mitral regurgitation is seen.
There is moderate pulmonary artery systolic hypertension. There
is an anterior space which most likely represents a prominent
fat pad.
IMPRESSION: Suboptimal image quality due to body habitus. Left
ventricular systolic function is probably normal, a focal wall
motion abnormality cannot be excluded. The right ventricle is
not well seen but is probably normal. Mild mitral regurgitation.
Moderate elevation of pulmonary artery systolic pressure.
Brief Hospital Course:
___ with PMHx afib s/p PVI and maze procedure, COPD, OSA, HTN,
presents with DOE and chest pressure.
#) DYSPNEA ON EXERTION: Ruled out for MI with trop neg x2. EGK
without ischemic changes. Exam slightly fluid overloaded
although sats 98% on RA and CXR shows no overt edema. Echo
consistent with pulmonary hypertension / right heart failure.
D-dimer negative. Patient performed well with ___ and O2sat was
94% on RA prior to and after exertion. Symptoms felt to be due
to some combination of COPD/restrictive lung disease and/or
chronotropic incompetence. Had been evaluated for permanent
pacemaker placement by Dr. ___. However, given recent
PFTs showing obstruction/restriction, elected to pursue
cardiopulmonary exercise tolerance test with tracking of HR by
continuous ECG on the day following discharge ___. He had
not previously been on bronchodilators so he was given
prescriptions for these upon discharge.
#) OSA: Continued home CPAP
#) HTN: Started lisinopril 5mg daily
#CODE: Full
#CONTACT: HCP ___ (___)
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Omeprazole 20 mg PO DAILY
3. Tiotropium Bromide 1 CAP IH DAILY
RX *tiotropium bromide [Spiriva with HandiHaler] 18 mcg 1 cap IH
daily Disp #*30 Capsule Refills:*0
4. azelastine *NF* 0.15 % (205.5 mcg) NU BID
5. bee pollen *NF* 580 mg Oral qd
6. Fish Oil (Omega 3) 1000 mg PO DAILY
7. Omnaris *NF* (ciclesonide) 50 mcg NU 2 sprays daily
8. Albuterol Inhaler 1 PUFF IH Q4H:PRN dyspnea
RX *albuterol 1 PUFF IH every four (4) hours Disp #*3 Inhaler
Refills:*0
9. Furosemide 20 mg PO DAILY
RX *furosemide 20 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
10. Lisinopril 2.5 mg PO DAILY
RX *lisinopril 2.5 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Heart failure
Chronic obstructive pulmonary disease
Chronotropic insufficiency with exercise-induced fatigue
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 with shortness of breath
which we may be due to either your underlying heart or lung
disease. In order to sort this out we have recommended
cardiopulmonary exercise testing which you should undergo
tomorrow at 8:00am. Please keep your other follow-up
appointments as scheduled.
Followup Instructions:
___
|
19725020-DS-19
| 19,725,020 | 25,473,309 |
DS
| 19 |
2148-08-12 00:00:00
|
2148-08-14 08:35:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
codeine
Attending: ___.
Chief Complaint:
Falls, Fever
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___. is a ___ with hx bipolar disorder and HTN on
atenolol presenting s/p fall.
He fell yesterday and today walking downhill. He was carrying a
rug at the time. He describes walking down the hill and being
unable to control the speed of his descent, and then falling
down and hitting his knees and the side of his head. No syncope.
He has had a cough for the last couple days. No myalgias, no
constipation/diarrhea. No headache, neck pain, or neck
stiffness. No dysuria. He is going to the bathroom frequently
but not more than normal. No dizziness/lightheadedness,
palpitations, or blurry vision prior to falls. No loss of bowel
or bladder control.
In the ED, he was reportedly a little altered on exam i/s/o
being febrile. As temperature came down, became a little more
coherent.
He denies symptoms of mania including spending lots of money,
being unable to sleep, or gambling (which was a problem before).
Denies depressed mood. Says he has been very stable on his
lithium. Denies thoughts of harming himself or others.
In the ED patient's vital signs: 103.4 80 180/100 16 94% RA.
He was given:
Acetaminophen 1000mg PO x1
1L NS
Labs in the ED notable for: UA with trace protein but otherwise
negative, flu PCR negative, lactate 1.6, Cr 1.1, LFTs WNL,
lipase 23, H&H 11.3/37.6, Utox negative.
Imaging notable for CXR showing mild pulmonary vascular
congestion with probable trace bilateral pleural effusions and
mild bibasilar atelectasis. Non-con head CT showed mild right
periorbital swelling and no acute intracranial process, and CT
c-spine was without fracture or traumatic malalignment.
He was admitted to medicine for fever and possible delirium.
Vitals prior to transfer: 99.2 58 151/74 21 97% RA
On arrival to floor, patient endorses no complaints.
ROS: Full 10 pt review of systems negative except for above.
Past Medical History:
-S/p appendectomy
-BPH
-Bipolar disorder
-Calcified pineal cyst
-Colonic polyps
-Erectile dysfunction
-Right shoulder pain
-Hip pain
-Knee pain
-Hypertension
-Hyperlipidemia
-Microcytosis
-Obstructive sleep apnea
-Tobacco abuse
-Seborrheic dermatitis
Social History:
___
Family History:
Paternal aunt and cousin with bipolar disorder, father and
grandfather with ETOH abuse and dependence. Mother dependent on
diet pills.
Physical Exam:
Admission Physical Exam:
========================
Vitals: 98.6 143/66 55 17 100RA
General: Alert, oriented, no acute distress
HEENT: Abrasion on right scalp, Sclera anicteric, PERRL, EOMI,
MMM, OP clear, mild R eye puffiness
Neck: Supple, JVP not elevated, no LAD
Lungs: CTAB
CV: RRR, normal S1 + S2, no m/r/g
Abdomen: Soft, NT/ND, +BS, no rebound tenderness or guarding, no
organomegaly
Ext: WWP, 2+ pulses, no clubbing, cyanosis or edema
Skin: Abrasion on right scalp and right hand, no rash
Neuro: A/O x3. Full strength in all muscle groups upper and
lower extremities. CN II-XII grossly intact. Gait exam deferred.
Psych: Slightly strange affect, responds appropriately, mood
normal. No overt psychosis. No HI/SI.
Discharge Physical Exam:
========================
Pertinent Results:
Admission Labs:
===============
___ 03:26PM BLOOD WBC-6.8 RBC-4.94 Hgb-11.3* Hct-37.6*
MCV-76* MCH-22.9* MCHC-30.1* RDW-15.1 RDWSD-41.3 Plt ___
___ 03:26PM BLOOD Neuts-82.0* Lymphs-8.4* Monos-8.1
Eos-0.9* Baso-0.3 Im ___ AbsNeut-5.54 AbsLymp-0.57*
AbsMono-0.55 AbsEos-0.06 AbsBaso-0.02
___ 03:26PM BLOOD Glucose-101* UreaN-16 Creat-1.1 Na-138
K-4.9 Cl-106 HCO3-22 AnGap-15
___ 03:26PM BLOOD ALT-20 AST-29 AlkPhos-67 TotBili-0.4
___ 03:26PM BLOOD Lipase-23
___ 03:26PM BLOOD Albumin-4.2
___ 03:26PM BLOOD TSH-1.4
___ 03:26PM BLOOD ASA-NEG Acetmnp-NEG Bnzodzp-NEG
Barbitr-NEG Tricycl-NEG
___ 03:43PM BLOOD Lactate-1.6
Discharge Labs:
===============
Micro:
======
Urine culture ___:
Blood cultures ___:
Urine culture ___:
Studies:
========
CXR ___:
Mild pulmonary vascular congestion with probable trace bilateral
pleural effusions and mild bibasilar atelectasis.
Non-con head CT ___:
Mild right periorbital swelling and no acute intracranial
process.
CT c-spine ___:
No fracture or traumatic malalignment.
Brief Hospital Course:
___ man with bipolar d/o and HTN who was admitted for fever,
URI symptoms, and fall without clear etiology or precipitant.
#Fever & #Community acquire pneumonia: One temperature reading
of 103.4 on presentation to the ED, Tmax on HD2 100.8. Only ___
SIRS criteria. Pt endorsed new cough. No rhinorrhea or
pharyngitis. Flu swab negative. UA and CXR in ED unremarkable.
No evidence of prostatitis, as pt was noted to have
nontender/nonboggy prostate on rectal exam in ED. When pt spiked
fever on HD2, UA and CXR were repeated. UA was again
unremarkable, but repeat CXR showed RLL consolidation with air
bronchograms. Given CXR findings appreciated less than 24 hours
after admission, PNA was not thought to be hospital associated.
Pt was started on ceftriaxone and azithromycin on ___. He was
normoxemic without supplemental oxygen requirement and had no
leukocytosis during admission. He was transitioned to oral
levofloxacin on ___ to complete a 5-day course at home (stop
___. Blood cultures pending on discharge. Urine cultures x2
negative. Pt discharged with home ___ nurse for temperature
checks, HR, and BP checks.
#Fall: The patient presented with fall without clear
precipitant. Per history, sounds like a mechanical fall. No
syncope. In the ED, work-up was negative for fractures,
significant injuries, or any intracranial processes. Pt had fall
precautions while in-house. Pt likely has post-concussive
syndrome after falling and hitting his head. He seemed mildly
confused and forgetful on exam. Unsure of pt's baseline mental
status, but per family pt is cognitively slower than normal. No
focal neurological deficits. Per ___, pt has shuffling gait and
rightward gait deviation, which could be due to post-concussive
syndrome. Per OT, pt failed his post-TBI cognitive screen. Will
be given information about ___ clinic on discharge.
Due to post-concussive syndrome, pt cannot drive until cleared
by PCP. Per ___ and OT recs, pt was discharged with home OT (due
to concussive symptoms) and home ___.
# Bradycardia: On the floor, pt was persistently bradycardic
(40s-50s), asymptomatic. ECG with rate 58, LAD, 1st degree AV
block (PR 214). Telemetry showed no arrhythmias besides
asymptomatic bradycardia. Borderline orthostatic VS (SBP
decreased 161 -> 142). Atenolol d/c'ed due to likely
contribution to bradycardia and orthostasis. Pt discharged with
___ nurse for temperature, HR, and BP checks given
antihypertensive regimen change.
# Bipolar Disorder: The patient has hx of bipolar disorder,
which he reports is well controlled. Home Lithium Carbonate 1200
mg PO qHS continued while in-house. Lithium level therapeutic
(1.4). TSH WNL. Pt did have proteinuria in the s/o long-term
lithium use, which should be followed up as an outpatient.
# R shoulder pain: Followed by orthopedics for outlet
impingement/ subacromial bursitis. Received hydrocortisone
injections several months ago. Home ibuprofen PRN continued.
#BPH: Patient complains of baseline urinary frequency, likely
due to BPH +/- nephrogenic DI from lithium. No dysuria or
objective signs of UTI. No signs of prostatitis on rectal exam.
Home terazosin and oxybutynin continued.
#Hyperlipidemia: Continue home simvastatin.
#Hypertension: Home atenolol d/c'ed i/s/o bradycardia that may
have contributed to fall. Started amlodipine 5mg daily. Pt
discharged with ___ services to monitor BP. Can uptitrate
amlodipine if needed. This medication was chosen over others due
to desire to avoid a diuretic given a possible component of
nephrogenic DI.
#OSA: Home CPAP continued.
Transitional Issues:
[] Complete 5 day course of levofloxacin for treatment of
pneumonia (___).
[] Repeat UA and consider further workup as an outpatient given
proteinuria on UA ___ and ___ i/s/o lithium use.
[] Close PCP ___ on ___ for pneumonia and
post-concussive syndrome.
[] Atenolol discontinued i/s/o bradycardia and fall. Started
amlodipine 5mg daily. Please ___ BP on new regimen and adjust
PRN.
[] Pt cannot drive until cleared by PCP.
# CONTACT: ___ (wife) ___
# CODE: Full
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Terazosin 5 mg PO QHS
2. Lithium Carbonate 1200 mg PO QHS
3. Oxybutynin 15 mg PO Q24H
4. Ketoconazole 2% 1 Appl TP TID:PRN rash
5. Ketoconazole Shampoo 1 Appl TP ASDIR
6. Atenolol 50 mg PO QAM
7. Simvastatin 20 mg PO QPM
8. Ibuprofen 800 mg PO Q6H:PRN shoulder pain
9. sildenafil 100 mg oral ASDIR
10. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Ibuprofen 800 mg PO Q6H:PRN shoulder pain
3. Lithium Carbonate 1200 mg PO QHS
4. Oxybutynin 15 mg PO Q24H
5. Simvastatin 20 mg PO QPM
6. Terazosin 5 mg PO QHS
7. Acetaminophen 650 mg PO Q8H:PRN fever, pain
8. Amlodipine 5 mg PO DAILY
RX *amlodipine 5 mg 1 tablet by mouth daily Disp #*30 Tablet
Refills:*0
9. Ketoconazole 2% 1 Appl TP TID:PRN rash
10. Ketoconazole Shampoo 1 Appl TP ASDIR
11. Sildenafil 100 mg ORAL ASDIR
12. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 tablet(s) by mouth twice a day Disp
#*30 Tablet Refills:*0
13. Senna 8.6 mg PO BID:PRN constipation
RX *sennosides [senna] 8.6 mg 1 tab by mouth twice a day Disp
#*60 Tablet Refills:*0
14. Levofloxacin 750 mg PO DAILY
RX *levofloxacin 750 mg 1 tablet(s) by mouth daily Disp #*5
Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary:
Mechanical fall
Community-Acquired Pneumonia
Secondary:
Bipolar Disorder
BPH
Hyperlipidemia
Hypertension
OSA
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You came into the hospital after having two falls. You were
found to have no broken bones. A CT scan of your head showed no
bleeding, but you have a mild concussion after falling and
hitting your head. You should call your doctor if you notice
headaches, memory problems, nausea/vomiting, or confusion. You
should consider following up in Cognitive Clinic after
discharge. Due to your concussion, you cannot drive until your
PCP says that it is safe.
You had a fever and a cough in the ED, which were likely due to
a pneumonia. You should call your doctor if you develop
sustained fevers at home, worsening cough, chest pain, shortness
of breath.
Thank you for allowing us to be involved in your care.
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
19725417-DS-10
| 19,725,417 | 27,668,527 |
DS
| 10 |
2167-09-08 00:00:00
|
2167-09-08 19:33:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
anorexia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with h/o hypothyroidism, RA presenting with depression,
anorexia, weakness. The son reports that his mother is in a
nursing home with worsening depression over the last couple of
weeks. She has had decreased p.o. intake. On ___ she had a
choking episode. Since at time she has had a productive cough.
In the ED, initial VS were: 99.0, 83, 165/46, 75% RA. Pt had ABG
with PaO2 of 84 on RA. No significant respiratory distress. Sats
improved to 100%. In ED, labs notable for ABG of 7.41/53/84.
Chem panel with Na of 119, K of 6.2 --> D50 + insulin with
repeat 5.4. Cl 83, Bicarb 31. Trop 0.01. CXR concerning for PNA.
Renal was consulted. Pt had UA with 11 WBCs and few bacteria. Bl
cx sent. Pt given Zosyn, Ceftriaxone and levoflox. Pt given
albuterol and ipratrop nebs. Xanax 0.25mg x1. Pt admitted to
MICU for observation.
On arrival to the MICU, pt without complaints. Per
interpretation by daughter-n-law and son, pt denies CP, SOB, abd
pain, n/v, diarrhea, fevers/chills. Pt reports sore throat.
Baseline cough with slight increase in congestion and cough over
past few days. Also with some nasal congestion. No muscle aches.
Pt has had poor PO intake for the past 2wks ___ poor appetite.
Pt's son reports she has been very depressed recently. Per his
report, she was complaining of some issues with her left ear and
went to her last week and had wax cleared out, no reported ear
infection. Today she went to see her PCP and was referred in for
concern of a PNA.
Past Medical History:
# follicular femur lymphoma
- diagnosed after PET scan performed for increasing pulmonary
nodules showed increased uptake in L femur
- s/p 18 sessions of XRT ___ to distal L femur
- followed at ___
# rheumatoid arthritis
# osteoarthritis
# bronchiectasis
# benign hypertension
# GERD
# h/o pulmonary nodules
Social History:
___
Family History:
noncontributory
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vital signs: 99.0 165/46 83 75%RA
General: small frail woman, lying in bed, sleeping but easily
arousable, ___ speaking only
HEENT: Sclera anicteric, MMM, oropharynx clear
CV: RRR, no murmurs
Lungs: diffuse expiratory rattle, decreased BS at R base, good
air movement bilaterally
Abdomen: soft, non-tender, non-distended, bowel sounds present
Back: severe kyphoscoliosis
GU: +foley
Ext: 2+ ___ edema bilaterally up to level of the knees, ___ warm
and well perfused; severe deviation of fingers ___ RA
Neuro: grossly intact
DISCHARGE PHYSICAL EXAM:
Vitals: 97.7 (98.7) 164/68 (140-180/56-64)
88 (70-88) 20 (___) 92%RA (98-99% 1L)
I/O: 340 / 410+ BMx3 (soft)
GENERAL - Alert, interactive, well-appearing, ___
in NAD
HEENT - PERRLA, EOMI, sclerae anicteric, MMM, OP clear
HEART - RRR, nl S1-S2, no MRG.
LUNGS - Scattered inspiratory rhonchi
ABDOMEN - NABS, soft/NT/ND, no masses or HSM
EXTREMITIES - swan neck deformities and arthritis mutilans of
hands, bilateral lower extremity edema 2+ bilaterally in ankles
and 1+ at the knees, 2+ peripheral pulses
NEURO - awake, A&Ox3, CNs II-XII grossly intact
SKIN - No rashes appreciated
Pertinent Results:
ADMISSION LABS:
___ 05:40PM GLUCOSE-103* UREA N-40* CREAT-1.4*
SODIUM-119* POTASSIUM-6.2* CHLORIDE-83* TOTAL CO2-31 ANION
GAP-11
___ 05:40PM ALT(SGPT)-15 AST(SGOT)-23 LD(LDH)-175
CK(CPK)-63 ALK PHOS-102 TOT BILI-0.2
___ 05:40PM cTropnT-0.01
___ 05:40PM proBNP-3488*
___ 05:40PM TOT PROT-7.3 ALBUMIN-3.0* GLOBULIN-4.3*
CALCIUM-7.3* PHOSPHATE-5.2* MAGNESIUM-3.4*
___ 05:40PM TSH-11*
___ 05:40PM TYPE-ART PO2-84* PCO2-53* PH-7.41 TOTAL
CO2-35* BASE XS-6
___ 05:40PM LACTATE-0.5 K+-5.8*
___ 05:40PM WBC-8.6# RBC-3.08* HGB-8.9* HCT-27.3* MCV-89
MCH-29.0 MCHC-32.7 RDW-14.5
___ 05:40PM NEUTS-73.7* ___ MONOS-2.2 EOS-0.3
BASOS-0.2
___ 05:40PM PLT COUNT-612*#
RELEVANT LABS:
___ 06:00AM BLOOD TSH-7.3*
___ 10:00AM BLOOD Cortsol-31.8*
___ 06:00AM BLOOD Free T4-1.0
DISCHARGE LABS:
___ 08:00AM BLOOD WBC-5.1 RBC-2.96* Hgb-8.6* Hct-27.2*
MCV-92 MCH-29.0 MCHC-31.5 RDW-14.6 Plt ___
___ 08:00AM BLOOD ___ PTT-28.9 ___
___ 08:00AM BLOOD Glucose-81 UreaN-26* Creat-1.2* Na-130*
K-4.8 Cl-94* HCO3-28 AnGap-13
___ 08:00AM BLOOD Calcium-7.4* Phos-3.9 Mg-2.6
MICROBIOLOGY:
___ Blood culture: no growth
___ Urine culture: no growth
___ MRSA screen: no growth
___ Stool C. diff: negative
___ Urine Legionella: negative
STUDIES:
___ CXR PA/lat: Mild-to-moderate pulmonary edema, slightly
worse in the interval, with persistent small bilateral pleural
effusions and bibasilar airspace opacities likely reflecting
atelectasis, but infection is not excluded.
___ CT chest:
1. Multifocal peribronchial thickening and consolidation, with
more confluent consolidation in the left lower lobe, are
consistent with multifocal infection. Dense consolidation in
the right lower lobe is relaxation atelectasis or another site
of pneumonia. Repeat chest CT after treatment in a few weeks is
recommended to rule out any unrelated pulmonary nodules.
2. Moderate cardiomegaly, bilateral small effusions and
pulmonary edema.
3. Severe coronary atherosclerosis.
4. Mild scattered areas of bronchiectasis. Moderate emphysema
5. A 17 mm left thyroid nodule, for which a thyroid ultrasound
is
recommended, if this has not been performed before.
___ EKG: NSR @ 66 bpm, NA/NI, low voltage throughout. No ST
elevations or depressions.
___ TTE:
-LV EF 60%
-PASP 36 mmHg
Conclusions
The left atrium is normal in size. 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%). Tissue Doppler
imaging suggests an increased left ventricular filling pressure
(PCWP>18mmHg). Right ventricular chamber size is 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 mildly thickened.
There is no mitral valve prolapse. Trivial mitral regurgitation
is seen. There is mild pulmonary artery systolic hypertension.
There is no pericardial effusion.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
preserved regional and global biventricular systolic function.
Pulmonary artery hypertension. Increased PCWP.
Brief Hospital Course:
___ with h/o hypothyroidism, RA presenting with anorexia and
productive cough.
ACTIVE ISSUES:
# Multifocal pneumonia: Right lower lobe effusion with possible
infiltrate concerning for possible PNA on admission CXR in the
setting of productive cough suggestive of possible pneumonia
although story not overwhelming. Does have known bronchiectasis
so at higher risk for pneumonia also raising concern for chronic
aspiration. No fever of absolute WBC but dose have evidence of
inflammation with thrombocytosis (could be other causes of this)
which also raises a question for a chronic process. Concern for
aspiration due to subacute nature of illness and clinical
appearance which raises concern not controlling her secretions.
Pt put on Unasyn for aspiration PNA coverage. Blood cultures
were sent and remain NGTD. Pt had CT chest to better evaluate
abnormal CXR, which showed multifocal process concerning for
infection and findings consistent with chronic aspiration and
mild bronchiectasis. She was transitioned to Augementin to
finish a 10-day course for aspiration pneumonia (complete on
___
# Significant depression: Unclear etiology. Per family, she has
been more "down in the dumps" over last 2 weeks with decreased
oral intake. ___ be exacerbated by current illness or
hypothyroidism in setting of stopping synthroid. Patient was not
very communicative regarding current emotions. Home
amytriptyline and alprazolam held but retarted when mental
status was stable.She was restarted on her previously prescribed
synthroid.
# Poor nutritional status: Albumin only 3 but hasn't been eating
much last few weeks. Seems behavioral potentially in setting of
depression. Nutrition consulted and pt started on supplements
with meals.
# ___: Creatinine of 1.2-1.4 significantly over baseline of 0.6
in ___. Etiology was most likely prerenal in the setting of
low urine sodium and history of poor PO intake for weeks.
However, creatinine did not improve with IV fluids. Patient may
have had insult to the kidneys prior to this admission that
established a new creatinine baseline range. She maintained
excellent urine output.
# Hyponatremia: Likely multifactorial. Low urine sodium in the
setting of normal urine osmols suggested possibility of SIADH,
especially in the setting of possible pneumonia or pulmonary
process. Pt with history suggesting hypovolemic process. She was
given IVF challenge (concurrently with lasix for hyperK), and Na
improved from 119 to 125. Subsequently, she was
fluid-restricted, and sodium improved to 130, suggesting a
prominent role of SIADH. There may have also been some
contribution from hypothyroidism, although even though her TSH
was low, her free T4 was WNL. Morning cortisol was normal.
Improving at time of discharge.
# Hyperkalemia: 6.2 on presentation, improved to 5.4 after D50
and insulin in the ED. K back up to 6.2 without EKG changes. Pt
given IVF and lasix and K downtrended. Within normal range at
the time of discharge.
# Hypothyrodism: Recently untreated per family as they say pt no
longer on 75mcg of levothyroxine. Last TSH was elevated. Worry
that thsi may be responsible for part of low Na and worsened
depression. TSH at 11, restarted levothyroxine at 50mcg.
# Thrombocytosis: Unclear etiolog,y but likely represents
inflammatory process. DDx is infection (PNA) vs malignancy
(lymphoma) vs Rheum (RA) vs ? hypothyrodism (untreated).
Improved over the ___ of admission.
# Lower extremity edema: Noted by patient to be a chronic issue.
This improved slightly with leg elevation. TTE on ___
showed LV EF of 60% with preserved regional and global systolic
function, mild LVH, elevated PCWP and PASP elevated to 36 mmHg.
Patient may benefit from initiation of diuretic therapy, with
careful monitoring of volume balance and sodium balance.
CHRONIC ISSUES:
# HTN: Continued home amlodipine, metop
# RA: chronic, stable, no currently on treatment
TRANSITIONAL ISSUES:
1. Code status: full
2. Patient should continue fluid restriction at home of 1200 cc
3. Daily weighs should be monitored carefully.
4. Monitor fluid status. Patient may benefit from diuretics,
given lower extremity edema and elevated wedge pressure.
5. repeat imaging of her chest with CT to evaluate for
resolution of of the lower lobe consolidation and to exclude
underlying pulmonary nodules.
6. consider non-emergent U/S to evaluate thyroid nodule seen on
chest CT
7. please re-assess her sodium and BUN/Cr level at f/u to
determine need for further referral to ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB
2. Alendronate Sodium 70 mg PO QSUN
3. ALPRAZolam 0.25 mg PO BID
4. Amitriptyline 10 mg PO HS
5. Amlodipine 10 mg PO DAILY
6. Guaifenesin-CODEINE Phosphate 5 mL PO BID
7. Metoprolol Succinate XL 25 mg PO BID
8. Ondansetron 8 mg PO Q12H:PRN nausea
9. Potassium Chloride 10 mEq PO DAILY Duration: 24 Hours
10. Triamcinolone Acetonide 0.1% Cream 1 Appl TP BID
11. Loratadine *NF* 10 mg Oral Daily
Discharge Medications:
1. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB
2. ALPRAZolam 0.25 mg PO BID
3. Amlodipine 10 mg PO DAILY
4. Amoxicillin-Clavulanic Acid ___ mg PO Q12H
RX *amoxicillin-pot clavulanate 500 mg-125 mg 1 tablet(s) by
mouth twice daily Disp #*6 Tablet Refills:*0
5. Triamcinolone Acetonide 0.1% Cream 1 Appl TP BID
6. Metoprolol Succinate XL 25 mg PO BID
7. Loratadine *NF* 10 mg Oral Daily
8. Guaifenesin-CODEINE Phosphate 5 mL PO BID
9. Alendronate Sodium 70 mg PO QSUN
10. Amitriptyline 10 mg PO HS
11. Levothyroxine Sodium 50 mcg PO DAILY
RX *levothyroxine [Levothroid] 50 mcg 1 tablet(s) by mouth daily
Disp #*30 Tablet Refills:*0
12. Multivitamins 1 TAB PO DAILY
RX *multivitamin [Multi-Day] 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*0
13. Ondansetron 8 mg PO Q12H:PRN nausea
14. Guaifenesin ___ mL PO Q6H:PRN shortness of breath, cough
RX *guaifenesin 100 mg/5 mL ___ mL Liquid(s) by mouth four
times per day Disp #*1 Bottle Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSES:
Aspiration pneumonia
Hyponatremia
SECONDARY DIAGNOSES:
Depression
Hypothyroidism
Lower extremity edema
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking care of you at ___
___. You came in with increased sputum production and
concern for pneumonia from your doctor's office. A CT scan and
x-ray showed a pneumonia and you were treated with antibiotics.
You also were found to have some electrolyte abnormalities which
were corrected. Your recent weakness and depression may also be
secondary to low thyroid levels and we recommend you take your
levothyroxine at home. You will need to have your levels
rechecked with your doctor after you leave.
A CT of your chest showed several areas of pneumonia. You
should get a repeat chest CT to ensure that these changes
resolve after treatment of your infection. The CT also showed a
thyroid nodule. Please discuss getting a thyroid ultrasound
with your primary doctor.
An ultrasound of your heart on ___ showed good heart
function, with some volume overload. Your primary care
physician ___ follow your volume status carefully, and may
decide to start treatment for this in the future. At home,
please try to adhere to a fluid restriction of 1200 cc per day,
as this should help control the level of salt in your blood and
your volume balance.
Please see attached for an updated list of your medications.
Wishing you all the best!
Followup Instructions:
___
|
19725494-DS-9
| 19,725,494 | 22,307,181 |
DS
| 9 |
2132-12-05 00:00:00
|
2132-12-06 20:08:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Cephalosporins / Codeine / Prednisone / Nsaids /
Augmentin / Morphine / Compazine / Ceclor / Depakote /
amoxicillin
Attending: ___.
Chief Complaint:
Constipation
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ y/o woman with history of multiple SBO in the setting of
complicated abdominal surgery history, asthma, past
narcotic/ETOH abuse, bipolar d/o and depression presenting for
abdominal pain thought to be partial SBO vs ileus.
She reported that she began having exacerbation of asthma,
followed by abdominal pain. She reports that she has been
passing small amount of gas, however her abdomen has been
distended. She reports one episode of nonbloody emesis. Last
bowel movement was ___. Passed flatus on the morning of
___. She denies any hematochezia. She denies any fevers,
chills, chest pain, current shortness of breath. She reports
that she feels much improved after the breathing treatments and
steroids provided at the outside hospital.
In the ED: Initial VS: 98.5 f, hr 80S, bp 100-110/40-70s, RR 16,
98% RA
Exam: n/a
Labs: WBC 9.7 Hgb 10 plts 165 INR 1.0 lactate 2.2 -> 1.8
lytes normal, Cr 0.7 UA bland
Imaging:
- CT A/P ___:
Patient is status post prior abdominal surgeries with
anastomosis in the bowel noted at multiple levels. There are
multiple loops of fluid-filled dilated small bowel in the mid
abdomen without a definite transition point to suggest
obstruction, similar to prior exam in ___. Large stool
burden is again seen throughout the colon, compatible with
constipation.
Consults: Surgery was consulted in the ED and rec'ced: "No
transition point noted on CT. Scan is actually slightly improved
from previous CT in ___. Patient has history of chronic
constipation and quite extensive stool burden noted on CT,
recommend admit to medicine for eval of chronic constipation vs
ileus. With extensive abdominal surgical history and no
transition point, there is no indication for surgical management
at this time."
Patient had NG tube placed in the ED.
Patient received: IV dilaudid 0.5 x3, Zofran, Albuterol nebs,
metoclopramide
On the floor, the patient confirms the above history. She tells
me that her respiratory symptoms began about 8 weeks ago with
persistent cough. She denies any increase in sputum production.
She reports that she has been placed on at least 3 courses of
antibiotics, and recently finished a course of doxycycline for
this. She is on a prolonged steroid taper, currently taking
prednisone 30 mg daily. She denies any fevers or chills, no
rhinorrhea or congestion. She feels slightly short of breath at
present and continues to have a dry cough.
With respect to her abdominal pain, she says that it has been
worsening for several weeks as well, however it began
intolerable recently. She passed flatus this morning. Nausea but
no emesis today. She tells me that although she has had SBOs in
the past, this is the worst it has ever been.
ROS: (+) Per HPI, 10-point ROS otherwise negative.
Past Medical History:
Hep C
depression
bipolar
asthma
DVT
anorexia
GERD
CIA thrombus s/p stent placement
Narcotic Abuse
Alcohol Abuse
.
PSH:
- ___ ex lap for oarian cyst
- ___ ex lap for ruptired ovarian cyst
- ___ LOA's for SBO
- ___ hysterectomy
- ___ duodenojejunostomy for SMA syndrome
- ___ LOA for SBO
- ___ partial gastrectomy for gastric ulcer
- ___x lap incision
- ___ ex lap for intussuception
- ___ - ___ LOA x 4 for SBO
Social History:
___
Family History:
Patient is adopted and doesn't know birth parents history
Physical Exam:
================
ON ADMISSION
================
Vitals: 97. 9 113 / 70 81 18 92 RA
General: Mildly uncomfortable appearing but in no acute distress
HEENT: PERRL, EOMI, NGT in place
Neck: Supple
CV: RRR, no m/r/g
Lungs: Diffuse expiratory wheezing and frequent dry cough
Abdomen: No bowel sounds, distended and tympanitic, well-healed
longitudinal midline scar, diffusely tender to palpation
Ext: Warm, well-perfused
Neuro: AOx3, cranial nerves grossly intact, gait deferred,
resting tremor
Skin: Scattered ecchymoses on legs and arms
===============
ON DISCHARGE
==============
Vitals: 98.3 PO 108/59 R Lying 69 18 91 Ra
HEENT: PERRL, EOMI
Neck: Supple
CV: RRR, no m/r/g
Lungs: Diffuse expiratory wheezing and frequent dry cough
Abdomen: positive bowel sounds this morning, less distended,
well-healed longitudinal midline scar, diffusely tender to
palpation
Ext: Warm, well-perfused
Neuro: AOx3, cranial nerves grossly intact, gait deferred,
resting tremor
Skin: Scattered ecchymoses on legs and arms
Pertinent Results:
===================
LABS
===================
___ 04:58AM BLOOD WBC-9.7# RBC-3.88* Hgb-10.0*# Hct-32.9*
MCV-85 MCH-25.8*# MCHC-30.4*# RDW-14.7 RDWSD-45.1 Plt ___
___ 04:58AM BLOOD Neuts-87.1* Lymphs-6.1* Monos-5.6
Eos-0.4* Baso-0.1 Im ___ AbsNeut-8.41* AbsLymp-0.59*
AbsMono-0.54 AbsEos-0.04 AbsBaso-0.01
___ 04:58AM BLOOD ___ PTT-25.0 ___
___ 04:58AM BLOOD Glucose-128* UreaN-21* Creat-0.7 Na-140
K-4.6 Cl-103 HCO3-22 AnGap-15
___ 04:58AM BLOOD ALT-24 AST-22 AlkPhos-85 TotBili-0.3
___ 04:58AM BLOOD Albumin-4.0 Calcium-8.7 Phos-3.4 Mg-2.1
___ 03:36AM BLOOD WBC-7.3 RBC-3.99 Hgb-10.4* Hct-33.4*
MCV-84 MCH-26.1 MCHC-31.1* RDW-14.4 RDWSD-44.1 Plt ___
___ 03:36AM BLOOD Neuts-62.4 ___ Monos-11.3 Eos-3.5
Baso-0.1 Im ___ AbsNeut-4.57 AbsLymp-1.58 AbsMono-0.83*
AbsEos-0.26 AbsBaso-0.01
___ 03:36AM BLOOD Glucose-110* UreaN-10 Creat-0.8 Na-142
K-3.6 Cl-102 HCO3-31 AnGap-9*
___ 07:24AM BLOOD ALT-21 AST-20 LD(LDH)-225 AlkPhos-77
TotBili-0.3
=================
MICRO
=================
URINE CULTURE (Final ___: < 10,000 CFU/mL.
___ 4:58 am Blood Culture NGTD
GRAM STAIN (Final ___: >25 PMNs and >10 epithelial
cells/100X field. Gram stain indicates extensive contamination
with upper respiratory secretions. Bacterial culture results
are invalid.
==============
IMAGING
==============
___ CTA
1. No evidence of acute pulmonary embolism or other acute
intrathoracic
abnormality.
2. Trace bilateral pleural effusions with subjacent atelectasis.
___ CT abd w/ contrast
Patient is status post prior abdominal surgeries with
anastomosis in the bowel noted at multiple levels. There are
multiple loops of fluid-filled dilated small bowel in the mid
abdomen without a definite transition point to suggest
obstruction, similar to prior exam in ___. Large stool
burden is again seen throughout the colon, compatible with
constipation.
Brief Hospital Course:
___ female with h/o multiple SBO in the setting of
complicated abdominal surgery history, asthma, past
narcotic/ETOH abuse, bipolar d/o and depression presenting for
abdominal pain thought to be partial SBO vs ileus.
# SBO, abdominal pain: CT imaging on admission showed multiple
loops of fluid-filled dilated small bowel in the mid abdomen
without a definite transition point to suggest obstruction
though patient with tremendous pain and difficulty tolerating
po. She was treated conservatively with NPO and aggressive bowel
regimen, graduating to full liquids on day of discharge with
multiple bowel movements. Follow up with GI Dr. ___
___.
# Pneumonia, cough: patient with history of asthma + recent
prolonged steroid course and courses of abx. CT Chest was
encouraging though with ongoing wheezing and cough on exam.
Possibly a component of narcotic withdrawal
bronchospasm/bronchorrhea. Discharged on steroid taper outlined
below + levofloxacin for possible CAP that had not yet been
treated with a fluoroquinolone. Follow up with primary
pulomologist Dr. ___.
=======================
Transitional Issues:
=======================
[]Discharged on 5-day course levoflox for possible CAP to end
___
[]Steroid taper: methylpred 24 through ___, then 16 mg x 3
days, then 8 mg x 3 days (ends ___
[]Patient states she is to be on full liquids indefinitely until
further recommendations from GI outpt doctor Dr. ___
[]PCP, ___, GI follow up
#Contact: ___ ___
#Code: Full (confirmed)
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Sertraline 150 mg PO DAILY
2. PredniSONE 30 mg PO DAILY
Tapered dose - DOWN
3. PredniSONE 20 mg PO DAILY
Tapered dose - DOWN
4. PredniSONE 10 mg PO DAILY
Tapered dose - DOWN
5. ipratropium bromide 0.06 % nasal DAILY
6. Ranitidine 300 mg PO BID
7. Linzess (linaclotide) 290 mcg oral DAILY
8. LamoTRIgine 100 mg PO BID
9. OLANZapine (Disintegrating Tablet) 20 mg PO QHS
10. Montelukast 10 mg PO DAILY
11. BusPIRone 30 mg PO BID
12. budesonide 0.5 mg/2 mL inhalation BID
13. Fexofenadine 60 mg PO DAILY
14. Baclofen 10 mg PO TID
15. ClonazePAM 1 mg PO BID
16. Senna 36 mg PO BID
17. Bisacodyl 20 mg PO DAILY
18. Docusate Sodium 200 mg PO BID
Discharge Medications:
1. Levofloxacin 750 mg PO DAILY Duration: 2 Days
___ and ___
RX *levofloxacin 750 mg 1 tablet(s) by mouth once a day Disp #*2
Tablet Refills:*0
2. Methylprednisolone 24 mg PO DAILY Duration: 2 Doses
___ and ___
RX *methylprednisolone 8 mg 3 tablet(s) by mouth daily Disp #*6
Tablet Refills:*0
3. Methylprednisolone 16 mg PO DAILY Duration: 3 Doses
___
This is dose # 2 of 3 tapered doses
RX *methylprednisolone 16 mg 1 tablet(s) by mouth daily Disp #*3
Tablet Refills:*0
4. Methylprednisolone 8 mg PO DAILY Duration: 3 Doses
___
This is dose # 3 of 3 tapered doses
RX *methylprednisolone 8 mg 1 tablet(s) by mouth once a day Disp
#*3 Tablet Refills:*0
5. TraMADol 50 mg PO Q4H:PRN Pain - Moderate
RX *tramadol 50 mg 1 tablet(s) by mouth every four (4) hours
Disp #*30 Tablet Refills:*0
6. Baclofen 10 mg PO TID
7. Bisacodyl 20 mg PO DAILY
8. Budesonide 0.5 mg/2 mL inhalation BID
9. BusPIRone 30 mg PO BID
10. ClonazePAM 1 mg PO BID
11. Docusate Sodium 200 mg PO BID
12. Fexofenadine 60 mg PO DAILY
13. ipratropium bromide 0.06 % nasal DAILY
14. LamoTRIgine 100 mg PO BID
15. Linzess (linaclotide) 290 mcg oral DAILY
16. Montelukast 10 mg PO DAILY
17. OLANZapine (Disintegrating Tablet) 20 mg PO QHS
18. Ranitidine 300 mg PO BID
19. Senna 36 mg PO BID
20. Sertraline 150 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
SBO
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Ms. ___,
You were hospitalized for abdominal pain and a small bowel
obstruction. We treated you with pain medication and a bowel
regimen, and your symptoms resolved. You will follow up with
your PCP, ___, and pulm doctor.
It was a pleasure taking care of you!
Your ___ team
Followup Instructions:
___
|
19725695-DS-7
| 19,725,695 | 27,164,809 |
DS
| 7 |
2172-09-03 00:00:00
|
2172-09-04 19:17:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Iodinated Contrast Media - IV Dye
Attending: ___.
Chief Complaint:
Fall
Major Surgical or Invasive Procedure:
___ - Left hip hemiarthroplasty (Dr. ___
History of Present Illness:
___ is a ___ year-old man with a history of herpes
zoster ophthalmicus (right eye), glaucoma, CKD, Chronic iron
deficiency anemia, HLD, prostate cancer who is presenting with
fall. Pt states that he had a mechanical fall when attempting to
ambulate from bed. Denies preceding or concurrent Sx. Denies
head strike or neck/back injury. Was able to call for help, no
sig downtime. LLE pain at L hip, decreased ROM.
Patient was at ___ for eye pain control and they
called ___ and told her he was being transferred to
___. Went there 2 weeks ago was walking without the aid
of walker or cane. Daughter thinks he became weaker at
___, which she noticed when she took him to ___ for a
pain appointment and said he was "atrophied". She is concerned
that tramadol is confusing him. She does not believe that he has
dementia, that he just has some short term memory loss. She has
noticed acute onset between his thinking and pain medication.
RIGHT zoster ophtalmicus started ___. Started antiviral
treatment at ___ around ___ and finished a 10 day
course of treatment. Per daughter, glaucoma worse in the right
eye. Hospitalized in ___ for eye pain and post-herpetic
shingles pain.
Called ___. They said that he was going to the bathroom on
his own and fell. Fall not witnessed. He was found down.
In the ED, initial VS were T 99.1 HR 94 BP 158/77 RR 16 O2 95%
RA
Exam notable for
A&O
RRR + murmur
CTAB anteriorly
left shoulder bruising though nontender, normal ROM
abd s/nt/nd
pain over left hip, legs neurovasc intact
2+ edema in feet
Labs showed Trop 0.15 that trended down to 0.13, UA with RBCs
but no signs of infection, lactate 1.0, BUN 47/Cr 1.6, WBC 10.4
Hgb 8.7, INR 0.9
Imaging showed left displaced femoral neck fracture. CT head,
c-spine with no acute processes. CXR clear.
Received:
- ___ 10:16 PO/NG Methazolamide 50 mg ___
- ___ 10:16 PO TraMADol 50 mg ___
- ___ 10:16 PO/NG Gabapentin 400 mg ___
- ___ 10:16 PO Acetaminophen 1000 mg ___
- ___ 11:18 IVF ___ ( 1000 mL ordered)
___ Started 100 mL/hr
- ___ 14:06 IVF ___ ___ Confirmed No
Change in Rate, rate continued at 100 mL/hr
- ___ 15:36 PO/NG Gabapentin 400 mg ___
Transfer VS were T 98.6 HR 74 BP 153/73 RR 14 O2 93% on RA
Ortho and cardiology were consulted. Ortho felt the fracture
warrented surgical intervention. They discussed with the patient
and his HCP who both wanted surgery. They recommended admission
to medicine given unclear mechanism of fall. Cardiology saw the
ECG with no significant ST-TW changes. Troponin likely elevated
I/s/o fall and demand ischemia. No active chest pain, so no
cardiac interventions recommended.
Decision was made to admit to medicine for further management
and evaluation prior to surgery.
On arrival to the floor, patient reports that his pain is well
controlled, ___. Does not want more pain medication. Does not
remember his fall, but thinks that he tripped. Did not feel
lightheaded, dizzy, or see any stars etc. prior to falling.
REVIEW OF SYSTEMS:
(+) Left hip 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.
All other 10-system review negative in detail.
Past Medical History:
- HTN
- Asthma
- HLD
- Prostate cancer s/p XRT (___)
- Bladder cancer s/p surgical resection ___, BID
___
- AAA s/p repair ___, ___
- Glaucoma
- Zoster ophtalmicus
- Dementia
- Hypertension
- CAD
- Left femoral neck fracture s/p hemiarthoplasty ___
Social History:
___
Family History:
No family history of premature CAD, SCD or cardiomypathies
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: T 97.5 BP 172/93 HR 89 RR 22 O2 96% RA
GENERAL: NAD, reports that he is in ___ pain, elderly man,
appears very cachectic overall
HEENT: AT/NC, EOMI, Right pupil > left pupil with minimal
reaction (apparently is not baseline per ___. anicteric
sclera, pink conjunctiva, MMM, good dentition. Keeps right eye
closed more than left eye, however no acute pain, vision loss,
or conjunctival injection.
NECK: Non-tender supple neck, no LAD, no JVD
HEART: RRR, S1/S2, ___ systolic murmur crescendo-decrescendo at
the USB that radiates to the carotids + ___ systolic murmur at
the apex that obliterates S2 and radiates to the axilla.
LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: no cyanosis, clubbing or edema, moving all 4
extremities with purpose but pain with movement of left leg.
GU: Foley & diaper in place
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact, except right CNII
SKIN: Warm and well perfused, no excoriations or lesions, no
rashes
DISCHARGE PHYSICAL EXAM:
VS: T 98.2 BP 156/78 HR 82 RR 18 O2 100% RA
GENERAL: NAD, alert and awake, comfortable elderly man, appears
very cachectic overall. AOx3
HEENT: AT/NC, EOMI, Right pupil > left pupil with no reaction.
Anicteric sclera, pink conjunctiva, MMM, good dentition. Keeps
right eye closed more than left eye, however no acute pain,
vision loss, or conjunctival injection.
HEART: RRR, S1/S2, ___ systolic murmur crescendo-decrescendo at
the USB that radiates to the carotids + ___ systolic murmur at
the apex that obliterates S2 and radiates to the axilla.
LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding
EXTREMITIES: no cyanosis, clubbing or edema, moving all 4
extremities with purpose but pain with movement of left leg.
Left hip with dressing in place, c/d/i.
PULSES: 2+ DP pulses bilaterally
NEURO: CN III-XII grossly intact
Wound: CDI, staples in place
Pertinent Results:
______________________
ADMISSION LABS:
___ 07:25AM BLOOD WBC-10.4* RBC-2.77* Hgb-8.7* Hct-26.8*
MCV-97 MCH-31.4 MCHC-32.5 RDW-17.1* RDWSD-60.2* Plt ___
___ 07:25AM BLOOD Glucose-89 UreaN-47* Creat-1.6* Na-136
K-4.3 Cl-102 HCO3-22 AnGap-16
___ 07:25AM BLOOD Calcium-8.4 Phos-3.8 Mg-2.4
___ 07:25AM BLOOD cTropnT-0.15*
___ 12:52PM BLOOD cTropnT-0.13*
___ 07:46AM BLOOD Lactate-1.0
______________________
MICROBIOLOGY:
___ Urine Culture - NEGATIVE
___ Blood Culture - PEDNING
______________________
IMAGING:
___ ECHO:
- IMPRESSION: Bileaflet mitral valve prolapse with moderate to
severe mitral regurgitation. Mild aortic valve stenosis. Mild
symmetric left ventricular hypertrophy with preserved regional
and global biventricular systolic function. Mild pulmonary
artery systolic hypertension. Mildly dilated ascending aorta. No
structural cardiac cause of syncope identified.
___ HIP 1 VIEW:
There has been placement of a left hemiarthroplasty that appears
well seated.
Further information can be gathered from the operative report.
Incidental note is made of extensive vascular graft.
___: pathology: femoral head, left, hemiarthroplasty
Patient: ___
___ MRN: ___ ___ Date: ___ Age: ___ Y Sex:M
___ #: ___ Patient Location: Discharged___
Ordering Provider: ___, MD ___ Provider: ___
___, MD
SURGICAL PATHOLOGY REPORT - Final
Received fresh in one container labeled with the patient's name,
___, the medical
record number, and additionally labeled "left femoral hip" is a
5.2 x 5.0 x 4.8 cm irregularly-shaped
femoral head. The articular surface displays slight eburnation.
Osteophytes are not identified. The
femoral neck margin is hemorrhagic and jagged. The specimen is
sectioned to reveal a yellow-red
trabecular cut surface. Representative sections are submitted in
1A-1B, following prior decalcification to processing.
Chest X-ray ___
IMPRESSION:
In comparisons study of ___, the patient has taken a better
inspiration.
Cardiac silhouette is within normal limits and there is no
vascular
congestion, pleural effusion, or acute focal pneumonia.
Continued tortuosity
of the descending aorta.
DISCHARGE LABS:
___ 07:00AM BLOOD WBC-6.9 RBC-2.56* Hgb-8.1* Hct-24.5*
MCV-96 MCH-31.6 MCHC-33.1 RDW-17.3* RDWSD-60.1* Plt ___
___ 10:38AM BLOOD Glucose-147* UreaN-36* Creat-1.8* Na-137
K-4.9 Cl-103 HCO3-19* AnGap-20
___ 10:38AM BLOOD Calcium-8.0* Phos-4.1 Mg-2.3
___ 11:06AM BLOOD WBC-6.6 RBC-3.00* Hgb-9.2* Hct-28.5*
MCV-95 MCH-30.7 MCHC-32.3 RDW-17.2* RDWSD-59.0* Plt ___
___ 11:06AM BLOOD Plt ___
___ 10:05AM BLOOD Glucose-117* UreaN-46* Creat-1.7* Na-135
K-4.9 Cl-103 HCO3-20* AnGap-17
___ 07:25AM BLOOD CK(CPK)-109
___ 10:38AM BLOOD Calcium-8.0* Phos-4.1 Mg-2.3
Brief Hospital Course:
___ is a ___ year-old man with a history of herpes
zoster ophthalmicus (right eye), glaucoma, CKD, chronic iron
deficiency anemia, who presented with mechanical fall, found to
have left femoral neck fracture on imaging, admitted for syncope
work up prior to having surgery here. ___ was done and revealed
mild AS and moderate to severe MR and he was cleared for
surgery. The procedure went well with no complications. Post-op
pain was well controlled with tramadol, APAP, and pregabalin. ___
saw the patient and recommended d/c to rehab.
ACTIVE ISSUES:
===================================
#LEFT FEMORAL NECK FRACTURE:
Patient reported to have a mechanical fall at home as noted
below. There was a foreshortened basicervical left femoral neck
fracture. The femoral head appeared seated in the acetabulum
relatively normally. Cleared by both medicine and cardiology.
- S/P ___ L hip hemiarthoplasty
WBAT LLE
Continue Lovenox 30 mg QPM until ___
- Pain control with acetaminophen + tramadol (dose reduced to 25
mg Q12H:PRN, from 50 mg Q4H to avoid delirium/somnolence) +
Lyrica + lidocaine patches/cream.
- ___ recommended d/c to rehab
#FALL:
From the story it was difficult to confirm the mechanism of
fall, but it did sound mechanical given that the patient had
been getting weaker per his daughter. ___ with mild AS. The
patient was up trying to ambulate to the bathroom during the
night when he fell. As above, ___ recommended rehab.
#POST-HERPETIC NEURALGIA:
Controlled on current pain regimen. The pain waxes and wanes.
Tried switching gabapentin to pregabalin ___, renally dosed,
which seemed to have a good effect. Further pain regimen as
noted above.
#HYPERTENSION:
Home lisinopril and methazolamide were possibly discontinued
recently. He was not been getting them at ___. Re-started
lisinopril after surgery. Held methazolamide upon discharge to
be restarted if blood pressures were higher.
#GLAUCOMA:
Recent admission to ___ on ___ where per daughter,
he has h/o glaucoma, was seen several days prior to admission,
pressure on R eye was 45, and 25 on L eye. He was prescribed
with 3 kinds of eye drops. He was again seen by ophthalmologist
that morning, pressure had improved a lot on both sides: 25 for
R eye and 16 for left eye. He has had cataract surgery in the
right eye. He is blind in his right eye at baseline now.
- Ophthalmologist: ___ MD, ___ in
___ ___. Tried to get in contact but Dr. ___
is out of town this week.
- Eye drop regimen: carbonic anhydrase inhibitor + prostaglandin
analog + alpha-2 agonist
CHRONIC/STABLE ISSUES:
===================================
#ASTHMA: Continue home ___ steroid DAILY + monteleukast
+ albuterol inhaler PRN
#ALLERGIC RHINITIS: Continue home cetirizine and nasal sprays
#HYPERLIPIDEMIA: Continue home pravastatin
#POOR APPETITE: Continue Megace
#TYPE 2 NSTEMI: RESOLVED
Likely demand ischemia I/S/O fall. Trop leak of 0.15 initially,
down to 0.13. CK-MB flat which is reassuring. Cardiology saw the
patient in the ED and saw no concerning ST-TW changes on the
ECG. Patient does have a history of CAD. Started the patient on
low dose metoprolol here, already on ACEi/aspirin.
TRANSITIONAL ISSUES:
====================================
CODE STATUS: Full code
CONTACT: ___ (daughter/HCP) ___
_________________________
FYI:
- Patient's glaucoma medication regimen is a carbonic anhydrase
inhibitor (brinzolamide) + prostaglandin analog (bimatoprost) +
alpha-2 agonist (brimonidine). There was some uncertainty about
this at time of admission.
- To complete 1 month of 30 mg QPM Lovenox (last day ___
- Patient was switched from gabapentin to pregabalin for control
of post-herpetic neuralgia of the right eye, and it seems to be
working at discharge
_________________________
TO DO:
[ ] Assess pain control. The patient is very sensitive to pain
medications and they easily affect his mental status.
[ ] Re-start methazolamide if needed for better blood pressure
control
[ ] Hgb was uptrending and Cr was downtrending at time of
discharge. Please recheck hemoglobin and chemistries at rehab on
___ for ___
[ ] Consider restarting Lisinopril if blood pressures increase
after discharge.
[ ] Megace was decreased to 400mg given prothrombotic risk.
Please consider titrating off this medication after discharge if
otherwise not indicated.
[ ] ___ with PCP and ___ with cardiology as
indicated by PCP
[ ] ___ with ophthalmology as outpatient
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
2. Lisinopril 10 mg PO DAILY
3. azelastine-fluticasone 137-50 mcg/spray nasal DAILY
4. Erythromycin 0.5% Ophth Oint 0.5 in BOTH EYES TID
5. Gabapentin 400 mg PO TID
6. Megestrol Acetate 800 mg PO DAILY
7. Lidocaine 5% Patch 1 PTCH TD QAM
8. Lidocaine 5% Ointment 1 Appl TP DAILY:PRN pain
9. brinzolamide-brimonidine ___ % ophthalmic 1 gtt ___ every 6
hours
10. Dorzolamide 2% Ophth. Soln. 1 DROP BOTH EYES DAILY
11. Methazolamide 50 mg PO DAILY
12. Bisacodyl 10 mg PR QHS:PRN constipation
13. magnesium hydroxide 400 mg (170 mg) oral DAILY:PRN
constipation
14. Fluticasone Propionate NASAL 1 SPRY NU DAILY
15. Simvastatin 20 mg PO QPM
16. Montelukast 10 mg PO DAILY
17. TraMADol 50 mg PO Q4H:PRN Pain - Moderate
18. budesonide-formoterol 80-4.5 mcg/actuation inhalation DAILY
19. bimatoprost 0.01 % ophthalmic QHS
20. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
21. albuterol sulfate 90 mcg/actuation inhalation Q4H:PRN
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Docusate Sodium 100 mg PO BID
3. Enoxaparin Sodium 30 mg SC QPM
Start: ___, First Dose: Next Routine Administration Time
4. Metoprolol Succinate XL 12.5 mg PO DAILY
5. Polyethylene Glycol 17 g PO DAILY
6. Pregabalin 25 mg PO TID
7. Senna 17.2 mg PO HS
8. TraMADol 25 mg PO Q12H:PRN Pain - Moderate
RX *tramadol 50 mg 0.5 (One half) tablet(s) by mouth Twice a day
Disp #*10 Tablet Refills:*0
9. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
10. albuterol sulfate 90 mcg/actuation inhalation Q4H:PRN
11. azelastine-fluticasone 137-50 mcg/spray nasal DAILY
12. bimatoprost 0.01 % ophthalmic QHS
13. Bisacodyl 10 mg PR QHS:PRN constipation
14. brinzolamide-brimonidine ___ % ophthalmic 1 gtt ___ every
6 hours
15. budesonide-formoterol 80-4.5 mcg/actuation inhalation DAILY
16. Erythromycin 0.5% Ophth Oint 0.5 in BOTH EYES TID
17. Fluticasone Propionate NASAL 1 SPRY NU DAILY
18. Lidocaine 5% Ointment 1 Appl TP DAILY:PRN pain
19. Lidocaine 5% Patch 1 PTCH TD QAM
20. magnesium hydroxide 400 mg (170 mg) oral DAILY:PRN
constipation
21. Megestrol Acetate 800 mg PO DAILY
22. Montelukast 10 mg PO DAILY
23. Simvastatin 20 mg PO QPM
24. HELD- Lisinopril 10 mg PO DAILY This medication was held.
Do not restart Lisinopril until blood pressure increases or
otherwise instructed by your physician
25. HELD- Methazolamide 50 mg PO DAILY This medication was
held. Do not restart Methazolamide until your doctors ___
to take it again
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary diagnosis: mechanical fall, left femoral neck fracture
Secondary problem: glaucoma, hypertension
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 because you fell and broke
your left hip.
In the hospital, the following was done:
- The surgeons repaired your left hip
When you leave, you should do the following:
- Follow up with your doctors as noted below
- Note any medication changes or updates below
- Work on getting stronger at rehab so that it is safe for you
to walk again
It was a pleasure taking care of you,
Your ___ Team
Followup Instructions:
___
|
19726079-DS-19
| 19,726,079 | 20,418,078 |
DS
| 19 |
2181-02-22 00:00:00
|
2181-03-01 10:18:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Augmentin / epinephrine / Valium / acetaminophen / aspirin
Attending: ___.
Chief Complaint:
fever
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms. ___ is a ___ yo female with a history of colonic polyps,
diverticulosis, hx of diverticulitis (last bout ___
presenting with ongoing abdominal pain and fevers.
Pt reports that symptoms began initially about ___ days ago
with abdominal pain, described as aching and pressure located in
her lower abdomen, mainly left sided. At that time, she endorsed
some constipation and sensation of bloating as well. She was
seen in urgent care clinic, labs sent were notable for normal
WBC, normal creatinine, no antibiotics started. Howver, the
following day she continued to feel unwell so she was started on
moxiflox for presumed diverticulitis (hx of flagyl intolerance
in the pain, causes nausea). Her symptoms persisted but improved
on the ___ after having a large bowel movement. However,
overnight on ___, pt had worsening of her abdominal pain,
constipation and fever to 101.3 at home, prompting her to
present to the ED. She has been taking moxi as prescribed, and
is currently on day 9 of 10 day course. She reported
constipation since her last bowel movement on ___.
In the ED, initial vitals: 101.4 100 146/62 16 97% RA. She had a
CT scan that showed mild inflammation around the sigmoid colon
without definite evidence of diverticulitis, no drainable fluid
collection or free air to suggest abscess or perforation. She
was tolerating a PO diet, but was admitted given concern for
possible under-treated diverticulitis. She was started on flagyl
prior to admission. Her UA was notable for 10 ketones, otherwise
unremarkable. Notably, nursing noted that pt had 5 bowel
movements in the ED with improvement in her abdominal pain.
Vitals prior to transfer: 98.3 68 98/44 16 99% RA
Currently, pt reports feeling much better since having bowel
movements. She is wondering if she needs surgery for her
diverticulitis. Her appetite has been good recently and she is
wondering what she can eat for dinner.
Past Medical History:
___
colonic polyps
? c diff
osteopenia
diverticulosis
hx diverticulitis
___
cataracts
Social History:
___
Family History:
Father with CAD, PVD
Mother with breast cancer and pancreatic cancer
Grandmother with diabetes
Physical Exam:
ADMISSION EXAM:
================
Vitals- 97.7 104/53 72 14 97% RA
General- Alert, oriented, no acute distress
HEENT- Sclera anicteric, MMM, oropharynx clear
Neck- supple, JVP not elevated, no LAD
Lungs- CTAB no wheezes, rales, rhonchi
CV- RRR, Nl S1, S2, No MRG
Abdomen- soft, NT/ND bowel sounds present, no rebound tenderness
or guarding
GU- no foley
Ext- warm, well perfused, 2+ pulses, no edema
Neuro- CNs2-12 intact, motor function grossly normal
DISCHARGE EXAM:
================
Vitals- Tm 100.2 Tc 97.7 95/49 78 16 97% RA
General- Alert, oriented, no acute distress
HEENT- Sclera anicteric, MMM, oropharynx clear
Neck- supple, JVP not elevated, no LAD
Lungs- CTAB no wheezes, rales, rhonchi
CV- RRR, Nl S1, S2, No MRG
Abdomen- soft, NT/ND bowel sounds present, no rebound tenderness
or guarding
GU- no foley
Ext- warm, well perfused, 2+ pulses, no edema
Neuro- CNs2-12 intact, motor function grossly normal
Pertinent Results:
ADMISSION LABS:
==================
___ 02:50AM BLOOD WBC-5.3 RBC-4.05* Hgb-12.5 Hct-37.4
MCV-92 MCH-30.8 MCHC-33.3 RDW-12.9 Plt ___
___ 02:50AM BLOOD Glucose-108* UreaN-13 Creat-0.9 Na-138
K-4.1 Cl-101 HCO3-25 AnGap-16
DISCHARGE LABS:
==================
___ 08:00AM BLOOD WBC-5.8 RBC-4.05* Hgb-12.3 Hct-37.4
MCV-93 MCH-30.4 MCHC-32.9 RDW-13.0 Plt ___
___ 08:00AM BLOOD Glucose-118* UreaN-9 Creat-0.9 Na-140
K-4.1 Cl-102 HCO3-26 AnGap-16
___ 08:00AM BLOOD Calcium-9.5 Phos-4.0 Mg-2.0
URINALYSIS:
==============
___ 02:25AM URINE Color-Straw Appear-Clear Sp ___
___ 02:25AM URINE Blood-SM Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-10 Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG
___ 02:25AM URINE RBC-<1 WBC-<1 Bacteri-NONE Yeast-NONE
Epi-<1 TransE-<1
MICROBIOLOGY:
=============
___ 2:50 am BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
IMAGING:
===========
CT ABD & PELVIS WITH CONTRAST Study Date of ___
IMPRESSION:
Mild inflammation around the sigmoid colon without definite
evidence of
diverticulitis. No drainable fluid collection or free air to
suggest abscess or perforation.
Brief Hospital Course:
___ yo female with history of diverticulitis presenting with
several days of abdominal pain and 1 day of fevers in the
setting of 9 day treatment course of moxifloxacin. Her pain is
now improved s/p multiple bowel movements in the ED.
ACTIVE ISSUES:
===============
# diverticulitis: Pt recently started on 10 day course of
moxifloxacin for presumed diverticulitis by PCP, currently on
day ___ when she presented with one isolated fever of unclear
etiology, only localizing symptom being abdominal pain. Her
imaging was fairly unremarkable with only mild inflammation in
the sigmoid area. She completed her 10 day course of
antibiotics, and was started on an additional 7 day course of
clindamycin for any residual, undertreated anaerobic infection
(initially trialed on Flagyl but did not tolerate as this caused
her to be short of breath). She was pain free and afebrile at
time of discharge. Given multiple episodes of diverticulitis, pt
was questioning if she needed surgery, however this decision was
deferred to discussion with her PCP and outpatient GI physician.
# constipation: Pt reports intermittent constipation over the
past few weeks, with abdominal pain improving with bowel
movements. She does not have significant history of
constipation, though reportedly does get constipated with her
bouts of diverticulitis. She has known colonic polyps, last
colonoscopy ___ with no obstruction. She was started on
senna, Colace and MiraLax with good result.
CHRONIC ISSUES:
# depression: Continued on Zoloft.
# hyperlipidemia: Continued simvastatin.
TRANSITIONAL ISSUES:
# hematuria: Pt with incidentally noted small blood on UA in ED.
She should follow up as an outpatient.
# Pt should discuss the need for surgery with her PCP and GI
physician.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Simvastatin 10 mg PO DAILY
2. Sertraline 75 mg PO DAILY
Discharge Medications:
1. Sertraline 75 mg PO DAILY
2. Simvastatin 10 mg PO DAILY
3. Polyethylene Glycol 17 g PO DAILY
RX *polyethylene glycol 3350 17 gram 1 powder(s) by mouth daily
Disp #*30 Packet Refills:*0
4. Clindamycin 450 mg PO Q8H
RX *clindamycin HCl 300 mg 1 capsule(s) by mouth every 8 hours
Disp #*18 Capsule Refills:*0
RX *clindamycin HCl 150 mg 1 capsule(s) by mouth every 8 hours
Disp #*18 Capsule Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY:
possible diverticulitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking care of you at ___
___. You were admitted for fevers and abdominal pain.
You had a CT scan that showed just minimal inflammation in part
of your colon. We completed your course of moxifloxacin, and
started you on clindamycin to treat any residual infection. Your
abdominal pain improved with having several bowel movements.
Congratulations on your new grandchild!
Followup Instructions:
___
|
19726617-DS-18
| 19,726,617 | 22,708,541 |
DS
| 18 |
2139-02-14 00:00:00
|
2139-02-14 22:03:00
|
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Right carotid artery stenosis
Major Surgical or Invasive Procedure:
Right carotid endarterectomy
History of Present Illness:
On ___ patient presented to ___ with
two days of transient LUE numbness and tingling. She was in her
usual state of health when she felt acute onset of left hand
numbness primarily in the medial 3 fingers. The sensation
resolved after ___ minutes. The next day, she had numbness of
the LUE extending from her hand to her distal forearm which then
went away, and then on the day of admission had transient
numbness extending to her proximal left arm and left side of
face. She denies any changes in vision, dizziness/headaches,
difficulty with speech/comprehension, weakness of any extremity,
or neck pain throughout this time. At ___, she had
an MRI demonstrating multifocal infarcts in the right MCA
distribution, both combination of new and subacute findings.
Last
numbness was ___ morning, no episodes since then.
Her cryptogenic stroke history is as follows: in ___, she
was
admitted for LUE weakness/numbness/tingling and found to have
scattered infarcts in the right frontal lobe, right frontal
gyrus, right inferior temporal gyrus. She underwent an extensive
workup at that time which revealed less than 50% stenosis of
bilateral ICA. Holter monitor demonstrated no atrial
fibrillation. TCDs did not show any sign of emboli. TEE showed
right to left shunting at the atrial level consistent with
patent
foreman ovale. She underwent a lower extremity ultrasound which
demonstrated no DVTs. An MRV of the pelvis was performed which
demonstrated no DVT. She was recommended to either start
empiric
apixaban versus an implantable recorder, she chose the former.
She has been taking her apixaban as instructed as an outpatient,
and she was started on atorvastatin as well as aspirin and
Plavix, the latter for 30 days after the ___ stroke.
Currently she denies fevers/chills, chest pain/SOB, abdominal
pain. Of note, her blood pressure is very labile at baseline and
she was both hypotensive to SBP ___ and hypertensive to SBP 200s
over the past few days. On physical exam, patient is
neurologically intact. Full strength and sensation bilaterally
in
upper and lower extremities, no evidence of facial droop or
slurred speech.
Past Medical History:
PAST MEDICAL HISTORY:
- HTN
- reports home sBP usually 130-140s, but occasionally 160s
-episodes of post-prandial hypotension
- has tried multiple meds (metoprolol, amlodipine,
HCTZ-lisinopril) but has had difficulties with symptomatic
hypotension
- CKD
- HLD
- asthma
- osteopenia
- L knee arthroscopic surgery
- gout
Social History:
___
Family History:
Mother - deceased at age ___ CAD, COPD, colon Ca, HLD, TB
Father - deceased at age ___ lung Ca + tobacco
Brother - HLD
Sister - HLD
Physical Exam:
Admission Vascular Surgery Physical
PHYSICAL EXAM
Vital Signs: Temp: 98.4 RR: 20 Pulse: 89 BP: 117/75
Neuro/Psych: Oriented x3, Affect Normal, NAD.
Neck: No masses, Trachea midline, Thyroid normal size,
non-tender, no masses or nodules, No right carotid bruit, No
left
carotid bruit.
Nodes: No clavicular/cervical adenopathy, No inguinal
adenopathy.
Skin: No atypical lesions.
Heart: Regular rate and rhythm.
Lungs: Clear, Normal respiratory effort.
Gastrointestinal: Non distended, No masses, Guarding or rebound,
No hepatosplenomegally, No hernia, No AAA.
Extremities: No popiteal aneurysm, No femoral bruit/thrill, No
RLE edema, No LLE Edema, No varicosities, No skin changes,
Cyanosis.
Pulse Exam (P=Palpation, D=Dopplerable, N=None)
RUE Radial: P.
___ Radial: P.
RLE Femoral: P.
LLE Femoral: P.
Discharge Physical Exam
PHYSICAL EXAM
Neuro/Psych: Oriented x3, Affect Normal, NAD. No gross or focal
motor deficits. CN II-XII grossly intact.
Neck: R neck dressing taken down, staples taken out, replaced
with steri strips. Mild neck swelling, no palplable
hematoma/fluid collection.
Heart: Regular rate and rhythm.
Lungs: Normal respiratory effort.
Gastrointestinal: Non distended, No masses, Guarding or rebound,
Extremities: Warm, well perfused, motor function intact
Pulse Exam (P=Palpation, D=Dopplerable, N=None)
RUE Radial: P.
___ Radial: P.
RLE Femoral: P.
LLE Femoral: P.
Pertinent Results:
Admission Lab
___ 10:03PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 05:15AM BLOOD %HbA1c-5.7 eAG-117
___ 10:03PM BLOOD Albumin-3.7 Calcium-8.8 Phos-3.5 Mg-2.1
___ 10:03PM BLOOD cTropnT-<0.01
___ 05:15AM BLOOD CK-MB-<1 cTropnT-<0.01
___ 03:11PM BLOOD CK-MB-4 cTropnT-0.01
___ 10:03PM BLOOD ALT-15 AST-13 AlkPhos-72 TotBili-0.2
___ 10:03PM BLOOD Glucose-104* UreaN-18 Creat-0.9 Na-148*
K-3.7 Cl-108 HCO3-27 AnGap-13
___ 10:03PM BLOOD ___ PTT-30.7 ___
___ 05:15AM BLOOD Lupus-NEG
___ 10:03PM BLOOD Neuts-67.3 ___ Monos-7.1 Eos-0.0*
Baso-0.3 Im ___ AbsNeut-4.26 AbsLymp-1.59 AbsMono-0.45
AbsEos-0.00* AbsBaso-0.02
___ 10:03PM BLOOD WBC-6.3 RBC-3.58* Hgb-12.4 Hct-35.5
MCV-99* MCH-34.6* MCHC-34.9 RDW-11.9 RDWSD-42.7 Plt ___
___ 10:03PM BLOOD WBC-6.3 RBC-3.58* Hgb-12.4 Hct-35.5
MCV-99* MCH-34.6* MCHC-34.9 RDW-11.9 RDWSD-42.7 Plt ___. Redemonstrated few small right frontal hypodensities likely
representing
acute to subacute infarcts better evaluated on the recent MRI
head study.
2. Evidence of a 2 mm penetrating atherosclerotic ulcer arising
from the
posterior aspect of the proximal right ICA. Approximately 50%
narrowing of
the proximal right internal carotid artery.
3. No CTA evidence of arterial dissection, aneurysm or
high-grade stenosis.
Carotid Duplex Neck
RIGHT:
The right carotid vasculature has minimal heterogeneous
atherosclerotic
plaque.
The peak systolic velocity in the right common carotid artery is
61 cm/sec.
The peak systolic velocities in the proximal, mid, and distal
right internal
carotid artery are 75, 83, and 70 cm/sec, respectively.
The peak end diastolic velocity in the right internal carotid
artery is 27
cm/sec.
The ICA/CCA ratio is 1.3.
The external carotid artery has peak systolic velocity of 78
cm/sec.
The vertebral artery is patent with antegrade flow.
LEFT:
The left carotid vasculature has minimal
heterogeneousatherosclerotic plaque.
The peak systolic velocity in the left common carotid artery is
84 cm/sec.
The peak systolic velocities in the proximal, mid, and distal
left internal
carotid artery are 69, 69, and 52 cm/sec, respectively.
The peak end diastolic velocity in the left internal carotid
artery is 27
cm/sec.
The ICA/CCA ratio is 0.82.
The external carotid artery has peak systolic velocity of 59
cm/sec.
The vertebral artery is patent with antegrade flow.
IMPRESSION:
Right ICA <40% stenosis.
Left ICA <40% stenosis.
Discharge Labs
___ 02:50AM BLOOD Hct-35.3
___ 05:15AM BLOOD WBC-6.9 RBC-3.86* Hgb-13.0 Hct-38.4
MCV-100* MCH-33.7* MCHC-33.9 RDW-12.1 RDWSD-43.8 Plt ___
___ 05:15AM BLOOD ___ PTT-29.2 ___
___ 02:50AM BLOOD Creat-0.8 K-4.1
___ 05:15AM BLOOD Glucose-102* UreaN-17 Creat-0.7 Na-148*
K-3.8 Cl-108 HCO3-26 AnGap-14
___ 03:11PM BLOOD CK-MB-4 cTropnT-0.01
Brief Hospital Course:
Ms. ___ presented initally to ___ on ___ in
the setting of two recent, transient episodes of LUE
numbness/weakness. At ___, she had an MRI
demonstrating multifocal infarcts in the right MCA distribution,
a combination of new and subacute findings. In the setting of
these multifocal infarcts and a complex medical history (recent
history of cryptogenic stroke (___), known R ICA stenosis
(50%), known PFO on AC (apixaban)), Ms. ___ was transferred
to ___ for further care.
She was admitted to the neurology service and began stroke
workup. She was completely neurologically intact on
presentation. CTA head/neck showed 2mm penetrating
atherosclerotic ulcer in her R ICA, and approximately 50%
narrowing of the proximal right internal carotid artery.
Comparison with prior CTA (___) demonstrated a possible small
break in prior R ICA thrombus. Venous duplex was negative for
DVT, TTE was negative for intra-cardiac thrombus.
Hypercoaguability workup was grossly negative, some pending
results at time of discharge (cardiolipin pending, anti-thrombin
negative, B2-glycoprotein negative). She was transiently started
on Coumadin before being transitioned to a heparin drip for
anticoagulation. She was evaluated by our team (vascular
surgery) on ___, and felt to be a good candidate for right
carotid endarterectomy. Given her negative TTE, negative ___
venous duplex, and possible interval changes in appearance of
the thrombus in her R ICA, concern was high for carotid etiology
for her symptoms. She was taken to the OR on ___ for right
carotid endarterectomy. Surgery was uncomplicated. A hemorrhagic
plaque was removed from the right ICA. See op note for full
details. Given the gross appearance of the plaque, it seems very
likely her symptoms were related to her R ICA disease. Post-op,
Ms. ___ was neurologically intact (no gross, focal, or
cranial nerve deficits). She recovered in the post-operative
care unit for several hours before being transferred to the
floor for continued monitoring.
Her post-op course was largely uncomplicated. She had a mild
headache on the morning of post-op day 1, and complained of mild
nausea in the setting of having taken morning medications prior
to eating. Her headache and nausea resolved over the course of
the morning. Given her nausea in the setting of recent procedure
under general anesthesia, troponins were sent to rule out MI.
Troponins were negative (Troponin T <0.01). Her nausea had
resolved by mid-morning. Ms. ___ had an episode of
asymptomatic hypertension to SBP 150-160s on post-op day 1, for
which she was given metoprolol x1 with good response. Ms.
___ was normotensive (SBP 120s-130s) at time of discharge.
Prior to discharge, staples were removed from her R neck
incision and were replaced with steri-strips. Her steri-strip
dressed incision was clean/dry/intact at the time of discharge.
Ms. ___ was discharge on the evening of post-op 1 with
instructions to follow up in clinic with Dr. ___ in 1
month, with repeat carotid duplex. She was discharged on Plavix
(new medication, 75mg QD), off anticoagulation.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Albuterol Inhaler 2 PUFF IH Q6H:PRN COPD/asthma
2. Allopurinol ___ mg PO DAILY
3. Apixaban 5 mg PO BID
4. Atorvastatin 80 mg PO QPM
5. Clopidogrel 75 mg PO DAILY
6. Fluticasone Propionate 110mcg 2 PUFF IH BID
7. Furosemide 20 mg PO DAILY
8. Aspirin 81 mg PO DAILY
9. Docusate Sodium 100 mg PO DAILY
Discharge Medications:
1. Albuterol Inhaler 2 PUFF IH Q6H:PRN COPD/asthma
2. Allopurinol ___ mg PO DAILY
3. Clopiogrel 75mg PO QD (ongoing until f/u with neurology)
4. Atorvastatin 80 mg PO QPM
5. Clopidogrel 75 mg PO DAILY
6. Fluticasone Propionate 110mcg 2 PUFF IH BID
7. Furosemide 20 mg PO DAILY
8. Aspirin 81 mg PO DAILY
9. Docusate Sodium 100 mg PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Right carotid stenosis, right middle
cerebral artery territory stroke.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
It was a pleasure taking care of you at ___
___. You were admitted to the hospital after a
carotid endarterectomy. This surgery was done to restore proper
blood flow to your brain. To perform this procedure, an
incision was made in your neck. You tolerated the procedure
well and are now ready to be discharged from the hospital.
Please follow the recommendations below to ensure a speedy and
uneventful recovery.
WHAT TO EXPECT:
Bruising, tenderness, mild swelling, numbness and/or a firm
ridge at the incision site is normal. This will improve
gradually in the next 2 weeks.
You may have a sore throat and or mild hoarseness. Warm tea,
throat lozenges, or cool drinks usually help.
It is normal to feel tired for ___ weeks after your surgery.
MEDICATION INSTRUCTIONS:
Before you leave the hospital, you will be given a list of all
the medicine you should take at home. If a medication that you
normally take is not on the list or a medication that you do not
take is on the list please discuss it with the team!
It is very important that you take Aspirin every day! You
should never stop this medication before checking with your
surgeon.
You should require less pain medication each day. You should
take Tylenol ___ every 6 hours, as needed for neck pain.
.Tylenol is used as an ingredient in some other over-the-counter
and prescription medications. Be aware of how much total
Tylenol you are taking in a day. Do not take more than a daily
total of 3000mg of Tylenol. If Tylenol is not enough, take your
prescription pain medication very sparingly. You should never
drive or operate machinery while on narcotics.
Narcotic pain medication can be very constipating. If you take
narcotics, please also take a stool softener such as Colace.
If constipation becomes a problem, your pharmacist can suggest
an additional over the counter laxative.
CARE OF YOUR NECK INCISION:
You may shower 48 hours after your procedure. Avoid direct
shower spray to the incision. Let soapy water run over the
incision, then rinse and gently pat the area dry. Do not scrub
the incision.
Your neck incision may be left open to air and uncovered unless
you have a small amount of drainage at the site. If drainage is
present, place a small sterile gauze over the incision and
change the gauze daily.
Do not take a bath or go swimming for 2 weeks.
ACTIVITY:
Do not drive for one week after your procedure. Do not ever
drive after taking narcotic pain medication.
You should not push, pull, lift or carry anything heavier than
5 pounds for the next 2 weeks.
After 2 weeks, you may return to your regular activities
including exercise, sexual activitiy and work.
DIET:
It is normal to have a decreased appetite. Your appetite will
return over time. Follow a well-balanced, heart healthy diet,
with moderate restriction of salt and fat.
SMOKING:
If you smoke, it is very important for you to stop. Research
has shown that smoking makes vascular disease worse. Talk to
your primary care provider about ways to quit smoking.
The ___ Smokers' Helpline is a FREE and confidential
way to get support and information to help you quit smoking.
Call ___
CALLING FOR HELP
If you need help, please call us at ___. If you call
during non-business hours, you will reach someone who can help
you reach the vascular surgeon on call.
To get help right away, call ___.
Call the surgeon right away for:
headache that is not controlled with pain
medication or headache that is getting worse
fever of 101 degrees or more
bleeding from the incision, or drainage the is new
or increased, or drainage that is white yellow or green
pain that is not relieved with medication, or pain
that is getting worse instead of better
If you notice any of the following signs of stroke, call ___ to
get help right away.
sudden numbness or weakness of the face, arm or
leg (especially on one side of the body)
sudden confusion, trouble speaking or trouble
understanding speech
trouble seeing in one or both eyes
sudden trouble walking, dizziness, loss of balance
or coordination
sudden severe headache with no known cause
Followup Instructions:
___
|
19726655-DS-22
| 19,726,655 | 29,288,738 |
DS
| 22 |
2174-05-29 00:00:00
|
2174-05-29 09:06:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Beta-Blockers (Beta-Adrenergic Blocking Agts) /
hydrochlorothiazide
Attending: ___.
Chief Complaint:
symptomatic hyponatremia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ year-old woman who presents with a
week of increased nausea, decreased PO intake, slower gait, and
confusion, found to have symptomatic hyponatremia. Since
___, she was had a slower gait and been slightly more
confused. However, starting about a week ago her daughters
became
increasingly concerned. She continued to walk, but was very slow
and deliberate in her movements. She was eating less. And subtly
she was confused. She denied fevers, chills, night sweats,
cough,
hemoptysis, weight loss, abdominal pain. She did have an episode
of an upset stomach three days ago which self resolved, with
diarrhea at that time. She has not had any new medications. In
___, she was briefly off her rivaroxaban after she bruised her
arm, but this was restarted. She saw her primary care Dr.
(___), who performed a BMP and noted that her sodium was 120. He
stopped her HCTZ, and instructed her to eat salty foods.
However,
her sodium was 117 the next day, therefore he instructed the
patient to present to medicine.
In the ED, AVSS. Sodium initially 117. Was fluid restricted and
sodium improved to 120, then 123. K was noted to be 3.2, and
patient was given 60 mEq of Kcl. UA with 20 WBCs and large ___,
and patient was given 1 gm ceftriaxone. Patient was therefore
admitted to medicine for SIADH.
Past Medical History:
A Fib
Moderate AS (echo in ___, asymptomatic)
HLD
Social History:
___
Family History:
Sister had leukemia.
Physical Exam:
ADMISSION EXAM
VITALS: 98.3 PO 134 / 54 75 18 98 Ra
GENERAL: Alert and in no apparent distress
EYES: Anicteric, pupils equally round
ENT: Ears and nose without visible erythema, masses, or trauma.
Oropharynx without visible lesion, erythema or exudate
CV: S1, S2, RRR (not irreg) IV/VI AS murmur with radiation to
the
neck
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: Moderate suprapubic fullness
MSK: Neck supple, moves all extremities, strength grossly full
and symmetric bilaterally in all limbs
SKIN: No rashes or ulcerations noted
NEURO: CN II-XII intact, finger-to-nose intact bilaterally.
Patient has normal gait
PSYCH: pleasant, appropriate affect
Patient examined on day of discharge, BPs 110-150, ambulated
with a normal gait, steadier than yesterday. Otherwise exam
unchanged.
Pertinent Results:
LABORATORY RESULTS:
___ 03:05PM BLOOD WBC-7.2 RBC-4.14 Hgb-12.1 Hct-34.3 MCV-83
MCH-29.2 MCHC-35.3 RDW-12.9 RDWSD-39.2 Plt ___
___ 02:15AM BLOOD WBC-7.0 RBC-3.81* Hgb-11.2 Hct-30.9*
MCV-81* MCH-29.4 MCHC-36.2 RDW-12.8 RDWSD-37.6 Plt ___
___ 06:49AM BLOOD WBC-5.3 RBC-3.38* Hgb-9.9* Hct-27.8*
MCV-82 MCH-29.3 MCHC-35.6 RDW-12.7 RDWSD-38.3 Plt ___
___ 02:15AM BLOOD Neuts-75.2* Lymphs-14.6* Monos-8.1
Eos-1.6 Baso-0.4 Im ___ AbsNeut-5.29 AbsLymp-1.03*
AbsMono-0.57 AbsEos-0.11 AbsBaso-0.03
___ 03:05PM BLOOD UreaN-8 Creat-0.7 Na-120* K-3.6 Cl-76*
HCO3-26 AnGap-18
___ 02:15AM BLOOD Glucose-134* UreaN-8 Creat-0.6 Na-117*
K-3.6 Cl-81* HCO3-24 AnGap-12
___ 12:03PM BLOOD Na-123*
___ 05:34AM BLOOD Glucose-86 UreaN-9 Creat-0.6 Na-126*
K-4.6 Cl-91* HCO3-25 AnGap-10
___ 06:49AM BLOOD ALT-12 AST-22 AlkPhos-63 TotBili-1.4
___ 03:05PM BLOOD AST-31 AlkPhos-84
___ 03:05PM BLOOD Triglyc-75 HDL-102 CHOL/HD-1.7 LDLcalc-52
___ 06:49AM BLOOD Albumin-3.8 Phos-3.0 Mg-1.9
Chest X-ray
No acute intrathoracic process.
Brief Hospital Course:
Ms. ___ was initially admitted for symptomatic hyponatremia.
Her urine electrolytes suggested thiazide effect (high-normal
urine sodium, normal urine osmolality). The drug was
discontinued, and she was fluid restricted (1 liter), placed on
a high salt diet, and given Ensure with meals. Her sodium slowly
improved -- 117 -> 120 -> 123 -> 126. On day of discharge, her
sodium was 128. She has been instructed to never take a
thiazide, continue her fluid restriction (though with "free"
Ensures), and eat a high salt diet until she follows up with Dr.
___ primary care physician. When her sodium normalizes,
she can stop these restrictions.
HOSPITAL COURSE BY PROBLEM:
1. Symptomatic hyponatremia.
- 1 liter fluid resctrion
- high salt diet
- Ensure TIDWM
- follow up Na in ___ days
2. HTN. Blood pressures at goal, so another agent was not added.
- continue amlodipine and losartan
3. Rivaroxaban. Discussed with Dr. ___. With her renal
function, she should be on a dose of 15 mg daily. Have provided
her a new prescription.
4. HLD. Continue atorvastatin.
> 35 minutes were spent on discharge activities.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. amLODIPine 10 mg PO DAILY
2. Atorvastatin 20 mg PO QPM
3. Losartan Potassium 100 mg PO DAILY
4. Rivaroxaban 20 mg PO DAILY
5. Estrace (estradiol) 0.01 % (0.1 mg/gram) vaginal 2X/WEEK
6. Fluocinolone Acetonide 0.025% Cream 1 Appl TP BID
Discharge Medications:
1. Rivaroxaban 15 mg PO DINNER
2. amLODIPine 10 mg PO DAILY
3. Atorvastatin 20 mg PO QPM
4. Estrace (estradiol) 0.01 % (0.1 mg/gram) vaginal 2X/WEEK
5. Fluocinolone Acetonide 0.025% Cream 1 Appl TP BID
6. Losartan Potassium 100 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Sympomatic hyponatremia
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 symptomatic hyponatremia
(low sodium), likely from your hydrochlorothiazide (HCTZ). You
were treated by stopping the medication, increasing your salt
intake, fluid restricting yourself to one liter daily, and
drinking high solute beverages (Ensure) with meals. You sodium
level of discharge was 128. I fully expect everything to return
to normal within a week. You will have close follow up with Dr.
___ will slowly be able to increase your fluid intake (and
decrease the salty foods).
The only other change I am making is decreasing the dose of your
rivaroxaban (the blood thinner) to 15 mg.
Followup Instructions:
___
|
19726711-DS-15
| 19,726,711 | 27,176,707 |
DS
| 15 |
2124-10-01 00:00:00
|
2124-10-01 15:54:00
|
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: OBSTETRICS/GYNECOLOGY
Allergies:
Vicodin / Codeine
Attending: ___.
Chief Complaint:
Vaginal bleeding after intercourse
Major Surgical or Invasive Procedure:
REPAIR OF CERVICAL/VAGINAL LACERATION, CYSTOSCOPY
History of Present Illness:
___ G1P1 who presented with heavy vaginal bleeding about one hour
after sexual intercourse. She had intercourse about 4 hours
before presenting to triage and noted the onset of heavy
bleeding about one hour later, including passage of small clots.
She noted that the intercourse today was with the same partner
as prior, and that she had a bit more pain during intercourse
than usual. She denies use of lubricants or vaginal estrogens.
She is post-menopausal for the
past ___ years and has not had any post-menopausal bleeding.
She denied fevers, chills, chest pain, shortness of breath,
dizziness, lightheadedness, nausea or vomiting.
Past Medical History:
PPCOS, ___'s thyroiditis
Social History:
___
Family History:
NC
Physical Exam:
VITALS: Temp 97, HR 93, BP 104/70, RR 16, O2 sat 96% on RA
General: NAD
HEENT: moist mucus membranes
Cardiac: RRR, no murmurs
Pulm: normal work of breathing
Abdomen: soft, non-tender, no masses
Ext: no clubbing, cyanosis, edema
Pelvic
-External Genitalia: normal
-Vagina: atrophic mucosa, introitus without lesions or
abrasions
-Cervix: unable to visualize cervix or vaginal walls due to
copious amount of clot and bleeding in vaginal vault. About
200cc
total of blood and clot cleared with ring forceps and scopettes.
Pertinent Results:
___ 04:46AM WBC-16.4* RBC-3.85* HGB-12.5 HCT-36.5 MCV-95
MCH-32.5* MCHC-34.2 RDW-14.6 RDWSD-51.0*
___ 04:46AM PLT COUNT-225
___ 12:42AM WBC-14.0* RBC-4.63 HGB-14.6 HCT-43.8 MCV-95
MCH-31.5 MCHC-33.3 RDW-14.6 RDWSD-50.9*
___ 12:42AM NEUTS-76.3* LYMPHS-16.4* MONOS-6.0 EOS-0.6*
BASOS-0.3 IM ___ AbsNeut-10.72* AbsLymp-2.30 AbsMono-0.84*
AbsEos-0.09 AbsBaso-0.04
___ 12:42AM ___
___ 12:42AM PLT COUNT-242
Brief Hospital Course:
On ___, Ms. ___ was admitted to the gynecology
service after undergoing cervical and vaginal laceration repair
and a cystoscopy. Please see the operative report for full
details. Her post-operative course was uncomplicated.
Immediately post-op, her pain was well controlled.
On post-operative day 0, her urine output was adequate, so her
foley was removed, and she voided spontaneously. Her diet was
advanced without difficulty, and did not require medication for
pain. She was then discharged home in stable condition with
outpatient follow-up scheduled.
Discharge Medications:
1. Ibuprofen 600 mg PO Q6H:PRN Pain - Moderate
For pain
RX *ibuprofen 600 mg 1 tablet(s) by mouth every ___ hours Disp
#*30 Tablet Refills:*0
2. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain -
Moderate
For pain
RX *oxycodone 5 mg 1 tablet(s) by mouth every ___ hours Disp #*5
Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Right sulcal and cervical laceration
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 after your
procedure. You have recovered well and the team believes you are
ready to be discharged home. Please call 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.
* Nothing in vaginal for 2 weeks or until after ob/gyn
appointment
Call your doctor for:
* fever > 100.4F
* severe abdominal pain
* difficulty urinating
* vaginal bleeding requiring >1 pad/hr
* abnormal vaginal discharge
* redness or drainage from incision
* nausea/vomiting where you are unable to keep down fluids/food
or your medication
Constipation:
* Drink ___ liters of water every day.
* Incorporate 20 to 35 grams of fiber into your daily diet to
maintain normal bowel function. Examples of high fiber foods
include:
Whole grain breads, Bran cereal, Prune juice, Fresh fruits and
vegetables, Dried fruits such as dried apricots and prunes,
Legumes, Nuts/seeds.
* Take Colace stool softener ___ times daily.
* Use Dulcolax suppository daily as needed.
* Take Miralax laxative powder daily as needed.
* Stop constipation medications if you are having loose stools
or diarrhea.
To reach medical records to get the records from this
hospitalization sent to your doctor at home, call ___.
Followup Instructions:
___
|
19726813-DS-16
| 19,726,813 | 26,879,064 |
DS
| 16 |
2150-04-24 00:00:00
|
2150-05-03 04:49:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
escitalopram / fluoxetine / hydroxyzine / trazodone
Attending: ___.
Chief Complaint:
Left hip pain
Major Surgical or Invasive Procedure:
Left short TFN ___ ___
History of Present Illness:
Ms. ___ is ___ year old female with a history of COPD,
moderate mitral regurgitation, HTN, HLD who presents after a
mechanical fall and was found to have left intratrochanteric hip
fracture with plan for operative repair. Medicine is consulted
for perioperative evaluation.
The patient reports that she was walking down the stairs in her
home on ___. She was adjusting her air-conditioning unit and
lost her grip on her walker and fell. She initially presented to
___, where she was found to have an
intertrochanteric fracture and was transferred to ___ for
orthopedic surgery evaluation.
The patient reports that approximately two weeks prior to
presentation she had increased cough and sputum production. She
presented to her doctor, who prescribed a two-week course of
prednisone and cefprozil for unclear indication, but possible
pneumonia. The patient reports that since she began these
medications on ___, her cough and sputum production have
improved. At present, she reports that she continues to have
cough, which is chronic for her. She reports scant clear sputum.
No shortness of breath. She uses Advair and Spiriva for her
COPD, and uses her albuterol inhaler or neb several times per
day.
The patient reports occasional palpitations, but is not having
them at present. She denies any chest pain at rest or with
exertion. She denies any syncope or pre-syncope. She denies any
dyspnea on exertion, orthopnea, or PND. She does have peripheral
edema, which has been previously attributed to her amlodipine.
Her last Internal Medicine office visit with Dr. ___ on
___ was reviewed. At that time, patient noted she had
ongoing coughing and wheezing. This was thought to be related in
part to GERD.
Last Cardiology visit with Dr. ___ on ___. At that time,
she was noted to have moderate eccentric mitral regurgitation,
but she has no symptoms attributable to her MR and expectant
management was recommended.
On interview this morning, the patient reports that she has hip
pain but otherwise feels comfortable. She continues to have
cough, which is usual for her. She feels better after a neb
treatment but denies any shortness of breath. She has no fevers
or chills. No abdominal pain, nausea, or vomiting. She does feel
slightly bloated and constipated. She last had a bowel movement
yesterday. She denies any other complaints at this time.
ROS: As per HPI. 10-point ROS otherwise negative.
Past Medical History:
CARDIAC HISTORY:
HTN
HLD
Mitral regurgitation
OTHER PAST MEDICAL HISTORY:
COPD
Anxiety
GERD
Intracranial aneurysm (4mm MCA aneurysm)
Multinodular goiter
AAA s/p repair
PAST SURGICAL HISTORY:
AAA s/p repair
Social History:
___
Family History:
Sister with AAA. Mother's side of family with coronary artery
disease.
Physical Exam:
ADMISSION PHYSICAL:
=============================
VITAL SIGNS:98.4 PO 167/74 R Lying 73 18 96 4L
GENERAL: Elderly woman lying in bed in no acute distress
HEENT: Anicteric sclerae, PERRL, EOMI, dry mucous membranes
CARDIAC: RRR, no murmurs auscultated
LUNGS: Clear to auscultation anteriorly; patient unable to sit
due to pain; no wheezes at time of exam
ABDOMEN: Soft, nontender, nondistended
EXTREMITIES: Warm, well-perfused, no peripheral edema
SKIN: Eccyhmoses on forearms
NEURO: AOx3, no focal deficits, gait deferred
PSYCH: Appropriate mood and affect
Delirium (Confusion Assessment Method, CAM): CAM negative.
[-] 1. Acute change in mental status or fluctuating mental
status
[-] 2. Inattention (eg difficulty focusing, easily distractible)
[-] 3. Disorganized thinking (eg rambling, illogical flow)
[-] 4. Altered level of consciousness (eg not alert)
1 and 2 and (either 3 or 4) constitute a diagnosis of delirium
DISCHARGE PHYSICAL:
======================
Vitals: 99.0, 173/74, 96, 18, 94 on 3L
General: alert, oriented, no acute distress, not using accessory
muscles, conversant and appropriate
HEENT: sclera anicteric, dry MM, oropharynx clear
Neck: supple, JVP not elevated
Lungs: clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: regular rate and rhythm, normal S1 + S2, soft systolic
murmur
Abdomen: soft, non-tender, non-distended, no rebound tenderness
or guarding
GU: foley
Ext: warm, well perfused, no edema
Pertinent Results:
ADMISSION LABS:
___ 12:35AM BLOOD WBC-13.7* RBC-4.34 Hgb-8.8* Hct-30.6*
MCV-71* MCH-20.3* MCHC-28.8* RDW-17.7* RDWSD-44.2 Plt ___
___ 12:35AM BLOOD Neuts-77.9* Lymphs-9.3* Monos-11.1
Eos-0.5* Baso-0.2 Im ___ AbsNeut-10.64* AbsLymp-1.27
AbsMono-1.51* AbsEos-0.07 AbsBaso-0.03
___ 12:35AM BLOOD Plt ___
___ 12:35AM BLOOD Glucose-187* UreaN-24* Creat-0.7 Na-139
K-3.0* Cl-103 HCO3-26 AnGap-13
___ 07:30AM BLOOD Calcium-8.6 Phos-2.4* Mg-2.1
___ 12:55AM URINE Color-Straw Appear-Clear Sp ___
___ 12:55AM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-TR
___ 12:55AM URINE RBC-1 WBC-8* Bacteri-NONE Yeast-NONE
Epi-1 TransE-<1
INTERVAL LABS:
___ 07:05AM BLOOD CK-MB-7 cTropnT-0.01 proBNP-1272*
___ 07:20AM BLOOD Calcium-8.5 Phos-2.4* Mg-2.1 Iron-14*
___ 07:20AM BLOOD calTIBC-267 Ferritn-38 TRF-205
DISCHARGE LABS:
___ 07:00AM BLOOD WBC-7.9 RBC-3.64* Hgb-8.2* Hct-27.0*
MCV-74* MCH-22.5*# MCHC-30.4* RDW-21.3* RDWSD-54.2* Plt ___
___ 07:00AM BLOOD Plt ___
___ 07:00AM BLOOD ___ PTT-28.4 ___
___ 07:00AM BLOOD Glucose-131* UreaN-15 Creat-0.8 Na-144
K-3.8 Cl-105 HCO3-26 AnGap-17
___ 07:00AM BLOOD Calcium-9.1 Phos-3.5 Mg-2.1
MICROBIOLOGY
___ URINE URINE CULTURE-FINAL {ENTEROBACTER
CLOACAE COMPLEX}
URINE CULTURE (Final ___:
ENTEROBACTER CLOACAE COMPLEX. ___ CFU/mL.
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.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROBACTER CLOACAE COMPLEX
|
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN--------- 0.5 S
GENTAMICIN------------ <=1 S
MEROPENEM------------- 0.5 S
NITROFURANTOIN-------- 64 I
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
DIAGNOSTICS:
IMAGING:
CXR (___): Bilateral ___ opacities, interstitial
edema
___ IMAGING:
TTE (___):
- There is posterior leaflet mitral valve prolapse. There is
moderate mitral regurgitation detected by spectral and color
Doppler. The jet of the mitral regurgitation is directed
anteriorly.
- Left ventricular cavity size is normal. Systolic function
appears normal. There are segmental left ventricular wall motion
abnormalities present. The estimated ejection fraction is 60%.
- The right ventricular size is normal. The right ventricular
systolic function is normal.
CT Chest (___):
New 4 mm solid pulmonary nodule in the left lower lobe, for
which
continued surveillance is advised. Multiple other 2 to 4 mm
nodules are unchanged from ___, and therefore likely benign.
Stable changes of centrilobular emphysema. Unchanged
nonobstructing nephrolithiasis. Follow up CT chest in ___ months
to assess for stability of new 4 mm pulmonary nodule.
___ Imaging LOWER EXTREMITY FLUORO
IMPRESSION:
Fluoroscopic images show placement of a fixation device about
fracture of the proximal left femur. Further information can
be gathered from the operative report.
___ Imaging HIP NAILING IN OR ___
IMPRESSION:
Fluoroscopic images show placement of a fixation device about
fracture of the proximal left femur. Further information can be
gathered from the operative report.
___ Imaging CHEST (PORTABLE AP)
FINDINGS:
There are probable trace bilateral pleural effusions with
overlying
atelectasis. No pneumothorax is identified. The size of the
cardiac
silhouette is at the upper limits of normal. Calcification of
the aortic arch is again noted.
IMPRESSION:
Trace bilateral pleural effusions with overlying atelectasis.
Superimposed pneumonia in the proper clinical context cannot be
excluded. No evidence of pulmonary edema.
___ Imaging 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.
There is a filling defect in a right lower lobe subsegmental
pulmonary artery, consistent with pulmonary embolism (___).
No evidence of right heart strain.
The pulmonary arteries are otherwise well opacified to the
subsegmental level, with no evidence of filling defect within
the main, right, left, lobar or segmental pulmonary arteries.
The main pulmonary artery is enlarged, measuring 3.2 cm,
suggestive of pulmonary arterial hypertension.
There is a 1.3 x 1.2 cm left hilar lymph node (___) and a 1.1
x 0.9 cm right hilar lymph node (___). There are multiple
prominent, though nonenlarged, mediastinal lymph nodes. There
is no supraclavicular, axillary or mediastinal lymphadenopathy.
Imaged portions of the thyroid demonstrate a heterogeneous right
thyroid lobe lesion, measuring 1.7 x 1.5 cm (___).
There is no evidence of pericardial effusion. There is no
pleural effusion.
Diffuse moderate upper lobe predominant centrilobular
emphysema. There is bibasilar atelectasis. The airways are
patent to the subsegmental level.
Limited images of the upper abdomen demonstrate a left adrenal
1.5 x 1.0 cm lesion, incompletely characterized on this
single-phase study.
There is extensive atherosclerotic calcification of the
coronary arteries and imaged portions of the abdominal aorta,
including extensive calcification at the ostia of the celiac
artery and SMA.
No lytic or blastic osseous lesion suspicious for malignancy is
identified.
IMPRESSION:
1. There is a filling defect in a right lower lobe subsegmental
pulmonary artery, consistent with pulmonary embolism. No
evidence of right heart strain.
2. Diffuse moderate upper lobe predominant centrilobular
emphysema.
3. Heterogeneous right thyroid lobe nodule, measuring 1.7 x 1.5
cm. If not previously performed, consider thyroid ultrasound
for further evaluation on a nonemergent basis.
4. There is a 1.5 x 1.0 cm lesion in the left adrenal gland,
incompletely characterized on this single-phase study. Consider
dedicated adrenal CT for further evaluation on a nonemergent
basis.
5. The main pulmonary artery is mildly enlarged, suggestive of
pulmonary arterial hypertension.
6. Hilar lymphadenopathy, possibly reactive.
RECOMMENDATION(S): If not previously performed, consider
thyroid ultrasound for further evaluation on a nonemergent
basis.
Consider dedicated adrenal CT for further evaluation on a
nonemergent basis.
___ Imaging BILAT LOWER EXT VEINS
FINDINGS:
There is normal compressibility, flow, and augmentation of the
bilateral common femoral, femoral, and popliteal veins. Normal
color flow and compressibility are demonstrated in the posterior
tibial and peroneal veins.
There is normal respiratory variation in the common femoral
veins bilaterally.
A medial branch off one of the left posterior tibial veins has
echogenic intraluminal material, is partially compressible, and
has partial color flow, compatible with nonocclusive thrombus.
No evidence of medial popliteal fossa (___) cyst.
IMPRESSION:
1. No evidence of deep venous thrombosis in the right lower
extremity veins.
2. No evidence of deep venous thrombosis in the left femoral,
popliteal, posterior tibial, or peroneal veins.
3. Non-occlusive thrombus in a medial branch of one of the
left posterior tibial veins.
___ Imaging BILAT UP EXT VEINS US
FINDINGS:
There is normal flow with respiratory variation in the
bilateral subclavian veins.
The bilateral internal jugular, axillary and brachial veins are
patent, show normal color flow and compressibility.
The bilateral basilic, and cephalic veins are patent and
compressible.
IMPRESSION:
No evidence of deep vein thrombosis in the bilateral upper
extremity veins.
Brief Hospital Course:
Ms. ___ is ___ ___ year old female with a history of COPD,
moderate mitral regurgitation, HTN, HLD who presented after a
mechanical fall and was found to have left intratrochanteric hip
fracture with plan for operative repair. The patient underwent
successful uncomplicated repair on ___.
ORTHOPEDICS COURSE:
The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have Left intertrochanteric hip fracture and was admitted to
the orthopedic surgery service. The patient was taken to the
operating room on ___ for Left short TFN (___), 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. She remained with a moderate oxygen
requirement on POD1, but there were no acute desaturations. 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.
Prior to surgery, the patient had hypoxic respiratory failure
requiring 4L oxygen, and she continues to require 5L of oxygen
post-operatively. Of note, the patient has a history of COPD and
was also recently treated for pneumonia with a cephalosporin and
prednisone. The medicine consult team saw the patient, and
recommended completion of 5 additional days of azithromycin.
MEDICAL COURSE:
#Hypoxemia
#Emphysema
#RLL sub-segmental pulmonary embolism
Following patient's transfer from orthopedics to medicine
patient continued to require ___ L of oxygen by nasal cannula.
Trial of nebulizers was given, though the patient did not
demonstrate marked wheezes. She was thought to have a component
of chronic COPD. She also received a CTA Chest for ongoing
concern regarding her hypoxia and tachycardia. This test
disclosed a subsegmental pulmonary embolus in the RLL.
Ultrasounds of lower and upper extremities failed to show a DVT.
Her history of intracranial hemorrhage was reviewed prior to
initiating anticoagulation: she had a stable 4mm right MCA
bifurcation aneurysm (last imaged ___, supposed to be followed
___ years) and history of SAH in ___ after a fall(managed
non-operatively, source of bleed was not the aneurysm). The
benefit of anticoagulation benefits was thought to outweigh
risks. She did not have CT evidence of right heart strain. She
was treated initially with a heparin drip before being
transitioned to apixiban 5 mg bid. It remained unclear if her
hypoxemia was acute from a small PE or chronic given her history
of emphysema. It was also unclear if her PE was present before
or after her fall/fracture given that she presented with
hypoxemia, and per record review ___ was low ___ on room
air at a follow up visit for COPD. Recommendation was made to
pursue an echocardiogram to rule out pulmonary hypertension.
This may be considered as an outpatient.
#Possible COPD flare
Given patient's moderate emphysema noted on her CT chest and
presence of sputum, fatigue with exertion, and oxygen
requirement, she was treated empirically for a COPD exacerbation
with azithromycin 250 mg qd q24hr (end date ___ and nebulizer
treatments with ipratropium and albuterol. She was also given
Advair twice a day.
#Fall / L Hip fracture: After medicine transfer patient
continued to receive input from orthopedics regarding her wound
management, which was monitored frequently in the setting of her
starting anticoagulation. Patient had pain management with
scheduled APAP, oxycodone, and hydromorphone. She was given
vitamin D. She may benefit from BMD screening and likely
initiation of a bisphosphonate as an outpatient. At the time of
discharge the patient's pain was well controlled with oral
medications, incisions were clean/dry/intact, and the patient
was voiding/moving bowels spontaneously. The patient is WBAT in
the Left lower extremity. The patient will follow up with Dr.
___.
#Microcytic anemia
Patient continued to demonstrate a microcytic anemia following
her transfer from orthopedics, which was thought to possibly be
related to blood loss from surgery, but this was also present on
presentation. It was unclear what the instigating factor was for
her anemia. She received 1u PRBCs on ___. She may benefit from
outpatient colonoscopy and further anemia workup.
#Incidentalomas: During the course of her various hospital
imaging patient had both right thyroid lobe nodule and an
adrenal lesion that may warrant follow-up tests as an outpatient
on a non-emergent basis. She may benefit from a thyroid
ultrasound and an adrenal dedicated CT as an outpatient.
TRANSITIONAL ISSUES:
[ ] Patient should be evaluated by her cardiologist with a
repeat TTE given her ongoing hypoxemia.
[ ] Patient grew Enterobacter in her urine from ___ below.
Given that she was asymptomatic, antibiotics were not started.
_________________________________________________________
ENTEROBACTER CLOACAE COMPLEX
|
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN--------- 0.5 S
GENTAMICIN------------ <=1 S
MEROPENEM------------- 0.5 S
NITROFURANTOIN-------- 64 I
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
[ ] See above for incidentalomas.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 500 mg PO Q8H
2. Albuterol Inhaler 1 PUFF IH Q4H:PRN Wheezing
3. amLODIPine 5 mg PO DAILY
4. Aspirin 325 mg PO DAILY
5. Vitamin D 1000 UNIT PO DAILY
6. Fluticasone-Salmeterol Diskus (100/50) 1 INH IH BID
7. Furosemide 20 mg PO DAILY
8. Mirtazapine 7.5 mg PO QHS
9. Ranitidine 150 mg PO BID
10. Sertraline 75 mg PO DAILY
11. Simvastatin 40 mg PO QPM
12. Tiotropium Bromide 1 CAP IH DAILY
Discharge Medications:
1. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN shortness of
breath, wheezing, productive cough
2. Apixaban 5 mg PO BID
3. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation
4. Calcium Carbonate 500 mg PO QID:PRN heartburn
5. Docusate Sodium 100 mg PO BID
6. Ipratropium-Albuterol Neb 1 NEB NEB Q6H
7. OxyCODONE (Immediate Release) 2.5-5 mg PO Q4H:PRN pain
RX *oxycodone [Oxaydo] 5 mg 0.5 - 1 tablet(s) by mouth every 4
hours as needed for pain Disp #*15 Tablet Refills:*0
8. Polyethylene Glycol 17 g PO DAILY
9. Senna 8.6 mg PO DAILY
10. Acetaminophen 500 mg PO Q8H
11. amLODIPine 5 mg PO DAILY
12. Fluticasone-Salmeterol Diskus (100/50) 1 INH IH BID
13. Furosemide 20 mg PO DAILY
14. Mirtazapine 7.5 mg PO QHS
15. Ranitidine 150 mg PO BID
16. Sertraline 75 mg PO DAILY
17. Simvastatin 40 mg PO QPM
18. Vitamin D 1000 UNIT PO DAILY
19. HELD- Aspirin 325 mg PO DAILY This medication was held. Do
not restart Aspirin until you discuss it with your primary care
doctor.
20. HELD- Tiotropium Bromide 1 CAP IH DAILY This medication was
held. Do not restart Tiotropium Bromide until you stop taking
DuoNebs.
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Left intertrochanteric femur fx
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Ms. ___,
You were admitted to the hospital after experiencing a fall. You
were found to have evidence of a left hip fracture that was
operated on by surgery. Both before and after your surgery you
were found to have shortness of breath requiring oxygen, which
was concerning. You were evaluated with blood work and imaging
that showed some chronic findings in your lungs suggestive of a
process called emphysema. We treated you for this with
nebulizers. You also had evidence of a small blood clot that may
have been blocking some blood flow. It is unclear how long this
clot has been there, but we recommend treating it with a blood
thinner for at least 6 months. We have started you on this blood
thinning medication (apixiban) while in the hospital.
You may need to take oxygen at home given the extent of
shortness of breath you experience on room air.
After you leave the hospital we recommend you have formal
evaluation of your heart function with an echocardiogram.
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:
- WBAT
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.
WOUND CARE:
- You may shower. No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- Please remain in your dressing and do not change unless it is
visibly soaked or falling off.
DANGER SIGNS:
Please call your PCP or surgeon's office and/or return to the
emergency department if you experience any of the following:
- Increasing pain that is not controlled with pain medications
- Increasing redness, swelling, drainage, or other concerning
changes in your incision
- Persistent or increasing numbness, tingling, or loss of
sensation
- Fever > 101.4
- Shaking chills
- Chest pain
- Shortness of breath
- Nausea or vomiting with an inability to keep food, liquid,
medications down
- Any other medical concerns
FOLLOW UP:
Please follow up with your Orthopaedic Surgeon, Dr. ___.
You will have follow up with ___, NP in the
Orthopaedic Trauma Clinic 14 days post-operation for evaluation.
Call ___ to schedule appointment upon discharge.
Please follow up with your primary care doctor regarding this
admission within ___ weeks and for and any new
medications/refills.
It was a pleasure taking care of you.
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
19727323-DS-18
| 19,727,323 | 21,047,557 |
DS
| 18 |
2182-04-05 00:00:00
|
2182-04-05 20:11:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
S/p fall
Major Surgical or Invasive Procedure:
Intubation (___)
Left long trochanteric fixation nail (___)
History of Present Illness:
___ legally blind man with IDDM, Stage 5 CKD, HTN who presents
with hip pain after falling in his house on ___.
Pt was in his USOH, rushing to get food ready by the microwave
as he was very hungry, when he became light headed; he tried to
grab onto something but fell to the ground, after which he felt
pain in his left hip. Per his daughter, he is frequently falling
but downplays his symptoms. He denies LOC, headstrike, neck or
back pain, seizure, CP or palpitations. He states he becomes
lightheaded when he is hungry often. His lantus regimen was
reduced from 10u to 5u qhs last month secondary to low blood
sugars.
He was seen at ___ where he had a benign CT head and
Cspine and plain films of his L pelvis/femur/knee/hip that
showed a displaced proximal femur shaft fracture with no signs
of hip injuries.
He denies any chest pain, dyspnea or weakness, lightheadedness,
headache, recent illness, fevers, chills, cough, n/v/d, numbness
or tingling distally.
In the ED, initial vitals were: 98.0 88 166/77 14 100% RA
Exam notable for no murmur, neuro intact with the exception of
baseline visual deficits/. deformity of left thigh, 2+ dp and
pt, sensation intact.
Labs were notable for
-WBC 15.3 with 88.8% PMN, Hgb 9 (unclear baseline), plt 216
-Chem10 notable for K 4.9 (5.1 on recheck), BUN/Cr 59/5.9,
Bicarb 16, Glucose 245, AG 20
-trops 0.03 x 2
-CK 68 with MB 2
-U/A notable for 100 protein, 300 glucose, otherwise bland
Patient was given:
___ 06:33 IV HYDROmorphone (Dilaudid) .5 mg
___ 07:23 PO NIFEdipine CR 90 mg
___ 07:23 PO Metoprolol Succinate XL 50 mg
___ 07:55 SC Insulin 2 Units
___ 09:32 IV HYDROmorphone (Dilaudid) 1 mg
Patient was admitted to medicine for management of CKD prior to
surgery. He received pre-operative labs, CXR, and ECG, as well
as a plain film of his L knee showing a traction pin seen
traversing the proximal left tibia without fracture with a small
suprapatellar effusion. He also received calcium gluconate and
25g D5W + 10u insulin x1 for hyperkalemia.
Past Medical History:
-Insulin-dependent T2DM
--Diabetic retinopathy
-CKD Stage 5
-HTN
-Glaucoma
Social History:
___
Family History:
unable to confirm
Physical Exam:
ADMISSION PHYSICAL EXAM
=================================
VS: Tc 97.9 BP 144 / 64 HR 72 RR 18 SpO2 100% RA
Gen: Cachectic man in NAD with pin through leg in traction;
intermittently falling asleep during interview
HEENT: MMM, soft palate rises symmetrically, sclerae
noninjected or icteric
CV: rrr, nml S1+S2, no mrg
Pulm: clear to auscultation anteriorly
Abd: BS+; nondistended, nontender
GU: No foley
Ext: distal LLEs cold without mottling; no edema or erythema
Skin: some flaking over abdomen; no rash
Neuro: No asterixis; pupils 6cm and unreactive.
DISCHARGE PHYSICAL EXAM
==================================
VS: T 98.4 BP 133/56 HR 89 RR 18 SpO2 98% Ra
I/O 590/800
Gen: Thin blind man in NAD, lying comfortably in bed
HEENT: glassy conjunctiva b/l; MMM, soft palate rises
symmetrically, sclerae noninjected or icteric
CV: rrr, nml S1+S2, no mrg
Pulm: mild wheeze, no crackles.
Abd: BS+; nondistended, nontender, no r/g
GU: No foley
Ext: WWP bilaterally but R foot warmer than L; LLE in ACE wrap
from ankle up to knee, mild swelling without tenderness
throughout up to left mid thigh; able to move toes. LLE wound
just distal to knee with minimal dried blood and
non-purulent-appearing drainage through bandage. ___ pulses
intact b/l.
Skin: some flaking over abdomen
Neuro: following directions consistently; moving all extremities
including LLE. Pupils chronically nonreactive but EOMI.
Pertinent Results:
___
==============================
___ 04:15AM BLOOD WBC-15.3*# RBC-3.61* Hgb-9.0* Hct-30.6*
MCV-85 MCH-24.9* MCHC-29.4*# RDW-19.6* RDWSD-61.1* Plt ___
___ 04:15AM BLOOD ___ PTT-32.2 ___
___ 04:15AM BLOOD Glucose-245* UreaN-59* Creat-5.9* Na-141
K-4.9 Cl-105 HCO3-16* AnGap-25*
___ 02:57PM BLOOD Calcium-8.0* Phos-7.1* Mg-2.2
___ 03:12PM BLOOD ___ pO2-40* pCO2-47* pH-7.18*
calTCO2-18* Base XS--11
DISCHARGE LABS
==============================
___ 08:00AM BLOOD WBC-8.4 RBC-2.93* Hgb-8.0* Hct-25.0*
MCV-85 MCH-27.3 MCHC-32.0 RDW-17.1* RDWSD-52.7* Plt ___
___ 08:00AM BLOOD Glucose-212* UreaN-104* Creat-7.9* Na-140
K-4.5 Cl-103 HCO3-17* AnGap-25*
___ 08:00AM BLOOD Calcium-6.9* Phos-3.8 Mg-2.0
IMAGING
==============================
CXR ___ IMPRESSION:
No acute cardiopulmonary process.
X-RAY KNEE ___ FINDINGS:
Traction pin seen traversing the proximal left tibia. There is
no fracture. There is a small suprapatellar effusion.
Enthesophyte seen at the quadriceps tendon insertion on the
patella.
MICROBIOLOGY
================================
___ 5:25 pm BLOOD CULTURE Source: Venipuncture.
Blood Culture, Routine (Pending): No growth to date.
___ 3:58 pm MRSA SCREEN Source: Nasal swab.
**FINAL REPORT ___
MRSA SCREEN (Final ___: No MRSA isolated.
___ 4:15 am URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
IMAGING:
==========
+ ___ Renal US
Portable ultrasound exam is limited. the right kidney measures
8.9 cm. The left kidney measures 9.0 cm. There is no
hydronephrosis, stones, or masses bilaterally. A Foley catheter
decompresses the bladder.
IMPRESSION: No evidence of hydronephrosis or stones.
+ ___ CXR
ompared to ___, there is a new confluent area of
opacification over the right lower lung, likely secondary to
collapse of the lateral segment of the right middle lobe
secondary to a mucous plug. However, pneumonia is also a
possibility in the appropriate clinical setting. An
endotracheal tube is positioned approximately 5 cm above the
carina. The remainder of the exam is not significantly changed.
No evidence of pulmonary edema, pleural effusion, or
pneumothorax.
1. Compared to ___, probable collapse of the
lateral segment of the right middle lobe, likely secondary to a
mucous plug. However, pneumonia is also a possibility in the
appropriate clinical setting.
2. Endotracheal tube positioned approximately 5 cm above the
carina.
+ ___ Knee 2 view
Traction pin seen traversing the proximal left tibia. There is
no fracture. There is a small suprapatellar effusion.
Enthesophyte seen at the quadriceps tendon insertion on the
patella.
+ ___ CXR
A portable erect frontal chest radiograph demonstrates a normal
cardiomediastinal silhouette and well-aerated lungs without
focal consolidation, pleural effusion, or pneumothorax.
Degenerative changes of the bilateral shoulders are noted.
No acute cardiopulmonary process.
Brief Hospital Course:
___ legally blind gentleman with IDDM, HTN, CKD Stage 5 not on
HD suffering from a displaced fractured proximal femur s/p fall
___, admitted for medical optimization prior to TFN on ___.
Pre-op course complicated by worsening renal function, metabolic
acidosis, electrolyte abnormalities, and acute-on-chronic
anemia. Patient transferred to ICU on ___ after TFN procedure
due to inability to extubate, likely secondary to medical
sedation in the setting of renal failure. Extubated successfully
on ___, and transitioned to the floor. Treated for HAP given
CXR infiltrate, fever, and leukocytosis. Should have close
follow-up after DC with nephrology for initiation of dialysis.
****************MICU COURSE******************
___ legally blind gentleman with IDDM, HTN, CKD Stage 5 not on
HD s/p fall with displaced fractured proximal femur s/p
trochanteric fixation nail on ___ with difficulty extubating
post-surgery related to the use of sedating medications in the
setting of renal failure. He was briefly on phenylephrine for
MAPs <60 while in the PACU, noted to be minimally responsive.
During the case, his estimated EBL was 100cc, his Hgb was 6.5,
and he was transfused 1 unit PRBCs.
#Hypoxemic Resp Failure
Given that the patient remained intubated and requiring pressor
support, transfer to MICU for further management was requested.
On arrival to the MICU overnight on ___, patient opened his
eyes to voice and follows commands, he was intubated and
required AC with minimal vent settings due to low tidal volumes.
Morning of ___, patient was more response, switched to pressure
support ___ with good minute ventilation and passed spontaneous
breathing trial with RISBI 32, he was extubated around 1400 on
___ maintained on shovel mask 35% with SaO2 >95%.
# ___ on CKD: In terms of his renal failure, UCx was sent,
patient made ___ cc/hr of dark yellow urine. K+ remained ___
with bicarb ___, VBG with pH 7.27 and remained euvolemic.
Renal was consulted, no urgent need for dialysis. Per renal, he
received a total of 4 g calcium gluconate for hypocalcemia, was
started on calcium acetate phos binder for hyperphosphotemia and
1300 mg BID sodium bicarbonate.
# Pneumonia
# Leukocytosis
# Fever
CXR demonstrated a consolidation and collapse of the right
lateral middle lobe concerning for aspiration with rising white
count of 20K concerning for HAP vs. CAP. Patient received 1g
vanco on ___ at 10 AM and 500 mg ceftazidime for treatment.
BCx were sent.
MEDICINE SERVICE COURSE
==========================
#Hypoxic Respiratory Failure:
#Concern for Aspiration PNA: Febrile in ICU with rising WBC
count and w/ RLL opacity on ___ CXR, likely RLL atelectasis ___
mucous plugging but aspiration PNA / aspiration pneumonitis
possible, so started on vanc/ceftazadime. CXR ___ showed marked
improvement with radiology suggesting RLL edema from
re-expansion vs. RLL infiltrate. MRSA screen, blood cx, and
urine cx x2 negative. Transitioned to renally-dosed levofloxacin
to end on ___.
# Proximal Left femur fracture: After fall at home, evaluated by
orthopedic surgery and planned for TFN after medical evaluation.
Pain initially managed with IV dilaudid, which likely
contributed to acidosis. TFN ___ complicated by difficult
extubation and MICU stay ___ for respiratory failure.
Followed by orthopedic surgery throughout admission.
# Acute on chronic normocytic anemia: Hgb nadir 6.6 on ___,
from 9.0 on admission. Etiology likely acute blood loss after
femur fracture with subsequent slow oozing around operative
site, exacerbating chronic anemia from renal failure. Hemolysis
unlikely with normal LDH, haptoglobin, and Tbili. Patient
received total 4U pRBC during admission.
# Metabolic acidosis:
# CKD Stage 5:
# Hyperkalemia: Pre-operative labs notable for hyperkalemia,
mixed respiratory and metabolic acidosis, hypocalcemia, and
hyperphosphatemia, consistent with chronic renal failure
exacerbated by respiratory suppression and volume depletion.
Hyperkalemia improved with insulin, hydration, and diuresis.
Acidosis improved with decreasing narcotics. Renal team
evaluated patient during admission and determined no indication
for acute initiation of dialysis.
# Insulin dependent T2DM: HgbA1c ___ home lantus
recently decreased from 10u to 5u qhs for concern for
hypoglycemia I/s/o good glycemic control. Home lantus held
initially; restarted after surgery in the setting of
hyperglycemia, likely from enhanced insulin clearance with
improved renal function.
# Fall: Pt reports fall near kitchen counter ___ w/o headstrike
or LOC. Most likely mechanical fall ___ visual impairment and
diabetic neuropathy or orthostatic I/s/o autonomic neuropathy;
less likely CNS cause given lack of focal symptoms, or
arrhythmia given stable ECG and tele without evens. Other
etiologies to consider include vasovagal, ACS (TropT 0.03 x2; no
STEMI), hypoglycemia. Pt and family report h/o multiple falls
and fall hazards in house where pt lives alone; preventing
future falls will necessitate adequate home services and ideally
24hr care.
# Hypertension: Home nifedipine and metoprolol held
post-operatively in the setting of hypotension but restarted
when patient became hypertensive prior to discharge. Home
lisinopril held in the setting of worsened renal function and
hyperkalemia.
TRANSITIONAL ISSUES
==========================
[] Please draw repeat CBC and Chem10 by ___ to follow-up
anemia and renal function
[] Patient will need close nephrology follow-up. Discussion
should continue with the patient and his family about initiation
of dialysis.
[] Consider starting erythropoeitin for anemia in CKD.
[] Per renal, started on calcium acetate and sodium bicarbonate
during admission.
[] Lisinopril stopped given low GFR and possible contribution to
hyperkalemia.
[] Social work and case management should continue to follow
with patient at rehab, as he could likely benefit from a home
safety evaluation
[] Post-op wound care: Please change dressing with gauze and
tegaderm every ___ days or when saturated
[] Please help patient make follow-up appointment with Dr. ___
___ (Orthopedics) on or around ___ (2 weeks
post-operation)
[] Would consider bisphosphonate therapy after optimization of
calcium and vitamin D by nephrology given likely fragility
fracture
CODE STATUS: Full Code
CONTACT: ___ (Son ___ ___ (daughter) at
same number
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Gabapentin 200 mg PO QHS
2. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP BOTH EYES BID
3. Glargine 5 Units Bedtime
4. Lisinopril 40 mg PO DAILY
5. Metoprolol Succinate XL 50 mg PO DAILY
6. NIFEdipine CR 90 mg PO DAILY
7. vardenafil 20 mg oral DAILY:PRN
8. Aspirin 81 mg PO DAILY
9. Calcitriol 0.25 mcg PO DAILY
10. Lactic Acid 12% Lotion 1 Appl TP DAILY
11. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES Q8H
12. Latanoprost 0.005% Ophth. Soln. 1 DROP LEFT EYE QHS
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
2. Calcium Acetate 1334 mg PO TID W/MEALS
3. Docusate Sodium 100 mg PO BID
4. Levofloxacin 500 mg PO Q48H Duration: 2 Doses
For 8 day total course: Please dose on ___ and ___
5. Polyethylene Glycol 17 g PO DAILY
6. Senna 17.2 mg PO QHS:PRN constipation
7. Sodium Bicarbonate 1300 mg PO BID
8. TraMADol 25 mg PO Q6H:PRN pain
RX *tramadol 50 mg 0.5 (One half) tablet(s) by mouth every 6
hours Disp #*20 Tablet Refills:*0
9. Glargine 5 Units Bedtime
10. Aspirin 81 mg PO DAILY
11. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES Q8H
12. Calcitriol 0.25 mcg PO DAILY
13. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP BOTH EYES BID
14. Gabapentin 200 mg PO QHS
15. Lactic Acid 12% Lotion 1 Appl TP DAILY
16. Latanoprost 0.005% Ophth. Soln. 1 DROP LEFT EYE QHS
17. Metoprolol Succinate XL 50 mg PO DAILY
18. NIFEdipine CR 90 mg PO DAILY
19. vardenafil 20 mg oral DAILY:PRN
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS
Displaced fracture of proximal femur
SECONDARY DIAGNOSES
Repeated falls
Chronic kidney disease, Stage V
Type 2 diabetes mellitus, insulin-dependent
Respiratory failure
Anemia
Metabolic acidosis
Hypertension
Diabetic retinopathy
Glaucoma
Hyperkalemia
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 because you fell and broke
your leg. We fixed your leg with surgery. We also gave you some
blood to replace the blood that you had lost after you broke
your leg.
While you were here we also found that your kidney disease has
gotten worse, and that you will need to start dialysis soon. We
started new medications while you were in the hospital to make
sure that your body has the right amount of nutrients and
minerals like calcium, phosphate, potassium, and bicarbonate.
You improved and were sent to a rehabilitation facility in order
to help you regain your strength before going home.
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
-___ medical atttention if you have new or concerning symptoms
or you develop
It was a pleasure participating in your care. We wish you the
best!
-Your ___ Care Team
Followup Instructions:
___
|
19727446-DS-10
| 19,727,446 | 27,649,876 |
DS
| 10 |
2205-09-29 00:00:00
|
2205-09-29 11:28:00
|
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 hip pain
Major Surgical or Invasive Procedure:
No surgical intervention
History of Present Illness:
___ male presents with the above fracture s/p mechanical
fall. She is transferring from her trip to bed when he fell
onto
his right hip. Denies any other injuries. Denies any head
strike or loss of consciousness. He does not have any numbness
or tingling distally. He has not ambulated since the injury but
typically does not ambulate much at baseline. He denies any
fevers, chills, or dysuria. He was assessed at ___,
found
to have a periprosthetic hip fracture, and sent to the BI for
further assessment and management.
Past Medical History:
SCC (presumed cutaneous origin) metastatic to R axilla and R
supraclavicular area
- ___: excision of R supraclavicular and R axillary mets, R
axillary lymphadenectomy
- ___: chemo-XRT (stopped ___ radiation toxicity to the
skin; also c/b radiation
pneumonitis)
Numerous other localized SCC lesions, s/p Mohs surgery
Melanoma, s/p excision ___ (1.95 mm, ulcerated, 6 mits)
Prostate cancer s/p definitive XRT (c/b radiation proctitis) and
Lupron
Chronic dissection of L ICA
Cerebrovascular disease
Peripheral sensory polyneuropathy
CKD III
Gout
GERD with ___ esophagus
h/o massive lower GI bleed
Osteoarthritis.
Venous insufficiency
s/p R total hip arthroplasty
s/p ORIF, distal left tibia and fibula
s/p inguinal hernia repair
Social History:
___
Family History:
Twin sister died of colon cancer.
Another sister died of lung cancer.
Mother had breast cancer.
Physical Exam:
General: Well-appearing elderly male in no acute distress.
right lower extremity:
- Skin intact
- No deformity, edema, ecchymosis, erythema, induration
- Soft, non-tender thigh and leg
- Actively ranges hip with mild pain
- Fires ___
- SILT S/S/SP/DP/T distributions
- 1+ ___ pulses, WWP
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 Vancouver A periprosthetic hip fracture and was
admitted to the orthopedic surgery service. The patient was
treated nonoperatively and worked with physical therapy who
determined that discharge to rehab 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 weightbearing as tolerated with
___-off precautions in the right lower extremity, and will be
discharged on heparin for DVT prophylaxis. The patient will
follow up with Dr. ___ routine.
While in the hospital patient was followed by the internal
medicine team for orthostatic hypotension in setting of known
autonomic dysfunction. His orthostasis did improve somewhat
with 1 unit of blood and conservative measures like compression
stockings, increased fluid intake, and slowly getting out of
bed. He was noted to have a baseline anemia at presentation and
he was started on iron per the medicine team. They recommend
the patient follow-up with his primary care provider regarding
his baseline anemia.
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:
COSYNTROPIN [CORTROSYN] - Cortrosyn 0.25 mg solution for
injection. 1 mL IM one time injection w/cortisol labs - (Not
Taking as Prescribed)
FLUDROCORTISONE - fludrocortisone 0.1 mg tablet. TAKE 1
TABLET(S)
BY MOUTH IN THE AM
GABAPENTIN - gabapentin 100 mg capsule. TAKE 1 CAPSULE BY MOUTH
EVERY MORNING AND 2 CAPSULES AT BEDTIME
LIPASE-PROTEASE-AMYLASE [CREON] - Creon 3,000 unit-9,500
unit-15,000 unit capsule,delayed release. capsule(s) by mouth 4
tabs 3 times daily - (Prescribed by Other Provider) (Not Taking
as Prescribed: Patient not taking medication as prescribed )
MIRTAZAPINE - mirtazapine 15 mg tablet. TAKE 1 TABLET BY MOUTH
EVERY DAY
MUPIROCIN - mupirocin 2 % topical ointment. Apply to wound as
directed With dressing change
OMEPRAZOLE - omeprazole 40 mg capsule,delayed release. TAKE 1
CAPSULE BY MOUTH EVERY DAY
SERTRALINE - sertraline 50 mg tablet. 1 tablet(s) by mouth at
bedtime - (Prescribed by Other Provider)
Medications - OTC
ACETAMINOPHEN [ACETAMINOPHEN PAIN RELIEF] - Acetaminophen Pain
Relief 500 mg tablet. tablet(s) by mouth PRN - (Prescribed by
Other Provider)
CYANOCOBALAMIN (VITAMIN B-12) [VITAMIN B-12] - Vitamin B-12
1,000
mcg tablet. 1 tablet(s) by mouth once daily - (Prescribed by
Other Provider)
Discharge Medications:
1. Acetaminophen 650 mg PO 5X/DAY
2. Docusate Sodium 100 mg PO BID
3. Ferrous Sulfate 325 mg PO EVERY OTHER DAY
RX *ferrous sulfate [Feosol] 325 mg (65 mg iron) 1 tablet(s) by
mouth Every other day Disp #*30 Tablet Refills:*0
4. Heparin 5000 UNIT SC BID
RX *heparin (porcine) 5,000 unit/mL (1 mL) 5000 units
subcutaneously twice a day Disp #*60 Cartridge Refills:*0
5. Senna 17.2 mg PO HS
6. Calcium Carbonate 500 mg PO TID
7. Creon 12 1 CAP PO TID W/MEALS
8. Cyanocobalamin 100 mcg PO DAILY
9. Fludrocortisone Acetate 0.1 mg PO DAILY
10. Gabapentin 100 mg PO QAM
11. Gabapentin 200 mg PO QHS
12. Mirtazapine 15 mg PO QHS
13. Omeprazole 40 mg PO DAILY
14. Sertraline 50 mg PO QHS
15. Vitamin D 800 UNIT PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
___ A periprosthetic hip fracture
Discharge Condition:
AVSS
NAD, A&Ox3
RLE: Skin is clean and dry. Fires FHL, ___, TA, GCS. SILT
___ n distributions. 1+ DP pulse, wwp distally.
Discharge Instructions:
INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY:
- You were in the hospital for nonoperative management of an
orthopedic injury. It is normal to feel tired or "washed out"
after hospitalization, 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:
- WBAT RLE with troch-off precautions
- You have been orthostatic with Physical Therapy, as has been
your baseline prior to this hospitalization. Please ensure you
are hydrating well, wearing compression ___ stockings, and
standing up slowly.
MEDICATIONS:
1) Take Tylenol ___ every 6 hours around the clock. This is
an over the counter medication.
ANTICOAGULATION:
- Please take heparin twice daily for 4 weeks
Physical Therapy:
Weightbearing as tolerated right lower extremity with troch-off
precautions
Treatments Frequency:
No surgery was performed and there are no wounds
Followup Instructions:
___
|
19727619-DS-14
| 19,727,619 | 28,893,993 |
DS
| 14 |
2161-12-21 00:00:00
|
2161-12-21 11:24:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Allergies/ADRs on File
Attending: ___.
Chief Complaint:
S/p fall
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
___ M with history of HTN and CAD s/p CABG who initially
presented to ___ after being found down outside of
a bar after a presumed fall. On EMS arrival he smelled of
alcohol and had a GCS of 3, so an LMA was placed in the field
for airway protection. He was initially brought to the ___ where he was intubated, and OG was placed. CT of
head/neck/face was done revealing nasal fractures including
septal fracture. An eyebrow laceration was stapled at the OSH.
He was transferred to ___ for plastic surgery evaluation. In
our ED, extubated after improvement in mental status. Found to
have nasal fracture, plastic surgery evaluated and indicated no
urgency for surgery, recommend outpatient follow up. Pt initial
under obs in the ED but developed tachypnea and tachycardia
which led to TICU admission. A bedside U/S showed a collapsing
IVC so pt was IVF resuscitated with improvement in tachycardia
over the last 24hrs from 120s to 100-110s. SBP in ED last night
dropped temporarily to ___, but was fluid responsive. SBPs today
100-110s.
Pt was found to have bilateral opacities on CXR which was
thought to be an aspiration pneumonitis given intubation and pt
also vomited last night. Pt was given 1x dose of unasyn in ED
last night when hemodynamics changed but ABX were not continued
in the TICU given low supsicion for true infection. Pt did have
a leukocytosis with bandemia. Pt's respiratory status has been
stable today per report on 3L NC. He is not tachypneic. The TICU
team monitored for EtOH withdrawal and consider initiating a
phenobarb protocol but pt and his family reported rare EtOH use
and the ICU team did not feel there were other symptoms of EtOH
withdrawal. Pt receiving tylenol PRN for pain control. Currently
on LR at 75cc/hr.
CK was noted to be 6000. IVF were given, CK trended and down to
4000s. UOP good.
Pt being transferred to medicine for further management of
tachycardia, hypoxemia and CHF/volume status.
ED course: Pt given 3L NS. Lowest SBP 76.
TICU: HR 110s, BPs 110-130s/60s, RR ___, 91% 3L NC. UOP
75-250cc/hr.
On evaluation, pt reports pain in upper abdomen and back. Denies
CP, SOB, HA, facial pain.
ROS:
(+) Per HPI
Past Medical History:
CAD s/p CABG
HTN
HLD
COPD
T2DM
Social History:
___
Family History:
Noncontributory.
Physical Exam:
EXAM ON ADMISSION:
General: elderly male, sitting up in bed, in mild distress
HEENT: ecchymosis and swelling below bilateral eyes, staple line
over R eyebrow and ecchymosis and dried blood over R eye, dried
blood over nose
Neck: supple, no JVD
CV: tachy rate at 110, no murmurs appreciated, CABG scar
Lungs: coarse bilateral rhonchi, mild accessory muscle use with
small amount of belly breathing, speaks in full sentences
Abdomen: mildly distended, tympanic to percussion, +BS,
nontender
GU: foley in place
Ext: trace ___ edema, warm and well perfused
Neuro: A&Ox3, moves all extremities
EXAM ON DISCHARGE:
VS: Tm 98, 88 (88-90), 132/80 (124-141/74-80), 94 on RA
General: elderly male, sitting up in bed, in no acute distress
HEENT: ecchymosis and swelling below bilateral eyes, staple line
over R eyebrow and ecchymosis and dried blood over R eye, dried
blood over nose; PERRL
Neck: supple, no JVD
CV: HR ___, no murmurs appreciated, heart sounds distant
Lungs: breathing comfortably on RA; lung fields clear b/l
without wheezes or crackles
Abdomen: mildly distended, tympanic to percussion, +BS,
nontender
GU: no foley
Ext: trace ___ edema, warm and well perfused
RShoulder: No tenderness on palpation. No obvious
deformities/dislocations. No ecchymoses. Good sensation and
strength distally. Pain with passive movement in all directions.
Only able to perform minimal active movement.
Skin: lesions on face as described above, scrapes on hands,
scrapes on right knee; no other ecchymoses
Neuro: A&Ox3; PERRL; moves all extremities
Pertinent Results:
============================================
LABS ON ADMISSION:
============================================
___ 09:10PM BLOOD WBC-13.1* RBC-5.08 Hgb-15.5 Hct-47.5
MCV-94 MCH-30.5 MCHC-32.6 RDW-12.8 Plt ___
___ 01:34AM BLOOD Neuts-82* Bands-10* Lymphs-4* Monos-4
Eos-0 Baso-0 ___ Myelos-0
___ 01:34AM BLOOD Hypochr-NORMAL Anisocy-NORMAL
Poiklo-NORMAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL
___ 09:10PM BLOOD ___ PTT-32.7 ___
___ 02:16PM BLOOD Glucose-95 UreaN-19 Creat-0.9 Na-138
K-4.4 Cl-105 HCO3-21* AnGap-16
___ 02:16PM BLOOD Calcium-8.2* Phos-3.2 Mg-1.9
============================================
LABS ON DISCHARGE:
============================================
___ 06:10AM BLOOD WBC-5.0 RBC-4.11* Hgb-12.5* Hct-38.4*
MCV-93 MCH-30.4 MCHC-32.6 RDW-13.1 Plt ___
___ 06:10AM BLOOD Calcium-8.7 Phos-3.1 Mg-2.1
============================================
OTHER RESULTS:
============================================
___ 01:34AM BLOOD CK(CPK)-6333*
___ 02:16PM BLOOD CK(CPK)-4720*
___ 07:20AM BLOOD CK(CPK)-4716*
___ 06:51AM BLOOD CK(CPK)-1566*
___ 01:34AM BLOOD CK-MB-17* MB Indx-0.3 cTropnT-0.02*
___ 02:16PM BLOOD CK-MB-16* MB Indx-0.3
___ 09:10PM BLOOD ASA-NEG ___ Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
MICRO -
___ BCX: PND
OTHER RESULTS -
___ ECHO
IMPRESSION: regional left ventricular systolic dysfunction
suggestive of CAD. No significant valvular abnormality.
___ MRI R SHOULDER
Full thickness supraspinatus tear (S4:I12) with adjacent
subacromial bursitis. Subchondral cysts are in the
postero-superior portion of the humeral head next to the
insertion of supraspinatus tendon.
Mild bone marrow edema involves humeral metahphysis and
diaphysis.
___ XRAY R SHOULDER
Degenerative changes of the right glenohumeral joint with some
superior displacement raising concern for a rotator cuff injury.
No evidence of an acute displaced fracture or dislocation.
Brief Hospital Course:
___ gentleman with HTN, CAD s/p CABG, and COPD admitted after
being found down on ___, intubated at ___ due to GCS
of 3, transferred to ___ evaluation of nasal fractures,
extubated, and subsequently transferred to medicine for
management of hypoxemia, tachypnea, tachycardia, and rhabdo.
# Found down: Events surrounding pt being found down were
unwitnessed and are not clear. CT head with no acute
intracranial abnormalities. Differential includes intoxication,
mechanical slip and fall, arrhythmia, MI, hypotension, vagal
episode. Arrhythmia unlikely as pt. has abrasions on hands
indicating that he braced himself. Also no events on telemetry
during admission. MI also unlikely as minimal troponemia, no
significant changes on EKG, and no focal wall motion
abnormalities on echo. EtOH level 125 on admission Pt. unable to
recall events of that night. Pt. not orthostatic on day 2 of
hospital stay. Most likely this pt. was intoxicated and
slipped/lost his balance and fell. Pt. will go to rehab for
physical therapy and home safety evaluation.
# Aspiration pneumonia. Pt. with hypoxemia, tachypnea,
tachycardia, and opacities on CXR consistent with aspiration
event. Pt. also with leukocytosis and bandemia. Given that pt.
was down for significant period of time, aspiration is likely.
He was treated with a 7 day course of metronidazole and
levofloxacin for aspiration pneumonia and aggressive pulmonary
hygeine including incentive spirometry and nebulizers. He did
well. At the time of discharge he was saturating well on room
air without signs/symptoms of infection.
# Full thickness supraspinatous tear in R shoulder: Confirmed
on MRI. No underlying bone fractures/dislocations seen on CT or
Xray. Pt. with significantly limited shoulder movement, which
is problematic given that pt. is right hand dominant. Pt. was
seen by ortho who recommended conservative treatment with
physical therapy and follow-up as outpatient to reassess
functionality. Pt. was seen by physical therapy and
occupational therapy and placed in a sling.
# Nasal fractures: Pt. evaluated by plastics on admission who
felt no need for urgent/emergent surgery. Per protocol with
nasal fractures, plastics does not leave official note but will
see them as outpatient.
# Rhabdomyolysis: CK initially 6333 but downtrended with IVF. No
impairment in renal function.
# Pain: Pt. with significant total body pain, exaerbated by deep
breaths and cough. Likely due to fall and rhabdomyolysis. Pain
was treated successfully with acetaminophen and tramadol.
# Sinus Tachycardia: After extubation and arrival to the trauma
ICU, pt. went into sinus tachycardia. This was felt to likely be
due to a combination of pain, infection, and hypovolemia. These
were all treated and his tachycardia rapidly improved. Pt. was
initially on CIWA to monitor for alcohol withdrawal but did not
score and it was discontinued.
# CAD s/p CABG in 1990s: Pt. was continued on ASA. His
lisinopril and simvastatin were initially held given rhabdo and
risk for ___. They were restarted at discharge. LASIX?
# Diabetes mellitus, type 2: Pt. reports he was diagnosed about
___ ago and is not sure how well controlled it is. He has
never required insulin and is on glyburide. While his glyburide
was initially held, it was restarted prior to discharge.
# COPD: Pt. continued on home inhalers/nebulizers.
# TRANSITIONAL ISSUES:
- consider better blood glucose monitoring and control
- pt. should complete 7 day course of flagyl and levofloxacin to
end ___
- pt. should follow-up with orthopedics in ___ weeks either at
___ or the ___
- pt. should follow-up with plastic surgery in 2 weeks at ___
- pt. should continue with ___ for rotator cuff tear
- consider vit D given age and gait instability
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Simvastatin 40 mg PO DAILY
2. Furosemide 20 mg PO DAILY
3. Lisinopril 20 mg PO DAILY
4. Omeprazole 20 mg PO DAILY
5. GlyBURIDE 2.5 mg PO DAILY
6. Albuterol Inhaler ___ PUFF IH Q4H:PRN SOB
7. flunisolide 25 mcg (0.025 %) nasal Daily
8. Tiotropium Bromide 1 CAP IH DAILY
9. budesonide-formoterol 160-4.5 mcg/actuation inhalation 2
puffs BID
10. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Furosemide 20 mg PO DAILY
3. GlyBURIDE 2.5 mg PO DAILY
4. Omeprazole 20 mg PO DAILY
5. Tiotropium Bromide 1 CAP IH DAILY
6. Acetaminophen 650 mg PO Q6H
Do not exceed 3gm/day.
7. Bisacodyl ___AILY
Do not take if stools are loose.
8. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN SOB, wheezing
Switch to inhalers once able to take without pain.
9. Docusate Sodium 100 mg PO BID
Do not take if stools are loose.
10. Heparin 5000 UNIT SC TID
11. Levofloxacin 500 mg PO Q24H
STARTED ___. END ___.
12. MetRONIDAZOLE (FLagyl) 500 mg PO Q8H
STARTED ___. END ___.
13. Polyethylene Glycol 17 g PO BID
Do not take if stools are loose.
14. Senna 1 TAB PO BID
Do not take if stools are loose.
15. TraMADOL (Ultram) 25 mg PO Q6H:PRN pain
16. budesonide-formoterol 160-4.5 mcg/actuation INHALATION 2
PUFFS BID
17. flunisolide 25 mcg (0.025 %) NASAL DAILY:PRN allergies
18. Lisinopril 20 mg PO DAILY
19. Simvastatin 40 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary diagnoses:
Fall
Rhabdomyolysis
Aspiration pneumonia
Right shoulder rotator cuff tear
Facial fractures
Secondary diagnoses:
Diabetes mellitus, type 2
Coronary artery disease
Chronic obstructive pulmonary disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. ___,
You were admitted to ___ after being found down. You had
significant facial fractures, muscle injury, rotator cuff tear,
and pneumonia. Your facial fractures were evaluated by plastics
and felt to be stable. They will follow you up in the outpatient
setting. With respect to you muscle injury, this resolved with
intravenous hydration and you will regain strength with physical
therapy. You were seen by ortho for your rotator cuff tear. They
feel it should improve with physical therapy, and you should
follow-up with either the ortho department here at ___ or at
the ___. With respect to your pneumonia, you were treated with
antibiotics and should continue these until ___.
It was a pleasure taking care of you. We wish you all the best.
Sincerely,
Your medicine team at ___
Followup Instructions:
___
|
19727623-DS-4
| 19,727,623 | 23,466,304 |
DS
| 4 |
2179-11-21 00:00:00
|
2179-11-21 13:36:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
lightheadedness, ___
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ y/o M with PMH notable for CAD s/p stent in
early ___ and 3v CABG in ___, DM, hypercholesterolemia, who
presents with dizziness and was found to have ___. Patient was
visiting his brother in the ___ building, when he had an
episode of dizziness and lightheadedness in the hallway. He felt
that he was falling but caught himself. He denies LOC. Patient
and wife note that he looked clammy with diaphoresis (wife says
he has been pale and having HA x2 days). He received orange
juice upstairs and felt better afterwards. He was then sent to
the ED for further evaluation.
He reports having mild nausea for last 2 days. This was worse
with eating, resulting in decreased PO intake. He did not eat
anything on day of presentation. Otherwise patient denies
fevers, chills, shortness of breath, chest pain, palpitations,
vomiting, diarrhea, or abdominal pain. He reports no chest
discomfort, urinary symptoms, or recent medication changes. Of
note, his urine is chronically cloudy, sweet-smelling, and foamy
___ DM. Also of note, he reports his diabetes regimen has been
changed multiple times due to poor control and he was previously
on insulin, currently on oral anti-hyperglycemic agents.
In the ED, initial vitals were: 97.6 68 135/65 20 97% RA.
An EKG revealed nonspecific T wave changes in lateral leads.
Trops were negative x2. A stress test showed nonspecific ST
changes without angina or presyncopal sxs, although he did have
a blunted heart rate response (73% predicted). CBC showed mild
leukocytosis and Chem7 revealed Cr of 2.8 up from baseline of
1.1 (on ___ per PCP). He was observed overnight, and the
following morning's Cr was 2.5. He subsequently received 2L NS
in the ED. On the floor, his vitals are stable, and he reports
feeling asymptomatic.
Past Medical History:
- CAD s/p CABGx3 in ___ and stent in early ___
- DM
- HTN
- HLD
Social History:
___
Family History:
Mother with colon cancer. Father's side of family with DM.
Denies hx of CAD or renal disease.
Physical Exam:
EXAM ON ADMISSION:
==================
Vital Signs: 98.4 157/89 70 18 97 RA
General: Alert, oriented, no acute distress
HEENT: Sclerae anicteric, MMM, oropharynx clear, EOMI, PERRL,
neck supple, JVP not able to evaluate, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Flank: no CVA tenderness
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
GU: No foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: AAOx3, ambulating.
EXAM AT DISCHARGE:
==================
Vitals: T 97.9, BP 124/73, HR 51, RR 18, SAT 97 RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: obese, soft, non-tender, non-distended, bowel sounds
present
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Skin: no rashes
Neuro: AAOx3, ambulating
Pertinent Results:
LABS ON ADMISSION:
==================
___ 04:02PM GLUCOSE-179* UREA N-32* CREAT-2.8* SODIUM-139
POTASSIUM-4.3 CHLORIDE-104 TOTAL CO2-20* ANION GAP-19
___ 04:02PM WBC-13.4* RBC-4.78 HGB-13.5* HCT-40.3 MCV-84
MCH-28.2 MCHC-33.5 RDW-14.1 RDWSD-43.5
___ 04:02PM PLT COUNT-280
___ 04:02PM NEUTS-75.7* LYMPHS-14.2* MONOS-9.0 EOS-0.4*
BASOS-0.4 IM ___ AbsNeut-10.13* AbsLymp-1.90 AbsMono-1.21*
AbsEos-0.05 AbsBaso-0.05
___ 05:55PM URINE BLOOD-SM NITRITE-NEG PROTEIN-300
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-2* PH-6.0
LEUK-NEG
___ 05:55PM URINE GRANULAR-106*
___ 04:02PM cTropnT-<0.01
___ 08:09PM cTropnT-<0.01
STUDIES:
========
STRESS TEST Study Date of ___
IMPRESSION: Fair/average exercise tolerance for age. No anginal
symptoms or pre-syncopal symptoms with nonspecific ST-T wave
changes. Occasional isolated VPBs with one ventricular couplet
and one ventricular triplet. Appropriate blood pressure response
to exercise. Blunted heart rate response to exercise.
CHEST (PA & LAT) Study Date of ___ 5:11 ___
FINDINGS: Patient is status post median sternotomy peerno focal
consolidation is seen. No pleural effusion or pneumothorax is
seen. Cardiac silhouette is borderline in size. Mediastinal
contours are unremarkable. No pulmonary edema is seen.
IMPRESSION: No acute cardiopulmonary process.
RENAL U/S (Study Date of ___ 8:01AM)
IMPRESSION:
1. Normal renal ultrasound.
2. Incidentally noted on limited views the liver is diffusely
echogenic consistent with hepatic steatosis. Other forms of
liver disease and more advanced liver disease including
significant hepatic fibrosis/cirrhosis can't be excluded on this
study.
LABS ON DISCHARGE:
==================
___ 06:05AM BLOOD Glucose-81 UreaN-28* Creat-2.2* Na-145
K-4.5 Cl-110* HCO3-20* AnGap-20
___ 06:05AM BLOOD Calcium-9.1 Phos-3.2 Mg-2.4
___ 06:05AM BLOOD WBC-8.0 RBC-4.41* Hgb-12.5* Hct-37.5*
MCV-85 MCH-28.3 MCHC-33.3 RDW-14.1 RDWSD-43.8 Plt ___
Brief Hospital Course:
Mr. ___ is a ___ M with h/o CAD, DM who presents with
lightheadedness/dizziness and ___ with Cr >2x baseline.
# ___: Pt presented with Cr 2.8 up from baseline 1.1 (measured
___ per PCP). Cr has since downtrended to and stabilized at
2.1-2.2. Nausea with poor PO intake and possible orthostasis
would suggest prerenal ___ with possible ischemic ATN. However,
urine lytes (UNa, FeNA, FeUrea) and BUN:Cr would suggest against
pre-renal etiology. Normal renal U/S (___) rules out post-renal
etiology. Urine sediment shows granular casts, which is not
specific for any particular intrarenal cause. Clinical exam and
history is not suggestive of glomerular etiology, and no classic
nephrotoxic drug taken recently other than ACE-I. Given
asymptomatic presentation with benign exam and downtrending Cr,
he can be followed as an outpatient for resolution ___ and/or
work up of subacute ___ on CKD.
# DM: His home PO meds were held while inpatient given poor PO
intake prior to admission and risk for hypoglycemia given the
setting of ___. He was put on fingersticks QACHS with insulin
sliding scale. He had a minimal insulin requirement (2 units
total) during his hospitalization. On discharge, his metformin
and glimiperide were stopped given renal function. Januvia is
now renally dosed with a reduction to 50 mg daily.
# HTN: He was hypertensive on admission to 157/89, but BPs
stable at 110-140s/60-70s. His home lisinopril was held given
___. His home amlodipine and metoprolol were continued.
# CAD: Patient is s/p stent and CABGx3. EKG on admission with
precordial T wave inversions and chronic inferior Q waves.
Stress test on ___ showed nonspecific ST-T wave changes without
angina or pre-syncopal sxs. His home rosuvastatin, clopedigrel,
ASA, metoprolol were continued.
# Leukocytosis: Pt presented with leukocytosis to 13.4. CXR was
negative. Clinical picture not concerning for acute infectious
process at the time (afebrile, stable BPs). Urine culture was
negative. His leukocytosis resolved to WBC ___.
TRANSITIONAL ISSUES:
====================
[ ] Follow up appointment with PCP to check electrolytes and Cr,
possible Nephrology referral
[ ] Outpatient management of hypertension: ACE-I held on
discharge due to ___
[ ] Outpatient management of diabetes: metformin was stopped due
to newly impaired renal function; glimepiride was stopped due to
risk of hypoglycemia from his newly impaired renal function;
Januvia now renally dosed with reduction to 50 mg daily instead
of 100 mg daily.
Greater than 30 minutes was spent in care coordination and
counseling on the day of discharge.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. amLODIPine 2.5 mg PO DAILY
2. Clopidogrel 75 mg PO DAILY
3. Rosuvastatin Calcium 40 mg PO QPM
4. glimepiride 4 mg oral BID
5. Metoprolol Succinate XL 50 mg PO QHS
6. MetFORMIN (Glucophage) 1000 mg PO BID
7. Lisinopril 10 mg PO QHS
8. Januvia (SITagliptin) 100 mg oral DAILY
9. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Januvia (SITagliptin) 50 mg oral DAILY
2. amLODIPine 2.5 mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. Clopidogrel 75 mg PO DAILY
5. Metoprolol Succinate XL 50 mg PO QHS
6. Rosuvastatin Calcium 40 mg PO QPM
7. HELD- Lisinopril 10 mg PO QHS This medication was held. Do
not restart Lisinopril until your primary care doctor instructs
you to do so.
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
==================
- Acute kidney injury on chronic kidney disease
SECONDARY DIAGNOSES:
====================
- Diabetes
- Coronary artery disease
- 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 to care for you at the ___
___.
Why did you come to the hospital?
- You were feeling lightheaded and were evaluated in the
emergency department. In the emergency department, they
discovered that your kidney function had significantly worsened
since your visit with your primary care physician early in
___. You were admitted in order to evaluate your kidney
function.
What did you receive in the hospital?
- In the hospital, you received a number of blood and urine
laboratory tests to evaluate your kidney function and potential
causes of kidney injury. You also received a kidney ultrasound
to evaluate for kidney injury. You also received a cardiac
stress test to evaluate your cardiac function. You were also
given intravenous fluids in the emergency department.
- We did not identify an exact cause of your kidney impairment,
but the kidney function was stable at the time of discharge. You
will need close follow up with your primary care doctor and
likely a referral to see a kidney specialist as well.
What should you do once you leave the hospital?
- You should follow up with your primary care physician about
your kidney function.
- You should have follow up with a kidney doctor. You preferred
to see your primary care doctor before having a referral to one.
- Please have your labs checked the day before your appointment
with your PCP. Your PCP's office said that you can just go to
the walk-in lab location.
- We made several changes to your medications because of your
impaired kidney function. Please stop taking metformin,
glimepiride, and lisinopril until you speak with your PCP. Also,
please take only ___ tablet of Januvia instead of a full tablet
to avoid low blood sugar levels.
- Please stay hydrated by drinking plenty of water and eat a
low carbohydrate diet before seeing your regular doctor.
- If you see blood in the urine, foul smelling urine, develop
fevers or chills, become acutely confused, develop chest pain or
shortness of breath, or develop significant leg swelling, do not
hesitate to contact your physician or be seen in the emergency
department.
We wish you the best!
Your ___ Care Team
Followup Instructions:
___
|
19727821-DS-2
| 19,727,821 | 25,756,599 |
DS
| 2 |
2162-11-21 00:00:00
|
2162-11-21 12:59:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Headache.
Major Surgical or Invasive Procedure:
___ Left Craniotomy for Tumor Excision.
___ Cerebral angiogram with coil embolization of the
anterior branch of the left middle meningeal artery.
History of Present Illness:
___ yo F with Headache x 3 weeks found on outpatient work up
to have a large left mass. Pt was escorted from MRI scanner to
ED. Pt notes that she has had an intermittent severe HA for the
past 3 weeks, at times ___, relieved by rest, exacerbated by
movement. Also reports occasional unsteadiness when walking.
No
falls. Denies numbness, weakness, tingling, blurred vision,
double vision. The risks and benefits of surgical intervention
were discussed and the patient consented to the procedure.
Past Medical History:
None, 2 normal vaginal deliveries.
Social History:
___
Family History:
NC.
Physical Exam:
PHYSICAL EXAMINATION ON ADMISSION:
O: T:98.6 HR:80 BP: 120/79 RR:18 Sat:99% RA
Gen: WD/WN, comfortable, NAD.
HEENT: normocephalic, atraumatic
Neck: Supple.
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
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: Mild right nasolabial fold flattening. Facial sensation
intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
XI: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power ___ throughout. No pronator drift.
Sensation: Intact to light touch bilaterally.
Coordination: normal on finger-nose-finger, rapid alternating
movements.
PHYSICAL EXAMINATION ON DISCHARGE:
Alert and oriented x3. Speech fluent and clear. Comprehension
intact.
CN II-XII grossly intact with slight edema surrounding left eye.
Motor examination: ___ motor strength in all four extremities.
Incision: closed with staples, clean, dry and intact. No
drainage on the day of discharge.
Pertinent Results:
MR HEAD W AND W/O CONTRAST ___
7.3 cm AP x 6.7 cm SI by 6.0 cm TV enhancing extra-axial mass in
the left
frontal lobe which most likely represents a large meningioma.
This mass is resulting in significant mass effect as detailed
above. As this mass
demonstrates prominent vascularity, a CTA could be obtained for
pre-surgical
planning.
CTA HEAD W&W/O C & RECONS Study Date of ___ 12:55 ___
IMPRESSION:
1. Large extra-axial left frontal mass with heterogeneous
enhancement and apparently increased vascularity, likely
consistent with a meningioma, causing significant mass effect,
midline shifting and effacement of the perimesencephalic
cisterns as described in detail above.
2. There is mass effect in the anterior and left middle cerebral
arteries
arteries from mass effect with no evidence of vascular
occlusion, no aneurysms
are identified.
___ MRI brain functional
Unchanged large extra-axial mass with heterogenous enhancement,
increased
perfusion, and mass effect within the left frontal lobe
including posterior deviation of the fibers of the corticospinal
tract. The majority of BOLD activation during assessment of
language function is seen within the left cerebral hemisphere;
however, there is no significant activity identified adjacent to
the mass lesion.
___ Cerebral angiogram coil/embolization
Successful coil embolization of the anterior branch of the left
middle meningeal artery feeding into the left large sphenoid
wing meningioma. The ACA branches have been pushed
significantly to the right side and MCA has slightly smaller
than normal size and has been pushed laterally and inferiorly.
No procedure-related complication was noted and the patient
remained neurologically intact afterwards.
___ Head CT w/o contrast
Status post left frontotemporal craniotomy with postsurgical
changes, causing significant mass effect on basal cisterns and
10 mm of midline shift.
___ Brain MRI w&w/o contrast
Interval left-sided craniotomy with large left frontal lobe mass
resection including expected postoperative subdural and
parenchymal blood products, pneumocephalus, and dural
enhancement. Decreased mass effect on the lateral ventricles and
decreased midline shift. Intrinsic T1 hyperintensity within the
inferior medial aspect of the resection cavity indicative of
postoperative blood products which limits evaluation for
residual enhancement although there are small areas of nodular
enhancement within the superior medial margin of the resection
cavity --
continued followup is recommended.
Brief Hospital Course:
On ___ the patient was being escorted to the ED after an
outpatient MRI was performed and the patient was found to have a
large left frontal mass. The patient was admitted to the
neurosurgery service.
On ___ the patient was alert and oriented to person, place and
time. The patient was moving all of her extremities with full
strength, and was noted to have a slight right pronator drift.
The patients pupils were equal, round and reactive to light, and
her extraocular movements were intact. The patient had a CTA of
the head.
___ The patient remained neurologically stable, and was alert
and oriented to person place and time. The patient was moving
all of her extremities with full strength and the patients
pupils were equal round and reactive to light, 4.5-3 mm
bilaterally.
On ___ the patient remained neurologically intact, moving
all of her extremities with full strength. The patient was alert
and oriented to person place and time and independently
ambulating. The patient underwent an angiogram under
interventional neuroradiology for embolization of the tumor.
On ___, the patient underwent a left craniotomy and resection
of tumor. She tolerated the procedure well. She was transferred
to the SICU for recovery.
On ___, the patient was stable in the SICU over night. She
had post operative imaging ordered. Her diet was advanced.
On ___, the patient was stable over night. Her post operative
MRI showed post op changes within the resection cavity. No post
op bleeding, gross total resection of lesion. Her foley was
DC'd and she was transferred to the floor. There was a slight
amount of drainage from the incision hear her left ear. A
dressing was applied and it was monitored overnight.
On ___, the patient remained neurologically intact. The
dressing was removed and there was no active drainage from the
incision. She was ambulating independently, voiding without
difficulty and tolerating a diet. It was determined she would be
discharged to home today.
Medications on Admission:
Daily multivitamin.
Discharge Medications:
1. Acetaminophen-Caff-Butalbital ___ TAB PO Q8H:PRN headache
Do not exceed greater than 4g Acetaminophen in a 24-hour period.
RX *butalbital-acetaminophen-caff 50 mg-325 mg-40 mg 1 tablet(s)
by mouth every 8 hours Disp #*40 Tablet Refills:*0
2. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
Do not drive while taking this medication. Hold for sedation,
drowsiness or RR <12.
RX *oxycodone 5 mg ___ tablet(s) by mouth every 4 hours Disp
#*40 Tablet Refills:*0
3. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 tablet(s) by mouth BID. Disp #*60
Tablet Refills:*0
4. LeVETiracetam 500 mg PO BID
RX *levetiracetam 500 mg 1 tablet(s) by mouth BID. Disp #*60
Tablet Refills:*3
5. Omeprazole 20 mg PO DAILY
RX *omeprazole 20 mg 1 tablet(s) by mouth daily. Disp #*30
Tablet Refills:*0
6. Dexamethasone 4 mg PO Q8H Duration: 48 Hours
RX *dexamethasone 1 mg 1 tablet(s) by mouth as directed by taper
below. Disp #*62 Tablet Refills:*0
7. Dexamethasone 3 mg PO Q8H Duration: 48 Hours
8. Dexamethasone 2 mg PO Q8H Duration: 48 Hours
9. Dexamethasone 2 mg PO Q12H Duration: 48 Hours
10. Multivitamins 1 TAB PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Left Frontal Mass.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Discharge Instructions
Brain Tumor
Surgery
· You underwent surgery to remove a brain lesion from your
brain.
· Please keep your incision dry until your staples are
removed.
· You may shower at this time but keep your incision dry.
· It is best to keep your incision open to air but it is ok
to cover it when outside.
· Call your surgeon if there are any signs of infection like
redness, fever, or drainage.
Activity
· We recommend that you avoid heavy lifting, running,
climbing, or other strenuous exercise until your follow-up
appointment.
· You make take leisurely walks and slowly increase your
activity at your own pace once you are symptom free at rest.
___ try to do too much all at once.
· No driving while taking any narcotic or sedating
medication.
· If you experienced a seizure while admitted, you are NOT
allowed to drive by law.
· No contact sports until cleared by your neurosurgeon. You
should avoid contact sports for 6 months.
Medications
· Please do NOT take any blood thinning medication (Aspirin,
Ibuprofen, Plavix, Coumadin) until cleared by the neurosurgeon.
· You have been discharged on Keppra (Levetiracetam). This
medication helps to prevent seizures. Please continue this
medication as indicated on your discharge instruction. It is
important that you take this medication consistently and on
time.
** You have been prescribed a steroid taper, Dexamethasone.
Take this medication as prescribed. You are also being
prescribed Omeprazole as a stomach protectant which should be
taken with the Dexamethasone.
** You have been prescribed Docusate Sodium for constipation
which you might experience while taking pain medications.
What You ___ Experience:
· You may experience headaches and incisional pain.
· You may also experience some post-operative swelling
around your face and eyes. This is normal after surgery and most
noticeable on the second and third day of surgery. You apply
ice or a cool or warm washcloth to your eyes to help with the
swelling. The swelling will be its worse in the morning after
laying flat from sleeping but decrease when up.
· You may experience soreness with chewing. This is normal
from the surgery and will improve with time. Softer foods may be
easier during this time.
· Feeling more tired or restlessness is also common.
· Constipation is common. Be sure to drink plenty of fluids
and eat a high-fiber diet. If you are taking narcotics
(prescription pain medications), try an over-the-counter stool
softener.
When to Call Your Doctor at ___ for:
· Severe pain, swelling, redness or drainage from the
incision site.
· Fever greater than 101.5 degrees Fahrenheit
· Nausea and/or vomiting
· Extreme sleepiness and not being able to stay awake
· Severe headaches not relieved by pain relievers
· Seizures
· Any new problems with your vision or ability to speak
· Weakness or changes in sensation in your face, arms, or
leg
Call ___ and go to the nearest Emergency Room if you experience
any of the following:
· Sudden numbness or weakness in the face, arm, or leg
· Sudden confusion or trouble speaking or understanding
· Sudden trouble walking, dizziness, or loss of balance or
coordination
· Sudden severe headaches with no known reason
Followup Instructions:
___
|
19728114-DS-14
| 19,728,114 | 26,163,953 |
DS
| 14 |
2150-12-30 00:00:00
|
2150-12-30 20:37:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
trazodone
Attending: ___.
Chief Complaint:
neck pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. ___ is a ___ y/o male with hx of chronic ETOH who per
report was involved in a straight on collision with another
vehicle when taking a left turn. Per report, he hit his head on
the door handle. He went home after the accident; unclear if he
was drinking prior to the MVA or if he started drinking only
after he got home. He states he did not get cited, and went home
and had a few drinks, but was obviously intoxicated. He states
he
recalls the event, and denies LOC. He decided to come in to the
ED because his neck was hurting. He endorses neck pain, worse on
palpation, denies numbness tingling, n/v, dizziness, SOB or CP.
Past Medical History:
- Alcohol abuse (multiple hospitalizations for DTs, seizures)
- HTN
- Psoriasis
- Anxiety/depression/PTSD
- Multiple ortho injuries including R shoulder, L arm
- Multiple concussions
Social History:
___
Family History:
denies any significant FH
Physical Exam:
Discharge Physical Exam:
VS: Temp 98.0; SBP 142/90s; HR 85; RR 18; O2 99% RA
Gen: Middle age man, NAD, wearing neck brace
HENT: EOMI, sclera anicteric, MMM
Lungs: CTAB
Heart: RRR, S1 and S2
Abdomen: soft, NT, ND, +BS
Ext: warm, well perfused, no ___ edema
Psych: normal mood and affect
Neuro: AOx3, no focal deficits
Pertinent Results:
___ 07:24AM BLOOD WBC-3.4* RBC-3.59* Hgb-11.1* Hct-34.6*
MCV-96 MCH-30.9 MCHC-32.1 RDW-15.8* RDWSD-55.6* Plt ___
___ 07:24AM BLOOD Glucose-83 UreaN-7 Creat-0.7 Na-141 K-4.2
Cl-101 HCO3-24 AnGap-16
___ 07:24AM BLOOD Calcium-8.4 Phos-3.0 Mg-2.0
Brief Hospital Course:
FICU COURSE ___
=============================
Mr. ___ is a ___ male with past medical history of
alcohol abuse who presented to ___ with alcohol withdrawal in
setting of recent MVC and a new RUE DVT, subsequently
transferred to the ICU for further management.
ACUTE ISSUES
============
#Alcohol abuse
#Alcohol withdrawal
The patient was found to have a ETOH level of 331 at ___
on presentation to ___ ETOH level was 12 and was noted to be
in active withdrawal in ED. Upon arrival to the ___ he was put
on a phenobarbital withdrawal protocol. He was also given
treatment-dose thiamine as well as folate and a multivitamin.
Clonidine, Hydroxyzine, and Haldol were ordered on an as needed
basis. Social work was consulted to provide substance abuse
counseling which patient declined. The patient was monitored
closely through the night and was deemed stable enough to be
transferred ot the medical floors. He no longer was scoring so
was discharged home off phenobarbital he was encouraged to
abstain from further alcohol use. He was discharged with folate
and thiamine.
#RUE DVT
Incidentally found on imaging to have concern for DVT. On
further eval with RUE US to have extending from the basilica
vein into the axillary and subclavian veins. Vascular surgery
was consulted who recommended anticoagulation. Patient is
candidate for NOAC. Confirmed with his pharmacy that his
insurance will cover apixiban for minimal copayment. However it
was noted by pharmacy that phenobarbital interacts with apixiban
making its therapeutic potential unknown while phenobarbital
remains in his system for 2 weeks. Discussed starting ___
instead with patient who stated he preferred to use lovenox to
bridge until he could start apixiban. He was given lovenox
teaching and instructions to continue with lovenox for the next
two weeks before switching over to apixiban. He understood this
instructions and gave himself his most recent lovenox injection
without difficulties. He will follow up Dr. ___ vascular
as outpatient. The patient will need close PCP ___ as well
as further history/workup for possible hypercoagulable states.
#C4 fracture
The fracture most likely occurred in the setting of the MVA. It
was found to be non-displaced and a wet read of a CTA neck (done
at ___ was without evidence of vascular injury. The
patient was evaluated by spine surgery who recommended a hard
cervical collar for 4 weeks and outpatient ___ with Dr.
___ in 4 weeks. For pain control he was given oxycodone 5mg
Q4h #15 tablets. ___ was checked and was negative for any
previous narcotic prescriptions. He was advised not to take with
alcohol and to abstain completely as noted above. He was also
recommended to use Tylenol/ibuprofen as well.
#AGMA
The patient presented with an anion gap of 22 which was
suspected to be due to alcoholic ketosis. His acidosis was
monitored for resolution and a lactate was checked and was found
to be 2. AGMA resolved prior to discharge
CHRONIC ISSUES
==============
#HTN
The patient was not on anti-hypertensives at home but his blood
pressures were closely monitored per withdrawal protocol.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. CloNIDine 0.1 mg PO TID
2. DiphenhydrAMINE 50 mg PO QHS:PRN sleep
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
2. Apixaban 5 mg PO BID
please start taking on ___
RX *apixaban [Eliquis] 5 mg 5 tablet(s) by mouth twice a day
Disp #*60 Tablet Refills:*0
3. Enoxaparin Sodium 100 mg SC Q12H
Start: Today - ___, First Dose: Next Routine Administration
Time
continue taking through ___
RX *enoxaparin 100 mg/mL 100 mg SQ twice a day Disp #*28 Syringe
Refills:*0
4. FoLIC Acid 1 mg PO DAILY
RX *folic acid 1 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
5. Ibuprofen 600 mg PO Q8H:PRN Pain - Moderate
6. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain -
Moderate
Reason for PRN duplicate override: Alternating agents for
similar severity
RX *oxycodone 5 mg 5 capsule(s) by mouth every four (4) hours
Disp #*15 Capsule Refills:*0
7. CloNIDine 0.1 mg PO TID
8. DiphenhydrAMINE 50 mg PO QHS:PRN sleep
Discharge Disposition:
Home
Discharge Diagnosis:
RUE DVT
C4 fracture
alcohol withdrawal
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted following your motor vehicle accident with
neck pain. You were found to have a C4 fracture and were placed
in a hard neck collar for protection. You were also found to
have a blood clot in your right arm and were started on
anticoagulation for this.
Followup Instructions:
___
|
19728121-DS-9
| 19,728,121 | 21,385,439 |
DS
| 9 |
2152-02-23 00:00:00
|
2152-02-23 22:07:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Iodine-Iodine Containing / Cipro / hydrochlorothiazide
Attending: ___
Chief Complaint:
Shoulder pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with history of one-vessel CAD s/p MI with LCx lesion s/p
promus DES on ___ with repeat c. cath on ___ with patent
stent and non-obstructive CAD who presented to ___ ED with
left scapular/shoulder pain. She woke up this morning with a
sore upper left back. The discomfort has since spread to her
shoulder and has had shooting down arm and up neck. With her
prior MI, she had similar symptoms in the right back. She has
had a cough. Denies chest pain, SOB, fevers, nausea, emesis. She
called Cardiologist who recommended her coming to ED. She took
asa 325 at home.
In the ED, initial vitals were 2 97.8 79 147/65 18 99% ra. IN
the ED patient initially had pain but subsequently was pain
free. She deneid pain without dyspnea, and lungs were clear. Due
to concern re dissection, ED wanted contrast CT but pt has
iodine allergy. She was thus given 50 MG PO prednisone in ED,
and plan for 50 MG PO prednisone after 6 hours, and then 50 MG
PO prednisone and 50 MG benadryl 1 hour prior to CT scan.
ED Labs were performed and sig for Na 142 K 3.7 Cl 98 HCO3 30
BUN 20 Cr 0.9 (baseline) Glc 115, WBC 8.7 Hgb 14.1 Hct 42.5 Plt
290 Diff E 6.1,Coags within normal limits and troponin < 0.01 at
16:15. ECG showed normal sinus rhythm, NA/NA without changes
concerning for acute ischemia and similar to prior dated
___.
VS on transfer were VS on transfer: 18:20 0 98.0 78 143/66 20
98%. Pt had ___ back pain on transfer to floor. No recent
stressors etc.
On review of systems, the patient denies any prior history of
stroke, TIA, deep venous thrombosis, pulmonary embolism,
bleeding at the time of surgery, myalgias, joint pains, cough,
hemoptysis, black stools or red stools. The patient denies
recent fevers, chills or rigors. The patient denies exertional
buttock or calf pain. All of the other review of systems were
negative.
Cardiac review of systems is notable for absence of chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
ankle edema, palpitations, syncope or presyncope.
Past Medical History:
1. CARDIAC RISK FACTORS: +Diabetes, +Dyslipidemia, +Hypertension
2. CARDIAC HISTORY:
CAD- LAD<50% stenosis, ___ diag 50%, RCA 30%. Promus DES to Left
Circ ___
2+ TR
3. OTHER PAST MEDICAL HISTORY:
- Hypertension with end-organ damage based on LVH noted on ECHO
and mild proteinuria
- Anemia
- Constipation/GERD
- Coronary artery disease
- Diabetes mellitus
- Hypercalcemia
- Overweight
- pancreatic cyst
Social History:
___
Family History:
EXTENSIVE CAD, DM. ___ died of MI at ___.
Physical Exam:
ADMISSION PHYSICAL EXAMINATION:
VS: 98.2 158/101 (L) 164/69 (R) 70 18 94 ra ___
GENERAL: Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthelasma.
NECK: Supple with flat JVD.
CARDIAC: PMI located in ___ intercostal space, midclavicular
line. RR, normal S1, S2. ___ systolic ejection murmur in RUSB.
No diasolic murmur. No murmur in back. No thrills, lifts. No S3
or S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominal bruits.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ ___ 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ ___ 2+
NEURO: grossly intact
DISCHARGE PHYSICAL EXAMINATION:
VS: 98.2 126/58 HR 72 RR18 98% ra
GENERAL: Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva pink, no
pallor or cyanosis of the oral mucosa. MMM, OP clear
NECK: Supple with flat JVD.
CARDIAC: RR, normal S1, S2. ___ systolic ejection murmur in
RUSB. No diasolic murmur. No murmur in back. 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. +BS
EXTREMITIES: No c/c/e
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
Pertinent Results:
ADMISSION LABS:
___ 04:15PM BLOOD WBC-8.7 RBC-4.91 Hgb-14.1 Hct-42.5 MCV-87
MCH-28.8 MCHC-33.2 RDW-13.9 Plt ___
___ 04:15PM BLOOD Neuts-62.0 ___ Monos-5.3 Eos-6.1*
Baso-0.4
___ 04:15PM BLOOD ___ PTT-29.4 ___
___ 04:15PM BLOOD Glucose-115* UreaN-20 Creat-0.9 Na-142
K-3.7 Cl-98 HCO3-30 AnGap-18
___ 08:50AM BLOOD Calcium-10.2 Phos-4.2 Mg-1.7
___ 11:38PM BLOOD D-Dimer-244
___ 04:15PM BLOOD cTropnT-<0.01
___ 08:50AM BLOOD CK-MB-1 cTropnT-<0.01
___ 06:30PM URINE Color-Straw Appear-Clear Sp ___
___ 06:30PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG
___ 06:30PM URINE RBC-1 WBC-<1 Bacteri-NONE Yeast-NONE
Epi-0
CTA chest ___
IMPRESSION:
1. No evidence for pulmonary embolism or aortic dissection.
2. Mild central airway thickening, probably inflammatory, but
no evidence for pneumonia or other acute disease.
3. Mild degenerative changes along the thoracic spine.
Exercise stress ___
IMPRESSION: No ischemic ECG changes. NO anginal type symptoms.
Appropriate hemodynamic response. Good functional capacity
demonstrated.
CXR ___
The heart size is normal. The cardiomediastinal silhouette is
unremarkable. The lungs are clear without consolidations,
effusions or pneumothorax. No acute bony abnormality.
IMPRESSION: No acute intrathoracic process.
Brief Hospital Course:
___ with history of one-vessel CAD s/p MI with LCx lesion s/p
promus DES on ___ with repeat cath on ___ with patent stent
and non-obstructive CAD who presented with shoulder pain, ruled
out for MI and had a normal stress test.
# SHOULDER PAIN: Pt presented with shoulder pain and there was
initially concern fro pulmonary embolus vs dissection. Cardiac
enzyme were negative and EKG was unchanged from prior. Unlikely
to be ischemic in nature as non-exertional but still concerning
given prior prsentation of MI in this patient and atypical
presentations of MI in woman and diabetics, so she underwent
exercise stress test, which was normal. D-dimer was negative and
CTA chest was negative for dissection. Most likely explanation
is musculoskeltal or radicular etiology. Pain resolved on the
morning following admission, most likely from anti-inflammatory
effect of high dose steroids. Continued aspirin.
# chronic diastolic heart failure: Has preserved EF and some
hypertrophy of LV so likely has some diastolic dysfunction
secondary to HTN. Continued home lasix 40mg daily.
# T2DM: Continued levemir and used insulin sliding scale in
place of metformin while inpatient.
# Hypertension: continued atenolol, nifedipine and lisinopril at
home doses. ___ need further optimization as outpatient, not
currently at goal.
# GERD: continued omeprazole
TRANSITIONAL ISSUES:
- Full code, husband is HCP
- ___ need anti-hypertensive regimen adjustment
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lisinopril 40 mg PO DAILY
hold for sbp<100
2. Atenolol 100 mg PO DAILY
hold for sbp<100
3. MetFORMIN (Glucophage) 1000 mg PO BID
4. Polyethylene Glycol 17 g PO DAILY:PRN constipation
5. Fluticasone Propionate NASAL 2 SPRY NU DAILY
6. NIFEdipine CR 30 mg PO DAILY
hold for sbp<100
7. Atorvastatin 40 mg PO DAILY
8. Furosemide 40 mg PO DAILY
hold for sbp<100
9. Centrum *NF* (multivit & mins-ferrous
glucon;<br>multivit-iron-min-folic acid) 3,500-18-0.4 unit-mg-mg
Oral qd
10. Omeprazole 20 mg PO DAILY:PRN GERD
11. Aspirin 325 mg PO DAILY
12. LEVEMIR 12 Units Breakfast
LEVEMIR 14 Units Bedtime
Discharge Medications:
1. Aspirin 325 mg PO DAILY
2. Atenolol 100 mg PO DAILY
3. Atorvastatin 40 mg PO DAILY
4. Fluticasone Propionate NASAL 2 SPRY NU DAILY
5. Furosemide 40 mg PO DAILY
6. Lisinopril 40 mg PO DAILY
7. NIFEdipine CR 30 mg PO DAILY
8. Omeprazole 20 mg PO DAILY:PRN GERD
9. Polyethylene Glycol 17 g PO DAILY:PRN constipation
10. Centrum *NF* (multivit & mins-ferrous
glucon;<br>multivit-iron-min-folic acid) 3,500-18-0.4 unit-mg-mg
Oral qd
11. MetFORMIN (Glucophage) 1000 mg PO BID
12. LEVEMIR 12 Units Breakfast
LEVEMIR 14 Units Bedtime
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: shoulder pain
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear ___ were admitted with shoulder pain and work up showed that
this was most likely muscular or nerve pain. EKG, cardiac
enzymes, and a stress test and a CT scan of your chest were all
normal. Your pain resolved and ___ were able to be discharged
home.
If your cough continues for more than ___ weeks, talk to your
PCP about changing your medication called lisinopril, as this
can cause chronic dry cough. ___ should also ask your PCP about
an ultrasound for your thyroid, as your CT scan showed some
small thyroid nodules.
Followup Instructions:
___
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|
2149-03-31 17:03:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Acute left leg ischemia
Major Surgical or Invasive Procedure:
Left femoral cutdown, iliac thrombectomy, and ilioprofunda
bypass with synthetic graft
History of Present Illness:
Mr. ___ is a ___ y/o M refered from the clinic with 5-day
history of left leg pain in the setting of severe peripheral
arterial disease, status post left BKA. He complains of
discomfort of the anterior thigh and knee cap, extending over
his residual limb.
The distal leg has felt persistently cold. This pain is constant
throughout the day or night. He denies fever and complains of
chills and sweating last night.
Of note, he has a left below-knee amputation and ambulates with
a walker and a below-knee prosthesis. For the past 4 days, he
has not been able to ambulate because of this pain.
Past Medical History:
PMHX:
HLD
HTN
IDDM
Significant PVD
CKD
Glaucoma
Past Surgical History
___
Redo left femoral to anterior tibial artery bypass with
ringed PTFE
Exploration of right greater saphenous vein
___ - percutaneous revasc
___ - LLE bypass, ?saphenous conduit
___ - repeat LLW bypass, ?prosthetic conduit (All performed at
___ by Dr. ___
Hydrocele surgery
Left eye cataract surgery
Social History:
___
Family History:
Unknown
Physical Exam:
___: no acute distress. appears comfortable.
ABDOMEN: Soft, non tender
heart : RRR no murmurs
Lung CTAB
EXTREMITIES: The left femoral pulse is faintly palpable. Cannot
palpate a convincing left popliteal pulse.
Right fem pulses palp. No palpable pedal pulses. There are
right DP and ___ signals.
Left groin incision well approximated with staples. There is no
surrounding erythema or drainage. No foul odor. There is no
edema.
The left fem-pop graft is easily visible and palpable. No
tenderness over the graft. He demonstrates full range of motion
of left knee. Sensory exam grossly intact. Medial left
leg scar consistent with prior bypass. The skin is intact.
There is no ulcerations, tissue loss.
Pertinent Results:
___ 05:17AM BLOOD WBC-8.5 RBC-4.77 Hgb-11.3* Hct-34.2*
MCV-72* MCH-23.7* MCHC-33.0 RDW-14.0 RDWSD-36.0 Plt ___
___ 05:17AM BLOOD Glucose-104* UreaN-14 Creat-1.4* Na-140
K-4.5 Cl-100 HCO3-27 AnGap-13
Brief Hospital Course:
Mr. ___ was admitted to the vascular surgical service and
started on a heparin drip. With initiation of heparin, his pain
resolved. CTA demonstrated occlusion of the left external iliac
artery, common femoral artery, superficial femoral artery, and
popliteal artery as well as occlusion
of the 2 bypass grafts arising from the common femoral artery to
the level of the anterior tibial artery. No demonstrable flow
seen within the arteries below the knee. Underwent uncomplicated
left femoral cutdown, left iliac thrombectomy, ilioprofunda
bypass with synthetic graft on ___. Post operatively, he was
started on Plavix 75mg daily.
His pain was well controlled on Tylenol and gabapentin. He
worked with physical therapy and was deemed appropriate for
discharge home with home physical therapy. Prior to discharge
the patient was tolerating a diet, voiding without issues,
ambulating with physical therapy, with pain controlled on a p.o.
regimen. All appropriate follow-up was arranged and
communicated with the patient. All questions were answered
prior to discharge.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES Q8H
2. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild
3. Gabapentin 200 mg PO BID
4. Metoprolol Succinate XL 50 mg PO DAILY
5. Timolol Maleate 0.25% 1 DROP BOTH EYES BID
6. nut.tx.gluc.intol,lac-free,soy 8 oz oral TID
7. Docusate Sodium 100 mg PO DAILY
8. Ranitidine 150 mg PO BID
9. Atorvastatin 40 mg PO QPM
10. Glargine 30 Units Bedtime
Humalog 25 Units Lunch
Humalog 25 Units Dinner
11. Furosemide 20 mg PO DAILY
12. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Clopidogrel 75 mg PO DAILY
RX *clopidogrel 75 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
2. HYDROmorphone (Dilaudid) 2 mg PO Q6H:PRN Pain - Moderate
RX *hydromorphone [Dilaudid] 2 mg ___ tablet(s) by mouth every
6 hours Disp #*10 Tablet Refills:*0
3. Senna 8.6 mg PO BID:PRN constipation
RX *sennosides [senna] 8.6 mg ___ tabs by mouth BID PRN Disp
#*60 Tablet Refills:*0
4. Acetaminophen 1000 mg PO TID
RX *acetaminophen 500 mg 2 tablet(s) by mouth every 8 hours Disp
#*60 Tablet Refills:*0
5. Atorvastatin 80 mg PO QPM
This will help slow down progression of hardening of arteries
RX *atorvastatin 80 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
6. Docusate Sodium 100 mg PO DAILY
RX *docusate sodium [Colace] 100 mg ___ capsule(s) by mouth BID
PRN Disp #*60 Capsule Refills:*0
7. Gabapentin 200 mg PO BID
8. Glargine 30 Units Bedtime
Humalog 25 Units Lunch
Humalog 25 Units Dinner
9. Aspirin 81 mg PO DAILY
10. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES Q8H
11. Furosemide 20 mg PO DAILY
12. Metoprolol Succinate XL 50 mg PO DAILY
13. nut.tx.gluc.intol,lac-free,soy 8 oz oral TID
14. Ranitidine 150 mg PO BID
15. Timolol Maleate 0.25% 1 DROP BOTH EYES BID
Discharge Disposition:
Home With Service
Facility:
___
___ Diagnosis:
acute on chronic left lower extremity ischemia
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. ___,
It was a pleasure taking care of you at ___
___. You were admitted to the hospital after surgery
on your leg. This surgery was done to improve blood flow to
your leg. You tolerated the procedure well and are now ready to
be discharged from the hospital. Please follow the
recommendations below to ensure a speedy and uneventful
recovery.
Vascular Leg Surgery Discharge Instructions
What to except:
It is normal feel tired for ___ weeks after your surgery
You might notice some leg swelling. Keep your leg elevated as
much as possible. This should decrease the swelling. You
should also be wearing an ACE bandage to the left leg when you
are out of bed.
Your leg might feel tired and sore. This should improve
gradually.
Your incision might be sore, slightly raised, and pink.
Medications:
Before you leave the hospital, you will be given a list of all
the medicine you should take at home. If a medication that you
normally take is not on the list or a medication that you do not
take is on the list please discuss it with the team!
It is very important that you take Aspirin every day! You
should never stop this medication before checking with your
surgeon. A new medication, called Clopidogrel (Plavix) has been
added. This should help protect your new bypass. You should
take this everyday. In addition to this, your dose of
Atorvastatin (Lipitor) has been increased from 40mg to 80mg
daily. This can help to slow down the accumulation of plaque in
your arteries. Your gabapentin dose has increased, to help you
with post operative pain. You are advised to take Tylenol
___ every 8 hours as needed for pain.
Pain Management:
It is normal to feel some discomfort/pain following surgery.
This should gradually improve everyday.
It is not uncommon to experience some constipation. You can
take over the counter stool softeners. If constipation becomes
a problem, your pharmacist can suggest additional over the
counter medications.
Your pain should get better day by day. If you find the pain is
getting worse instead of better, please contact the clinic.
Activity:
You should not be driving until after your provider tells you
this is ok at your follow up appointment.
Walking is good because it helps your muscles get stronger and
improves blood flow. Start with short walks every day. If you
can, go a little further each time, letting comfort be your
guide.
Do not take a tub bath or swim until your staples are removed
and your wound is healed.
You may go outside. But avoid traveling long distances until
your next visit.
You may resume sexual activity after your incisions are well
healed.
You may shower. Do not let the shower spray right on the
incision. Let the soapy water run over the incision, then
rinse. Gently pat the area dry. Do not scrub the incision, Do
not apply ointment or lotions to the incision.
You do not need to cover the incision if there is no drainage,
If there is a small amount of drainage, put a small sterile
gauze or Bandaid over the incison.
It is normal to feel a firm ridge along the incision, This will
go away as your wound heals.
Avoid direct sun exposure to the incision area for 6 months.
This will help keep the scar from becoming discolored.
Over ___ months, your incision will fade and become less
prominent.
Diet
Follow a well-balanced, health healthy diet, without too much
salt and fat.
Drinking more fluid may also help.
If you go 48 hours without a bowel movement, or having pain
moving your bowels, call your primary care physician.
Followup Instructions:
___
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2192-12-26 10:50:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
___ crush injury to back
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ man BIBA from scene s/p workplace accident. Per EMS/patient
report, pt was working on the ___ floor of a construction site,
was bent over, and a 200lb piece ___ fell 15ft onto his
lower back. Pt was able to stand and ambulate at first then
required assistance to get down to the ground. Pt arrived A&Ox3,
calm, and c/o Lower L side/ back pain.
___ spoke briefly with pt at bedside in the trauma bay to offer
support and inquire about calling NOK. Pt shared that he would
like to call his wife once his medical work up is done so he'll
have information to tell her. ___ validated this choice and
encouraged him to reach out for further support prn.
Wife ___: ___
Past Medical History:
-Headaches
-Hypertrophic cardiomyopathy
-AICD placement
-Tonsillectomy
Social History:
___
Family History:
non-contributory
Physical Exam:
Admission Physical Exam:
General: Alert and Well Developed
HEENT: Normal ENT inspection. Neck: No Lymphadenopathy and
Supple Respiratory: No Resp Distress
CHEST: non-tender and normal Breath Sounds
Cardio-Vascular: No murmur, No rub and RRR
Abdomen: Normal Bowel Sounds, No Organomegaly,
Non-tender and Soft Back: No CVA tenderness Extremity: No
edema and Normal Equal pulses Neurological: Alert, Oriented
X3 and No Gross Weakness; strength 5+eq in all 4 ext. no
focal sensory deficits Skin: No rash and No Petechiae
Psychological: Mood/Affect Normal
Discharge Physical Exam:
VS: T: 97.7 PO, BP: 138/68, HR: 63 RR: 19 O2: 97% RA
General: A+Ox3, NAD
HEENT: normocephalic, atraumatic
NECK: no cervical spine tenderness with palpation. Full ROM
without pain
CHEST: non-tender to palpation, normal excursion
CV: RRR
PULM: CTA b/l
ABD: soft, non-distended, non-tender to palpation
BACK: mild ecchymosis at lower left back extending to mid-back
Soft and mildly tender to palpation. Mild pain with palpation
along lumbar spine, consistent with known L1, L2 TP fractures
Extremities: warm, well-perfused, no edema b/l
Pertinent Results:
Imaging:
___: CT Torso:
1. Minimally displaced fractures involving the left L1 and L2
transverse
process.
2. Mild cardiomegaly with AICD extending into the right
ventricle.
3. Duplex left renal collecting system with atrophic upper pole
moiety.
___: CXR:
No acute findings.
Labs:
___ 06:55PM GLUCOSE-105* UREA N-16 CREAT-1.1 SODIUM-138
POTASSIUM-4.1 CHLORIDE-99 TOTAL CO2-23 ANION GAP-20
___ 06:55PM CK(CPK)-589*
___ 06:55PM CALCIUM-9.8 PHOSPHATE-3.6 MAGNESIUM-2.1
___ 01:30PM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 01:30PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
___ 12:20PM GLUCOSE-86 UREA N-18 CREAT-1.0 SODIUM-137
POTASSIUM-4.0 CHLORIDE-101 TOTAL CO2-20* ANION GAP-20
___ 12:20PM WBC-7.6 RBC-5.71 HGB-14.2 HCT-43.4 MCV-76*
MCH-24.9* MCHC-32.7 RDW-14.6 RDWSD-38.9
___ 12:20PM NEUTS-58.6 ___ MONOS-7.5 EOS-2.4
BASOS-0.7 IM ___ AbsNeut-4.48 AbsLymp-2.31 AbsMono-0.57
AbsEos-0.18 AbsBaso-0.05
___ 12:20PM PLT COUNT-204
Brief Hospital Course:
Mr. ___ is a ___ y/o M who was at work at a ___ site
when a 200 pound bar fell on his back. He presented to the ___
ED with severe back pain and a trauma basic was called on
arrival. On HD1, the patient underwent CT Torso which revealed
fractures of the left L1 and L2 transverse processes. CXR
revealed no acute findings. Given the patient's crush injury, he
was admitted to the Trauma Surgical service to monitor CK and
also for evaluation by Physical Therapy. He was started on IV
fluids and was transferred to the surgical floor.
On HD2, a tertiary exam was performed which revealed no other
acute traumatic injuries. The patient's CK downtrended from 589
to 358. His IV fluids were discontinued and the patient was
written for a regular diet. The patient worked with physical
therapy, and the patient was safe to be discharged home with a
cane for support.
The patient was alert and oriented throughout hospitalization;
pain was managed with initially managed with acetaminophen and
oxycodone. The patient remained stable from a cardiovascular and
pulmonary standpoint; vital signs were routinely monitored. Good
pulmonary toilet, early ambulation and incentive spirometry were
encouraged throughout hospitalization. The patient's intake and
output were closely monitored. The patient's fever curves were
closely watched for signs of infection, of which there were
none. The patient's blood counts were closely watched for signs
of bleeding, of which there were none. The patient received
subcutaneous heparin and ___ dyne boots were used during this
stay and was encouraged to get up and ambulate as early as
possible.
At the time of discharge, the patient was doing well, afebrile
and hemodynamically stable. The patient was tolerating a diet,
ambulating, voiding without assistance, and pain was well
controlled. The patient received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with the discharge plan.
Medications on Admission:
Naproxen
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild
2. Docusate Sodium 100 mg PO BID
please hold for loose stool
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*30 Capsule Refills:*0
3. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain -
Moderate
do NOT drink alcohol or drive while taking this medication
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*20 Tablet Refills:*0
4. Senna 8.6 mg PO BID:PRN constipation
RX *sennosides [senna] 8.6 mg 1 tablet by mouth twice a day Disp
#*30 Tablet Refills:*0
5.Outpatient Physical Therapy
Dx: gait instability
Px: good
Duration: 13 (thirteen) months
6.straight cane
Dx: gait instability
Px: good
Duration 13 (thirteen) months
Discharge Disposition:
Home
Discharge Diagnosis:
-L1, L2 transverse process fractures
-Left flank/back pain crush injury
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (cane)
Discharge Instructions:
Dear Mr. ___,
It was a pleasure caring for you at the ___
___. You were admitted to the hospital after
suffering a crush injury to your back from a falling ___. You
had imaging which revealed spine tip fractures which will heal
without intervention. You were given IV fluids and had blood
levels checked which showed no extensive muscle breakdown from
your injury. You have worked with Physical Therapy and will
receive a cane and outpatient physical therapy.
You are now ready to be discharged home to continue your
recovery. Please note the following discharge instructions:
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within ___ hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications, unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than ___ lbs until you follow-up with your
surgeon.
Avoid driving or operating heavy machinery while taking pain
medications.
Followup Instructions:
___
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Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
RUQ pain, liver mass
Major Surgical or Invasive Procedure:
US guided liver biopsy
History of Present Illness:
Mrs. ___ is a ___ year old ___ speaking woman with no
known chronic medical issues, recently discovered liver and lung
masses, presents with worsening RUQ pain.
Patient was admitted recently to ___ on ___
with RUQ pain at which time she had a CT that showed masses in
her liver and lung concerning for metastatic cancer. Biopsy was
deferred to outpatient. She had an appointment scheduled with
Dr.
___ on ___ in Oncology.
While at ___ she had labs showing mild transaminitis, INR 1.3,
LDH 1013, tbili 1.3, dbili 0.5, CTP 104, HBcAb+. Oncology
recommended biopsy with testing for EGFR, AIK and PDL1, which
was
not yet performed. Of note, patient reported having occasional
hematochezia to the ___ physicians, but she denies this to me.
At home she has been taking Tylenol for her pain. Her pain gets
worse about two hours after eating. It is worst in the RUQ and
radiates to her LUQ. She says she has been able to eat a normal
amount and denies any known weight changes. She has a difficult
time understanding (despite interpreter) the question about
whether she is eating less now than previously. She says the
only
change over the past ___ years is that she ate a different kind
of rice while in ___, but says there are no other changes.
She denies fevers, chills, vomiting, constipation or diarrhea.
Comprehensive 10-point review of systems is otherwise negative.
ED course:
- Exam: RUQ tenderness and guarding, milder LUQ tenderness
- Labs: Notable for AST 58, ALT 33, ALP 377, WBC 14.1
- Imaging: Multiple liver mets
- Meds: Morphine 2mg IV, 1L NS
- Plan: Admit for expedited evaluation of likely metastatic
cancer.
Past Medical History:
- No known history
Social History:
___
Family History:
Mother: ___, HTN
Father: ___, HTN
No known cancer
Physical Exam:
Admission PE:
Vital signs: T 97.3, BP 132/81, P 80, RR 18, O2 100% on RA
General: Alert, oriented, no acute distress
HEENT: Sclerae anicteric, MMM, oropharynx clear, EOMI, PERRL,
neck supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Significant hepatomegaly with liver edge palpable
~4-5cm
below costal margin, +RUQ tenderness, otherwise soft, non-tender
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, ___ strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait deferred
Discharge PE:
Pertinent Results:
RUQ ultrasound (___):
1. Unremarkable ultrasound appearance of the gallbladder.
2. No multiple liver masses are again demonstrated.
BMP:
130 | 92 | 8
---------------< 137
4.8 | 23 | 0.7
ALT: 44 AP: 377 Tbili: 0.9 Alb: 3.4
AST: 58 Lip: 30
CBC:
14.1 > 10.5/35.5 < 197
Lactate 2.3
UHcg: negative
UA: trace protein
Brief Hospital Course:
Mrs. ___ is a ___ year old ___ speaking woman with no
known chronic medical issues, recently discovered liver and lung
masses, presents with worsening RUQ pain.
# RUQ PAIN, due to
# DIFFUSELY METASTATIC DISEASE TO LUNG/LIVER:
Diffuse metastatic disease seen in lung and liver. Almost
certainly due to malignancy. She underwent US guided biopsy of a
liver lesion. She is very reluctant to take medications for
pain, counseled at length of importance of trying these
medications when needed.
- Follow-up with oncologist as scheduled
- Follow-up biopsy results
- Continue PRN Tylenol, prescribed PRN oxycodone.
#Hepatitis B
Core antibody positive, viral load pending.
-Follow-up with hepatology
# HOSPITAL ISSUES:
- Fluids: D51/2NS @ 125cc/hr while NPO
- Nutrition: regular
- Access: PIV
- DVT PPx: Compression boots for now, heparin subq when safe
- Contact: Husband, ___, ___
- ___: home without services
Medications on Admission:
None
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
2. Ondansetron ODT 4 mg PO Q8H:PRN nausea
RX *ondansetron 4 mg 1 tablet(s) by mouth every eight (8) hours
Disp #*30 Tablet Refills:*0
3. OxyCODONE (Immediate Release) 5 mg PO Q8H:PRN Pain - Severe
RX *oxycodone 5 mg 1 tablet(s) by mouth every eight (8) hours
Disp #*30 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Abdominal pain
Multiple liver and lung lesions concerning for metastatic
disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were admitted for worsened abdominal pain. You underwent a
biopsy of a liver lesion. Please take your pain medications as
prescribed to control your pain.
Followup Instructions:
___
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|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
Penicillins / Benzodiazepines / Morphine / Macrolide Antibiotics
/ Tetracycline Analogues / Aspirin / Demerol / Compazine /
Codeine / Norpramin / Ultram / Nsaids / doxycycline / Oxycodone
/ Valium / Librium / Talwin / Lidocaine / diphenhydramine /
Phenergan
Attending: ___.
Chief Complaint:
RLE pain
Major Surgical or Invasive Procedure:
RLE irrigation and debridement, placement of drains, and complex
closure.
History of Present Illness:
Complex knee laceration sustained on ___ which was I&D'd and
closed primarily
Past Medical History:
Hyperlipidemia,
Hx of Lyme,
Osteoarthritis,
h/o hepatitis A requiring hospitalization,
h/o pneumothorax s/p chest tube,
melanoma,
recurrent UTIs,
h/o Cdiff
Social History:
___
Family History:
Not relevant to patient presentation
Physical Exam:
RLE:
Incision c/d/I
Dressing c/d/I
SILT S/S/SP/DP/T, Firing ___
+2 pulses
Brief Hospital Course:
The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have R knee laceration and was admitted to the orthopedic
surgery service. The patient was taken to the operating room on
___ for R knee I&D and complex closure, which the patient
tolerated well. For full details of the procedure please see the
separately dictated operative report. The patient was taken from
the OR to the PACU in stable condition and after satisfactory
recovery from anesthesia was transferred to the floor. The
patient was initially given IV fluids and IV pain medications,
and progressed to a regular diet and oral medications by POD#1.
The patient was given ___ antibiotics and
anticoagulation per routine. The patient's home medications were
continued throughout this hospitalization. The patient worked
with ___ who determined that discharge to home was appropriate.
The ___ hospital course was otherwise unremarkable.
At the time of discharge the patient's pain was well controlled
with oral medications, incisions were clean/dry/intact, and the
patient was voiding/moving bowels spontaneously. The patient is
WBAT in the RLE extremity, and will not go home on DVT
prophylaxis due to risk of bleeding. The patient will follow up
with Dr. ___ per 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. methenamine hippurate unknown unknown oral Q24H
2. Gabapentin 600 mg PO QAM
3. Gabapentin 300 mg PO NOON
4. Gabapentin 1200 mg PO QPM
5. melatonin 10 mg oral QHS:PRN
Discharge Medications:
1. Acetaminophen 650 mg PO 4X/DAY
RX *acetaminophen [8 HOUR PAIN RELIEVER] 650 mg 1 tablet(s) by
mouth 4 times a day Disp #*60 Tablet Refills:*0
2. Docusate Sodium 100 mg PO BID
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth daily
Disp #*30 Capsule Refills:*0
3. Gabapentin 600 mg PO QAM
4. Gabapentin 300 mg PO NOON
5. Gabapentin 1200 mg PO QPM
6. melatonin 10 mg oral QHS:PRN
7. Methenamine Hippurate unknown oral Q24H
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
R knee laceration with associated internal degloving injury
Discharge Condition:
AAOx3, mentating appropriately, NVI.
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:
- WBAT RLE
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:
- none
WOUND CARE:
- You may shower. No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- Please remain in your dressing and do not change unless it is
visibly soaked or falling off.
- Splint must be left on until follow up appointment unless
otherwise instructed
- Do NOT get splint wet
Followup Instructions:
___
|
19729398-DS-13
| 19,729,398 | 24,478,797 |
DS
| 13 |
2141-05-03 00:00:00
|
2141-05-06 22:54:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Right sided Chest pain
Major Surgical or Invasive Procedure:
Endobronchial Ultrasound with Transbronchial Needle Aspiration
(EBUS-TBNA)
History of Present Illness:
___ y/o high functioning F history of Raynauds, osteoporosis,
endocarditis s/p bovine MVR (___) presents with right lower
chest/rib pain since yesterday.
Patient states she has had fatigue and reduced excercise/daily
activity tolerance for last several months. She has had
substernal chest pain and shortness of breath for several weeks
and had a cardiology appointment scheduled for tomorrow. However
starting yesterday morning she began experiencing pain a sharp
pain across her right lower chest, worsened by movement,
ambulation, laying supine, and deep breaths. Patient denies
trauma. She denies cough, no fevers/chills/sore throat. No
aparrent weight loss No palpitations. She called her
cardiologist who advised she come to the ED for evaluation.
In the ED, initial vs were 4 99.1 70 157/85 18 100%
Labs were performed:
- UA unremarkable
- Trop < 0.01 (1300)
- Na 143 K 4 Cl 105 HCO3 27 BUN 13 Cr 0.7 Glc 94
- WBC 3.4(L) Hgb 14.2 Plt 229 Diff N 72.1
- ALT 17 AST 25 ALP 83 Tbili 0.5 Albumin 4.9
Additional studies were performed:
- EKG: sinus 72bpm, LAD, normal intervals, incomplete LBBB.
Inferior Infarct and anteroseptal infarct (both age
undetermined)
- TropnT <0.01
- CXR: no acute abnormality
- CTA chest: No pulmonary embolism. There is a right upper lobe
paramediastinal lesion measuring 4.0 (TV) x 3.1 (AP) x 5.1
(CC) cm. There is a peripheral irregular lesion in the right
upper lobe measuring 1.5 cm in addition to right hilar
lymphadenopathy and mild centrilobular emphysema. Findings are
most concerning for primary neoplasm with peripheral extension.
Infection is less likely though possible in the appropriate
clinical circumstance. If clinical suspicion for malignancy -
can likely be biopsied
via a transbronchial approach.
These findings were discussed with her PCP, and she was admitted
for a neoplastic work-up with likely biopsy.
Transfer VS: 17:19 97.1 72 159/79 16 100%
On arrival to the floor, patient reports she still has some
right sided pain, but it is tolerable without medications. She
feels slightly short of breath as well.
REVIEW OF SYSTEMS: Positive for an itchy rash on her back that
occurred twice in past 2 weeks. Was evaluated by dermatologist
and given a lotion. She is uncertain what it looked like.
Denies fever, chills, night sweats, headache, vision changes,
rhinorrhea, congestion, sore throat, cough, abdominal pain,
nausea, vomiting, diarrhea, constipation, BRBPR, melena,
hematochezia, dysuria, hematuria.
All other 10-system review negative in detail.
Past Medical History:
- osteoporosis
- Raynauds phenomenon
- mitral valve prolapse s/p mitral valve repair for endocarditis
in ___ with bovine MVR
- history of atypical-like ductal hyperplasia s/p lumpectomy
(___). Pathology showed extensive columnar cell change with
associated microcalcifications and focal atypical ductal
hyperplasia.
Focal atypical lobular hyperplasia. Changes consistent with
previous needle biopsy.
- 3 cm fibroids that have been unchanged for many years
PAST SURGICAL HISTORY:
- Remarkable for lumpectomy appendectomy status post mitral
valve prolapse replacement as well
SCREENING TESTS:
- Pap smear was ___ normal.
- Mammogram was in ___ at the ___ was normal.
- Colonoscopy in ___ (+ for hematochezia at that time):
Impressions: Grade 1 internal hemorrhoids. Otherwise normal
Colonoscopy to cecum
Social History:
___
Family History:
Cancer: Positive for mother who had lymphoma, maternal
aunt who had cervical cancer, maternal aunt who had aplastic
anemia. No family history of breast or ovarian cancer.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: 97.9 146/67 p65 R18 100% on RA
GEN: Alert. Cooperative. In no apparent distress and comfortable
HEENT/NECK: PERRLA. EOMI. Mucous membranes pink/moist. No
icterus. No conjunctival pallor
CHEST: Clear to auscultation B/L. No wheezes or crackles. Pain
on palp to right rib cage
CV: Loud ?split S1, S2. +Cardiac heave No murmurs/gallops/rubs
appreciated. Pulses 2+ throughout. No JVD. No splinter
hemmhorages
ABDOMEN: BS present. Soft. Nontender. Nondistended. No
organomegaly noted.
EXTREMITIES: No edema, No gross deformities, clubbing, or
cyanosis but distal extremities cool.
NEURO: CNII-XII intact, motor and sensory grossly normal.
SKIN: No rashes, bruises or ulcerations.
LYMPH: No cervical, supraclavicular or axillary nodes palpable
DISCHARGE PHYSICAL EXAM:
Afebrile with vital signs within normal limits
GEN: Alert. Cooperative. In no apparent distress and comfortable
HEENT/NECK: PERRLA. EOMI. Mucous membranes pink/moist. No
icterus. No conjunctival pallor
CHEST: Clear to auscultation B/L. No wheezes or crackles. Pain
on palp to right rib cage
CV: Loud S1, S2. +Cardiac heave. No murmurs/gallops/rubs
appreciated. Pulses 2+ throughout. No JVD. No splinter
hemmhorages
ABDOMEN: BS present. Soft. Nontender. Nondistended. No
organomegaly noted.
EXTREMITIES: No edema, No gross deformities, clubbing, or
cyanosis but distal extremities cool.
SKIN: No rashes, bruises or ulcerations.
Pertinent Results:
ADMISSION:
___ 01:00PM BLOOD WBC-3.4* RBC-4.58 Hgb-14.2 Hct-42.9
MCV-94 MCH-31.1 MCHC-33.2 RDW-12.8 Plt ___
___ 06:40AM BLOOD ___ PTT-34.0 ___
___ 01:00PM BLOOD Glucose-94 UreaN-13 Creat-0.7 Na-143
K-4.0 Cl-105 HCO3-27 AnGap-15
___ 01:00PM BLOOD ALT-17 AST-25 AlkPhos-83 TotBili-0.5
___ 01:00PM BLOOD cTropnT-<0.01
___ 09:42PM BLOOD cTropnT-<0.01
___ 06:40AM BLOOD cTropnT-<0.01
___ 01:00PM BLOOD Lipase-30
___ 01:00PM BLOOD Albumin-4.9
___ 06:40AM BLOOD Calcium-9.6 Phos-3.3 Mg-2.3
.
DISCHARGE:
___ 07:00AM BLOOD WBC-4.6 RBC-4.51 Hgb-14.2 Hct-41.7 MCV-92
MCH-31.5 MCHC-34.1 RDW-12.5 Plt ___
___ 07:00AM BLOOD Glucose-89 UreaN-14 Creat-0.8 Na-141
K-4.2 Cl-103 HCO3-29 AnGap-13
EBUS-TBNA biopsies of paratracheal mass and lymph nodes pending
at time of discharge
IMAGING:
___ Radiology CHEST (PA & LAT)
FINDINGS: Median sternotomy wires and prosthetic valve are
stable. The lungs are clear. There is no focal consolidation.
There is no pleural effusion or pneumothorax. The
cardiomediastinal silhouette is stable.
IMPRESSION: No acute cardiopulmonary process.
.
___ Radiology CTA CHEST W&W/O C&RECON
CT CHEST WITH INTRAVENOUS CONTRAST: There is an 8 mm hypodense
nodule within the left lobe of the thyroid gland (3:14). No
supraclavicular or axillary lymphadenopathy is identified.
Arising from the right upper lobe
paramediastinal region, there is an irregular mass lesion
measuring 4.0 (TV) x 3.1 (AP) x 5.1 (CC) cm (2:23 and 601B:30).
Additionally, there is confluent right hilar lymphadenopathy
with the largest discrete lymph node measuring 1.6 x 1.3 cm
(2:45). The right upper lobe lesion causes mass effect upon the
right upper lobe segmental bronchus, though does not cause
obstruction. Peripherally within the right upper lobe, there is
a second irregular lesion with surrounding ground-glass opacity.
The dense portion of this peripheral lesion measures 1.5 x 1.1
cm (2:33). Overall, the above findings are most concerning for
a primary lung neoplasm with peripheral extension of tumor into
the periphery and associated hilar adenopathy. An infectious
process is also within the differential although less likely.
There are additional punctate ground-glass nodules in the
bilateral upper lobes which are nonspecific in appearance,
though may be related to metastatic disease (2:23, 22, 25, 26,
29, 36). No pleural effusion is identified. There is diffuse
moderate centrilobular emphysema.
There is no pulmonary embolism to subsegmental levels. The
thoracic aorta
demonstrates moderate atherosclerotic calcifications, though is
non-aneurysmal throughout its course and demonstrates no signs
of acute aortic syndrome. A prosthetic mitral valve is noted.
There is biatrial enlargement. No pericardial effusion is
identified. Limited views of the upper abdomen appear within
normal limits.
BONE AND SOFT TISSUES: No bone destructive lesion or acute
fracture is
identified. Median sternotomy wires appear intact.
.
IMPRESSION:
1. 5.1 cm irregular right apical paramediastinal mass with
peripheral
satellite nodule and hilar lymphadenopathy. In the absence of
infectious
symptoms, findings are most concerning for a primary lung
neoplasm. If biopsy is considered, the dominant apical
paramediastinal lesion can likely be accessed via a
transbronchial approach.
2. Scattered nonspecific punctate ground-glass nodules within
both upper
lobes.
3. No pulmonary embolism or acute aortic syndrome.
4. Biatrial enlargement with prosthetic mitral valve.
5. 8 mm left thyroid nodule. Non-emergent thyroid ultrasound
could be
completed for further characterization if it has not been done
previously.
.
ECHO ___:
Conclusions
The right atrium is moderately dilated. There is mild symmetric
left ventricular hypertrophy with normal cavity size and
regional/global systolic function (LVEF>55%). The right
ventricular cavity is mildly dilated with mild global free wall
hypokinesis. [Intrinsic right ventricular systolic function is
likely more depressed given the severity of tricuspid
regurgitation.] There is abnormal septal motion/position. 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. Mild (1+) aortic regurgitation
is seen. A bioprosthetic mitral valve prosthesis is present. No
masses or vegetations are seen on the mitral valve, but cannot
be fully excluded due to suboptimal image quality. 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. Severe [4+] tricuspid regurgitation is seen. There is
mild pulmonary artery systolic hypertension. There is no
pericardial effusion.
.
IMPRESSION: normal regional and global left ventricular systolic
function. Mildly dilated and hypokinetic right ventricle. Mitral
bioprosthesis with normal gradients. Severe tricuspid
regurgitation. At least mild mitral regurgitation.
Compared with the prior study (images reviewed) of ___,
the right ventricle appears dilated/hypokinetic and the severity
of tricuspid regurgitation has increased
Brief Hospital Course:
___ history of Raynauds, osteoporosis, endocarditis s/p bovine
MVR (___) presents with right lower chest/rib pain and found to
have incidental right upper lobe paramediastinal lesion in
addition peripheral irregular lesion in right uppler lobe with
right hilar lymphadenopathy concerning for primary vs.
metastatic malignancy.
ACTIVE ISSUES:
# Paramediastinal mass and pulmonary lymphadenopathy - Given the
appearance on imaging and lack of evidence for prosthetic valve
endocarditis or other infection, there is concern for
malignancy. The patient was made aware of the concern and
understood. Interventional Pulmonology performed endobronchial
ultrasound with transbronchial biopsy of the mass and lymph
nodes, with a followup appointment on ___ to discuss the
results.
# Right sided pleuritic chest pain - Given the point nature of
her pain, it was thought this may represent another
intrathoracic lesion and perhaps a metastasis. There may be a
lesion visible in the proximity of her pain on the CTA of the
chest. The patient was evaluated and ruled out for pulmonary
embolism. If her biopsies detemine malignancy, staging with PET
scan or possibly a bone scan could help reveal metastatic
disease. The patient was provided with pain control.
CHRONIC ISSUES:
# Raynaud's Phenomonen - Continued home Nifedipine
# Held patient's OTC vitamins and supplements while inpatient.
TRANSITIONAL ISSUES:
1) Incidental findings: 8 mm left thyroid nodule. Non-emergent
thyroid ultrasound could be completed for further
characterization if it has not been done previously.
2) Echo with worsening of TR to severe. "Compared with the prior
study...of ___, the right ventricle appears
dilated/hypokinetic and the severity of tricuspid regurgitation
has increased."
3) Follow up of biopsy results with Inverventional Pulmonology
and Heme/Onc referral if indicated. Patient is aware of
possibility of cancer.
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from PatientwebOMR.
1. Alendronate Sodium 70 mg PO QSUN
2. NIFEdipine CR 60 mg PO DAILY
For Raynauds Phenomenon
3. Aspirin 81 mg PO DAILY
4. calcium carbonate-vitamin D3 *NF* Unkown Oral QDaily
5. Ascorbic Acid Dose is Unknown PO DAILY
Discharge Medications:
1. NIFEdipine CR 60 mg PO DAILY
For Raynauds Phenomenon
2. Alendronate Sodium 70 mg PO QSUN
3. Ascorbic Acid ___ mg PO DAILY
4. Aspirin 81 mg PO DAILY
5. calcium carbonate-vitamin D3 *NF* 0 Unknown ORAL QDAILY
6. Docusate Sodium 100 mg PO BID
Hold for loose stools.
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*28 Capsule Refills:*2
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*60 Capsule Refills:*2
7. Senna 1 TAB PO BID:PRN Constipation
Hold for loose stools.
RX *sennosides [senna] 8.6 mg 1 tablet by mouth once a day Disp
#*30 Tablet Refills:*2
8. Lidocaine 5% Patch 1 PTCH TD DAILY Pain
Patient may decline
RX *lidocaine 5 % (700 mg/patch) apply to affected area daily
Disp #*14 Transdermal Patch Refills:*0
9. Acetaminophen ___ mg PO Q8H:PRN Pain
RX *acetaminophen 500 mg ___ tablet(s) by mouth every eight (8)
hours Disp #*100 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: Paramediastinal Mass, atypical chest pain
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___:
It was a pleasure to care for you at ___
___. You were admitted because you were having chest
pain and shortness of breath, and a CT-scan found concerning
masses and lymph nodes in your chest. We had our Interventional
Pulmonologists perform biopsies, and you should meet with them
as an outpatient to discuss the results. We also performed an
Echocardiogram (ultrasound of the heart) which showed that your
mitral valve is functioning but there is some leaking of your
tricuspid valve (more than seen on prior Echos). We notified
Dr. ___ the findings and advise you to follow up with him
to discuss if there is anything that needs to be done at this
time.
We have not made any changes to your usual home medications.
You may START acetaminophen (Tylenol) and a Lidocaine patch for
pain relief as needed.
Followup Instructions:
___
|
19729398-DS-14
| 19,729,398 | 26,986,193 |
DS
| 14 |
2141-07-30 00:00:00
|
2141-07-30 15:04:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
shortness of breath, palpitation
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ yo F w/ h/o T2N3M0 adenocarcinoma of the RUL receiving
chemoRT with cisplatin and etoposide (cycle 2 day 5 completed
___, Raynauds, HTN, bioprosthetic MVR, p/w dyspnea and
tachycardia.
Patient endorsing dyspnea and palpitations x1week. No lower
extremity edema or postional nocternal dyspnea. She feels
intermittent fast heart rate. During these episodes she denies
chest pain or syncope. She denies melena, hematochezia, and
history of GIB. She also c/o non-productive cough worsening
over the past few weeks. Denies fever, cough, nausea, vomiting.
She has had a nonproductive cough. Denies any previous history
of DVT or PE. No pleuritic chest pain.
In the ED, VS: 96.8 130 144/76 22 94%. Labs - K 4.4, trop 0.03,
ALT/AST ___, WBC 3.4, Hct 25.2, Plt 85. ECG showed atrial fib w/
RVR. CT head neg for acute IC process. CTA neg for PE, but + for
new RUL opacities, new bl pleural effusions. Blood cx sent. She
received metoprolol 5mg iv, then 25mg po, and HR improved to
___. She also received 325mg asa, zofran, cefepime and levo.
Cardiology evaluated pt and recommended rate control, starting
asa 325mg, pradaxa, and f/u w/ outpt cardiologist Dr. ___.
En route from the ED, she had nausea, w/ one epsiode of emesis.
Currently, denies nausea. Dyspnea has improved, and she denies
CP.
ROS: 14 point ROS is otherwise negative.
Past Medical History:
Onco Hx
-RUL adenocarcinoma:
Presented with progressive SOB, fatigue, and right lower chest
and rib pain on ___. She underwent chest CT on ___ that
revealed a 5.1 cm irregular right apical paramediastinal mass
with a peripheral satellite nodule and hilar lymphadenopathy. On
___, EBUS TBNA at ___ revealed a right paratrachael mass
and bx confirmed adenocarinoma of the lung. Additional
endobronchial biopsies at station 11L, station 7 and 11R were
not diagnostic.
___iopsy. LN involvement was
present at station 4R, low 4R, 4L and level 7 nodes. There was
no
adenocarcinoma in the 2R lymph node.
___ Start of radiation therapy
___ C1D1 Cisplatin/etoposide
___ Follow-up visit before cycle 2
___ C2D1 Cisplatin/etoposide
___ C2D5 Cisplatin/etoposide
Getting RT to R upper lobe, R hilum
PMH
- osteoporosis
- Raynauds phenomenon
- mitral valve prolapse s/p mitral valve repair for endocarditis
in ___ with bovine MVR
- history of atypical-like ductal hyperplasia s/p lumpectomy
(___). Pathology showed extensive columnar cell change with
associated microcalcifications and focal atypical ductal
hyperplasia.
Focal atypical lobular hyperplasia. Changes consistent with
previous needle biopsy.
- 3 cm fibroids that have been unchanged for many years
- Colonoscopy in ___ (+ for hematochezia at that time):
Impressions: Grade 1 internal hemorrhoids. Otherwise normal
Colonoscopy to cecum
PAST SURGICAL HISTORY:
- Remarkable for lumpectomy appendectomy status post mitral
valve prolapse replacement as well
Social History:
___
Family History:
Mother who had lymphoma, maternal aunt who had cervical cancer,
maternal aunt who had aplastic anemia. No family history of
breast or ovarian cancer.
Physical Exam:
VS: 97.8 ___ 18 98%RA
GENERAL: Well-appearing, thin female, in no apparent distress
HEENT: EOMI, MMM
CV: irregular rate, diastolic murmur at apex
PULM: Decreased breath sounds bilat, no wheezes / rales
ABD: Soft, non-tender, non-distended, + BS
EXTREMITIES: No ___ edema, 2+ radial and DP pulses
NEURO: No focal deficits
Pertinent Results:
ADMISSION LABS:
___ 01:30PM PLT SMR-LOW PLT COUNT-85*
___ 01:30PM NEUTS-90.5* LYMPHS-6.0* MONOS-2.3 EOS-0.7
BASOS-0.4
___ 01:30PM WBC-3.4*# RBC-2.68* HGB-8.7* HCT-25.2* MCV-94
MCH-32.4* MCHC-34.6 RDW-15.6*
___ 01:30PM ALBUMIN-3.6 CALCIUM-8.7 PHOSPHATE-3.4
MAGNESIUM-1.9
___ 01:30PM cTropnT-0.03*
___ 01:30PM ALT(SGPT)-57* AST(SGOT)-52* ALK PHOS-95 TOT
BILI-0.4
___ 01:30PM estGFR-Using this
___ 01:30PM GLUCOSE-93 UREA N-24* CREAT-0.9 SODIUM-133
POTASSIUM-4.4 CHLORIDE-101 TOTAL CO2-21* ANION GAP-15
___ 02:03PM LACTATE-1.4
___ 02:04PM VoidSpec-QNS FOR AB
___ 02:19PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
___ 02:19PM URINE COLOR-Straw APPEAR-Clear SP ___
___ 03:45PM ___ PTT-28.3 ___
DISCHARGE LABS:
___ 06:42AM BLOOD WBC-1.8* RBC-2.73* Hgb-9.0* Hct-24.4*
MCV-90 MCH-33.1* MCHC-37.0* RDW-15.7* Plt ___
___ 06:42AM BLOOD Plt ___
___ 06:42AM BLOOD Glucose-101* UreaN-15 Creat-0.7 Na-129*
K-4.0 Cl-98 HCO3-25 AnGap-10
___ 06:42AM BLOOD Calcium-8.3* Phos-2.3* Mg-1.5*
ECG: afib w/ rvr
Intervals Axes
Rate PR QRS QT/QTc P QRS T
127 0 ___ 0 -24 85
CXR:
IMPRESSION:
Known right upper lobe mass and post-obstructive pneumonia
The study and the report were reviewed by the staff radiologist.
CT HEAD:
IMPRESSION: No acute intracranial process. MRI is more
sensitive for
detection of metastasis.
CTA CHEST:
IMPRESSION:
1. No pulmonary embolism.
2. Right upper lobe pneumonia.
3. New bilateral pleural effusions right greater than left,
right atrial
enlargement, and reflux of contrast into the hepatic veins is
consistent with right heart failure.
4. No significant change in right upper lobe mass consistent
with known
malignancy.
Brief Hospital Course:
___ yo F w/ h/o T2N3M0 adenocarcinoma of the RUL receiving
chemoRT with cisplatin and etoposide (cycle 2 day 5 completed
___, Raynauds, HTN, bioprosthetic MVR, p/w dyspnea and
tachycardia, found to have new onset afib w/ RVR in the ED,
stable RUL mass but new RUL ground-glass opacities on CT scan.
#Atrial fibrillation w/ RVR: New onset. Increased risk given
MVR, and likely ___ radiation vs ?pneumonia. Patient remained
hemodynamically stable. Evaluated by cardiology in the ED w/
recommendations for metoprolol for rate control, full dose
aspirin. Anticoagulation was held by oncology team given that
patient is currently on chemotherapy and has dropping platelets.
Patient rate was well controled with PO metoprolol. She was
started on ASA 325mg daily. Patient will have outpatient follow
up with cardiology after discharge.
#Pneumonia: New RUL ggo's seen on CTA. CTA negative for PE. CXR
concerning post-obstructive pneumonia. Pt afebrile, but c/o
cough. Patietn was manged on levofloxacin.
#Dyspnea, Pleural effusions: Likely secondary to atrial
fibrillation with rapid ventricular response as dypnea resolved
when heart rate controlled in combination with new pneumonia.
Last echo (___) notable for mild MR ___ working mitral
bioprosthesis), normal LV function, severe TR and RV
hypokinesis, though no evidence of right-sided failure on exam.
#Hyponatremia: Likely SIADH given adenocarcinoma and high urine
osms. Corrected with aggressive fluid restriction (1L per day).
#Lung adenocarcinoma: Receiving chemoRT with cisplatin and
etoposide.
#Pancytopenia: Likely ___ chemotx.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. NIFEdipine CR 60 mg PO DAILY
For Raynauds Phenomenon
2. Alendronate Sodium 70 mg PO QSUN
3. calcium carbonate-vitamin D3 *NF* 0 Unknown ORAL QDAILY
4. Clobetasol Propionate 0.05% Cream 1 Appl TP BID
5. Hydrocortisone Cream 1% 1 Appl TP BID:PRN itch
to rash on chest
6. Prochlorperazine 10 mg PO Q6H:PRN nausea
7. Ondansetron 8 mg PO Q8H:PRN nausea
Discharge Medications:
1. Clobetasol Propionate 0.05% Cream 1 Appl TP BID
2. Hydrocortisone Cream 1% 1 Appl TP BID:PRN itch
to rash on chest
3. NIFEdipine CR 60 mg PO DAILY
For Raynauds Phenomenon
4. Prochlorperazine 10 mg PO Q6H:PRN nausea
5. Aspirin 325 mg PO DAILY
RX *aspirin 325 mg 1 tablet(s) by mouth qdaily Disp #*30 Tablet
Refills:*0
6. Metoprolol Succinate XL 75 mg PO DAILY
RX *metoprolol succinate 50 mg 1.5 tablet(s) by mouth qdaily
Disp #*60 Tablet Refills:*0
7. Alendronate Sodium 70 mg PO QSUN
8. calcium carbonate-vitamin D3 *NF* 0 Unknown ORAL QDAILY
9. Ondansetron 8 mg PO Q8H:PRN nausea
10. Outpatient Lab Work
electrolyte panel - please fax results to Dr. ___
___
11. Levofloxacin 750 mg PO DAILY Duration: 3 Days
RX *levofloxacin [Levaquin] 750 mg 1 tablet(s) by mouth qdaily
Disp #*4 Tablet Refills:*0
RX *levofloxacin [Levaquin] 750 mg 1 tablet(s) by mouth qday
Disp #*3 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Atrial fibrillation with rapid ventricular response
Community acquired pneumonia
Lung adenocarcinoma
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 ___ oncology service after having an
episode of atrial fibrillation with rapid ventricular response
(fast heart rate). For this, you received medications to slow
your heart rate. Normally, people with atrial fibrillation
receive anticoagulation. You did not recived anticoagulation
(aside from a daily aspirin) because your chemotherapy alters
your blood counts. You cardiologists will monitor your atrial
fibrillation as an outpatient. We also discovered that you had
pneumonia, for which you are being treated with oral
antibiotics.
Followup Instructions:
___
|
19729398-DS-16
| 19,729,398 | 21,533,897 |
DS
| 16 |
2142-09-12 00:00:00
|
2142-09-15 11:30:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Dyspnea on exertion
Major Surgical or Invasive Procedure:
DC cardioversion
History of Present Illness:
___ year old female with PMH afib on dabigatran s/p cardioversion
x 2 (___), MVP s/p MVR, metastatic NSCLC s/p chemoRT with
malignant pleural effusion s/p pleurX placement (___)
presenting with DOE x 2 days. She patient presented to ___
clinic today for scheduled cyle 2 of palliative
carboplatin/pemetrexed, and reported DOE. At baseline, she can
walk up a flight of stairs, walk across a room, and do light
housework. Yesterday while doing housework, she felt
increasingly short of breath, and today while climbing the
stairs, she became very short of breath halfway up and had to
rest. Endorses intermittent palpitations both at rest and with
ambulation. States that this feels similar to prior episode of
afib. Denies chest pain, dizziness or lightheadedness.
In ___ clinic patient was noted O2 sat 98% resting with HR
___, 82% with ambulation adn HR 140s. Patient was sent to ED for
likely intermittent afib/flutter with RVR. Of note, patient was
recently discharged from BI ___ for thorascopy, pleurodesis,
placement of CT and pleurX for recurrent malignant R pleural
effusions. Course c/b small right apical PTX. Prior to
discharge, chest tube was removed, but pleurX left in place,
which has been draining < 10 cc/day. Additionally, patient had
dose of amiodarone reduced from 200 mg PO QD to 100 mg PO QD at
Cardiology f/u appt on ___.
In the ED, initial vitals: 98.4 84 126/73 16 100%
- Labs notable for CBC baseline, BMP wnl, INR 1.5, Trop < 0.01,
proBNP: 8065
- EKG: Aflutter HR 78, RBBB, LAFB unchanged from prior, no STE
- CXR: Decreased right apical pneumothorax and a small residual
loculated right pleural effusion.
- CTA was negative for PE
- Bedside TTE: EF nl, no effusion
- Cardiology was consulted, who recommended admission to EP
service for TEE/cardioversion in AM.
On the floor, patient reports subjective palpitations.
Review of Systems:
(+) per HPI, +diarrhea after taking laxatives and stool
softeners
(-) fever, chills, weight gain or loss, 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:
Onco Hx
-RUL adenocarcinoma:
Presented with progressive SOB, fatigue, and right lower chest
and rib pain on ___. She underwent chest CT on ___ that
revealed a 5.1 cm irregular right apical paramediastinal mass
with a peripheral satellite nodule and hilar lymphadenopathy. On
___, EBUS TBNA at ___ revealed a right paratrachael mass
and bx confirmed adenocarinoma of the lung. Additional
endobronchial biopsies at station 11L, station 7 and 11R were
not diagnostic.
___iopsy. LN involvement was
present at station 4R, low 4R, 4L and level 7 nodes. There was
no
adenocarcinoma in the 2R lymph node.
___ Start of radiation therapy
___ C1D1 Cisplatin/etoposide
___ Follow-up visit before cycle 2
___ C2D1 Cisplatin/etoposide
___ C2D5 Cisplatin/etoposide
Getting RT to R upper lobe, R hilum
PMH
- osteoporosis
- Raynauds phenomenon
- mitral valve prolapse s/p mitral valve repair for endocarditis
in ___ with bovine MVR
- history of atypical-like ductal hyperplasia s/p lumpectomy
(___). Pathology showed extensive columnar cell change with
associated microcalcifications and focal atypical ductal
hyperplasia.
Focal atypical lobular hyperplasia. Changes consistent with
previous needle biopsy.
- 3 cm fibroids that have been unchanged for many years
- Colonoscopy in ___ (+ for hematochezia at that time):
Impressions: Grade 1 internal hemorrhoids. Otherwise normal
Colonoscopy to cecum
PAST SURGICAL HISTORY:
- Remarkable for lumpectomy appendectomy status post mitral
valve prolapse replacement as well
Social History:
___
Family History:
Mother who had lymphoma, maternal aunt who had cervical cancer,
maternal aunt who had aplastic anemia. No family history of
breast or ovarian cancer.
Physical Exam:
Vitals - T: 97.7 BP: 107/55 HR: 99 RR: 18 02 sat: 95%RA
GENERAL: NAD, cachectic, very pleasant, alert and oriented
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
patent nares, MMM, good dentition, nontender supple neck, no
LAD, no JVD
CARDIAC: tachycardic, irregular rate, normal S1/S2, ___
holosytolic murmur best heard at ___
LUNG: CTAB, no rales, breathing comfortably without use of
accessory muscles, slight decreased BS at right lung base,
pleureX on R
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: moving all extremities well, no cyanosis, clubbing
or edema
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
Pertinent Results:
ADMISSION LABS:
___ 03:30PM GLUCOSE-124* UREA N-22* CREAT-0.9 SODIUM-135
POTASSIUM-4.0 CHLORIDE-100 TOTAL CO2-22 ANION GAP-17
___ 03:30PM cTropnT-<0.01
___ 03:30PM proBNP-8065*
___ 03:30PM TSH-2.9
___ 03:30PM WBC-10.8 RBC-3.30* HGB-10.2* HCT-30.5* MCV-92
MCH-31.0 MCHC-33.6 RDW-16.8*
___ 03:30PM NEUTS-95.7* LYMPHS-2.2* MONOS-1.9* EOS-0.2
BASOS-0.1
___ 03:30PM PLT COUNT-308
___ 03:30PM ___ PTT-63.7* ___
___ 11:55AM UREA N-21* CREAT-1.0
___ 11:55AM ALT(SGPT)-36 AST(SGOT)-29 ALK PHOS-109* TOT
BILI-0.4
___ 11:55AM WBC-12.1*# RBC-3.50* HGB-10.6* HCT-32.9*
MCV-94 MCH-30.2 MCHC-32.1 RDW-17.2*
___ 11:55AM PLT COUNT-331#
___ 11:55AM ___ ___
DISCHARGE LABS:
___ 06:15AM BLOOD WBC-9.9 RBC-3.63* Hgb-10.9* Hct-34.0*
MCV-94 MCH-30.0 MCHC-32.0 RDW-16.7* Plt ___
___ 06:15AM BLOOD ___ PTT-50.9* ___
___ 06:15AM BLOOD Glucose-84 UreaN-16 Creat-1.0 Na-137
K-4.3 Cl-101 HCO3-24 AnGap-16
___ 06:15AM BLOOD cTropnT-<0.01
___ 06:15AM BLOOD Calcium-9.5 Phos-3.2 Mg-2.5
IMAGING:
CXR ___:
Decreased right apical pneumothorax and a small residual
loculated right
pleural effusion.
CTA ___:
1. No pulmonary embolism or acute aortic syndrome.
2. Similar appearance of a known superior segment right lower
lobe non-small cell lung carcinoma with associated radiation
fibrosis.
3. Significant interval resolution of prior large right pleural
effusion. Right pleural drainage catheter and associated
minimal pleural air are noted.
4. Unchanged moderate centrilobular emphysema.
5. Numerous ground-glass nodules concerning for bronchoalveolar
cell
carcinoma are unchanged.
6. Stable cardiomegaly with right moderate-to-severe atrial
dilatation
ECHO ___:
Mild spontaneous echo contrast but no thrombus is present in the
left atrial appendage. No spontaneous echo contrast or
mass/thrombus is seen in the body of the left atrium or the
right atrium/right atrial appendage. The right atrial appendage
ejection velocity is depressed (<0.2m/s). No atrial septal
defect is seen by 2D or color Doppler. There are simple atheroma
in the aortic arch and descending thoracic aorta. The aortic
valve leaflets (3) are mildly thickened. Trace aortic
regurgitation is seen. A bioprosthetic mitral valve prosthesis
is present. The motion of the mitral valve prosthetic leaflets
appears normal. Transvalvular gradient could not be obtained.
Mild (1+) mitral regurgitation is seen. There is borderline
pulmonary artery systolic hypertension.
IMPRESSION: Mild spontaneous echo contrast but no thrombus in
the left atrial appendage. No thrombus or spontaneous echo
contrast in the LA/RA/RAA. Welll-seated mitral valve
bioprosthesis with mild regurgitation.
EKG ___ 13:01:
afib, HR 78, left axis deviation, left anterior fascicular
block, Q waves in III, J point elev V2-V4 (c/w prior)
Brief Hospital Course:
___ year-old female with history of atrial fibrillation s/p
cardioversion x2 on pradaxa, metastatic NSCLC (Stage IIIB) on
palliative chemo, malignant pleural effusion s/p talc
pleuredesis, who presented with progressive dyspnea, found to
have rapid atrial fibrillation.
# ATRIAL FIBRILLATION:
Symptomatic (dyspnea), and rapid. First diagnosed ___ in
setting of PNA. Underwent cardioversion x2 previously with early
recurrence of atrial fibrillation, despite being on flecainide
the second time. Started amiodarone in ___ with spontaneous
CV to sinus and did not have confirmed recurrence of atrial
fibrillation until this admission. Amiodarone dose was decreased
from 200mg to 100mg recently. This hospitalization received
TEE/cardioversion with return to sinus rhythm and her amiodarone
dose was increased back to 200mg daily. She continued pradaxa.
TSH was within normal limits. Of note, at the time of discharge
her heart rhythm appeared to have a wandering atrial pacemaker
but she did not return back into rapid atrial fibrillation.
Patient was instructed to follow up with her outpatient
cardiologist within the next two weeks.
# Lung Cancer: (Stage IIIB NSCLC) Recently developed metastatic
disease. Previously treated with cisplatin/ etoposide and
radiation. Initiated on palliative carboplatin and pemetrexed
for disease progression on ___. Chemotherapy has been on
hold since, first for talc pleuredesis, now for atrial
fibrillation. She will continue further management as per
outpatient oncologists pending resolution of acute atrial
fibrillation. Her pleural effusion was drained (via her chronic
pleurex) while in the hospital as she was due for drainage.
# Dyspnea: Likely due to atrial fibrillation as above. Pleural
effusion is stable and chronic, and apical pneumothorax
improved. No signs or symptoms of infection. CTA was negative
for pulmonary embolus. Dyspnea improved with cardioversion.
# Hypertension: Continued home nifedipine
TRANSITIONAL ISSUES:
- Emergency Contact: ___ (son) ___
- cardiology follow up
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amiodarone 100 mg PO DAILY
2. Dabigatran Etexilate 150 mg PO BID
3. Furosemide 20 mg PO DAILY
4. Metoprolol Succinate XL 50 mg PO DAILY
5. NIFEdipine CR 60 mg PO DAILY
6. Docusate Sodium 100 mg PO BID
7. Polyethylene Glycol 17 g PO DAILY
8. Senna 8.6 mg PO BID constipation
9. Alendronate Sodium 70 mg PO QSUN
10. calcium carbonate-vitamin D3 0 Unknown ORAL QDAILY
11. Ondansetron 8 mg PO Q8H:PRN nausea
12. Prochlorperazine 10 mg PO Q6H:PRN nausea
Discharge Medications:
1. Amiodarone 200 mg PO DAILY
RX *amiodarone 200 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
2. Dabigatran Etexilate 150 mg PO BID
3. Docusate Sodium 100 mg PO BID
4. Furosemide 20 mg PO DAILY
5. Metoprolol Succinate XL 50 mg PO DAILY
6. NIFEdipine CR 60 mg PO DAILY
7. Polyethylene Glycol 17 g PO DAILY
8. Senna 8.6 mg PO BID constipation
9. Alendronate Sodium 70 mg PO QSUN
10. calcium carbonate-vitamin D3 0 Unknown ORAL QDAILY
11. Ondansetron 8 mg PO Q8H:PRN nausea
12. Prochlorperazine 10 mg PO Q6H:PRN nausea
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
atrial fibrillation with rapid ventricular response
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear ___,
___ were admitted to the hospital with an abnormal heart rhyhtm
called atrial fibrillation. We cardioverted ___ and your heart
rate is now normal. We would like ___ to increase your
amiodarone to 200mg daily.
Please see below for follow up appointments.
Followup Instructions:
___
|
19729398-DS-17
| 19,729,398 | 20,379,157 |
DS
| 17 |
2142-11-29 00:00:00
|
2142-11-30 11:01:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Hemoptysis
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old F h/o NSCLC with mets to LNs, progression of disease
despite chemo/xrt now on maintenance palliative pemetrexed p/w
hemoptysis. Pt has had cough productive of yellow sputum x 2
weeks with hemoptysis x 2 days. Hemoptysis occurs severl times a
day, up to but never exceeding a teaspoon. Pt has felt fatigued
and has had difficulty with usual ADLs. She denies f/c,
cp/dyspnea, n/v/d, abd pain. Last chemo on ___.
.
Of note, pt given a 10 day course of doxycycline for her cough
on ___. She took a trip to ___ and covered every aspect of her
skin except her hadns and developed a rash like a "severe
sunburn" on the backs of her hands.
.
In the ED: 98.6 66 103/55 18 100%ra. chem7 wnl. u/a neg. wbc
2.7, hct 25.5, 166 (last cbc ___ wbc 6, hct 27.8, plt 335). anc
2241. cxr: Stable appearance of the chest with extensive
scarring in the right lung due to radiation fibrosis better
assessed on prior CT with small right pleural effusion,
loculated appearing stable. Pt admitted to OMED.
.
ROS: as above; o/w complete ROS negative
Past Medical History:
Onco Hx
-RUL adenocarcinoma:
Presented with progressive SOB, fatigue, and right lower chest
and rib pain on ___. She underwent chest CT on ___ that
revealed a 5.1 cm irregular right apical paramediastinal mass
with a peripheral satellite nodule and hilar lymphadenopathy. On
___, EBUS TBNA at ___ revealed a right paratrachael mass
and bx confirmed adenocarinoma of the lung. Additional
endobronchial biopsies at station 11L, station 7 and 11R were
not diagnostic.
___iopsy. LN involvement was
present at station 4R, low 4R, 4L and level 7 nodes. There was
no
adenocarcinoma in the 2R lymph node.
___ Start of radiation therapy
___ C1D1 Cisplatin/etoposide
___ Follow-up visit before cycle 2
___ C2D1 Cisplatin/etoposide
___ C2D5 Cisplatin/etoposide
Getting RT to R upper lobe, R hilum
PMH
COPD
Afib on Pradaxa
MVP s/p bovine MVR
- osteoporosis
- Raynauds phenomenon
- mitral valve prolapse s/p mitral valve repair for endocarditis
in ___ with bovine MVR
- history of atypical-like ductal hyperplasia s/p lumpectomy
(___). Pathology showed extensive columnar cell change with
associated microcalcifications and focal atypical ductal
hyperplasia.
Focal atypical lobular hyperplasia. Changes consistent with
previous needle biopsy.
- 3 cm fibroids that have been unchanged for many years
- Colonoscopy in ___ (+ for hematochezia at that time):
Impressions: Grade 1 internal hemorrhoids. Otherwise normal
Colonoscopy to cecum
PAST SURGICAL HISTORY:
- Remarkable for lumpectomy appendectomy status post mitral
valve prolapse replacement as well
Social History:
___
Family History:
Mother who had lymphoma, maternal aunt who had cervical cancer,
maternal aunt who had aplastic anemia. No family history of
breast or ovarian cancer.
Physical Exam:
Admission Physical Exam:
t 98.5 bp96/45 hr66 rr20 sat100% ra
NAD
eomi, perrl
neck supple
no ___
chest: b/l apical and anterior
exp wheeze: clears with cough
rrr
abd benign
ext w/wp
neuro non-focal
erythema on dorsal
aspect of hands
.
Discharge Physical Exam:
Vitals - 99.1 110/58 75 18 96RA
GENERAL: NAD, cachectic elderly woman who is resting comfortably
in bed
SKIN: warm and well perfused, no rashes
HEENT: AT/NC, EOMI, PERRLA, anicteric sclera
NECK: nontender supple neck, no LAD
CARDIAC: RRR, S1/S2, no mrg
LUNG: decreased breath sounds on the right, bibasilar crackles
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact
Pertinent Results:
Admission Labs:
___ 07:40PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
___ 07:40PM URINE RBC-1 WBC-1 BACTERIA-NONE YEAST-NONE
EPI-<1
___ 07:40PM URINE HYALINE-7*
___ 07:40PM URINE MUCOUS-RARE
___ 06:30PM GLUCOSE-100 UREA N-22* CREAT-1.0 SODIUM-140
POTASSIUM-4.2 CHLORIDE-104 TOTAL CO2-25 ANION GAP-15
___ 06:30PM CALCIUM-9.1 PHOSPHATE-3.5 MAGNESIUM-1.9
___ 06:30PM WBC-2.7*# RBC-2.52* HGB-8.3* HCT-25.5* MCV-97
MCH-32.9* MCHC-34.0 RDW-16.8*
___ 06:30PM NEUTS-86.7* LYMPHS-8.2* MONOS-3.5 EOS-1.3
BASOS-0.2
___ 06:30PM PLT COUNT-166#
.
Discharge Labs:
___ 07:25AM BLOOD WBC-1.8*# RBC-3.09* Hgb-9.9* Hct-28.2*
MCV-91 MCH-32.1* MCHC-35.2* RDW-18.1* Plt Ct-89*
___ 07:25AM BLOOD Neuts-38* Bands-0 Lymphs-15* Monos-44*
Eos-3 Baso-0 ___ Myelos-0
___ 07:25AM BLOOD Glucose-95 UreaN-13 Creat-0.8 Na-137
K-4.6 Cl-104 HCO3-25 AnGap-13
___ 07:25AM BLOOD ALT-28 AST-35 LD(LDH)-434* AlkPhos-97
TotBili-0.8
___ 07:25AM BLOOD Calcium-9.0 Phos-3.4 Mg-2.0
.
Microbiology:
# Urine Culture (___): Final.
.
Pathology: None.
.
Imaging/Studies:
# CXR (___): IMPRESSION: Stable appearance of the chest with
extensive scarring in the right lung due to radiation fibrosis
better assessed on prior CT with small right pleural effusion,
loculated appearing stable.
Brief Hospital Course:
___ year woman whose past medical history is significant for
___ with mets to LNs, progression of disease despite chemo/xrt
now on maintenance palliative pemetrexed who presents with
hemoptysis.
# Hemoptysis: She had several episodes of hemoptysis two days
prior to coming into the hospital. The hemoptysis was up to but
never exceeded a teaspoon. It not appear to be large enough
volume to cause blood loss anemia. She also has had nose bleeds
since last getting chemotherapy. She was afebrile and no new
infilitrate was noted her admission chest x-ray.
During this hospitalization, she did not have any hemoptysis.
She did continue to have cough productive of yellow sputum. Her
productive cough is of unclear etiology. Her benzonotate dose
was increased and guaifenesin with codeine, guaifenesin with
dextromethorphan, and omeprazole were added. She noted slight
improvement but she continued to cough much of the day.
# Anemia/Leukopenia: Likely secondary to pemetrexed
chemotharapy. She was transfused 2u PRBCs on ___. Her
hematocrit improved. WBCs appeared to be at a nadir but was
uptrending at the time of discharge.
# Non-Small Cell Lung Cancer: She is on palliative pemetrexed.
She has already had radiation to the right lung. Her hemoptysis
is possibly secondary to disease progression though recent CT
chest showed stable dx.On pradaxa so could also represent local
irritation from chronic cough w/ bleeding on anti-coagulation..
# A-fib: Rate and rhythm were controlled. Continued home
amiodarone, metoprolol, and nifedipine. Pradaxa was held on
admission in the setting of hemoptysis but was resumed at the
time of discahrge.
# ? Compensated Diastolic CHF: Her home dose of Lasix was
continued.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Alendronate Sodium 70 mg PO QWEEK
2. Amiodarone 200 mg PO DAILY
3. Benzonatate 100 mg PO TID
4. Dabigatran Etexilate 150 mg PO BID
5. Fluticasone Propionate NASAL 1 SPRY NU DAILY
6. FoLIC Acid 1 mg PO DAILY
7. Furosemide 20 mg PO DAILY
8. Metoprolol Succinate XL 50 mg PO DAILY
9. NIFEdipine CR 60 mg PO DAILY
10. Ondansetron 8 mg PO Q8H:PRN n/v
11. Prochlorperazine 10 mg PO Q6H:PRN n/v
Discharge Medications:
1. Amiodarone 200 mg PO DAILY
2. Benzonatate 200 mg PO TID
RX *benzonatate 200 mg 1 capsule(s) by mouth three times a day
Disp #*90 Capsule Refills:*0
3. Dabigatran Etexilate 150 mg PO BID
4. Fluticasone Propionate NASAL 1 SPRY NU DAILY
5. FoLIC Acid 1 mg PO DAILY
6. Metoprolol Succinate XL 50 mg PO DAILY
7. NIFEdipine CR 60 mg PO DAILY
8. Cepastat (Phenol) Lozenge 2 LOZ PO Q2H:PRN cough
9. Guaifenesin-CODEINE Phosphate ___ mL PO QHS cough
RX *codeine-guaifenesin [Guaiatussin AC] 100 mg-10 mg/5 mL 10 mL
by mouth at bedtime Refills:*0
10. Guaifenesin-Dextromethorphan 10 mL PO Q6H:PRN cough
RX *dextromethorphan-guaifenesin [Guaifenesin-DM] 100 mg-10 mg/5
mL 10 mL by mouth every six (6) hours Refills:*0
11. Omeprazole 40 mg PO DAILY
RX *omeprazole 40 mg 1 capsule(s) by mouth daily Disp #*30
Capsule Refills:*0
12. Alendronate Sodium 70 mg PO QWEEK
13. Furosemide 20 mg PO DAILY
14. Ondansetron 8 mg PO Q8H:PRN n/v
15. Prochlorperazine 10 mg PO Q6H:PRN n/v
Discharge Disposition:
Home
Discharge Diagnosis:
Anemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were admitted with hemoptysis and fatigue. Your blood
counts improved with transfusions and you are safe to go home.
Followup Instructions:
___
|
19729564-DS-6
| 19,729,564 | 28,805,256 |
DS
| 6 |
2140-10-28 00:00:00
|
2140-10-28 19:06:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
house dust / pollen
Attending: ___.
Chief Complaint:
Right ___ swelling
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ hx HFmrEF, atrial fibrillation on warfarin, hypertension,
h/o
VT s/p ICD placement, MDD, GAD who comes to the ED for right
___
swelling.
Patient was initially seen at ___ ED on ___ following a
gardening accident. At approximately 3 ___ on ___, the patient
was hammering a piece of metal pipe into the ground to prevent
rabbits from entering his garden when a piece of cast iron
shattered and lacerated the webspace between his index and
middle
finger on his right ___. Suffered a right second webspace
complex injury with multiple dorsal skin flaps and retained
forein body s/p repair. Given tetanus shot and ancef. Sent home
with Keflex for 10 days.
However, right ___ worsened, hot and swollen since last ___
and slowly traveling up his elbow. He denied: fevers, chills,
malaise. ___ painful. No drainage from the ___. Blisters also
began forming on back of ___.
He denies: headache, vision changes, sore throat, cough, runny
nose, fever, aches/pains, chest pain, shortness of breath,
abdominal pain, bowel habit changes, or dysuria.
In the ED,
- Initial vitals were: 98.0 53 152/50 20 99% RA
- Exam was notable for: laceration w/no purulence, swollen and
red/warm ___ w/warmth/swelling extending up to elbow,
neurovascular intact and distal pulses intact
- Labs were notable for:
WBC 7.4 H/H 11.2/36.4 Plt 225
___ 20.7 PTT 34 INR 1.9
CRP 100.1
BMP wnl with BUN 17 and Cr 1.2
- Studies were notable for:
R arm x-ray: New diffuse dorsal swelling with persistent
visualization of multiple radiopaque foreign body at the volar
aspect of the second web space. No definite subcutaneous gas.
- ___ surgery was consulted: recommend IV antibiotics and
observation for reevaluation in the morning after on IV
antibiotics. If his wrist pain is worse in the morning he may
need to have an aspiration to rule out septic arthritis of the
wrist. Activity: NWB RUE in volar splint, elevated from pole;
Antibiotics: per ED, clindamycin and vancomycin; Dressings: in
volar splint with strict elevation
- Patient was given:
___ 16:21 PO/NG Acetaminophen 650 mg
___ 16:21 IV Morphine Sulfate 4 mg
___ 16:59 IV Clindamycin 600 mg
___ 17:12 PO/NG Warfarin 2.5 mg
___ 17:12 PO/NG Atorvastatin 80 mg
___ 18:52 IV Vancomycin 1000 mg
On arrival to the floor, he states that his ___ is feeling a
bit
better. He can move the wrist but it hurts a lot to do so. No
fevers, no shaking chills.
Past Medical History:
Paroxysmal atrial fibrillation on chronic Coumadin
Non-ischemic dilated cardiomyopathy, initial EF 25%, more
recently stable at 40-45%
Prolonged VT, s/p ICD
CHF
Pedal edema
Hypercholesterolemia/hyperlipidemia
Hypertension
RBBB
Thoracic aortic aneurysm
Bicuspid Aortic Valve
Congenital Heart Disease with intracardiac shunting
Anemia
OSA, CPAP compliant
Obesity
Asthma
Pleural effusion on right, large, chronic, loculated
Gout
Anxiety
Lumbosacral spondylosis
Right diaphragmatic hernia
Ventral hernia
Cataracts
Anxiety
Amblyopia
Severe restrictive lung disease
Lumbar spondylosis
Obesity
Fatty Liver
Inguinal hernia repair
Restless leg syndrome
Cataract surgery, bilateral
Social History:
___
Family History:
-brother: prostate ___
-father: MI
Physical ___:
ADMISSION PHYSICAL EXAM:
========================
VITALS: reviewed in omr
GENERAL: Alert and interactive. In no acute distress.
HEENT: PERRL, EOMI. Sclera anicteric and without injection. MMM.
NECK: Supple, JVP difficult to assess given body habitus
CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No
murmurs/rubs/gallops.
LUNGS: Clear to auscultation bilaterally. No wheezes, rhonchi or
rales. No increased work of breathing.
ABDOMEN: Normal bowels sounds, non distended, non-tender to deep
palpation in all four quadrants.
EXTREMITIES: Right arm in splint ace wrap -held up to IV pole.
Upon undressing, has nontender but swollen olecranon process.
Length of right arm from olecranon to ___ is erythematous and
edematous. He is able to flex the wrist ___ degrees actively
but exquisite pain. 2+ pitting edema to midknee.
NEUROLOGIC: AOx3. Moving all 4 limbs spontaneously.
DISCHARGE PHYSICAL EXAM:
========================
___ 0841 Temp: 97.6 PO BP: 143/58 L Lying HR: 47 RR: 18 O2
sat: 97% O2 delivery: Ra
GENERAL: Alert and interactive. Sitting in bed listening to
music on his iPhone. In no acute distress.
HEENT: PERRL, EOMI. Sclera anicteric and without injection. MMM.
NECK: Supple, JVP difficult to assess given body habitus
CARDIAC: Distant, faint heart sounds due to body habits. Regular
rhythm, normal rate. Audible S1 and S2. No murmurs/rubs/gallops.
LUNGS: Clear to auscultation bilaterally. No wheezes, rhonchi or
rales. No increased work of breathing.
ABDOMEN: Normal bowels sounds, non distended, non-tender to deep
palpation in all four quadrants.
EXTREMITIES: Right arm not in the splint ace wrap, but in sling
suspended from IV pole. Length of right arm from olecranon to
___ is erythematous and edematous, dorsal > ventral edema. He
is able to flex the wrist ___ degrees actively but with mild
pain. 2+ pitting edema to mid-knee. Nontender but swollen
olecranon process.
NEUROLOGIC: AOx3. Moving all 4 limbs spontaneously.
Pertinent Results:
ADMISSION LABS
___ 04:13PM BLOOD WBC-7.4 RBC-4.13* Hgb-11.2* Hct-36.4*
MCV-88 MCH-27.1 MCHC-30.8* RDW-16.4* RDWSD-53.8* Plt ___
___ 04:13PM BLOOD Neuts-75.2* Lymphs-13.0* Monos-10.3
Eos-0.7* Baso-0.3 Im ___ AbsNeut-5.55 AbsLymp-0.96*
AbsMono-0.76 AbsEos-0.05 AbsBaso-0.02
___ 04:13PM BLOOD ___ PTT-34.0 ___
___ 04:13PM BLOOD Glucose-78 UreaN-17 Creat-1.2 Na-140
K-4.6 Cl-100 HCO3-26 AnGap-14
___ 04:13PM BLOOD Calcium-8.2* Phos-3.7 Mg-2.1
___ 04:13PM BLOOD CRP-100.1*
DISCHARGE LABS
___ 07:19AM BLOOD WBC-6.7 RBC-3.90* Hgb-10.5* Hct-34.0*
MCV-87 MCH-26.9 MCHC-30.9* RDW-16.4* RDWSD-52.5* Plt ___
___ 07:19AM BLOOD Neuts-73.6* Lymphs-15.3* Monos-8.6
Eos-1.4 Baso-0.3 Im ___ AbsNeut-4.90 AbsLymp-1.02*
AbsMono-0.57 AbsEos-0.09 AbsBaso-0.02
___ 10:15AM BLOOD ___ PTT-36.8* ___
___ 07:19AM BLOOD Glucose-104* UreaN-20 Creat-1.3* Na-142
K-3.7 Cl-102 HCO3-27 AnGap-13
___ 07:19AM BLOOD Calcium-8.1* Phos-4.0 Mg-2.3
MICROBIOLOGY
___ blood cultures x2 no growth to date
___ 10:17 am STOOL CONSISTENCY: LOOSE Source:
Stool.
**FINAL REPORT ___
C. difficile PCR (Final ___:
NEGATIVE.
(Reference Range-Negative).
The C. difficile PCR is highly sensitive for toxigenic
strains of C.
difficile and detects both C. difficile infection (CDI)
and
asymptomatic carriage.
A negative C. diff PCR test indicates a low likelihood of
CDI or
carriage.
IMAGING
___ Xray (PA, lateral, oblique) ___
1) New diffuse dorsal swelling with persistent visualization of
multiple radiopaque foreign body at the volar aspect of the
second web space
2) No definite subcutaneous gas.
Brief Hospital Course:
BRIEF HOSPITAL COURSE:
======================
Mr ___ is a ___ hx HFmrEF, atrial fibrillation on
warfarin, hypertension, h/o VT s/p ICD placement, MDD, GAD who
was recently seen on ___ for traumatic right ___ injury s/p
repair who re-presented to the ED with worsening right ___ and
forearm edema, erythema, and pain most consistent with
cellulitis.
Pt was evaluated by ___ Surgery in the ED, who did not feel
that further repair, debridement, or wrist joint aspiration was
indicated. RUE kept elevated, treated with IV clindamycin +
vancomycin x3 days (___) with clinical improvement
(decreased pain + swelling), transitioned to oral Augmentin +
Doxycycline on ___, discharged with plan for 7 day course
(___) and close follow-up in ___ clinic.
TRANSITIONAL ISSUES:
====================
#RUE Wound and cellulitis
[] F/u resolution of RUE cellulitis following completion 7 day
course of augmentin 875mg Q12H and doxycycline 100mg BID
(___).
[] F/u ___ laceration repair, will require suture removal
(placed ___ by ___ Surgery) - plan per ___ Surgery.
#Anticoagulation
[] INR within 3 days of discharge since patient on antibiotics
and INR uptrending prior to discharge
ACUTE/ACTIVE ISSUES:
====================
#Right ___ cellulitis:
Patient suffered a right ___ second webspace complex injury
with multiple dorsal skin flaps and retained foreign body s/p
repair on ___ in the ED. Presented on this admission with
likely cellulitis overlying prior site of injury and repair,
despite 10 day course of cephalexin started ___ (pt reports
good med adherence). HDS, no fever or leukocytosis prior or
during admission. Per ___ surgery consult, RUE was kept
elevated in sling and he was started IV clindamycin and
vancomycin (___) with improvement in pain and swelling. No
significant concern for joint involvement. PO oxycodone PRN for
pain. He was transitioned to oral abx (Augmentin + Doxycline) on
___ and discharged home with plan to complete 7 day course
(___) with close follow-up in ___ clinic next week.
#Olecranon bursitis:
Patient also presenting with evidence concerning for chronic
olecranon bursitis of RUE. Given acetaminophen 1000mg q8H for
pain management, oxycodone 5mg PRN breakthrough pain. No concern
from orthopedics for an infected bursitis.
#HFmrEF:
TTE at At___ on ___ revealed EF 45%. Written for home
furosemide 80mg QD, up to 120mg for worsening ___ edema. He
states some days he does not take any furosemide, some days he
takes one 40mg tablet, and other days takes ___ tablets.
Appeared mildly hypervolemic on admission, s/p diuresis with
60-80mg IV Lasix, then restarted home Lasix 80 mg PO on day of
discharge. Continued home lisinopril, metoprolol succinate,
aspirin, atorvastatin. Maintained strict I/Os, daily weights and
2g sodium diet while in hospital.
#Anticoagulation:
INR up to 2.9 ___ AM. Likely in the setting of antibiotics and
infection. Was given 1 mg ___ warfarin prior to dc. Upon
discharge he was not counseled to change his warfarin dosing at
this time. However he was called after his discharge to further
discuss this plan. Specifically, it was suggested that he
contact his ___ clinic to arrange an INR check the next day
since his antibiotics were changed and the INR had uptrended
prior to discharge.
CHRONIC/STABLE ISSUES:
======================
#Atrial fibrillation:
Patient was continued home metoprolol succinate 50mg daily for
rate control, home amiodarone for rhythm control and home
warfarin (goal INR ___ for anticoagulation (see above).
#Anemia: baseline in ___ H/H ___. Admission H/H ___,
near baseline. No clinical suspicion of bleeding.
#CKD: likely iso of longstanding HTN and DMT2. AT CHA, baseline
over in ___ 1.3-1.5. On admission, Cr 1.2.
#OSA:
Continued home CPAP.
#h/o of ventricular tachycardia: s/p ICD placement
#Hypertension:
Continued home lisinopril 10mg daily
#MDD:
#GAD:
Continued home paroxetine, bupropion XL, clonazepam PRN
#Restless leg syndrome:
Continued home ropinirole.
#Hyperlipidemia:
Continue home aspirin daily and atorvastatin.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. BuPROPion XL (Once Daily) 300 mg PO DAILY
2. OxyCODONE (Immediate Release) ___ mg PO Q6H:PRN Pain -
Moderate
3. Atorvastatin 80 mg PO QPM
4. ClonazePAM 0.5 mg PO DAILY:PRN anxiety
5. Amiodarone 200 mg PO DAILY
6. Lisinopril 10 mg PO DAILY
7. Metoprolol Succinate XL 25 mg PO DAILY
8. Furosemide 80 mg PO DAILY
___ MD to order daily dose PO DAILY16
10. PARoxetine 30 mg PO DAILY
11. rOPINIRole 3 mg PO QPM
12. Aspirin 81 mg PO DAILY
13. Poly-Iron (polysaccharide iron complex) 150 mg iron oral
DAILY
Discharge Medications:
1. Amoxicillin-Clavulanic Acid ___ mg PO Q12H Duration: 7 Days
Last day ___
2. Doxycycline Hyclate 100 mg PO BID Duration: 7 Days
Last day ___
3. Amiodarone 200 mg PO DAILY
4. Aspirin 81 mg PO DAILY
5. Atorvastatin 80 mg PO QPM
6. BuPROPion XL (Once Daily) 300 mg PO DAILY
7. ClonazePAM 0.5 mg PO DAILY:PRN anxiety
8. Furosemide 80 mg PO DAILY
9. Lisinopril 10 mg PO DAILY
10. Metoprolol Succinate XL 25 mg PO DAILY
11. OxyCODONE (Immediate Release) ___ mg PO Q6H:PRN Pain -
Moderate
12. PARoxetine 30 mg PO DAILY
13. Poly-Iron (polysaccharide iron complex) 150 mg iron oral
DAILY
14. rOPINIRole 3 mg PO QPM
15. ___ MD to order daily dose PO DAILY16
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary:
RUE cellulitis
Secondary:
Chronic olecranon bursitis
Heart failure with mid-range ejection fraction
Atrial fibrillation
Obstructive sleep apnea
Chronic kidney disease
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 being a part of your care!
WHY WERE YOU IN THE HOSPITAL?
- You initially came to the ED on ___ after sustaining an
injury in the finger space between your first and second
fingers. It was repaired by the ___ Surgery team here at and
you were given 10 days of an antibiotic called cephalexin
(Keflex).
- Despite being on the antibiotic, you noticed that your ___
started to get more red, swollen and painful at home.
WHAT HAPPENED WHILE YOU WERE IN THE HOSPITAL?
- You were seen by the ___ Surgery team in the ED. They felt
that your symptoms were most likely due to a skin infection
(cellulitis) rather than deeper infection or infection of the
joint. You did not need any additional procedures or surgery.
- You kept your ___ elevated for your time in the hospital.
- You were given IV antibiotics for 3 days to treat the
cellulitis.
- You were switched from IV to 2 oral antibiotics (Augmentin +
Doxycycline).
- You were given IV diuretic for mild volume overload.
WHAT SHOULD YOU DO WHEN YOU LEAVE THE HOSPITAL?
- Please pick up the prescriptions for Augmentin and Doxycycline
from your pharmacy and continue them for a 7-day course. Please
finish all the antibiotics.
- Please keep your right ___ elevated and keep it dry. Please
call the ___ Surgery clinic at ___ this week for
additional instructions regarding wound care and suture removal.
- Please follow up with your PCP and in ___ Surgery clinic in 1
week.
- Weigh yourself every morning, call MD if weight goes up more
than 3 lbs.
We wish you the best!
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
19729635-DS-16
| 19,729,635 | 23,068,441 |
DS
| 16 |
2186-07-25 00:00:00
|
2186-07-28 20:41:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
___: laparoscopic appendectomy
History of Present Illness:
Mr. ___ is a ___ yo M with h/o HTN presenting with lower
periumbilical abdominal pain that began yesterday. The pain
initially began as a ___ discomfort that progressed to a
___ pain by 8pm. By 2:30a, the pain intensified to a ___. It
does not radiate. He endorses nausea and ___ episodes of NBNB
vomiting yesterday with anorexia. He had 2 normal bowel
movements
yesterday, but is not passing flatus. He denies fever, chills,
or
dysuria, though he had a decreased urinary frequency, which he
attributes to no fluid intake.
Past Medical History:
HTN
Social History:
___
Family History:
unknown
Physical Exam:
Physical Exam: upon admission: ___
Vitals: 98.6 84 141/97 16 100|RA
GEN: alert, conversant, well appearing, NAD
HEENT: anicteric sclera
CV: RRR, no murmurs appreciated
PULM: Clear to auscultation b/l anteriorly
ABD: Soft, nondistended, TTP lower periumbilical, no rebound or
guarding, negative psoas sign, neg obturator sign, negative
Rovsing sign
Ext: warm, well perfused, +2 ___ pulses
Physical examination upon discharge: ___:
vital signs: 98.7, hr=50-90, bp=128/78 rr=16, 98% room air
General: NAD
CV: ns1, s2, no murmurs
LUNGS: clear
ABDOMEN: hypoactive BS, soft, non-tender, right abd. drain with
pink-tinged fluid, port sites clean and dry, umbilical port
intact with staples
EXT: no calf tenderness bil., no pedal edema bil
NEURO: alert and oriented x, speech clear
Pertinent Results:
___ 07:40AM BLOOD WBC-12.2* RBC-4.74 Hgb-13.8 Hct-41.8
MCV-88 MCH-29.1 MCHC-33.0 RDW-13.5 RDWSD-43.9 Plt ___
___ 08:26AM BLOOD WBC-15.8* RBC-5.13 Hgb-14.8 Hct-45.2
MCV-88 MCH-28.8 MCHC-32.7 RDW-13.9 RDWSD-45.1 Plt ___
___ 10:45AM BLOOD WBC-18.4* RBC-5.71 Hgb-16.1 Hct-49.9
MCV-87 MCH-28.2 MCHC-32.3 RDW-13.7 RDWSD-44.1 Plt ___
___ 08:26AM BLOOD Neuts-78* Bands-1 Lymphs-8* Monos-10
Eos-3 Baso-0 ___ Myelos-0 AbsNeut-12.48*
AbsLymp-1.26 AbsMono-1.58* AbsEos-0.47 AbsBaso-0.00*
___ 07:40AM BLOOD Plt ___
___ 08:16AM BLOOD Plt ___
___ 07:40AM BLOOD Glucose-91 UreaN-14 Creat-1.0 Na-136
K-3.8 Cl-99 HCO3-23 AnGap-18
___ 08:16AM BLOOD Glucose-122* UreaN-17 Creat-0.9 Na-135
K-4.2 Cl-98 HCO3-24 AnGap-17
___ 10:45AM BLOOD Glucose-111* UreaN-17 Creat-1.1 Na-131*
K-6.3* Cl-94* HCO3-20* AnGap-23*
___ 10:45AM BLOOD ALT-59* AST-77* AlkPhos-57 TotBili-1.8*
___ 07:40AM BLOOD Calcium-8.0* Phos-2.9 Mg-2.0
___ 08:16AM BLOOD Calcium-8.2* Phos-3.0 Mg-2.1
___ 10:55AM BLOOD Lactate-1.7 Na-135 K-4.7 Cl-100
calHCO3-21
___: CT abd and pelvis:
1. Markedly dilated appendix measuring up to 21 mm with adjacent
fat
stranding, consistent with uncomplicated acute appendicitis.
2. A 17 mm intermediate density lesion in the upper pole of the
left kidney likely represents a hyperdense cyst. A nonurgent
renal ultrasound could be considered for confirmation.
___: chest x-ray:
There are no prior chest radiographs available for review.
Transesophageal tube ends in the stomach. Cardiomegaly is
moderate. Right pleural effusion is small. No left pleural
effusion. No pneumothorax. No pulmonary edema or pneumonia.
___: cat scan abd./pelvis:
. Right lower quadrant abscess measuring 2.6 x 5.8 x 4.1 cm.
2. Intra-pelvic abscess measuring 4.2 x 1.8 x 1.9 cm.
3. Dilated loops of small bowel measuring up to 4 cm without
sharp transition point and becomes more normal in caliber in the
ileum. This may represent postop ileus or early obstruction.
Clinical correlation is recommended.
4. 1.4 cm hypodense lesion at the upper pole of the left kidney
which does not appear to be a simple cyst. A non-emergent renal
ultrasound is recommended.
RECOMMENDATION(S): Non-emergent renal ultrasound.
___: ___ drainage:
Successful US-guided placement of ___ pigtail catheter into
right mid
abdominal collection. Samples was sent for microbiology
evaluation.
___ 6:39 pm PERITONEAL FLUID
**FINAL REPORT ___
GRAM STAIN (Final ___:
2+ ___ per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final ___:
Reported to and read back by ___ ___
11:55AM.
PSEUDOMONAS AERUGINOSA. RARE GROWTH.
OF TWO COLONIAL MORPHOLOGIES.
GRAM NEGATIVE ROD(S). RARE GROWTH.
GRAM POSITIVE BACTERIA. RARE GROWTH.
MIXED BACTERIAL FLORA.
This culture contains mixed bacterial types (>=3) so an
abbreviated workup is performed. Any growth of
P.aeruginosa,
S.aureus and beta hemolytic streptococci will be
reported. IF
THESE BACTERIA ARE NOT REPORTED, THEY ARE NOT PRESENT
in this
culture.
Work-up of organism(s) listed discontinued (excepted
screened
organisms) due to the presence of mixed bacterial flora
detected
after further incubation.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
PSEUDOMONAS AERUGINOSA
|
CEFEPIME-------------- 2 S
CEFTAZIDIME----------- 4 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- 8 S
TOBRAMYCIN------------ <=1 S
ANAEROBIC CULTURE (Final ___: NO ANAEROBES ISOLATED.
Brief Hospital Course:
___ year old male who presented to the hospital with
___ pain. Upon admission, the patient was made NPO,
given intravenous fluids, and underwent imaging. Lab work showed
an elevated white blood cell count. A cat scan of the abdomen
was done which showed a dilated appendix measuring up to 21 mm
with adjacent fat stranding, consistent with uncomplicated acute
appendicitis. Based on these findings, the patient was taken to
the operating room where he underwent a laparoscopic
appendectomy. The appendix was reported to be necrotic. The
operative course was stable with minimal blood loss. The
patient was extubated after the procedure and monitored in the
recovery room.
During the post-operative course, the patient's bowel function
was slow to return and his abdomen became more distended.
Despite narcotic analgesia, he experienced an increase in his
abdominal pain. A ___ tube was placed for abdominal
decompression and a cat scan was ordered. Cat scan imaging
showed 2 loculated fluid collections concerning for abscesses.
The patient was taken to ___ for placement of a pigtail catheter
into the right mid abdominal collection. Purulent material was
aspirated from the collection and sent for culture. The patient
continued on a course of ciprofloxacin and flagyl. His white
blood cell count was monitored and trended down.
On POD #6, bowel function returned and the ___ tube was
removed. The patient was started on clear liquids and advanced
to a regular diet. His pain was controlled with oral analgesia
and he was voiding without difficulty.
The patient was discharged to his home in ___ on POD #8 in
stable condition. His abdominal pain had subsided and he
declined pain medication. He was given a prescription to
complete a course of ciprofloxacin and flagyl. Drain care was
reviewed in addition to general post-operative instructions.
Follow-up care was initiated at ___. The patient was
given contact numbers of the ___ facility and was awaiting an
appointment for his post-operative visit. The Acute care clinic
telephone number was also provided.
Peritoneal fluid culture: ___: PSEUDOMONAS AERUGINOSA
Medications on Admission:
none
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
2. Calcium Carbonate 500 mg PO QID:PRN gas pain
3. Ciprofloxacin HCl 500 mg PO Q12H
___
RX *ciprofloxacin HCl [Cipro] 500 mg 1 tablet(s) by mouth every
twelve (12) hours Disp #*11 Tablet Refills:*0
4. Docusate Sodium 100 mg PO BID
5. MetroNIDAZOLE 500 mg PO Q8H
last dose ___
RX *metronidazole 500 mg 1 tablet(s) by mouth every eight (8)
hours Disp #*25 Tablet Refills:*0
6. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain -
Moderate
do not drive while on this medication
7. Senna 8.6 mg PO BID:PRN constipaton
8. Simethicone 40-80 mg PO QID:PRN gas pain
9. ___ 50% Pad ___SDIR
10. Zolpidem Tartrate 5 mg PO QHS
11. Losartan Potassium 50 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
acute appendicitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital with abdominal pain. You were
found to have appendicitis. You were taken to the operating
room to have your appendix removed. You developed a fluid
collection in your abdomen after the surgery and you required
placement of a drainage catheter. Your vital signs have been
stable and you are preparing for discharge home with the
following instructions. You plan to travel to ___ and ___
follow-up at ___. Your paper work has been sent down and they
are working on an appointment for you. You are being discharged
with the following instructions:
You were admitted to the hospital with acute appendicitis. You
were taken to the operating room and had your appendix removed
laparoscopically. You tolerated the procedure well and are now
being discharged home with the following instructions:
Please follow up at the appointment in clinic listed below. We
also generally recommend that patients follow up with their
primary care provider after having surgery. We have scheduled an
appointment for you listed below.
ACTIVITY:
Do not drive until you have stopped taking pain medicine and
feel you could respond in an emergency.
You may climb stairs.
You may go outside, but avoid traveling long distances until you
see your surgeon at your next visit.
Don't lift more than ___ lbs for ___ weeks. (This is about the
weight of a briefcase or a bag of groceries.) This applies to
lifting children, but they may sit on your lap.
You may start some light exercise when you feel comfortable.
You will need to stay out of bathtubs or swimming pools for a
time while your incision is healing. Ask your doctor when you
can resume tub baths or swimming.
HOW YOU MAY FEEL:
You may feel weak or "washed out" a couple weeks. You might want
to nap often. Simple tasks may exhaust you.
You may have a sore throat because of a tube that was in your
throat during surgery.
You could have a poor appetite for a couple days. Food may seem
unappealing.
All of these feelings and reactions are normal and should go
away in a short time. If they do not, tell your surgeon.
YOUR INCISION:
Tomorrow you may shower and remove the gauzes over your
incisions. Under these dressings you have small plastic bandages
called steristrips. Do not remove steri-strips for 2 weeks.
(These are the thin paper strips that might be on your
incision.) But if they fall off before that that's okay.
Your incisions may be slightly red around the stitches. This is
normal.
You may gently wash away dried material around your incision.
Avoid direct sun exposure to the incision area.
Do not use any ointments on the incision unless you were told
otherwise.
You may see a small amount of clear or light red fluid staining
your dressing or clothes. If the staining is severe, please call
your surgeon.
You may shower. As noted above, ask your doctor when you may
resume tub baths or swimming.
YOUR BOWELS:
Constipation is a common side effect of narcotic pain
medicaitons. If needed, you may take a stool softener (such as
Colace, one capsule) or gentle laxative (such as milk of
magnesia, 1 tbs) twice a day. You can get both of these
medicines without a prescription.
If you go 48 hours without a bowel movement, or have pain moving
the bowels, call your surgeon.
PAIN MANAGEMENT:
It is normal to feel some discomfort/pain following abdominal
surgery. This pain is often described as "soreness".
Your pain should get better day by day. If you find the pain is
getting worse instead of better, please contact your surgeon.
You will receive a prescription for pain medicine to take by
mouth. It is important to take this medicine as directed. Do not
take it more frequently than prescribed. Do not take more
medicine at one time than prescribed. Do not drink alcohol or
drive while taking narcotic pain medication.
Your pain medicine will work better if you take it before your
pain gets too severe.
Talk with your surgeon about how long you will need to take
prescription pain medicine. Please don't take any other pain
medicine, including non-prescription pain medicine, unless your
surgeon has said its okay.
If you are experiencing no pain, it is okay to skip a dose of
pain medicine.
Remember to use your "cough pillow" for splinting when you cough
or when you are doing your deep breathing exercises.
If you experience any of the following, please contact your
surgeon:
- sharp pain or any severe pain that lasts several hours
- pain that is getting worse over time
- pain accompanied by fever of more than 101
- a drastic change in nature or quality of your pain
MEDICATIONS:
Take all the medicines you were on before the operation just as
you did before, unless you have been told differently.
If you have any questions about what medicine to take or not to
take, please call your surgeon.
DANGER SIGNS:
Please call your surgeon if you develop:
- worsening abdominal pain
- sharp or severe pain that lasts several hours
- temperature of 101 degrees or higher
- severe diarrhea
- vomiting
- redness around the incision that is spreading
- increased swelling around the incision
- excessive bruising around the incision
- cloudy fluid coming from the wound
- bright red blood or foul smelling discharge coming from the
wound
- an increase in drainage from the wound
Followup Instructions:
___
|
19730165-DS-17
| 19,730,165 | 26,281,041 |
DS
| 17 |
2134-07-11 00:00:00
|
2134-07-11 15:49:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Lisinopril / Hydralazine And Derivatives
Attending: ___
Chief Complaint:
menorrhagia, symptomatic anemia (blood loss)
Major Surgical or Invasive Procedure:
endometrial biopsy
History of Present Illness:
___ G1P1 with history of irregular menses, CKD on pertoneal
dialysis p/w menorrhagia X 4 days. She reports bleeding has been
increasing over the course of the last four days such that she
has had to change her pad every half hour because it is soaked.
She also reports passing baseball sized clots. She reports
history of irregular menses which are typically heavy, but has
not had any similarly heavy bleeding since her vaginal delivery
___ years ago. She reports symptoms of dizziness and L arm and
face tingling, but denies any syncopal events. Her last Hct on
___ was 28 per her ___ clinic note. LMP ___.
.
In the ED initial vital signs were 97.7 80 150/69 16 100%. Labs
notable for Hct 16, K of 6.4. EKG with SR at 88, NA
She was ordered for two units pRBCs. Pt refused kayexelate,
insulin/dextrose. Bleeding improved over several pelivic
examinations. Pelvic ultrasound showed thin endometrial stripe
and clot near the cervix. ObGyn, therefore, recommended
observation, with potential surgical intervention if bleeding
recurred. Vital signs on transfer were: 98.6 HR 94 165/96 RR 24
100% RA.
.
.
On the floor, patient reports continued blood loss, last pad
just changed, soaked through in one hour. All other symtpoms
described above now resolved, feels 100% improved. Repeat Hct
19.
.
Review of systems:
(+) Per HPI, easy bruising since developing renal failure.
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, shortness of breath, or wheezing.
Denies chest pain, chest pressure, palpitations, or weakness.
Denies nausea, vomiting, diarrhea, constipation, abdominal pain,
or changes in bowel habits. Denies dysuria, frequency, or
urgency. Denies arthralgias or myalgias. Denies rashes or skin
changes.
Past Medical History:
-GIP1
- H/o TAB
- " Ovarian cysts"
- ESRD with peritoneal dialysis, awaiting transplant
- HTN
Social History:
___
Family History:
Sister who died from complications of a renal transplant, a
mother who has severe chronic kidney disease, and a maternal
grandfather who also had some form of glomerulonephritis.
Physical Exam:
ADMISSION EXAM:
Vitals: T:98.8 BP:176/100 P:117 R:13 O2: 100%
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, + conjunctival pallor, MMM, oropharynx
clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, few basilar rales, now
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding. PD catheter.
GU: no foley, pad soaked with 3X3inch clot. Visual and bimanual
exam deferred given many recent exams today.
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
DISCHARGE EXAM:
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, + conjunctival pallor, MMM, oropharynx
clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding. PD catheter.
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
ADMISSION LABS:
___ 03:52PM BLOOD WBC-4.7 RBC-1.83*# Hgb-5.5*# Hct-16.0*#
MCV-87 MCH-29.8 MCHC-34.1 RDW-16.9* Plt ___
___ 03:52PM BLOOD Neuts-85.5* Lymphs-11.3* Monos-1.8*
Eos-1.2 Baso-0.2
___ 03:52PM BLOOD ___ PTT-20.3* ___
___ 03:52PM BLOOD Glucose-127* UreaN-59* Creat-13.5*#
Na-137 K-6.5* Cl-98 HCO3-27 AnGap-19
___ 10:09PM BLOOD Calcium-6.6* Phos-8.2* Mg-2.0
OTHER LABS:
___ 08:30AM BLOOD Ret Aut-1.2
___ 08:30AM BLOOD calTIBC-217* Ferritn-131 TRF-167*
___ 08:30AM BLOOD Albumin-3.2* Calcium-6.9* Phos-8.0*
Mg-2.0 Iron-195*
___ 03:52PM BLOOD HCG-<5
___ 08:32AM BLOOD ___ pH-7.45 Comment-GREEN TOP
___ 04:03PM BLOOD Hgb-5.3* calcHCT-16
___ 08:32AM BLOOD freeCa-0.84*
DISCHARGE LABS:
___ 07:50AM BLOOD WBC-6.1 RBC-2.83* Hgb-8.7* Hct-24.3*
MCV-86 MCH-30.6 MCHC-35.8* RDW-15.0 Plt Ct-79*
___ 08:30AM BLOOD Neuts-76.8* Lymphs-15.5* Monos-5.6
Eos-2.0 Baso-0.2
___ 07:50AM BLOOD Glucose-102* UreaN-50* Creat-11.5* Na-137
K-4.5 Cl-99 HCO3-28 AnGap-15
___ 07:50AM BLOOD Calcium-7.3* Phos-7.4* Mg-1.7
IMAGES:
TRANSVAG U/S:1. No mass or polyp to explain the patient's
bleeding. 2. Free fluid likely reflecting peritoneal dialysis
Brief Hospital Course:
___ year old female with history of irregular menses, ESRD on
peritoneal dialysis who presents with 4 days of menorrhagia.
# Anemia: Pt had Hct of 16 in ED in setting on ongoing vaginal
bleeding. Over hospital course received a total of 5 units
PRBCs and 1 unit FFP. Refused platelets despite comorbid
thrombocytopenia. Anemia thought to be multifactorial, with
acute on chronic etiologies. Acutely, pt had menorrhagia
thought to be secondary to anovulatory cycles. Chronically, pt
has anemia of chronic disease from reduced epo production in
setting of chronic renal failure. Anemia stabilized after PRBC
transfusions and gyn intervention to stop vaginal bleeding with
depo provera. She was also started on epo and iron
supplementation. She will follow up with renal and gyn as an
outpatient.
# Menorrhagia: Pt's vaginal bleeding is most consistent with
anovulatory bleeding, of which she has a history thought to be
___ CKD. Pelvic ultrasound revealed thin endometrial stripe and
no other obvious source of bleeding such as fibroids or cysts.
Gyn was consulted and recommended starting depo provera 10mg po
BID for 2 weeks plus iron supplementation. Pt was begun on this
after which bleeding stopped and Hct stabilized. She had an
endometrial biopsy on ___ to rule out malignancy and
results were pending at the time of discharge. Given the
improvement in bleeding with medical intervention, gyn did not
recommend operative management at this time. She will follow up
with gyn within 1 month.
# Chronic Kidney Disease: Pt does 4 overnight exchanges of 2L
over 2 hrs of 1.5 % dextrose solution with cycler at home. Pt
was hyperkalemic on arrival with K 6.4, improved to 6.0 without
intervention. On EKG, she had peaked t-waves in V3 on admission
but these findings were similar to previous EKG in ___ and were
not diffuse. She refused interventions such as kayexelate and
insulin/dextrose. She resumed her usual peritoneal HD while in
house, and electrolytes were repleted as indicated. Repeat EKG
remained stable. She will follow up with renal as an
outpatient.
# Hypertension: antihypertensives were initially held due to
ongoing blood loss. On hospital day 2 these were restarted
because BP remained stable and was elevated. SBP as high as
190s during admission, but pt refused to take some of her
anti-hypertensives and sometimes only took a fraction of the
dose provided. Pt states "when she takes" her meds her BP is
good, however, during hospitalization she was frequently
non-compliant. Recommend outpatient follow up with PCP and
education on importance of medication compliance, especially in
a patient who is hoping for a transplant.
TRANSITIONAL ISSUES:
1. medication education re: anti-hypertensives
2. follow up with gynecology re: dysfunctional uterine bleeding
and endometrial biopsy results
3. follow up with renal re: peritoneal dialysis and electrolyte
repletion
Medications on Admission:
AMLODIPINE 5 mg daily
ERGOCALCIFEROL 50,000 unit qweek X 10 weeks
LABETALOL 300mg bid
CALCIUM CARBONATE 200 mg bid
Discharge Medications:
1. amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. labetalol 100 mg Tablet Sig: Three (3) Tablet PO BID (2 times
a day).
3. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
Sig: One (1) Tablet, Chewable PO twice a day.
4. medroxyprogesterone 10 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day) for 2 weeks.
Disp:*28 Tablet(s)* Refills:*0*
5. ferrous sulfate 325 mg (65 mg iron) Tablet Sig: One (1)
Tablet PO twice a day.
6. ergocalciferol (vitamin D2) 50,000 unit Capsule Sig: One (1)
Capsule PO once a week for 10 weeks.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
Menorrhagia
Secondary Diagnoses:
End Stage Renal Disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear ___,
It was a pleasure taking care of you at ___
___. You were admitted for vaginal bleeding. You
required several blood transfusions to keep your blood counts up
but the bleeding has since decreased significantly. You also had
an endometrial biopsy to evaluate what caused the bleeding. You
will be contacted with the results of the biopsy. While you were
here, you were continued on peritoneal dialysis.
Please make the following changes to your medications:
1. Please take provera 10mg BID for 14 days total.
1. Please take ferrous sulfate 325mg by mouth twice a day for
iron supplementation.
Please continue all other medications as prescribed.
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs.
Followup Instructions:
___
|
19730192-DS-3
| 19,730,192 | 27,451,750 |
DS
| 3 |
2151-03-08 00:00:00
|
2151-03-08 18:23:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Code Stroke
Major Surgical or Invasive Procedure:
NA
History of Present Illness:
The patient is a ___ year-old right handed ___ man with
no significant PMH who presents to the ED after left leg
involuntary movement and weakness. Neurology is consulted as
part
of a code stroke protocol.
Mr. ___ has been in ___ visiting his daughter for the
past 3 weeks and was due to return to ___ tonight. At 5:35pm
he was sitting on the couch when he developed acute shortness of
breath and his left leg and foot started to "kick" involuntarily
for 10 seconds. He had trouble getting off the couch and
noticed
that he was "leaning to the left" when he finally got up. The
left leg was weak only for a minute after the event. There was
no
alteration of consciousness or other neurologic deficit during
that time. He was able to talk with his daughter appropriately
during the whole event. No subsequent events.
Over the past 3 weeks, he has been using the left hand less than
normally. His family has pointed this out to him, but he denied
clumsiness or weakness.
He did have new headaches the past week. The headaches were
moderate severity and would arise at different points throughout
the day. Not worse when lying down and they did not awaken him
from sleep. He did take advil yesterday and a few days prior
which relieved the pain.
On neurologic review of systems, the patient denies
lightheadedness or confusion. Denies difficulty with producing
or
comprehending speech. Denies loss of vision, blurred vision,
diplopia, vertigo, tinnitus, hearing difficulty, dysarthria, or
dysphagia. Denies numbness, parasthesia. Denies loss of
sensation. Denies bowel or bladder incontinence or retention.
On general review of systems, the patient denies fevers, rigors,
night sweats, or noticeable weight loss. Denies chest pain,
palpitations. Denies nausea, vomiting, diarrhea, constipation,
or
abdominal pain. No recent change in bowel or bladder habits.
Denies dysuria or hematuria. Denies myalgias, arthralgias, or
rash.
Past Medical History:
- s/p bladder surgery (unclear indication)
- s/p hernia repair
Social History:
___
Family History:
Father with colon cancer. No family history of
stroke, seizure or other cancer
Physical Exam:
Vitals: 96.8 122 159/93 24 97%
General: NAD
HEENT: NCAT, no oropharyngeal lesions, neck supple
___: RRR, no M/R/G
Pulmonary: CTAB, no crackles or wheezes
Abdomen: Soft, NT, ND, +BS, no guarding
Extremities: Warm, no edema
Neurologic Examination:
- Mental Status - Awake, alert, oriented x 3. Attention to
examiner easily maintained. Recalls a coherent history. Able to
recite months of year backwards. Speech is fluent with full
sentences, intact repetition, and intact verbal comprehension.
Naming intact. No paraphasias. Normal prosody. No dysarthria.
No evidence of hemineglect. No left-right confusion.
- Cranial Nerves - Right pupil 3mm, Left pupil 3.5mm, both
constrict to light briskly. On fundoscopy, could not visualize
discs. VF full to finger wiggle, although difficult to assess
as
he would not fixate on target. EOMI, no nystagmus. V1-V3 without
deficits to light touch bilaterally. No facial movement
asymmetry. Hearing intact to finger rub bilaterally. Palate
elevation symmetric. SCM/Trapezius strength ___ bilaterally.
Tongue midline.
- Motor - Normal bulk. Left arm with increased tone. Left hand
>
right hand intention tremor. Parietal drift.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 5- ___- ___ 5 5 4+ 5 5 5
R 5 ___ ___ 5 5 5 5 5 5
- Sensory - No deficits to light touch, pin, or temperature
bilaterally. No extinction to DSS.
-DTRs:
Bi Tri ___ Pat Ach
L 3 2 3 3+ 2
R 2 2 2 2 2
Great toe tonically upgoing bilaterally, more pronounced on
left.
No clonus. Crossed adductor present on left, not on right.
- Coordination - Intention tremor, but no dysmetria, on FNF
bilaterally, L>R. Orbits around left arm. Left hand RAM is
clumsy compared to right.
- Gait - Normal initiation. Narrow base. Normal stride length.
Stable without sway. Negative Romberg.
on discharge the patient is afebrile with stable VS.
His neurologic exam differs from above in that he is now ___
strength in the bl upper and lower extremities.
Pertinent Results:
___ 06:00PM BLOOD WBC-11.8* RBC-5.37 Hgb-15.9 Hct-45.1
MCV-84 MCH-29.5 MCHC-35.2* RDW-13.9 Plt ___
___ 07:40AM BLOOD WBC-9.4 RBC-5.37 Hgb-15.6 Hct-44.3 MCV-83
MCH-29.1 MCHC-35.2* RDW-14.3 Plt ___
___ 06:00PM BLOOD ___ PTT-27.2 ___
___ 07:40AM BLOOD Glucose-149* UreaN-23* Creat-1.2 Na-140
K-3.8 Cl-107 HCO3-21* AnGap-16
___ 08:48PM BLOOD ALT-19 AST-17 AlkPhos-77 TotBili-0.3
___ 07:40AM BLOOD CK(CPK)-120
___ 08:48PM BLOOD cTropnT-<0.01
___ 07:40AM BLOOD CK-MB-3 cTropnT-<0.01
___ 08:48PM BLOOD Albumin-4.1 Calcium-9.3 Phos-1.8* Mg-2.0
___ 08:48PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 06:13PM BLOOD Glucose-104 Lactate-2.5* Na-145 K-4.5
Cl-103 calHCO3-23
___ 07:58PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
CTA head/neck ___
1. Right frontal 2.6 cm extra-axial mass with large surrounding
vasogenic
edema. Please refer to subsequently performed MRI for further
characterization.
2. Right upper lobe 9 mm spiculated nodule (series 3, image 32)
with
mediastinal lymphadenopathy. This is suspicious for a primary
lung malignancy.
3. 6 mm lucency within the left lamina of T5 (series 3, image
8). It is
uncertain whether this is a lytic metastasis or a benign lesion
MRI ___
FINDINGS:
There is a 2.2 x 1.7 cm dural-based mass in the right frontal
convexity region adjacent to the superior sagittal sinus. There
is no significant surrounding dural enhancement seen. The mass
demonstrates much less homogeneous enhancement and expected from
meningioma. There is extensive surrounding edema seen with mass
effect on the right lateral ventricle. No other areas of
abnormal enhancement seen. There is no significant midline shift
or hydrocephalus. No blood products are identified. There is no
meningeal enhancement. No acute infarcts are seen. The mass does
not demonstrate restricted diffusion.
IMPRESSION:
Right frontal convexity mass with extensive surrounding edema.
Although the mass is dural-based, the appearances are not
typical for a meningioma and could represent a dural-based
metastatic lesion. Clinical correlation recommended
CT abd/pelvis ___. Hepatic hypodensities, as described above, may represent
biliary
cysts/hamartomas. However, metastasis cannot be excluded given
patient's
history. Recommend liver US for further characterization.
2. No evidence of osseous metastatic disease
CT chest ___
1. Dominant mass in the right lower lobe , suggestive of primary
lung
malignancy. Two additional suspicious spiculated nodules are
seen in the right upper lobe.
2. Bilateral PE.
3. Central and right supraclavicular lymphadenopathy
Head CT ___
Right frontal convexal enhanced mass lesion with associated
vasogenic edema and mass effect, including subfalcine herniation
of the cingulate gyrus, is similar to prior exam
Bilateral Lower Ext Duplex ___: IMPRESSION:
Left-sided deep vein thromboses involving the popliteal, one
peroneal, and gastrocnemius veins. No right-sided deep vein
thrombosis.
CT Head w/ Contrast ___: IMPRESSION:
Right frontal parafalcine mass and associated edema are not
significantly
changed from 2 days prior. The extensive edema associated with
the mass is not typical for a meningioma, and aggressive
etiology is suspected.
Brief Hospital Course:
___ is a ___ year-old right handed man with no
significant PMH who presented to the ED after a simple partial
siezure involving his left leg. He was initially called as a
code stroke for trace left arm and leg weakness. He was found to
have a right sided frontal mass with considerable edema -
concerning for metastatic disease. CT torso demonstrates a lung
mass concerning for primary malignancy and bilateral pulmonary
embolus.
He was started on Keppra without further seizure events.
Dexamethasone was started with improvement in edema on repeat
head CT scan. Famotidine was instituted for GI prophylaxis. The
patient was seen and evaluated by medical-oncology and
neuro-oncology as well as discussed in our multidisciplinary
tumor board. Initially once his PEs were discovered, he was
started on heparin drip, but this was transitioned to lovenox
for discharge.
Though there are risks associated with travel given his mass and
Left leg DVTs, after discussion with our sub specialists and
patient/family- it was felt reasonable safe to return home to
___. Close outpatient follow-up was strongly counselled to
the patient and family.
Medications on Admission:
1. Ibuprofen 400 mg PO Q8H:PRN headache
Discharge Medications:
1. Dexamethasone 6 mg PO Q6H
RX *dexamethasone 6 mg 1 tablet(s) by mouth every six (6) hours
Disp #*120 Tablet Refills:*0
2. Famotidine 20 mg PO Q12H
RX *famotidine [Acid Controller] 20 mg 1 tablet(s) by mouth
twice a day Disp #*60 Tablet Refills:*0
3. LeVETiracetam 750 mg PO BID
RX *levetiracetam [Keppra] 750 mg 1 tablet(s) by mouth twice a
day Disp #*60 Tablet Refills:*0
4. Ibuprofen 400 mg PO Q8H:PRN headache
5. Enoxaparin Sodium 70 mg SC Q12H
Start: Today - ___, First Dose: Next Routine Administration
Time
RX *enoxaparin 80 mg/0.8 mL 80 mg SQ twice a day Disp #*10
Syringe Refills:*0
6. Lorazepam 1 mg PO Q4H:PRN seizure
RX *lorazepam [Ativan] 1 mg 1 tablet(s) by mouth daily PRN Disp
#*10 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Seizure
Likely metastatic lung cancer
Likely Brain Mets
DVT
Discharge Condition:
Mental Status: Clear and coherent.
Activity Status: Ambulatory - Independent.
Level of Consciousness: Alert and interactive.
Discharge Instructions:
Mr ___,
You were admitted to the neurology service at ___ after you
had a seizure. a CT scan showed that there was a mass in your
brain with swelling (edema) around it. You were started on
medications (steroids) to control the edema, and a seizure
medication to prevent further seizures. A CT scan of your chest
showed a mass in your lungs along with blood clots in the blood
vessels of your lungs. You were also found to have a blood clot
in your left leg. As such, you were started on a blood thinner
(lovenox/enoxaparin) to control these blood clots. You were seen
by our oncologists and will follow up with your doctor in ___
for further management.
It was a pleasure taking care of you,
- Your ___ Care team.
Followup Instructions:
___
|
19730381-DS-9
| 19,730,381 | 26,692,730 |
DS
| 9 |
2194-09-23 00:00:00
|
2194-09-24 22:34:00
|
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:
Attempted emergent carotid angioplasty/thrombectomy (___)
NG tube placement (___)
___ placement (___)
Dobhoff tube placement (___)
Dobhoff tube placement (___)
Percutaneous endoscopic ___ (___)
EP ablation for sustained SVT (___)
attach
Pertinent Results:
ADMISSION LABS:
====================
___ 01:50PM BLOOD ___
___ Plt ___
___ 01:50PM BLOOD ___
___ Im ___
___
___ 01:50PM BLOOD ___ ___
___ 01:50PM BLOOD ___
___ 01:29AM BLOOD ___
___
___ 01:50PM BLOOD ___
___ 01:50PM BLOOD cTropnT-<0.01
___ 01:29AM BLOOD ___
___ 12:52AM BLOOD ___
___ 11:31PM BLOOD ___
___
___ 01:50PM BLOOD ___
___
___ 09:12AM BLOOD ___
___ Base XS--8
___ 01:57PM BLOOD ___
___
___ 02:57PM BLOOD ___
DISCHARGE LABS:
====================
___ 05:42AM BLOOD ___
___ Plt ___
___ 05:42AM BLOOD ___ ___
___ 05:42AM BLOOD ___
___
___ 06:20AM BLOOD ___ LD(LDH)-214 ___
___
___ 05:42AM BLOOD ___
IMAGING/PROCEDURES:
====================
CTA Head/Neck ___
"IMPRESSION:
1. Limited study as described.
2. Loss of ___ differentiation in the left insula,
compatible with
acute left MCA infarct.
3. No acute intracranial hemorrhage.
4. Occlusion of the left superior M2 middle cerebral artery
division with
distal reconstitution.
5. ___ stenosis of the majority of the left internal
carotid artery
from the origin, as described.
6. Approximately 60% stenosis of the right internal carotid
artery at its
origin, with probable focal chronic dissection.
7. Severe stenosis of the origin of the left subclavian artery.
8. Artifact limits evaluation perfusion imaging.
9. Additional findings as described above."
Carotid/Cerebral Bilat ___:
"IMPRESSION:
1. Left cervical internal carotid artery occlusion
2. Left inferior division M 2 branch occlusion
3. Right cervical internal carotid artery stenosis of 50%
RECOMMENDATION(S):
1. Medical Management"
CXR ___:
"IMPRESSION:
Interval placement of a left chest wall single lead ICD is well
as a
nasogastric tube which extends to the upper stomach. Further
advancement is
recommended to ensure that the side port lies beyond the GE
junction."
CT Head w/out contrast ___:
"IMPRESSION:
1. Interval evolution of a left MCA territorial infarct. No
acute
intracranial hemorrhage."
CXR ___:
"There is mild pulmonary edema that is new compared to prior.
Cardiomegaly, post cardiac surgery changes and position of the
pacemaker are
unchanged."
Portable abdomen KUB ___:
"IMPRESSION:
1. No evidence of bowel obstruction or ileus."
Chest Port Line Placement ___:
"There has been interval placement of a right upper extremity
PICC which
terminates in the lower superior vena cava. There is no
pneumothorax. The
___ of the enteric tube terminates at the gastroesophageal
junction.
Advancement by 5 cm is recommended. No other significant
interval change."
CXR Tube placement ___:
"There has been interval placement of a Dobbhoff enteric tube
which terminates in the body of the stomach on the final image.
No other significant interval change."
TTE ___:
"IMPRESSION: No source of embolus seen in the setting of
suboptimal image quality. Mild
symmetric left ventricular hypertrophy with severe global
hypokinesis. Cannot exclude LV
thrombus on the current study. Right ventricle with at least
mild systolic dysfunction. Mild mitral
regurgitation. At least mild tricuspid regurgitation. At least
mild pulmonary artery systolic
hypertension."
Cardiac Perfusion (REST) ___:
"IMPRESSION:
1. Medium sized, severe resting perfusion defect involving the
LAD territory.
2. Large, severe resting perfusion defect involving the RCA
territory.
3. Increased left ventricular cavity size. Severe systolic
dysfunction with akinesis involving the LAD and RCA territories
and severe global hypokinesis."
Video Oropharyngeal Swallow ___:
"IMPRESSION:
1. Medium sized, severe resting perfusion defect involving the
LAD territory.
2. Large, severe resting perfusion defect involving the RCA
territory.
3. Increased left ventricular cavity size. Severe systolic
dysfunction with
akinesis involving the LAD and RCA territories and severe global
hypokinesis."
CXR ___:
"Lungs are low volume with bibasilar atelectasis. ___
pacemaker is
unchanged. The Dobbhoff tube tip projects at the level of the
distal
esophagus, needs to be further advanced by ___ cm. There is no
pleural
effusion. Cardiomediastinal silhouette is stable."
Portable Abdomen ___:
"Lungs are low volume with bibasilar atelectasis. ___
pacemaker is
unchanged. The Dobbhoff tube tip projects at the level of the
distal
esophagus, needs to be further advanced by ___ cm. There is no
pleural
effusion. Cardiomediastinal silhouette is stable."
CT A/P With Contrast ___:
"1. Moderate upper abdominal pneumoperitoneum may be
postprocedural versus
related to a mechanical leak from the PEG tube. The PEG tube
appears to be in satisfactory position. No evidence of bowel
injury. Mildly prominent small bowel loops in the anterior
upper abdomen most likely relate to mild ileus secondary to the
pneumoperitoneum.
2. No other acute ___ findings. No ascites.
No evidence of bowel obstruction."
EP Brief Procedure Report ___:
"Findings
Spontaneous and easily inducible sustained SVT with single APDs
suggestive of reentrant mechanism. TCL ___ ms. ___
atrial activation high on interatrial septum noted during
catheter placement. Earliest A HBE preceding proximal CS. RV
dissociated from SVT with RV pacing. Entrainment showed VAAV
response. Activation mapping demonstrated earliest activation
high RA posterior to crista. EGM -30ms pre p wave with QS on
unipolar. AT terminated 10 seconds into first ablation lesion.
Additional lesions delivered surrounding area. Following RF no
inducoble arrhythmias with single extrastimuli to AERP."
Brief Hospital Course:
TRANSITIONAL ISSUES:
====================
[] Medications STARTED: aspirin 81mg PO daily, lansoprazole oral
disintegrating tab 30mg PO daily, metoprolol tartrate 12.5mg PO
Q6H, oxycodone liquid 2.5mg PO Q6H PRN for 1 week, valsartan
20mg PO daily, polyethylene glycol 17g PO daily prn, multimatin
with minerals once daily, insulin regimen as follows:
- Glargine 44U breakfast, 44U at bedtime
- Sliding scale: regular in scale 17+5:30>120 Q6hr (conservative
2u increase per increment)
[] Medications CHANGED: atorvastatin 20mg to 80mg
[] Medications STOPPED: metoprolol succinate 50mg PO oral BID,
___ 1 tab PO BID, toujeo Max ___,
empagliflozin 10mg PO daily, Insulin lispro, omeprazole 20mg PO
daily
[] Cardiology:
- Consider stress test as an outpatient. Patient with rest
cardiac perfusion study demonstrating severe resting perfusion
defect involving the LAD territory and large/severe resting
perfusion defect involving the RCA territory. Patient did not
want to undergo stress imaging while here in the hospital, but
he will need close ___ given significant disease
- Consider restarting ___. He was started on
valsartan, but we were unable to titrate as inpatient given
borderline blood pressures
- He would benefit from consideration of spironolactone as an
outpatient if tolerated from a blood pressure perspective
- ___ HRs after SVT ablation and adjust metoprolol as
tolerated
- Consider transitioning metoprolol tartrate 12.5mg Q6H to
carvedilol BID if patient has persistent dysphagia for ease of
dosing
[] Neurology:
- Patient's aspirin/Plavix regimen length of therapy will need
to be determined
- He may benefit from ___ of his carotids and
consideration of outpatient intervention for known ICA stenosis
[] Gastroenterology:
- Pt with diagnosis of Crohn's Disease, now with PEG tube.
Please assess tolerance of PEG tube feeds and adjust Crohn's
Disease management as needed
[] Rehab/PCP
- ___ regimen was changed significantly during
hospitalization. He would benefit from outpatient HbA1c and
assessment of response to insulin therapy. Furthermore, he is
now on bolus tube feeds so his insulin may need to be adjusted
further
- Labs: repeat CBC and electrolytes in 1 week. H/H on discharge
___. Consider holding home magnesium if patient's magnesium
is elevated
- Patient with iron of 21 (normal range 40). Iron was not
started as an inpatient, but he would benefit from consideration
of iron in the outpatient setting, either IV or PO if PEG tube
compatible
[] ___ Therapy:
- Patient will need ongoing work with speech/swallow, physical
therapy and occupational therapy as noted in the page 1
discharge instructions
# CODE STATUS: Full, presumed
# CONTACT: Wife ___
SUMMARY:
=====================
___ year old man with PMH of CAD, CHF with EF 25% ___
placement), HTN, DMII, HLD and Crohn's Disease (on mesalamine)
who initially presented to ___ with aphasia and
right face/arm weakness before being transferred to ___ for
stroke management with attempt at emergent carotid angioplasty,
however, subsequently terminated due to failure to pass the ICA,
and started on medical management with heparin before
transitioning to aspirin/plavix. His course was complicated by
SVT with type II NSTEMI, persistent dysphagia requiring PEG tube
placement, and type II diabetes with poor glucose control.
ACTIVE ISSUES:
======================
# Acute left MCA stroke:
# Oropharyngeal dysphagia
Initially presented to ___ and had telestroke
evaluation with NIHSS 4 for face weakness and aphasia. ___
revealed an area of hypodensity in the left frontal lobe with
extension into the cortex CTA w/ complete occlusion of L ICA and
?L M2 occl. On arrival to ___, found to have worsened NIHSS 9
(more dysarthria and aphasia as well as right arm drift). The
suspected etiology of stroke is artery to artery embolism given
his significant left carotid artery disease, and he was taken
for emergent carotid angioplasty/thrombectomy but was
unsuccessful (could not pass through ICA) and hence procedure
was terminated. He was started on heparin GTT and was admitted
to ICU for continued care. He was subsequently transitioned to
aspirin and Plavix, and he will have ___ with Neurology
who will further dictate the length of his medical therapy. He
was evaluated by ___ OT and ST. As below, his course was
complicated by persistent oropharyngeal dysphagia. He had an NG
tube that was transitioned to PEG tube, which was placed for
alternative means of nutrition while continuing to work with the
speech and swallow rehab services to improve swallowing ability.
#Atrial tachycardia, SVT
#NSTEMI
#CAD s/p CABGx4
#HFrEF (EF 28%)
He developed SVT that was felt to be triggered by critical
illness, volume overload and not being on home metoprolol while
hospitalized. Found to have elevated troponins, which was felt
to be demand ischemia due to SVT in the setting of CAD. SVT did
not resolve with Valsalva or metoprolol. He was given adenosine
multiple times before undergoing ablation with EP. TTE
demonstrated marked left ventricular cavity dilation with severe
global hypokinesis without intraventricular thrombus seen.
Patient had rest cardiac perfusion study demonstrating severe
resting perfusion defect involving the LAD territory and
large/severe resting perfusion defect involving the RCA
territory. Patient did not want to undergo stress imaging while
here in the hospital, but he will need close ___ given
significant disease and will need consideration of stress
imaging. He was started on valsartan, but we were unable to
titrate as inpatient given borderline blood pressures, and there
should be consideration of starting ___ as an
outpatient. His metoprolol succinate could not be placed through
the PEG tube, and thus he was transitioned to metoprolol
tartrate 12.5mg PO Q6H. He may need to be transitioned to
carvedilol as an outpatient for easy of dosing. He would also
benefit from consideration of spironolactone if tolerated from a
blood pressure perspective
# IDDM:
Patient with history of uncontrolled diabetes. He worked with
the endocrinology team here and his insulin was adjusted as
follows: lantus 44U QAM and at bedtime. His insulin sliding
scale was adjusted with Regular insulin as noted in the
discharge paperwork. He subsequently had significantly improved
glucose control, and his glucoses remained within good control
while on tube feeds, however, as they are being changed, they
will need to be titrated while at rehab. His home empagliflozin,
Humalog slidding scale, and Toujeo Max (___) was discontinued
on discharge.
# Microcytic anemia
Patient with microcytic anemia, likely ___ chronic inflammation
with concomittent iron deficiency. He was on various
anticoagulation agents, but did not have any signs of active
bleeding. He did have one episode of a nose bleed that developed
in the nostril with his NG tube, and it developed after he
picked at his nose. His H/H on discharge was stable at
10.0/31.4. He would benefit from iron therapy as an outpatient.
# Nutrition: pt with abdominal pain s/p PEG tube placement.
KUB/CT demonstrated free air, which is not unexpected after PEG
tube placement. Surgery evaluated and okay to use PEG and no
indications for repeat surgery. Abdominal pain improved, but
persisted on discharge around the peg tube site. His abdominal
exam was reassuring and he had no peritoneal signs on exam at
discharge, although he continues to have localized pain around
the PEG tube. He was discharged on liquid oxycodone 2.5 Q6H prn
for ___s acetaminophen 1000 PO Q6H prn. He
tolerated his continuous tube feeds well, but was transitioned
to bolus feeds for ease. He had intermittent diarrhea as he was
started on bolus feeds, but it was improving on discharge. He
was discharged with the PEG tube and he will have PCP/GI
___. If, after working with speech/swallow, he begins to
tolerate oral feeds, he can have his PEG tube discontinued.
CHRONIC ISSUES:
================
# BPH: Continue tamsulosin
#GERD: Transitioned omeprazole to Lantoprazole 30mg PO daily via
PEG tube
This patient was prescribed, or continued on, an opioid pain
medication at the time of discharge (please see the attached
medication list for details). As part of our safe opioid
prescribing process, all patients are provided with an opioid
risks and treatment resource education sheet and encouraged to
discuss this therapy with their outpatient providers to
determine if opioid pain medication is still indicated.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. ALPRAZolam 0.5 mg PO TID:PRN SocHx: tobacco use
2. Atorvastatin 20 mg PO QPM
3. Clopidogrel 75 mg PO DAILY
4. ___ 1 TAB PO BID
5. Fenofibrate 160 mg PO DAILY
6. empagliflozin 10 mg oral DAILY
7. Fish Oil (Omega 3) ___ mg PO BID
8. Omeprazole 20 mg PO DAILY
9. Tamsulosin 0.4 mg PO QPM
10. HumaLOG KwikPen Insulin (insulin lispro) 200 unit/mL (3 mL)
subcutaneous TID W/MEALS
11. Fluticasone Propionate NASAL 1 SPRY NS BID
12. metoprolol succinate 50 mg oral BID
13. Toujeo Max ___ SoloStar (insulin glargine ___ conc) 170
units subcutaneous DAILY
14. magnesium 250 mg oral BID
15. Apriso (mesalamine) 0.750 g oral BID
16. coenzyme Q10 200 mg oral DAILY
17. Betamethasone Dipro 0.05% Lot. 1 Appl TP BID
18. Hydrocortisone Cream 2.5% 1 Appl TP BID
Discharge Medications:
1. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild/Fever
2. Aspirin 81 mg PO DAILY
3. Glargine 44 Units Breakfast
Glargine 44 Units Bedtime
Insulin SC Sliding Scale using REG Insulin
4. Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY
5. Metoprolol Tartrate 12.5 mg PO Q6H
6. Multivitamins W/minerals 1 TAB PO DAILY
7. OxyCODONE Liquid 2.5 mg PO Q6H:PRN Pain - Moderate
RX *oxycodone 5 mg/5 mL 2.5 ml by mouth four times a day
Refills:*0
8. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - Third
Line
9. Valsartan 20 mg PO DAILY
10. Atorvastatin 80 mg PO QPM
11. Tamsulosin 0.4 mg PO DAILY
12. ALPRAZolam 0.5 mg PO TID:PRN SocHx: tobacco use
13. Apriso (mesalamine) 0.750 g oral BID
14. Betamethasone Dipro 0.05% Lot. 1 Appl TP BID
15. Clopidogrel 75 mg PO DAILY
16. coenzyme Q10 200 mg oral DAILY
17. Fenofibrate 160 mg PO DAILY
18. Fish Oil (Omega 3) ___ mg PO BID
19. Fluticasone Propionate NASAL 1 SPRY NS BID
20. Hydrocortisone Cream 2.5% 1 Appl TP BID
21. magnesium 250 mg oral BID
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary Diagnosis
=================
Left MCA Stroke
Supraventricular tachycardia
Secondary Diagnoses:
==================
Coronary Artery Disease
NSTEMI
Heart Failure with reduced Ejection Fraction
Anemia
Type II Diabetes
Benign prostatic hyperplasia
GERD
Hypertension
Hyperlipidemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive, but aphasic
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr ___,
It was a pleasure caring of ___ at ___.
WHY WAS I IN THE HOSPITAL?
===========================
-___ were admitted to the hospital for a stroke
WHAT HAPPENED TO ME IN THE HOSPITAL?
===========================
- ___ were treated with medications for your stroke
- They attempted to open up one of your arteries to treat your
stroke, but it was obstructed, and thus, they focused on
management of your stroke with medications
- ___ were found to have an intermittent abnormal fast heart
rate. ___ were given medications for this and underwent a
procedure with the electrophysiology cardiologists to stop this
from happening. Your heart rate improved
- Your medications were adjusted to help improve your heart
function
- ___ had a tube placed in your stomach for the purposes of
nutrition
- ___ were started on feeds through your tube since ___ were
unable to take in anything by mouth
- ___ worked with the speech, physical and occupational
therapists to help ___ recover from your stroke
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
============================
- Continue to take all your medicines and keep your
appointments.
We wish ___ the best!
Sincerely,
Your ___ Team
Followup Instructions:
___
|
19730509-DS-7
| 19,730,509 | 23,174,794 |
DS
| 7 |
2126-10-06 00:00:00
|
2126-10-07 10:22:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending: ___
Chief Complaint:
left leg swelling and pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ h.o LLE dvt x2 during previous pregnancies and metrorrhagia
___ to uterine adenomyosis receiving Lupron Depo shots presents
w L leg swelling and pain x1week. Patient said that she has
intermittent swelling of her LLE. She was seen by Dr. ___ in
___ who felt that she had post-phlebitic syndrome and
recommended compression stockings. She said that she has
intermittent swelling, but over the past week it has gotten a
lot worse and persistent. She also has associated pain
especially her left calf and around her knee. She went to urgent
care clinic and was sent to ___ for evaluation.
LLE dopplers showed extensive DVT and she asked to be
transferred to ___ for her care as she had been here in the
past.
Patient also complaining of intermittent chest pain worse with
cough and with palpation. denies radiation of pain, pain with
exertion, n/v, diaphoresis. Has some associated SOB with
exertion although says that is from her obesity. She has
difficulty walking long distances and exercising as a result of
her LLE pain. This has been getting worse and has been unable to
stand on her left lower extremity today.
In the ED, initial vitals are as follows: 97.7 81 135/74 16 100%
RA,
Labs notable for thrombocytopenia at 105, The pt underwent CTA
chest to rule out PE given new onset chest pain while in the ED
that was negative. The pt received heparin bolus and drip
started. Vitals prior to transfer: (36.7 °C), Pulse: 69, RR: 16,
BP: 126/73, Rhythm: sr, O2Sat: 97, O2Flow: (room air), Pain:
___.
ROS: Denies fever, chills, night sweats, headache, vision
changes, rhinorrhea, congestion, sore throat, cough, shortness
of breath, abdominal pain, nausea, vomiting, diarrhea,
constipation, melena, hematochezia, dysuria, hematuria.
Past Medical History:
DVT during pregnancy ___
Uterus, adenomyosis
Abnormal uterine bleeding
S/P colonoscopy
High risk HPV infection
Obese
Low back pain
Folliculitis
Hidradenitis suppurativa
Anemia, iron deficiency
Boil of vulva
High-Risk Pregnancy
DVT (Deep Venous Thrombosis)
BIPOLAR DISORDER, UNSPEC
LEIOMYOMA - UTERUS, UNSPEC
ESOPHAGEAL REFLUX
FAMILY PLANNING
ANXIETY STATES, UNSPEC
? CROHN'S DISEASE, UNSPEC SITE - not a clear diagnosis according
to her
Social History:
___
Family History:
Mother had a tendency to clot, also Crohn's
disease and hypertension (died in a car crash). She thinks that
her mother's father also had clotting disease.
Physical Exam:
Admission:
Vitals - T: 98.1 BP: 142/88 HR: 64 RR: 20 02 sat:100% RA
GENERAL: Pleasant, well appearing, breathing comfortably in NAD
HEENT: No scleral icterus. MMM. OP clear.
CARDIAC: Regular rhythm, normal rate. Normal S1, S2. No murmurs,
rubs or ___, tenderness to palpation over chest wall.
LUNGS: CTAB, good air movement biaterally.
ABDOMEN: NABS. Soft, NT, ND. No HSM
EXTREMITIES: LLE more edematous than the right. calf tenderness
on the left and popliteal tenderness as well. 2+ radial/dorsalis
pedis/ posterior tibial pulses bilaterally.
SKIN: ecchymoses on medial distal LLE
NEURO: A&Ox3. Appropriate. CN ___ grossly intact. Preserved
sensation throughout. ___ strength throughout. Gait assessment
deferred
PSYCH: Listens and responds to questions appropriately, pleasant
Discharge:
GENERAL: Pleasant, well appearing, breathing comfortably in NAD
HEENT: No scleral icterus. MMM. OP clear.
CARDIAC: Regular rhythm, normal rate. Normal S1, S2. No murmurs,
rubs or ___, tenderness to palpation over chest wall.
LUNGS: CTAB, good air movement biaterally.
ABDOMEN: NABS. Soft, NT, ND. No HSM
EXTREMITIES: LLE more edematous than the right. calf tenderness
on the left and popliteal tenderness as well. 2+ radial/dorsalis
pedis/ posterior tibial pulses bilaterally.
SKIN: ecchymoses on medial distal LLE
NEURO: A&Ox3. Appropriate. CN ___ grossly intact. Preserved
sensation throughout. ___ strength throughout. Gait assessment
deferred
Pertinent Results:
Labs:
___ 01:30AM BLOOD WBC-6.8 RBC-4.17* Hgb-12.6 Hct-36.3
MCV-87 MCH-30.1 MCHC-34.6 RDW-13.3 Plt ___
___ 01:30AM BLOOD ___ PTT-29.0 ___
___ 01:30AM BLOOD Glucose-105* UreaN-16 Creat-0.7 Na-141
K-3.7 Cl-104 HCO3-25 AnGap-16
___ 01:30AM BLOOD HCG-<5
Imaging:
Doppler U/S of LLE: final read pending at discharge
CTA Chest: final read pending at discharge
Brief Hospital Course:
Ms. ___ is a ___ year old female with a history of 2 previous
deep vein thromboses in the LLE during previous pregnancies who
presented with one week of left leg swelling and pain.
ACTIVE ISSUES:
====================
# Left leg pain, swelling: It is not entirely clear whether
these symptoms are from a recurrent DVT or from post-phlebitic
syndrome. She had an ultrasound showing DVT at both the OSH and
at ___ confirming a DVT. However it is unclear if this is
persistence of her DVT from ___ or a recurrent DVT. Hematology
was consulted and recommended lifelong anticoagulation at this
point. Since she is of child-bearing age, she was recommended to
use lovenox for anticoagulation however she did not wish to do
so long-term because she does not like the injections. She was
amenable to going on Coumadin with a Lovenox bridge. The patient
was counseled extensively on the risks of birth defects with
coumadin and that she must use 2 forms of birth control. Patient
will follow-up with Dr. ___ in hematology to discuss
duration of anti-coagulation. Patient will be managed by
___ clinic at ___. Next INR check due ___.
Patient advised to wear compression stocking to prevent further
post-phlebitic syndrome. She should talk to outpatient social
worker if unable to afford stocking.
# Chest pain: She had chest pain on palpation that is most
likely costochondritis. The patient did have a small
non-occlusive pulmonary embolism on the left, but its size and
location are unlikely to explain her pain. Regardless she needs
anticoagulation as discussed above.
# Metrorrhagia: The patient has a long history of heavy periods
thought to be secondary to fibroids. There was discussion of
hysterectomy in the past, but the decision was not to perform
surgery at that time. Therefore she has been treated with
lupron. However, now that she will be on prolonged
anticoagulation there may be concern for more intense bleeding
from her fibroids. In addition the patient was advised to find
an alternative to lupron since it may increase risk of DVT.
Therefore the patient will need to discuss alternative
treatments such as hysterectomy with her PCP ___ OB/GYN. The
difficulty in balancing the two conflicting concerns of bleeding
and clotting were discussed extensively with the patient. She
will need to have a careful risk/benefit discussion with her
outpatient providers to determine the best course of action.
# Fatty liver: discovered incidentally on CT. Defer further
work-up/follow-up to oupatient.
TRANSITIONAL ISSUES:
======================
- Patient will be managed by ___ clinic at ___.
Next INR check due ___.
- PCP ___ need to pursue further workup for incidental
discovery of fatty liver.
- Patient should have 2 forms of birth control while on
coumadin.
- Duration of anticoagulation will need to be determined by
hematology and PCP.
Medications on Admission:
Leuprolide (LUPRON DEPOT) 3.75 mg Intramuscular Syringe Kit
(given 2 doses, last ___
Zolpidem 10 mg Oral Tablet - not taking
Discharge Medications:
1. enoxaparin 120 mg/0.8 mL Syringe Sig: One Hundred Twenty
(120) mg Subcutaneous Q12H (every 12 hours).
Disp:*2400 mg* Refills:*0*
2. Coumadin 5 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
-left leg deep venous thrombosis
-chest pain
Secondary:
-fatty liver
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking care of you during this admission. You
were admitted with left leg pain and swelling with concern for
new clot. We repeated an ultrasound here to confirm this. Given
the clot, we recommended anti-coagulation with Lovenox. However,
you preferred Coumadin. As you know and we discussed, ___
can cause birth defects. Therefore, it is very important that
you use two forms of contraception to prevent pregnancy.
Coumadin will also require blood draws to monitor your INR. You
will be on Lovenox until your Coumadin levels are at goal INR
between ___.
We also recommend that you stop Lupron injections as these may
be associated with increased risk of clotting.
Please continue the medications you were taking prior to this
admission, but please discuss stopping Lupron with your doctor.
You can also discuss alternative forms of medications or
treatment for your heavy bleeding.
We also strongly recommend that you wear the compression
stockings to help with the leg swelling. Please discuss this
with your primary doctor regarding getting prior authorization
for this.
We also found that on the CT of the abdomen that you had fatty
liver. This is something that should be monitored by your
primary care doctor. Please discuss this at your follow-up
appointment.
It is very important that you go to all follow-up appointments
as discussed below.
Followup Instructions:
___
|
19730587-DS-7
| 19,730,587 | 28,357,347 |
DS
| 7 |
2126-06-20 00:00:00
|
2126-06-20 16:52:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
sob
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ otherwise healthy presents with dyspnea. Pt had been in
usual state of health until 1 week ago, when she developed
productive cough with bloody tinges in sputum, and had chills.
She went to ___ ED and CXR was obtianed that revealed PNA. Pt
was prescribed 7d of levofloxacin, but continued to have cough
with some bloody tinged sputum that seemed to be geting more
maroon colored. She was at work yesterday (she works for ___
___ at ___, who nboted that she awas unusually SOB. She went
to see PCP, who also noted SOB, adn referred her to ED.
In the ED, initial vital signs were 0 97.8 65 130/79 18 100% RA.
Patient was given: Albuterol 0.083% Neb Soln 0.083%, Ipratropium
Bromide Neb 2.5mL, Heparin Sodium 25,000 unit, Heparin Sodium
5000 Units / mL- 1mL Vial. 0 98.1 87 120/80 16 100%
Per patient, at the onset of sx, she had some arthralgias,
chills, sore throat, and cough, and x1 episode of nonbloody
emesis. No fevers, abd pain, dysuria, leg pain / discomfort.
Most sx except SOB have currently resolved. Pt recently traveled
to ___ from ___ from ___, 2 weeks prior to
presentation. She denies any long car rides. Pt's mother has
"heart issues" and is on a "blood thinner". Pt denies being on
OCPs.
On the floor, T 97.9 107/44 hr 91 rr 20 100RA. She is dysnpneic
on talking but otherwise denies chest pain.
Past Medical History:
GERD
Social History:
___
Family History:
Mother with "heart problem" on "blood thinner"
Father unknown
Physical ___:
Vitals- 97.8 65 130/79 18 100% RA
General: Dyspneic while talking, otherwise NAD
CV: RRR nl s1 s2
Lungs: CTAB no wheezes/rales/rhonchi
Abdomen: obese, soft NT.ND
Ext: WWP no palpable cords or tenderness
V/S not dyspneic, 100% on RA
CV: RRR n1 s1 s2
Lungs: CTAB
Abd: soft nt/nd
Neuro: CN2-12 intact, upper and lower extremities symmetric and
___ strength no pronator drift, ambulating well
Pertinent Results:
ADMIT LABS:
___ 07:20AM BLOOD WBC-5.1 RBC-4.38 Hgb-12.4 Hct-35.9*
MCV-82 MCH-28.4 MCHC-34.7 RDW-12.5 Plt ___
___ 07:20AM BLOOD Plt ___
___ 07:20AM BLOOD Glucose-86 UreaN-10 Creat-0.9 Na-140
K-4.0 Cl-106 HCO3-25 AnGap-13
___ 07:20AM BLOOD Calcium-9.0 Phos-4.3 Mg-2.0
___ 11:50AM BLOOD D-Dimer-1577*
DISCHARGE LABS:
___ 01:10PM BLOOD WBC-5.4 RBC-4.40 Hgb-12.4 Hct-36.3 MCV-83
MCH-28.3 MCHC-34.3 RDW-12.2 Plt ___
___ 01:10PM BLOOD Neuts-47.8* Lymphs-44.6* Monos-6.3
Eos-0.7 Baso-0.7
___ 12:59PM BLOOD ___ PTT-26.7 ___
___ 01:10PM BLOOD Plt ___
___ 11:50AM BLOOD Glucose-96 UreaN-9 Creat-0.8 Na-139 K-3.6
Cl-104 HCO3-23 AnGap-16
___ 11:50AM BLOOD D-Dimer-___*
IMAGING:
CTA CHEST ___
IMPRESSION:
1. Right lower lobe segmental acute pulmonary embolus.
2. Nodular and ground-glass opacities along the right oblique
fissure, as well as within the bilateral lower lobes and left
upper lobe, likely represent multifocal pneumonia.
CXR ___
FINDINGS:
PA and lateral views of the chest. The lungs are clear of
consolidation or
effusion. The cardiomediastinal silhouette is within normal
limits. No acute
osseous abnormalities detected.
IMPRESSION:
No acute cardiopulmonary process.
Brief Hospital Course:
___ without PMH, nonsmoker, not on OCPs, and recent treatment
for ?PNA presents wtih PE.
# PE: Pt presents with 1 week ago h/o pleuritic chest pain,
bloody sputum, presenting with worsenign SOB. In ED, she had
elevated d-dimer. CXR showed ground glass opacity could be PNA,
but could also be from PE. CTA showed a PE. Pt was given IV
heparin, and transitioned to lovenox bridge to coumadin. ___
ultimaely decided against coumadin d/t concern for regular INR
hecks. So pt was dc-ed on lovenox for ___ mo. Pt did not have
any peripheral edema / cords / or evidence of DVT clinically.
.
With regard to causality, pt had recently traveled to ___
about ___ weeks prior to this presentation, which may have been
inciting factor. She denies OCP use and smoking tobacco. She
also has no FHx of clotting d/o. In the setting of first PE,
would not perform work-up for coagulation d/o.
# Ground glass opacity on CXR: Patient may have had an atypical
PNA that is resolving or some/all of these changes may be
related to PE. Would not expect radiographic e/o PNA to resolve
<6 weeks even if she had a PNA. Pt was afebrile during
hospitalization, so treatment she has already had is likely
adequate.
# GERD: cont ranitidine and omeprazole
TRANSITION ISSUES
# follow-up on duration of lovenox as outpatient
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Omeprazole 20 mg PO DAILY
2. Ranitidine 300 mg PO DAILY
Discharge Medications:
1. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 tablet(s) by mouth twice a day Disp
#*60 Capsule Refills:*0
2. Senna 1 TAB PO BID:PRN constipation
RX *sennosides [senna] 8.6 mg 1 tab by mouth twice a day Disp
#*60 Tablet Refills:*0
3. Omeprazole 20 mg PO DAILY
4. Ranitidine 300 mg PO DAILY
5. Enoxaparin Sodium 80 mg SC Q12H
RX *enoxaparin 80 mg/0.8 mL 80 mg sub q q12 hours Disp #*60
Syringe Refills:*3
Discharge Disposition:
Home
Discharge Diagnosis:
Pulmonary embolism
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were admitted to ___ for a pulmonary embolism (a clot in
your lungs). We gave you anticoagulation medication and your
symptoms of shortness of breath improved. You will need to
continue taking lovenox for 3 months.
Followup Instructions:
___
|
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|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROSURGERY
Allergies:
hydrocodone / Oxycodone / Plavix
Attending: ___.
Chief Complaint:
fall
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms. ___ was on ASA 81mg who fell when transferring from her
bed to commode. The fall was unwitnessed with no loss of
consciousness. She was found to have a small traumatic ICH and
sent to ___ for further evaluation. She also sustained a
laceration to her right eyebrow which was sutured in the
emergency department. The patient denies headache, numbness,
weakness, nausea, vomiting,
blurred vision, double vision. She denies neck pain, loss of
bowel or bladder function.
Past Medical History:
recent PNA, Afib, HTN, RA, spinal stenosis, Paralysis
agitans, SICCA syndrome, Anemia
Social History:
___
Family History:
NC
Physical Exam:
O: T: 98.1 BP: 139/46 HR:64 R: 18 91% O2Sats
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: ___ EOMs
Neck: Supple.
Neuro:
Mental status: Awake and alert, moderately cooperative with
exam,
normal
affect.
Orientation: Oriented to person, place only.
Language: Speech fluent.
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 limited by pain, but patient moves all
extremities. No pronator drift
Sensation: Intact to light touch
Exam on Discharge
Pertinent Results:
___ 03:20PM GLUCOSE-83 UREA N-18 CREAT-0.6 SODIUM-135
POTASSIUM-3.6 CHLORIDE-100 TOTAL CO2-27 ANION GAP-12
___ 03:20PM WBC-5.0 RBC-3.43* HGB-9.7* HCT-29.8* MCV-87
MCH-28.3 MCHC-32.6 RDW-19.5*
___ 03:20PM ___ PTT-28.9 ___
___ ___
No change in small left subarachnoid hemorrhage. The previously
seen
focus of hyperdensity in the right frontal lobe is no longer
seen. There
remains no mass effect or edema.
___ CT-c spine
IMPRESSION: No acute fracture. Mild anterolisthesis and
retrolisthesis as described above, unclear age. Moderate
degenerative changes of the cervical.
Brief Hospital Course:
On ___, the patient was admitted from the emergency room to the
floor. She had a repeat NCHCT which showed a stable small left
subarachnoid hemorrhage and the disappearance of a hyperdensity
in the right frontal lobe.
On ___ the patient's magnesium was repleted. Her c-collar was
cleared after she had a negative CT of her c-spine.
On ___, the patient was discharged to rehab. The patient was
doing well, afebrile with stable vital signs, tolerating a
regular diet, ambulating with the assistance of hosptital staff,
voiding without assistance, stable neuro exam and pain was well
controlled. The patient was given written instructions
concerning precautionary instructions and the appropriate
follow-up care. All questions were answered prior to discharge
and the patient expressed readiness for discharge.
Discharge Disposition:
Extended Care
Facility:
___
___ Diagnosis:
Traumatic subarachnoid hemorrhage
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane). Patient uses a wheelchair.
Discharge Instructions:
Nonsurgical Brain Hemorrhage
Take your pain medicine as prescribed.
Exercise should be limited to walking; no lifting, straining,
or excessive bending.
Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, or
Ibuprofen etc. You may restart your Aspirin 81mg 5 days from
the date of your bleed (___)
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
New onset of tremors or seizures.
Any confusion, lethargy or change in mental status.
Any numbness, tingling, weakness in your extremities.
Pain or headache that is continually increasing, or not
relieved by pain medication.
New onset of the loss of function, or decrease of function on
one whole side of your body.
*** You have sutures above your R eyebrow. These sutures have
to come out on ___. This can be done at your rehab.
Followup Instructions:
___
|
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2136-09-24 00:00:00
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2136-09-24 18:57:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Percocet
Attending: ___.
Chief Complaint:
leg pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ is a ___ male with PMH HTN, HLD, BPH,
extensive varicose veins, presenting with 6 days of left ___
pain,
sent to ED from outpt ultrasound with extensive left lower
extremity DVT.
Had outpatient ___ Doppler which showed occlusive DVT in left
superficial femoral, popliteal, peroneal and posterior tibial
veins. Denies hx DVT, no recent surgeries, no prolonged
immobilization, no prior hx DVT or clot. Denies cp, sob,
lh/dizziness. Additionally denies f/c/n/v, abd pain,
diarrhea/constipation, dysuria, melena/hematochezia,
hematemesis,
hematuria.
In the ED:
- Initial vital signs were notable for: T97.5, HR 58, BP 150/76,
RR 18, O2 98% RA
- Exam notable for: LLE calf tenderness
- Labs were notable for: wnl CBC/Chem, Cr 1.0, trop <0.01, INR
1.1
- Studies performed include: none
- Patient was given: Lovenox 80mg
- Consults: none
Past Medical History:
Positive PPD
Hypertension
Anxiety
BPH
Chronic back pain s/p intraarticular facet injections
Vitamin D deficiency
Benign essential tremors
Appendectomy at ___ years of age
Social History:
___
Family History:
from ___
Physical Exam:
ADMISSION PHYSICAL EXAM
=======================
VITALS: T97.8, HR 61, BP 150/71, RR 18, O2 97% RA
GENERAL: Alert and interactive. In no acute distress.
HEENT: NCAT. PERRL, EOMI. Sclera anicteric and without
injection.
MMM.
Neck: supple. No cervical lymphadenopathy.
CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No
murmurs/rubs/gallops. No JVD.
RESP: Clear to auscultation bilaterally. No wheezes, rhonchi or
rales. No increased work of breathing.
ABDOMEN: Normal bowels sounds, non distended, non-tender to deep
palpation in all four quadrants.
MSK: No spinous process tenderness. No CVA tenderness. No
clubbing, cyanosis, or pitting edema. Pulses DP 2+ bilaterally.
EXT: LLE with tenderness from popliteal fossa to mid-calf, left
___ appears slightly larger than right, no pitting edema, no
erythema or warmth.
SKIN: Warm. No rash.
NEUROLOGIC: CN2-12 intact. ___ strength throughout. Normal
sensation to light touch. AOx3.
PSYCH: appropriate mood and affect
DISCHARGE PHYSICAL EXAM
========================
Note contains an addendum. See bottom.
Note Date: ___ Time: 1723
Note Type: Progress note
Note Title: Medicine Progress Note
Electronically signed by ___, MD on ___
at 5:25 pm Affiliation: ___
Electronically cosigned by ___, MD on ___
at 5:31 pm
=================================
MEDICINE ADMISSION NOTE
Date of admission:
=================================
PCP: ___., MD
CC: DVT, left leg pain
INTERAL EVENTS
-none
SUBJECTIVE
reports feeling very well today, mild calf L pain, no SOB
PHYSICAL EXAM:
24 HR Data (last updated ___ @ 1513)
Temp: 97.4 (Tm 98.1), BP: 136/80 (121-150/70-81), HR: 67
(61-69), RR: 18 (___), O2 sat: 99% (96-99), O2 delivery: Ra
GENERAL: Alert and interactive. In no acute distress.
HEENT: NCAT. PERRL, EOMI. Sclera anicteric and without
injection.
MMM.
Neck: supple. No cervical lymphadenopathy.
CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No
murmurs/rubs/gallops. No JVD.
RESP: Clear to auscultation bilaterally. No wheezes, rhonchi or
rales. No increased work of breathing.
ABDOMEN: Normal bowels sounds, non distended, non-tender to deep
palpation in all four quadrants.
MSK: No spinous process tenderness. No CVA tenderness. No
clubbing, cyanosis, or pitting edema. Pulses DP 2+ bilaterally.
EXT: LLE with tenderness from popliteal fossa to mid-calf, left
___ appears slightly larger than right, no pitting edema, no
erythema or warmth.
SKIN: Warm. No rash.
NEUROLOGIC: CN2-12 intact. ___ strength throughout. Normal
sensation to light touch. AOx3.
PSYCH: appropriate mood and affect
Pertinent Results:
ADMISSION LABS
=================
___ 12:38PM BLOOD WBC-7.1 RBC-4.62 Hgb-13.9 Hct-42.1 MCV-91
MCH-30.1 MCHC-33.0 RDW-13.3 RDWSD-44.6 Plt ___
___ 12:38PM BLOOD Neuts-53.4 ___ Monos-9.2 Eos-3.5
Baso-0.3 Im ___ AbsNeut-3.76 AbsLymp-2.35 AbsMono-0.65
AbsEos-0.25 AbsBaso-0.02
___ 12:38PM BLOOD Glucose-89 UreaN-14 Creat-1.0 Na-139
K-5.1 Cl-101 HCO3-26 AnGap-12
___ 12:38PM BLOOD Calcium-9.5 Phos-3.0 Mg-2.3
DISCHARGE LABS
=================
___ 07:43AM BLOOD WBC-6.5 RBC-4.40* Hgb-13.4* Hct-40.0
MCV-91 MCH-30.5 MCHC-33.5 RDW-13.1 RDWSD-43.6 Plt ___
___ 07:43AM BLOOD Glucose-108* UreaN-17 Creat-1.0 Na-143
K-5.2 Cl-106 HCO3-24 AnGap-13
___ 07:43AM BLOOD Plt ___
___ 07:43AM BLOOD Calcium-9.1 Phos-2.5* Mg-2.3
___ 12:38PM BLOOD cTropnT-<0.01
IMAGING
=========
___ ___ ___
Radiology ReportUNILAT LOWER EXT VEINS LEFTStudy Date of
___ 8:06 AM
___ ___ 8:06 AM
UNILAT LOWER EXT VEINS LEFT Clip # ___
Reason: evaluate for pathology
UNDERLYING MEDICAL CONDITION:
___ year old man with pain in posterior aspect of left knee
and at times he
notices a mass
REASON FOR THIS EXAMINATION:
evaluate for pathology
Final Report
EXAMINATION: US LOWER EXTREMITY, SOFT TISSUE LEFT
INDICATION: ___ year old man with pain in posterior aspect of
left knee and at
times he notices a mass// evaluate for pathology evaluate
for pathology
TECHNIQUE: Grayscale and color Doppler ultrasound was performed
of the left
lower extremity to evaluate for DVT.
COMPARISON: None.
FINDINGS:
Grayscale and Doppler evaluation of the left common femoral,
superficial
femoral, and popliteal veins was performed. There is normal
color flow of the
bilateral common femoral veins. There is occlusive thrombus in
the left
superficial femoral, popliteal, peroneal, and posterior tibial
veins.
Additional note of a partially thrombosed superficial varicose
vein in the
left posterior calf.
IMPRESSION:
Occlusive DVT in the left superficial femoral, popliteal,
peroneal and
posterior tibial veins.
Partially thrombosed superficial varicose vein in the left
posterior calf.
NOTIFICATION: The findings were discussed with ___ M.D. by
___,
M.D. on the telephone on ___ at 9:04 am, 10 minutes after
discovery of
the findings. The patient will be transported by ambulance
directly to the
emergency department for further evaluation.
___, MD electronically signed on ___ ___ 9:06
AM
Brief Hospital Course:
BRIEF HOSPITAL COURSE:
====================
___ male with PMH HTN, HLD, BPH, extensive varicose
veins, presented with 6 days of left ___ pain, found to have
extensive unprovoked left lower extremity DVT. He remained
hemodynamically stable without concern for PE. He was started on
therapeutic lovenox and transitioned to ___ on discharge.
TRANSITIONAL ISSUES:
=====================
[ ] Perform lung cancer screening CT given pt's smoking history
and new DVT
[ ] f/u presence of possible gout given pt reported episodes of
L sided toe pain
[ ] Patient was started on apixaban for DVT, ensure he finished
loading 7 day dosing and transitions to 5mg BID dosing on ___
[ ] consider need for statin given most recent lipid panel shows
HLD
Code: Full Code
ACUTE ISSUES:
=============
# Left lower extremity DVT, unprovoked
Pt with left lower extremity pain for 6 days. Underwent U/S as
outpatient and found to have extensive left lower extremity DVT
of left superficial femoral, popliteal, peroneal and posterior
tibial veins. No known risk factors, appeared to be unprovoked
although would benefit from CT screening for lung cancer given
smoking history. He remained hemodynamically stable throughout
hospitalization without concern for PE. He received lovenox 80mg
SC q12h and was transitioned to ___ upon discharge.
CHRONIC ISSUES:
===============
# HTN
continued home propranolol 20mg BID
# Essential Tremor
continued home clonazepam 0.5mg BID and propranolol 20mg BID
# BPH
continued home finasteride 5mg qPM
# HLD
Not on any home medications. Most recent lipid panel ___ with
elevated cholesterol 200s, LDL 145, HDL 37, ___ 200s.
consider PCP ___ for management HLD
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. ClonazePAM 0.5 mg PO BID
2. Finasteride 5 mg PO QPM
3. Propranolol 20 mg PO BID
Discharge Medications:
1. Apixaban 10 mg PO BID Duration: 7 Days
2. Apixaban 5 mg PO BID
start taking 5mg twice a day of the apixaban after you finish
the 7 day course of 10mg twice a day
3. ClonazePAM 0.5 mg PO BID
4. Finasteride 5 mg PO QPM
5. Propranolol 20 mg PO BID
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS
deep venous thrombosis of left leg
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking part in your care here at ___!
Why was I admitted to the hospital?
- You were admitted for a blood clot in your left leg
What was done for me while I was in the hospital?
- You were started on blood thinners to treat the blood clot in
your leg
What should I do when I leave the hospital?
- You should continue to take your medications as prescribed.
Take apixaban 10 mg by mouth twice a day(first dose ___ ___ for
7 days, then take 5mg by mouth twice a day
- Please go to your appointments as scheduled
Sincerely,
Your ___ Care Team
Followup Instructions:
___
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|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: CARDIOTHORACIC
Allergies:
No Allergies/ADRs on File
Attending: ___.
Chief Complaint:
Sudden shortness of breath
Major Surgical or Invasive Procedure:
Right chest tube placement
History of Present Illness:
Mr ___ is a ___ ___ worker, prior smoker, with no
other significant pmh presenting with one day history of sharp,
sudden onset R chest pain radiating across the front of his
chest
to the L side. The pain started suddenly last night, was not
doing anything at the time of onset. Pain gradually worsened,
but
he was able to sleep. No trauma to chest, was not working
yesterday. This AM went to work with unchanged R chest pain.
Lifted heavy concrete bags at work, then realized pain was too
significant to continue working and was having some difficulty
speaking. Went home before noon. Shortness of breath worsened.
Went to urgent care, was sent via ambulance to ___ ER. In ER,
found to have unremarkable vitals (98.3/___/130/93/___/94% RA),
but
PA/lateral CXR displayed near complete collapse of R lung with
some leftward shifting of the mediastinum concerning for
impending tension pneumothorax. A pigtail catheter was placed
into the R basilar thorax to evacuate the pneumothorax, and the
post-placement CXR showed complete resolution of the
pneumothorax. Thoracic surgery is consulted at this point for
evaluation and management recommendations.
Pt has never had this happen before. No recent chest trauma. No
surgeries to chest in past. No fevers, chills, sweats. Feels
that
his breathing is better post-pigtail, but the pain is slightly
worse.
Past Medical History:
PAST MEDICAL HISTORY:
None
PAST SURGICAL HISTORY:
Skin cyst removal on chin and toe
Social History:
SOCIAL HISTORY:
Cigarettes: Ex smoker, quit ___ years ago. Smoked 1 pack/day for
___ years.
30pckt/years
ETOH: [ ] No [x] Yes drinks/day: __1___
Drugs: denies
Exposure: [ ] No [x] Yes [ ] Radiation
[ ] Asbestos [ ] Other: ___ years in
___
Occupation: ___
Marital Status: [x] Married [ ] Single
Lives: [ ] Alone [x] w/ family [ ] Other:
Other pertinent social history: ___
Family History:
no known pertinent family hisotyr
Physical Exam:
Subjective: Patient is doing well.
VS:
T: 98.2 BP: 118/75 HR:74 RR: 18 O2Sat: 94% on RA
GENERAL
[x] WN/WD [x] NAD [x] AAO [ ] abnormal findings:
HEENT
[x] NC/AT [x] EOMI [x] PERRL/A [x] Anicteric
[x] OP/NP mucosa normal [x] Tongue midline
[x] Palate symmetric [x] Neck supple/NT/without mass
[x] Trachea midline [x] Thyroid nl size/contour
[ ] Abnormal findings:
RESPIRATORY
[x] CTA/P [x] Excursion normal [x] No fremitus
[x] No egophony [x] No spine/CVAT
[x] Abnormal findings: Chest tube incision on right axillary
midline w/o signs of infection
CARDIOVASCULAR
[x] RRR [x] No m/r/g [x] No JVD [x] PMI nl [x] No edema
[x] Peripheral pulses nl [x] No abd/carotid bruit
[ ] Abnormal findings:
GI
[x] Soft [x] NT [x] ND [x] No mass/HSM [x] No hernia
[ ] Abnormal findings:
GU [x] Deferred
[ ] Nl genitalia [ ] Nl pelvic/testicular exam [ ] Nl DRE
[ ] Abnormal findings:
NEURO
[x] nonfocal
MS
[x] No clubbing [x] No cyanosis [x] No edema [x] No
tenderness [x] Tone/align/ROM nl [x] Palpation nl [ ]
Abnormal findings:
LYMPH NODES
[x] Cervical nl [x] Supraclavicular nl [x] Axillary nl
[x] Inguinal nl [ ] Abnormal findings:
SKIN
[x] No rashes/lesions/ulcers
[x] No induration/nodules/tightening [ ] Abnormal findings:
PSYCHIATRIC
[x] Nl judgment/insight [x] Nl memory [x] Nl mood/affect
[ ] Abnormal findings:
Pertinent Results:
___ 04:20PM BLOOD WBC-7.4 RBC-4.70 Hgb-14.7 Hct-43.1 MCV-92
MCH-31.3 MCHC-34.1 RDW-14.2 RDWSD-48.3* Plt ___
___ 04:20PM BLOOD Neuts-42.6 ___ Monos-7.0
Eos-17.6* Baso-0.7 Im ___ AbsNeut-3.17 AbsLymp-2.36
AbsMono-0.52 AbsEos-1.31* AbsBaso-0.05
___ 04:20PM BLOOD Glucose-89 UreaN-10 Creat-1.0 Na-138
K-3.8 Cl-106 HCO3-21* AnGap-11
___ 04:20PM BLOOD ALT-30 AST-31 AlkPhos-86 TotBili-0.4
Imaging:
CXR Floor Post chest tube pull ___ 2:03pm
Interval removal of the right-sided pigtail catheter. The small
right apical pneumothorax is barely perceptible. Small
bilateral effusions with bibasilar atelectasis are unchanged.
Cardiomediastinal silhouette is stable. No new consolidations
CXR Floor ___ 8:36am
Comparison to ___. The right pigtail catheter is in
stable correct position. No right pneumothorax, no right
pleural effusion. Minimal left pleural effusion with basilar
atelectasis and retrocardiac atelectasis. Borderline size of
the cardiac silhouette.
CXR ER ___ 5:14am
1. Unchanged position of a right sided pigtail catheter with no
appreciable
residual pneumothorax.
2. Trace right pleural effusion.
3. Interval obscuration of the left hemidiaphragm is compatible
with
atelectasis.
CXR ER ___ 8:40pm
Large right-sided hydropneumothorax with findings concerning for
tension.
Brief Hospital Course:
Mr ___ is a ___ ___, prior smoker, with no
other significant pmh presenting with one day history of sharp,
sudden onset R chest pain radiating across the front of his
chest to the L side. The pain started suddenly last night, was
not
doing anything at the time of onset. Pain gradually worsened,
but he was able to sleep. No trauma to chest, was not working
yesterday. This AM went to work with unchanged R chest pain.
Lifted heavy concrete bags at work, then realized pain was too
significant to continue working and was having some difficulty
speaking. Went home before noon. Shortness of breath worsened.
Went to urgent care, was sent via ambulance to ___ ER. In ER,
found to have unremarkable vitals (98.3/87/130/93/18/94% RA),
but PA/lateral CXR displayed near complete collapse of R lung
with some leftward shifting of the mediastinum concerning for
impending tension pneumothorax. A pigtail catheter was placed
into the R basilar thorax to evacuate the pneumothorax, and the
post-placement CXR showed complete resolution of the
pneumothorax. Thoracic surgery is consulted at this point for
evaluation and management recommendations. The patient remained
on the ED until ___ when he was transferred to the thoracic
surgery floor. On ___ his CT was pulled out and the
post-pull CXR was unremarkable.
Mr. ___ had an uneventful hospital stay and is being
discharged today (___) and will see Dr. ___ in clinic
for his follow up on ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. This patient is not taking any preadmission medications
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
RX *acetaminophen 500 mg 2 tablet(s) by mouth every eight (8)
hours Disp #*100 Tablet Refills:*0
2. Docusate Sodium 100 mg PO BID
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice
a day Disp #*10 Capsule Refills:*0
3. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain -
Moderate
RX *oxycodone [Oxaydo] 5 mg 1 tablet(s) by mouth every six (6)
hours Disp #*15 Tablet Refills:*0
4. Senna 8.6 mg PO BID
RX *sennosides [senna] 8.6 mg 1 Tablet by mouth twice a day Disp
#*10 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Right spontaneous pneumothorax, resolved
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
* You were admitted to the emergency department at the hospital
for spontaneous lung collapse. You are now ready for discharge.
* Continue to use your incentive spirometer 10 times an hour
while awake.
* Check your incisions daily and report any increased redness or
drainage. Cover the area with a gauze pad if it is draining.
* Your chest tube dressing may be removed in 48 hours. If it
starts to drain, cover it with a clean dry dressing and change
it as needed to keep site clean and dry.
* You may need pain medication once you are home but you can
wean it over the next week as the discomfort resolves. Make
sure that you have regular bowel movements while on narcotic
pain medications as they are constipating which can cause more
problems. Use a stool softener or gentle laxative to stay
regular.
* No driving while taking narcotic pain medication.
* Take Tylenol on a standing basis to avoid more opiod use.
* Continue to stay well hydrated and eat well to heal your
incisions
* Shower daily. Wash incision with mild soap & water, rinse, pat
dry
* No tub bathing, swimming or hot tubs until incision healed
* No lotions or creams to incision site
* Walk ___ times a day and gradually increase your activity as
you can tolerate.
Call Dr. ___ ___ if you experience:
-Fevers > 101 or chills
-Increased shortness of breath, chest pain or any other
symptoms that concern you.
Your thoracic surgery team
Followup Instructions:
___
|
19731136-DS-10
| 19,731,136 | 25,314,645 |
DS
| 10 |
2150-10-06 00:00:00
|
2150-10-06 13:59:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Bactrim / Shellfish Derived / Ace Inhibitors / Levaquin /
ceftriaxone / Celexa / Zyprexa / Remeron
Attending: ___.
Chief Complaint:
altered mental status and cough
Major Surgical or Invasive Procedure:
___ placement
History of Present Illness:
___ year old ___ woman with dementia, chronic kidney
disease, complex partial seizure disorder, HTN, anemia,
depression, sarcoidosis, GERD, and recurrent UTIs, presenting
with AMS and cough.
Patient is unable to answer pertinent questions as she answers
"yes" to everything and otherwise speaks about irrelevant topics
inappropriately, such as God and people's daughters. Of note,
she was recently discharged on ___ from ___ with diagnoses
of UTI treated with meropenem and hypoactive delirium.
Per medical record notes, speaking with staff at ___
in ___, and her health care proxy, patient became less
interative and more lethargic these past couple of days. Had a
bad cough and was bringing up phlegm. She developed shortness of
breath and had a temperture to 101. On her EMS ride, she had a
period of increasing 02 requirement via nonrebreather with
tachypneas to ___.
In the ED, initial vital signs were T 97.0 HR 80 BP 166/91 RR 18
O2 sat 99% RA. For presumed pneumonia with suspicion for a left
lower lobe infiltrate, patient received 1g vancomycin and 500mg
azithromycin. Her UA showed 73 WBC, few bacteria, no yeast and
thus, she was treated with 100mg nitrofurantoin. Lower extremity
doppler was negative and V/Q scan was requested. Other
significant labs include Na 127 K 5.2 Cl 92 HCO3 28 BUN 61 Cr
2.6 Glc 136. She received 1L IVF.
On the floor, T 98 BP 173/79 HR 75 RR 16 O2 sat 98%. Patient
answers "yes" to most questions, including SOB, feeling sad or
depressed. At times speaks about irrelevant topics as mentioned
above. She does not respond appropriately when asked regarding
pain symptoms.
Past Medical History:
Psychiatric illness
Paranoid delusions
Seizure disorder
Vascular dementia
Hypertension
Hyperlipidemia
Depression
Chronic kidney disease
Multinodular goiter
History of angioedema
GERD
Hyperthyroidism
Sarcoidosis
Osteoporosis
Social History:
___
Family History:
Non-Contributory
Physical Exam:
Admission Exam:
Vitals- T98 BP 173/79 HR 75 RR 16 O2 Sat 98%
General: laying in bed sleeping, but easily arousable,
___ but often tries to communicate in ___
HEENT: PERRLA, EOMI, oropharynx clear no lesions
Neck: supple, no cervical or supraclavicular lymphadenopathy
CV: r/r/r, II/VI holosystic murmur left sternal border
Lungs: poor inspiratory effort, but otherwise clear to
auscultation bilaterally, no
Abdomen: soft, nontender, nondistended
GU: foley in place
Ext: 2+ pitting edema to shins on right, 1+ pitting edema on
left, right calf diameter larger than left, 2+ dorsalis pedis
pulses, no clubbing, cyanosis or edema
Neuro: CN II-XII grossly intact, patient uncooporative with exam
but otherwise moving all 4 extremities
Discharge Exam:
Pertinent Results:
Admission labs:
___ 01:20AM BLOOD WBC-8.4 RBC-3.32* Hgb-9.9* Hct-30.3*
MCV-91 MCH-29.9 MCHC-32.7 RDW-13.3 Plt ___
___ 01:20AM BLOOD Neuts-74.8* Lymphs-16.2* Monos-5.8
Eos-2.8 Baso-0.2
___ 10:40AM BLOOD ___ PTT-35.3 ___
___ 01:20AM BLOOD Glucose-136* UreaN-61* Creat-2.6* Na-127*
K-5.2* Cl-92* HCO3-28 AnGap-12
___ 10:40AM BLOOD ALT-33 AST-30 AlkPhos-123* TotBili-0.2
___ 01:20AM BLOOD proBNP-831*
___ 01:20AM BLOOD Calcium-8.8 Phos-4.2 Mg-2.4
Discharge labs:
Phenytoin:
___ 10:40AM BLOOD Phenyto-3.8*
___ 06:25AM BLOOD Phenyto-3.2*
___:
___ 10:40AM BLOOD ___ PTT-35.3 ___
___ 06:30AM BLOOD ___ PTT-37.1* ___
___ 10:17AM BLOOD ___ PTT-46.1* ___
___ 06:25AM BLOOD ___ PTT-44.4* ___
Other labs:
___ 06:25AM BLOOD Ret Aut-2.0
___ 06:25AM BLOOD calTIBC-235* Folate-4.4 Hapto-173
Ferritn-104 TRF-181*
___ 10:40AM BLOOD TSH-0.81
___ 01:43AM BLOOD Lactate-1.7
Imaging:
___ CXR:
FINDINGS: AP and lateral chest radiographs. Lung volumes are
low and the right hemidiaphragm is persistently elevated.
However, there is no focal consolidation, pleural effusion, or
pneumothorax. Right basilar atelectasis is stable. The heart
is mildly enlarged. Leftward deviation of the trachea is from
the patient's enlarged right thyroid lobe. Compression
deformity of one of the upper lumbar vertebral bodies is similar
to prior CT in ___.
IMPRESSION: No acute cardiopulmonary process.
___ R lower extremity doppler:
FINDINGS: There is normal respiratory phasicity in the common
femoral veins bilaterally. The veins of the right lower
extremity are very small, limiting the examination. However,
normal flow and augmentation is demonstrated in the right common
femoral and superficial femoral veins. Compressibility is not
demonstrated in the popliteal vein, though flow and augmentation
are normal. The calf veins are not visualized.
IMPRESSION: Limited examination. Very small right lower
extremity veins. No evidence of deep vein thrombosis. Calf
veins not visualized.
Brief Hospital Course:
Impression: ___ year old female with complex past medical
history, most signficantly including dementia, recurrent UTI,
stage 4 CKD, and complex partial seizure disorder, who presents
with AMS and cough.
**ACUTE ISSUES**
# Altered mental status: most likely delirium secondary to
infectious processes. UA on admission suspicious for infection
and patient was started on empiric meropenem given previous
culture suspectabilities and her extensive allergies. Cultures
grew 1000 colonirs gram negative rods. Repeated CXR did not
suggest a pneumonia, although pneumonitis could certainly cause
transitient coughing and altered mental status. Patient had 1
episode of agitation on HD 2 requiring soft mittens but her
agitation resolved by the evening and at discharge, mittens had
been removed for 24 hours.
# Cough: Although patient reportedly had a productive cough and
required oxygenation by EMS, she did not have any episodes of
tachypnea, decreases in her oxygen saturation, or coughing
during her hospitalization. Repeated CXR have been negative for
an acute cardiopulmonary process. Patient could have pneumonitis
from transient aspiration events. Patient is on meropenem for
her urinary tract infections as above and would therefore be
covered for any anareobic or gram negative organisms. With
stable vital signs, she is unlikely to have an MRSA infection
requiring vancomycin.
# Urinary tract infection: UA on admission highly suggestive of
UTI and urine cultures grew gram negative rods, as mentioned
above. We would recommend treating this as a complicated UTI
requiring ___ days of antibiotics, preferably ertapenem given
its once a day dosing and ease of use in patients with kidney
disease. Please continue THROUGH ___.
# Acute on chronic kidney disease: On admission, creatine up to
2.6. Her baseline appears to be 1.8-2.0. Most likely secondary
to hypovolemia as creatinine improved to 2.1 with hydration.
# Hyponatremia: Patient's serum sodium at 127 at admission and
corrected with volume repletion.
**CHRONIC ISSUES**
# Anemia: On admission, h/h was 9.9/30.3, which is slightly
lower than her baseline of approximately 11.5/35. She dropped
acutely down to 8.9/27.5 on HD 3, most likely multifactorial
with element of bleeding from an attempted PICC placement. Iron
studies revealed a low TIBC with normal iron and ferritin
levels, which suggests anemia of chronic disease. Additionally,
her reticulocyte count was 2.0, giving a reticulocyte index of
<2, indicating she has some primary production problems. Given
her stage 4 CKD, this could further indicate a decline in her
renal function.
# Hypertension: continued home labetalol 100mg TID and norvasc
10mg daily.
# h/o DVT: Patient is on coumadin for previous DVT of the upper
extremity diagnosed in ___. Coumadin was continued and
adjusted according to daily INR levels. At discharge, INR
therapeutic at 2.6.
# h/o complex partial seizures: On admission, phenytoin level at
3.6 and 3.2 on HD 3. Dr. ___ neurologist, suggested
a loading dose of phenytoin and increasing daily doses to 75mg
BID. Please check a level on ___ and fax results to Dr.
___ at ___.
# L eye neovascular glaucoma with fixed pupil: Continued home
erythromycin eye ointments and artificial tears
# Constipation: At prior hospitalization, patient found to be
constipated and was started on senna, colace, and miralax, which
was continued to good effect at SNF. Continued this regimen
during hospitalization with daily bowel movements.
# Depression: On admission, patient endorsed feelings of sadness
and depression with a flat affect. Continued escitalopram at
15mg daily.
# Multinodular goiter s/p subtotal thyroidectomy ___: not
currently on any therapy, TSH was within normal limits
# Asthma: Continued fluticasone.
**TRANSITIONAL ISSUES**
- Continue ertapenem THROUGH ___
- Continue warfarin dosing protocol
- Check phenytoin levels on ___ and fax results to Dr.
___ at ___
- Please resume physical therapy from prior to admission
- repeat LFT's to monitor for resolution of transamintis
- check INR on ___
- PENDING STUDIES AT TIME OF DISCHARGE:
### blood cultures x 2 sets (___) - no growth to date, final
pending
### urine culture (___) - no growth to date, final pending
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amlodipine 10 mg PO DAILY
2. Artificial Tears Preserv. Free 2 DROP BOTH EYES TID
3. Docusate Sodium 100 mg PO BID
4. Escitalopram Oxalate 15 mg PO DAILY
5. Fluticasone Propionate NASAL 2 SPRY NU DAILY
6. Phenytoin Infatab 75 mg PO QAM
7. Labetalol 100 mg PO TID
8. Warfarin 7.5 mg PO DAILY16
9. Phenytoin Infatab 50 mg PO QPM
10. Polyethylene Glycol 17 g PO DAILY
11. Senna 1 TAB PO BID
12. Erythromycin 0.5% Ophth Oint 0.5 in LEFT EYE QHS
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary diagnosis: urinary tract infection, acute kidney injury
Secondary diagnosis: dementia, chronic kidney disease
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Lethargic but arousable.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking care of you at ___
___. You were admitted because your caretakers
noticed you were less interactive, appeared more tired, and had
a cough. We discovered a urinary tract infection when you
arrived and are treating you with an antibiotic. We checked for
other sources of infection, in your blood and your lungs, and
did not find any infections. Your kidneys were not functioning
like normal, but improved with good hydration. Your phenytoin
level was discovered to be low so we increased your dose,
according to recommendations by your neurologist, Dr. ___.
- Please increase your phenytoin dose to 75mg twice a day
- Please be sure to eat and drink well to prevent any further
kidney injury
Followup Instructions:
___
|
19731136-DS-8
| 19,731,136 | 29,773,405 |
DS
| 8 |
2149-07-13 00:00:00
|
2149-07-13 17:08:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Bactrim / Shellfish Derived / Ace Inhibitors / Levaquin /
mirtazapine / ceftriaxone
Attending: ___.
Chief Complaint:
Fevers, Altered mental status, ? Seizures
Major Surgical or Invasive Procedure:
Intubation ___
Extubation ___
Direct laryngoscopy, bronchoscopy, left substernal thyroidectomy
through cervical approach, with right subtotal thyroidectomy
History of Present Illness:
Ms. ___ is a ___ year old female with a history of seizure
disorder who presented from her rehab facility with questionable
seizures and fevers. Per report, the patient was found yesterday
evening by workers at the facility to be aphasic, not responding
to commands or questions. At that time the workers thought she
was just tired and left her alone. In the morning at change of
shift, care takers who were more familiar with the patient's
clinical status were concerned she was having a seizure.
Additionally, at that time temperatures were reocrded at 101.4
at rehab.
.
In the ED, initial VS were T:100.2/repeat 101.3 and with rectal
temp of 104, BP 138/72, HR: 96, RR 20, Satting 100% on RA.
Initally, patient presented not following commands and
lethargic. Labs were significant for creatinine of 2.0 (baseline
1.5-2.0), glucose to 266, WBC count of 18.3 with 94% PMN's,
elevated K+ although labs were hemolysed. Phenytoin levels were
12.3. Lactate was 3.2 and she received 3 liters of NS, with
followup lactate of 2.6. Urinalysis was positive for large
amounts of WBC's, bacteria, and some RBC's. Given her fevers and
altered mental status, an LP was performed, and she was
empirically provided with vancomycin, ceftraixone, ampicillin,
and acyclovir. LP results were was grossly negative for
infectious etiologies. CXR did not show gross evidence of
pneumonia, and CT head was negative for ICH. She had a stat EEG
which was nonspecific, and neurology was consulted and will
eventually perform a full video EEG. The patient was given 2 mg
of IV lorazepam for suspceted fevers. Shortly after, oxygen
saturations dropped to the low 80's and the patient was
intubated for hypoxic respiratory distress. Per report, patient
was a difficult intubation requring use of a bougie. Propofol
was used for induction, and after her propofol bolus her blood
pressures dropped to the low 80's systolic, but responded with
decreases in propofol infusion.
Upon transfer to the floor, vitals were BP 102/47 HR74 and
T101.3 after rectal APAP.
.
On arrival to the MICU,patient is intubated and sedated on the
vent unresponsive.
.
Review of systems:
Unable to obtain.
Past Medical History:
Psychiatric illness
Paranoid delusions
Seizure disorder
Vascular dementia
Hypertension
Hyperlipidemia
Depression
Chronic kidney disease
Multinodular goiter
History of angioedema
GERD
Hyperthyroidism
Social History:
___
Family History:
Unable to obtain
Physical Exam:
ON ADMISSION TO ICU:
General: Intubated and sedated on the vent. Not responding to
verbal commands.
HEENT: Sclera anicteric, MMM, poor dentition.
Neck: supple, JVP not appreciated, no LAD
CV: Distant HS. Regular rate and rhythm, normal S1 + S2, no
murmurs, rubs, gallops
Lungs: Coarse breath sounds auscultated anteriorly, but
otherwise clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: Protuberant. Soft, non-tender, hypoactive bowel sounds
present, no organomegaly
GU: foley in place with no urine (recently drained)
Ext: Cool hands and feet with poor peripheral lower extremity
pulses and 1+ radial pulses bilaterally. No edema appreciated.
No clubbing.
Neuro: Cannot complete full exam given sedation on vent. Laying
supine without evidence of decerabrate posturing. Pupils are
pinpoint and poorly reactive. No blink to corneal irritation.
Unable to appreciate DTR's in upper extremities or lower
extremities. Upgoing Babinski's bilaterally.
.
ON ADMISSION TO INPATIENT MEDICINE:
General: Alert, disoriented, tangential, speaking ___, no
acute distress
HEENT: PERRL 4->3mm bilat, sclera anicteric, MMM, oropharynx
clear
Neck: supple, JVP not elevated, surgical incision intact without
erythema, swelling, drainage. JP drain in place with
serosanguinous fluid.
Lungs: Clear bilaterally to anterior auscultation, no wheezes,
rales, ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: Midline scar below umbilicus, soft, non-tender,
non-distended, bowel sounds present, no rebound tenderness or
guarding, no organomegaly
GU: Foley in place with clear yellow urine
Ext: Cool, brisk cap refill, left upper extremity edema, bilat
___ edema, no clubbing, cyanosis
.
DICHARGE PHYSICAL EXAM:
General: AAOx3, speaking in ___, no acute distress
HEENT: PERRL, sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, surgical incision intact without
erythema, swelling, drainage.
Lungs: Clear bilaterally to anterior and posterior auscultation,
no wheezes, rales, ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: Midline scar below umbilicus, soft, non-tender,
non-distended, bowel sounds present, no rebound tenderness or
guarding, no organomegaly
Ext: WWP, brisk cap refill, bilat UE edema L>R, trace bilat ___
edema, no clubbing, cyanosis
Pertinent Results:
ADMISSION LABS:
___ 02:15PM BLOOD WBC-18.3*# RBC-3.99* Hgb-11.6* Hct-38.0
MCV-95 MCH-29.0 MCHC-30.4* RDW-13.1 Plt ___
___ 02:15PM BLOOD Neuts-93.8* Lymphs-3.1* Monos-1.9*
Eos-0.9 Baso-0.1
___ 02:15PM BLOOD ___ PTT-26.6 ___
___ 02:15PM BLOOD Glucose-266* UreaN-27* Creat-2.0* Na-133
K-8.4* Cl-99 HCO3-25 AnGap-17
___ 08:58PM BLOOD ALT-32 AST-33 AlkPhos-76 TotBili-0.3
___ 02:15PM BLOOD cTropnT-<0.01
___ 02:15PM BLOOD Albumin-4.0
___ 08:58PM BLOOD Albumin-3.3* Calcium-9.6 Phos-1.1*#
Mg-1.6
___ 05:29AM BLOOD TSH-0.62
___ 05:29AM BLOOD T4-5.4
___ 03:52AM BLOOD Free T4-1.1
___ 03:50AM BLOOD C4-27
___ 02:15PM BLOOD Phenyto-12.3
___ 04:21PM BLOOD Type-ART Rates-14/ Tidal V-500 PEEP-5
FiO2-100 pO2-439* pCO2-37 pH-7.40 calTCO2-24 Base XS-0 AADO2-243
REQ O2-48 -ASSIST/CON
___ 02:31PM BLOOD Lactate-3.2* K-5.7*
___ 04:21PM BLOOD O2 Sat-97
___ 02:09PM BLOOD freeCa-1.32
.
MICROBIOLOGY DATA:
___ Urine Culture:
KLEBSIELLA PNEUMONIAE
. |
AMPICILLIN/SULBACTAM-- 16 I
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN--------- I
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- 64 I
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
.
___ 4:55 pm CSF;SPINAL FLUID Source: LP #3.
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final ___: NO GROWTH.
VIRAL CULTURE (Preliminary): NO VIRUS ISOLATED
.
___ 8:59 pm MRSA SCREEN Source: Nasal swab.
**FINAL REPORT ___
MRSA SCREEN (Final ___: No MRSA isolated.
.
___ 12:05 am SPUTUM Source: Endotracheal.
**FINAL REPORT ___
GRAM STAIN (Final ___:
>25 PMNs and <10 epithelial cells/100X field.
NO MICROORGANISMS SEEN.
RESPIRATORY CULTURE (Final ___:
RARE GROWTH Commensal Respiratory Flora.
YEAST. RARE GROWTH.
.
___ 1:56 am BLOOD CULTURE FROM CVL LINE.
Blood Culture, Routine (Pending):
.
___ 9:55 am BLOOD CULTURE Source: Line-RIJ SET#2.
Blood Culture, Routine (Preliminary):
STAPHYLOCOCCUS, COAGULASE NEGATIVE.
Isolated from only one set in the previous five days.
SENSITIVITIES PERFORMED ON REQUEST..
Aerobic Bottle Gram Stain (Final ___:
Reported to and read back by ___. ___ ON ___ AT
0105.
GRAM POSITIVE COCCI IN PAIRS AND CLUSTERS.
.
___:
URINE CULTURE (Final ___:
YEAST. 10,000-100,000 ORGANISMS/ML..
.
RADIOLOGICAL STUDIES:
CT HEAD - ___
FINDINGS: There is no evidence of intracranial hemorrhage, mass
effect, shift
of normally midline structures, or vascular territorial infarct.
Ventricles
and sulci are mildly prominent consistent with age-related
atrophy.
Calcifications of the carotid siphons are again noted. No
fractures or soft
tissue abnormalities are seen. Imaged portions of the mastoid
air cells and
paranasal sinuses appear unremarkable.
IMPRESSION: No evidence of intracranial hemorrhage.
.
CHEST XRAY - ___
FINDINGS: Supine AP portable view of the chest was obtained.
There has been
interval placement of endotracheal tube, terminating
approximately 3 cm below
the carina. Nasogastric tube is seen coursing below the level
of the
diaphragm and terminating in the expected location of the distal
stomach. The
aorta is calcified and tortuous. The cardiac silhouette is not
enlarged.
Paratracheal opacity is again seen as also seen on the prior
study. Subtle
medial right base patchy opacity could relate to aspiration. No
pleural
effusion or pneumothorax is seen.
IMPRESSION:
1. Endotracheal and nasogastric tubes in appropriate position.
2. Subtle streaky medial right base opacity could relate to
aspiration
depending on the clinical situation.
.
RIGHT UPPER EXTREMITY ULTRASOUND
The left and right subclavian venous waveforms show normal and
symmetric
tracings with respiratory variability normally noted. The right
internal
jugular is patent and easily compressible. The axillary and
both brachial
veins are also easily compressible and fully patent. The
basilic vein is
patent but the cephalic vein is thrombosed. Extensive
subcutaneous edema is
noted in the arm.
CONCLUSION: 1. No evidence of DVT in the right upper
extremity. Superficial
cephalic venous thrombus is noted.
.
BILATERAL UPPER EXTREMITY ULTRASOUND
FINDINGS: Gray-scale and Doppler sonography was performed of
the bilateral
internal jugular, subclavian, axillary, paired brachial,
basilic, and cephalic
veins. A known superficial venous thrombus in the right
cephalic vein is
unchanged from ___ with minimal flow demonstrated on power
Doppler
analysis. The right internal jugular vein contains a small
nonocclusive
thrombus. A right-sided PICC is in position within one of the
paired right
brachial veins extending into the right subclavian vein, which
demonstrates
normal compressibility, augmentation and flow. All remaining
visualized
venous structures in the right upper extremity show normal
compressibility,
augmentation, and flow. In the left upper extremity, the left
internal
jugular vein contains a small non-occlusive thrombosis with
preserved flow.
The remaining visualized venous structures in the left upper
extremity show
normal compressibility, augmentation and flow.
IMPRESSION:
1. Small non-occlusive thrombi in the right internal jugular
vein and left
internal jugular vein.
2. Stable nearly occlusive superficial venous thrombosis of the
right
cephalic vein from ___.
.
DISCHARGE LABS:
___ 05:30AM BLOOD WBC-8.8 RBC-2.86* Hgb-8.2* Hct-27.4*
MCV-96 MCH-28.8 MCHC-30.1* RDW-15.2 Plt ___
___ 04:40AM BLOOD Neuts-67.4 ___ Monos-4.7 Eos-5.9*
Baso-0.1
___ 05:30AM BLOOD Glucose-116* UreaN-16 Creat-1.5* Na-144
K-4.0 Cl-105 HCO3-29 AnGap-14
___ 05:30AM BLOOD Calcium-8.4 Phos-3.5 Mg-2.0
___ 05:29AM BLOOD TSH-0.62
___ 03:52AM BLOOD Free T4-1.1
___ 05:29AM BLOOD T4-5.4
___ 05:59AM BLOOD Cortsol-18.9
___ 03:50AM BLOOD C4-27
___ 05:30AM BLOOD Phenyto-11.3
.
PENDING LABS:
Blood Cultures from ___
Brief Hospital Course:
Ms. ___ is a ___ year old female with a history of seizure
disorder who presented from her rehab facility with questionable
seizures and fevers.
.
# Altered mental status/encephalopathy: Pt was initially
admitted with unresponsiveness with concern for seizure given
her seizure disorder. Neurology was consulted and EEG was
performed that did not show seizure activity. She was found to
have a UTI, urine culture grew klebsiella. She was treated with
ceftriaxone that was later changed to meropenem given concern
for possible angioedema (see below). She was then found to have
fungal UTI and was started on fluconazole (see below). Mental
status returned to baseline. She was continued on her home dose
of phenytoin then uptitrated as she was subtherapeutic (see
below).
.
# Seizure disorder: Patient initially presented with concern for
seizures. Neurology was consulted and EEG did not show seizure
activity. Patient continued on her home dilantin dose. On ___
patient had seizure x3. Dilantin level was checked and was
undectable. Patient was reloaded with IV fosphenytoin.
Patient's home dilantin dose was increased to 125 mg BID.
Dilantin level at time of discharge was 14.9 when corrected for
hypoalbuminemia. Please recheck patient's dilantin dose in
three days and adjust dilantin dosing; target dilantin level is
16.
.
# UTI, bacterial, and UTI, candidal: Pt initially had klebsiella
UTI treated with meropenem. She had repeat UA after seizure with
150 WBCs. Urine culture grew yeast x3. Discussed with ID,
started fluconazole for 10 days. Last dose for fluconazole is
___. Please follow up with a repeat UA at the end of
fluconazole course.
.
# Respiratory distress: Upon presentation to ED, concern was
high for seizure and pt received benzodiazepines. In this
setting, she developed hypoxia and required intubation. She
required minimal ventilatory support and was able to follow
commands without need for much sedation. Extubation was
attempted on ___ but she required re-intubation within 3
hours due to respiratory distress. She had a large amount of
laryngeal edema that was felt to be responsible for her failed
extubation and she was placed on IV steroids to reduce swelling.
She had several allergies to antibiotics with adverse reaction
being angioedema. Given concern that her ceftriaxone may be
causing angioedema, she was switched to meropenem. Extubation
was attempted again on ___ she once again developed
respiratory distress and hypoxia within 6 hours and required
re-intubation. A large amount of edema was again noted. ENT
was consulted regarding tracheostomy. They recommended CT neck
to evaluate size of her large multinodular goiter. They brought
her to the OR on ___ for subtotal thyroidectomy and
extubation was again performed on ___. While in the ICU,
patient's total body balance was positive 14 liters and crackles
were appreciated on lung exam and she had edema of her limbs.
Patient was given lasix and her edema improved along with her
lung exam. Please monitor patient's fluid status and
respiratory status and give diuretics as needed. Extra fluid in
her body should mobilize and be excreted in urine.
.
# s/p Subtotal thyroidectomy: Pt was noted to have large
multinodular goiter. TFTs were within normal limits. She had
been on methimazole as outpatient; this was not continued in
___. CT neck showed large goiter and pt was seen by ENT who
recommended thyroidectomy as the goiter was compressing her
trachea and may have been the reason for her failed extubations.
Thoracic surgery was also called regarding possible
tracheomalacia seen on CT scan. Thoracic surgery felt that this
was not tracheomalacia but rather compression of trachea from
thyroid mass. She underwent thyroidectomy on ___. Right
thyroid lobe was left; parathyroids were left in place. Calcium
was monitored carefully postoperatively. She had JP drain in
place after surgery which was removed. She should follow up with
her endocrinologist 3 weeks after discharge and Dr. ___ to
follow up with outcome of surgery.
.
# Volume overload / upper extremity edema: Patient's total body
fluid balance during her ICU stay was positive 14 liters. She
required several doses of IV lasix as she developed pulmonary
edema. Her upper extremities were noted to be swollen (L>R).
Bilateral upper extremity ultrasound was obtained and showed
no-occlussive thrombi in right and left IJ. No anti-coagulation
was initated as there is no clear evidence of benefit in
non-occlussive thrombi. Please continue to monitor patient's
upper extremities and reevaluate as needed.
.
# Transitional issues:
1) Follow up with ENT in 2 weeks; must call to schedule
appointment
2) Follow up with endocrinology in 3 weeks; must call to
schedule appointment
3) Follow up with PCP regarding this hospitalization
4) Recheck dilantin level in 3 days (must correct for
hypoalbuminemia) and consider readjusting dosing; target level
is 16.
5) Notable labs on last check here: Hct 27.4, Cr 1.5, ALT 47,
AST 31, phenytoin (Dilantin) level 11.3. These can be
followed-up after discharge.
Medications on Admission:
Medications (from Rehab)
Dilantin 100 mg PO qhs
Fluticasone nasal spray 50mcg 1 spray each nostril BID
Mucinex ___ mg 1 tab po BID
Calcium carbonate 600 mg give 1 tab po BID
Docusate 100 mg PO BID
metorpolol tartrate 75 mg BID
Artificial tears 1 drop both eyes TID
Donepezil 5 mg qhs
Combivent nebs 5 times a day prn
Vitamin D2 ___ units po qweek until ___
Vitamin D by mouth 1000 U qday ___ and on
Trazodone 25 mg PO qhs
Bisacodyl 10 mg po PRN
Robitussin 10 cc's po q4hrs prn cough
APAP 500 mg PO q6hrs prn
Discharge Medications:
1. Acetaminophen ___ mg PO Q4H:PRN pain or fever
max 4g/day
2. Albuterol-Ipratropium ___ PUFF IH Q4H:PRN wheezing, shortness
of breath
3. Calcium Carbonate 600 mg PO BID
4. Docusate Sodium 100 mg PO BID
5. Donepezil 5 mg PO HS
6. Metoprolol Tartrate 75 mg PO BID
7. Phenytoin Infatab 125 mg PO BID
8. Bacitracin Ointment 1 Appl TP QID
9. Fluconazole 100 mg PO Q24H Duration: 10 Days
Last Day ___. Multivitamins 1 TAB PO DAILY
11. Senna 1 TAB PO BID:PRN constipation
12. Artificial Tears ___ DROP BOTH EYES TID
13. Bisacodyl 10 mg PO DAILY:PRN constipation
14. Fluticasone Propionate NASAL 2 SPRY NU BID
1 spray each nostril
15. Guaifenesin ___ mL PO Q4H:PRN cough
16. Vitamin D 50,000 UNIT PO 1X/WEEK (___)
until ___
17. Vitamin D 1000 UNIT PO DAILY
until ___
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSES:
1) Seizure disorder
2) Klebsiella urinary tract infection
3) Yeast urinary tract infection
4) Non-occlusive thombi in right and left internal jugular veins
5) Goiter s/p subtotal thyroidectomy
6) Volume overload secondary to aggressive fluid resuscitation
.
SECONDARY DIAGNOSES:
1) Hypertension
2) Hyperlipidemia
3) Chronic kidney disease
4) GERD
Discharge Condition:
Alert and oriented to time, place, and person.
Non-ambulatory.
Clinically stable and improved.
Discharge Instructions:
You were admitted to the medicine service for workup and
management of your confusion. Your confusion was likely
multifactorial as outlined below.
.
You were given lorazepam because there were concerns of
seizures, but EEG monitoring did not reveal any evidence of
seizure. As a consequence, your breathing was suppressed and had
to be sedated and intubated to help you breath better. After
successful removal of your breathing tube, you had a seizure and
was found that your dilantin level was subtherapeutic secondary
to propofol withdrawal and malabsorption of dilantin due to the
tube feed you were receiving while intubated. You received
loading doses of dilantin and your maintenance dose was
increased to 125mg twice daily from 100mg twice daily. On the
day of discharge, your dilantin level adjusted for
hypoalbuminemia was 14.9. Please have your doctor and nurses at
___ check your dilantin level (must correct for
albumin level to get effective dilantin level) in three days and
consider adjusting your dilantin dose. The goal dilantin level
is 16.
.
You were found to have a bacterial urinary tract infection.
This may have been a large contributor of your confusion. Your
urine culture grew Klebsiella that was resistant to
ampicillin/sulbactam, ciprofloxacin, and nitrofurantoin, but
sensitive to cefazolin, cefepime, ceftriaxone, and meropenem.
You were initially treated with ceftriazone, but showed signs of
allergic response and was treated with meropenem. At the end of
the course of meropenem, your urine culture grew yeast.
Therefore, you were started on fluconazole on ___, which is an
anti-fungal antibiotic. The last dose of fluconazole will be on
___.
.
You were noted to have increased swelling of your extremities
and crackles in your lungs as a result of aggressive fluid
resuscitation in the intensive care unit. You received
diuretics to take off fluids until no more crackles were heard
in your lungs. After this, your body should be able to mobilize
the extra fluid in your body and put out in your urine. You
also received ultrasound examination of your upper extremities
as there were concerns for blood clots. Ultrasound imaging
showed non-occlussive blood clots in your right and left
internal jugular veins. There is no clear evidence for benefit
in treating non-occlussive blood clots. Therefore, we did not
start anti-coagulation. Please follow up with your primary care
physician to monitor swelling in your arms and your body's fluid
status.
.
While you were intubated in the medical intensive care unit,
there were difficulties removing the breathing tube. This was
thought to be secondary to your enlarged thyroid. Therefore, a
surgery was done to remove part of your thyroid by the ear,
nose, and throat surgeons. Please continue to use the
anti-bacterial ointment until you see the surgeons for followup
in two weeks. Please call to schedule the followup appointment
as described below.
Followup Instructions:
___
|
19731685-DS-3
| 19,731,685 | 21,005,127 |
DS
| 3 |
2166-02-10 00:00:00
|
2166-02-10 17:21:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Lipitor / Flomax / metformin
Attending: ___.
Chief Complaint:
right groin pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ woman with a history of CHF, AS, GERD,
hyperparathyroidism, DMII c/b neuropathy, CKD III, HTN, and
anemia notably not on any anticoagulation who presented
originally to ___ with acute onset right groin
pain on the morning of ___. She is primarily wheelchair-bound
secondary to right knee pain s/p TKR and the pain came on while
she was getting up from her wheelchair. She does not remember
any
recent trauma. At ___ a CT showed a retroperitoneal
hematoma and she was transferred to ___ for further care.
Past Medical History:
CHF
Aortic stenosis
GERD
Obesity
Hyperparathyroidism
DMII c/b neuropathy
Osteoarthritis
Dyslipidemia
Hypertension
Osteoporosis with multiple compression fractures
COPD
Spinal stenosis
Anemia
Social History:
___
Family History:
Noncontributory
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
GENERAL: elderly woman comfortably lying in bed eating, wearing
nasal canula, AxOx3 (not exact date)
HEENT: PERRL, EOMI, MMM
NECK: supple, no lymphadenopathy, JVD elevated just above
clavicles
CARDIAC: RRR, loud systolic ejection murmur best heard at ___
radiataing to carotids, no rubs or gallops
LUNGS: diffuse crackles to mid-lung fields, no wheezes
ABDOMEN: soft, nontender, no bruising around umbilicus or flanks
EXTREMITIES: 1+ pitting edema to mid-shins bilaterally, warm
NEUROLOGIC: AxOx3, moving all 4 extremities with purpose
SKIN: no rashes, ecchymoses
DISCHARGE PHYSICAL EXAM
=======================
___ ___ Temp: 97.7 PO BP: 99/57 HR: 64 RR: 18 O2 sat: 95%
O2 delivery: 3L FSBG: 189
GENERAL: well-appearing, NAD
HEENT: anicteric sclerae, NC/AT
CARDIAC: ___ SEM heard best at RUSB.
LUNGS: Diffuse crackles and decreased breath sounds.
ABDOMEN: Soft, NT, ND
EXTREMITIES: No ___ edema. Left posterior upper extremity with
visible ecchymoses, underlying hematoma, related to site of ___
injections.
NEUROLOGIC: alert, interactive, AxOx3 CN grossly intact
Pertinent Results:
ADMISSION LABS:
===============
___ 03:00AM BLOOD WBC-7.4 RBC-3.45* Hgb-9.6* Hct-31.0*
MCV-90 MCH-27.8 MCHC-31.0* RDW-14.2 RDWSD-46.5* Plt ___
___ 03:00AM BLOOD Neuts-77.6* Lymphs-13.5* Monos-6.4
Eos-1.6 Baso-0.4 Im ___ AbsNeut-5.70 AbsLymp-0.99*
AbsMono-0.47 AbsEos-0.12 AbsBaso-0.03
___ 03:00AM BLOOD ___ PTT-27.4 ___
___ 03:00AM BLOOD Glucose-134* UreaN-40* Creat-1.3* Na-144
K-5.1 Cl-106 HCO3-27 AnGap-11
STUDIES:
========
CT Ab/P ___
1. Tiny right psoas and iliopsoas pseudoaneurysms. The
intramuscular
hematomas appear essentially unchanged. The extra muscular
retroperitoneal hematoma appears minimally increased. No
evidence of extramuscular extravasation or pseudoaneurysm.
2. Unchanged left greater than right lower lobe atelectasis.
Difficult to
exclude pneumonia in the appropriate clinical setting.
3. Chronic appearing L1 and L4 compression deformities with 5 mm
osseous
retropulsion of L1.
4. Incidental left adrenal adenomas.
5. Incidental 8 mm splenic artery aneurysm.
TTE ___
The left atrial volume index is moderately increased. 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>70%). The estimated cardiac index is high (>4.0L/min/m2).
Tissue Doppler imaging suggests an increased left ventricular
filling pressure (PCWP>18mmHg). Right ventricular chamber size
and free wall motion are normal. The number of aortic valve
leaflets cannot be determined. The aortic valve leaflets are
moderately thickened. There is moderate aortic valve stenosis
(valve area 1.2cm2). No aortic regurgitation is seen. Mild (1+)
mitral regurgitation is seen. [Due to acoustic shadowing, the
severity of mitral regurgitation may be significantly
UNDERestimated.] There is moderate pulmonary artery systolic
hypertension. There is no pericardial effusion.
IMPRESSION: Moderate aortic stenosis. Moderate symmetric left
ventricular hypertrophy with dynamic systolic function.
Increased PCWP.
DISCHARGE LABS
==============
___ 05:17AM BLOOD WBC-8.5 RBC-3.12* Hgb-8.6* Hct-27.8*
MCV-89 MCH-27.6 MCHC-30.9* RDW-13.7 RDWSD-44.2 Plt ___
___ 05:10AM BLOOD Glucose-138* UreaN-110* Creat-2.2* Na-138
K-4.1 Cl-92* HCO3-33* AnGap-13
___ 05:10AM BLOOD Calcium-8.7 Phos-4.8* Mg-2.9*
Brief Hospital Course:
___ with HTN, NIDDM, CHF, AS, GERD, CAD and COPD on ___ O2 at
home who was admitted for a spontaneous RP hematoma, then
developed ___ and mixed respiratory failure due to heart failure
exacerbation.
ACUTE ISSSUES:
==============
# RETROPERITONEAL BLEED
# ACUTE BLOOD LOSS ANEMIA
The patient experienced right-sided groin pain at her facility
and was found to have a stable retroperitoneal bleed. She
received a CTA that did not show active bleeding. She was
evaluated by vascular surgery and ___ who recommended no
intervention. Her H/H was monitored and remained stable.
# ACUTE ON CHRONIC DIASTOLIC HEART FAILURE
# ACUTE ON CHRONIC HYPOXIC AND HYPERCARBIC RESPIRATORY FAILURE
The patient has chronic diastolic heart failure. During her
admission, she developed acute hypoxia and dyspnea and was
intubated. She was volume overloaded, likely in the setting of
contrast induced nephropathy as below, and was aggressively
diuresed. She was successfully extubated and was given IV
diuretics until euvolemic. Her diuretic regimen was torsemide 20
mg daily on discharge. Her home metolazone was discontinued and
was not restarted on discharge. Her discharge weight was 181.22
lb.
___ ON CKD
Cr peaked at 4.0 from baseline on admission of 1.3 - 1.5. This
was attributed to contrast-induced nephropathy from CTA on the
day of admission as the ___ developed roughly 48-72 hours
afterwards. There was also likely a component of cardiorenal
syndrome as it improved with diuresis. Her creatinine decreased
to 2.2 at discharge.
# COPD
On ___ oxygen by nasal cannula at home. After extubation, she
was at her baseline oxygen requirement. She continued her
nebulizer treatments.
# KLEBSIELLA UTI
She was diagnosed with a UTI due to Klebsiella in the ICU.
Notably, her urinalysis and urine culture were obtained at the
time of Foley placement and do not represent a catheter
associated infection. She was treated with ceftriaxone from
___.
CHRONIC ISSUES:
===============
# CAD
She continued her home carvedilol, aspirin, and pravastatin.
# NIDDM
Sitagliptin was held while inpatient and she was continued on an
insulin sliding scale. Given her renal dysfunction, her home
sitagliptin was decreased to 25mg daily.
# HX OF RLE HARDWARE INFECTION
She continued suppressive amoxicillin.
#DEPRESSION
She continued her home Sertraline.
#GERD
She continued her home famotidine.
TRANSITIONAL ISSUES:
====================
[ ] DISCHARGE WEIGHT: 181.22 lb
[ ] DISCHARGE Cr/BUN: 2.2/110
[ ] DISCHARGE DIURETIC: Torsemide 20 mg PO daily
[ ] The patient developed ___ on CKD during this admission,
likely due to contrast-induced nephropathy. Her Cr was 2.2 at
discharge. Please re-check her creatinine in ___ days.
[ ] The patient's diuretic regimen was changed to Torsemide 20mg
daily, no more metolazone. Please check her volume status and
BMP in ___ days.
[ ] Please consider surveillance echocardiograms for monitoring
of aortic stenosis
[ ] Has IVC filter, indication and date placed unclear
[ ] Incidental left adrenal adenomas noted on CT Ab/P
[ ] Incidental 8 mm splenic artery aneurysm. Vascular surgery
attending Dr ___ was not convinced that this is a true
aneurysm on review of imaging - does not need vascular
follow-up.
[ ] Decreased her home Sitagliptin to 25mg daily given her renal
dysfunction. Please assess glycemic control as an outpatient and
adjust regimen as needed.
#CODE: Full Code (confirmed)
#CONTACT: ___ (___)
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Cyanocobalamin 1000 mcg PO DAILY
3. Carvedilol 12.5 mg PO BID
4. SITagliptin 100 mg oral DAILY
5. Omeprazole 20 mg PO QAM
6. Pravastatin 80 mg PO QPM
7. Sertraline 100 mg PO DAILY
8. Torsemide 10 mg PO DAILY
9. Metolazone 2.5 mg PO DAILY:PRN shortness of breath
10. Docusate Sodium 100 mg PO BID
11. Amoxicillin 500 mg PO DAILY
12. Glucosamine (glucosamine sulfate) ___ mg oral DAILY
Discharge Medications:
1. SITagliptin 25 mg oral daily
2. Torsemide 20 mg PO DAILY
3. Amoxicillin 500 mg PO DAILY
4. Aspirin 81 mg PO DAILY
5. Carvedilol 12.5 mg PO BID
6. Cyanocobalamin 1000 mcg PO DAILY
7. Docusate Sodium 100 mg PO BID
8. Glucosamine (glucosamine sulfate) ___ mg oral DAILY
9. Omeprazole 20 mg PO QAM
10. Pravastatin 80 mg PO QPM
11. Sertraline 100 mg PO DAILY
12. HELD- Metolazone 2.5 mg PO DAILY:PRN shortness of breath
This medication was held. Do not restart Metolazone until you
see your nephrologist.
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
retroperitoneal bleed
acute on chronic diastolic heart failure
acute on chronic kidney injury
urinary tract infection
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. ___,
It was a pleasure being involved in your care.
Why you were hospitalized:
==========================
- You were hospitalized because you were bleeding into your
back.
What happened in the hospital:
==============================
- You had imaging that showed a bleed in your back.
- You were seen by interventional radiologists and vascular
surgeons who determined that you did not need an intervention
because the bleeding had stopped on its own.
- Your blood counts were stable.
- You developed kidney damage, likely from the contrast given
for imaging of your bleed as well as a heart failure
exacerbation.
- You were treated for heart failure with diurectic medications
to help get some of the extra fluid off of your body.
- You were treated for a urinary tract infection.
What you should do when you go home:
====================================
- Take all of your medications as described below.
- Attend all of your follow-up appointments as described below.
- Weigh yourself daily. If you gain 3 lbs in 1 day or 5 lbs in 2
days, call your doctors.
We wish you the best!
Your ___ Team
Followup Instructions:
___
|
19731741-DS-17
| 19,731,741 | 23,188,105 |
DS
| 17 |
2137-01-19 00:00:00
|
2137-01-21 19:30:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / trimethoprim
Attending: ___.
Chief Complaint:
s/p fall
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ F w/ hx ESRD ___ PCKD, HTN, OSA w/ BIPAP, chronic pain,
obesity, depression p/w CP and dyspnea x 12 days. Pt initially
presented to OSH on ___ ___nd dyspnea. She had been
sleeping on a hard mattress and developed left sided rib pain
with no fall. She was hospitalized for 6 days, given keflex and
symptomatic treatment for left sided rib pain. However, she had
a mechanical fall today and left rib pain is now worse. No
headstrike or LOC. Pt states she is still have left sided chest
pain that radiates to her back and under her breast, worse with
exertion. Not reproduced with palpation. Pt had 3 episodes of
emesis today, no fevers/chills/ nausea/diarrhea/cough. Dyspnea
has been progressing. No orthopnea, PND, or hx of CHF. No PE
risk factors such as prolonged travel, immobilization, leg
swelling.
In the ED initial vitals were: 97.8 104 127/99 20 99%
Non-Rebreather
- Labs were significant for trop 0.04, d dimer 2200, cre 9.8,
HCT 35.
- Patient was given pred 50, duoneb, azithro, percocet
Vitals prior to transfer were: 98.6 88 146/80 20 97% RA
Review of Systems:
Otherwise negative in detail
Past Medical History:
HTN
COPD vs Asthma
Anxiety
polycystic kidney disease/ CKD
Social History:
___
Family History:
Diabetes, sickle cell disease, coronary artery disease in her
mother's side. On her father's side medical
history is lacking due to the early death of her grandparents
and father with the trauma.
Physical Exam:
ADMISSION PHYSICAL EXAM:
98.5 85 155/75 26 92% 6L
GENERAL: respiratory distress
HEENT: AT/NC, EOMI, PERRL, MMM
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs
LUNG: CTAB, no wheezes, rales, rhonchi; tenderness to palpation
of left chest
ABDOMEN: nondistended, +BS, nontender in all quadrants
EXTREMITIES: moving all extremities well, no cyanosis, clubbing
or edema
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
DISCHARGE PHYSICAL EXAM:
Vitals: 98.9 156/98 (114-156)/(67-98) 83 (67-98) 18 (___)
95%RA (95-96%RA)
General: Alert, extremely obese woman in NAD
HEENT: AT/NC, EOMI, PERRL, MMM. Skin fold bulging from interior
R eye orbit into sclera.
Neck: Supple, no LAD.
Lungs: CTAB, w/r/r.
CV: RRR. S4 audible at R and L upper sternal border.
Abdomen: Soft, diffuse mild tenderness to palpation, normoactive
bowel sounds
Ext: Warm and dry. Difficult to appreciate edema and perfusion
due to body habitus.
Neuro: CN II-XII grossly intact.
Pertinent Results:
ADMISSION LABS
___ 01:24AM GLUCOSE-97 UREA N-75* CREAT-9.8*# SODIUM-139
POTASSIUM-4.2 CHLORIDE-105 TOTAL CO2-21* ANION GAP-17
___ 01:24AM ALT(SGPT)-7 AST(SGOT)-14 ALK PHOS-246* TOT
BILI-0.2
___ 01:24AM LIPASE-28
___ 01:24AM WBC-6.9 RBC-3.92* HGB-10.0*# HCT-35.3* MCV-90
MCH-25.6*# MCHC-28.4*# RDW-18.1*
___ 01:24AM NEUTS-74.4* ___ MONOS-3.0 EOS-4.6*
BASOS-0.2
___ 01:24AM ALBUMIN-3.9
___ 01:24AM D-DIMER-2773*
___ 01:24AM cTropnT-0.04*
___ 11:00AM ___ PTT-150* ___
___ 11:00AM PTH-1110*
___ 11:00AM CK-MB-5 cTropnT-0.03*
___ 11:00AM CK(CPK)-258*
PERTINENT LABS
___ 05:10PM BLOOD ANCA-NEGATIVE B
___ 05:10PM BLOOD ___
___ 05:10PM BLOOD RheuFac-8
___ 05:10PM BLOOD HIV Ab-NEGATIVE
DISCHARGE LABS
___ 07:45AM BLOOD WBC-5.6 RBC-3.91* Hgb-10.2* Hct-35.4*
MCV-91 MCH-26.0* MCHC-28.7* RDW-17.8* Plt ___
___ 09:40AM BLOOD Glucose-91 UreaN-70* Creat-7.8* Na-141
K-5.4* Cl-109* HCO3-17* AnGap-20
___ 09:40AM BLOOD Calcium-6.2* Phos-5.8* Mg-1.8
STUDIES
___ EKG
Artifact is present. Sinus rhythm. There is a late transition
with small
R waves in the anterior leads consistent with possible
infarction. Low voltage in the precordial leads. No previous
tracing available for comparison.
___ CXR
IMPRESSION:
1. Moderate cardiomegaly.
2. No displaced rib fractures identified on these views;
however, assessment is limited secondary to body habitus. If
clinical suspicion remains for occult rib fracture, dedicated
rib series radiographs or chest CT is recommended.
___ RENAL US
IMPRESSION:
Enlarged kidneys with multiple cysts seen bilaterally consistent
with polycystic kidney disease. No hydronephrosis is identified
and no suspicious fluid levels within the cysts are visualized.
___ LENIs
IMPRESSION:
No evidence of deep venous thrombosis in the either leg from the
common femoral to the popliteal veins. Note is made that the
calf veins were not visualized bilaterally. This is a limited
study due to the patient's body habitus.
___ TTE:
The left atrial volume index is moderately increased. The
estimated right atrial pressure is ___ mmHg. There is mild
symmetric left ventricular hypertrophy. The left ventricular
cavity is moderately dilated when not indexed to BSA, nut normal
when indexed to BSA. Due to suboptimal technical quality, a
focal wall motion abnormality cannot be fully excluded. Overall
left ventricular systolic function is normal (LVEF>55%). Right
ventricular chamber size is normal with borderline normal free
wall function. The number of aortic valve leaflets cannot be
determined. No aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. Trivial mitral regurgitation is
seen. There is moderate pulmonary artery systolic hypertension.
There is an anterior space which most likely represents a
prominent fat pad.
Brief Hospital Course:
___ F w/ hx ESRD ___ PCKD, HTN, OSA w/ BIPAP, chronic pain,
obesity, depression p/w CP and dyspnea x 12 days. Pt initially
presented to OSH on ___ ___nd dyspnea.
ACTIVE ISSUES
# Hypoxemia - Most likely due to significant obstructive sleep
apnea as significant hypoxia was primarily noted during apneic
episodes. CXR showed no pulmonary edema. PE thought to be
unlikely given Well's score of 1, intermittent hypoxia rather
than persistent hypoxia, and negative LENIs (unable to obtain
CTA of V/Q scan due to CKD and morbid obesity). Given
nonspecific findings of right heart strain on EKG, patient
thought to likely also have pulmonary hypertension although OSH
ECHO showed no evidence of elevated PA pressures or R heart
strain. Initial ABG showed a primary respiratory acidosis which
improved with BiPAP. In addition to obesity hypoventilation and
OSA, it was thought that because of musculoskeletal chest pain,
her hypercarbia was due to splinting/hypoventilation. The
patient's chest pain was controlled with standing tylenol and
prn tramadol. She was provided with BiPAP and her hypoxia
improved to O2sats of 88-94% on RA. An ECHO here did show
evidence of moderate pulmonary hypertension. Pulmonary team was
consulted in regards to patient's elevated A-a gradient and
continued desats. They felt as did primary team that there were
many contributing factors including OSA, obesity and possible
hypoventilation. They recommended HIV, ANCA, RF, and ___ to
rule out connective tissue disorders and risk for atypical
infection. These tests were negative. They additionally felt
that patient would benefit from home O2, outpatient sleep study
and PFTs. Patient would also benefit for further work up of
possible diastolic heart failure as a contributing factor to her
hypoxemia. Patient continued supplemental O2 in house with
intermittent use of the BiPAP as tolerated.
# Chest Pain - Chest pain was thought to be musculoskeletal in
nature as it was reproducible in exam to deep palpation; most
likely due to sleeping on a hard mattress and exacerbated by a
mechanical fall prior to admission. There was no clear
pleuritic component to her chest pain. Well's score was 1, and
given that her hypoxia only occurred during apneic episodes
rather than constantly, PE was thought to be unlikely. We were
unable to obtain CTA and V/Q scan in the setting of her CKD and
morbid obesity. LENIs were negative for DVT although limited by
her body habitus; patient was not discharged on anticoagulation.
ACS thought to be unlikely in setting of stable troponins; EKG
only showed nonspecific evidence of right-sided heart strain.
Chest pain thought unlikely to be related to uremic
pericarditis. Chest pain was reportedly well controlled with
standing Tylenol and Tramadol prn and completely resolved by
time of discharge.
CHRONIC ISSUES:
#) Polycystic kidney disease. Elevated Cr 9.8 which per OSH
records and her outpatient nephrologist (Dr. ___ at ___
___ is chronic. Renal ultrasound confirmed multiple
bilateral cysts. She had failed multiple fistulas in the past,
the most recent in ___. She recently underwent bilateral upper
extremity vein mapping prior to admission at ___ and
per Dr. ___ hopefully obtain a graft for eventual
hemodialysis. Patient will need follow-up with Dr. ___
___.
#) Depression/Anxiety - Continued fluoxetine. Patient seen by
social work while in-house.
#) HTN - Restarted home atenolol although at decreased dose in
setting of CKD. Patient's BP was not very well controlled on
reduced dose Atenolol so Amlodipine 5mg daily was added for
additional BP control.
#) Chronic pain - Percocet held as did not want patient to
worsen hypoventilation with narcotics. Pain well controlled
with Tylenol and prn tramadol.
#) COPD/Asthma - Continued home albuterol prn.
***TRANSITIONAL ISSUES***
- Patient will need f/u appointment with Dr. ___
nephrologist) for work-up for new fistula/graft (at ___
___).
- Patient will follow up with Dr. ___ further outpatient
work up including PFTs and sleep study.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atenolol 50 mg PO DAILY
2. Fluoxetine 20 mg PO DAILY
3. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN SOB
4. Oxycodone-Acetaminophen (5mg-325mg) 1 TAB PO Q6H:PRN pain
Discharge Medications:
1. Fluoxetine 20 mg PO DAILY
RX *fluoxetine 20 mg 1 capsule(s) by mouth daily Disp #*30
Capsule Refills:*0
2. Calcitriol 0.25 mcg PO DAILY
RX *calcitriol 0.25 mcg 1 capsule(s) by mouth daily Disp #*30
Capsule Refills:*0
3. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain
Please hold for oversedation or RR < 10
RX *tramadol 50 mg 1 tablet(s) by mouth every six (6) hours Disp
#*20 Tablet Refills:*0
4. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN SOB
RX *albuterol sulfate 2.5 mg/3 mL (0.083 %) 1 INH Nebulizer
q6hrs Disp #*30 Vial Refills:*0
5. Acetaminophen 1000 mg PO Q8H
RX *acetaminophen 500 mg 2 tablet(s) by mouth every eight (8)
hours Disp #*90 Tablet Refills:*0
6. Atenolol 25 mg PO DAILY
RX *atenolol 25 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
7. Amlodipine 5 mg PO DAILY
RX *amlodipine 5 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
8. Ranitidine 75 mg PO DAILY
RX *ranitidine HCl 75 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
obstructive sleep apnea
Secondary:
polycystic kidney disease
obesity
hypertension
anxiety
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure caring for you at ___
___. You were admitted to the hospital because you
were having shortness of breath and chest pain. With regards to
your chest pain, we believe that you have musculoskeletal chest
pain due to sleeping on your hard mattress and from your fall.
We do not think your chest pain is related to your heart or your
lungs. We found no evidence of a blood clot in your lungs or
your legs. With regards to your shortness of breath, we believe
that you have obstructive sleep apnea. This means that when you
are asleep, you have periods where you do not breathe properly.
This can cause you to be very sleepy during the day. Therefore,
it is extremely important that you follow up with the pulmonary
team as an outpatient for further testing.
We also found that your kidney function is poor. It is very
important that you follow-up with your outpatient nephrologist.
Please follow-up with your outpatient providers as instructed
below.
Thank you for allowing us to participate in your care. All best
wishes for your recovery.
Sincerely,
Your ___ medical team
Followup Instructions:
___
|
19731864-DS-20
| 19,731,864 | 26,717,645 |
DS
| 20 |
2179-09-08 00:00:00
|
2179-09-09 16:28:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
___
Attending: ___.
Chief Complaint:
Nausea/vomiting
Hematemesis
Supratherapeutic INR
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ female with the past medical
history noted below who presents w/ N/V for the past two days.
She reports that she had had increased sensation of sinus
fullness, post-nasal drip following her dental procedure roughly
___ ago. Her left maxillary area has been tender since her
procedure. For the past two days, her post-nasal drip has
worsened. She had numerous episodes of emesis yesterday. One of
the emesis episodes was notable for blood clots. Given that she
is on anticoagulation, this prompted a visit to the urgent care.
At urgent care, her INR was noted to be 5 so she was sent to
emergency department at ___ for further evaluation. She denies
any recent travel. No recent sick contacts. She denies any
fever,
chills, CP, SOB, abdominal pain, blood per rectum, dysuria.
In the ED, she was found to be afebrile and HDS. Initial
laboratory data notable for Hgb 10.4 and INR 2.9. Given her
history, she was admitted to medicine for further workup.
ROS: Pertinent positives and negatives as noted in the HPI. All
other systems were reviewed and are negative.
Past Medical History:
a fib on coumadin, h/o breast cancer (not active), h/o
lumpectomy ___ years ago), HTN, HLD, hypothyroidism, osteopenia
Social History:
___
Family History:
Mother and father thought to have had HTN, but patient is
unsure. No family history of CAD, DM or hyperlipidemia.
Physical Exam:
Physical exam on admission
VITALS: 98.3
___
GENERAL: Alert and in no apparent distress, very thin, elderly
female
EYES: Anicteric, pupils equally round
ENT: Ears and nose without visible erythema, masses, or trauma.
Oropharynx without visible lesion, erythema or exudate
CV: Heart regular, no murmur, no S3, no S4. No JVD.
RESP: Lungs clear to auscultation with good air movement
bilaterally. Breathing is non-labored
GI: Abdomen soft, non-distended, non-tender to palpation. Bowel
sounds present. No HSM
GU: No suprapubic fullness or tenderness to palpation
MSK: Neck supple, moves all extremities, strength grossly full
and symmetric bilaterally in all limbs
SKIN: No rashes or ulcerations noted
NEURO: Alert, oriented, face symmetric, gaze conjugate with
EOMI,
speech fluent, moves all limbs, sensation to light touch grossly
intact throughout
PSYCH: pleasant, appropriate affect
Pertinent Results:
___ 07:55PM BLOOD WBC-3.5* RBC-3.27* Hgb-9.3* Hct-30.3*
MCV-93 MCH-28.4 MCHC-30.7* RDW-16.3* RDWSD-55.4* Plt ___
___ 10:45PM BLOOD Neuts-86.9* Lymphs-5.8* Monos-6.6
Eos-0.0* Baso-0.3 Im ___ AbsNeut-5.79 AbsLymp-0.39*
AbsMono-0.44 AbsEos-0.00* AbsBaso-0.02
___ 08:35PM BLOOD ___ PTT-47.4* ___
___ 10:45PM BLOOD ___ PTT-42.6* ___
___ 10:16AM BLOOD ___
___ 07:24AM BLOOD ___
___ 07:24AM BLOOD Glucose-85 UreaN-15 Creat-1.1 Na-142
K-4.0 Cl-104 HCO3-26 AnGap-12
___ - EKG: NSR, prolonged QTc
___ - CXR: No acute cardiopulmonary process
___ - CT abd/pelvis w/ contrast: No bowel obstruction, but
prominent small bowel loops with fecalization could suggest
enteritis. 1.9 cm heterogeneous, solid left renal mass,
concerning for renal cell carcinoma.
___ - CT maxillofacial:
1. Findings consistent with acute left maxillary sinusitis, in
communication with a periapical lucency around a partially
intact
left maxillary molar tooth with fragmentation of the
surrounding
bone. Findings should be correlated with the recent dental
procedure
and the timing of that procedure, as these findings may
represent
acute sinusitis of odontogenic origin.
2. Evaluation of the surrounding soft tissues limited due to
streak artifact from dental amalgam, though no drainable fluid
collections are identified.
3. Opacification is also noted in the anterior left ethmoidal
air
cells. Mild mucosal thickening of the left
Brief Hospital Course:
Ms. ___ is a ___ female with history of AF on
Coumadin, hypothyroidism, HTN, recent dental procedure who p/w
hematemesis in the setting of supratherapeutic INR and acute
onset N/V.
#Hematemesis in setting of
#Supratherapeutic INR
GI team consulted who recommended close CBC and hemodynamic
monitoring with plan for EGD on a nonemergent basis. The
patient's hematemesis and self resolved on holding coumadin.
EGD was performed and
did not reveal a source of bleeding. GI recommended PPI,
which was started (omeprazole 40 mg daily) We resumed
anticoagulation with coumadin and advised patient to avoid supra
therapeutic INR and to consider treatment with DOAC. She is
not interested in DOAC, stating she has seen the ads about the
side effects and has her doubts. She states that her INR is
typically within the proper range - ___, and that she will have
it checked through PCP ___. Given that she was started on
augmentin for sinusitis, pharmacy advised her to continue on
coumadin 5 mg of snow.
#Enteritis
Likely viral process. Low suspicion for bacterial infection.
Nausea and vomiting resolved with as needed antiemetics.
#OroAntral communication resulting in maxillary sinusitis
following recent dental procedure
___ recommended 2-week course of Augmentin with close
outpatient oral surgeon follow-up. Daughter will arrange for
outpatient f/u. She will finish a two week course of this
#UTI - seen on Ucx, but may represent asymptomatic bacteriuria.
Will also be covered by augmentin
#Incidental renal mass - discussed with urology who feel that it
is likely an angiomyolipoma that was seen in prior scans. They
have left a note in OMR. I have asked on radiologists to
comment on this as well.
# Intermittent diarrhea, unintentional weight loss: Daughter is
concerned about patient's ongoing intermittent diarrhea and ?
contribution to unintentional weight loss. Patient did not have
any diarrhea while in the hospital so w/u could not be
initiated. Our schedulers are working on obtaining outpatient
GI f/u.
Seen by ___ who advised home ___. Ordered.
Discharge plan discussed extensively with patient and daughter.
Greater than ___ hour spent on care on day of discharge
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Alendronate Sodium 70 mg PO 1X/WEEK (FR)
2. Diltiazem Extended-Release 240 mg PO DAILY
3. Furosemide 20 mg PO DAILY:PRN weight gain, ___ edema
4. Levothyroxine Sodium 100 mcg PO DAILY
5. Warfarin 10 mg PO 3X/WEEK (___)
6. Warfarin 5 mg PO 4X/WEEK (___)
7. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
8. Calcium Carbonate 500 mg PO DAILY
9. Vitamin D 1000 UNIT PO DAILY
10. Multivitamins 1 TAB PO DAILY
Discharge Medications:
1. Amoxicillin-Clavulanic Acid ___ mg PO Q12H
take this for 12 more days. prescription called into your
pharmacy
2. Omeprazole 40 mg PO DAILY
Use this until you see the GI doctors to determine ___ long you
should stay on this.
3. Warfarin 5 mg PO DAILY16
4. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
5. Alendronate Sodium 70 mg PO 1X/WEEK (FR)
6. Calcium Carbonate 500 mg PO DAILY
7. Diltiazem Extended-Release 240 mg PO DAILY
8. Furosemide 20 mg PO DAILY:PRN weight gain, ___ edema
9. Levothyroxine Sodium 100 mcg PO DAILY
10. Multivitamins 1 TAB PO DAILY
11. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Hematemesis
Enteritis
Supratherapeutic INR
UTI
Oralantral communication following recent dental procedure
Discharge Condition:
Discharge conditionstable
Mental statusalert and oriented x3
Ambulatory
Discharge Instructions:
You were admitted to the hospital for nausea/vomiting, blood in
the vomit and found to have elevated INR, which is a marker of
your Coumadin level. CT of your abdomen showed some evidence of
inflammation in your small bowel. The exact cause of this
finding is unclear at this time and can be related to viral
process as known as viral gastroenteritis. During your
hospitalization, you complained of left-sided facial pain,
postnasal drainage, and headache. Given your recent dental
procedure, you underwent CT scan of face/sinuses, which showed
some complications of your recent transfer procedure. We
discussed your case with our oral surgeons who recommended that
you start on antibiotics and follow-up with your outpatient oral
surgeon.
You had an endoscopy given your bleeding but we did not any
ongoing blood loss. Your INR was above 7 when you came in so we
think that you bled due to your blood being too thin. Please
continue to take the medication omeprazole 40 mg (sent to your
pharmacy) until you follow up with GI.
Your augmentin may increase your levels of Coumadin so we
recommend that you take Coumadin five milligrams daily for now.
Please go to the lab on ___ to get your level rechecked.
You and your daughter are concerned about your intermittent
diarrhea and weight loss. We are working on a GI appointment.
You had some low grade temperatures the day prior to discharge,
and these may have been from your sinusitis and UTI. The
antibiotic augmentin will cover both infections.
Followup Instructions:
___
|
19731864-DS-21
| 19,731,864 | 25,209,337 |
DS
| 21 |
2179-12-02 00:00:00
|
2179-12-08 15:41:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
___
Attending: ___.
Chief Complaint:
Decreased alertness and weakness
Major Surgical or Invasive Procedure:
___ Thrombectomy
___ ___ guided PICC placement
___ PEG tube placement
History of Present Illness:
EU ___ (aka ___ is an ___ yr F w/ hx of
Breast
CA s/p lumpectomy and chemo/XRT, L ICA aneurysm s/p coiling,
HTN,
HLD, and Afib on Xarelto who presents with decreased
responsiveness and weakness. Pt was reportedly in USOH until
earlier this afternoon when family heard a thud coming from her
room. When they entered they found her down and unresponsive on
the ground. She woke up slightly as they aroused her but was
non-interactive. EMS was called her brought pt urgent to ED for
evaluation. After neurologic evaluation in ED, CT imaging was
performed with apparent L M1 occlusion and notable mismatch
ratio
on CTP. Pt was thus taken for thrombectomy.
Of note, pt's Xarelto was recently held x 2 days for tooth
extraction. Otherwise, pt is compliant with medication. Per
family, pt is relatively independent at home, continues to
drive
locally.
Past Medical History:
Breast CA dx in ___ lumpectomy in ___, HER-2 and ER
positive s/p APT regimen and Anastrozole
Cerebral aneurysm s/p coiling in ___
Afib on Xarelto/Coumadin
MR/TR
CHFrEF
HTN
HLD
Hypothyroidism
Social History:
___
Family History:
Mother and father thought to have had HTN, but patient is
unsure. No family history of CAD, DM or hyperlipidemia.
Physical Exam:
ADMISSION EXAM:
===============
Vitals: T: 97.9 HR: 73 BP: 199/92 RR: 20 SaO2: 95% RA
General: Somnolent, O2 NC in place, collar in place
HEENT: NCAT, no oropharyngeal lesions, neck supple
___: RRR, no M/R/G
Pulmonary: CTAB, no crackles or wheezes
Abdomen: Soft, NT, ND, +BS, no guarding
Extremities: Warm, no edema
Neurologic Examination:
MS: Somnolent, arousable to verbal stimuli. EO spontaneously.
Regards and tracks examiner on L. Does not follow commands.
CN: PERRL 3->2mm, EOM unable to cross midline to R, unable to
check forced gaze due to presence of hard collar, Decreased
blink
on R. Grimaces appropriately to noxious stimuli with mild facial
asymmetry L>R.
Sensorimotor: Intact bulk and tone b/l. AG in LUE, drift in LLE.
Moves RUE/RLE in position of bed. Withdraws to noxious in all
extremities b/l. No adventitious movements or asterixis
present.
___: Deferred
DISCHARGE EXAM:
===============
Tmax: 36.8 °C (98.3 °F)
Tcurrent: 36.6 °C (97.9 °F)
HR: 71 (67 - 85) bpm
BP: 129/71(87) {115/61(76) - 149/76(95)} mmHg
RR: 17 (13 - 23) insp/min
SpO2: 98%
Heart rhythm: AF (Atrial Fibrillation)
Wgt (current): 56.4 kg (admission): 56.4 kg
Exam
General: Thin, eyes open looks around the room
HEENT: NCAT, mild left lower jaw swelling but difficult to
assess, purses lips and won't allow me to open her mouth
___: Irregularly irregular
Pulmonary: Breathing on RA
Abdomen: Soft, NT, ND, no guarding
Extremities: Warm, no edema, no swelling or erythema of right
shoulder, mild pain to palpation and movement
Neurologic Examination:
MS: Eyes open spontaneously, Regards and tracks examiner to the
right of midline. Does not follow commands. Says "stop that now"
when examining her
CN: Looks fully to the right but does still have left gaze
preference, Grimaces appropriately to noxious stimuli with mild
facial asymmetry L>R. Resists eye opening strongly bilaterally,
does not stick her tongue out to command
Sensorimotor: Decreased bulk throughout. Unable to do formal
confrontational testing
LUE: antigravity and spontaneous
RUE: antigravity at elbow and wrist, no proximal movement
RLE: withdraw to noxious, moves RLE to push me away from LLE
LLE: very sluggish foot flexion to noxious
reaction to noxious or touch in all 4 extremities.
DTRS: deferred
___: unable to assess formally but no overt
dysmetria when attempting to push away examiner
Pertinent Results:
ADMISSION LABS:
===============
___ 07:01PM URINE HOURS-RANDOM
___ 07:01PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG oxycodn-NEG mthdone-NEG
___ 07:01PM URINE COLOR-Straw APPEAR-Clear SP ___
___ 07:01PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-8.0
LEUK-NEG
___ 05:46PM GLUCOSE-117* CREAT-0.9 NA+-141 K+-4.2 CL--105
TCO2-28
___ 05:46PM estGFR-Using this
___ 05:40PM UREA N-14
___ 05:40PM ALT(SGPT)-9 AST(SGOT)-28 ALK PHOS-68 TOT
BILI-0.3
___ 05:40PM cTropnT-<0.01
___ 05:40PM ALBUMIN-3.8
___ 05:40PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
tricyclic-NEG
___ 05:40PM WBC-4.3 RBC-3.48* HGB-10.1* HCT-32.1* MCV-92
MCH-29.0 MCHC-31.5* RDW-15.9* RDWSD-53.6*
___ 05:40PM NEUTS-46.5 ___ MONOS-14.5* EOS-0.7*
BASOS-0.2 IM ___ AbsNeut-2.01 AbsLymp-1.61 AbsMono-0.63
AbsEos-0.03* AbsBaso-0.01
___ 05:40PM ___ PTT-29.3 ___
___ 05:40PM PLT COUNT-179
Discharge Labs
================
___ 04:03AM BLOOD WBC-6.1 RBC-3.07* Hgb-8.8* Hct-29.1*
MCV-95 MCH-28.7 MCHC-30.2* RDW-16.4* RDWSD-53.6* Plt ___
___ 04:03AM BLOOD Glucose-80 UreaN-11 Creat-0.7 Na-142
K-4.1 Cl-105 HCO3-26 AnGap-11
___ 04:03AM BLOOD Calcium-8.6 Phos-2.8 Mg-1.9
Important Interval Labs
=======================
___ 12:15AM BLOOD Triglyc-62 HDL-53 CHOL/HD-2.9 LDLcalc-91
___ 12:15AM BLOOD %HbA1c-5.3 eAG-105
___ 12:15AM BLOOD TSH-3.3
___ 04:42AM BLOOD CRP-57.5*
___ 04:03AM BLOOD CRP-28.2*
IMAGING:
========
CTA HEAD/NECK ___:
1. Distal left M1 occlusion with a mismatch volume of 229 mL.
2. Left MCA collaterals less than 50% compared to right side.
3. Calculated CBF < 30% is 6 mm. Much greater area of infarct
is seen on CTA MIPS images involving left insula, M1, M 5; and
probably M2, M3 territories.
4. Findings consistent with severe chronic small vessel ischemic
changes.
Probable chronic small infarct right centrum semiovale.
5. Left PCOM aneurysm embolization, with recanalization at the
aneurysm base.
6. Complete opacification left maxillary sinus, suggestion of
odontogenic
sinusitis. Chronic surrounding periostitis. Pre antral, retro
antral,
pterygopalatine space, buccal space inflammatory change
consistent with
infection.
7. Chronic small vessel ischemic changes intracranially.
8. Otherwise, mild atherosclerotic changes neck, intracranially.
9. Suggestion of pulmonary artery hypertension.
ENDOVASCULAR NEUROLOGY PROCEDURE ___:
Arterial occlusion of the superior M 2 division of the left
middle cerebral artery.
Mechanical thrombectomy could not performed due to excessive
tortuosity of the aortic arch and left common carotid artery.
CT HEAD ___:
1. Loss of gray-white differentiation in the left frontal lobe
and left sub insular cortex, consistent with infarction.
2. No intracranial hemorrhage.
3. Paranasal sinus disease with chronic inflammatory changes in
the left
maxillary sinus.
4. Dehiscence of the left maxillary sinus wall with inflammatory
soft tissue in the left buccal space, extending to the
pterygopalatine fossa. Clinical correlation and correlation
with prior imaging if available is recommended to document
stability of the finding as this could result in intracranial
extension of infectious process.
5. Additional findings described above.
MRI/MRA BRAIN ___:
1. Large late acute infarct within the right frontal lobe and
insular cortex with multiple punctate satellite infarcts.
2. Additional punctate infarcts within the left corona radiata,
left
periatrial white matter, left occipital cortex, right frontal
lobe, and right cerebellum.
3. There is recanalization of the mid to distal left M1 segment
occlusion seen on prior CT head. There remains occlusion of the
left M2 superior segment just distal to its take-off.
Additional multifocal mild to moderate arterial stenosis.
4. Complete opacification of the maxillary sinus with dehiscence
of the
inferior wall with extension into the left buccal space and
pterygopalatine fossa, as described on the prior CT.
5. Additional findings described above.
TTE ___:
The left atrial volume index is SEVERELY increased. There is no
evidence for an atrial septal defect by 2D/color Doppler. The
estimated right atrial pressure is >15mmHg. There is normal left
ventricular wall
thickness with a normal cavity size. There is normal regional
and global left ventricular systolic function. The visually
estimated left ventricular ejection fraction is 65%. There is no
resting left ventricular outflow tract gradient. Moderately
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 no aortic
regurgitation. The mitral valve leaflets are mildly thickened
with no mitral valve prolapse. There is mild to moderate [___]
mitral regurgitation. The tricuspid valve leaflets
are mildly thickened with systolic prolapse. There is
physiologic tricuspid regurgitation. There is moderate pulmonary
artery systolic hypertension. There is no pericardial effusion.
___ Shoulder X-ray
There is no fracture or dislocation involving the glenohumeral
or AC joint. There are no significant degenerative changes. A
calcified fragmented rim projects around the right humeral head
likely reflecting chondrocalcinosis. No suspicious lytic or
sclerotic lesions are identified. No periarticular calcification
or radio-opaque foreign body is seen. The visualized right lung
apex is unremarkable.
IMPRESSION:
No acute osseous abnormality of the right shoulder.
Chondrocalcinosis.
Brief Hospital Course:
___ is an ___ year old woman with past history of breast
CA s/p lumpectomy and chemo/XRT, left ICA aneurysm s/p coiling,
HTN, HLD, and atrial fibrillation on Xarelto who presented with
decreased responsiveness and weakness subsequently found to have
large left M2 occlusion s/p unsuccessful thrombectomy.
#L MCA ischemic stroke:
Exam was consistent with large area of ischemia in L MCA
territory seen on CTA/CTP with noted right hemiparesis and
global aphasia. MRI revealed significant left frontal superior
MCA infarct but no hemorrhage. Etiology of stroke likely
cardioembolic in the setting of atrial fibrillation and recent
discontinuation of anticoagulation therapy for dental procedure.
No significant findings on CTA clearly pointing to an artery to
artery cause. TTE was notable for increased left atrial volume
index and no evidence of cardiac source of embolus. Risk factors
were significant for LDL 91, HgbA1C 5.3 and TSH 3.3. She was
started on aspirin and atorvastatin. Anticoagulation was
restarted with xarelto after PEG placement. She was also started
on fluoxetine for mood after stroke.
#Mastoid Sinusitis
#Bisphosphonate associated osteonecrosis of the jaw with
actinomyces infection
Her hospital course was complicated by mastoid sinusitis for
which both ENT and OMFS services were consulted. She spiked
fevers while inpatient and broad spectrum abx were started. OMFS
and ENT recommended cefepime and metronidazole for possible
sinusitis. Records from outside dentist were obtained where she
had had tooth extraction and debridement prior to admission.
Pathology results from this tissues was c/w bisphosphonate
associated osteonecrosis of the jaw with actinomyces infection.
ID was consulted who recommended treatment with IV penicillin G
for 6 weeks then plan for prolonged course of oral penicillin.
Outside pathology slides were requested for review at ___ and
were pending at time of discharge. Per OMFS there were no plans
for further debridement or intervention and recommended
antibiotics per ID. After starting penicillin she remained
afebrile without leukocytosis. CRP was elevated at 57.5 and
trended down to 28.2 after starting penicillin. Patient will
follow up with ENT as an outpatient and ID. In addition will
need weekly CRP and labs per OPAT note. Projected end date of IV
antibiotics ___. PICC was placed prior to discharge for long
term antibiotics.
Her alendronate should not be continued as an outpatient. Her
calcium and vit D were continued
#Urinary Retention: During admission patient failed voiding
trial and was requiring very frequent straight cath. To reduce
trauma a foley was placed. She was discharge with foley to have
voiding trial repeated at rehab.
#Shoulder pain: During hospitalization patient developed
intermittent right shoulder pain with movement. Xray showed
chondrocalcinosis, no fracture or other osseous lesions. This
was managed symptomatically with lidocaine patch, tylenol and
___.
#Afib: After PEG placement she was restarted on therapeutic
anticoagulation with xarelto. Her diliazem was not restarted
during hospitalization initially to allow BP to autoregulate. HR
remained in ___ during admission so this was not restarted.
Can consider starting half dose diliazem if needed for HR. Her
home Lasix was held as there was not evidence of volume overload
during admission and order was written for PRN for leg swelling.
#Hypothyroidism: continued home levothyroxine
Transitional Issues
=====================
[]OPAT Antimicrobial Regimen and Projected Duration:
Agent & Dose: Penicillin G 3million q 4 hours
Start Date: ___
Projected End Date: ___
LAB MONITORING RECOMMENDATIONS: NOTE: For lab work to be drawn
after discharge, a specific standing order for Outpatient Lab
Work is required to be placed in the Discharge Worksheet -
Post-Discharge Orders. Please place an order for Outpatient Labs
based on the MEDICATION SPECIFIC GUIDELINE listed below:
ALL LAB RESULTS SHOULD BE SENT TO:
ATTN: ___ CLINIC - FAX: ___
WEEKLY: CBC with differential, BUN, Cr, CRP
[]Rehab: Please do voiding trial as appropriate and remove Foley
[]Rehab: Patient's Diltiazem was not restarted during
hospitalization initially to allow BP to autoregulate. HR
remained in ___ during admission so this was not restarted.
Can consider starting half dose diliazem if needed for HR.
[]Please pause TF tonight for xarelto administration and start
bolus TF when able. Nutrition recommendation for bolus TF
Promote 240ml 6x/day
[]patient discharged off home RPN Lasix
[]Omeprazole was changed to lansoprazole so that it could be
given through PEG
[]Follow up with ENT
[]Follow up with Neurology
[]Follow up with GI per prior scheduled appointment
AHA/ASA Core Measures for Ischemic Stroke and Transient Ischemic
Attack
1. Dysphagia screening before any PO intake? (x) Yes, confirmed
done - () Not confirmed () No. If no, reason why:
2. DVT Prophylaxis administered? (x) Yes - () No. If no, why not
(I.e. bleeding risk, hemorrhage, etc.)
3. Antithrombotic therapy administered by end of hospital day 2?
(x) Yes - () No. If not, why not? (I.e. bleeding risk,
hemorrhage, etc.)
4. LDL documented? (x) Yes (LDL =91) - () No
5. Intensive statin therapy administered? (simvastatin 80mg,
simvastatin 80mg/ezetemibe 10mg, atorvastatin 40mg or 80 mg,
rosuvastatin 20mg or 40mg, for LDL > 70) (x) Yes - () No [if LDL
>70, reason not given:
[ ] Statin medication allergy
[ ] Other reasons documented by physician/advanced practice
nurse/physician ___ (physician/APN/PA) or pharmacist
[ ] LDL-c less than 70 mg/dL
6. Smoking cessation counseling given? () Yes - (x) No [reason
() non-smoker - (x) unable to participate]
7. Stroke education (personal modifiable risk factors, how to
activate EMS for stroke, stroke warning signs and symptoms,
prescribed medications, need for followup) given (verbally or
written)? (x) Yes - () No
8. Assessment for rehabilitation or rehab services considered?
(x) Yes - () No. If no, why not? (I.e. patient at baseline
functional status)
9. Discharged on statin therapy? (x) Yes - () No [if LDL >70,
reason not given:
[ ] Statin medication allergy
[ ] Other reasons documented by physician/advanced practice
nurse/physician ___ (physician/APN/PA) or pharmacist
[ ] LDL-c less than 70 mg/dL
10. Discharged on antithrombotic therapy? (x) Yes [Type: ()
Antiplatelet - (x) Anticoagulation] - () No
11. Discharged on oral anticoagulation for patients with atrial
fibrillation/flutter? (x) Yes - () No - If no, why not (I.e.
bleeding risk, etc.) () N/A
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
2. Calcium Carbonate 500 mg PO DAILY
3. Levothyroxine Sodium 100 mcg PO DAILY
4. Vitamin D 1000 UNIT PO DAILY
5. Warfarin 5 mg PO DAILY16
6. Amoxicillin-Clavulanic Acid ___ mg PO Q12H
7. Alendronate Sodium 70 mg PO 1X/WEEK (FR)
8. Furosemide 20 mg PO DAILY:PRN weight gain, ___ edema
9. Omeprazole 40 mg PO DAILY
10. Multivitamins 1 TAB PO DAILY
11. Diltiazem Extended-Release 240 mg PO DAILY
Discharge Medications:
1. Atorvastatin 40 mg PO QPM
2. FLUoxetine 10 mg PO DAILY
3. Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY
4. Lidocaine 5% Patch 1 PTCH TD QAM apply to shoulder
5. Magnesium Oxide 400 mg PO BID Duration: 2 Doses
6. Penicillin G Potassium 3 Million Units IV Q4H
7. Rivaroxaban 15 mg PO DINNER
8. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
9. Calcium Carbonate 500 mg PO DAILY
10. Levothyroxine Sodium 100 mcg PO DAILY
11. Multivitamins 1 TAB PO DAILY
12. Vitamin D 1000 UNIT PO DAILY
13. HELD- Diltiazem Extended-Release 240 mg PO DAILY This
medication was held. Do not restart Diltiazem Extended-Release
until you follow up with your PCP
14. HELD- Furosemide 20 mg PO DAILY:PRN weight gain, ___ edema
This medication was held. Do not restart Furosemide until you
follow up with your PCP
___:
Extended Care
Facility:
___
Discharge Diagnosis:
Acute ischemic stroke
Atrial fibrillation
Hypertension
Hyperlipidemia
Congestive heart failure
Discharge Condition:
Mental Status: Confused - always.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Level of Consciousness: Alert and interactive.
Discharge Instructions:
Dear ___,
You were hospitalized due to symptoms of decreased
responsiveness and weakness resulting from an ACUTE ISCHEMIC
STROKE, a condition where a blood vessel providing oxygen and
nutrients to the brain is blocked by a clot. The brain is the
part of your body that controls and directs all the other parts
of your body, so damage to the brain from being deprived of its
blood supply can result in a variety of symptoms.
Stroke can have many different causes, so we assessed you for
medical conditions that might raise your risk of having stroke.
In order to prevent future strokes, we plan to modify those risk
factors. Your risk factors are:
- Hypertension
- Atrial fibrillation
- Hyperlipidemia
We are changing your medications as follows:
- Start taking atorvastatin 40mg daily
- Continue taking your xarelto for anticoagulation
Please take your other medications as prescribed.
Please follow up with Neurology and your primary care physician
as listed below.
If you experience any of the symptoms below, please seek
emergency medical attention by calling Emergency Medical
Services (dialing 911). In particular, since stroke can recur,
please pay attention to the sudden onset and persistence of
these symptoms:
- Sudden partial or complete loss of vision
- Sudden loss of the ability to speak words from your mouth
- Sudden loss of the ability to understand others speaking to
you
- Sudden weakness of one side of the body
- Sudden drooping of one side of the face
- Sudden loss of sensation of one side of the body
Sincerely,
Your ___ Neurology Team
Followup Instructions:
___
|
19732106-DS-3
| 19,732,106 | 28,157,367 |
DS
| 3 |
2173-05-20 00:00:00
|
2173-05-20 18:53:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Bactrim / Augmentin
Attending: ___.
Chief Complaint:
r. facial droop w/ abnormal brain MRI
Major Surgical or Invasive Procedure:
Lumbar Puncture ___
Flexible bronchoscopy, tumor destruction, endobronchial biopsy,
cryo biopsy, TBNA ___.
History of Present Illness:
___ hx of HIV ___: CD4 365 Viral Load 33) presents after
finding on MRI of multiple ring enhancing lesions.
His presentation begins when he developed R facial droop
approximates 6 weeks prior, intermittently associated with
headaches and numbness and tingling down his right arm. His PCP
diagnosed ___ Palsy, and he received a weeklong course of
prednisone and valacyclovir with minimal improvement. As he was
having posterior headaches intermittently, typically in the AM,
he was initially to have MRI, but this headache stopped and so
this was deferred. He was also having R eye lacrimation. He got
his MRI on ___, with the finding of multiple ring enhancing
lesions, and was sent to the ED for evaluation.
In the ED, initial vitals were: 98.6 70 138/72 12 99% RA
- Labs were significant forK 4.4, BUn/Cr ___, mild relative
anemia of 12.8/37.2 from 13.___ six weeks prior.
- Imaging from prior to presentation reveals ring enhancing
lesions
- The patient was given nothing
Vitals prior to transfer were 98 78 114/76 18 100% RA
Upon arrival to the floor, he endorses the above story, denies
headache or any neurologic changes over the past six weeks.
Review of systems otherwise negative.
REVIEW OF SYSTEMS:
(+) Per HPI
Past Medical History:
Thalassemia trait
Human immunodeficiency virus (HIV) disease
Need for pneumocystis prophylaxis
Hyperlipidemia
Eosinophilia
Hemoglobin low
History of hepatitis B
Anogenital warts in male s/p laser ablation of perianal
condyloma and treatment of internal anal condyloma
Social History:
___
Family History:
No known history of lymphoma
Physical Exam:
ADMISSION PHYSCIAL EXAM
============================
Vitals: 97.8 125/64 74 18 100% RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, pupils are
equal and reactive to light
Neck: Supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
GU: No foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CN II-XII intact with exception of motor function on
right face, unable to completely close right eye, sensation
intact on right face, ___ strength upper/lower extremities,
grossly normal sensation, vision intact on both sides, gait
deferred.
DISCHARGE PHYSICAL EXAM
==========================
VS: Tm 98.4 BP 101/56 HR 55 20RR 99% on RA
I/Os: pMN ___. p24hr ___.
GENERAL: Alert, oriented, comfortable
HEENT: Sclerae anicteric, MMM, oropharynx w/minor excoriations
NECK: supple, no LAD
RESP: CTAB no wheezes, rales, rhonchi
CV: RRR, Nl S1, S2, No MRG
ABD: Soft, NT/ND bowel sounds present
GU: no foley
EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CN II-XII intact with exception of CN7 motor function on
right face, unable to completely close right eye, sensation
intact on right face, able to raise eyebrows bilaterally, tongue
midline. PERRLA. ___ strength throughout, grossly normal
sensation. Ambiguous tone with increased tone in legs vs.
voluntary flexion. Brisk 2+ reflexes bilaterally, with down
going babinski.
SKIN: No excoriations or rash.
Pertinent Results:
ADMISSION LABS:
===============
___ 11:03PM WBC-7.6 LYMPH-32 ABS LYMPH-2432 CD3-51 ABS
CD3-1229 CD4-18 ABS CD4-443 CD8-31 ABS CD8-748* CD4/CD8-0.6*
___ 11:03PM PLT COUNT-313
___ 11:03PM NEUTS-60.7 ___ MONOS-5.4 EOS-1.9
BASOS-0.3
___ 11:03PM WBC-7.6 RBC-4.33* HGB-12.8* HCT-37.2* MCV-86
MCH-29.5 MCHC-34.4 RDW-14.9
___ 11:03PM estGFR-Using this
___ 11:03PM GLUCOSE-96 UREA N-20 CREAT-0.9 SODIUM-134
POTASSIUM-6.7* CHLORIDE-101 TOTAL CO2-24 ANION GAP-16
___ 12:39AM K+-4.4
___ 06:21AM PLT COUNT-308
___ 06:21AM WBC-7.3 RBC-4.11* HGB-11.8* HCT-35.3* MCV-86
MCH-28.6 MCHC-33.3 RDW-14.9
___ 09:39AM ALBUMIN-3.8 CALCIUM-9.5 PHOSPHATE-3.0
MAGNESIUM-1.8
___ 09:39AM ALT(SGPT)-20 AST(SGOT)-20 LD(LDH)-230 ALK
PHOS-92 TOT BILI-0.2
___ 09:39AM GLUCOSE-92 UREA N-17 CREAT-0.7 SODIUM-136
POTASSIUM-4.2 CHLORIDE-104 TOTAL CO2-22 ANION GAP-14
___ 05:35PM CEREBROSPINAL FLUID (CSF) WBC-3 RBC-2* POLYS-0
___ ___ 05:35PM CEREBROSPINAL FLUID (CSF) PROTEIN-238*
GLUCOSE-64
DISCHARGE LABS:
===============
___ 06:57AM BLOOD WBC-18.8* RBC-4.33* Hgb-12.4* Hct-37.5*
MCV-87 MCH-28.7 MCHC-33.2 RDW-15.0 Plt ___
___ 06:57AM BLOOD Plt ___
___ 11:03PM BLOOD WBC-7.6 Lymph-32 Abs ___ CD3%-51
Abs CD3-1229 CD4%-18 Abs CD4-443 CD8%-31 Abs CD8-748*
CD4/CD8-0.6*
___ 06:57AM BLOOD Glucose-129* UreaN-21* Creat-0.9 Na-136
K-4.4 Cl-100 HCO3-25 AnGap-15
___ 06:57AM BLOOD Calcium-9.8 Phos-3.4 Mg-1.9
URINE
========
___ 02:52PM URINE Osmolal-799
___ 02:52PM URINE Hours-RANDOM Creat-144 Na-94 K-74 Cl-54
CSF
======
___ 05:35PM CEREBROSPINAL FLUID (CSF) WBC-3 RBC-2* Polys-0
___ ___ 05:35PM CEREBROSPINAL FLUID (CSF) TotProt-238*
Glucose-64
___ 05:35PM CEREBROSPINAL FLUID (CSF) CSF HOLD-PND
___ 06:27PM CEREBROSPINAL FLUID (CSF) TB - PCR-PND
___ 06:27PM CEREBROSPINAL FLUID (CSF) TOXOPLASMA GONDII BY
PCR-Test. Not detected.
___ 06:27PM CEREBROSPINAL FLUID (CSF) ___ VIRUS (JCV) DNA
QUANTITATIVE PCR-PND
___ 06:27PM CEREBROSPINAL FLUID (CSF) ___ VIRUS,
QUAL TO QUANT, PCR-PND
___ 05:35PM CEREBROSPINAL FLUID (CSF) HERPES SIMPLEX VIRUS
PCR-Test NEG.
___ 5:35 pm CSF;SPINAL FLUID Source: LP #3.
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final ___: NO GROWTH.
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
ACID FAST CULTURE (Preliminary):
The sensitivity of an AFB smear on CSF is very low..
If present, AFB may take ___ weeks to grow..
Enterovirus Culture (Preliminary): No Enterovirus
isolated.
MICROBIOLOGY:
==============
___ STOOL OVA + PARASITES: NO OVA AND PARASITES
SEEN.
___ STOOL OVA + PARASITES: NO OVA AND PARASITES
SEEN.
___ CSF;SPINAL FLUID GRAM STAIN-FINAL; FLUID
CULTURE-FINAL; FUNGAL CULTURE-PRELIMINARY; ACID FAST
CULTURE-PRELIMINARY; Enterovirus Culture- GRAM STAIN (Final
___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
This is a concentrated smear made by cytospin method,
please refer tohematology for a quantitative white blood cell
count..
FLUID CULTURE (Final ___: NO GROWTH.
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
ACID FAST CULTURE (Preliminary):
The sensitivity of an AFB smear on CSF is very low..
If present, AFB may take ___ weeks to grow..
___ CSF;SPINAL FLUID CRYPTOCOCCAL ANTIGEN:
CRYPTOCOCCAL ANTIGEN NOT DETECTED.
___ BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
___ BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
___ SEROLOGY/BLOOD CRYPTOCOCCAL ANTIGEN:
CRYPTOCOCCAL ANTIGEN NOT DETECTED.
___ Immunology (CMV) CMV Viral Load-FINAL
INPATIENT:
CMV Viral Load (Final ___:
CMV DNA not detected.
___ Blood (EBV) ___ VIRUS VCA-IgG
AB-FINAL; ___ VIRUS EBNA IgG AB-FINAL; ___
VIRUS VCA-IgM AB-FINAL INPATIENT
___ VIRUS VCA-IgG AB (Final ___: POSITIVE
BY EIA.
___ VIRUS EBNA IgG AB (Final ___: POSITIVE
BY EIA.
___ VIRUS VCA-IgM AB (Final ___:
NEGATIVE <1:10 BY IFA.
INTERPRETATION: RESULTS INDICATIVE OF PAST EBV INFECTION.
In most populations, 90% of adults have been infected at
sometime
with EBV and will have measurable VCA IgG and EBNA
antibodies.
Antibodies to EBNA develop ___ weeks after primary
infection and
remain present for life. Presence of VCA IgM antibodies
indicates
recent primary infection.
___ Blood (CMV AB) CMV IgG ANTIBODY-FINAL; CMV
IgM ANTIBODY-FINAL INPATIENT
POSITIVE FOR CMV IgG ANTIBODY BY EIA.
141 AU/ML.
Reference Range: Negative < 4 AU/ml, Positive >= 6 AU/ml.
CMV IgM ANTIBODY (Final ___:
NEGATIVE FOR CMV IgM ANTIBODY BY EIA.
INTERPRETATION: INFECTION AT UNDETERMINED TIME.
A positive IgG result generally indicates past exposure.
Infection with CMV once contracted remains latent and may
reactivate
when immunity is compromised.
___ Blood (Toxo) TOXOPLASMA IgG ANTIBODY-FINAL;
TOXOPLASMA IgM ANTIBODY-FINAL INPATIENT :POSITIVE FOR TOXOPLASMA
IgG ANTIBODY BY EIA.
16 IU/ML.
Reference Range: Negative < 4 IU/ml, Positive >= 8 IU/ml.
TOXOPLASMA IgM ANTIBODY (Final ___:
NEGATIVE FOR TOXOPLASMA IgM ANTIBODY BY EIA.
INTERPRETATION: INFECTION AT UNDETERMINED TIME
___ SEROLOGY/BLOOD RAPID PLASMA REAGIN
TEST-FINAL INPATIENT: negative
___ BLOOD CULTURE Blood Culture, Routine-PENDING
EMERGENCY WARD
___ IMMUNOLOGY HIV-1 Viral
Load/Ultrasensitive-FINAL: HIV-1 RNA is not detected.
IMAGING
=========
___ MRI Brain (Outside Study): IMPRESSION: Numerous b/l
intracranial lesions many of which are hemorrhagic and are
associated with significant vasogenic edema. The largest mass is
in the left occipital lobe demonstrating blood products of
various chronicity.
___: CT HEAD W/O CONTRAST:lesions are most consistent with
multiple metastatic foci in the setting of a newly discovered
lungs mass, characterized on chest CT from ___.
___ CT Chest/Abd/Pelvis IMPRESSION:Large multilobulated
left upper lobe mass partially invading into the left apical
segment bronchus compatible with primary malignancy with
additional areas in the left upper lobe worrisome for local
spread. No other metastatic lesions identified in the abdomen
or pelvis.
___ BONE Scan: Preliminary report has not yet been
released for viewing.
PATHOLOGY
=============
___ Cytology FINE NEEDLE ASPIRATION: pending
___ Pathology Tissue: BRONCHUS, BIOPSY (TRANSBRONCHIAL
/ENDOBRONCHIAL): pending
Brief Hospital Course:
___ from ___ with hx of HIV (CD4 443, Viral Load
undetectable, on HAART) who presents with R. facial droop, HA,
found to have primary lung lesion and multiple b/l ring
enhancing hemorrhagic brain lesions. ___ bronchoscopy and
needle biopsy of lung lesion, with results pending, plan for
follow up with RadOnc and HemeOnc.
#Brain mets from primary lung lesion: Symptoms include r. facial
droop, R. eye lacrimation, and intermittent HA, and numbness and
tingling in R. arm. ___ MRI showed multpile b/l
ring-enhancing, hemorrhagic, edematous lesions w/o midline
shift. An LP was performed for infectious/malignancy work up.
Infectious workup to date has been negative, with some results
pending. CSF xanthochromia, elevated protein, and elevated
lymphocytes, consistent with brain mets. Patient had a CT
chest/abd/thorax which revealed a lung primary lesion, making
brain lesions almost certainly to be metastatic lesions ___
primary lung cancer. The patient was evaluated by infectious
disease, heme-onc, and rad-onc, neurology, and neurosurgery.
Mr. ___ was started on high dose steroids to reduce brain
swelling and Keppra as a prophylaxis against seizures. In the
setting of high dose steroid use he was started on atovaquone
for prophylaxis against PCP pneumonia, omeprazole, calcium, and
vitamin D supplements. Anticoagulation is contraindicated given
that he has hemorrhagic brain lesions. Plan for patient to
receive brain mapping as outpatient ___ for follow up with
radiation oncology.
#lung mass: ___ CT chest w/ lg multilobulated LUL mass
partially invading into the left apical segment bronchus
compatible with primary malignancy with additional areas in the
left upper lobe worrisome for local spread. Brain mets seen on
brain MRI, no other metastatic lesions identified in the
abd/pelvis. Alk phos 92, not elevated; bone scan for bone
metastases completed ___ with resultes pending.
Bronchoscopy and fine needle biopsy was performed ___ with
results pending. Patient has no cough, SOB, or hemoptysis.
#Hyponatremia: Patient had abnormal sodium 131, measured
osmolality 285, and euvolemia on exam, concerning for SIADH ___
CNS disease or lung malignancy. Urine: Creat:144, Na:94
Osmolal:799 --> FENa 0.4% is consistent with SIADH. He was
fluid restricted to 2L per day. His sodium normalized to 136 on
discharge.
#Leukocytosis: WBC 18.8, ___ new high dose steroids with PMN
demargination. Bronchoscopy ___ also be contributing. No
signs of infection were noted.
#Hyperglycemia: Glu 129, ___ high dose steroids.
#HIV: CD4 443, Viral Load undetectable, continued on
Emtiritabine-Tenofovir, Raltegravir. As described above,
patients presentation is concerning for metastatic lung cancer
not HIV related infection. Negative infectious work up to date:
RPR for syphilis neg. Neg for TB. Serum EBV PCR 6778H,
non-contributory. EBV, CMV, Toxo IgG pos, IgM neg, consistent
with past exposure but no current infection. Stool culture x1
neg for ova and parasites. Further stool cultures pending.
#normocytic anemia: Admission Hct 35.3, Hg 11.8, MCV 86. Most
likely physiologic variation related to thalassemia trait given
iron studies normal vs. Anemia of chronic disease. Iron: 69
calTIBC: 321 Ferritn: 64 TRF: 247
#Hepatitis B: LFTs wnl.
# CODE STATUS: Full Code Confirmed
# CONTACT: (Brother ___
___ Issues:
========================
[]Patient has had no seizures but we feel that seizure
prophylaxis with Keppra 1000mg QD is appropriate given multiple
brain with edema and hemorrhage.
[]High dose dexamethasone is appropriate to reduce brain
swelling. This medication will be tapered as an outpatient.
[]Patient should be maintained on omeprazole, calcium, and
vitamin D to prevent complications of high dose steroids.
[]Patient reports allergy to bactrim, and so Atovaquone has been
used for PCP prophylaxis in the setting of high dose steroids.
[]Patient is likely to undergo radiation therapy, he will need a
CT brain mapping, and appointment has been scheduled for
___.
[]Patient has pending cytology and surgical biopsy results from
his bronchoscopy. These will be followed up by oncology.
[]If patient has any change in neurologic function, he should go
to the the ED and may need to undergo urgent whole brain
radiotherapy.
[]Outpatient work up of anemia may be considered
[]PFT's (___) as outpatient, unless recommendation for
urgent surgical procedure inpatient.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Emtricitabine-Tenofovir (Truvada) 1 TAB PO DAILY
2. Raltegravir 400 mg PO BID
3. Aquaphor Ointment 1 Appl TP TID:PRN affected area
Discharge Medications:
1. Aquaphor Ointment 1 Appl TP TID:PRN affected area
2. Emtricitabine-Tenofovir (Truvada) 1 TAB PO DAILY
3. Raltegravir 400 mg PO BID
4. Atovaquone Suspension 750 mg PO BID
RX *atovaquone 750 mg/5 mL 5 mL by mouth twice a day Refills:*0
5. Calcium Carbonate 500 mg PO BID
RX *calcium carbonate [Calcium 500] 500 mg calcium (1,250 mg) 1
tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*0
6. Dexamethasone 4 mg PO Q6H
RX *dexamethasone 4 mg 1 tablet(s) by mouth every six (6) hours
Disp #*24 Tablet Refills:*0
7. LeVETiracetam 1000 mg PO BID seizure prophylaxis
RX *levetiracetam 1,000 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*0
8. Omeprazole 40 mg PO DAILY
RX *omeprazole 40 mg 1 capsule(s) by mouth daily Disp #*30
Capsule Refills:*0
9. Vitamin D ___ UNIT PO DAILY
RX *ergocalciferol (vitamin D2) 2,000 unit 1 tablet(s) by mouth
Daily Disp #*30 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
========
Lung Mass
Brain Metastases (with probable lung primary)
Central Cranial Nerve VII Palsy
Secondary:
==========
Hyponatremia
Normocytic Anemia
Thalassemia
HIV on HAART
Hepatitis B
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
Thank you for letting us participate in your care during your
hospitalization at ___. You came to the hospital because of
right sided facial droop, and an outside MRI that showed brain
lesions. We performed a lumbar puncture to evaluate your
cerebral spinal fluid. We also did several imaging studies, and
found that you have a mass in your lung which is most likely
lung cancer. The lesions in your brain are most likely
metastases from the lung cancer. You had a bronchoscopy and a
biopsy was taken from the lesion in your lung. The results from
the biopsy are pending. You will need to be closely followed by
Hematology-Oncology, and Radiation Oncology for treatment.
Please attend all of your scheduled appointments, as your
treatment will be very important.
In the hospital we started you on high dose steroids to reduce
brain swelling. This medication may help improve your symptoms
of right facial droop. High dose steroids have a number of
complications including immunosupression, GI bleeding, and
osteoporosis. We put you on a number of medications to prevent
these complications including Atovaquone, omeprazole, calcium,
and vitamin D.
You did not have any seizures while in the hospital, but because
of the lesions in your brain we have put you on Keppra, an
anti-seizure medication as a prophylaxis.
The results from your lung biopsy are still pending. Your
treatment will depend on these results. Hematology-oncology and
radiation-oncology will follow up on these results.
It was a pleasure caring for you and we wish you the best of
luck.
Followup Instructions:
___
|
19732106-DS-6
| 19,732,106 | 28,428,111 |
DS
| 6 |
2174-02-27 00:00:00
|
2174-02-28 15:24:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Bactrim / Augmentin
Attending: ___
___ Complaint:
Nausea, inability to take PO
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with HIV (last CD4 202, VL 680), metastatic lung cancer to
the brain (per above) recently diagnosed and discharged w/
candidal esophagitis (on fluconazole) p/w persistent nausea,
poor appetite a and weight loss.
Has poor po intake but trying to keep up w/ fluids. Denies abd
pain. ___ note says emesis x 1` yesterday but denies that here.
No cough, chest pain or fevers. No dysuria or diarrhea. Denies
headache or neurologic symptoms. Says he came to ___ b/c
Nephrologist told him to do so. Denies odynophagia.
In the ___, initial VS were: 99.4, 82, 111/73, 100%ra
Labs were notable for: Hgb 10.9 (discharge was ), K 5.9, Cr
1.9, Lipase 49, ALT/AST 42 / 59, Tbili normla, ALP norm, Gluc
115, UA wnl.
Imaging included: CT HEAD, w/o contrast --> no new mass effect
Last admission ___ - ___ he had significant odynophagia,
presumed to be ___ esophagitis and empirically started on
Fluconazole. He was also found to have low CD4 and new VL. He
improved with treatment of the esophagitis and on day of
discharge was able to eat a regular diet without n/v.
After going home he states that he did not eat Ensure or Boost
because he does not like their taste. He had smoothies, which he
enjoyed. He did not fill his script for Zofran, so is not using
it. Denies any emesis.
He saw Dr. ___ ID Doctor) who notes that the patient did
not fill his Fluconazole prescription because his swallowing was
better. He saw Nephrology at ___ on ___ and they recommended
___. Told him to stop his HIV meds (will clarify).
Treatments received: IV Zofran + 1L NS
On arrival to the floor, patient is comfortable. Does not recall
many parts of the story unless asked specifically, but denies
any active pain or nausea. Poor appetite, otherwise ROS as
above.
Past Medical History:
PAST ONCOLOGIC HISTORY
-- see OMR for full details but diagnosed NSLC On ___ he
underwent bronchoscopy with biopsy of the LUL mass (already had
brain mets at that time)
-- carboplatin and pemetrexed
-- ___ initiated maintenance chemotherapy with pemetrexed
-- last Chemo ___
PAST MEDICAL HISTORY:
- Thalassemia trait
-Human immunodeficiency virus (HIV) disease
-Hyperlipidemia
-Eosinophilia
-History of hepatitis B
-Anogenital warts
Social History:
___
Family History:
No family history of CA
Physical Exam:
ADMISSION PHYSICAL:
--------------------
VS: 97.7, 128/57, 54, 100%
113 lbs <-- 116 lbs 4 days ago
GENERAL: NAD, comfortable in bed with multiple layers of
clothing. fully oriented, and answers questions appropriately
HEENT: relatively moist mucosa, no thrush, no scleral icterus,
thin
CARDIAC: regular rhythm, rate in the ___, s1/s2
LUNG: posterior auscultation, clear without focal adventitious
sounds
ABD: thin, non tender, nd, +BS, quiet
EXT: thin, no edema
SKIN: No cellulitis of the rLE
PULSES: palpable
BACK: no vertebral body tenderness, no CVAT
NEURO: lifts both legs off the bed equally without difficulty,
speech is clear, face symmetric, tongue midline
Access :PIV
DISCHARGE PHYSICAL:
--------------------
VS: 98.7, 100/64, 79, 18, 98% RA
I/O: 180/660 last 8 hours; ___ last 24 hours; no BM's
Weight: pending today <- 49.9 kg yesterday <- 51.5kg <- 113 lbs
on admission <- 116 lbs 4 days ago
GENERAL: NAD, upset, but comfortable in bed with multiple layers
of clothing. fully oriented, and answers questions
appropriately; very thin, malnourished appearing
HEENT: Bald, sclera anicteric, moist mucosa, no thrush
CARDIAC: RRR, no m/r/g
LUNG: CTAB with good air movement, without focal adventitious
sounds
ABD: thin, non tender, ND, +BS, quiet
EXT: thin, +digital clubbing, WWP, no pitting edema
SKIN: No cellulitis of the RLE; dry skin over b/l anterior shins
PULSES: palpable b/l in DP and radials
BACK: no vertebral body tenderness, no CVAT
NEURO: lifts both legs off the bed equally without difficulty,
speech is clear, face symmetric, tongue midline
Access: PIV
Pertinent Results:
ADMISSION LABS:
----------------
___ 10:42AM BLOOD WBC-8.1 RBC-3.44*# Hgb-10.9*# Hct-33.8*#
MCV-98 MCH-31.7 MCHC-32.2 RDW-18.1* RDWSD-62.0* Plt ___
___ 10:42AM BLOOD Neuts-60.2 ___ Monos-13.4*
Eos-1.7 Baso-0.4 Im ___ AbsNeut-4.86# AbsLymp-1.83
AbsMono-1.08* AbsEos-0.14 AbsBaso-0.03
___ 10:42AM BLOOD Plt ___
___ 10:42AM BLOOD Glucose-115* UreaN-15 Creat-1.9* Na-143
K-5.9* Cl-103 HCO3-23 AnGap-23*
___ 10:42AM BLOOD ALT-42* AST-59* AlkPhos-107 TotBili-0.2
___ 10:42AM BLOOD Lipase-49
___ 10:42AM BLOOD Albumin-3.8
___ 01:02PM URINE Color-Yellow Appear-Clear Sp ___
___ 01:02PM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG
___ 01:02PM URINE RBC-<1 WBC-2 Bacteri-FEW Yeast-NONE Epi-0
OTHER IMPORTANT LABS:
___ 06:30AM BLOOD Hapto-430*
___ 07:00AM BLOOD PEP-NO SPECIFI
___ 07:00AM BLOOD HCV Ab-NEGATIVE
___ 10:51PM URINE U-PEP-NO PROTEIN Osmolal-210
___ 10:51PM URINE Hours-RANDOM UreaN-125 Creat-42 Na-63
K-20 Cl-58 TotProt-7 Prot/Cr-0.2
___ 02:23PM URINE Eos-NEGATIVE
MICROBIOLOGY:
--------------
___ Urine Culture: Negative
___ HBV Viral Load: Negative
___ HBsAg-NEGATIVE HBsAb-POSITIVE IgM HBc-NEGATIVE
___ CMV Viral Load: Negative
IMAGING AND OTHER STUDIES:
CT NON CON HEAD ___
1. 6 mm hyperdense focus in the medial left occipital lobe may
reflect calcification from previously imaged hemorrhagic
metastasis at this location. Difficult to exclude trace
underlying hemorrhage. Otherwise, no hemorrhage. No evidence
of acute infarction.
2. Edema in the right frontal lobe near the vertex is likely
related to known multifocal supratentorial metastases, not
definitively visualized on this examination, better evaluated on
prior MRI. No mass-effect
CT Torso with PO Contrast ___:
-Chest:
1. Spiculated left upper lobe mass measuring up to 19 mm is
slightly smaller
compared with ___.
2. No evidence of new or progressive intrathoracic malignancy.
3. Mild mid and proximal esophageal wall thickening compatible
with history of
___ esophagitis.
4. CT evidence of anemia, correlate with lab values.
5. Stable sub 4 mm pulmonary nodules as described above.
-Abdomen/Pelvis:
1. No evidence of small bowel obstruction or other acute
abdominopelvic
pathology.
DISCHARGE LABS:
----------------
___ 07:45AM BLOOD WBC-5.5 RBC-2.46* Hgb-7.8* Hct-24.0*
MCV-98 MCH-31.7 MCHC-32.5 RDW-17.6* RDWSD-59.0* Plt ___
___ 07:45AM BLOOD Glucose-80 UreaN-12 Creat-2.2* Na-142
K-4.3 Cl-106 HCO3-23 AnGap-17
___ 07:00AM BLOOD ALT-34 AST-40 LD(LDH)-374* AlkPhos-87
TotBili-0.3
___ 07:45AM BLOOD Calcium-9.4 Phos-3.8 Mg-1.8
Brief Hospital Course:
Mr. ___ is a ___ y/o man with HIV (last CD4 202, VL 680),
metastatic lung cancer to the brain, recently diagnosed and
discharged w/ candidal esophagitis (on fluconazole) p/w
persistent nausea, poor appetite and weight loss.
# Failure to thrive:
The patient presented with primary issue of nausea, vomiting,
and inability to take PO since prior discharge. The etiology of
his symptoms were unclear during this admission. They were felt
unlikely to be due to kidney failure given low serum BUN or
obstruction given unrevealing CT torso. Potential etiologies of
his symptoms were felt to be possible reactivation of his HIV,
gastroparesis ___ prior chemo, or potentially incompletely
treated esophageal candidiasis (as below, patient missed
multiple doses of fluconazole following prior discharge). With
empiric treatment on reglan and supportive management on
anti-emetics and IV fluids, the patient's symptoms eventually
resolved. He was started on Dronabinol to encourage appetite
stimulation and he was set up with ___ services on discharge
home to facilitate post-hospitalization transition.
# Progressive Renal Failure of Unclear Etiology complicated by
Pre-renal Azotemia:
The patient was recently discharged with Cr of about 1.7, amidst
work-up of progressive renal failure of unclear etiology over
the course of multiple months. This admission, the patient
presented with Cr as high as 2.5 per outpatient labs, which was
responsive partially to IVF rehydration, suggesting component of
underlying pre-renal azotemia. Regarding etiology of his
underlying renal dysfunction, differential included
medication-induced (PPI and tenofovir discontinued for risk of
this prior to this admission), HIV-associated nephropathy
(especially in setting of re-activating HIV), or other intrinsic
process. He was urinating without difficulty and had recent
renal ultrasound without any signs of obstruction. The patient
was again evaluated by renal, who recommended work-up negative
for infection and amyloid. Urine lytes again were consistent
with intrinsic process. The discussion of biopsy was also
raised, but deferred to the outpatient setting. Rationale for
this decision included lack of a clear, treatable etiology
biopsy would be expected to reveal and the presence of multiple
co-morbidities (HIV and cancer) that would complicate the likely
(immunosuppressive) treatment of whatever would be found on
biopsy. The patient was established with renal follow-up prior
and his outpatient nephrologist was contacted directly prior to
discharge.
# Anemia: During the patient's prior hospitalization, he had a
baseline hgb of ___. Iron studies at that point were c/w anemia
of inflammation. On this admission, the patient had Hgb of 10.9,
which slowly dropped to nadir of 7.5 without clear signs of
bleed or hemolysis. The patient's hgb did stabilize around 8
prior to discharge with most likely explanation of his symptoms
felt ___ blood loss due to constant phlebotomy c/b poor bone
marrow reserve. He did not require any transfusions and was
supplemented with folate throughout this admission. He was
arranged with close follow-up and instructions to have CBC
re-checked shortly after discharge.
# Candidal Esophagitis: During the prior admission, the patient
was found to have ___ esophagitis on the basis of thrush on
exam, odynophagia, and positive HIV viral load with relief on
fluconazole. He was started on a 14 day course of fluconazole,
but on discharge, was unable to fill his medications and missed
several doses. On re-admission, the patient was restarted on
fluconazole to complete his 14 day course (last dose on
___. Again, he was set up with ___ to help assist in the
post-discharge transition.
# HIV: The patient has had a long history of HIV, most recently
managed on Truvada and raltegravir. He had newly decreased CD4
count of 202 and positive VL of 680 (CD4 >___ on
___ during his last admission and per most recent outpatient
notes by HIV provider, he was taken off all HIV medications,
likely due to fear of tenofovir-associated toxicity. HIV
genotyping and integrase genotyping were not performed by lab
___ viral load <1000 and <500, respectively. He was not treated
with anti-retroviral therapy as he had follow up with his
primary HIV provider shortly after discharge. No therapy was
initiated while inpatient so as not to interfere with any
potential plans of primary HIV provider.
# NSCLC: The patient has known h/o metastatic NSCLC currently on
pemetrexed maintenance therapy. Last dose of dex and pemetrexed,
however, was ___. Per outpatient oncologist, he has not been
treated with any further therapy since his prior discharge. He
was continued on supportive management as above and scheduled
for follow-up with his outpatient oncologist.
CHORNIC/RESOLVED/STABLE:
# Hyperkalemia: The patient's potassium on admission was 5.9 but
with a moderately hemolyzed specimen. On recheck, K was 4.4 and
remained within normal limits throughout the rest of the
admission.
# Transaminitis: The patient had mildly elevated transaminitis
I/s/o hemolyzed blood specimen. On re-check, AST/ALT were found
to be normal. He did have HBV and HCV testing showing either
cleared prior HBV infection or HBV immunization and no exposure
to HCV.
TRANSITIONAL ISSUES:
-Patient has follow-up set up with outpatient HIV provider,
___, and Oncologist. He needs to keep all of these
appointments.
-The patient intermittently refused his Atovaquone this
admission due to fear of nausea. He agreed to take this
medication at home with anti-emetics PRN, but should follow up
with his HIV provider regarding further PCP prophylaxis
-Given poor ECOG status and multiple other active issues, the
patient has been off any cancer therapy (most recently on
maintenance pemetrexed) for many weeks. He should follow up with
his oncologist regarding further management of NSCLC
-The patient did not receive anti-retroviral treatment of his
HIV during this admission. He needs to follow up with Dr. ___
___ regarding further management of his HIV.
-The patient had rising Cr with continued unclear etiology of
progressive renal impairment. Biopsy was deferred in the
inpatient setting until management of HIV and NSCLC is
elucidated. He should follow up with outpatient nephrology after
discharge. Discharge Cr was 2.2.
-The patient was started on Dronabinol 5mg PO BID for appetite
stimulation, which was continued at discharge
-The patient was started on Metoclopramide 10mg PO qACHS for
empiric treatment of nausea felt possibly secondary to
gastroparesis. This was continued at discharge, but he should
follow up with his PCP regarding whether to continue this
medication
-Patient had downtrending Hemoglobin from ~11 on admission to ~8
on discharge. He remained hemodynamically stable throughout and
this was likely attributed to phlebotomy and acute stress I/s/o
poor bone marrow reserve.
-Patient was discharged with instructions to have CBC with
differential and Cr drawn and faxed to his PCP.
-CODE STATUS: Full Code
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atovaquone Suspension 750 mg PO BID
2. Emtricitabine-Tenofovir (Truvada) 1 TAB PO DAILY
3. FoLIC Acid 1 mg PO DAILY
4. LeVETiracetam 1000 mg PO BID seizure prophylaxis
5. Lorazepam 1 mg PO Q8H:PRN Anxiety
6. Ondansetron 8 mg IV Q8H:PRN Nausea
7. Raltegravir 400 mg PO BID
8. Cyanocobalamin 100 mcg PO DAILY
9. Fluconazole 200 mg PO Q24H
10. Maalox/Diphenhydramine/Lidocaine ___ mL PO QID:PRN
Mouth/Throat Pain
11. Vitamin D 400 UNIT PO DAILY
Discharge Medications:
1. Atovaquone Suspension 750 mg PO BID
2. LeVETiracetam 1000 mg PO BID seizure prophylaxis
3. Lorazepam 1 mg PO Q8H:PRN Anxiety or Nausea
4. Maalox/Diphenhydramine/Lidocaine ___ mL PO QID:PRN
Mouth/Throat Pain
5. Dronabinol 5 mg PO BID
RX *dronabinol 5 mg 1 capsule(s) by mouth twice a day Disp #*30
Capsule Refills:*0
6. Metoclopramide 10 mg PO QIDACHS
RX *metoclopramide HCl 10 mg 1 tablet by mouth with each meal
and before bed Disp #*40 Tablet Refills:*0
7. Cyanocobalamin 100 mcg PO DAILY
8. FoLIC Acid 1 mg PO DAILY
9. Vitamin D 400 UNIT PO DAILY
10. Outpatient Lab Work
Please draw CBC with differential (ICD10: D64.9) on ___ and
fax results to Dr. ___ (___) and Dr. ___
(___)
11. Outpatient Lab Work
Please draw BMP (ICD10: N17.9) on ___ and fax results to Dr.
___ (___) and Dr. ___ (___)
12. Polyethylene Glycol 17 g PO DAILY
RX *polyethylene glycol 3350 [Miralax] 17 gram 1 powder(s) by
mouth once a day Disp #*30 Packet Refills:*0
13. Ondansetron 8 mg IV Q8H:PRN Nausea
14. Ondansetron 4 mg PO Q8H:PRN nausea
RX *ondansetron HCl 4 mg 1 tablet(s) by mouth every 8 hours Disp
#*30 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS/ES:
-Failure to Thrive
SECONDARY DIAGNOSIS/ES:
-Acute Kidney Injury due to Pre-renal Azotemia
-Chronic Kidney Injury of Unclear Etiology
-HIV currently not on Anti-Retroviral Therapy
-Stage IV Non-Small Cell Lung CA
-Anemia of Inflammation
-___ Esophagitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were admitted to the hospital because you were having
symptoms of severe nausea and vomiting and were noticed at your
PCP's office to have worsening kidney function. In the hospital,
you were given fluids through your IV for rehydration and
medications to manage your nausea. You also had a CAT scan of
your abdomen that did not show any concerning signs of blockage
or infection. Lastly, you were given medications to help
stimulate your appetite and improve your overall nutrition and
strength.
With these measures, your nausea improved and your kidney
function stabilized. It is very important that you continue to
take your home medications and follow up with your outpatient
doctors after ___ (as detailed in the rest of your
discharge paperwork). It is especially important that you follow
up with your Primary Care doctor, ___,
and Dr. ___.
Thank you for allowing us to be a part of your care,
Your ___ Team
Followup Instructions:
___
|
19732106-DS-8
| 19,732,106 | 27,973,156 |
DS
| 8 |
2174-07-24 00:00:00
|
2174-07-24 20:04:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Bactrim / Augmentin
Attending: ___.
Chief Complaint:
"blacked out"
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
___ with a history of metastatic NSCLC to brain s/p radiation,
HIV (undetectable HIV VL in ___, on ART), and CKD who presented
to the ED after syncopal episode.
Per ED notes, brought in by his brother after he witnessed
"blackout" at home, which pt now corroborates. ___ has no memory
of the event but denies having loss of continence after he came
to. He has been feeling decreased appetite and feels not keeping
up with po intake as of late but no
nausea/vomiting/headache/neck
pain/fever/dizziness. Denies prior h/o seizure. Is on keppra for
h/o brain mets. ED reports brother stated pt reported feeling
weak and slumped into his brothers arms, but no LOC, though that
is contrary to what pt is reporting now. Pt also reports
diarrhea
several days ago but none since yesterday, no blood in stool. No
dysuria, cough, difficulty breathing. Notes that pt had h/o one
seizure in high school (again pt denies this to me currently).
Note that he was recently discharged ___ after hospitalization
at ___ p/w chest pain noted to be forgetful and inappropriate.
For
encephalopathy, noted cognition worsening past several months
with brain MRI ___ having shown decreased mets to brain. Folate
and B123 were normal, LP with negative gram stain and elevated
protein, Neuro-onc evaluated the patient and recommended lumbar
puncture and follow-up with cytology, PEP, HIV, HSV, ___ virus,
VZV, tau, and phos-tau protein, culture, crypto Ag, VDRL,
b2-microglob, and CEA. Per ID, also checked HIV VL in CSF, serum
crypto Ag, RPR, CS crypto Ag, CSF VDRL, and HIV VL and CD4.
mental status stabilized and he went home ___ with 24 hr
supervision.
ED COURSE:
97.8 74 124/73 98% RA. UA nomal. chem with BUN/creat ___.
trop <0.01. Hct 24.8, WBC 14 with 80% bands. lactate 1.1. CXR
without acute process. Head CT without bleed or acute process.
On arrival to the floor he feels very well with no significant
complains other than decreased appetite. All other 10 point ROS
neg.
Past Medical History:
Past Medical History:
PAST ONCOLOGIC HISTORY:
___ presented to ___ for headache, right facial weakness
___ MRI from OSH showed innumerable enhancing lesions with
extensive surrounding edema supra and infratentorially
___ CT chest showed large left upper lobe mass lesion
Pathology: adenocarcinoma, negative for ALK, ROS-1, EGFR or KRAS
mutations
___ to ___: WBRT total dose 2000cGy over 5 fractions
at 400 cGy/fraction
___ initiated treatment with carboplatin and pemetrexed and
had six cycles.
___ initiated maintenance chemotherapy with pemetrexed
___ Premetrexed was held due to anorexia, weight loss,
esophagitis, and kidney dysfunction
___ to ___ hospitalized at ___ for failure to
thrive. Working diagnosis of ___ esophagitis, treated with
fluconazole.
PAST MEDICAL HISTORY:
- Thalassemia trait
-Human immunodeficiency virus (HIV) disease
-Hyperlipidemia
-Eosinophilia
-History of hepatitis B
-Anogenital warts
Social History:
___
Family History:
No family history of CA
Physical Exam:
ADMISSION PHYSICAL EXAM
=======================
VITAL SIGNS: 98.2 130/70 55 18 100% RA
General: NAD, calm relaxed and pleasant
HEENT: MMM, no OP lesions, no cervical, supraclavicular, or
axillary adenopathy, no thyromegaly
CV: RR, NL S1S2 no S3S4 MRG
PULM: mild crackles at bases
GI: BS+, soft, NTND, no masses or hepatosplenomegaly
LIMBS: No edema, clubbing, tremors, or asterixis; no inguinal
adenopathy
SKIN: No rashes or skin breakdown
NEURO: Oriented to self and BI, not to year and thinks it is Dec
but is able to remember recent holiday was ___. Cranial
nerves
II-XII are within normal limits excluding visual acuity which
was
not assessed, no nystagmus; strength is ___ of the proximal and
distal upper and lower extremities; no tremor or asterixis
DISCHARGE EXAM
===============
VITAL SIGNS: 98.5, 106/78, 71, 18, 96%/RA TFB 606
General: NAD, sitting up in bed
HEENT: MMM, thick yellow-white adherent coating of tongue, no
___
CV: RRR, NL S1S2 no MRG
PULM: Non-labored breathing. Minimal crackles R lung base. No
other rales/rhonchi/wheezes.
GI: BS+, SNTND, no HSM, no rebound/guarding
EXT: No edema bilaterally
SKIN: No lesions/rashes. Hypopigmented scattered macuoles on
legs.
NEURO: A&Ox3.
Pertinent Results:
ADMISSION LABS
==============
___ 04:13PM URINE COLOR-Straw APPEAR-Clear SP ___
___ 04:13PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
___ 01:20PM WBC-11.3* RBC-2.26* HGB-7.1* HCT-22.0* MCV-97
MCH-31.4 MCHC-32.3 RDW-13.1 RDWSD-46.0
___ 01:20PM PLT COUNT-333
___ 05:55AM UREA N-15 CREAT-2.4* SODIUM-135 POTASSIUM-4.0
CHLORIDE-102 TOTAL CO2-22 ANION GAP-15
___ 05:55AM estGFR-Using this
___ 05:55AM ALT(SGPT)-15 AST(SGOT)-14 ALK PHOS-56 TOT
BILI-0.3
___ 05:55AM cTropnT-<0.01
___ 05:55AM CALCIUM-9.0 PHOSPHATE-3.4 MAGNESIUM-1.9
IRON-41*
___ 05:55AM calTIBC-174* FERRITIN-272 TRF-134*
___ 05:55AM WBC-11.9* RBC-2.21* HGB-7.0* HCT-21.4* MCV-97
MCH-31.7 MCHC-32.7 RDW-13.2 RDWSD-46.7*
___ 05:55AM PLT COUNT-330
___ 05:55AM ___ PTT-36.3 ___
___ 09:17PM URINE HOURS-RANDOM
___ 09:17PM URINE HOURS-RANDOM
___ 09:17PM URINE UHOLD-HOLD
___ 09:17PM URINE GR HOLD-HOLD
___ 09:17PM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 09:17PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
___ 09:17PM URINE RBC-0 WBC-<1 BACTERIA-NONE YEAST-NONE
EPI-0
___ 08:31PM LACTATE-1.1
___ 08:21PM GLUCOSE-98 UREA N-18 CREAT-2.6* SODIUM-136
POTASSIUM-4.3 CHLORIDE-100 TOTAL CO2-19* ANION GAP-21*
___ 08:21PM estGFR-Using this
___ 08:21PM cTropnT-<0.01
___ 08:21PM TSH-1.4
___ 08:21PM WBC-14.2* RBC-2.46* HGB-7.9* HCT-24.8*
MCV-101* MCH-32.1* MCHC-31.9* RDW-13.2 RDWSD-48.6*
___ 08:21PM NEUTS-80* BANDS-0 LYMPHS-10* MONOS-2* EOS-3
BASOS-1 ___ METAS-4* MYELOS-0 AbsNeut-11.36* AbsLymp-1.42
AbsMono-0.28 AbsEos-0.43 AbsBaso-0.14*
___ 08:21PM HYPOCHROM-NORMAL ANISOCYT-NORMAL
POIKILOCY-OCCASIONAL MACROCYT-1+ MICROCYT-NORMAL
POLYCHROM-NORMAL OVALOCYT-OCCASIONAL
___ 08:21PM PLT SMR-NORMAL PLT COUNT-364
MICROBIOLOGY:
Blood cultures (___): no growth
IMAGING
CXR (___):
FINDINGS:
PA and lateral views of the chest provided. Lungs are
hyperinflated and clear without focal consolidation, large
effusion or pneumothorax. The nodule in the left upper lobe
seen on recent CT is subtly conspicuous and appear similar. The
cardiomediastinal silhouette is normal. Imaged osseous
structures are intact. No free air below the right
hemidiaphragm is seen.
IMPRESSION:
As above.
NCHCT (___):
IMPRESSION: No acute intracranial anomaly noncontrast head CT.
If there is concern for subtle brain mass, consider MRI, if
there are no contraindications.
MRI Brain w and w/o contrast (___):
IMPRESSION:
1. Interval stability or resolution of multiple supra and
infratentorial enhancing, hemorrhagic metastases. No new
lesions seen. No new mass, mass effect, large hemorrhage, or
evidence of acute infarction.
2. Unchanged 8 mm enhancing left frontal scalp lesion.
CXR ___
Right lower lobe pneumonia. Possible right middle lobe
involvement.
DISCHARGE LABS
===============
___ 06:40AM BLOOD WBC-8.7 RBC-2.65* Hgb-8.2* Hct-24.4*
MCV-92 MCH-30.9 MCHC-33.6 RDW-14.5 RDWSD-48.8* Plt ___
___ 06:40AM BLOOD Glucose-77 UreaN-22* Creat-2.5* Na-137
K-4.0 Cl-104 HCO3-19* AnGap-18
___ 06:40AM BLOOD Calcium-9.1 Phos-2.5* Mg-1.9
Pertinent Labs:
=================
___ 07:00AM BLOOD VitB12-731
___ 05:55AM BLOOD calTIBC-174* Ferritn-272 TRF-134*
___ 07:22AM BLOOD Prolact-54*
___ 08:21PM BLOOD TSH-1.4
Brief Hospital Course:
Mr. ___ is a ___ with metastatic NSCLC to brain s/p XRT,
HIV (undetectable HIV VL in ___, on ART), and CKD who presented
to the ED after LOC.
#LOC: Pt's episode of slumping in chair, with eyes rolling back
and foaming at the mouth, LOC, improved MS/orientation on
morning after admission, from the confusion reported on
admission, are most consistent w/seizure, and he is at risk
given his known hx of seizure, brain metastasis, and that fact
that he may have not been taking his prescribed Keppra. Patient
had declining leukocytosis also c/w seizure. Infection as cause
of initial LOC is less likely given pt was afebrile, CXR neg,
blood cx pending, UA not done. Also could have been syncope
(convulsive, vasovagal, cardiogenic), although would have
expected prodromal sx (nausea, chest pain, SOB, palpitations,
sweating), which patient denies. Trop x3 <0.01. Brain MRI
suggests no interval change in brain mets. Has had no events on
telemetry since admission. Had had no events on EEG monitoring
for 24 hrs. Continued home keppra with seizure precautions and
O2 monitoring in house.
#Pneumonia. New cough with yellow-white sputum, and rising WBC
raised c/f infection. CXR showed likely RLL pneumonia with
possible RML involvement. Pt was started on levofloxacin to
complete 8 day course (last day ___ so doses should be given on
___ and ___ as Q48hr). Leukocytosis down-trended.
#Cognitive decline: Pt was recently admitted for extensive
exhaustive workup in ___, see HPI. Of note pt's CSF studies
from last visit showed an antibody to Tau/beta 42. Per Dr. ___,
___ Abs are seen iso of brain mets and XRT, likely reflecting
an inflammatory response, rather than a marker of Alzheimer's
dementia. His decline is likely multifactorial, ___ to
HIV-related dementia (note VL undectable in ___ and brain
metastasis, which are stable on MRI ___. No events on 24 hr EEG
monitoring as above. TSH wnl. B12 wnl. Per ___, patient at
baseline but per OT requiring rehab. Will dc to SNF
#Anemia: Pt had Hct drop on ___ from 21.4 from 24.8 on ___. Hct
23.6 on ___. Patient denies bloody diarrhea, but had guaiac+
stool in ED, although all additional stools have been guaiac
neg. Pt's TSH, B12, folate wnl. Repeat iron studies c/w ACD. T+S
___. Trended CBC, with goal Hb<7. Pt received 1U of pRBC on ___
iso H/H of ___ and responded appropriately.
#CKD: Cr near baseline ~2 range since ___, 2.4 on admission.
2.3 on ___. Nephrology saw pt for this during last admission, he
has had exposure to several agents (tenofovir, carboplatin,
and, less likely, pemetrexed) which can cause kidney injury that
can become chronic. HIV associated nephropathy is also possible.
The pt will follow w/ Dr. ___ at ___ nephrology and
consideration of renal biopsy had been suggested at time of
recent discharge. Renally dosed meds. Continued reduced bicarb
(650 BID from home dose 1300 BID) to reduce stomach upset that
may have been contributing to reduced PO intake. Trended Chem10.
#HIV: The patient is currently on boosted
darunavir/dolutegravir/ rilpivirine. His most recent CD4 in
___ was 389 and VL undetectable. Continued pt's home regimen
in-house.
#Metastatic NSCLC: Currently off cancer-directed chemotherapy.
Continued home PRN Zofran, relgan, Ativan, and marinol Continued
home folic acid, keppra, atovaquone, vitamin D. Need to t/b with
Dr. ___ at ___.
TRANSITIONAL ISSUES:
- Levofloxacin due on ___ and ___ to complete 8 day course
- Family meeting was held ___ with HCP and patient was made
DNR/DNI
- Patient with baseline anemia of chronic disease with H/H
___ on discharge
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Atovaquone Suspension 750 mg PO BID
2. Darunavir 800 mg PO DAILY
3. dolutegravir 50 mg oral DAILY
4. Dronabinol 5 mg PO BID:PRN Nausea
5. FoLIC Acid 1 mg PO DAILY
6. Lorazepam 1 mg PO Q8H:PRN Anxiety or Nausea
7. Vitamin D 400 UNIT PO DAILY
8. RiTONAvir 100 mg PO DAILY
9. Metoclopramide 10 mg PO QID:PRN Nausea
10. rilpivirine 25 mg oral DAILY
11. Polyethylene Glycol 17 g PO DAILY:PRN Constipation
12. Nystatin Oral Suspension 5 mL PO QID
13. Sodium Bicarbonate 1300 mg PO BID
14. LevETIRAcetam 500 mg PO BID seizure prophylaxis
15. Ondansetron 8 mg PO Q8H:PRN nausea
16. Cyanocobalamin 100 mcg PO DAILY
17. Prochlorperazine 10 mg PO Q6H:PRN nausea
Discharge Medications:
1. Levofloxacin 500 mg PO Q48H
RX *levofloxacin [Levaquin] 500 mg 500 mg by mouth Q48H Disp #*4
Tablet Refills:*0
2. Mirtazapine 7.5 mg PO QHS
RX *mirtazapine 7.5 mg 7.5 mg by mouth at bedtime Disp #*30
Tablet Refills:*0
3. Lorazepam 0.5 mg PO Q8H:PRN Anxiety or Nausea
4. Atovaquone Suspension 750 mg PO BID
5. Cyanocobalamin 100 mcg PO DAILY
6. Darunavir 800 mg PO DAILY
7. dolutegravir 50 mg oral DAILY
8. Dronabinol 5 mg PO BID:PRN Nausea
9. FoLIC Acid 1 mg PO DAILY
10. LevETIRAcetam 500 mg PO BID seizure prophylaxis
11. Ondansetron 8 mg PO Q8H:PRN nausea
12. Polyethylene Glycol 17 g PO DAILY:PRN Constipation
13. rilpivirine 25 mg ORAL DAILY
14. RiTONAvir 100 mg PO DAILY
15. Sodium Bicarbonate 1300 mg PO BID
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
Seizure
Hospital Acquired Pneumonia
SECONDARY DIAGNOSIS:
HIV
Metastatic ___
CKD
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure to be part of your care here at ___.
You were admitted because you had a seizure, likely due to the
presence of metastases from your cancer present in your brain,
and you were not taking your anti-seizure medication (Keppra)
regularly. You were restarted on your anti-seizure medications
and your mental status improved during your stay.
You also developed a lung infection (pneumonia), which we began
treating with antibiotics (levofloxacin). You should continue
taking this medication for 8 days total, last day of antibiotics
will be ___.
You were also found to have low blood counts (anemia) and
received a unit of blood.
If you develop any confusion, have any further seizures, or
notice any difficulty breathing, fever/chills, please contact
your doctor.
You will be discharged to a rehab center.
We wish you the best,
Your ___ Team
Followup Instructions:
___
|
19732173-DS-7
| 19,732,173 | 20,847,337 |
DS
| 7 |
2131-02-22 00:00:00
|
2131-02-23 10:40:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Chest pain, transfer
Major Surgical or Invasive Procedure:
___ Pericardiocentesis, Pericardial Drain
History of Present Illness:
Ms. ___ is a ___ female with PCOS, OCD, and
?Familial Mediterranean fever on colchicine twice a day (never
formally diagnosed) with h/o multiple fluid collections (pleural
effusion, pelvic fluid collection, liver fluid collection) who
was transferred from ___ for chest pain, tachycardia, and
fevers; subsequently found to have a large pericardial effusion.
Patient reports for 2 days that she had been feeling unwell with
symptoms including nausea, vomiting, chest pain, and shortness
of breath. She went to her PCP ___ ___ where she was found to
have an elevated d-dimer. From her PCP she was sent to ___
___ where a CTA was performed showing no evidence of PE but
did show concern for pericardial effusion. She was also noted to
be febrile to 101.1 and tachycardic to the 130s with a normal
blood pressure. She was covered with vancomycin and Zosyn due to
concern for sepsis. In the setting of these findings, she was
transferred to ___ for further evaluation.
Of note patient was recently admitted on ___ with two weeks
abdominal pain found to have a liver fluid collection. The
fluid was drained by ___ and 60 cc of clear yellow fluid was
removed. The fluid had 25 WBC with 77% PMNs and protein and
glucose levels were normal. Gram stain was negative and culture
ultimately had no growth. At that time it was felt that the
fluid and pain combined with the lung findings on exam are most
likely due to serositis which would be consistent with a
rheumatologic disorder, ie FMF. Symptoms most likely represent a
flare of her underlying disease as she says this feels similar
to her prior episodes a few years ago.
In the ED,
- Initial vitals were: P 3, T 99.7, HR 128, BP 132/79, RR 18,
SpO2 96% RA
- Exam notable for: uncomfortable appearing, tachycardic but
regular, distant heart sounds but no
appreciable m/r/g
- Labs notable for:
8.6
9.2>----<465
30.3
138 | 101 | 8
----------------<106
4.4 | 23 | 0.4
Ca 8.9 Mg 1.9 P 3.9
___ 15.2 PTT 26.7 INR 1.4
MB <1 Troponin-T <0.01
CRP 206.4
Urine: Rare mucous, Protein 30, HCG negative
- Studies notable for:
- TTE ___ IMPRESSION: Normal biventricular cavity sizes and
normal LV regional/global systolic function with borderline
right ventricular free wall systolic function. No valvular
pathology or pathologic flow identified. Large
circumferential pericardial effusion with echocardiographic
evidence for increased pericardial pressure physiology.
- Patient was given:
- 500 mL LR
- Colchicine 0.6 mg
- Ibuprofen 600 mg
On arrival to the CCU, she reports that she is feeling well. She
denies any pain at her drain site and reports only that it
'feels weird.' She is otherwise in good spirits with her family
at bedside.
ROS: Positive per HPI. Remaining 10 point ROS reviewed and
negative.
Past Medical History:
PCOS
OCD
Social History:
___
Family History:
Reviewed and found to be not relevant to this illness/reason for
hospitalization.
Physical Exam:
Admission Physical Exam:
========================
VS: HR 109 BP 122/84 RR 24 SpO2 94%
GENERAL: Well developed, well nourished in NAD. Oriented x3.
Mood, affect appropriate.
HEENT: NC AT, PERRLA, EOMI, MMM
NECK: Supple. Unable to assess JVP as patient she needed to be
flat post-procedure.
CARDIAC: Tachycardic, cardiac rub present, no murmurs of
gallops.
LUNGS: Crackles at the bases bilaterally.
ABDOMEN: Soft, NT, ND, +BS
EXTREMITIES: Warm, well perfused. No clubbing, cyanosis, or
peripheral edema.
SKIN: No significant lesions or rashes.
PULSES: Distal pulses palpable and symmetric.
NEURO: Grossly intact.
Discharge Physical Exam:
========================
VS:
24 HR Data (last updated ___ @ 554)
Temp: 98.2 (Tm 98.4), BP: 120/66 (99-129/63-80), HR: 95
(92-97), RR: 18, O2 sat: 95% (93-95), O2 delivery: RA
Fluid Balance (last updated ___ @ 706)
Last 8 hours Total cumulative -300ml
IN: Total 0ml
OUT: Total 300ml, Urine Amt 300ml
Last 24 hours Total cumulative -180ml
IN: Total 120ml, PO Amt 120ml
OUT: Total 300ml, Urine Amt 300ml
GEN: lying in bed in NAD, appears uncomfortable.
NECK: supple
CV: borderline tachycardic, regular rhythm, +friction rub.
otherwise no murmurs
PULM: crackles at the bases bilaterally but no increased WOB
ABD: soft, NT, ND, +BS
EXTR: WWP, no clubbing, cyanosis, or peripheral edema.
SKIN: no significant lesions or rashes.
PULSE: distal pulses palpable and symmetric.
NEURO: grossly intact.
Pertinent Results:
Admission Labs:
===============
___ 04:38PM OTHER BODY FLUID TOT PROT-5.8 GLUCOSE-78
LD(LDH)-701 ALBUMIN-3.0
___ 04:38PM OTHER BODY FLUID TNC-6445* ___
POLYS-40* LYMPHS-52* MONOS-0 EOS-2* MACROPHAG-6*
___ 09:03AM URINE HOURS-RANDOM
___ 09:03AM URINE UCG-NEGATIVE
___ 09:03AM URINE COLOR-Yellow APPEAR-Clear SP
___
___ 09:03AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30*
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
___ 09:03AM URINE RBC-1 WBC-1 BACTERIA-NONE YEAST-NONE
EPI-1
___ 09:03AM URINE MUCOUS-RARE*
___ 06:17AM LACTATE-0.8
___ 05:55AM GLUCOSE-106* UREA N-8 CREAT-0.4 SODIUM-138
POTASSIUM-4.4 CHLORIDE-101 TOTAL CO2-23 ANION GAP-14
___ 05:55AM estGFR-Using this
___ 05:55AM CK-MB-<1 cTropnT-<0.01
___ 05:55AM CALCIUM-8.9 PHOSPHATE-3.9 MAGNESIUM-1.9
___ 05:55AM TSH-2.8
___ 05:55AM CRP-206.4*
___ 05:55AM WBC-9.2 RBC-4.34 HGB-8.6* HCT-30.3* MCV-70*
MCH-19.8* MCHC-28.4* RDW-16.0* RDWSD-40.2
___ 05:55AM NEUTS-60.7 ___ MONOS-10.5 EOS-2.7
BASOS-0.5 IM ___ AbsNeut-5.60 AbsLymp-2.32 AbsMono-0.97*
AbsEos-0.25 AbsBaso-0.05
___ 05:55AM PLT COUNT-465*
___ 05:55AM ___ PTT-26.7 ___
Pertinent Studies:
==================
___ TTE
CONCLUSION: The left atrial volume index is normal. The right
atrium is mildly enlarged. There is no evidence for an atrial
septal defect by 2D/color Doppler. The estimated right atrial
pressure is >15mmHg. There is normal left ventricular wall
thickness with a normal cavity size. There is normal regional
and global left ventricular systolic function. Quantitative
biplane left ventricular ejection fraction is 75 %. Left
ventricular cardiac index is normal (>2.5 L/min/m2). There is no
resting left ventricular outflow tract gradient. Normal right
ventricular cavity size with low 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
with a normal descending aorta diameter. The aortic valve
leaflets (3) appear structurally normal. There is no aortic
valve stenosis. There is no aortic regurgitation. The mitral
valve leaflets appear structurally normal with no mitral valve
prolapse. There is trivial mitral regurgitation. The pulmonic
valve leaflets are normal. The tricuspid valve leaflets appear
structurally normal. There is trivial tricuspid regurgitation.
The pulmonary artery systolic pressure could not be estimated.
There is a large circumferential pericardial effusion (measuring
2.5 cm adjacent to left ventricle, 1.1 cm adjacent to right
ventricle and 1.5 cm at apex). There is increased respiratory
variation in transmitral/transtricuspid inflow and right atrial
invagination c/w increased pericardial pressure/ tamponade
physiology.
IMPRESSION: Normal biventricular cavity sizes and normal LV
regional/global systolic function with borderline right
ventricular free wall systolic function. No valvular pathology
or pathologic flow identified. Large circumferential
pericardialffusion with echocardiographic evidence for increased
pericardial pressure physiology.
CXR ___
Final Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with pericardial effusion now s/p
drain// eval intrathoracic changes
TECHNIQUE: AP portable chest radiograph
COMPARISON: CT chest dated ___
IMPRESSION:
The size of the cardiac silhouette is enlarged but likely
unchanged in keeping with a known pericardial effusion. A
pericardial drain is present. There is a right pleural effusion.
Bibasilar opacities may reflect atelectasis or pneumonia. No
pneumothorax.
TTE ___
CONCLUSION: There is normal regional and global left ventricular
systolic function. The right ventricle has normal free wall
motion. There is a small circumferential pericardial effusion.
There is increased respiratory variation in
transmitral/transtricuspid inflow but no right atrial/right
ventricular diastolic collapse. Compared with the prior TTE
(images reviewed) of ___ , the pericardial effusion is
now smaller. Respiratory variation in the mitral and tricuspid
inflows remains present, but right atrial or ventricular
invagination is not seen.
TTE ___
IMPRESSION: Very small residual echo dense pericardial effusion
with some evidence of effusoconstrictive physiology. Compared
with the prior TTE (images reviewed) of ___ , the
pericardial effusion is smaller with no residual simple fluid.
TTE ___
CONCLUSION: The estimated right atrial pressure is ___ mmHg.
There is normal regional left ventricular systolic function.
Overall left ventricular systolic function is normal. The
visually estimated left ventricular ejection fraction is 55 60%.
The right ventricle has normal free wall motion. There is
abnormal interventricular septal motion c/w pericardial
constriction. There is a small loculated posterior pericardial
effusion.
IMPRESSION: Small loculated posterior pericardial effusion.
Compared with the prior TTE ___, effusion appears more
loculated, but overall the findings are quite similar.
Discharge Labs:
================
___ 07:26AM BLOOD WBC-6.9 RBC-4.43 Hgb-8.7* Hct-30.8*
MCV-70* MCH-19.6* MCHC-28.2* RDW-15.9* RDWSD-39.2 Plt ___
___ 07:26AM BLOOD Plt ___
___ 07:26AM BLOOD ___ PTT-26.6 ___
___ 07:26AM BLOOD Glucose-88 UreaN-7 Creat-0.4 Na-143 K-4.3
Cl-103 HCO3-26 AnGap-14
___ 07:26AM BLOOD ALT-10 AST-8 LD(LDH)-123 AlkPhos-55
TotBili-0.2
___ 07:26AM BLOOD Calcium-8.9 Phos-3.4 Mg-1.9
___ 07:26AM BLOOD CRP-99.3*
Pertinent Labs:
================
___ 05:45AM BLOOD ___
___ 05:55AM BLOOD CRP-206.4*
___ 05:45AM BLOOD Ferritn-112
___ 05:55AM BLOOD TSH-2.8
___ 05:45AM BLOOD HBsAg-NEG
___ 05:45AM BLOOD HIV Ab-NEG
___ 05:45AM BLOOD HCV Ab-NEG
___ 06:17AM BLOOD Lactate-0.8
Brief Hospital Course:
Ms. ___ is a ___ female with PCOS, OCD, and
?Familial Mediterranean Fever on colchicine BID (never formally
diagnosed) with h/o multiple fluid collections (pleural
effusion, pelvic fluid collection, liver fluid collection) who
was transferred from ___ for chest pain, tachycardia, and
fevers; subsequently found to have a large pericardial effusion.
TRANSITIONAL ISSUES
====================
*Medication Changes*
NEW
- Aluminum-Magnesium Hydrox.-Simethicone ___ mL PO/NG QID:PRN
indigestion
- Naproxen 500 mg PO Q12H
- Pantoprazole 40 mg PO Q24H
[ ] Please follow-up with Rheumatology as an outpatient
[ ] Follow-up with Atrius Cardiology
[ ] Consider repeat TTE as outpatient
Discharge weight: 99.3 kg
Discharge Creatinine: 0.4
#CORONARIES: Unknown
#PUMP: Unknown
#RHYTHM: Sinus tachycardia
ACUTE ISSUES:
=============
#PERICARDIAL EFFUSION
#PERICARDITIS
Potentially secondary to FMF, though this would be rare as <1%
of FMF cases involve the pericardium. Second episode. Do suspect
some form of autoimmune disease given high inflammatory markers
(CRP>200), pericardial fluid studies c/w inflammatory process
but no bacteria seen. No recent viral infections. BUN/Cr wnl,
thus not uremia-related. Trop <0.01. Bedside TTE with minimal
evidence of tamponade, remained HDS. S/p pericardial drain
placement ___. Repeat TTE ___ showed no reaccumulation.
Inflammation treated with colchicine and naproxen. GI protection
employed with pantoprazole and Maalox.
#?FAMILIAL MEDITERRANEAN FEVER
#CONCERN FOR AUTOIMMUNE DISEASE
In past, pt diagnosed with probable FMF (followed by ___
though genetic testing done in ___ was negative for any of the
known gene mutations at the time. Of note, she has a family
history of rheumatologic conditions with two family members
diagnosed with GPA. As above, would be concerned for other
autoimmune processes and if needs additional mgmt besides
colchicine/naproxen. Records of previous workup had been sent to
Rheumatology (Dr. ___ here, but pt unfortunately
re-presented here before ___ appt. If is FMF, would be
concerned for colchicine-resistant FMF given reported good
adherence. Continue colchicine and naproxen as above and
follow-up with rheumatology as an outpatient.
CHRONIC ISSUES:
===============
#OCD
Continued home paroxetine 30mg daily. Held lorazepam and
Adderall while inpatient, can resume on discharge.
#PCOS
Patient took home OCP.
#CODE: Full, presumed
#CONTACT/HCP: ___
Relationship: MOTHER
Phone: ___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. Adderall XR (dextroamphetamine-amphetamine) 10 mg oral DAILY
2. Mili (norgestimate-ethinyl estradiol) 0.25-35 mg-mcg oral
DAILY
3. PARoxetine 30 mg PO DAILY
4. Colchicine 0.6 mg PO BID
5. LORazepam 0.5 mg PO QAM:PRN for flying
Discharge Medications:
1. Aluminum-Magnesium Hydrox.-Simethicone ___ mL PO QID:PRN
indigestion
RX *alum-mag hydroxide-simeth [Maalox Advanced] 200 mg-200 mg-20
mg/5 mL ___ mL by mouth QID PRN Refills:*0
2. Naproxen 500 mg PO Q12H
RX *naproxen [Naprosyn] 500 mg 1 tablet(s) by mouth Q12hr Disp
#*60 Tablet Refills:*0
3. Pantoprazole 40 mg PO Q24H
RX *pantoprazole 40 mg 1 tablet(s) by mouth Daily Disp #*30
Tablet Refills:*0
4. Amphetamine-Dextroamphetamine XR
(dextroamphetamine-amphetamine) 10 mg oral DAILY
5. Colchicine 0.6 mg PO BID
RX *colchicine 0.6 mg 1 capsule(s) by mouth twice a day Disp
#*60 Capsule Refills:*0
6. LORazepam 0.5 mg PO QAM:PRN for flying
7. Mili (norgestimate-ethinyl estradiol) 0.25-35 mg-mcg oral
DAILY
8. PARoxetine 30 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
==================
Pericarditis
Pericardial Effusion
Concern for autoimmune disease
Discharge Condition:
Mental Status: Clear and coherent.
Activity Status: Ambulatory - Independent.
Level of Consciousness: Alert and interactive.
Discharge Instructions:
Dear Ms. ___,
WHY WERE YOU ADMITTED TO THE HOSPITAL?
- You were admitted to the hospital because you were short of
breath and we noticed you had fluid around your heart
(pericardial effusion).
WHAT WAS DONE WHILE YOU WERE IN THE HOSPITAL?
- A drain was placed to remove the fluid from around your heart.
Once the fluid collection was much smaller the drain was
removed.
- We checked some images to make sure there was no
reaccumulation of the fluid.
- Rheumatologists came to see you to give us some tests to run
to determine what is causing these fluid collections.
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.
- 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:
___
|
19732316-DS-9
| 19,732,316 | 27,202,129 |
DS
| 9 |
2131-05-21 00:00:00
|
2131-05-31 12:55:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
Laparosopic appendectomy
History of Present Illness:
___ w/h/o depression p/t ER with ~24 hrs of abdominal pain
initially epigastric, now in RLQ. It has improved somewhat
since medication in the ER. No f/c/ns. +Nausea, +Vomitedx1.
+anorexia. No dysuria/hematuria. No vaginal
discharge/bleeding. No change in bowel habits.
Past Medical History:
PMH: depression
PSH: wisdom teeth extraction
Social History:
___
Family History:
NC
Physical Exam:
On admission:
Vitals: 98.3 86 146/94 16 99% RA
Gen: NAD
CV: RRR
ABD: Obese, Soft, Mild TTP RLQ
Ext: no c/c/e
At discharge:
T 99.3, HR 89, BP 144/96, RR 20, O2Sat 99% @ RA
Gen: Lying in bed, comfortable, in NAD
Neuro: A&Ox3, moving all extremities
Card: RRR, no M/R/G, nl S1/S2
Resp: CTAB, no W/R/R
Abd: soft, non-tender, non-distended. Lap sites x3 dressed,
c/d/i.
Ext: warm, well-perfused, no edema. Palpable distal pulses.
Pertinent Results:
___ 03:45AM BLOOD WBC-13.7* RBC-5.03 Hgb-13.5 Hct-41.1
MCV-82 MCH-26.8* MCHC-32.8 RDW-14.8 Plt ___
___ 03:45AM BLOOD Glucose-117* UreaN-11 Creat-0.8 Na-135
K-5.4* Cl-102 HCO3-21* AnGap-17
CT abd/pelv (___): acute uncomplicated appendicitis
Brief Hospital Course:
Upon finding of acute appendicitis on CT, the patient was taken
to the ___ for laparoscopic appendectomy, which went without
complication. The patient was admitted to the floor
post-operatively and started on a regular diet, which she
tolerated well. Pain was well-controlled on oral medications.
The patient had no difficulties voiding and ambulating. She
remained afebrile and hemodynamically stable. The patient was
ready for discharge on POD1 and was discharged home with pain
medications and instructions to follow up in ___.
Medications on Admission:
Trazodone
Discharge Medications:
1. Acetaminophen ___ mg PO Q6H:PRN pain
RX *acetaminophen 500 mg 1 to 2 tablet(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 capsule(s) by mouth twice a day
Disp #*6 Capsule Refills:*0
3. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
RX *oxycodone 5 mg 1 tablet(s) by mouth every six (6) hours Disp
#*12 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Acute appendicitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were admitted to ___ for
inflammation of your appendix causing you abdominal pain,
nausea, and vomiting. You underwent surgery to remove the
appendix. You recovered nicely post-operatively.
At the time of discharge, you received all necessary treatment
for your diagnosis. You were given prescriptions for pain
medication. Please see us in Acute Care Surgery clinic for
follow up within 2 weeks of going home.
Please adhere to the following instructions for discharge:
Call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within ___ hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications, unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than ___ lbs until you follow-up with your
surgeon.
Avoid driving or operating heavy machinery while taking pain
medications.
Incision Care:
*Please call your doctor or nurse practitioner if you have
increased pain, swelling, redness, or drainage from the incision
site.
*Avoid swimming and baths until your follow-up appointment.
*You may shower, and wash surgical incisions with a mild soap
and warm water. Gently pat the area dry.
*Your wound is covered with steri-strips, they will fall off on
their own. Please remove any remaining strips ___ days after
surgery.
Followup Instructions:
___
|
19732922-DS-20
| 19,732,922 | 20,690,159 |
DS
| 20 |
2146-04-19 00:00:00
|
2146-04-22 17:36:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Low back pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ yo M h/o migraines was in usual state of health until he had
suddent onset ___ left low back pain after lifting his 9 month
old (18lb) child two nights ago. Pain is in left low back and
left hip joint. Pain has been constant, dull ache since then,
___ at rest. Worse with standing/moving, which causes sharp
pain up to ___ severity. Pain has some radiation to the left
foot with standing/walking. He denies paresthesias in left leg.
No bowel/bladder incontinence. Has taken Advil and Oxycodone at
home with minimal effect. Had one other episode of acute back
pain a long time ago, has mild back spasms off and on. Denies
recent trauma. No dysuria. No fever, +chills. +50lb
unintentional weight loss over past few months. Pt reports
unintentional weight loss happened in high school as well,
resolved spontaneously and was followed by increased appetite
and weight recovery. Also has intermittent swollen lymph nodes
under jaw/chin. Denies night sweats.
In the ED, initial vitals were: 99.0 96 148/95 16 100%. He
received IV hydromorphone 1mg, PO hydromorphone 2mg,
oxycodone/acetaminophen 1 tab, diazepam 5mg, ketorolac 30mg IV;
pt reports PO meds did not help and he got a little more relief
with IV med.
On the floor, VS 97.8 141/88 57 20 99% RA. Labs drawn.
Review of systems:
(+) Per HPI
Gen: Chills, weight loss as per HPI
HEENT: Migraines at baseline, no vision change, no
rhinorrhea/nasal congestion, no sore throat
Pulm: No SOB, no cough
CV: No chest pain
GI: No abd pain, nausea, vomiting, diarrhea or constipation, no
incontinence of stool
GU: No dysuria, no incontinence of urine
MSK: Back pain as above, no other myalgia/arthralgia
Skin: No rash
Heme: No abnormal bruising/bleeding, occasional LAD
Past Medical History:
Migraines, daily to every other day
Chlamydia per chart
Tension HA per chart
Prior hospitalization for fever and stomach virus
Social History:
___
Family History:
DM (father)
HTN (mother and father)
___ (mother)
No family history of cancer.
Physical Exam:
ADMISSION PHYSICAL EXAM - patient discharged the same day
Vitals: 97.8 141/88 57 20 99% RA
Per ED record, weight 96.82kg, height 74 inches
General: ___ male laying in bed, NAD except for a pang of pain
during interview and obvious discomfort with standing
HEENT: NC/AT, MMM, no scleral icterus
Neck: No cervical/supraclavicular/submandibular/submental LAD
CV: RRR, no m/g/r
Lungs: CTA b/l
Abdomen: +BS, soft, NT/ND
DRE: Normal rectal tone, intact pinprick sensation ___
Ext: WWP, no edema. Leg raise on both sides reproduces pain
Back: Spine nontender to palpation, pain at left low back/iliac
crest not reproducible with palpation
Neuro: CN ___ intact. MOTOR - shoulder flexion, elbow
flexion/extension, ankle plantar/dorsiflexion full and
symmetric. SENSORY - light touch intact distal UEs and LEs.
COORD: finger-nose-finger and heel-knee-shin WNL. Stands with
difficulty, gait slow but without limp.
Skin: No obvious rashes.
Heme: No axillary/neck LAD
Pertinent Results:
LABS
___ 11:05AM PLT COUNT-166
___ 11:05AM WBC-5.5 RBC-4.76 HGB-15.1 HCT-48.2 MCV-101*#
MCH-31.7 MCHC-31.3 RDW-12.1
___ 11:05AM TSH-3.8
___ 11:05AM CALCIUM-9.5 PHOSPHATE-3.1 MAGNESIUM-2.0
___ 11:05AM LD(LDH)-176
___ 11:05AM GLUCOSE-103* UREA N-17 CREAT-1.1 SODIUM-139
POTASSIUM-4.1 CHLORIDE-101 TOTAL CO2-28 ANION GAP-14
___ 01:10PM HIV Ab-NEGATIVE
STUDIES
Lumbar spine x-rays (AP,LAT,FLEX,EX) ___
There are very rudimentary ribs seen at T12, with five
non-rib-bearing
lumbar-type vertebrae. There is normal alignment with
preservation of the
lumbar lordosis. Degenerative disc disease noted at L5-S1;
however, the
endplates appear preserved. No appreciable facet joint
degenerative change
can be seen. No lytic or sclerotic bone lesions. Unremarkable
bowel gas
distribution.
IMPRESSION: Mild degenerative disc disease at L5-S1.
Brief Hospital Course:
___ M h/o migraines p/w acute onset low back pain, likely due
to musculoskeletal sprain.
ACTIVE DIAGNOSES
# Low back pain: Suspect musculoskeletal sprain given acute
onset pain with lifting. Also possible is disc herniation given
radiation of pain to left leg, though pt is without paresthesias
of left leg. History of unintentional weight loss and
intermittent LAD raises possibility of malignancy, though pt is
young and healthy-appearing so this would be a surprising
finding. No apparent other red flags on history, including h/o
cancer, immunosuppresion, prolonged steroid use, IVDU, urinary
sx, fever, bladder/bowel incontinence, urinary retention.
Physical exam negative for ___ anesthesia, loss of rectal
tone, other neuro deficits or vertebral tenderness. Blood counts
WNL, which is reassuring against lymphoma given h/o weight loss
and self-reported intermittent lymphadenopathy.
Lumbar spine x-ray was obtained to assess for structural
abnormality and showed mild degenerative disc disease at L5-S1.
In the ED, pt received IV hydromorphone 1mg, PO hydromorphone
2mg, oxycodone/acetaminophen 1 tab, diazepam 5mg, and ketorolac
30mg IV. On the floor, serum creatinine returned normal, so
patient was started on naproxen with instructions to discontinue
ibuprofen use while on naproxen. He was also given
prescriptions for acetaminophen (1000mg PO q 8hrs standing while
pain persists, then PRN pain) and diazepam q HS PRN pain. He
was advised not to drive or operate heavy machinery after taking
diazepam. He was treated with ice and advised to continue icing
the painful area at home. He was advised that bedrest has NOT
been shown to improve back pain, so he should continue activity
as tolerated. Follow-up with pt's primary care provider was
scheduled soon after discharge, and he should obtain referral
for outpatient physical therapy if is back pain is not improved
within two weeks of discharge.
# Weight loss: Pt reports 50lb weight loss over several months.
Unclear etiology; differential diagnosis includes
hyperthyroidism, chronic viral illness. Low suspicion for
malignancy though it is on differential. Pt appears well
nourished, with BMI 27.4 based on height/weight from ED record.
TSH was normal at 3.8, and HIV antibody was negative. LDH was
checked given pt's self-reported history of intermittent
lymphadenopathy, and it was normal at 176, decreasing suspicion
for malignancy such as lymphoma. Pt reports unintentional
weight loss in high school as well, which was followed by
increased appetite and weight recovery. Further work-up should
be undertaken as an outpatient if unintentional weight loss
persists.
# Macrocytosis: MCV 101, just above upper limit normal. Pt
without anemia (Hgb 15.1, Hct 48.2). No further work-up for now.
CHRONIC ISSUES
# History of migraines: Controlled by copious ibuprofen at home,
as much as 3000mg/day (ibuprofen 500-1000mg BID to TID).
Ibuprofen was stopped and replaced by naproxen. Pt was advised
to stop ibuprofen while taking naproxen. If he resumes
ibuprofen once he is finished with naproxen, he was advised to
take it as directed on the label. He may require further
management of migraine headaches as an outpatient in order to
adequately control pain without so much ibuprofen.
TRANSITIONAL ISSUES
# Outpatient physical therapy if back pain has not resolved
within two weeks of discharge (around ___
# Further work-up of unintentional weight loss as outpatient if
clinically indicated
# Pt was advised to stop ibuprofen while on naproxen. If he
resumes ibuprofen after naproxen is finished, he should take it
as directed on the label. He may benefit from further
management of migraine headaches as an outpatient in order to
adequately control pain without so much ibuprofen.
# Macrocytosis: MCV 101, just above upper limit normal. Pt
without anemia (Hgb 15.1, Hct 48.2). Further work-up as
outpatient if necessary.
# CODE: Full, confirmed with pt ___
# CONTACT: sister ___ (HCP per patient), # ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Ibuprofen ___ mg PO BID TO TID
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
RX *acetaminophen 500 mg 2 tablet(s) by mouth q 8 hrs Disp #*80
Tablet Refills:*0
2. Naproxen 500 mg PO Q12H
Be sure to take naproxen with food
RX *naproxen 500 mg 1 tablet(s) by mouth q 12 hrs Disp #*20
Tablet Refills:*0
3. Diazepam 5 mg PO HS:PRN pain
This med may make you dizzy. Do NOT operate a vehicle or heavy
machinery after taking it.
RX *diazepam 5 mg 1 tab by mouth q HS Disp #*14 Tablet
Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: Musculoskeletal sprain
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 low back pain. A
spine x-ray was done which did not reveal an acute change such
as a fracture on the preliminary reading. Your neurological
exam was reassuring that the spinal cord is not damaged by your
low back pain. You were treated with pain medications. The
optimal medications for treatment are oral, so it was deemed
appropriate that you be discharged to home for further recovery.
Please see the attached medication list for your home
treatment. You should STOP taking Advil because naproxen is in
the same family of drugs. Take naproxen with food in your
stomach. After you are finished with the naproxen, if you
choose to resume taking Advil, please take it according to the
dosing directed on the bottle since the amount you have been
taking is too much.
Apply ice to the low back at the area of pain for 20 minutes at
a time to enhance relief. Bedrest has NOT been shown to improve
back pain, so continue activity as tolerated. It is okay not to
go back to work till ___.
Follow-up with your primary care provider in two weeks. If your
back pain is not improved by then, it would be appropriate to
start on physical therapy as an outpatient.
Followup Instructions:
___
|
19732976-DS-11
| 19,732,976 | 29,138,251 |
DS
| 11 |
2186-12-27 00:00:00
|
2187-01-06 09:46:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: UROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Chief Complaint: left flank pain, transfer for severe
pyelonephritis
Reason for MICU transfer: sepsis
Major Surgical or Invasive Procedure:
___ right internal jugular central venous line placement
History of Present Illness:
Ms. ___ is a ___ lady with h/o right nephrectomy for
non-functioning kidney now s/p left pyeloplasty 1 week ago who
is transferred from an OSH due to severe left pyelonephritis s/p
left robot-assisted pyeloplasty one week earlier.
On ___ she underwent cystoscopy, left retrograde pyelogram,
left ureteral stent placement, and robot-assisted left
laparoscopic pyeloplasty. Then on ___ she came to
clinic, passed a voiding trial, and her foley was removed. She
reports that the same evening she began feeling shaking chills,
suprapubic pain, and left flank pain. She took Acetaminophen
and Ibuprofen for the pain. Her urine was blood-tinged, cloudy,
and foul-smelling. Has been urinating four times a day. She
thought this was expected so she did not seek help. Then last
night she developed nausea and vomiting, so this morning she
decided to go to the ED.
In the ___ ED, her initial VS were T103,
HR 128 (sinus), BP 91/62, RR 18, POx 98%RA. Labs were notable
for WBC 21.5 (35%bands, 57%N), lactate 2.4. UA suggested UTI.
Blood cultures were drawn. She received 2L NS. She received
Ertapenem. Since she receives her Urology care at ___, she
was transferred here.
In the ___ ED, initial VS were: HR 110, BP 83/51, RR 16, POx
98% RA. She spiked to 101.5 so she had blood cultures drawn and
received Acetaminophen 500mg PO. Labs were notable for WBC 15.4
(89.6%N, no bands), lactate 0.9, UA with 103 WBC, large leuks,
mod nitrite. Labs were also notable for anemia, hypomagnesemia.
She was volume resuscitated with 6L IVF but her MAP remained in
the ______. RIJ CVL was placed and she was started on
Norepinephrine. Per Urology, her SBP is normally SBP 90. They
recommended renal ultrasound which showed fullness of her left
extra-renal pelvis, though no hydronephrosis, trace free fluid
around lower pole of left kidney but no large fluid collection.
Due to sepsis requiring pressors she was admitted to the MICU.
VS prior to transfer were T101.5 114 93/66 16 100% RA.
On arrival to the MICU, she feels fine. Still has left flank
discomfort. Is very thirsty.
Review of systems:
(+) Per HPI. Also has had arthralgias in her hands and feet
since ___. Some palpitations prior to presentation. Mild
nonproductive cough since then too. Constipation. Has had a
headache since these surgeries but no photophobia or phonophobia
or stiff neck.
(-) Denies recent weight loss or gain. Denies sinus tenderness,
rhinorrhea or congestion. Denies shortness of breath or
wheezing. Denies chest pain, chest pressure or weakness. Denies
diarrhea or changes in bowel habits. Denies rashes or skin
changes.
Past Medical History:
#. chronic right ureteral/UPJ obstruction, likely congenital
-s/p right hand-assisted laparoscopic nephrectomy ___
#. left ureteropelvic junction obstruction
-s/p left pyeloplasty ___
#. recurrent urinary tract infections
#. pre-eclampsia ___ years ago
#. s/p appendenctomy ___
Past Medical History: Nonfunctioning right kidney.
recurrent urinary tract infections as
well as recurrent bladder infections when she was a child. She
has approximately two infections per year.
Past Surgical History:
1. Right hand-assisted laparoscopic nephrectomy on ___.
2. Laparoscopic appendectomy for a ruptured appendicitis in
___.
3. Robotic left pyeloplasty ___
Social History:
___
Family History:
She has one child that had to undergo two surgeries at age ___
___ for bilateral hydronephrosis.
Physical Exam:
ADMISSION EXAM
Vitals: T 100.5 °F, HR 105, BP 89/63, RR 23, SpO2 98%RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Back: left CVA tenderness
Abdomen: soft; non-distended; no masses; scars in place and
clean-appearing; mild suprapupic tenderness but no fulness
GU: foley in place draining yellow urine with sediment
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, ___ strength upper/lower extremities,
grossly normal sensation, gait deferred
DISCHARGE EXAM
WdWn, female, NAD, AVSS
Interactive, cooperative
Abdomen soft
Bilateral lower extremities w/out edema or pitting and there is
no reported calf pain to deep palpation
Urine color is clear yellow
Pertinent Results:
ADMISSION LABS
___ 09:45AM BLOOD WBC-15.4*# RBC-3.62* Hgb-10.8* Hct-31.5*
MCV-87 MCH-29.7 MCHC-34.1 RDW-13.1 Plt ___
___ 09:45AM BLOOD Neuts-89.6* Lymphs-6.2* Monos-3.8 Eos-0.2
Baso-0.1
___ 09:45AM BLOOD Glucose-104* UreaN-17 Creat-0.8 Na-140
K-3.5 Cl-105 HCO3-25 AnGap-14
___ 09:45AM BLOOD Albumin-2.8* Calcium-6.8* Phos-2.2*
Mg-1.0*
___ 09:46AM BLOOD Lactate-0.9
URINALYSIS
___ 09:45AM URINE Color-Straw Appear-Hazy Sp ___
___ 09:45AM URINE Blood-MOD Nitrite-POS Protein-30
Glucose-NEG Ketone-10 Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-LG
___ 09:45AM URINE RBC-27* WBC-103* Bacteri-MOD Yeast-NONE
Epi-<1
MICRO DATA
___ URINE URINE CULTURE-PENDING
___ BLOOD CULTURE Blood Culture-PENDING
___ BLOOD CULTURE Blood Culture-PENDING
___ RENAL ULTRASOUND [preliminary report]
-s/p right nephrectomy
-Pigtail stent in left collecting system
-Fullness of left extra-renal pelvis - though no hydronephrosis
-Possible small stone in left kidney
-Trace free fluid around lower pole of left kidney. No large
fluid collection.
-Pt with foley catheter in place - therefore post-voiding
imaging not
completed
___ CXR [preliminary report]
RIJ CVL terminates in mid SVC.
No acute intrathoracic process.
Brief Hospital Course:
Ms. ___ is a ___ lady with h/o right nephrectomy for
non-functioning kidney now s/p left pyeloplasty 1 week ago who
presents with urosepsis.
#. Hypotension: from urosepsis, bacteremia.
She had fever, rigors, and leukocytosis. On presentation to the
OSH was developing shock with elevated lactate, bandemia. With
cloudy foul-smelling urine after recent Urologic procedure, she
most likely has a urinary source (see below). She was volume
resuscitated with IV fluids (~12L total between the OSH and
here) and was weaned off pressors. Her baseline BP is in the
high 80's/low 90's, and she remained stable without any need to
resume pressors.
#. Pyelonephritis:
She is s/p left pyeloplasty & stent placement for left UPJ
obstruction. She developed pyelonephritis/bacteremia after
foley catheter removal. The left ureteral
stent being in place allowed free reflux of urine into the left
kidney, which likely made her susceptible to upper tract
infection. Ultrasound ruled out urinoma, and no suggestion of
___ abscess or other complication. She had received
Ertapenem because of report of prior sensitivity data, but upon
further investigation she has no h/o resistant UTIs.
Antibiotics were changed to Ceftriaxone based on OSH sensitivity
data. She was transferred to Urology.
#. ___: Cr 1 at OSH (baseline is 0.5), likely prerenal.
This resolved with IVF (Cr down to 0.8 here), so was likely
prerenal. No evidence of hydro on U/S. She had been taking
Ibuprofen 600mg BID for pain so this could be contributing. She
was volume resuscitated and Cr decreased.
#. Hypomagnesemia: unclear etiology.
She has no h/o no chronic diarrhea. Not on medications known to
cause low magnesium. No h/o heavy alcohol use.
Post-obstructive diuresis can cause hypomagnesemia, but no
evidence for obstruction. Her Mg was repleted and remained
normal.
#. Anemia: no suspicion for bleed.
At the OSH her Hct was 35.1 which is close to her baseline; her
Hct 31.5 probably reflected hemodilution.
Her transfer to the urology service from ___ was delayed
because of bed shortage and need of private room. She
transfered from MICU to urology service 12R on ___ around
13:30 and with K of 2.8 which was immediately repleted on
arrival. Antibiotics switched from cefepime back to ceftriaxone
with finalization of cultures. Her urine output remained good
and she was discharged home after remaining afebrile for over
48hrs. She maintained a regular diet, was having regular bowel
movements and she had no pain management issues. She had her
foley removed and she passed a voiding trial and commenced with
a program of timed voids. She was discharged home with oral
ciprofloxacin, to which her infection was sensitive, and clear
instructions on continuing her timed voids. She will follow up
for ureteral stent removal in the future and was given oral
antibiotics to start taking one day before her stent removal
.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. drospirenone-ethinyl estradiol *NF* ___ mg Oral daily
2. Acetaminophen 1000 mg PO Q8H:PRN pain/fever
3. Ibuprofen 600 mg PO BID:PRN pain/fever
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H:PRN pain/fever
2. Ciprofloxacin HCl 500 mg PO Q12H
RX *ciprofloxacin [Cipro] 500 mg ONE tablet(s) by mouth twice a
day Disp #*24 Tablet Refills:*0
3. Multivitamins W/minerals 1 TAB PO DAILY
RX *multivitamin,tx-minerals ONE tablet(s) by mouth daily Disp
#*30 Tablet Refills:*0
4. drospirenone-ethinyl estradiol *NF* ___ mg Oral daily
5. Ibuprofen 600 mg PO BID:PRN pain/fever
6. STENT REMOVAL and ANTIBIOTICS
You will follow up for ureteral stent removal in the next few
weeks. START the CIPROFLOXACIN antibiotic ONE DAY before the
scheduled removal and continue for two days afterwards.
7. URETERAL STENT REMOVAL
-You will follow up for ureteral stent removal with Dr. ___
___ on ___ as listed above.
Please start the antibiotics provided (Ciprofloxacin) on the
morning of ___ as directed.
8. TIMED VOIDING
Please continue with TIME VOIDING while you are awake. Please
VOID or attempt to void EVERY TWO HOURS while awake-- EVEN if
there is no urge to do so.
Discharge Disposition:
Home
Discharge Diagnosis:
Urosepsis, pyelonephritis
s/p ___ cystoscopy, left retrograde pyelogram, left
ureteral
stent placement and robot assisted left laparoscopic
pyeloplasty.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
***Please continue with TIME VOIDING while you are awake. Please
VOID EVERY TWO HOURS while awake EVEN if there is no urge to do
so.
-You may experience some pain associated with spasm of your
ureter; This is normal. Take the Tylenol medication for pain
control or substitute the prescribed narcotic pain medication if
additional pain relief is needed.
-Ureteral stents MUST be removed or exchanged and therefore it
is IMPERATIVE that you follow-up as directed.
-For your safety and the safety of others; PLEASE DO NOT drive,
operate dangerous machinery, or consume alcohol while taking
narcotic pain medications.
-Resume your pre-admission/home medications except as noted.
ALWAYS call to inform, review and discuss any medication changes
and your post-operative course with your primary care doctor.
-___ vigorous physical activity or sports for 4 weeks or until
otherwise advised
-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
-You may shower and bathe normally
-Do not drive or drink alcohol while taking narcotics and do not
operate dangerous machinery
-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
-If you have fevers > 101.5 F, vomiting, or increased redness,
swelling, or discharge from your incision, call your doctor or
go to the nearest emergency room.
Followup Instructions:
___
|
19733031-DS-16
| 19,733,031 | 22,572,984 |
DS
| 16 |
2157-02-08 00:00:00
|
2157-02-12 20:25:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
Penicillins / Aspirin / Pradaxa
Attending: ___.
Chief Complaint:
Code stroke
Major Surgical or Invasive Procedure:
Interventional angiography for clot retrieval
History of Present Illness:
Reason for consult: code stroke
Neurology at bedside for evaluation after code stroke activation
within: 3 minutes
Time (and date) the patient was last known well: 3:25pm ___
___ Stroke Scale Score: 12
t-PA given: No Reason t-PA was not given or considered: xarelto
within 24 hours.
I was present during the CT scanning and reviewed the images
instantly within 20 minutes of their completion.
___ Stroke Scale score was 12:
1a. Level of Consciousness: 0
1b. LOC Question: 0
1c. LOC Commands: 0
2. Best gaze: 0
3. Visual fields: 0
4. Facial palsy: 2
5a. Motor arm, left: 3
5b. Motor arm, right: 0
6a. Motor leg, left: 4
6b. Motor leg, right: 0
7. Limb Ataxia: 0
8. Sensory: 2
9. Language: 0
10. Dysarthria: 1
11. Extinction and Neglect: 0
HPI:
___ with PMHx significant for AFIB on ___ (last dose
6:30pm
the day prior to admission), previous strokes (last in ___, no
residual deficits), HTN who had the sudden onset of left facial
droop and left weakness around 3:25pm. The patient and her
husband had gone out during the day and returned home around 3pm
with no major issues. He was in another room when he heard a
loud noise. He rushed to her side to find that she had fallen
and
had a left facial droop and marked left sided weakness. 911 was
called and she was transferred to ___ where a code stroke was
activated.
On neuro ROS, (+) weakness, (+) numbness, (+) chronic right eye
blindness. The pt denies headache. Denies difficulties producing
or comprehending speech. No bowel or bladder incontinence or
retention. Denies baseline difficulty with gait.
Past Medical History:
- multiple strokes, last ___ (R PCA, L Sup MCA)
- Atrial fibrillation (tried Coumadin but INR difficult to keep
therapeutic and had a stroke while on it, stopped pradaxa
because
of stomach upset, currently on xarelto)
- hypertension
- hypothyroidism
- atypical chest pain
- status post appendectomy
- recurrent diverticulitis
Social History:
___
Family History:
- per omr, paternal aunt has CAD. Father, mother, and siblings
have negative cardiac history
Physical Exam:
Admission Exam:
- Vitals: 98.1 ___ 16 99%RA
- General: Brightly Awake
- HEENT: NC/AT
- Neck: Supple
- Pulmonary: no increased WOB
- Cardiac: irregular
- Abdomen: soft, nontender, obese
- Skin: no rashes or lesions noted.
NEURO EXAM:
- Mental Status: Brightly awake, alert, oriented x 3. Able to
relate history. Language is fluent with intact repetition and
comprehension. Normal prosody. There were no paraphasic errors.
Able to name high frequency objects only but she is from ___
originally. Speech dysarthric secondary to droop. Able to follow
both midline and appendicular commands. There was no evidence of
neglect.
- Cranial Nerves:
PERRL 3 to 2mm. Baseline blindness in the right eye (can see
light only). VFF to confrontation with no extinction to DSS.
EOMI
without nystagmus. Facial sensation 20% to pin prick. Left
facial
droop. Hearing intact to room voice.
- Motor: Increased bulk throughout. Slight inward rotation of
the
LUE in the plane of the bed only, no anti-gravity movement.
Unable to move the LLE or wiggle the left toes. RUE and RLE
antigravity with no apparent weakness.
- Sensory: 20% sensation to the left to pinprick. Despite
sensory
deficit, no extinction to DSS in upper or lower extremities or
on
visual testing.
- DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 1 0
R 2 2 2 1 0
Plantar response was extensor on the left.
- Coordination: No intention tremor noted. No dysmetria on FNF
on
the right.
FOLLLOW UP EXAM AFTER ARRIVAL TO THE ICU AFTER ANGIO:
- Mental Status unchanged except more drowsy, awoke readily to
stimulation
- Facial sensation 70% to pin prick. Left facial droop mildly
improved,
- Motor: Antigravity with all extremities but formal power exam
difficult due to marked motor impersistence, the score given is
the level of best effort
Delt Bic Tri WrE FFl FE IP Quad Ham TA Gastroc
L 5- ___ 3 0 5- 5 3 5 5
R 5- ___ 5 5 * * * 5 5
*unable to test because right leg in brace
- Sensory: 70% sensation to the left face/arm/leg to pinprick.
Despite sensory deficit, no extinction to DSS in upper or lower
extremities or on visual testing.
- Plantar response was extensor on the left
- No dysmetria on FNF on the right
Discharge Exam:
- Mental Status: awake, alert, oriented, able to name, repeat
and relate history w/o difficulty.
- CN: 3 to 2mm. Baseline blindness in the right eye (can see
light only). VFF to confrontation with limitation on RUQ. EOMI
without nystagmus. Left NLFF. Hearing grossly intact.
- Motor: plegic on LT upper and lower extremity, full on right
upper and lower extremity.
- Sensory: Intact to ST/temp ___. No extinction to DSS.
- Plantar response was extensor on the left
Pertinent Results:
IMAGING:
___ MR ___
1. Findings compatible with a right lateral lenticulostriate
distribution
infarct as well as additional foci of peripheral
diffusion-weighted
hyperintense signal without clear ADC hypointense correlate of
the peripheral right prefrontal gyrus.
2. Left frontal, right inferior cerebellar and right occipital
lobe
encephalomalacia. The right occipital lobe encephalomalacia is
new since a ___.
3. Allowing for motion degraded sequences, no evidence of large
acute
intracranial hemorrhage.
CTA HEAD AND NECK:
1. New occlusion of the distal right M1 segment with
reconstitution of the
right proximal M2 segments with increased mean transit time,
decreased
cerebral blood flow, and normal cerebral blood volume in the
right MCA
distribution, indicative of ischemic penumbra.
2. Patient vasculature in the neck with no evidence of internal
carotid artery stenosis by NASCET criteria.
3. Chronic infarctions in the left frontal and right occipital
lobes.
4. Unchanged, rounded, extra-axial mass in the left parietal
lobe with
hyperostosis of the adjacent calvarium, suggestive of
meningioma, correlation with MRI of the head with contrast is
advised for further characterization.
NEUROINTERVENTION:
TICI3 recanalization of right M2 branch occlusion.
CXR:
Moderate enlargement of the cardiac silhouette has increased
since ___ due to progressive cardiomegaly and/or pericardial
effusion. There is no mediastinal venous engorgement to suggest
elevated central venous pressure and the lungs are clear. There
is no edema. No pleural effusion. Lungs are fully expanded and
clear. Incidental note is made of a right cervical rib, a
potential cause of thoracic outlet syndrome, impingement on the
right subclavian vessels and brachial plexus.
CTA HEAD:
1. Occlusion or severe stenosis at the right MCA bifurcation,
with no filling of the proximal superior division of the right
MCA, but with distal filling of the superior division in the
sylvian fissure, suggestive of collateral flow.
2. New subtle hypodensity in the right putaminal and subinsular
white matter compared with prior CT head on ___ and
consistent with acute infarction seen on MRI performed on same
day.
CT HEAD:
1. Expected interval evolution of findings associated with known
right MCA
territory infarction. No hemorrhage. No new acute infarction
elsewhere.
2. Stable foci of encephalomalacia involving the right
cerebellar hemisphere, right occipital lobe, and left frontal
lobe.
3. Stable appearance of a rounded, extra-axial mass in the left
parietal lobe with hyperostosis of the adjacent calvarium,
suggestive of meningioma, better assessed on recent MRI.
CT CHEST:
No evidence of intra thoracic malignancy. Moderate dilatation
of the main
pulmonary artery, suggesting pulmonary hypertension. No
lymphadenopathy. No pleural pathology.
CT ABDOMEN PELVIS:
Focal 5 cm region of wall thickening of the sigmoid colon may be
inflammatory/contraction however correlation with colonoscopy is
recommended.
LABS:
___ 05:40AM BLOOD WBC-6.5 RBC-4.34 Hgb-12.5 Hct-39.2 MCV-90
MCH-28.8 MCHC-31.9* RDW-13.2 RDWSD-43.8 Plt ___
___ 06:40AM BLOOD WBC-6.9 RBC-4.42 Hgb-12.5 Hct-39.8 MCV-90
MCH-28.3 MCHC-31.4* RDW-13.2 RDWSD-43.7 Plt ___
___ 06:45AM BLOOD WBC-7.3 RBC-4.50 Hgb-13.0 Hct-40.7 MCV-90
MCH-28.9 MCHC-31.9* RDW-13.3 RDWSD-43.9 Plt ___
___ 06:15AM BLOOD WBC-7.9 RBC-4.63 Hgb-13.3 Hct-41.1 MCV-89
MCH-28.7 MCHC-32.4 RDW-13.4 RDWSD-43.5 Plt ___
___ 04:45AM BLOOD WBC-7.8 RBC-4.67 Hgb-13.4 Hct-41.9 MCV-90
MCH-28.7 MCHC-32.0 RDW-13.3 RDWSD-44.0 Plt ___
___ 02:12AM BLOOD WBC-7.6 RBC-4.15 Hgb-12.0 Hct-37.4 MCV-90
MCH-28.9 MCHC-32.1 RDW-13.7 RDWSD-45.4 Plt ___
___ 03:52AM BLOOD WBC-7.0 RBC-4.25 Hgb-12.1 Hct-38.8 MCV-91
MCH-28.5 MCHC-31.2* RDW-13.7 RDWSD-45.6 Plt ___
___ 04:20PM BLOOD WBC-6.9 RBC-4.84 Hgb-14.3 Hct-44.6 MCV-92
MCH-29.5 MCHC-32.1 RDW-13.6 RDWSD-46.2 Plt ___
___ 06:40AM BLOOD PTT-54.4*
___ 09:50AM BLOOD ___ PTT-58.9* ___
___ 02:38AM BLOOD PTT-53.9*
___ 08:39PM BLOOD ___ PTT-52.8* ___
___ 03:01PM BLOOD PTT-51.2*
___ 06:15AM BLOOD PTT-42.2*
___ 02:43AM BLOOD PTT-60.6*
___ 08:15PM BLOOD PTT-53.5*
___ 12:56PM BLOOD PTT-57.7*
___ 04:45AM BLOOD ___ PTT-52.1* ___
___ 08:36PM BLOOD ___ PTT-46.5* ___
___ 02:00PM BLOOD PTT-58.3*
___ 06:53AM BLOOD ___ PTT-106* ___
___ 02:12AM BLOOD ___ PTT-102.6* ___
___ 10:53PM BLOOD PTT-150*
___ 03:35PM BLOOD ___ PTT-27.7 ___
___ 03:52AM BLOOD ___ PTT-29.6 ___
___ 04:20PM BLOOD ___ PTT-31.7 ___
___ 03:35PM BLOOD AT-PND Heparin-0.04* ProtCFn-PND
ProtSFn-PND
___ 05:40AM BLOOD Glucose-102* UreaN-6 Creat-0.6 Na-140
K-4.0 Cl-105 HCO3-26 AnGap-13
___ 06:40AM BLOOD Glucose-122* UreaN-6 Creat-0.6 Na-137
K-3.9 Cl-106 HCO3-22 AnGap-13
___ 06:45AM BLOOD Glucose-100 UreaN-6 Creat-0.6 Na-140
K-3.8 Cl-102 HCO3-28 AnGap-14
___ 06:15AM BLOOD Glucose-103* UreaN-9 Creat-0.6 Na-139
K-3.9 Cl-102 HCO3-26 AnGap-15
___ 04:45AM BLOOD Glucose-84 UreaN-6 Creat-0.6 Na-138 K-3.8
Cl-101 HCO3-26 AnGap-15
___ 02:12AM BLOOD Glucose-103* UreaN-5* Creat-0.5 Na-137
K-4.1 Cl-103 HCO3-25 AnGap-13
___ 03:52AM BLOOD Glucose-102* UreaN-9 Creat-0.6 Na-141
K-3.6 Cl-105 HCO3-26 AnGap-14
___ 04:34PM BLOOD Creat-0.9
___ 04:20PM BLOOD UreaN-15
___ 04:20PM BLOOD ALT-27 AST-31 AlkPhos-115* TotBili-1.2
___ 04:20PM BLOOD Lipase-21
___ 03:52AM BLOOD CK-MB-3 cTropnT-<0.01
___ 04:20PM BLOOD cTropnT-<0.01
___ 05:40AM BLOOD Calcium-8.6 Phos-3.3 Mg-1.7
___ 06:15AM BLOOD Calcium-9.0 Phos-3.7 Mg-1.9
___ 04:45AM BLOOD Calcium-8.7 Phos-3.7 Mg-2.0
___ 02:12AM BLOOD Calcium-8.7 Phos-2.9 Mg-2.1
___ 03:52AM BLOOD Calcium-8.5 Phos-2.8 Mg-1.9 Cholest-131
___ 04:20PM BLOOD Albumin-4.2 Calcium-9.4 Phos-2.3* Mg-2.1
___ 04:45AM BLOOD VitB12-733
___ 02:00PM BLOOD D-Dimer-584*
___ 03:52AM BLOOD %HbA1c-5.8 eAG-120
___ 03:52AM BLOOD Triglyc-66 HDL-44 CHOL/HD-3.0 LDLcalc-74
___ 03:52AM BLOOD TSH-1.6
___ 04:20PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 04:29PM BLOOD Glucose-194* Lactate-1.9 Na-144 K-3.9
Cl-104 calHCO3-26
SED RATE BY MODIFIED 17 (< OR = 30 mm/h)
CARDIOLIPIN AB (IGG) <14 (WNL)
CARDIOLIPIN AB (IGM) <12 (WNL)
B2 GLYCOPROTEIN I (IGG)AB <9 <=20 SGU
B2 GLYCOPROTEIN I (IGM)AB <9 <=20 SMU
B2 GLYCOPROTEIN I (IGA)AB 11 <=20 ___
URINE:
___ 07:41PM URINE Color-Straw Appear-Clear Sp ___
___ 07:41PM URINE Blood-TR Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.5 Leuks-NEG
___ 07:41PM URINE RBC-11* WBC-<1 Bacteri-FEW Yeast-NONE
Epi-0
___ 07:41PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG oxycodn-NEG mthdone-NEG
URINE CULTURE (Final ___: NO GROWTH.
Brief Hospital Course:
BRIEF HOSPITAL COURSE
=======================
Ms. ___ is a ___ woman with PMHx significant for afib on
xarelto (last dose 6:30pm the day prior to admission), previous
strokes (last ___, HTN who had the sudden onset of left facial
droop and left weakness. She was found to have a right M2 cut
off on CTA, s/p clot retrieval, and a small R MCA stroke
affecting the insula, subcortical white matter, and basal
ganglia on MRI. While afib is the likely etiology of her stroke,
she has had multiple embolic strokes and failed multiple
anticoagulants, raising concern for a hypercoagulable disorder.
.
ICU Course:
The patient was admitted to the ICU post-angio retrieval of the
right M2 clot, for close monitoring. CT Head 24 hours after
intervention showed reocclusion. Blood pressure was allowed to
autoregulate between systolics 100-180, on half home dose
metoprolol. Home Lasix and lisinopril were held.
.
NEUROLOGY WARD COURSE:
___ is a ___ yo woman with a hx of paroxysmal atrial
fibrillation (on xarelto at the time of admission), HTN who
presented with weak L face and body. She was found to have a
right M2 cut off on CTA, s/p clot retrieval and re-occlusion
resulting in right MCA stroke affecting the insula, subcortical
white matter, and basal ganglia on MRI.
.
Her stroke risk factors were assessed and found stable. She had
an echo which showed no PFO/ ASD however did have increased
pulmonary hypertension. We believe atrial fibrillation is the
most likely etiology of her stroke, but she has had multiple
embolic strokes and failed multiple anticoagulants, raising
concern for a hypercoagulable disorder. We have checked b2
glycoprotein, cardiolipin antibodies, ESR which were all WNL.
Also assessed CT torso which was significant for an area of
thickening in the sigmoid, colonoscopy is recommended.
.
For anticoagulation we consulted Hematology. They recommended
using lovenox with transition to warfarin. However, the patient
refused to resume taking warfarin. We have discussed with her
cardiologist who has recommended that in the setting of
therapeutic failure with warfarin and xarelto we proceed with
Apixaban.
.
She will be discharged to ___ rehab for physical therapy
and close monitoring.
.
Other issues of note included
- Atrial fibrillation with RVR: Increased metoprolol tartrate
from 100/50 to 100 BID
- Foley catheter: Removed on ___
- Passed swallow evaluation with a modified diet
.
TRANSITIONAL ISSUES:
1. FOLLOW UP SIGMOID THICKENING WITH COLONOSCOPY.
2. FOLLOW UP INPATIENT HYPERCOAG STUDIES AND ORDER REST OF
HYPERCOAGULABLE WORK UP:
- homocysteine
- prothrombin gene mutation
- factor V leiden
- antithrombin III
3. HOLDING HOME LISINOPRIL, TARGETING NORMOTENSION CONSIDER
REINTRODUCING AS AN OUTPATIENT.
4. CONSIDER FURTHER EVALUATION FOR PULMONARY HYPERTENSION
SUGGESTED ON ECHOCARDIOGRAM
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Vitamin D ___ UNIT PO 1X/WEEK (WE)
2. Furosemide 60 mg PO DAILY
3. Levothyroxine Sodium 50 mcg PO DAILY
4. Lisinopril 40 mg PO DAILY
5. Metoprolol Tartrate 100 mg PO QAM
6. Metoprolol Tartrate 50 mg PO QPM
7. Omeprazole 40 mg PO DAILY
8. Rivaroxaban 20 mg PO DAILY
9. Potassium Chloride Dose is Unknown PO Frequency is Unknown
Discharge Medications:
1. Furosemide 60 mg PO DAILY
2. Levothyroxine Sodium 50 mcg PO DAILY
3. Metoprolol Tartrate 100 mg PO QPM
4. Metoprolol Tartrate 100 mg PO QAM
5. Vitamin D ___ UNIT PO 1X/WEEK (WE)
6. Apixaban 5 mg PO BID
7. Atorvastatin 40 mg PO QPM
8. Fluoxetine 20 mg PO DAILY
9. Omeprazole 40 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary:
1. Right MCA embolism with infarction.
Secondary:
1. HTN
2. Atrial fibrillation
3. Hypothyroidism
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Ms. ___,
You were admitted with symptoms of left sided weakness and were
found to have a stroke on the right side of your ___. You went
for invasive clot retrieval, which was successful. However your
area of infarct clotted again producing weakness of your left
side. We initially anticoagulated you with heparin and then
transitioned to an oral agent as below. We have also checked
your stroke risk factors, which were controlled. We evaluated
your heart with an echocardiogram which showed no clots but did
show high pressures in your lung vessels. We have controlled
your blood pressures with medications to which you have
responded well.
You had a workup for hypercoagulable disorders because you have
had multiple strokes while on different blood thinner
medications. Most of these results are pending and will be
discussed at you stroke appointment. You also had a CT of your
torso which was concerning for thickening in your intestine. You
will need a colonoscopy as an outpatient.
Education:
An ACUTE ISCHEMIC STROKE is a condition where a blood vessel
providing oxygen and nutrients to the ___ is blocked by a
clot. The ___ is the part of your body that controls and
directs all the other parts of your body, so damage to the ___
from being deprived of its blood supply can result in a variety
of symptoms.
Stroke can have many different causes, so we assessed you for
medical conditions that might raise your risk of having stroke.
In order to prevent future strokes, we plan to modify those risk
factors. Your risk factors are:
-atrial fibrillation
-hypertension
We are changing your medications as follows:
-Discontinued your rivaroxaban.
-started Apixaban
Instructions:
Please take your other medications as prescribed.
Please followup with Neurology and your primary care physician
as listed below.
If you experience any of the symptoms below, please seek
emergency medical attention by calling Emergency Medical
Services (dialing 911). In particular, since stroke can recur,
please pay attention to the sudden onset and persistence of
these symptoms:
- sudden partial or complete loss of vision
- sudden loss of the ability to speak words from your mouth
- sudden loss of the ability to understand others speaking to
you
- sudden weakness of one side of the body
- sudden drooping of one side of the face
- sudden loss of sensation of one side of the body
Followup Instructions:
___
|
19733031-DS-17
| 19,733,031 | 29,695,207 |
DS
| 17 |
2159-03-22 00:00:00
|
2159-03-23 07:18:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Aspirin / Pradaxa
Attending: ___.
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
NONE
History of Present Illness:
___ female with history of A. fib on Eliquis complicated
by multiple embolic strokes causing residual left hemiparesis,
hypertension, hyperlipidemia with 24 hours of LUQ ab pain-
constant, sharp, worse with cough, deep inspiration, movement.
Cough x 1 week- nonproductive. No fever, vomiting, diarrhea,
melena, hematochezia, dysuria,hematuria, numbness/tingling,
rash.
In the ED, initial VS were: T98.2, HR 88, BP 151/98, RR 16, O2
100% RA
Exam notable for: LUQ ab pain. Pt also with wheezing on exam
which she has never had (no hx of wheezing/asthma/COPD)
Labs showed: Hb 13.1->11.9
Flu B positive
Trop negative x2
Imaging showed: CT A/P 9.3 cm left rectus sheath hematoma with
punctate foci of hyperdensity similar
to blood pool concerning for possible active extravasation.
CXR: No acute cardiopulmonary abnormality. Mild cardiomegaly
unchanged.
Consults: ___ consulted, no intervention
Patient received:
- IV Morphine Sulfate 2 mg x4
- Albuterol nebs
- Ipratropium nebs
- K centra, 2 units FFP
- Metoprolol 100mg
- Atorvastatin 40mg
Transfer VS were: T99.8, HR 101, BP 165/100, RR 18, o2 98% RA
On arrival to the floor, patient reports severe LUQ pain,
although slightly improved from when she came in. The pain
started about 5 days ago with frequent coughing. She has had
fever, cough congestion for approximately 8 days. Currently
reports feeling feverish and is wheezing. Reports she had
similar
wheezing several years ago with viral illness. Has L sided arm
and leg weakness that is at baseline. Reports leg swelling L>R.
Denies headache, dizziness, nausea, vomiting chest pain,
shortness of breath, dysuria, constipation, diarrhea.
Past Medical History:
- multiple strokes, last ___ (R PCA, L Sup MCA)
- Atrial fibrillation (tried Coumadin but INR difficult to keep
therapeutic and had a stroke while on it, stopped pradaxa
because
of stomach upset, currently on xarelto)
- hypertension
- hypothyroidism
- atypical chest pain
- status post appendectomy
- recurrent diverticulitis
Social History:
___
Family History:
- Per omr, paternal aunt has CAD. Father, mother, and siblings
have negative cardiac history
Physical Exam:
ADMISSION EXAM:
===============
VS: 100.2 156 / 108L Lying ___ Ra
GENERAL: NAD, A&O x3
HEENT: AT/NC, EOMI, PERRL, L sided facial droop
NECK: supple, no LAD, no JVD
HEART: Irregular rhythm, S1/S2, no murmurs, gallops, or rubs
LUNGS: Diffuse wheezing throughout lung fields
ABDOMEN: nondistended, tender to palpation over LUQ, no rebound,
guarding, rigidity
EXTREMITIES: pitting edema below knees, L>R
PULSES: 2+ DP pulses bilaterally
NEURO: A&Ox3, unable to move L arm, able to move L toes,
strength in R ___ in upper and lower extremity
SKIN: diaphoretic, no rashes or lesions
DISCHARGE EXAM:
===============
VITALS: 98.0 107/69 88 18 98 RA
GENERAL: NAD, A&O x3, sitting upright in bed watching ___
HEENT: AT/NC, EOMI, PERRL, L sided facial droop (sable)
NECK: supple, no LAD, no JVD
HEART: Irregularly irregular rhythm, S1/S2, no murmurs, gallops,
or rubs
LUNGS: Scattered expiratory wheezing throughout lung fields
ABDOMEN: LUQ non-tender to palpation. No palpable mass. Not
pulsatile. No ecchymosis. Otherwise soft and without
hepatosplenomegaly.
EXTREMITIES: pitting edema below knees, L>R, wearing compression
stockings
PULSES: 2+ DP pulses bilaterally
NEURO: A&Ox3, unable to move L arm, able to move L toes,
strength in R ___ in upper and lower extremity
SKIN: diaphoretic, no rashes or lesions
Pertinent Results:
ADMISSION LABS:
===============
___ 09:38PM ___ PO2-60* PCO2-40 PH-7.45 TOTAL CO2-29
BASE XS-3
___ 09:24PM WBC-5.6 RBC-3.90 HGB-10.9* HCT-34.4 MCV-88
MCH-27.9 MCHC-31.7* RDW-14.1 RDWSD-45.3
___ 09:24PM NEUTS-77.9* LYMPHS-16.0* MONOS-5.5 EOS-0.0*
BASOS-0.2 IM ___ AbsNeut-4.37 AbsLymp-0.90* AbsMono-0.31
AbsEos-0.00* AbsBaso-0.01
___ 09:24PM PLT COUNT-155
___ 01:00PM cTropnT-<0.01
___ 09:39AM URINE HOURS-RANDOM
___ 09:39AM URINE UHOLD-HOLD
___ 09:39AM URINE COLOR-Straw APPEAR-Clear SP ___
___ 09:39AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30*
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.5
LEUK-NEG
___ 09:39AM URINE RBC-2 WBC-0 BACTERIA-NONE YEAST-NONE
EPI-<1
___ 09:39AM URINE MUCOUS-RARE*
___ 07:20AM OTHER BODY FLUID FluAPCR-NEGATIVE
FluBPCR-POSITIVE*
___ 06:53AM ___ PTT-33.7 ___
___ 06:33AM ___ COMMENTS-GREEN TOP
___ 06:33AM LACTATE-1.3
___ 06:15AM GLUCOSE-136* UREA N-14 CREAT-0.7 SODIUM-141
POTASSIUM-4.4 CHLORIDE-101 TOTAL CO2-24 ANION GAP-16
___ 06:15AM estGFR-Using this
___ 06:15AM ALT(SGPT)-22 AST(SGOT)-32 ALK PHOS-161* TOT
BILI-1.0
___ 06:15AM LIPASE-15
___ 06:15AM cTropnT-<0.01
___ 06:15AM ALBUMIN-4.2
___ 06:15AM WBC-5.2 RBC-4.83 HGB-13.4 HCT-42.9 MCV-89
MCH-27.7 MCHC-31.2* RDW-14.1 RDWSD-45.4
___ 06:15AM NEUTS-66.4 ___ MONOS-8.7 EOS-0.6*
BASOS-0.2 IM ___ AbsNeut-3.46 AbsLymp-1.23 AbsMono-0.45
AbsEos-0.03* AbsBaso-0.01
___ 06:15AM PLT COUNT-211
DISCHARGE LABS:
===============
___ 04:00AM BLOOD WBC-6.2 RBC-3.84* Hgb-10.6* Hct-34.1
MCV-89 MCH-27.6 MCHC-31.1* RDW-13.9 RDWSD-45.2 Plt ___
___ 04:00AM BLOOD ___
___ 04:00AM BLOOD Glucose-104* UreaN-11 Creat-0.5 Na-142
K-4.0 Cl-103 HCO3-29 AnGap-10
___ 04:00AM BLOOD Calcium-8.9 Phos-3.3 Mg-2.0
IMAGING:
========
CXR ___: No acute cardiopulmonary abnormality. Mild
cardiomegaly unchanged.
CT Abdomen/Pelvis without contrast ___: 9.3 cm left rectus
sheath hematoma with punctate foci of hyperdensity similar to
blood pool concerning for possible active extravasation.
TEE ___:
There is no spontaneous echo contrast in the body of the left
atrium. There is moderate/severe spontaneous echo contrast in
the left atrial appendage. The left atrial appendage ejection
velocity is normal.
___ width 2.0 cm; length 3.1 cm. No spontaneous echo contrast or
thrombus is seen in the body of the right atrium/right atrial
appendage. The right atial appendage ejection velocity is
depressed. There is no
evidence for an atrial septal defect by 2D/color Doppler. Global
systolic function is normal (LVEF greater than 55%). There are
no aortic arch atheroma and no atheroma in the descending aorta.
The aortic valve leaflets (3) are mildly thickened. No masses or
vegetations are seen on the aortic valve. No abscess is seen.
There is no aortic regurgitation. The mitral leaflets are mildly
thickened with no mitral valve prolapse. No masses or
vegetations are seen on the mitral valve. No abscess is seen.
There is mild to moderate [___] mitral regurgitation. The
tricuspid valve leaflets appear structurally normal. No
mass/vegetation are seen on the tricuspid valve No abscess is
seen. There is mild to moderate [___] tricuspid regurgitation.
The estimated pulmonary artery systolic pressure is moderately
elevated.
IMPRESSION: Good image quality. Moderate/severe spontaneous echo
contrast but no thrombus in the left atrial appendage. No
spontaneous echo contrast or thrombus in the left atrial
appendage/right atrium/right atrial appendage. Mild-moderate
mitral regurgitation with mild leaflet thickening but no
discrete vegetation or abscess. Moderate pulmonary artery
systolic hypertension.
Brief Hospital Course:
PATIENT SUMMARY:
================
___ female with history of A. fib on Eliquis complicated
by multiple embolic strokes causing residual left-sided
hemiparesis, hypertension, hyperlipidemia with 5 days of LUQ
pain in the setting of influenza-like illness found to have
rectus sheath hematoma and flu positive.
ACUTE ISSUES:
=============
#Rectus sheath hematoma
#LUQ abdominal pain
Patient with e/o 9 cm rectus sheath hematoma with concern for
possible active extravasation on CT. Patient remained
hemodynamically stable. Slight drop in Hgb 13.4->10.9.
Hemodynamically stable overnight. ___ be related strain from
frequent coughing in the setting of anticoagulation with
eliquis. Per ED team case was discussed with ___ who declined
intervention. Per discussion with Dr. ___ was reversed
with K centra and 2 units FFP in ED. Hemoglobin stabilized with
intervention. Apixaban was initially held, then RESUMED on
discharge, with a plan to follow-up with Dr. ___ on ___.
#Influenza
Patient influenza B positive. Reporting fever, cough and
congestion for the last week. Her cough has improved slightly,
but she is now wheezing. Denies any history of
asthma/COPD/tobacco use. CXR with no focal consolidations. Her
oxygen saturations have remained stable on room air. Given
Ipratropium/Albuterol nebs to help with wheezing. Outside window
for Tamiflu.
#Fevers
Patient with temperature of 100.2 on admission. Likely secondary
to influenza as above. Received FFP in ED, time course not
consistent with transfusion reaction. UA unremarkable. Given
Tylenol as needed. Resolved by the time of discharge.
#Atrial fibrillation
Patient with history of chronic atrial fibrillation. On apixaban
for anticoagulation and Metoprolol 100mg BID for rate control.
Metoprolol down-titrated to 12.5mg Q6hr (reduced dose given c/f
active bleed) upon admission and was uptitrated to home dose
prior to discharge given low concern for bleed. Apixaban 5 mg PO
BID was resumed on discharge.
#Lower extremity edema
Patient reports she is on Lasix 20mg BID, only taking in AM. Was
held upon admission out of concern for GI bleed. Resumed upon
discharge.
CHRONIC ISSUES:
===============
#Multiple embolic strokes causing residual left hemiparesis
Patient with L arm and leg weakness (baseline per patient).
Patient not on atorvastatin in the outpatient setting. ___ be
considered after discharge. Started on Fluoxetine 20mg after
stroke presumably as per ___ trial.
#HTN
Held home Lisinopril 20mg in setting of bleed with plan to
restart after follow-up appointment. Metoprolol dose reduced as
above.
#Hypothyroid
Continued home levothyroxine.
TRANSITIONAL ISSUES:
====================
# Patient not on atorvastatin. Consider starting in the
outpatient setting given history of CVA.
# Apixaban resumed on discharge.
# Lisinopril being held on discharge in context of bleed with
plan to restart after follow-up appointment with Dr. ___.
NEW MEDICATIONS:
Guaifenesin-CODEINE Phosphate ___ mL PO Q6H:PRN cough
HELD MEDICATIONS:
Lisinopril 20 mg PO DAILY
CHANGED MEDICATIONS:
None
# CODE: Full code
# CONTACT: ___ (daughter) ___
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Metoprolol Tartrate 100 mg PO BID
2. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
3. FLUoxetine 20 mg PO DAILY
4. Levothyroxine Sodium 50 mcg PO DAILY
5. Omeprazole 40 mg PO DAILY:PRN as needed
6. Apixaban 5 mg PO BID
7. Lisinopril 20 mg PO DAILY
8. Furosemide 20 mg PO BID
Discharge Medications:
1. Guaifenesin-CODEINE Phosphate ___ mL PO Q6H:PRN cough
RX *codeine-guaifenesin 10 mg-100 mg/5 mL ___ mL by mouth q6
HOURS Refills:*0
2. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
3. Apixaban 5 mg PO BID
RX *apixaban [Eliquis] 5 mg 1 tablet(s) by mouth twice a day
Disp #*60 Tablet Refills:*0
4. FLUoxetine 20 mg PO DAILY
5. Furosemide 20 mg PO BID
6. Levothyroxine Sodium 50 mcg PO DAILY
7. Lisinopril 20 mg PO DAILY
8. Metoprolol Tartrate 100 mg PO BID
9. Omeprazole 40 mg PO DAILY:PRN as needed
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY:
========
Rectal sheath hematoma
Influenza
Atrial fibrillation
SECONDARY:
==========
Hypertension
___ edema
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear ___,
It was a pleasure taking care of you at ___
___.
WHY WERE YOU IN THE HOSPITAL?
- You were in the hospital because of abdominal pain. You were
found to have a large bruise in your abdominal wall.
WHAT HAPPENED IN THE HOSPITAL?
- Your apixaban medication was stopped at first since it may
have contributed to your bleeding.
- Your blood counts were watched closely. They were stable.
WHAT SHOULD YOU DO AFTER LEAVING THE HOSPITAL?
- You should CONTINUE to take your apixaban after you leave.
- You will have a follow-up appointment with Dr. ___.
- You should take all of your other medications as prescribed.
- Follow up with you doctors as previously ___.
We wish you the best!
Your ___ Care Team
Followup Instructions:
___
|
19733165-DS-3
| 19,733,165 | 29,343,165 |
DS
| 3 |
2113-01-04 00:00:00
|
2113-01-05 16:12:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Loss of consciousness resulting in motor vehicle accident
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ year old female with no signficant past medical history whose
history of present illness begins last night. This morning the
patient was driving from home to the supermarket and she reports
hearing a loud crash and noticed she had wrecked her automobile.
Immediately following the accident, she was able to walk around
and she could recall all the events that happened immediately
after the car crash. She notes that she has no loss of bladder
or bowel function. No tongue biting. She denies a history of
seizures or syncope. She denies family history of fainting,
seizure, and sudden cardiac death. She reports sleeping well
last night. Her brother mentioned that she has been "under a lot
of stress lately secondary to getting engaged." He says that she
might have been distracted by all the commotion of her new
engagement. She was ___ into BI by ambulance.
In the ED, initial vital signs were 98.3, 79, 15, 165/88, 100%
room air. She received no medications. She received CT head,
neck, spine and her c-spine was cleared. Her right wrist was
splinted.
On arrival to the floor, patient reports ___, non-radiating
back pain and right wrist pain. She denies loss of sensation in
her extremities, headache, lightheadedness, numbness, bowel or
bladder incontinence.
.
ROS
Denies fever, chills, night sweats, headache, vision changes,
rhinorrhea, congestion, sore throat, cough, shortness of breath,
chest pain, abdominal pain, nausea, vomiting, diarrhea,
constipation, BRBPR, melena, hematochezia, dysuria, hematuria.
All other 10-system review negative in detail.
Past Medical History:
Back pain-treated with nsaids.
Social History:
___
Family History:
Non-contributory.
Father died at "a young age from leg swelling."
Mother with hypertension alive at ___.
No history of CAD, MI, SCD, seizure disorder, or syncope.
.
Physical Exam:
ADMISSION PHYSICAL EXAM
VS 98.2, BP 151/83, HR 68, RR 16 100% RA
GEN: Alert, oriented, no acute distress
HEENT: NCAT MMM EOMI sclera anicteric, OP clear
NECK: supple, no JVD, no LAD
PULM: Good aeration, CTAB no wheezes, rales, ronchi
CV: RRR normal S1/S2, no mrg
ABD soft NT ND normoactive bowel sounds, no r/g
EXT: WWP 2+ pulses palpable bilaterally, no c/c/e
NEURO: CNs2-12 intact, motor function grossly normal
SKIN: significant acne scars on face.
Discharge Physical Exam:
Vitals: 97.8, 112/73, 65, 19, 100 RA
GEN: Alert, oriented, no acute distress
HEENT: NCAT MMM EOMI sclera anicteric, OP clear
NECK: supple, no JVD, no LAD
PULM: Good aeration, CTAB no wheezes, rales, ronchi
CV: RRR normal S1/S2, no mrg
ABD soft NT ND normoactive bowel sounds, no r/g
EXT: WWP 2+ pulses palpable bilaterally, no c/c/e
NEURO: CNs2-12 intact, motor function grossly normal
SKIN: significant acne scars on face.
Pertinent Results:
I)Admission Labs:
___ 11:50AM BLOOD WBC-5.4 RBC-5.49* Hgb-13.1 Hct-43.0
MCV-78* MCH-23.9* MCHC-30.5* RDW-14.4 Plt ___
___ 06:57AM BLOOD Glucose-110* UreaN-11 Creat-0.8 Na-140
K-4.3 Cl-108 HCO3-26 AnGap-10
___ 06:57AM BLOOD cTropnT-<0.01
___ 11:50AM BLOOD cTropnT-<0.01
___ 06:57AM BLOOD Calcium-9.1 Phos-3.9 Mg-2.1
___ 11:50AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
___ 12:20PM URINE bnzodzpn-NEGATIVE barbitrt-NEGATIVE
opiates-NEGATIVE cocaine-NEGATIVE amphetmn-NEG mthdone-NEGATIVE
___ 12:20PM URINE UCG-NEGATIVE
___ 12:20PM URINE COLOR-Straw APPEAR-Clear SP ___
___ 12:20PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.5
LEUK-NEG
II) Microbiology
Blood cultures: no growth to date
III) Imaging:
CT-C-Spine:
IMPRESSION: No acute fracture or malalignment.
CT Head:
IMPRESSION:
No acute intracranial process.
RIGHT WRIST AND ELBOW FILMS: ___
IMPRESSION:
No acute fracture. Possible dorsal subluxation of the distal
ulna verses
suboptimal positioning creating this appearance. Clinical
correlation
recommended reagarding loctation of pain. Repeat exam can be
performed if
desired.
CT TORSO
IMPRESSION:
1. No acute intrathoracic or intra-abdominal injury.
2. No acute fracture or malalignment.
3. Umbilical hernia containing a small amount of bowel without
evidence of
strangulation.
4. Incidental note is made of the left renal vein draining into
an accessory
IVC on the left which drains into the hemiazygous vein.
IV) Studies
Lower Extremity Venous Ultrasound:
IMPRESSION: No evidence of lower extremity deep vein thrombosis.
TTE:
IMPRESSION: No structural cardiac cause of syncope seen. Normal
global and regional biventricular systolic function.
EEG:
IMPRESSION: Abnormal EEG due to occasional bursts of mixed
frequency
generalized slowing. This implies a dysfunction in midline
structures
but is not specific for any particular etiology; possible causes
include
vascular disease, head injury, or migraine, among many possible
causes.
There were no focal abnormalities or epileptiform features.
IV) Discharge/ Notable Labs:
___ 06:57AM BLOOD WBC-4.1 RBC-5.04 Hgb-12.5 Hct-41.4 MCV-82
MCH-24.7* MCHC-30.1* RDW-14.7 Plt ___
V) Studies pending at discharge:
Blood cultures: no growth to date
Brief Hospital Course:
___ year old woman with no signficant past medical history
admitted after motor vehicle accident for workup of possible
syncopal episode/loss of consciousness while driving. Hospital
course was notable for negative extensive syncope/seizure
workup. Prior to discharge, patient noted that she may have
fallen asleep at the wheel
# Loss of consciousness while driving:
The patient initially reported that she got in her car and drove
to work. She was driving and the next thing she remembered was a
large crashing sound. She initially reported that she did not
remember anything, remembered driving along a straightaway at
~25 mph and the next thing she knew she was in a car accident.
The patient has a negative family history for seizures, loss of
consciousness, pulmonary embolism, syncope, or sudden cardiac
death. Given the nature of loss of consciousness while driving
raised a large concern for structural heart deficits, seizures,
arrhythmias, and pulmonary emboli. The patient had a significant
workup including EKG which was notable for only findings
suggestive of LVH, but without ischemic changes, long QT or
characteristic EKG findings of Brugada syndrome or ARVCM.
Patient was monitored on telemetry and had no arrythmia events
or bradycardia. She also had a TTE which revealed a structurally
normal heart. Her cardiac biomarkers were negative and there was
low suspicion of an ischemic event. Patient also had an EEG for
workup of seizure which was non-specific and an infectious
workup including CXR, blood culture, and urinalysis all of which
were normal. Additionally, trauma series including CT chest with
contrast showed no evidence of vascular pathology including no
PE and bilateral LENIs did not show DVT. Therefore, after
extensive workup, there were no studies to implicate obvious
cardiac, neurologic, or vascular cause of loss of consciousness.
We discussed all of these findings with the patient, and after
discussion, patient reluctantly said that she had been up late
at her engagement party the night prior and may have fallen
asleep at the wheel on her way to work. Despite this, we advised
the patient not to drive until her follow up appointment in the
next ___ weeks with her PCP to make sure that she does not have
any more LOC episodes prior to driving again.
#Trauma from motor vehicle accident/Wrist pain:
The patient received a CT brain, spine, torso as well as right
arm, wrist, and elbow xrays. There was no suggestion of
fracture. Wrist films raised the question of a subluxation, but
clinically patient did not have any structural wrist pathology
and she did not require a brace for pain control prior to
discharge. She was able to ambulate easily and her pain was
controlled with mild analgesics.
No medication changes.
Transitional issues:
1.Capacity to safely operate a motor vehicle.
Our workup showed no signs of organic pathology which could have
caused the patient to have a car accident. Her echo was normal.
She had no lab abnormalities which would result in syncope or
encephalopathy. Her 20 minute EEG was not suggestive of seizure.
She had no events on telemetry. On hospital day 2, after her
workup was largely completed she reported falling asleep at the
wheel. We suggest that the patient not drive until her primary
care doctor evaluates her again for safety to operate a motor
vehicle.
Medications on Admission:
none
Discharge Medications:
1. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours).
Discharge Disposition:
Home
Discharge Diagnosis:
1. Wrist strain s/p motor vehicle collision
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were brought to ___ after having a car
accident. In the emergency department, extensive radiology tests
were done which showed that you did not have any fractures or
broken bones. You were admitted to medicine because you did not
remember your car accident and we were concerned that loss of
consciousness may have caused your accident. You received an
echocardiogram which showed that you have a normal heart. You
received an EEG which did not show any signs of seizure or
epilepsy. You also received a lower extremity ultrasound which
did not show any blood clots in your lower legs. You stated that
you may have fallen asleep while driving. Fortunately, you were
not seriously injured while driving. It is imperative that you
do not drive while sleepy or being unrested. You could have
crashed your car into pedestrians and hurt someone else.
Therefore, we suggest that you do not drive until you are
cleared by your PCP and he feels that you are safe to drive. We
have made no changes to your home medications.
For pain you can take over the counter pain medications.
1. One option is tylenol (acetaminophen). Please be sure to take
less than 4000mg in one. Also you must not drink while taking
tylenol.
If you experience any of the danger symptoms listed below please
call your PCP or return to the emergency department.
*You must not drive or operate any heavy machinery until you are
cleared to operate a motor vechile by your primary care
physician.
Followup Instructions:
___
|
19733289-DS-21
| 19,733,289 | 24,912,986 |
DS
| 21 |
2150-09-08 00:00:00
|
2150-09-10 21:05:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Abd Pain, Transfer
Major Surgical or Invasive Procedure:
ERCP ___
History of Present Illness:
___ ___ F hx HTN, HLD, p/w RUQ and epigastric pain.
She stated to the ED that she had gradual onset of pain the
night prior to admission, dull and aching that began after
eating. The pain radiates across her abdomen to her epigastric
region. She has had nausea and vomiting. Denied fevers,
diarrhea, black stools, chest pain or shortness of breath.
She went to an OSH where a CT was done and she was transferred
to ___. OSH CT: Gallbladder is contracted with cholelithiasis
without evidence of acute cholecystitis. ___ile duct
with probable mid and distal choledocholithiasis, largest
measuring 5 mm distally. Probable calculus at the common bile
duct ampulla measuring 5 mm.
In the ED, initial VS were: 97.9 100 127/83 20 95% RA.
ED labs were notable for: H/H 10.8/32.1. AST 653/ALT 462/AP
109/TBili 2.9. Cr 1.5. Lactate and trop were negative.
EKG showed: ? old inferior MI, NSR, no acute ischemic changes
Patient was given:
___ 06:36 IV Ondansetron 4 mg
___ 06:43 IV Morphine Sulfate 4 mg
___ 06:43 IVF NS
___ 07:47 IVF NS 1 mL
___ 07:48 IV Metoclopramide 10 mg
___ 07:48 IV MetroNIDAZOLE
___ 08:45 IV MetroNIDAZOLE 500 mg
Transfer VS were: 98.9 102 126/55 20 100% Nasal Cannula. She
went from the ED to the ERCP suite, and then came to the floor
in the early afternoon. There is an ERCP note in OMR.
When seen on the floor, she is accompanied by her daughter and
grand-daughter. Together the contribute that she had no
abdominal pain, nausea, or other concerns at this time. She has
not yet passed gas since her procedure but does not feel
distended or uncomfortable.
REVIEW OF SYSTEMS:
A ten point ROS was conducted and was negative except as above
in the HPI.
Past Medical History:
Hypothyroidism
Hyperlipidemia
Hypertension
Social History:
___
Family History:
No family history of liver or gallbladder disease.
Physical Exam:
PHYSICAL EXAM ON ADMISSION:
===========================
Vitals: 98.2 137 / 67 80 18 95 RA
Gen: Pleasant elder female reclined in bed, NAD
Eyes: Anicteric sclera
ENT: Normal hearing, no rhinitis, clear OP
CV: RRR, no r/g/m
Chest: CTAB, no w/r/r
GI: soft, NT, ND, BS+
MSK: No kyphosis. No synovitis.
Skin: No jaundice.
Neuro: AAOx3. No facial droop. Full strength all extremities.
Psych: Normal affect
PHYSICAL EXAM ON DISCHARGE:
===========================
VSS
Gen: NAD, resting comfortably in bed, obese
HEENT: EOMI, PERRLA, MMM, OP clear
CV: NS1/S2, RRR
Resp: CTAB
Abd: Soft, NT, ND +BS
Ext: no edema, +2 DP pulses
Neuro: CN II-XII intact, ___ strength throughout
Psych: normal affect
Skin: warm, dry no rashes
Pertinent Results:
LABS ON ADMISSION:
==================
___ 06:58AM BLOOD Lactate-1.9
___ 12:07AM BLOOD Calcium-7.6* Phos-3.9 Mg-1.5*
___ 06:45AM BLOOD cTropnT-<0.01
___ 06:45AM BLOOD ALT-462* AST-653* AlkPhos-109*
TotBili-2.9*
___ 06:45AM BLOOD Glucose-163* UreaN-15 Creat-1.5* Na-140
K-4.0 Cl-105 HCO3-22 AnGap-17
___ 06:45AM BLOOD ___ PTT-26.3 ___
___ 06:45AM BLOOD WBC-9.6 RBC-3.69* Hgb-10.8* Hct-32.1*
MCV-87 MCH-29.3 MCHC-33.6 RDW-12.8 RDWSD-40.4 Plt ___
___ 06:45AM BLOOD Neuts-82.3* Lymphs-10.8* Monos-5.9
Eos-0.3* Baso-0.2 Im ___ AbsNeut-7.93* AbsLymp-1.04*
AbsMono-0.57 AbsEos-0.03* AbsBaso-0.02
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 bulging.
The CBD was successfully cannulated with the Hydratome
sphincterotome preloaded with a 0.035in guidewire.
The guidewire was advanced into the intrahepatic biliary tree.
Contrast injection revealed a dilated CBD to approximately 14mm
in diameter and multiple filling defects consistent with stones
in the distal and mid CBD.
A sphincterotomy was successfully performed at the 12 o'clock
position.
No post sphincterotomy bleeding was noted.
The CBD was swept several times with successful removal of four
stones and small amounts of sludge material.
Occlusion cholangiogram showed no further filling defects.
There was excellent drainage of bile and contrast at the end of
the procedure.
The PD was not injected or cannulated.
Recommendations:
Admit to hospital for monitoring
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
Recommend surgical evaluation for possible cholecystectomy.
No aspirin, Plavix, NSAIDS, Coumadin for 5 days.
Continue with antibiotics - Ciprofloxacin 500mg BID x 5 days.
Follow for response and complications. If any abdominal pain,
fever, jaundice, gastrointestinal bleeding please call Advanced
Endoscopy Fellow on call ___
CXR ___:
IMPRESSION:
Bibasilar opacities, likely atelectasis, consider aspiration or
pneumonia if
clinically appropriate. Small pleural effusions are likely.
Pulmonary
vascular congestion, accentuated by shallow inspiration.
Moderate gastric
distention.
LABS ON DISCHARGE:
==================
___ 06:24AM BLOOD WBC-7.1 RBC-3.70* Hgb-10.5* Hct-31.2*
MCV-84 MCH-28.4 MCHC-33.7 RDW-12.7 RDWSD-39.0 Plt ___
___ 06:35AM BLOOD WBC-7.0 RBC-3.66* Hgb-10.4* Hct-31.3*
MCV-86 MCH-28.4 MCHC-33.2 RDW-12.9 RDWSD-39.6 Plt ___
___ 07:15AM BLOOD Neuts-59.7 ___ Monos-6.4 Eos-3.2
Baso-0.4 Im ___ AbsNeut-4.26 AbsLymp-2.14 AbsMono-0.46
AbsEos-0.23 AbsBaso-0.03
___ 06:45AM BLOOD Neuts-82.3* Lymphs-10.8* Monos-5.9
Eos-0.3* Baso-0.2 Im ___ AbsNeut-7.93* AbsLymp-1.04*
AbsMono-0.57 AbsEos-0.03* AbsBaso-0.02
___ 06:24AM BLOOD Plt ___
___ 06:35AM BLOOD Plt ___
___ 06:24AM BLOOD Glucose-107* UreaN-60* Creat-3.2* Na-135
K-4.1 Cl-100 HCO3-24 AnGap-15
___ 06:35AM BLOOD Glucose-98 UreaN-71* Creat-3.8* Na-140
K-4.2 Cl-100 HCO3-25 AnGap-19
___ 07:35AM BLOOD Glucose-103* UreaN-69* Creat-4.2* Na-140
K-4.1 Cl-98 HCO3-27 AnGap-19
___ 07:15AM BLOOD Glucose-114* UreaN-58* Creat-4.0* Na-140
K-4.1 Cl-98 HCO3-29 AnGap-17
___ 06:42PM BLOOD Glucose-149* UreaN-53* Creat-3.4* Na-139
K-3.9 Cl-97 HCO3-29 AnGap-17
___ 06:50AM BLOOD Glucose-123* UreaN-47* Creat-2.9*# Na-141
K-4.0 Cl-98 HCO3-29 AnGap-18
___ 06:20AM BLOOD Glucose-112* UreaN-36* Creat-1.7* Na-145
K-3.6 Cl-105 HCO3-30 AnGap-14
___ 06:06AM BLOOD Glucose-114* UreaN-35* Creat-1.9* Na-142
K-3.5 Cl-106 HCO3-24 AnGap-16
___ 05:02AM BLOOD Glucose-132* UreaN-27* Creat-2.3* Na-141
K-4.1 Cl-107 HCO3-19* AnGap-19
___ 06:45AM BLOOD Glucose-163* UreaN-15 Creat-1.5* Na-140
K-4.0 Cl-105 HCO3-22 AnGap-17
___ 06:24AM BLOOD ALT-44* AST-24 AlkPhos-75 TotBili-0.7
___ 06:35AM BLOOD ALT-57* AST-25 AlkPhos-79 TotBili-0.8
___ 07:35AM BLOOD ALT-74* AST-29 AlkPhos-80 TotBili-0.9
___ 07:15AM BLOOD ALT-99* AST-37 AlkPhos-82 TotBili-0.8
___ 06:50AM BLOOD ALT-146* AST-48* AlkPhos-89 TotBili-0.9
___ 06:20AM BLOOD ALT-182* AST-67* AlkPhos-87 TotBili-0.8
___ 06:06AM BLOOD ALT-255* AST-148* AlkPhos-99 TotBili-0.9
___ 05:02AM BLOOD ALT-383* AST-356* LD(LDH)-258*
AlkPhos-114* TotBili-1.8*
___ 06:45AM BLOOD ALT-462* AST-653* AlkPhos-109*
TotBili-2.9*
___ 05:02AM BLOOD Lipase-718*
___ 06:45AM BLOOD ___
___ 05:02AM BLOOD CK-MB-5 cTropnT-<0.01
___ 12:07AM BLOOD CK-MB-5 cTropnT-<0.01
___ 06:24AM BLOOD Calcium-8.5 Phos-4.1 Mg-2.3 Iron-80
Cholest-203*
___ 06:35AM BLOOD Calcium-8.5 Phos-4.8* Mg-2.4
___ 07:35AM BLOOD Calcium-8.4 Phos-4.8* Mg-2.2
___ 07:15AM BLOOD Calcium-8.5 Phos-5.0* Mg-2.1
___ 06:50AM BLOOD Calcium-9.1 Phos-4.7* Mg-1.8
___ 06:20AM BLOOD Calcium-8.8 Phos-3.2 Mg-1.9
___ 06:06AM BLOOD Calcium-8.5 Phos-3.0 Mg-2.2
___ 05:02AM BLOOD Albumin-3.7 Calcium-8.2* Phos-4.7* Mg-2.5
___ 12:07AM BLOOD Calcium-7.6* Phos-3.9 Mg-1.5*
___ 06:24AM BLOOD calTIBC-325 Ferritn-173* TRF-250
___ 06:24AM BLOOD %HbA1c-5.7 eAG-117
___ 06:24AM BLOOD Triglyc-329* HDL-34 CHOL/HD-6.0
LDLcalc-103
___ 07:35AM BLOOD TSH-2.9
___ 12:15AM BLOOD Lactate-0.8
___ 06:58AM BLOOD Lactate-1.9
ECHO ___
The left atrium is normal in size. The estimated right atrial
pressure is at least 15 mmHg. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity is small.
Due to suboptimal technical quality, a focal wall motion
abnormality cannot be fully excluded. Left ventricular systolic
function is hyperdynamic (EF = 80%). There is a mild resting
left ventricular outflow tract obstruction. Right ventricular
chamber size and free wall motion are normal. The aortic arch is
mildly dilated. There are focal calcifications in the aortic
arch. The aortic valve is not well seen. There is no aortic
valve stenosis. No aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. Trivial mitral
regurgitation is seen. The left ventricular inflow pattern
suggests impaired relaxation. The pulmonary artery systolic
pressure could not be determined. There is no pericardial
effusion.
IMPRESSION: Suboptimal image quality. The left ventricle is
small, thick-walled, hyperdynamic, and stiff.
Renal ultrasound: ___
FINDINGS:
The right kidney measures 10.1 cm. The left kidney measures 11.0
cm. There is mild fullness of the bilateral renal pelves without
overt hydronephrosis. There are no stones or renal masses
bilaterally. Normal cortical echogenicity and corticomedullary
differentiation are seen bilaterally. The bladder is only
minimally distended and not be fully assessed on the current
study. Ureteral jets are not seen.
IMPRESSION:
No hydronephrosis demonstrated, as on recent CT abdomen.
Chest X-ray ___
IMPRESSION:
Heart size is enlarged. Mediastinum is stable. Left more than
right basal consolidations are unchanged. There is interval
improvement up to almost complete resolution of pulmonary edema.
Brief Hospital Course:
___ ___ F hx HTN, HLD, p/w RUQ and epigastric pain,
c/f symptomatic choledocholithiasis. She is s/p ERCP and
sphincterotomy. During her hospitalization, she developed acute
hypoxic respiratory failure and hypertension post ERCP likely
due to flash pulmonary edema. She was diuresed and briefly
placed on BIPAP. She developed ___ with creatinine to 40 likely
due to combination of reinitiation ___ and IV Lasix,
creatinine improving on time of discharge. Given abdominal pain
has resolved, she was discharged home and instructed to
___ in two weeks for surgery ___ to evaluate for
cholecystectomy. Her creatinine will be need be followed up as
outpatient to ensure resolution of ___.
# Symptomatic Choledocholithiasis
# Transaminitis
# Gallstone Pancreatitis
S/p ERCP with sphincterotomy, having no pain and tolerating
diet.
-Discussed with acute care surgery, she can ___ in 2 weeks
as outpatient for
cholecystectomy.
- Cipro x5d (___), stopped on ___
- Trend LFTs
- No ASA/Plavix x5d
- Needs ___ resolved prior to surgery, will need to check
creatinine as outpatient
#Acute hypoxic respiratory failure
#Flash pulmonary edema
#HTN
#Acute heart failure exacerbation
Developed severe acute hypoxic respiratory failure and
hypertension post-ERCP likely due to flash pulmonary edema.
Received 40 mg IV Lasix and was briefly on BIPAP with resolution
of respiratory distress.
-Additional 40 mg IV Lasix given on ___, held on ___ given
elevated creatinine 2.9 and subsequently to 4.0, on discharge
creatinine was 3.2
-discontinued Losartan on ___, continued to hold HCTZ on
discharge. Restart as indicated following PCP ___.
-TTE on ___ with the left ventricle is small, thick-walled,
hyperdynamic, and stiff. Started on Metoprolol 12.5 mg TID per
cardiology recs, transitioned to Metoprolol 25 mg XL on
discharge.
#Preoperative cardiovascular evaluation
She has no known history of CAD and denies any history of chest
pain. No known prior history of heart failure but appears to
have an acute heart failure exacerbation. At baseline she is
fairly sedentary but reports being able to walk 2 blocks or 1
flight of stairs without dyspnea or CP.
-Held further diuresis on discharge given appears euvolemic and
creatinine 3.2,
received multiple doses of IV Lasix prior;
-Chest X-ray on ___: left more than right basal consolidations
are unchanged. There is interval improvement up to almost
resolution of pulmonary edema.
-Per cardiology recs, started on Metoprolol 12.5 mg TID, and
transitioned to Metoprolol 25 mg XL
-restarted statin on discharge, monitor LFTs
-Cholecystectomy evaluation to be done in two weeks
# ___
# Possible CKD vs. acute insult in setting of contrast and
recent
diuresis
No baseline Cr in system, initial creatinine 1.37 at ___. CT
A/P
without contrast at ___ did not show hydronephrosis or
obstruction. Worsening creatinine likely in the setting ___
and diuresis, will continue to monitor as outpatient.
- Avoid nephrotoxins
- Discontinued losartan and HCTZ and held on discharge
- renal ultrasound with no acute findings
- nephrology consulted and will need to obtain outpatient
nephrology consult if renal function does not return to
baseline.
# Normocytic Anemia
No e/o active bleeding.
- Trend H/H as outpatient
- ___ as outpatient for repeat labs and evaluation as
needed
#Cholecystectomy: return for outpatient evaluation in two weeks
for cholecystectomy evaluation by outpatient surgery.
# FEN: heart healthy low fat diet
# PPX: Heparin SQ while hospitalized
# Code status: Full Code
Transitional issues:
-Patient will need ___ for repeat CBC and chemistries/LFTs
-Consider outpatient ___ with renal and cardiology
-Repeat Chest X-ray prior to surgery to ensure resolution of
imaging findings from inpatient Chest X-ray
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 40 mg PO QPM
2. Multivitamins 1 TAB PO DAILY
3. Levothyroxine Sodium 50 mcg PO DAILY
4. losartan-hydrochlorothiazide 50-12.5 mg oral DAILY
5. fenofibrate micronized 134 mg oral DAILY
6. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Acute gallstone pancreatitis
Choledocholithiasis
Flash pulmonary edema
___
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms ___,
You were admitted for abdominal pain and were found to have
pancreatitis due to gallstones. You underwent an ERCP procedure
with removal of the stones. After the procedure you had severe
difficulty breathing and went to the ICU. You were treated with
Lasix to remove fluid and BIPAP and your breathing improved.
Your creatinine was found to be elevated (measure of your kidney
function) after removing the fluid, your creatinine on discharge
is 3.2. If it does not improve as an outpatient, you will have
to ___ with a kidney specialist.
You were also started on a new medication for your heart and
will need to ___ with your PCP for ___ for referral
to cardiology if needed.
You will be seeing surgery in two weeks for ___ of removal
of your gallbladder.
We wish you all the best in your recovery.
Best wishes,
Your ___ team
Followup Instructions:
___
|
19733664-DS-20
| 19,733,664 | 23,599,635 |
DS
| 20 |
2139-06-22 00:00:00
|
2139-06-22 16:29:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
___
Attending: ___
Chief Complaint:
Abdominal Pain, Fever, Confusion
Major Surgical or Invasive Procedure:
ERCP ___
History of Present Illness:
Mr. ___ is an ___ male with history of
metastatic pancreatic cancer, CAD, HTN, HLD, and DM was presents
from rehab with fever, abdominal pain, and confusion.
Patient was referred from rehab for increased delirium and
confusion over the course of the day. Labs showed elevated WBC
to
16 and temperature ___. He reports worsening abdominal pain.
Unable to obtain any history from the patient.
Patient recently admitted from ___ to ___ for planned
chemotherapy followed by dialysis. Admission was complicated by
elevated LFTs prompting ERCP which showed CBD malignant
stricture
with biliary stent placement. Patient continued to have
worsening
abdominal pain secondary to malignancy and underwent celiac
plexus block with good effect. He then developed sepsis
requiring
MICU and found to have Enterobacter bacteremia ultimately
discharged on cefepime for 14-day course to end ___. Prior
to
discharge had worsening LFTs and underwent repeat ERCP where
food
material was removed and new stent was placed. Of note, patient
found to have moderate
duodenal obstruction, most likely malignant, and he was placed
on
pureed diet. Finally, patient had goals of care discussion where
decision was made for no further chemotherapy and code status
changed to DNR/OK to intubate. Patient was ultimately discharged
to rehab with plan to transition to home hospice.
On arrival to the ED, initial vitals were 99.9 100 160/65 18 94%
RA. Exam was notable for mild jaundice, lungs clear, and diffuse
abdominal tenderness to palpation. Labs were notable for WBC
12.6, H/H 7.3/23.4, Plt 249, Na 135, K 4.0, BUN/Cr ___, Tbili
5.7, ALP 934, lactate 0.9, and UA bland. Patient febrile to
101.4. CT abdomen showed no fluid collections. Head CT negative
for bleed. Patient was given cefepime 2g IV, flagyl 500mg IV,
vancomcyin 1g IV, Tylenol ___ PO, and 500cc NS. Prior to
transfer vitals were 98.8 96 134/63 18 95% RA.
On arrival to the floor, patient reports "everything is feeling
better". Patient denies headache, vision changes,
dizziness/lightheadedness, weakness/numbnesss, shortness of
breath, cough, hemoptysis, chest pain, palpitations,
nausea/vomiting, diarrhea, hematemesis, hematochezia/melena,
dysuria, hematuria, and new rashes.
REVIEW OF SYSTEMS: A complete 10-point review of systems was
performed and was negative unless otherwise noted in the HPI.
Past Medical History:
Pancreatic cancer likely stage IV
- ___ Sustained fall in bathroom with headstrike due to
orthostatic hypotension after HD. Imaging negative for
intracranial bleed but required sutures.
- ___ Presented to ___ with abdominal distension and
pain. CT abdomen/pelvis w/o contrast (pt with ESRD) showed an
ill-defined hypodensity in the region of the pancreatic uncinate
process as well as new L1 and L3 fractures. Transferred to ___
for ortho spine consult who recommended TLSO.
- ___ CT abdomen/pelvis with contrast again demonstrates a
3.5 x 3.0 x 2.8 cm hypoenhancing mass centered at the uncinate
process of the pancreas worrisome for primary pancreatic
adenocarcinoma abutting the posterior margin of first branch of
the SMA which is patent as well as tiny hypodensities in the
liver which are incompletely characterized. Hyperdense lesions
in
the kidneys bilaterally, greatest of which was a 3.4 cm x 3.8 cm
lesion in the upper pole of the left kidney also reported.
- ___ EUS confirmed a 3.2 x 2.6 cm uncinate/head mass, FNB
confirms adenocarcinoma. CEA 4.8, CA ___: 26
- ___ Seen in Pancreatic Cancer MDC by Dr. ___
___
Dr. ___ felt patient is not resectable. Oncology
recommended single agent gemcitabine if within GOC of patient.
- ___ Renal u/s shows bilateral simple appearing renal
cysts
- ___ MRI abdomen w/o contrast shows innumerable liver
lesions with restricted diffusion and intermediate T2
hyperintense signal compatible with metastases measuring up to
11mm.
- ___ C1D1 Gemcitabine
- ___ C2D1 Gemcitabine 800 mg/m2 D1, D15 with HD
- ___: C2D15 Gemcitabine with dialysis
- ___: C3D1 Gemcitabine with dialysis
- ___: C3D15 gemcitabine with dialysis
- ___: admitted to ___ for planned
gemcitabine/HD.
developed malignant biliary obstruction, s/p ERCP x2 and
stenting. also underwent celiac plexus neurolysis and started on
methadone for pain. GOC changed; MOLST-> ___, no further
chemo, discharged to rehab with plan for outpatient hospice post
rehab.
PAST MEDICAL HISTORY:
- Pancreatic cancer, as above
- CAD
- HTN
- HLD
- IDDM2
- OSA
- Hypothyroidism
- H/o nephrolithiasis
- BPH s/p TURP
- H/o colonic adenoma
- H/o syncope
- IBS
- Cognitive delay
- Acute nonocclusive thrombi in b/l femoral vein extending to
left dsfpopliteal vein
Social History:
___
Family History:
No known family history of cancer.
Physical Exam:
ADMISSION EXAM:
===============
VS: Temp 98.2, BP 148/78, HR 96, RR 18, O2 sat 95% RA.
GENERAL: Pleasant man, in no distress, lying in bed comfortably.
HEENT: Anicteric, PERLL, OP clear.
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, diffuse tenderness to palpation, non-distended,
normal
bowel sounds.
EXT: Warm, well perfused, no lower extremity edema, erythema or
tenderness.
NEURO: A&Ox1 (name, able to ___ from ___ and ___ after prompting, does not know year or month), CN II-XII
intact. Moving all four extremities. Able to count backwards
from
10. Positive asterexis.
SKIN: No significant rashes.
DISCHARGE EXAM:
==============
VS: Tmax 100.0, T 98.6, 100-130/60s, 90s, 18, 96% RA
GENERAL: Chronically-ill appearing man lying in bed with eyes
closed.
HEENT: Anicteric, PERLL, OP clear.
CARDIAC: RRR, normal s1/s2
LUNG: Appears in no respiratory distress, right sided crackles
diffusely greater at base.
ABD: Soft, tender to deep palpation throughout. Mild distension,
soft NABS.
EXT: Warm, well perfused, no lower extremity edema, erythema or
tenderness.
NEURO: A&Ox1, CN II-XII intact. Moving all four extremities
SKIN: No significant rashes.
Pertinent Results:
ADMISSION LABS:
=================
___ 12:14AM BLOOD WBC-12.6* RBC-2.49* Hgb-7.3* Hct-23.4*
MCV-94 MCH-29.3 MCHC-31.2* RDW-17.2* RDWSD-59.2* Plt ___
___ 12:14AM BLOOD Neuts-86.5* Lymphs-3.4* Monos-6.8 Eos-1.6
Baso-0.2 NRBC-0.2* Im ___ AbsNeut-10.94* AbsLymp-0.43*
AbsMono-0.86* AbsEos-0.20 AbsBaso-0.02
___ 07:55AM BLOOD ___ PTT-26.3 ___
___ 12:14AM BLOOD Glucose-197* UreaN-21* Creat-2.2* Na-135
K-4.0 Cl-100 HCO3-25 AnGap-14
___ 12:14AM BLOOD ALT-58* AST-82* AlkPhos-934* TotBili-5.7*
DirBili-4.5* IndBili-1.2
___ 12:14AM BLOOD Lipase-94*
___ 12:14AM BLOOD Albumin-2.1* Calcium-7.5* Phos-2.3*
Mg-2.0
___ 12:21AM BLOOD Lactate-0.9
___ 01:49AM URINE Color-Yellow Appear-Clear Sp ___
___ 01:49AM URINE Blood-NEG Nitrite-NEG Protein-100
Glucose-300 Ketone-NEG Bilirub-SM Urobiln-2* pH-7.5 Leuks-NEG
___ 01:49AM URINE RBC-1 WBC-1 Bacteri-FEW Yeast-NONE Epi-<1
INTERVAL LABS:
___ 06:32AM BLOOD WBC-15.5* RBC-2.33* Hgb-7.0* Hct-22.6*
MCV-97 MCH-30.0 MCHC-31.0* RDW-17.0* RDWSD-59.6* Plt ___
___ 06:34PM BLOOD WBC-12.4* RBC-2.70* Hgb-8.1* Hct-25.5*
MCV-94 MCH-30.0 MCHC-31.8* RDW-17.2* RDWSD-58.4* Plt ___
___ 06:32AM BLOOD Glucose-194* UreaN-38* Creat-4.0*# Na-140
K-5.0 Cl-104 HCO3-23 AnGap-18
___ 06:07AM BLOOD Glucose-113* UreaN-44* Creat-4.6*# Na-139
K-4.4 Cl-103 HCO3-26 AnGap-14
___ 05:06AM BLOOD ALT-45* AST-42* LD(LDH)-178 AlkPhos-872*
TotBili-2.0*
___ 06:34PM BLOOD ALT-65* AST-68* LD(LDH)-210 AlkPhos-1271*
TotBili-2.7*
___ 06:34PM URINE Color-Yellow Appear-Hazy Sp ___
___ 06:34PM URINE Blood-TR Nitrite-NEG Protein-300
Glucose-150 Ketone-NEG Bilirub-SM Urobiln-NEG pH-7.0 Leuks-LG
___ 06:34PM URINE RBC-9* WBC-129* Bacteri-FEW Yeast-FEW
Epi-1 TransE-<1
MICRO:
___ 6:34 pm URINE Source: ___.
**FINAL REPORT ___
URINE CULTURE (Final ___:
YEAST. 10,000-100,000 CFU/mL.
IMAGING/STUDIES:
___ CT A/P W/O CONTRAST
IMPRESSION:
1. Increased bladder wall thickening concerning for cystitis
although possibly related to underdistention and chronic outlet
obstruction. Correlation with urinalysis recommended.
2. Moderate right and small left pleural effusions have
increased. Mild
pulmonary edema is new.
3. Re-demonstrated stranding around the celiac and SMA origins
with interval resolution of retroperitoneal gas.
4. No drainable fluid collection. Normal appendix. No evidence
colitis within the limits of the noncontrast examination.
___ ERCP
Impression:
The scout film revealed previous stent in place.
The bile duct was deeply cannulated with the sphincterotome then
exchanged for a balloon.
The lower third of the bile duct was swept. Contrast was
injected and there was brisk flow through the ducts.
A filling defect was seen in the mid CBD.
The biliary tree was swept with a 9-12mm balloon starting at the
bifurcation.
Food matter was again removed.
The CBD and CHD were swept repeatedly.
In the process of sweeping the biliary tree, the metal stent
migrated into the duodenum.
A rat tooth forceps was used to grasp and successfully remove
the metal stent.
A new 10mm X 60 mm ___ Wallflex metal uncovered
biliary stent was placed successfully. ___ ___, REF
___, LOT ___ .
Due to episodes of recurrent food obstructing the metal stent,
the decision was made to place the plastic stent.
A ___ X 5 cm Advanix double pigtail biliary stent was placed
successfully within the metal stent.
Excellent bile and contrast drainage was seen endoscopically and
fluoroscopically.
___ KUB
IMPRESSION:
No findings to suggest mechanical bowel obstruction. Findings
most likely represent ileus.
DISCHARGE LABS:
==============
___ 05:08AM BLOOD WBC-11.4* RBC-2.53* Hgb-7.6* Hct-23.9*
MCV-95 MCH-30.0 MCHC-31.8* RDW-16.8* RDWSD-57.2* Plt ___
___ 05:08AM BLOOD Glucose-108* UreaN-50* Creat-5.4*# Na-141
K-4.5 Cl-102 HCO3-24 AnGap-20
___ 05:08AM BLOOD ALT-72* AST-85* LD(LDH)-211 AlkPhos-1185*
TotBili-2.0*
___ 05:08AM BLOOD Calcium-7.6* Phos-4.5 Mg-2.3
Brief Hospital Course:
Mr. ___ is an ___ male with history of
metastatic pancreatic cancer, CAD, HTN, HLD, DM, ESRD on HD,
presented from rehab with fever, abdominal pain, and confusion,
found to have cholangitis which was treated with stent
replacement and antibiotics. He then likely suffered an
aspiration event and possibly ileus, which caused his mental
status to further deteriorate. After extensive ___ discussion,
plan was him to transition to ___ facility and discontinue
dialysis.
His active medical problems during his hospitalization are as
below:
# Sepsis:
# Elevated LFTs:
# Cholangitis: Patient had TBili>5 on admission, similar to
prior settings in which stent migration or malignant stricture
lead to cholangitis. On admission, the patient was broadened
from cefepime (on which he was discharged due to bacteremia) to
meropenem. Patient had repeat TBili>6 and was taken for ERCP,
and metal stent was replaced with plastic stent and 2x pigtail
catheter with subsequent downtrending of LFTs. The patient had
persistent abdominal pain, likely in setting of malignancy. He
was never bacteremic, so he was changed from meropenem to
cefepime and finished a course ending ___ as originally
planned.
# Toxic-Metabolic Encephalopathy: Present on admission and
partially cleared however patient not at mental status baseline.
Best explained initially by sepsis due to cholangitis then by
aspiration. Head CT without bleed on admission. More somnolence
likely due to overall decline.
# Metastatic Pancreatic Cancer: Diagnosed ___ with known
metastatic disease to the liver. Previously on palliative
gemcitabine but decision made recently for no further
chemotherapy. Recurrent malignant biliary strictures have caused
multiple episodes of cholangitis as above.
# Aspiration: Patient aspirated ___, and CXR showed diffuse R>L
lung process consistent with edema vs. possible pneumonia vs.
atelectasis. Patient and family have understanding of patient's
high aspiration risk given age and comorbidities. Plan was to
liberalize diet to let patient eat for comfort and code status
was transitioned to DNR/DNI.
# Abdominal Pain/Distension: Likely due to increased tumor
burden, including in the liver. He is s/p celiac plexus block
___. Per report from family, the patient was dosed methadone
twice as much as prescribed (Q4H instead of Q8H) at rehab. This
likely contributed to his delirium on presentation. His
methadone was spaced to 2.5mg PO BID per palliative care. He was
also started on hydromorphone (dilaudid) 2 mg PO q6h prn, which
helped to manage his pain. He had a KUB which showed evidence of
possible ileus, but no mechanical bowel obstruction.
# ESRD: ___ HTN, DM, BPH c/b urinary retention. Followed by ___
___. Received inpatient HD ___ throughout admission. After
___ discussions, the plan was to discontinue HD and discharge to
___ facility. He received his last dose of HD on ___ prior
to discharge.
CHRONIC ISSUES
===============
# Anemia: Chronic anemia associated with ESRD, worsened with
gemcitabine. Patient received pRBC with HD for Hgb<7. No
evidence of symptomatic anemia or blood loss anemia during the
admission.
# CAD/HLD: Continued home aspirin and simvastatin while in-house
but then discontinued given goals to transition to hospice.
# BPH: Continued finasteride in-house initially but patient was
refusing at nighttime so discontinued medication.
# DM: Complicated by neuropathy. Continued home lantus and
insulin sliding scale.
# Hypothyroidism: Continued home levothyroxine in-house
initially but discontinued due to minimize pills and maximize
comfort.
# Dyspepsia/PUD: Discontinued home regimen of sulcralfate and
ranitidine as above.
# Depression: Continued home citalopram.
TRANSITIONAL ISSUES
=====================
# Multiple non-essential medications that patient declined while
in-house were discontinued to maximize comfort. Please reassess
with family the need for remaining medications, especially
insulin, given his goals of care.
# Last HD session was on ___
# STARTED dilaudid 2 mg PO q6h prn
# HCP: ___, cell phone ___
# Code: DNR/DNI
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
2. Aspirin 81 mg PO DAILY
3. Bisacodyl 10 mg PR QHS:PRN Constipation
4. Citalopram 20 mg PO DAILY
5. Finasteride 5 mg PO QHS
6. Levothyroxine Sodium 125 mcg PO DAILY
7. Lidocaine 5% Patch 1 PTCH TD QPM
8. Polyethylene Glycol 17 g PO DAILY:PRN constipation
9. Prochlorperazine 10 mg PO Q6H:PRN nausea
10. Ranitidine 150 mg PO QAM
11. Senna 8.6 mg PO BID:PRN constipation
12. Simethicone 80 mg PO QID:PRN bloating
13. Simvastatin 20 mg PO QPM
14. Sucralfate 1 gm PO BID
15. Docusate Sodium 100 mg PO BID
16. Lactulose 30 mL PO BID:PRN constipation
17. Maalox/Diphenhydramine/Lidocaine 15 mL PO QID:PRN dyspepsia
18. Methadone 2.5 mg PO Q8H
19. CefePIME 500 mg IV Q24H
20. Glargine 8 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
Discharge Medications:
1. HYDROmorphone (Dilaudid) 2 mg PO Q6H:PRN Pain - Moderate
RX *hydromorphone 2 mg 1 tablet(s) by mouth every six (6) hours
Disp #*28 Tablet Refills:*0
2. Docusate Sodium 100 mg PO BID:PRN constipation
3. Methadone 2.5 mg PO BID
RX *methadone 5 mg/5 mL 2.5 mg by mouth twice daily Refills:*0
4. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
5. Citalopram 20 mg PO DAILY
6. Glargine 8 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
7. Lactulose 30 mL PO BID:PRN constipation
8. Lidocaine 5% Patch 1 PTCH TD QPM
9. Prochlorperazine 10 mg PO Q6H:PRN nausea
10. Senna 8.6 mg PO BID:PRN constipation
11. Simethicone 80 mg PO QID:PRN bloating
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS
=================
# Sepsis
# Cholangitis
# Enterobacter bacteremia
# Aspiration pneumonitis
SECONDARY DIAGNOSIS
====================
# Metastatic pancreatitic cancer
# End stage renal disease
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Lethargic but arousable.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you during your hospitalization
at ___. You returned to the hospital after your stent migrated
and you had worsening liver tests. You received a procedure
called an ERCP with replacement of the stent. You were continued
on IV antibiotics to complete your treatment of a blood
infection from your last hospitalization.
While you were here, we discussed that the best plan would be
for you to go to a ___ facility where we can focus on
comfort. Since dialysis is not going to contribute to your
quality of life, we made the decision to stop it. We also
stopped non-essential medications to maximize your comfort. Our
goal was to have you spend as much of your remaining time with
your family nearby.
We wish you the best,
Your ___ Care Team
Followup Instructions:
___
|
19733664-DS-8
| 19,733,664 | 23,514,131 |
DS
| 8 |
2138-04-04 00:00:00
|
2138-04-04 16:31:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Cipro
Attending: ___.
Chief Complaint:
Hyperkalemia, CKD, Presyncope
Major Surgical or Invasive Procedure:
EGD
History of Present Illness:
___ M with PMH of CKD Stage IV not on dialysis, IDDM2, CAD,
syncope, cognitive delay, and b/l femoral vein nonocclusive
thrombi on warfarin who presents with presyncope.
Pt reports increased generalized fatigue over the last week.
Endorses one episode of diarrhea today and several episodes
yesterday. Today, went to stand up from bed, developed
lightheadedness, and fell onto the bed. Denies chest pain,
shortness of breath, or palpitations preceding or during the
event. Denies fall from bed, head strike, LOC, headache, nausea,
or vomiting. Denies pain in arms or legs.
Was seen at ___, and was found to have increased Cr and
hyperkalemia. Received insulin, glucose, and IVF, and was
transferred to ___ for initiation of dialysis.
Of note, pt had two hospitalizations at ___ in ___. The first time the patient was admitted on ___
with a complaint of scrotal pain and cellulitis, which was
treated with broad-spectrum antibiotics that were transitioned
to Keflex prior to discharge. During this admission, b/l
nonocclusive femoral vein thrombi were discovered, and pt was
started on Coumadin. He was admitted again on ___ with
a complaint of generalized weakness, nausea, headache and
abdominal discomfort. He was found to have ___ on CKD Stage IV
(Cr 3.7 on presentation, up from 3.0 on prior discharge). ___
was thought to be prerenal i/s/o poor PO intake ___ abdominal
pain and nausea with a possible obstructive component from BPH
(renal US did not show e/o obstruction or hydronephrosis, but Cr
improved post-Foley placement). Cr on discharge ___ was 3.6,
which was thought to be the patient's new baseline. Pt also had
hyperkalemia to 6.0 without ECG changes, which was treated with
insulin, dextrose, and calcium gluconate. Also got two doses of
kayexalate during hospitalization. Discharge K 4.1.
In the ___ ___, initial vitals were: 98.3 68 162/69 16 97% RA.
Labs notable for K 5.2 -> 5.0, Cr 3.6, WBC 6.7, H&H 10.1/32.4,
INR 1.5 (warfarin subtherapeutic), and lactate 1.5.
ECG notable for RBBB with prolonged QRS (140ms) but no peaked T
waves.
Patient was seen by renal dialysis consult in the ___ when K was
5.0 post-treatment and determined that there was no urgent
indication for dialysis. They recommended admission to medicine
for hyperkalemia and eventual initiation of dialysis.
Vitals prior to transfer were: 97.9 72 141/74 20 99% RA.
On the floor, pt HDS and comfortable.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, shortness of breath. Denies chest pain
or tightness, palpitations. Denies nausea, vomiting,
constipation, or abdominal pain. No recent change in bowel or
bladder habits. No dysuria. Denies arthralgias or myalgias.
Past Medical History:
-CAD
-HTN
-HLD
-IDDM2
-OSA
- Hypothyroidism
-h/o nephrolithiasis
-BPH s/p TURP
-H/o colonic adenoma
-H/o syncope
-IBS
-Cognitive delay
-S/p CCY
-S/p achilles tendon repair
-Acute nonocclusive thrombi in b/l femoral vein extending to
left popliteal vein, on Coumadin
Social History:
___
Family History:
Father: died of ruptured hernia at age ___
Physical Exam:
Admission Physical Exam:
========================
VS: 98.0 143/66 73 20 100% RA
Gen: Alert and interactive, NAD
HEENT: NCAT, PERRL, EOMI, MMM, OP clear
CV: RRR, no m/r/g
Pulm: CTAB
Abd: Soft, NT/ND, +BS
GU: Foley
Ext: WWP, 2+ pulses, no cyanosis, clubbing, or edema
Skin: No rashes
Neuro: A&Ox2, CN II-XII intact, strength ___ throughout
Psych: Calm and cooperative
Discharge Physical Exam:
========================
VS: 98.4 152/73 70 16 99% RA
FSG: 111 (___)
Gen: Alert and interactive, NAD
HEENT: NCAT, PERRL, EOMI, MMM, OP clear
CV: RRR, no m/r/g
Pulm: CTAB
Abd: Soft, NT/ND, +BS
Rectal: Guaiac positive
GU: Foley
Ext: WWP, 2+ pulses, no cyanosis, clubbing, or edema
Skin: No rashes
Neuro: A&Ox2, CN II-XII intact, strength ___ throughout
Psych: Calm and cooperative
Pertinent Results:
Admission Labs:
===============
___ 03:05PM BLOOD WBC-6.7 RBC-3.57* Hgb-10.1* Hct-32.4*
MCV-91 MCH-28.3 MCHC-31.2* RDW-14.6 RDWSD-48.7* Plt ___
___ 03:05PM BLOOD Neuts-76.8* Lymphs-11.4* Monos-9.7
Eos-1.3 Baso-0.4 Im ___ AbsNeut-5.12 AbsLymp-0.76*
AbsMono-0.65 AbsEos-0.09 AbsBaso-0.03
___ 03:05PM BLOOD ___ PTT-27.3 ___
___ 03:05PM BLOOD Glucose-110* UreaN-86* Creat-3.6* Na-137
K-5.2* Cl-105 HCO3-22 AnGap-15
___ 03:05PM BLOOD ALT-26 AST-21 LD(LDH)-218 AlkPhos-154*
TotBili-0.2
___ 03:05PM BLOOD Lipase-69*
___ 06:32AM BLOOD cTropnT-0.12*
___ 01:03PM BLOOD cTropnT-0.11*
___ 03:05PM BLOOD Albumin-3.4* Calcium-8.2* Phos-3.5 Mg-2.6
___ 03:22PM BLOOD Lactate-1.5 K-5.0
___ 09:36PM BLOOD K-5.4*
Discharge Labs:
===============
___ 07:15AM BLOOD WBC-5.9 RBC-2.74* Hgb-7.8* Hct-24.9*
MCV-91 MCH-28.5 MCHC-31.3* RDW-14.8 RDWSD-49.1* Plt ___
___ 07:15AM BLOOD ___ PTT-30.0 ___
___ 07:15AM BLOOD Glucose-107* UreaN-82* Creat-3.7* Na-140
K-4.7 Cl-110* HCO3-20* AnGap-15
___ 07:15AM BLOOD Calcium-7.2* Phos-4.2 Mg-2.0
Micro:
======
Urine cx ___: Negative
Cdiff PCR ___: Negative
Norovirus PCR ___: Negative
Stool studies ___: Campylobacter, otherwise negative.
Studies:
========
ECG ___:
Sinus rhythm. Right bundle-branch block. Inferior myocardial
infarction, age indeterminate. Non-specific diffuse T wave
abnormalities. Compared to the previous tracing of ___ there
is no diagnostic interval change.
EGD ___:
Diffuse thickening of gastric folds in the stomach body.
(biopsy)
Several erosions were seen throughout the antrum. A thickened
fold was seen in the pre-pyloric antrum. Two clean based ulcers
were seen in the pre-pyloric antrum. These are possible sources
of patient's reported bleeding. (biopsy) Erythema in the
duodenum compatible with mild duodenitis. Otherwise normal EGD
to third part of the duodenum.
UE Venous Mapping ___:
Right arm: The right brachial artery measures 4.3 mm and shows
no
calcification. The radial artery measures 1.8 mm and it is
calcified.
Veins: The cephalic vein measures 2.1-2.4 mm in the forearm,
3.1 mm at the elbow and 1.5-1.8 in the upper arm. The basilic
vein measures 1.8-1.9 at the level of the elbow and 2.5-4.1 mm
above the elbow.
Left arm: Left brachial artery measures 4.4 mm in diameter in
shows mild calcification. The radial artery measures 2.2 mm and
is significantly calcified.
Veins: The cephalic vein measures 2.4-2.9 mm in the forearm,
2.6 mm at the elbow and 1.9-2.2 mm above the elbow. The basilic
vein measures 1.3 mm just below the elbow, 2.7 mm at the elbow
and 2.1-3.5 mm above the elbow.
___ head w/o contrast ___:
1. No evidence for acute intracranial abnormalities.
2. Trace aerosolized secretions in the right sphenoid sinus.
___ CXR PA & Lateral ___:
In comparison with the study of ___, there is little
interval change. Cardiac silhouette remains enlarged without
appreciable pulmonary vascular congestion. No evidence of
pneumonia.
+ EKG ___: RBBB, prolonged QRS (132ms), no peaked T waves
Brief Hospital Course:
___ M with PMH of CKD Stage IV not on dialysis, IDDM2, CAD,
syncope, cognitive delay, and b/l femoral vein nonocclusive
thrombi on warfarin who presents with presyncope. He was found
to have hyperkalemia, campylobacter diarrhea, UGI bleed,
orthostatic hypotension.
ACTIVE ISSUES:
==============
# Melena/Acute on chronic anemia:
Has history of gastritis on prior EGDs, which is most likely
etiology. Wife stopped PPI (___) at home. Heparin gtt
with supratherapeutic PTT (150) prior to d/c'ing gtt on ___,
which may have contributed to provoking UGI bleed. HDS. Hgb was
slowly downtrending (10.1 -> 9.4 -> 8.8 -> 8.7 -> 8.3 -> 7.8),
but now stable/uptrending after EGD. EGD ___ with diffuse
thickening of gastric folds in the stomach body, several
erosions throughout the antrum, a thickened fold in the
pre-pyloric antrum, two clean based ulcers in the pre-pyloric
antrum (possible sources of patient's bleeding, and erythema in
the duodenum compatible with mild duodenitis. Per GI, was
initially on Protonix IV BID, which was transitioned to 40mg PO
BID after EGD. Pt had active T&S, but never required
transfusion. Continued ASA 81mg given h/o CAD and warfarin given
DVTs. ___ should recheck CBC on ___.
# Presyncope:
Most likely orthostasis i/s/o poor PO intake, diarrhea, Toprol
XL, and probably an element of autonomic instability from pt's
underlying diabetes. Pt developed lightheadedness when arising
quickly from bed. No head strike or LOC. No CP or palpitations.
ECG in ___ showed RBBB with prolonged QRS (140), but otherwise no
arrhythmias. Repeat ECG on HD2 unchanged. Monitored on telemetry
x24 hours with no arrhythmias. Trop 0.12 -> 0.11 i/s/o CKD.
Episode was witnessed, and pt did not have any convulsions c/f
seizure. Orthostatic VS positive (SBP 150 -> 133, DBP 66 ->54).
Given 500cc NS bolus, after which orthostatic VS still positive
(SBP 126 -> 94). Decreased dose of Toprol XL from 150mg daily to
metop tartrate 25mg q6h in case this medication was contributing
to orthostasis. Repeat orthostatics after dose decrease still
positive (SBP 131 -> 104). Given 500cc NS bolus, and
orthostatics still positive. An underlying GI bleed could have
been contributing to orthostasis, as pt developed melena on HD3.
Orthostatics ___ negative, and pt reported very minimal
lightheadedness on standing. Was able to walk around floor with
nurse and ___ without difficulty. Pt should continue wearing TEDS
stockings at home.
# ___ on CKD:
Cr at baseline on admission (3.6). Cr peaked at 4.0, and is now
downtrending and not significantly different from his baseline
(3.7 on discharge). Most likely combination of prerenal and
postrenal etiologies. Prerenal i/s/o orthostasis, diarrhea, UGI
bleed, and poor PO intake. Postrenal contribution given BPH and
urinary retention on ___ necessitating Foley replacement after
failure of voiding trial. ___ was ___ again on ___, and pt
was ordered for straight cath PRN for bladder scan >600cc, which
he did not require. Pt scheduled for appointment with his
outpatient urologist after discharge.
# CKD Stage IV:
Likely due to IDDM2 and HTN. Cr 3.6 on admission, which is
similar to Cr on discharge from ___ on ___. Has been
admitted with hyperkalemia twice in the last month. Seen by Dr.
___ for the first time on ___. Was transferred to ___
from ___ for initiation of dialysis. Was seen by renal
consult in ___ ___, who felt there was no urgent indication for
dialysis. UE venous mapping performed for dialysis access
planning and showed patent vessels amenable to fistula creation.
Pt was seen by Transplant Surgery, who will see the pt in clinic
for further discussion of dialysis access options. Home
calcitriol and sodium bicarbonate continued. Pt given low Na, K,
and phos diet while in-house, and nutrition was consulted to
educate pt and family about low Na, low K, low phos diet.
# Hyperkalemia:
K 6.0 on arrival to ___. Given IVF, glucose, and
insulin. Transferred to ___ for possible initiation of
dialysis. K 5.2 -> 5.0 in ___ ___ with no ECG changes. K on HD2
4.5, repeat ECG on HD2 without peaked T waves. ECG on HD4 also
without TW changes. Never required additional insulin/dextrose
while in-house. K on discharge 4.7.
# Diarrhea/Nausea/Vomiting:
Pt with chronic diarrhea and abdominal pain. Acute diarrhea most
likely due to Campylobacter, which was found on stool studies.
Started on azithromycin 500mg daily x3 days due to cipro allergy
(per UpToDate). Other stool studies pending on discharge. Pt
recently began taking MgOH, which could have also been
contributing to the diarrhea. Occult UGI bleed may have been
contributing. Pt discharged from rehab 1 week PTA and was on
antibiotics ~6 weeks ago for cellulitis, which puts him at risk
for Cdiff. Cdiff PCR negative. The rehab he was discharged from
several days PTA is currently having norovirus outbreak, but
norovirus PCR negative. Pancreatitis r/o with lipase 69. LFTs
WNL except AP mildly elevated (154). Electrolytes were checked
daily and repleted PRN. PO MgOH was held during admission and
___ prior to discharge.
# C/f CAUTI:
Had Foley taken out 1 week PTA. Pt endorses abdominal pain, but
denies dysuria. ___ SIRS criteria. No WBC count, stable BP,
normal HR, afebrile. UA 105 WBCs, few bacteria, large ___, neg
nitrites. Initially treated with ceftriaxone IV for CAUTI, but
___ abx on HD2 per geriatrics attending given no urinary
symptoms. Urine cx negative.
CHRONIC ISSUES:
===============
# Recently diagnosed nonocclusive thrombi b/l femoral vein
extending to left popliteal vein:
Diagnosed during hospitalization at ___ in ___. INR low on admission (1.5). Given 5mg warfarin on
admission and HD2. Heparin bridge given very high risk for PE
due to VTE diagnosed <3 months ago. Heparin gtt ___ on HD3
given therapeutic INR (2.2). INR on discharge 2.2. ___ should
recheck INR and CBC on ___.
# Urinary Retention:
Per patient's wife, pt doing well with urination since Foley
catheter removed by urologist last week. Had Foley placed due to
possible contribution of urinary retention to worsening CKD. He
reports that he occasionally has urinary incontinence and
dribbling. Foley placed in ___ and removed on ___. Pt had to be
straight cathed x1 for bladder scan >800cc on ___. PVRs >500cc
on ___, so Foley replaced. Foley ___ again on ___. Pt was
bladder scanned q6h while pt awake and was ordered for straight
cath for >600cc, which he did not require. Per renal, retention
>250cc could put him at risk for post-renal ___ and
hyperkalemia. After reviewing the pt's bladder scans, renal
agreed with discharge without a Foley catheter and close urology
follow up. Patient was instructed to sit on toilet for 20
minutes to fully empty bladder and to call his doctor if
retaining urine >8 hours.
# CAD:
Continued simvastatin, Toprol XL, and ASA 81mg. Decreased Toprol
XL from 150mg to 100mg daily given orthostasis.
# IDDM:
Home glipizide was held while in-house and was replaced with a
Humalog ISS. Home glargine 12U qHS was continued. Pt was
discharged on home glargine and glipizide.
# Hypothyroidism:
Continued home levothyroxine.
Transitional Issues:
[] PCP and GI should follow up EGD biopsies
[] Will need repeat EGD +/- EUS in ___ weeks to document
healing of stomach ulcers and re-evaluate thickened gastric
folds.
[] Will need ___ imaging of pancreatic cyst
[] Will go home with ___ and home ___. Will likely require
outpatient ___ after home ___.
[] Found to have Campylobacter on stool studies. Started on
azithromycin 500mg daily x3 days given cipro allergy (per
UpToDate). PCP should ___ diarrhea symptoms after completing
antibiotic course. Pt takes probiotic at home.
Code Status: Full
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Calcitriol 0.5 mcg PO DAILY
3. GlipiZIDE 10 mg PO BID
4. Glargine 12 Units Bedtime
5. Ketoconazole 2% 1 Appl TP BID
6. Nystatin Cream 1 Appl TP BID
7. Levothyroxine Sodium 125 mcg PO DAILY
8. Metoprolol Succinate XL 150 mg PO DAILY
9. Benefiber Sugar Free (dextrin) (wheat dextrin) 3 gram/3.8
gram oral QAM
10. Sertraline 100 mg PO DAILY
11. Simvastatin 20 mg PO QPM
12. Tamsulosin 0.4 mg PO QAM AND QHS
13. Warfarin 2 mg PO DAILY16
14. Acetaminophen Dose is Unknown PO PRN pain
15. Calcium Carbonate 500 mg PO QID:PRN stomach pain
16. Saccharomyces boulardii 250 mg oral BID
17. Sodium Bicarbonate 650 mg PO TID
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Aspirin 81 mg PO DAILY
3. Calcitriol 0.5 mcg PO DAILY
4. Calcium Carbonate 500 mg PO QID:PRN stomach pain
5. Glargine 12 Units Bedtime
6. Ketoconazole 2% 1 Appl TP BID
7. Nystatin Cream 1 Appl TP BID
8. Sertraline 100 mg PO DAILY
9. Simvastatin 20 mg PO QPM
10. Sodium Bicarbonate 1300 mg PO BID
11. Tamsulosin 0.4 mg PO QAM AND QHS
12. Warfarin 2 mg PO DAILY16
13. Metoprolol Succinate XL 100 mg PO DAILY
RX *metoprolol succinate 100 mg 1 tablet by mouth daily Disp
#*30 Tablet Refills:*0
14. Pantoprazole 40 mg PO Q12H
RX *pantoprazole 40 mg 1 tablet by mouth twice daily Disp #*60
Tablet Refills:*0
15. Simethicone 80 mg PO QID:PRN bloating
RX *simethicone 80 mg 1 tablet by mouth four times daily Disp
#*50 Tablet Refills:*0
16. Benefiber Sugar Free (dextrin) (wheat dextrin) 3 gram/3.8
gram oral QAM
17. GlipiZIDE 10 mg PO BID
18. Levothyroxine Sodium 125 mcg PO DAILY
19. Saccharomyces boulardii 250 mg oral BID
20. Assist Device
Please provide 1 rolling walker.
ICD-10:
R26.81 Unsteadiness on feet
I95.1 Orthostatic hypotension
21. Azithromycin 500 mg PO Q24H Duration: 2 Doses
RX *azithromycin 500 mg 1 tablet by mouth daily Disp #*2 Tablet
Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary:
UGI bleed
Presyncope
Orthostatic hypotension
CKD Stage IV
Hyperkalemia
Viral gastroenteritis
Secondary:
Deep venous thrombosis
Urinary Retention
Anemia
CAD
IDDM
Hypothyroidism
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid
(___).
Discharge Instructions:
Dear Mr. ___,
You were transferred to ___
from ___ due to high potassium in your blood and concerns
that you would need to immediately start dialysis. Your
potassium levels came down with medications and IV fluids, and
you were seen by our kidney specialists, who did not need to
start dialysis in the hospital. You will, however, most likely
need to start dialysis within the next few months due to your
chronic kidney disease. Therefore, an ultrasound was performed
to map the veins in your arms and surgeons were consulted to
plan where to place a fistula for future use for dialysis. You
will need to follow up with both your kidney doctor, ___.
___ the transplant surgeons as an outpatient.
In the hospital, you were found to have urinary retention, which
may be contributing to your episodes of high potassium. You had
a Foley catheter placed twice due to the urinary retention. You
were able to urinate on your own prior to discharge, and were
discharged without a Foley catheter. You should sit on the
toilet for 20 minutes each time you feel the urge to urinate to
make sure you fully empty your bladder. If you cannot urinate in
an 8-hour period despite the urge, immediately go to the ___
___. You should follow up with your urologist, Dr.
___, on ___ at 10:40am.
You also came into the hospital after falling due to
lightheadedness on standing. You were given IV fluids to
rehydrate you after you had vomiting and diarrhea. Your dose of
a medication called metoprolol was decreased in case it was
contributing to your lightheadedness on standing. You should
continue wearing compression stockings on your legs to help with
your lightheadedness.
You came into the hospital with diarrhea and one episode of
vomiting. Your symptoms were most likely due to a bacteria
called Campylobacter that we found in your stool. You were
started on an antibiotic called azithromycin, which you should
take once daily for 2 more days after discharge. The magnesium
pills that you were taking at home may have also contributed to
your diarrhea, so they were stopped. You were found to be
bleeding from your stomach, which may have been contributing to
the diarrhea and lightheadedness. You had two ulcers in your
stomach and to treat these you were started on a medication
called pantoprazole (aka Protonix), which you should continue
taking twice daily to prevent further gastrointestinal bleeding.
As you know, you are on a blood thinning medication called
Coumadin to treat blood clots in your legs. Your Coumadin level
was too low on admission, so you were given higher doses of
Coumadin and a heparin drip to keep the blood thin until your
Coumadin level was in the therapeutic range. Your Coumadin dose
on discharge was the same as the dose you were previously taking
at home.
Thank you for allowing us to be involved in your care.
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
19733783-DS-14
| 19,733,783 | 25,614,483 |
DS
| 14 |
2170-01-27 00:00:00
|
2170-01-27 19:31:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Codeine / azithromycin
Attending: ___.
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
Thoracoscopic pleurodesis
Pleurex catheter placement
History of Present Illness:
This is a ___ year old female w/ cT4N1M1a, Stage IV NSCLC w/ mult
R pulm nodules who recently initated treatment with carboplatin
and alimta ___ who presents to ED with dyspnea on exertion.
She
reports mild dyspnea on exertion for past ___ days, now
worsening. Today was also associated with dull ache in R arm
that
was worse with deep breath also had some SOB at rest. At
baseline she can do basic household tasks and walk up stairs,
lately was having to stop due to feeling winded. She denies any
chest pain, orthopnea or leg swelling. She has had a morning
cough productive of green sputum but no other cough. No overt
fever/chills but had temp elevation to 99.5 when duaghter
checking at home.
She also has some pain and swelling of an old injury in her
L-wrist but has been able to use it well. She has been off
spironolactone for one week in case it was contributing to a
diffuse rash she has had for nearly one year, cause unknown.
In ED pt underwent CTA chest, no PE demonstrated but found to
have in creased R pleural effusion which has been prseent for
past 3 weeks. Had lateral TWI which were new on EKG, trop x1
negative
Past Medical History:
Stage IV NSLC
HTN
HLD
Pulm nodule ___
Anemia
Arthritis
Depression
Sinus bradycardia
Hypothyroid
S/p cataract surg
S/p bilat shoulder surgery
S/p tubal ligation
Social History:
___
Family History:
Father: CAD
Physical ___:
Discharge exam:
Vitals: 144/60 80 20 93% on 2L NC
Gen: NAD, lying in bed
Eyes: EOMI, sclerae anicteric
ENT: MMM, OP clear
CV: RRR, no MRG, full pulses, no edema
Resp: normal effort, no accessory muscle use, lungs CTAB.
GI: soft, NT, ND, BS+
MSK: full ROM all joints, no joint swelling or erythema
Skin: fading macular rash over arms and legs, residual
erythematous macules over chest and back
Neuro: alert, oriented x4, moves all ext, sensation intact to
light touch
Pertinent Results:
MICROBIOLOGY
============
___ 4:40 pm PLEURAL FLUID RIGHT PLEURAL EFFUSION.
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final ___: NO GROWTH.
ANAEROBIC CULTURE (Preliminary): NO GROWTH.
ACID FAST CULTURE (Preliminary):
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
POTASSIUM HYDROXIDE PREPARATION (Final ___:
NO FUNGAL ELEMENTS SEEN.
ACID FAST SMEAR (Final ___:
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
IMAGING/STUDIES
===============
___ ECG:
Sinus rhythm. Marked repolarization abnormalities consistent
with left
ventricular strain pattern, although criteria for left
ventricular hypertrophy are not met by voltage criteria. No
previous tracing available for comparison.
___ Chest CTA:
1. No evidence of pulmonary embolism.
2. Increased size of a large right mildly complex pleural
effusion.
3. Known lung cancer has slightly progressed with more confluent
nodules in the right lung, and increased mediastinal
lymphadenopathy. There is increased peribronchial thickening
particularly in the right lower lobe which may reflect worsening
disease or superimposed airway inflammation. Right lung septal
thickening persists and is consistent with lymphangitic spread
of tumor.
4. Severe centrilobular emphysema.
___ Wrist films:
Stable appearance of impacted distal radius fracture status post
removal of hardware.
___ Wrist MRI:
Moderate distal radioulnar joint effusion with synovitis and
nonspecific inflammatory changes within the surrounding soft
tissues without demonstration of an abscess. While marrow edema
at the distal radius and proximal poles of the lunate and
scaphoid can be explained by other etiologies (incompletely
healed intra-articular comminuted fracture, chronic ulnar
abutment and osteoarthritis, respectively) septic arthritis is
not excluded and clinical correlation is recommended. Mild first
and fourth extensor compartment tenosynovitis. Mild extensor
carpi ulnaris tenosynovitis and ulnar subluxation.
___ PATHOLOGY/CYTOLOGY PLEURAL FLUID: + adenocarcinoma
___ CT CHEST W/O CONTRAST:
1. Interval development of a large right lower lobe
consolidation and fluid filled left lower lobe bronchiectasis,
highly concerning for an underlying infectious etiology.
2. Status post right chest tube placement and right pleurodesis
with a small residual right pleural effusion and.
3. Innumerable, confluent metastatic deposits within the right
lung and mediastinal lymphadenopathy, largely unchanged compared
to the prior examination.
4. Moderate-severe centrilobular emphysema.
CXR ___
IMPRESSION:
The volume of the right lung has improved and the severity of
unilateral edema an lymphatic engorgement has decreased although
the overall volume of moderate residual right pleural effusion
is probably stable. A right basal pleural drain is unchanged in
position since at least ___. Left lung is hyperinflated and its pleural effusion has
resolved. The heart is mildly enlarged, unchanged. Tumor
enlarging and distorting the contours of the right hilus in the
right lower mediastinum, and scattered lung nodules are all
unchanged. No pneumothorax
Brief Hospital Course:
NARRATIVE:
==========
This is a ___ with NSCLC Stage IV recently started on
___, HTN, HL, depression, hypothyroidism, who presented
with worsening dyspnea in context of enlarging pleural effusion.
BY PROBLEM:
===========
# Malignant pleural effusion w/ hypoxic resp failure: She
underwent thoracoscopic pleurodesis by interventional
pulmonology on ___ ___ and transferred to the MICU for worsening
hypoxia. She became febrile on ___ and was broadened to
vanc/cefepime due to neutropenia. Pleural cultures were negative
but CT chest showed a R lower lobe consolidation concerning for
pneumonia. Antibiotics were continued until ___. She was never
intubated and her respiratory status gradually improved, so she
was transferred back to the floor with a Pleurex catheter.
Her Pleurx was kept to suction and output over the next several
days was less than 100cc per day. The pleurx was capped and will
be drained daily up to 1L or as needed at home. Fluid overload
may also have contributed to her hypoxia. Prior to admission she
was on spironolactone and hydrochlorothiazide which were stopped
due to a rash. After her ICU stay she was gently diuresed with
lasix. Her oxygen requirement at discharge is down to 2L via
nasal cannula and she will continue on home O2.
# Goals of care: Palliative care was consulted on ___ and a
family meeting was held on ___ with ___ and palliative
present. The patient was unable to participate due to pain but
her family members were present. However, the patient has
indicated she would prefer less invasive care, focus on feeling
better, and hopefully returning home. Family has asked about
hospice care and feel the patient would be open to hospice when
she is ready to leave hospital. Dr. ___ has
discussed that the patient is not strong enough for chemo at
present and may not get get strong enough. The patient met with
___ hospice and is agreeable to going home under hospice
care.
# Back pain, wrist pain: Palliative also assisted with pain
management during her hospitalization. The patient was on a
morphine PCA with a bolus rate, which was transitioned to
MSContin 15mg BID and MSIR ___ q4h prn and controlled on
discharge.
# Acute kidney injury: Patient has baseline creatinine of 0.6,
which increased to 1.0 during her brief stay in the ICU. Her
creatinine returned to baseline prior to transfer to the floor
after receiving IVF.
# Paraneoplastic dermatomyositis: Patient had intermittent
photosensitive rash, concern for DM in setting of lung cancer
which had flared at time of admission. Also had painful L wrist
effusion, unclear if related or coincidental. Also noted to
have recent elevated ___. Dermatology was consulted, she had a
negative anti-Jo1 antibody, CK, RNP, and aldolase. Treated with
steroids as below, with some improvement in her rash as well as
wrist effusion. Ortho/hand surgery was also consulted. She had
an MRI which was inconclusive, but there was low concern for
septic joint. A splint was placed on ___. She developed some
pain and swelling in the other wrist and small joints of both
hands as well. She was started on prednisone 20mg with some
improvement. She will continue this for a short course and quick
taper on discharge: 10mg for 2 days, then 5mg for two days and
off..
# Urinary Retention: Foley placed in ICU for bladder scan 400cc
-
drained 280cc. may have been dry or kidneys underperfused as Cr
also went up. DCed Foley ___, has been voiding freely since
# Restless legs: on ropinirole at home. This was a prominent
symptom for her while in the ICU, so sleep medicine was
consulted. They recommended increasing her dose of ropinirole.
However, she became very sleepy the next day on the increased
dose, so we reduced back to her home dose of 0.5 daily prn with
1mg at night
# Stage IV NSCLC with R pleural effusion, malignant: Stage IV
NSCLC - Just received C1D1 carboplatin/alimta on ___. Plan
was to repeat CT after two cycles but patient now leaning toward
no more chemo. She would like to continue to f/u with Dr
___ further discussion however at this time she is
ready to enroll in home hospice.
# Pancytopenia: Likely chemo related; it improved over the
course of her stay.
# Hypothyroidism: Continued synthroid.
# HTN: Held meds while she was here. These will not be restarted
given controlled BP and goals of care
TRANSITIONAL:
=============
# Disposition: home with hospice care
# Code status: DNR/DNI
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Ondansetron 8 mg PO BID
2. Acetaminophen 500 mg PO Q6H:PRN mild pain
3. TraMADOL (Ultram) ___ mg PO BID:PRN back pain
4. Ropinirole 0.5 mg PO QPM
5. Lorazepam 0.5 mg PO BID:PRN nausea, vomiting, anxiety,
insomnia
6. FoLIC Acid 1 mg PO DAILY
7. Levothyroxine Sodium 88 mcg PO DAILY
8. Prochlorperazine ___ mg PO Q6H:PRN nausea
9. Triamcinolone Acetonide 0.1% Cream 1 Appl TP BID
Discharge Medications:
1. Acetaminophen 500 mg PO Q6H:PRN mild pain
2. FoLIC Acid 1 mg PO DAILY
3. Levothyroxine Sodium 88 mcg PO DAILY
4. Lorazepam 0.5 mg PO BID:PRN nausea, vomiting, anxiety,
insomnia
5. Ondansetron 8 mg PO BID
6. Prochlorperazine ___ mg PO Q6H:PRN nausea
7. Morphine SR (MS ___ 15 mg PO Q12H
RX *morphine 15 mg 1 tablet(s) by mouth every twelve (12) hours
Disp #*60 Tablet Refills:*0
8. Morphine Sulfate (Oral Soln.) ___ mg PO Q4H:PRN pain
9. Morphine Sulfate (Concentrated Oral Soln) ___ mg PO Q4H:PRN
pain
RX *morphine concentrate 100 mg/5 mL (20 mg/mL) ___ mg by mouth
every four (4) hours Refills:*0
10. Ropinirole 1 mg PO QHS:PRN restless legs
11. Ropinirole 0.5 mg PO DAILY:PRN restless legs
12. Bisacodyl 10 mg PO/PR DAILY:PRN constipation
RX *bisacodyl [Laxative] 5 mg 1 tablet(s) by mouth as needed
Disp #*20 Tablet Refills:*1
13. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 tablet(s) by mouth twice a day Disp
#*30 Tablet Refills:*1
14. Polyethylene Glycol 17 g PO DAILY constipation
15. Senna 8.6 mg PO BID constipation
RX *sennosides [senna] 8.6 mg 1 tablet by mouth twice a day Disp
#*30 Capsule Refills:*1
16. PredniSONE 20 mg PO DAILY
RX *prednisone 5 mg 1 tablet(s) by mouth daily Disp #*6 Tablet
Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Symptomatic pleural effusion, treated by thoracoscopic
pleurodesis and pleurex catheter placement
Neutropenia, resolved
Left wrist swelling, improved
skin rash, improved
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking care of you during your stay at ___
___. You were admitted to the hospital
with shortness of breath. You had a large pleural effusion
(fluid on the lung) which was managed by drainage and a
procedure called thoracoscopic pleurodesis and pleurex catheter
placement. You had low oxygen levels after the procedure and
required brief ICU care. With some time and supportive care, you
are slowly improving. We discussed plans for the future
regarding treatment for your lung cancer. At this time your main
goal is to feel better and get back to your normal life rather
than pursue chemotherapy. You enrolled in home hospice care to
help you manage symptoms that may come up while you are at home.
Followup Instructions:
___
|
19733931-DS-16
| 19,733,931 | 28,345,643 |
DS
| 16 |
2112-04-16 00:00:00
|
2112-04-16 15:55:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
___ APPENDECTOMY LAPAROSCOPIC
History of Present Illness:
___ with history of PVD s/p bilateral iliac
stent on ASA who presents with RLQ abdominal pain. Patient noted
diffuse abdominal pain on ___ night. Since then, her pain has
localized to the right lower quadrant. Today she had nausea and
one episode of emesis. She denies fevers, chills, malaise,
diarrhea, and constipation. She has never had pain like this
before.
Past Medical History:
Hypertension, PVD, hypercholesterolemia
PSH: Peripheral vascular disease with bilateral iliac stents
Family History:
Noncontributory
Physical Exam:
Upon presentation to ___:
Vitals: 99.9 97 126/54 20 97%
GEN: A&O, NAD
HEENT: No scleral icterus, mucus membranes moist
CV: RRR, No M/G/R
PULM: Clear to auscultation b/l, No W/R/R
ABD: Soft, obese, mildly distended, focal tenderness in RLQ with
voluntary guarding, +rovsing's sign
Ext: No ___ edema, ___ warm and well perfused
Brief Hospital Course:
She was admitted to the Acute Care Surgery team and underwent CT
imaging of her abdomen/pelvis showing acute appendicitis,
uncomplicated with no drainable abscess. She was consented,
prepped and taken to the operating room for laparoscopic
appendectomy; perioperative antibiotics were given. There were
no intraoperative complications. Postoperatively her diet was
advanced and her home medications were resumed. Her pain was
well controlled with oral pain medications and she was
discharged on Tylenol and prn Oxycodone.
She was discharged to home with instructions for follow up with
her PCP and in the Acute Care Surgery clinic.
Medications on Admission:
Fluticasone 50 mcg BID, Lisinopril 20 mg daily, Simvastatin 40
mg daily, Aspirin 325 mg daily, Ceterizine 10 mg daily, Vitamin
D3 1000 U daily
Discharge Medications:
1. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q8H (every
8 hours).
2. oxycodone 5 mg Tablet Sig: ___ Tablets PO Q4H (every 4 hours)
as needed for pain.
Disp:*25 Tablet(s)* Refills:*0*
3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
4. fluticasone 50 mcg/actuation Spray, Suspension Sig: One (1)
Spray Nasal BID (2 times a day).
5. lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Ceterizine 10 mg daily
Discharge Disposition:
Home
Discharge Diagnosis:
Appendicitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital with appendicitis and
underwent an operation to remove your appendix.
You are being discharged with the following instructions:
You are being discharged on medications to treat the pain from
your operation. These medications will make you drowsy and
impair your ability to drive a motor vehicle or operate
machinery safely. You MUST refrain from such activities while
taking these medications.
Please call your doctor or return to the emergency room if you
have any of the following:
* You experience new chest pain, pressure, squeezing or
tightness.
* New or worsening cough or wheezing.
* If you are vomiting and cannot keep in 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 have shaking chills, or a fever greater than 101.5 (F)
degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that
concern you.
* Please resume all regular home medications and take any new
meds
as ordered.
Activity:
No heavy lifting of items ___ pounds for 6 weeks. You may
resume moderate
exercise at your discretion, no abdominal exercises.
Wound Care:
You may shower, no tub baths or swimming.
The white strips on your operation sites will fall off on their
own.
Please call the doctor if you have increased pain, swelling,
redness, or drainage from the incision sites.
Followup Instructions:
___
|
19734275-DS-7
| 19,734,275 | 21,437,288 |
DS
| 7 |
2187-08-25 00:00:00
|
2187-08-26 12:15:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Keflex / Compazine / Ambien / Reglan / Dilaudid
Attending: ___.
Chief Complaint:
constipation
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ F bipolar d/o, anorexia nervosa with chief complaint of
constipation. Pt is resident at ___ (eating disorder
unit, has anorexia and laxative abuse) who has h/o constipation,
worsened recently, seen at ___ (___) on ___, ct abd
then with umbilical hernia wo bowel contents and large fecal
load. Since then, pt has tried mag citrate x 2, ___ enemas, at
baseline on miralax and tid colace. Seen in office by Dr. ___,
___ noted no fecal ball on rectal, minimal distention, rx with
lactulose and mineral oil enema and fleet enemas wo success. Pt
referred to ED for admission for constipation.
.
In the ED, initial VS were 97.4 106 124/83 20 100% RA. CXR wnl,
KUB with considerable stool in colon, non-dilated colon, no free
air, no obstruction. Pt received magnesium citrate and lactulose
in the ED with no effect.
.
Currently, pt endorses mild abd discomfort, otherwise no
complaints. She does endorse worsening orthostatic hypotension
in the last few days while at ___.
.
REVIEW OF SYSTEMS:
Denies fever, chills, night sweats, headache, vision changes,
rhinorrhea, congestion, sore throat, cough, shortness of breath,
chest pain, vomiting, diarrhea, BRBPR, melena, hematochezia,
dysuria, hematuria.
Past Medical History:
anorexia nervosa
bipolar disorder
spontaneous pneumothorax x 2
knee osteoarthritis
Social History:
___
Family History:
noncontributory, no sick contacts
Physical Exam:
On admission:
VS - 97 116/83 82 18 100% RA
GENERAL - well-appearing in NAD, comfortable, appropriate
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear
NECK - supple, no JVD
LUNGS - CTA bilat
HEART - RRR, no MRG, nl S1-S2
ABDOMEN - NABS, distended and nontender, no masses, no
rebound/guarding
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
___ throughout
On discharge:
VS - 97.8 99/64 81 18 99%RA
GENERAL - well-appearing in NAD, comfortable, appropriate
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear
NECK - supple, no JVD
LUNGS - CTA bilat
HEART - RRR, no MRG, nl S1-S2
ABDOMEN - NABS, soft, nondistended and nontender, no masses, no
rebound/guarding
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)
NEURO - awake, A&Ox3
Pertinent Results:
On admission:
___ 07:20PM BLOOD WBC-6.7 RBC-4.01* Hgb-12.4 Hct-37.8
MCV-94 MCH-31.0 MCHC-32.9 RDW-12.6 Plt ___
___ 07:20PM BLOOD Neuts-69.7 ___ Monos-6.0 Eos-0.1
Baso-0.5
___ 07:20PM BLOOD Glucose-99 UreaN-18 Creat-0.7 Na-141
K-4.3 Cl-103 HCO3-35* AnGap-7*
On discharge:
___ 04:30AM BLOOD WBC-5.7 RBC-3.87* Hgb-12.2 Hct-36.5
MCV-94 MCH-31.4 MCHC-33.3 RDW-12.7 Plt ___
___ 04:30AM BLOOD Glucose-89 UreaN-15 Creat-0.7 Na-142
K-4.0 Cl-103 HCO3-33* AnGap-10
___ 04:30AM BLOOD Calcium-9.0 Phos-3.6 Mg-2.3
Urine:
___ 06:00PM URINE Color-Straw Appear-Cloudy Sp ___
___ 06:00PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-8.0 Leuks-NEG
___ 06:00PM URINE UCG-NEGATIVE
Chest (PA & LAT) ___:
FINDINGS: The heart is normal in size. The mediastinal and hilar
contours
appear within normal limits. The lungs are clear. There are no
pleural
effusions or pneumothorax. The osseous structures are
unremarkable.
IMPRESSION: No evidence of acute disease.
Abdomen (Supine & Erect) ___:
FINDINGS: The stomach is nondistended. There are no dilated
loops of large or small bowel. No air-fluid levels are
demonstrated. There is considerable stool throughout the
ascending and proximal transverse portions of the colon, more
than usually expected, although not more distally. The colon is
non-dilated. There is no free air. An intrauterine device
projects over the central pelvis. There is slight rightward
convex curvature of the lumbar spine. Patchy calcifications in
the right upper quadrant are probably due to costochondral
cartilaginous calcification.
IMPRESSION: Increased stool compared to what is usually
expected, but without evidence for obstruction.
Brief Hospital Course:
___ F bipolar disorder, anorexia nervosa with chief complaint of
constipation
.
# constipation: Pt was not on chronic narcotics or medications
that commonly cause constipation. However she was several weeks
into a treatment program for eating disorder amd had been
abusing laxatives which may have resulted in colonic dysmotility
vs slow transit in colon due to re-feeding. Recent outpatient
TSH had been normal. Pt had tried lactulose, enemas, mag
citrate, colace, miralax with no effect, only had had small
pellet-like stools. There was no stool in rectal vault per ED
assessment for disimpaction. KUB showed significant amount of
stool in the colon without evidence of obstruction. She was
continued on her colace and miralax and given Golytely with good
relief of constipation. She had several BMs during her hospital
course. She was discharged with the addition of fiber,
lactulose, and bisacodyl suppositories prn.
.
# Eating disorder: Pt was transferred from a psychiatric
facility where she was undergoing treatment for her eating
disorder. She was seen by a nutritionist while in the hospital
and continued on an eating disorder protocol with monitored
meals. She was continued on her psychiatric medications,
including seroquel, clonazepam, clonidine, and fluoxetine.
Electrolytes were monitored and within normal limits.
Medications on Admission:
-CLONAZEPAM - (Dose adjustment - no new Rx) - 1 mg Tablet - 0.5
(One half) Tablet(s) by mouth in am and 1 in pm
-CLONIDINE - (Prescribed by Other Provider) - 0.1 mg Tablet - 1
Tablet(s) by mouth once a day
-FLUOXETINE - (Prescribed by Other Provider) - 20 mg Capsule - 2
Capsule(s) by mouth once a day
-FLUTICASONE - 50 mcg Spray, Suspension - 2 sprays(s) in each
nostril at bedtime
-OMEPRAZOLE [PRILOSEC] - 20 mg Capsule, Delayed Release(E.C.) -
1
Capsule(s) by mouth bid, ___ prior to breakfast and dinner
-POLYETHYLENE GLYCOL 3350 [MIRALAX] - 17 gram/dose Powder - 17
gram(s) orally ___ oz of beverage bid as needed for as needed
for constipation
-QUETIAPINE [SEROQUEL] - (Prescribed by Other Provider) - 100 mg
Tablet - 1.5 Tablet(s) by mouth at bedtime
-ACETAMINOPHEN - 500 mg Tablet - 1 Tablet(s) by mouth to 2
tablets
every 8 hours prn joint pain not to exceed > 10 consecutive days
of use at above dose.
-ASPIRIN-ACETAMINOPHEN-CAFFEINE [EXCEDRIN MIGRAINE] - 250 mg-250
mg-65 mg Tablet - ___ Tablet(s) by mouth every 6 hour as needed
for HA
-CALCIUM CARBONATE-VITAMIN D3 [CALCIUM 500 + D] - 500 mg calcium
(1,250 mg)-200 unit Tablet - 1 Tablet(s) by mouth one po bid
-DOCUSATE SODIUM - 100 mg Capsule - 1 Capsule(s) by mouth three
times a day as needed for constipation
-MENTHOL [HALLS COUGH DROPS] - 5.8 mg Lozenge - ___ every ___
hour
as needed for cough
Discharge Medications:
1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO three
times a day.
2. clonazepam 1 mg Tablet Sig: ___ Tablet PO twice a day: Half
Tablet(s) by mouth in am and 1 in pm .
3. clonidine 0.1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. fluoxetine 20 mg Capsule Sig: Two (2) Capsule PO DAILY
(Daily).
5. fluticasone 50 mcg/Actuation Spray, Suspension Sig: Two (2)
Spray Nasal DAILY (Daily).
6. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO twice a day: ___ prior to
breakfast and dinner
.
7. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1)
packet PO DAILY (Daily). packet
8. quetiapine 100 mg Tablet Sig: 1.5 Tablets PO HS (at bedtime).
9. acetaminophen 500 mg Tablet Sig: ___ Tablets PO Q8H (every 8
hours) as needed for pain: do not exceed 4 grams in 24 hours.
10. Excedrin Migraine 250-250-65 mg Tablet Sig: ___ Tablets PO
every six (6) hours as needed for headache.
11. calcium carbonate-vitamin D3 500 mg(1,250mg) -200 unit
Tablet Sig: One (1) Tablet PO twice a day.
12. menthol 5.8 mg Lozenge Sig: ___ Mucous membrane every ___
hours as needed for cough.
13. lactulose 10 gram/15 mL Solution Sig: Thirty (30) mL PO
three times a day as needed for constipation.
Disp:*1000 mL* Refills:*0*
14. Benefiber (wheat dextrin) 1 gram Tablet Sig: One (1) Tablet
PO once a day: Take with full glass of water.
Disp:*30 Tablet(s)* Refills:*0*
15. bisacodyl 10 mg Suppository Sig: One (1) suppository Rectal
once a day as needed for constipation.
Disp:*30 suppository* Refills:*0*
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary:
Constipation
Secondary:
Anorexia nervosa
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
It was a pleasure taking care of you in the hospital. You were
admitted with constipation that resolved with drinking a
laxative. Your bowels may be desensitized from the laxatives
that you used in the past. It may take some time to re-train
your bowels to respond appropriately. In the meantime, you will
be discharged with medications that you may use if you are
constipated. Please remember that adequate fluid intake,
increased fiber in your diet, and exercise can help prevent
constipation.
The following medications were added:
1) START lactulose 30ml three times a day as needed for
constipation
2) START fiber 1 gram daily; please take this with full glass of
water
3) START bisacodyl suppository; one suppository daily as needed
for constipation
*Please continue to take your colace and miralax as you are
doing.
Followup Instructions:
___
|
19735078-DS-11
| 19,735,078 | 22,034,709 |
DS
| 11 |
2125-08-02 00:00:00
|
2125-08-03 16:27:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
shellfish derived
Attending: ___.
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
Thoroscopy w/ pleural biopsies and chest tube placement
History of Present Illness:
Mr. ___ is a ___ year old male with a history of recent
pleural effusions s/p thoracentesis on ___ who presents with
recurrent chest pain and pleural effusions.
After discharge from his procedure, his chest pain was improved
for a few days at about ___. He then tried to play basketball
with his family and the chest pain worsened to the point of
causing shortness of breath. He went home and took a percocet,
which helped the pain. However, after a few days the pain was
not improving, so he called his PCP who referred him into the
ED.
The pain is pleuritic, sharp, spans the bilateral chest, going
from about ___ at rest to ___ with deep breathing. It is
similar to the pain he had on his initial presentation, although
dyspnea was the predominant compliant on that presentation. The
last time he was chest pain free was about 1 month ago. He has
also had subjective fevers (measured 99.7 once at home), chills,
and drenching night sweats, which are new, over the past few
days. Denies weight loss, cough, sick contacts, history of
incarceration or TB contacts. Last visited the ___
___ in ___.
Of note, pleural fluid from his previous admission was exudative
___ Light's criteria), >10K WBCs, 67% lymphocytes. No malignant
cells were seen, negative quantiferion gold, negative HIV, no
growth from the pleural fluid cultures.
In the ED, initial vital signs were 98.9 94 125/74 16 97% RA.
CXR showed small bilateral pleural effusions. TTE was normal. He
was given pain control and admitted to medicine for likely
thoroscopy by IP.
On the floor, he endorses ___ pleuritic chest pain. Denies SOB.
Past Medical History:
Recent admission for pleural effusion. No other past medical
history.
Social History:
___
Family History:
h/o DVT/PE- None.
h/o clotting d/o- None.
h/o cancers- None.
h/o heart disease- MGM with "big" heart. Mother w/HTN.
Physical Exam:
ADMISSION EXAM:
=================
Vitals- 98.9 122/74 77 18 97%RA
General: Obese man in NAD, lying in bed, pleasant
HEENT: PERRL, sclerae anicteric, MMM, OP clear w/o erythema or
exudates, tonsils prominent (grade III)
Neck: supple, no LAD
CV: RRR, no m/r/g
Lungs: Dull at bases, otherwise clear.
Abdomen: Soft, obese, non-tender
GU: deferred
Ext: WWP, 2+ DP pulses, no edema
Neuro: moving all extremities grossly
Skin: No lesions observed.
DISCHARGE EXAM:
=================
Vitals- 98.8 120s-140s/60s-80s ___ 16 95-97% RA
General: Obese man in NAD, lying in bed, pleasant
Chest: chest tube wound c/d/i. ___ subcentimeter blisters filled
w/ serosanguinous fluid where tegaderm adhesive was.
CV: RRR, no m/r/g
Lungs: Diminished sounds at left apex and right base, otherwise
clear.
Abdomen: Soft, obese, non-tender
Ext: WWP, 2+ DP pulses, no edema
Neuro: moving all extremities grossly
Pertinent Results:
ADMISSION LABS:
=================
___ 05:05PM BLOOD WBC-10.9 RBC-4.86 Hgb-15.0 Hct-44.8
MCV-92 MCH-30.9 MCHC-33.5 RDW-11.8 Plt ___
___ 05:05PM BLOOD Neuts-62.6 ___ Monos-7.2 Eos-8.4*
Baso-0.8
___ 05:05PM BLOOD ___ PTT-38.5* ___
___ 05:05PM BLOOD Glucose-91 UreaN-16 Creat-1.1 Na-137
K-4.2 Cl-101 HCO3-24 AnGap-16
DISCHARGE LABS:
=================
___ 07:55AM BLOOD WBC-15.8* RBC-4.73 Hgb-14.4 Hct-44.2
MCV-94 MCH-30.4 MCHC-32.5 RDW-11.5 Plt ___
___ 07:55AM BLOOD ___ PTT-35.7 ___
___ 07:55AM BLOOD Glucose-92 UreaN-16 Creat-1.1 Na-139
K-4.1 Cl-100 HCO3-26 AnGap-17
___ 07:55AM BLOOD ALT-67* AST-28 LD(LDH)-221 AlkPhos-125
TotBili-0.6
___ 07:55AM BLOOD Calcium-9.8 Phos-4.7* Mg-1.8
___ 03:15PM BLOOD calTIBC-243* Ferritn-350 TRF-187*
___ 03:15PM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE
HBcAb-NEGATIVE
___ 07:55AM BLOOD HIV Ab-NEGATIVE
___ 08:20AM BLOOD RheuFac-14
___ 03:15PM BLOOD HCV Ab-NEGATIVE
STUDIES:
=================
___ Pleural biopsy: PATHOLOGIC DIAGNOSIS:
Left parietal pleura, posterior wall, biopsy:
- Chronic pleuritis with mild reactive changes of the lining
mesothelial cells.
- There is no evidence of malignancy or granulomatous
inflammation,
multiple levels examined.
___ Pleural Fluid Flow Cytometry:
Non-specific T cell dominant lymphoid profile; diagnostic
immunophenotypic features of involvement by a non-Hodgkin B-cell
lymphoma are not seen in specimen. Correlation with clinical
findings and morphology is recommended.
___ Pleural Fluid Microbiology:
GRAM STAIN (Final ___:
4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
This is a concentrated smear made by cytospin method,
please refer to
hematology for a quantitative white blood cell count..
FLUID CULTURE (Final ___: NO GROWTH.
ANAEROBIC CULTURE (Preliminary): NO GROWTH.
ACID FAST SMEAR (Final ___:
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
ACID FAST CULTURE (Preliminary):
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
POTASSIUM HYDROXIDE PREPARATION (Final ___:
NO FUNGAL ELEMENTS SEEN.
___ RUQ US:
1. 1.8 cm echogenic lesion in the left lobe of the liver which
is
indeterminate, possibly representing a hemangioma. If
clinically warranted, this could be further evaluated with an
MRI.
2. Otherwise, normal right upper quadrant ultrasound.
3. Bilateral pleural effusions.
___ CXR PA/L:
There has been interval removal of the left-sided chest tube.
There is a
small left pleural effusion. The left heart border is very
sharp suggesting there may be a small medial pneumothorax. This
volume loss at both bases. An underlying infectious infiltrate
can't be excluded.
Brief Hospital Course:
___ year old male with a history of recent pleural effusions s/p
thoracentesis on ___ who presents with recurrent chest pain
and pleural effusions.
# Pleuritis w/ pleural Effusions: Thoracentesis at last
admission showed exudative effusion ___ Light's criteria) with
lymphocytic predominance. This admission, he was taken to OR for
thoroscopy w/ pleural biopsies. Cultures/smears of repeat tap
were all negative. Pleural biopsies showed chronic inflammation.
Labs were significant for eosinophilia, elevated ALT and INR.
However, peripheral smear, hepatitis serologies, HIV, RPR, RF,
and flow cytometry of the pleural fluid were all normal. He will
follow up with pulmonary as an outpatient. He will complete 7
days levoflox 750mg daily (last day ___ and a prednisone taper
(20mg x 7 days, 10mg x 3 days, 5mg x 4 days).
# Elevated ALT and INR: RUQ shows 1.8 cm echogenic focus,
otherwise normal.
Hepatitis serologies were negative. Iron studies were consistent
w/ systemic inflammation.
# Chest pain: Due to pleuritis as above. Pleuritic, EKG
unchanged and normal, trop negative. Pain well controlled w/ po
oxycodone.
Transitional Issues:
-F/u w/ pulm for further workup of pleuritis.
-Recheck INR to confirm trend towards normal.
-Consider MRI for further workup of 1.8cm echogenic liver focus.
# Code: Full (discussed with patient)
# Emergency Contact: ___ (brother) ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Ibuprofen 600 mg PO Q8H:PRN pain
2. Acetaminophen 500 mg PO Q6H:PRN pain
3. Oxycodone-Acetaminophen (5mg-325mg) 1 TAB PO Q6H:PRN pain
Discharge Medications:
1. Acetaminophen 500 mg PO Q6H:PRN pain
2. Ibuprofen 600 mg PO Q8H:PRN pain
3. Oxycodone-Acetaminophen (5mg-325mg) 1 TAB PO Q6H:PRN pain
RX *oxycodone-acetaminophen 5 mg-325 mg 1 tablet(s) by mouth Up
to four times a day as needed for severe pain Disp #*30 Tablet
Refills:*0
4. PredniSONE 20 mg PO DAILY Duration: 7 Days
RX *prednisone 5 mg ___ tablet(s) by mouth Take 4 tablets daily
for five days, 2 tablets daily for the next 3 days, and 1 tablet
daily for the following 4 days. Disp #*30 Tablet Refills:*0
5. Polyethylene Glycol 17 g PO DAILY
RX *polyethylene glycol 3350 [Miralax] 17 gram 1 packet by mouth
daily as needed for constipation Disp #*10 Packet Refills:*0
6. Levofloxacin 750 mg PO DAILY Duration: 7 Days
RX *levofloxacin 750 mg 1 tablet(s) by mouth daily Disp #*4
Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Pleuritis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It has been a pleasure taking care of you. You were admitted to
the hospital for worsening chest pain, and were found to have
fluid around your lungs. You were taken to the operating room,
pleural biopsies were taken, and a chest tube was placed to
drain the fluid. After fluid stopped draining, the tube was
removed. Testing did not reveal any infection, but did find
evidence of chronic inflammation. You should complete a course
of oral prednisone and levofloxacin as below. You will follow up
with your primary care doctor and interventional pulmonology.
Followup Instructions:
___
|
19735078-DS-12
| 19,735,078 | 29,704,310 |
DS
| 12 |
2125-10-03 00:00:00
|
2125-10-05 22:36:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
shellfish derived
Attending: ___.
Chief Complaint:
Chest pain, cough, fever
Major Surgical or Invasive Procedure:
Pericardiocentesis w/ pericardial drain ___
History of Present Illness:
___ y/o M with recent recurrent pleural effusion s/p ___ x2 and
CT placement who presents for complaints of CP, cough and fever
to 102.2. States has been doing okay but past 2 weeks when he
came to the ER that he had fevers and since has become
progressively weaker with HA and anterior CP that extends across
his chest. At that time, he was described as having a likely
viral/flu like illness and was told would improve but had not
improved. Has some SOB with his CP and generalized orthopnea.
Has lost his appetite over this time with a weight loss from 297
to 258 lbs.
Of note, for his unknown cause of exudative pleural effusion, he
had a significant ___ with no e/o clear infection including
TB, negative HIV, neg ___, neg cytology and neg pleural biopsy.
The thought was that he had viral pleurisy leading to
presentation. Also had an eosinophilia of unclear etiology.
In the ED, initial vitals were 98.6 108 126/72 18 98%. CXR
showed significant cardiomegaly concerning for possible effusion
with additional pleural effusion. As a result, a TTE was
performed that revealed moderate to large pleural effusion,
though w/o evidence of tamponande. He was started on vanc and
ceftaz for empiric HCAP coverage.
On the floor, pt still feels fatigued with mild posterior HA and
___ CP that feels across his chest. Has mild orthopnea and SOB
with mild worsening with activities but improved since
presentation. No other focal complaints. Feels mildly febrile.
No dysuria or diarrhea. Has had mild nausea but none present.
Past Medical History:
1. CARDIAC RISK FACTORS: None
2. CARDIAC HISTORY:
- CABG: None
- PERCUTANEOUS CORONARY INTERVENTIONS: None
- PACING/ICD: None
3. OTHER PAST MEDICAL HISTORY:
- Recent pleural effusion with admission in ___ and ___
Social History:
___
Family History:
Maternal ___ with a big heart. Mother with HTN.
No family history of cancers or clotting disorders.
No family history of early MI, arrhythmia, or sudden cardiac
death.
Physical Exam:
ADMISSION EXAM:
===============
Vitals: 100 145/71 [pulsus 10 mm Hg] 114 22 92/RA
Weight: 117.3 kg
GENERAL: Obese male, lying in bed in NAD, awake and alert
HEENT: AT/NC, EOMI, PERRLA, anicteric sclera, MMM
NECK: Supple, no LAD, no JVD
CARDIAC: Distant heart sounds but with RRR, nl S1 S2, no MRG
LUNG: Aeration heard throughout upper airways with diminished
breath sounds at the bilateral bases with R>L w/ minimal
bibasilar crackles but without significant rales or wheezes, no
accessory muscle use
ABDOMEN: +BS, soft, obese though not distended, mild tenderness
to deep palpation of the RUQ and LUQ, but no rebound or
guarding, no significant HSM
EXT: Warm and ___, no cyanosis, clubbing or edema
PULSES: 2+ DP pulses bilaterally
NEURO: CN ___ grossly intact, strength ___ throughout,
sensation grossly normal, gait intact
SKIN: Feels febrile, no excoriations or lesions, no rashes
DISCHARGE PHYSICAL EXAM:
========================
Vitals: 99 ___ (112/66) [pulsus 6] ___ (75) 18
97/RA
Weight: 115.6 kg (___) 116 kg (___) 117.3 kg (admission)
I&Os: 1640/1100 (24h)
GENERAL: Obese male, lying in bed in NAD, awake and alert
HEENT: AT/NC, EOMI, PERRLA, anicteric sclera, MMM
NECK: Supple, no LAD, mild JVD
CARDIAC: Distant heart sounds but nl S1 S2, no appreciable
m/r/g, pericardial tube site appears ___ with minimal
tenderness on palpation and no erythema
LUNG: Aeration heard throughout upper airways with diminished
breath sounds at the bilateral bases with R>L w/ minimal
bibasilar crackles but without significant rales or wheezes, no
accessory muscle use
ABDOMEN: +BS, soft, obese, NT/ND, no significant HSM
EXT: Warm and ___, no cyanosis, clubbing or edema
PULSES: 2+ DP pulses bilaterally
NEURO: CN ___ grossly intact, moving extremities freely,
sensation grossly normal, gait intact
Pertinent Results:
LABS:
=====
___ 07:55AM BLOOD ___
___ Plt ___
___ 07:35AM BLOOD ___
___ Plt ___
___ 05:08AM BLOOD ___
___ Plt ___
___ 06:30AM BLOOD ___
___ Plt ___
___ 06:30AM BLOOD ___
___ Plt ___
___ 09:00AM BLOOD ___
___ Plt ___
___ 07:55AM BLOOD ___
___
___ 07:35AM BLOOD ___
___
___ 06:30AM BLOOD ___
___
___ 06:30AM BLOOD ___
___
___ 09:00AM BLOOD ___
___
___ 07:55AM BLOOD ___ ___
___ 07:35AM BLOOD ___ ___
___ 09:00AM BLOOD ___
___ 06:30AM BLOOD ACA ___ ACA ___
___ 03:24PM BLOOD ___
___ 07:55AM BLOOD ___
___
___ 07:35AM BLOOD ___
___
___ 05:08AM BLOOD ___
___
___ 06:30AM BLOOD ___
___
___ 06:30AM BLOOD ___
___
___ 09:00AM BLOOD ___
___
___ 07:55AM BLOOD ___ LD(LDH)-209 ___
___
___ 06:30AM BLOOD ___
___ 06:30AM BLOOD ___ LD(LDH)-296* ___
___
___ 09:00AM BLOOD ___ LD(___)-253*
___
___ 08:55PM BLOOD ___ cTropnT-<0.01
___ 09:00AM BLOOD cTropnT-<0.01
___ 05:08AM BLOOD ___
___ 09:00AM BLOOD ___
___ 06:30AM BLOOD ___
___ 04:27PM BLOOD ___ B
___ 03:24PM BLOOD ___
___ 04:27PM BLOOD ___
___ 09:00AM BLOOD ___
___ 03:24PM BLOOD ___
See OMR for ___ Tests: Pending HTLV1
IMAGING:
========
ECHO (___):
Conclusions
Overall left ventricular systolic function is low normal (LVEF
___. Right ventricular chamber size is normal. with
borderline normal free wall function. There is abnormal septal
motion/position. The mitral valve appears structurally normal
with trivial mitral regurgitation. The pulmonary artery systolic
pressure could not be determined. There is a very small
pericardial effusion. The effusion appears circumferential.
IMPRESSION: very small circumferential pericardial effusion.
Abnormal septal motion suggestive of ___
physiology. ___ biventricular systolic function. There is
increased variation in mitral/tricuspid inflows, due to
___ physiology rather than tamponade.
Compared with the prior study (images reviewed) of ___,
the findings are similar.
ECHO (___):
Left ventricular wall thicknesses and cavity size are normal.
Regional left ventricular wall motion is normal. Overall left
ventricular systolic function is low normal (LVEF ___. The
estimated cardiac index is normal (>=2.5L/min/m2). The right
ventricular cavity is mildly dilated with borderline normal free
wall function. The aortic valve leaflets (3) appear structurally
normal with good leaflet excursion and no aortic stenosis or
aortic regurgitation. The mitral valve appears structurally
normal with trivial mitral regurgitation. There is no mitral
valve prolapse. No mitral regurgitation is seen. The pulmonary
artery systolic pressure could not be determined. There is a
moderate sized echolucent circumferential pericardial effusion.
There are no echocardiographic signs of tamponade.
IMPRESSION: Moderate sized circumferential pericardial effusion.
Normal biventricular cavity sizes with borderline global left
and right ventricular systolic function.
Compared with the report of the prior study (images unavailable
for review) of ___, biventricular function appears less
vigorous and the pericardial effusion is larger.
CXR (___):
IMPRESSION: Significant increase in cardiac size, raising
strong concern for pericardial effusion. Please correlate with
echocardiogram. Also noted is pulmonary edema with small
bilateral pleural effusions.
CXR (___):
Enlargement of the cardiac silhouette has decreased. Large
right pleural
effusion is probably unchanged, allowing the difference in
positioning of the patient. There is mild vascular congestion.
Bibasilar opacities are likely atelectases. There is no
pneumothorax. Small left effusion is unchanged.
ABD US (___):
IMPRESSION:
1. Unchanged 1.7 cm hyperechoic lesion within the left lobe of
the liver that likely represents a hemangioma.
2. Bilateral pleural effusions.
CT Abd (___):
IMPRESSION:
1. No evidence of acute ___ process.
2. Bilateral pleural effusions and pericardial effusion. For
further details, please see the separate chest CT report
dictated by the cardiothoracic imaging section.
CT Chest (___):
IMPRESSION:
1. Significant interval increase in pericardial effusion.
2. Interval increase in bilateral pleural effusions, right much
greater than left, with associated compressive atelectasis.
Brief Hospital Course:
___ y/o M with recent recurrent pleural effusion s/p ___ x2 and
CT placement who presents for complaints of CP, cough and fever
to 102.2 with new pericardial effusion.
ACTIVE ISSUES:
==============
___ HOSPITAL COURSE:
___ y/o M with recent recurrent pleural effusion s/p ___ x2 and
CT placement who presents for complaints of CP, cough and fever
to 102.2 with new pericardial effusion. It was felt that he
needed drainage of his pericardial effusion and he was to the
CCU post procedure. In the cardiac cath lab 600 cc
serosanguinous fluid removed and sent to pathology for multiple
studies. Cardiac echo showed very minimal residual effusion.
He had no acute concerns on arrival to the CCU and did well
overnight. His pericardial drain had minimal output overnight
and was removed the following morning. He was called back out to
the floor.
# Pericardial Effusion
he pt had a echo that revealed no tamponade physiology with
pulsus stable at about 10, but given symptoms and concern for
developing tamponade, pt had pericardiocentesis on ___ with
600cc exudative fluid drained with pericardial tube removed the
following day. Pt was also started on ibuprofen and colchicine
on day of admission with significant improvement in his CP and
SOB. Cause of pericardial effusion likely related to unknown
inflammatory process of unclear etiology. While here, pt also
was found to have an elevated WBC that improved with mild
eosinophilia. Inflammatory labs were elevated with increased ESR
and CRP. Given his history of pleural effusions from unclear
etiology and now exudative pericardial effusion with increased
inflammatory markers, rheumatology was consulted with studies
sent, though prelim markers have all been negative. ID was also
consented given fevers and mild eosinophilia for possible
atypical infection with no clear source though final studies
still pending including universal PCR and PAS stain for
Whipple's of pleural biopsy. Eosinophilia was thought to be due
to instrumentation. However, stronglyoides studies still
pending. ___ was also consulted with intial
evaluation of the peripheral smear concerning for atypical
lymphocytes including possible "flower cells" prompting
evaluation for possible HTLV1 (pending). Pt at time of discharge
appeared significantly improved in sx without CP, DOE, fevers or
SOB with continued f/u on studies recommended on an outpatient
basis. Pt instructed on warning signs such as SOB and CP to
prompt ___.
# Recurrent pleural effusions
Previously tapped twice with pleural biopsy that showed
exudative, lymphocytic process with no e/o malignancy or
infection. Thought originally to be from viral pleurisy but
appears less likely given repeated recurrence. CT chest with
contrast showed decreased left sided effusion but worsening
right sided effusion. Satting well at discharge without
significant DOE or SOB. However, given reaccumulation of fluid,
recommended f/u with pulmonology as an outpatient with
consideration of possible drainage if becomes symptomatic. Still
search for underlying cause as described above since would
otherwise expect continued recurrence.
# Elevated LFTs
Appears to be hepatocellular in process. Has synthetic
dysfunction. Prior RUQ w/ lesion thought to be a hemangioma.
Prior hepatitis panel unremarkable. No recent medication
exposure to lead to elevations with reports of tylenol but
taking appropriate amounts. ___ be congestive hepatopathy vs
other infiltrative or inflam process related to above. RUQ
stable without clear changes. CT abdomen unrevealing. Trend LFTs
as an outpatient.
TRANSITIONAL ISSUES:
====================
- Trend LFTs and coags (synthetic function) at next visit w/ PCP
- ___ repeat CXR at next PCP visit in interim to monitor
for progression of pleural effusion before following up with
pulm
- F/u with final studies pending specifically HTLV I, Universal
PCR and Strongyloides. ___ fellow ___
___ will continue to follow, pending studies consider
potential ___ with ___
- Pathology to perform PAS smear looking for ___'s disease,
consider potential ID ___ if studies return suggestive of
infection
- Ensure f/u with cardiology and pulmonology as an outpatient
for continued management of pleural and pericardial effusion
- Continue ibuprofen and colchicine (typically 3 months) unless
directed by cardiologist ___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO Q6H:PRN Pain
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN Pain
Do NOT take more than 3 grams daily
2. Colchicine 0.6 mg PO BID
RX *colchicine [Colcrys] 0.6 mg 1 tablet(s) by mouth Twice a day
Disp #*60 Tablet Refills:*2
3. Ibuprofen 800 mg PO Q8H Pain
Please take with foods to protect your stomach.
RX *ibuprofen 800 mg 1 tablet(s) by mouth Every 8 hours Disp
#*60 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Pericardial Effusion (Fluid around the heart)
Pleural Effusion (Fluid around the lung)
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were admitted to the hospital for chest pain and fevers. You
were found to have new fluid around your heart leading to your
symptoms that was drained with improvement in both your chest
pain and breathing. You were also given ibuproen and colchicine
to decrease the inflammation around your heart. You will need to
take these medication until you see your cardiologist Dr.
___ who ___ determine how long you should continue
the medications.
You also had some right sided fluid in your lung that has been
stable but will need to be continue to be followed as an
outpatient with pulmonology.
The cause of the fluid around your lungs and heart remains
unclear. There were a number of specialists who saw you in the
hospital including infectious disease, rheumatology, and
___. There are study results still pending that
may help explain the cause of the fluid build up.
Please continue to ___ with your primary care physician
after leaving the hospital.
Take care.
- Your ___ Team
Followup Instructions:
___
|
19735084-DS-23
| 19,735,084 | 25,253,840 |
DS
| 23 |
2170-05-09 00:00:00
|
2170-05-09 11:18:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
lisinopril / Hydrochlorothiazide / Diovan / Latex /
Maalox:Benadryl:2%Lidocaine Mixture
Attending: ___.
Chief Complaint:
seizure
Major Surgical or Invasive Procedure:
none
History of Present Illness:
This is a ___ year old female with a history of metastatic lung
cancer (mets to adrenals, and brain) who presents with altered
mental status, likely seizure. Prior to this episode on day of
admission, Ms ___ denies having seizures, and states that she
had recently discontinued keppra and dexamethasone several days
ago. The patient's family states that they were on the phone
with her on the morning of admission when she suddenly became
unresponsive and they heard a funny noise thru the phone. They
went to check on her later in the afternoon they noticed her
body to be rigid with her arms completely extend it and with her
eyes rolled back. She was not responding to any commands. When
the movement stopped they attempted to talk to her but she was
confused and did not remember today's events. She has had no
fevers, chills, chest pain, shortness of breath, cough, nausea,
vomiting, trauma, or history of seizures.
In the ED, her mental status had improved. A head CT was
obtained along with chest x-ray which revealed possible
pneumonia; she received cefepime and vancomycin in the ED. She
received a keppra load of 2 gm. A UA was noted to be mildly
positive. She was admitted to the floor for further management.
Past Medical History:
___ on surveillance
Asthma
HTN
Anxiety
- ___: presented to ED with a panic attack. She had a chest
XR which reported a right hilar lesion and that same day she
underwent a CTA of the chest which revealed a large ill-defined
right hilar mass 4.8 x 3.2 cm obstructing the right upper lobe
bronchus with post-obstructive changes in the right upper lobe.
The right hilar mass also narrowed the right main bronchus and
bronchus intermedius and encompasses the azygous vein and abuts
the posterior margin of the SVC. It is contiguous with a 3.7 x
2.7 cm necrotic subcarinal soft tissue mass and also intimately
associated with the esophagus. Scattered small pulmonary
nodules were noted including an enhancing right upper lobe
nodule 11mm which may invade the mediastinum.
- ___: EBUS and bronch which showed an endobronchial lesion
in the right maintem bronchus at approximately 0.5-1cm from main
carina extending into the bronchus intermedius. The bronchus
intermedius was narrowed but patent. FNA of the endobronchial
lesion (cell block) was consistent poorly differentiated
non-small cell lung cancer with immunoreactivity for TTF-1 and
CK5/6 (focal), and negative for p63, ER, PR, and GCDFP. Cytology
from FNA of the right hilar mass was also consistent with
non-small cell lung cancer. 7 and 4R station lymph nodes were
biopsied and no malignant cells were reported in cytology of 4R
and 7.
- ___: PET CT with FDG-avid disease including the right
hilar mass, the right upper lobe 11mm nodule, the subcarinal
mass, an oval structure at the right cardiophrenic angle and a a
18 mm left adrenal lesion. An MR of the head from the same
revealed a new enhancing lesion compared to ___ in the left
high frontal lobe.
- ___: Cyberknife X1 to single brain metastasis left
frontal lobe.
- ___: She received palliative chemoradiation,
Carboplatin and Taxol 1 cycle.
- ___ Start of radiation therapy to the right hilar lung
mass with weekly Taxol starting ___. Finished ___.
- ___: Start of ___ cycle 3 and 4. Cycle 4 delayed
due to hypertension and ended ___.
- ___: MRI head with slight progression of frontal lobe
lesion.
- ___: progression of disease on PET/CT with new right
pleural effusion.
- ___: C1D1 Pemetrexed. Cycle 5 delayed 1 week due to
scheduling issues.
- ___: C10D1 pemetrexed
Social History:
___
Family History:
Mother has a history of breast cancer (mid ___ and recent colon
cancer.
Maternal aunt - breast cancer (in her ___
No known history of lung cancer.
Physical Exam:
Physical Examination:
VS: 98.0 138/96 88 18 98%RA
GEN: awake, alert, oriented to name, place and situation. no
acute signs of distress.
HEENT: NCAT, Pupils equal and reactive, sclerae non-icteric,
MMM.
Neck: Supple
CV: S1S2, reg rate and rhythm, no murmurs, rubs or gallops.
RESP: decreased throughout but good air movement bilaterally, no
rhonchi or wheezing.
ABD: Soft, non-tender, non-distended, no hepatosplenomegaly
EXTR: No lower leg edema
DERM: No active rash
Neuro: muscle strength grossly full and symmetric in all major
muscle groups
PSYCH: Appropriate and calm.
Pertinent Results:
___ 06:05AM BLOOD WBC-6.1 RBC-3.01* Hgb-10.0* Hct-30.5*
MCV-101* MCH-33.2* MCHC-32.8 RDW-15.7* Plt ___
___ 06:05AM BLOOD ___ PTT-34.8 ___
___ 06:05AM BLOOD Glucose-174* UreaN-6 Creat-0.9 Na-137
K-4.0 Cl-106 HCO3-20* AnGap-15
___ 06:05AM BLOOD Calcium-9.3 Phos-3.7 Mg-1.9
___ 04:53PM BLOOD Lactate-2.0
___ 02:08PM BLOOD Lactate-5.7*
CT head ___
IMPRESSION:
1. Rounded hypodense lesion at the left superior frontal lobe
with internal
hyperdensity possibly representing calcification is concerning
for
intracranial metastasis. Further evaluation with MRI is
recommended.
2. Focal encephalomalacia of the right frontal lobe may be
related to prior
infarct.
3. No acute intracranial hemorrhage, mass effect, or shift of
normally
midline structures.
Brief Hospital Course:
___ year old female with stage IV NSCLC with mets to brain and
adrenal glands presenting with new onset of seizure. She had
been on keppra and dexamethasone prophylaxis for brain met
treated with SRS and after discussion with neuro-oncology the
keppra was stopped and dexamethasone tapered off in the weeks
prior to this event. After admission she received IV keppra and
dexamethasone with no repeat seizure activity. She had an EEG,
the results of which are pending at this time. She was seen by
neuro-oncology with plan to continue on keppra at previous dose
500mg BID and to quickly taper off of dexamethasone again (2mg
daily for 5 days then stop).
Upon admission the patient was thought to potentially have a UTI
based on UA findings if many bacteria. She denies any associated
symptoms. She was treated with Bactrim DS BID. She is ___ dose
short of completing a ___ut this medication will be
stopped at discharge.
She has an appointment in 2 days to follow up with her
oncologists regarding further treatment of her lung cancer. a
PET/CT scan done just prior to admission shows progression of
disease. This will be discussed with the patient at her upcoming
appointment.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Acetaminophen w/Codeine 1 TAB PO Q8H:PRN pain
2. Albuterol Inhaler ___ PUFF IH Q4H:PRN SOB, wheezing
3. Amlodipine 5 mg PO DAILY
4. Atenolol 100 mg PO DAILY
5. FoLIC Acid 1 mg PO DAILY
6. Loratadine 10 mg Oral daily
7. Lorazepam 1 mg PO BID
8. Lorazepam 3 mg PO HS
Discharge Medications:
1. Amlodipine 5 mg PO DAILY
2. Atenolol 100 mg PO DAILY
3. Lorazepam 1 mg PO Q8H:PRN anxiety
4. Lorazepam 3 mg PO HS:PRN insomnia
5. Acetaminophen w/Codeine 1 TAB PO Q8H:PRN pain
6. Albuterol Inhaler ___ PUFF IH Q4H:PRN SOB, wheezing
7. FoLIC Acid 1 mg PO DAILY
8. Loratadine 10 mg Oral daily
9. LeVETiracetam 500 mg PO BID
RX *levetiracetam 500 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*0
10. Dexamethasone 2 mg PO DAILY Duration: 5 Days
Discharge Disposition:
Home
Discharge Diagnosis:
seizure
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital after suffering what we
suspect was a seizure based on descriptions provided by your
family members. Your history of a lung cancer metastasis in the
brain puts you at risk for seizures and you were previously on a
medication called Keppra to help reduce this risk. You had
stopped the Keppra a few weeks ago at the direction of your
doctors, but should now restart it to prevent further seizures.
You will also restart dexamethasone 2mg daily but will only take
this for 5 days and then stop. You were treated with Bactrim
while here for a possible urinary tract infection.
Followup Instructions:
___
|
19735084-DS-24
| 19,735,084 | 23,936,893 |
DS
| 24 |
2170-08-28 00:00:00
|
2170-08-29 21:25:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
lisinopril / Hydrochlorothiazide / Diovan / Latex /
Maalox:Benadryl:2%Lidocaine Mixture
Attending: ___.
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
___ - right-sided chest tube placement
___ - right-sided chest tube removal
History of Present Illness:
Ms. ___ is a ___ year old woman with metastatic NSCLC with
brain metastases s/p cyberknife to brain and palliative
chemoradiation (carboplatin, taxol) currently on pemetrexed
(___ ___ who presented to the ER with increased
shortness of breath. She has been on single agent pemetrexed and
prior PET scan in ___ showed slight progression of disease.
Her symptoms began 2 days prior to admission when she awoke with
left-sided rib pain under her breast and radiating to her back.
The pain was initially minimal, but constant. The pain has
progressed in severity. It is not always pleuritic, but
exacerbated most by movement and palpation. She then developed
worsening dyspnea. At rest she did not have significant dyspnea,
but was most pronounced with ambulation. She also has a cough
that is non-prodcutive. No recent fevers or chills. Mild
rhinorrhea. She has several family memebers that live with her
on occasion that are all sick with colds. None have flu-like
illness that she is aware of. No recent immobility or long
travel.
In the emergency department, initial vitals: 98.1 98 119/89 18
97%. Imaging with CXR and Chest CT showed a very large right
pleural effusion. IP was contacted and recommended that if the
effusion needed urgent drainage, the patient should go to the
ICU. Since she was hemodynamically stable and breathing on room
air, she was admitted to the floor for management and drainage
of the effusion. She also had an abdominal CT for abdomainl pain
and constipation. This did not show any acute abdominal process.
Initial labs were notable for WBC 13.1 (was 13.8 on ___ and
platelets 681. She was given vancomycin and zosyn. She received
5mg IV morphine for the left-sided rib pain. She was admitted to
OMED for management of the pleural effusion.
Past Medical History:
PAST ONCOLOGIC HISTORY:
- ___: presented to ED with a panic attack. She had
a chest XR which reported a right hilar lesion and that same day
she underwent a CTA of the chest which revealed a large
ill-defined right hilar mass 4.8 x 3.2 cm obstructing the right
upper lobe bronchus with post-obstructive changes in the right
upper lobe. The right hilar mass also narrowed the right main
bronchus and bronchus intermedius and encompasses the azygous
vein and abuts the posterior margin of the SVC. It is contiguous
with a 3.7 x 2.7 cm necrotic subcarinal soft tissue mass and
also
intimately associated with the esophagus. Scattered small
pulmonary nodules were noted including an enhancing right upper
lobe nodule 11mm which may invade the mediastinum.
- ___: EBUS and bronchoscopy which showed an endobronchial
lesion
in the right maintem bronchus at approximately 0.5-1cm from main
carina extending into the bronchus intermedius. The bronchus
intermedius was narrowed but patent. FNA of the endobronchial
lesion (cell block) was consistent poorly differentiated
non-small cell lung cancer with immunoreactivity for TTF-1 and
CK5/6 (focal), and negative for p63, ER, PR, and GCDFP.
Cytology from FNA of the right hilar mass was also consistent
with non-small cell lung cancer. 7 and 4R station lymph nodes
were biopsied and no malignant cells werereported in cytology of
4R and 7.
- ___: PET CT with FDG-avid disease including the right
hilar
mass, the right upper lobe 11mm nodule, the subcarinal mass, an
oval structure at the right cardiophrenic angle and a a 18 mm
left adrenal lesion. An MR of the head from the same revealed a
new enhancing lesion compared to ___ in the left high frontal
lobe.
- ___: Cyberknife X1 to single brain metastasis left
frontal lobe.
- ___: She received palliative chemoradiation,
Carboplatin and Taxol 1 cycle.
- ___ Start of radiation therapy to the right hilar lung
mass with weekly Taxol starting ___. Finished ___.
- ___: Start of ___ cycle 3 and 4. Cycle 4 delayed
due to hypertension and ended ___.
- ___: MRI head with slight progression of frontal lobe
lesion.
- ___: progression of disease on PET/CT with new right
pleural effusion.
- ___: C1D1 Pemetrexed. Cycle 5 delayed 1 week due to
scheduling issues. ___ admitted with new right sided
weakness and imaging findings concerning for radiation induced
necrosis of left frontal lesion versus progression of disease.
- ___ admitted for seizure after stopping dexamethasone
and
keppra. Head CT with resoling findings. Chest imaging concerning
for mild disease progression. I discussed with her the option of
continuing on current therapy versus changing and she elected to
continue on pemetrexed. She had a treatment delay due to
transportation issues and received C11 pemetrexed ___.
OTHER PAST MEDICAL HISTORY:
- Tobacco abuse
- Asthma
- Hypertension
- Anxiety
- h/o seizure secondary to radiation necrosis (___)
- h/o vulvar intraepithelial neoplasia III, s/p laser ablation,
on surveillance
- h/o anal intraepithelial neoplasia III, on surveillance
Social History:
___
Family History:
Mother has a history of breast cancer (mid ___ and recent colon
cancer.
Maternal aunt - breast cancer (in her ___
No known history of lung cancer.
Physical Exam:
On Admission:
VS: 99.1 108/68 112 16 94% on RA
GENERAL: alert and oriented, no acute distress, sitting up
comfortably in bed
HEENT: No scleral icterus, PERRL, EOMI, MMM, oropharynx is clear
wtihout lesions or erythema, poor dentition
NECK: supple, R EJ with intact dressing, no LAD
CHEST: tenderness to palpation under left breast and radiating
to mid-axillary line, no masses or lesions seen underlying this
area
CARDIAC: RRR. Normal S1, S2. No m/r/g.
LUNGS: No accessory muscle use. Distant breath sounds entire
right lung fields, left lung with dry crackles at base, no
wheeze or rhonchi. Dull to percussion of entire right lung
field. No egophony.
ABDOMEN: Soft, mild tenderness periumbillical region but no
rebound or guarding, nondistended, normoactive bowel sounds
EXTREMITIES: Warm, 2+ DP and radial pulses bialterally, no
clubbing, cyanosis, or edema
NEURO: A&Ox3. Appropriate affect. CN ___ tested and intact.
Preserved sensation throughout. ___ strength throughout. Gait
deferred.
On Discharge:
VS: 98.9 115/82 95 18 99% on RA
GENERAL: alert and oriented, no acute distress, lying
comfortably in bed
HEENT: No scleral icterus, PERRL, EOMI, MMM, oropharynx is clear
without lesions or erythema
NECK: supple, right EJ with intact dressing, no LAD
CARDIAC: RRR. Normal S1, S2. No m/r/g.
LUNGS: No accessory muscle use. Right lung with crackles and
wheezes, absent breath sounds at bases, left lung with dry
crackles at base. Dull to percussion of entire right lung field.
No egophony.
ABDOMEN: Soft, NTTP, no rebound or guarding, nondistended,
normoactive bowel sounds
EXTREMITIES: Warm, 2+ DP and radial pulses bialterally, no
clubbing, cyanosis, or edema
NEURO: A&Ox3. Appropriate affect. Face symmetric. Moves all 4
extremities. Gait deferred.
Pertinent Results:
On Admission:
___ 09:25PM BLOOD WBC-13.1* RBC-2.86* Hgb-9.1* Hct-30.6*
MCV-107* MCH-31.8 MCHC-29.8* RDW-18.7* Plt ___
___ 09:25PM BLOOD Neuts-73.3* Lymphs-16.7* Monos-8.6
Eos-1.1 Baso-0.4
___ 09:10AM BLOOD ___ PTT-38.5* ___
___ 09:25PM BLOOD Glucose-94 UreaN-6 Creat-0.8 Na-135 K-4.1
Cl-101 HCO3-21* AnGap-17
___ 09:25PM BLOOD CK-MB-1 cTropnT-<0.01
___ 09:25PM BLOOD Calcium-9.2 Phos-4.0 Mg-1.8
___ 09:39PM BLOOD Lactate-1.6
Imaging/Studies:
___ MRI Brain
IMPRESSION: Continued interval decrease in the size of a
peripherally
enhancing left frontal lobe lesion. No acute intracranial
disease or new
lesion, though a large portion of the right cerebrum is not able
to be
evaluated.
Pleural Fluid Studies:
___ 01:18PM PLEURAL Hct,Fl-5*
___ 01:18PM PLEURAL WBC-1333* Polys-59* Lymphs-23*
Monos-16* Eos-2*
___ 01:18PM PLEURAL TotProt-5.6 Glucose-1 LD(LDH)-3043
Amylase-43
Microbiology:
___ Blood culture: no growth to date
___ Urine culture: <10,000 organisms/ml.
___ Pleural fluid:
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final ___: NO GROWTH.
ANAEROBIC CULTURE (Preliminary): NO GROWTH.
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
Cytology:
___ Pleural fluid:
POSITIVE FOR MALIGNANT CELLS, consistent with adenocarcinoma.
On Discharge:
___ 06:40AM BLOOD WBC-8.8 RBC-2.76* Hgb-8.9* Hct-29.9*
MCV-108* MCH-32.1* MCHC-29.7* RDW-18.5* Plt ___
___ 06:40AM BLOOD Glucose-89 UreaN-7 Creat-0.9 Na-136 K-3.5
Cl-105 HCO3-19* AnGap-16
___ 06:40AM BLOOD ALT-12 AST-17 AlkPhos-159* Amylase-37
TotBili-0.3
___ 06:40AM BLOOD Calcium-9.1 Phos-3.8 Mg-1.8
Brief Hospital Course:
Ms. ___ is a ___ with metastatic NSCLC with brain metastases
s/p cyberknife and palliative chemoradiation currently on
premetrexed who presents with dyspnea, found to have massive
right pleural effusion. She had a chest tube placed which
drained bloody fluid (pleural studies c/w exudate, likely
malignant), which was removed on ___. She was to undergo
thoracoscopy with likely talc pleurodesis and pleurex placement
on ___, but the pt left AMA on ___ morning despite
extensive discussion regarding the risks of her leaving the
hospital prior to having the procedures done. The patient
verbalized and expressed understanding of these risks, and opted
to leave AMA. Her vitals and O2 sat were stable at time of her
leaving, and she was independently ambulatory.
ACTIVE ISSUES
# Right pleural effusion
Has had a known effusion for several months with interval
enlargement. This was the likely cause of her presenting
dyspnea. She remained stable on room air and was not tachypneic
throughout admission. IP was consulted and on ___ a chest tube
was placed; pleural studies at time of AMA were not convincing
for infection and were most c/w exudative/malignant effusion.
She was to undergo thoracoscopy with likely talc pleurodesis and
pleurex placement on ___, but the pt left AMA on ___
morning. ___ was contacted to see whether the thoracoscopy could
be scheduled as an outpatient.
# Leukocytosis: resolved.
Infectious versus leukemoid reaction in setting of
cancer/inflammation. Received vanc/zosyn in the ED to cover
broadly. No clear evidence of pneumonia on imaging and
antibiotics were not continued upon admission. At time of
discharge, her WBC was 8.6.
# Left-sided chest/rib pain: improved.
She has longstanding intermittent bilateral axillary pain. On
admission, her pain was primarily left-sided under her breasts
and axilla. It was tender to palpation suggestive of
musculoskeletal etiology. Could be referred from the effusion,
less likely cardiac given reproducibility. She was initially
tachycardic, but there was no evidence of PE on Chest CT,
although this was not dedicated CTA. Troponin was negative and
no ECG changes. Throughout admission, the left-sided pain
improved.
CHRONIC ISSUES
# Non-small cell lung cancer
Patient was due for MRI brain given history of brain metastases
s/p cyberknife. She had missed a prior outpatient appointment
and was scheduled for the day of admission. MRI obtained as
inpatient showed continued decrease in size of brain metastasis.
We continued Keppra for seizure prophylaxis. Follow-up with Dr.
___ Dr. ___ was obtained prior to the patient's
leaving AMA and the information was given to her as she was on
her way off of the ward.
# Asthma
No evidence of acute exacerbation. Continued home albuterol PRN
# Hypertension
Controlled. Continued home amlodipine, atenolol
# Tobacco abuse
Patient declined nicotine patch.
# Anxiety
Continued home buproprion, lorazepam
# Reflux
Continued home omeprazole
TRANSITIONAL ISSUES
- Patient was to undergo thoracoscopy with likely talc
pleurodesis and pleurex placement on ___, but the pt left
AMA on ___. ___ was contacted to see whether the
thoracoscopy could be scheduled as an outpatient which was
unable to be arranged prior to her leaving AMA.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen w/Codeine 1 TAB PO Q4H:PRN pain
2. Albuterol Inhaler 2 PUFF IH Q4H:PRN shortness of breath
3. Amlodipine 5 mg PO DAILY
4. Atenolol 100 mg PO DAILY
5. FoLIC Acid 1 mg PO DAILY
6. LeVETiracetam 500 mg PO BID
7. Lorazepam 1 mg PO BID
8. Omeprazole 40 mg PO DAILY
9. Polyethylene Glycol 17 g PO DAILY:PRN constipation
10. Guaifenesin ___ mL PO Q6H:PRN cough
11. Loratadine 10 mg PO DAILY
12. Lorazepam 3 mg PO HS
Discharge Medications:
1. Albuterol Inhaler 2 PUFF IH Q4H:PRN shortness of breath
2. Amlodipine 5 mg PO DAILY
3. Atenolol 100 mg PO DAILY
4. FoLIC Acid 1 mg PO DAILY
5. Guaifenesin ___ mL PO Q6H:PRN cough
6. LeVETiracetam 500 mg PO BID
7. Loratadine 10 mg PO DAILY
8. Lorazepam 1 mg PO BID
9. Lorazepam 3 mg PO HS
10. Omeprazole 40 mg PO DAILY
11. Polyethylene Glycol 17 g PO DAILY:PRN constipation
12. Acetaminophen w/Codeine 1 TAB PO Q4H:PRN pain
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: right pleural effusion
Secondary: metastatic 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 Ms. ___,
It was a pleasure taking care of you during your time at ___.
You were admitted with shorntess of breath. You were found to
have a lot of fluid around your right lung, something called a
"plearal effusion". You had a tube placed to drain the fluid on
___ which was removed on ___. You also had an MRI of your head
because you were due for this, which showed decreased size of
the tumor in your brain, which is good news. You were supposed
to stay for a procedure (thoracoscopy) to drain the remaining
fluid around your lung, which was to happen on ___.
You decided to leave the hospital against medical advice. We
counseled you on the risks of leaving including worsening
breathing, low oxygen levels, infection, and even death. Despite
these risks, you decided to leave the hospital.
Followup Instructions:
___
|
19735459-DS-11
| 19,735,459 | 26,590,361 |
DS
| 11 |
2131-11-17 00:00:00
|
2131-11-18 21:19:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
codeine / Ultram
Attending: ___.
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___, an ___ yo male with CHF, recent GIB and NSTEMI,
SqCC of the lung, OSA, severe AS and long smoking history who
present with acute on chronic DOE. He reports he had increasing
dyspnea on exertion over the last week or so, with notable
worsening after going to the bathroom at 3AM this morning. He
reports no cough, no fevers (previous notes mention mild incr
temp of 99.5 On Thues and ___, no leg swelling, no change in
his sleeping position (on his side), and no chest pain.
In the ED, initial vitals were: 98.5 75 143/57 20 95% 2L NC
He received his home meds in the ED, including his Torsemide
15mg.
CXR revealed the known LUL mass with markers consistent with his
known cancer and new basilar air space opacities with a new
small effusion.
On the floor, he states that subjectively his symptoms have
improved. Ambulatory sats on 2L were 92% at rest, 86% when
walking.
Review of systems:
(+) Per HPI
(-) Denies fever, night sweats, recent weight loss or gain.
Denies cough. 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 melena or BRBPR.
Past Medical History:
1. AS: Workup for valve replacement on hold pending cancer
treatment.
___ echo in ___ or ___ 0.9 cm2 with grad 71/44. Nl LVEF.
The 2. Lung cancer-diag by ___ ___:
Squamous cell lung cancer of the LUL T2aN0M0 - PET scan at ___
confirmed FDG avid nodes that could be consistent with disease
however, at least 2 biopsies was negative with positive lymph
node sampling. He had implants earlier this week in preparation
for Cyber knife radiation.
3. GI bleed: had black, tarry stools with neg EGD and and neg
colon exam. Tagged RBC study ___ small intest bleeding. Has not
recurred.
4. CAD:In setting of GI bleed at the ___ in ___, with hct
23, he had elev ___, ST depression and had cath.
Cardiac Cath ___ @ ___
Coronary angiography: right dominant. Moderately
calcifiedvesselsLMCA: normalLAD: minimal luminal
irregularityLCX: 30% OM2. 50% ostial in ramus intermedius
branchRCA: 30% ___, 30% mid.
5. Hypertension
6. HLD
7. prediabetic
8. CKD:most recent Cr 1.4-1.6 in the last ___ mos.
9. Hx of remote AF/flutter in the ___.
10 Carotid disease:50-69% LICA, < 50% ___
Social History:
___
Family History:
Mother died of MI at age ___. Father died of liver cancer approx
age ___. Brother died of complications from DM (?). Sister is
alive, currently battling breast cancer. Has son and daughter,
who are healthy.
Physical Exam:
PHYSICAL EXAM ON ADMISSION
Vitals: 98.9, 134/70, 72, 20, 97% on 3L
General: Alert, oriented x 3, no acute distress, sitting and
eating dinner
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, Right
pupil larger than left, shows evidence of surgical change.
Bilateral pupils reactive to light.
Neck: Supple, JVP appears elevated given pulsating earlobe, no
LAD
CV: Regular rate and rhythm, ___ holosystolic murmur radiates
into the neck bilaterally. No rubs, gallops
Lungs: Mild bibasilar crackles to ___ up lungfield. No
wheezes, rhonchi. No focal areas of decreased breath sounds.
Abdomen: Soft, non-tender, central adiposity noted, bowel sounds
present. Unable to assess organomegaly due to habitus. No
rebound or guarding
GU: No foley
Ext: Warm, well perfused no clubbing or cyanosis. 1+ nonpitting
edema to the upper shins.
Neuro: EOMI, pupils asymetric but reactive to light, tongue
protrusion midline, moves extremities equally.
PHYSICAL EXAM ON DISCHARGE
Vitals: T98.4 (98.4), BP 112/44 (112/44-141/47) HR 65 (65-79) RR
18 SaO2 99% on 2L to 96% on RA.
General: Alert, oriented x 3. No acute distress. Sleeping.
HEENT: Sclera anicteric. MMM. EOMI. PERRL, with R pupil > L
pupil (stable).
Neck: Supple, no cervical lymphad. JVP elevated at clavicle when
sitting at 90 degrees.
CV: RRR. III/VI systolic murmur. S1, S2.
Lungs: CTAB no W/R/R.
Abdomen: Soft, NT/ND. BS+. Obese. No rebound/guarding.
Ext: Warm, well perfused no clubbing or cyanosis. Trace-to-no ___
edema bilaterally at ankles.
Pertinent Results:
LABS ON ADMISSION
___ 05:45AM BLOOD WBC-2.9* RBC-2.66* Hgb-9.0* Hct-27.6*
MCV-104* MCH-33.9* MCHC-32.6 RDW-17.1* Plt ___
___ 05:45AM BLOOD Neuts-59 Bands-0 ___ Monos-15*
Eos-2 Baso-0 ___ Myelos-0
___ 05:45AM BLOOD Hypochr-NORMAL Anisocy-NORMAL Poiklo-1+
Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL Ovalocy-1+
___ 05:45AM BLOOD ___ PTT-30.9 ___
___ 08:20AM BLOOD Ret Aut-2.1
___ 05:45AM BLOOD Glucose-126* UreaN-27* Creat-1.3* Na-143
K-3.7 Cl-104 HCO3-26 AnGap-17
___ 05:45AM BLOOD proBNP-2247*
___ 05:45AM BLOOD cTropnT-<0.01
___ 12:52PM BLOOD cTropnT-<0.01
___ 09:18PM BLOOD Calcium-9.0 Phos-4.2 Mg-1.8
___ 08:20AM BLOOD VitB12-255
___ 08:20AM BLOOD TSH-0.74
___ 08:20AM BLOOD HIV Ab-NEGATIVE
LABS ON DISCHARGE
___ 07:45AM BLOOD WBC-2.5* RBC-2.56* Hgb-8.7* Hct-26.4*
MCV-103* MCH-33.9* MCHC-32.9 RDW-17.9* Plt ___
___ 07:45AM BLOOD FacVIII-169
___ 07:45AM BLOOD VWF AG-170 VWF Act-PND
___ 07:45AM BLOOD Glucose-95 UreaN-32* Creat-1.5* Na-142
K-4.3 Cl-102 HCO3-33* AnGap-11
___ 07:45AM BLOOD Calcium-9.2 Phos-3.8 Mg-2.2
PATHOLOGY
INDICATIONS FOR CONSULT:
Difficult crossmatch and/or evaluation of irregular antibody (s)
CLINICAL/LAB DATA: Mr. ___ is an ___ year old man with a
history of
CKD, GI bleed, aortic stenosis and squamous cell CA of the lung.
He was
seen in the ED at ___ on ___ for dyspnea on exertion.
A sample was sent for type and screen.
Laboratory history:
Patient ABO/Rh: Group O, Rh positive
Antibody screen: Positive
Antibody identity: Anti-E antibody
Patient phenotype: ___ negative
DAT: Negative
Transfusion history: No previous transfusions at ___.
Previously
transfused in ___ at unknown outside hospital.
DIAGNOSIS, ASSESSMENT AND RECOMMENDATIONS: Mr. ___ has a
new
diagnosis of anti-E antibody. ___ is a member of the ___
blood
group system. Anti-E antibody is clinically significant and
capable of
causing hemolytic transfusion reactions.
In the future, Mr. ___ should receive ___ negative
product
for all red cell transfusions. Approximately 71% of ABO
compatible blood
will be ___ negative. A letter and a wallet card with the
above
will be sent to the patient.
Cardiovascular ReportECGStudy Date of ___ 1:07:54 ___
Sinus rhythm and occasional atrial ectopy. Right bundle-branch
block.
Non-specific inferolateral ST segment changes persist as
recorded on ___
without diagnostic interim change.
IntervalsAxes
___
___
CHEST X ___ (PA & LAT) ___
FINDINGS:
The known left upper lobe mass contains fiducial markers. As
compared to the
prior exam, there are new bibasilar airspace opacities, more
conspicuous on
the left and new small bilateral pleural effusion. There is no
pneumothorax or
overt pulmonary edema. The cardiomediastinal silhouette is
normal and
unchanged.
IMPRESSION:
New, bibasilar airspace opacities, greater on the left, possibly
pneumonia.
Small bilateral pleural effusions are also new. Left upper lobe
bronchogenic
carcinoma. Chronic goiter.
Brief Hospital Course:
Mr. ___ is an ___ year old man with severe AS, CHF, HDL, CKD
stage 3, iron deficiency anemia, recently diagnosed left sided
SqCC of the lung, and CAD with recent NSTEMI type 2 in the
setting of a GI bleed who presents with acute-on-chronic dyspnea
likely due to CHF exacerbation and slow GI bleed.
# Acute-on-chronic dyspnea - Most likely CHF exacerbation +
anemia from suspected GI bleed given elevated BNP (2247 on
admission vs 400's in recent atrius records) and guaiac positive
stool without ___. His respiratory status and edema
improved with diuresis with IV Lasix, and he was counseled on
the importance of a low-sodium, fluid restricted diet. He was
discharged on his home dose of 15mg torsemide daily. He
received 1 unit pRBC with appropriate increase in H&H. He was
weaned from 3L on admission to room air. Ambulatory saturations
with >200ft ambulation were generally 92% on room air, with
desaturations to high 80's with prolonged walks. This was
repeated on 2L, without change in desaturation pattern. Admit
weight = 115kg, discharge weight = 112.5kg.
# macrocytic anemia: Received 1 unit pRBC, with post-crit CBC
showing adequate response. Patient with severe AS may be causing
mechanical destruction intravascularly, in addition to
underlying iron deficiency from suspected GI slow bleed. He had
black/dark but well formed stools. Stool guiac was positive x 2.
TSH WNL, B12 255. His iron supplementation was continued. He
was seen by the ___ hematology consult service, who
recommended repeating ___ factor panel, as the
previous one was sent in the setting of acute
illness/inflammation and may be falsely negative. This was to
evaluate as to whether DDAVP would be a useful medication.
# History of GIB: Given possibility for further valve
replacement after cancer treatment, further investigation into
GIB history will be helpful for outpatient treatment of AS (and
need for anticoagulation). He continued to have dark stools as
an inpatient, but they are formed and not grossly melanotic. H&H
was stable for >48 hours prior to discharge. Records from ___
were reviewed, and included a thorough work up with EGD,
colonoscopy, push endoscopy, and capsule study. Home PPI was
continued.
# CAD - Stable, Atorvastatin, metoprolol, and lisinopril were
continued.
# Hypertension: Currently controlled on home Lisinopril 20 mg
daily, amlodipine 5mg BID, and metoprolol succinate 75mg BID.
# HLD - continued home atorvastatin 80mg
# prediabetic - diabetic diet
# CKD: Recent baseline has been Cr 1.4-1.6, fluctuated between
1.2 and 1.7 during this admission.
# squamous cell lung cancer of the LUL T2aN0M0 - Was scheduled
for a radiation therapy appointment that was missed during this
hospitalization. This was rescheduled for ___.
# CODE: Full code. CPR x 20 minutes, does not wish to undergo
prolonged resuscitation efforts. OK to intubate.
# CONTACT: Wife, ___ ___
============================
TRANSITIONAL ISSUES
============================
- Please check CBC and electrolytes/Cr this week and at
appointment to monitor H&H and BUN/Cr
- Guaiac positive stool
- discharged on 15mg torsemide daily
- counseled on importance of low salt/fluid restriction diet.
- radiation therapy appointment rescheduled to ___
- ___ factor antigen was repeated per hematology
consult and was 170, rest of pvWF anel pending at discharge.
- Recommend outpatient work up for leukopenia, HIV screening was
negative
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Torsemide 15 mg PO DAILY
2. econazole 1 % topical BID:PRN itching, skin irritation
3. Amlodipine 5 mg PO BID
4. Fluticasone Propionate NASAL 2 SPRY NU DAILY
5. ipratropium bromide 0.03% nasal QHS
6. Lisinopril 20 mg PO DAILY
7. Ranitidine 150 mg PO BID
8. Metoprolol Succinate XL 75 mg PO BID
9. Loratadine 10 mg PO DAILY
10. diclofenac sodium 1 % topical BIN:PRN arthritic pain
11. Acetaminophen 500 mg PO Q6H:PRN pain
12. Ferrous Sulfate 325 mg PO DAILY
13. Pantoprazole 40 mg PO Q24H
14. Vitamin D ___ UNIT PO DAILY
15. Allopurinol ___ mg PO DAILY
16. Atorvastatin 80 mg PO DAILY
Discharge Medications:
1. Acetaminophen 500 mg PO Q6H:PRN pain
2. Allopurinol ___ mg PO DAILY
3. Amlodipine 5 mg PO BID
4. Atorvastatin 80 mg PO DAILY
5. Ferrous Sulfate 325 mg PO DAILY
6. Fluticasone Propionate NASAL 2 SPRY NU DAILY
7. Lisinopril 20 mg PO DAILY
8. Loratadine 10 mg PO DAILY
9. Metoprolol Succinate XL 75 mg PO BID
10. Pantoprazole 40 mg PO Q24H
11. Ranitidine 150 mg PO BID
12. Torsemide 15 mg PO DAILY
13. Vitamin D ___ UNIT PO DAILY
14. Artificial Tears ___ DROP BOTH EYES Q4H:PRN dry eyes
15. diclofenac sodium 1 % TOPICAL BIN:PRN arthritic pain
16. econazole 1 % topical BID:PRN itching, skin irritation
17. ipratropium bromide 0.03% nasal QHS
18. Outpatient Lab Work
ICD 578.0 - GI Bleed
Please check CBC and Chem 7 on ___ or ___ and fax results to
___
___
___: ___
Address: ___
Phone: ___
Fax: ___
Discharge Disposition:
Home With Service
Facility:
___
___:
Decompensated Congestive Heart Failure
Anemia (secondary to blood loss)
GI bleed
Severe Aortic Stenosis
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 ___ due to shortness of breath. This was
likely due to congestive heart failure causing fluid build up in
addition to anemia. To treat the fluid build up, you were
diuresed with IV furosemide (Lasix). To treat the anemia you
were given a unit of blood and your blood counts were monitored.
Although you are not having the brisk GI bleeding you had
previously experienced, tests showed that you do still have
hidden blood in your stool. This will need to be followed as an
outpatient prior to your aortic valve replacement.
Because you have congestive heart failure, it is important to
weigh yourself daily and call your primary care doctor or
cardiologist if you gain more than 2 lbs in a day or 5 lbs in a
week. Taking your medication, keeping a low salt diet and
maintaining a fluid restriction of 2L or less a day is key to
preventing fluid build up.
If you have black, loose stools it is important that you seek
evaluation in the emergency department to ensure you are not
having a large GI bleed. Other symptoms include shortness of
breath and lightheadedness. Please have your labs checked this
week and at your PCP appointment to see that your blood counts
are stable.
Your cyberknife appointment that was originally scheduled for
___ was rescheduled to ___, please see below for details.
Please get labs checked on ___ or ___ at
___ with the lab slip provided at discharge.
Sincerely,
Your ___ Team
Followup Instructions:
___
|
19735459-DS-16
| 19,735,459 | 23,448,907 |
DS
| 16 |
2132-10-06 00:00:00
|
2132-10-08 15:20:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
codeine / Ultram
Attending: ___.
Chief Complaint:
Right hand swelling
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with SCLC s/p cyberknife, ___, AS s/p TAVR, chronic hypoxia
on home O2 recently admitted for CHF exacerbation, who presents
with low grade fever and right hand swelling.
Patient was recently admitted for CHF exacerbation and
discharged only 3 days prior. He was diuresed and home diuretics
were increased on discharge. His dyspnea had improved and was in
his USOH this AM when his ___ noted a temp of 100.1 and swelling
in his right ___ MCP. He was then referred to the ED.
In the ED, initial vitals were: 97.8 78 111/33 20 84% Nasal
Cannula
- Labs were significant for BNP 2300 Patient triggered for
hypoxia, but on review this is his baseline O2 sats, especially
with any exertion.
Xray of hand showed some dorsal swelling, but no fractures or
intra-articular pathology. He was admitted to the medicine
service given concern for cellulitis.
Past Medical History:
1. Lung cancer-diag by CXR ___: Squamous cell lung
cancer of the LUL T2aN0M0- PET scan at ___ confirmed FDG avid
nodes that could be consistent with disease however, at least 2
biopsies was negative with positive lymph node sampling.
2. Severe aortic stenosis, s/p TAVR
3. Chronic diastolic congestive heart failure
4. GI bleed, ? ___ syndrome
5. Hypertension
6. Hyperlipidemia, mixed
7. Chronic kidney disease, stage III, baseline Cr 1.4-1.6.
8. History of remote AF/flutter in the ___.
9. Carotid disease:50-69% LICA, <50% ___. S/p CEA
10. OSA on home CPAP
11. Gout
12. BPH
13. Allergic rhinitis
14. Anti-E antibody, difficult crossmatch
Social History:
___
Family History:
Mother died of MI at age ___. Father died of liver cancer approx
age ___. Brother died of complications from DM (?). Sister is
alive, currently battling breast cancer. Has son and daughter,
who are healthy
Physical Exam:
On Admission:
Vitals: 97 153/53 79 20 96% 2___
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: Supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
GU: No foley
Ext: 1+ pitting edema in ___ ___ to level of knee
Joint: Right ___ MCP with erythema and possible joint effusion.
Minimal pain on both active and passive ROM. Limited extension
and flexion.
Neuro: CNII-XII intact, ___ strength upper/lower extremities,
grossly normal sensation.
On Discharge:
Vitals: 97.8 116/33 64 18 98% 2LNC
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: Supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: CTAB
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
GU: No foley
Ext: 1+ pitting edema in the LLE (chronic), no edema in the RLE
Joint: No swelling around R/L MCPs, improved ROM. No warmth or
erythema
Neuro: Ax0 x3
Pertinent Results:
On Admission:
___ 06:57AM BLOOD WBC-3.4* RBC-2.29* Hgb-8.4* Hct-26.2*
MCV-114* MCH-36.7* MCHC-32.1 RDW-14.3 RDWSD-59.9* Plt ___
___ 06:57AM BLOOD Glucose-98 UreaN-42* Creat-1.5* Na-138
K-4.2 Cl-101 HCO3-22 AnGap-19
___ 06:57AM BLOOD Calcium-8.6 Phos-3.7 Mg-2.2
___ 06:04PM BLOOD Lactate-1.7
Pertinent Interval:
___ 09:37AM BLOOD Ret Aut-1.9 Abs Ret-0.04
___ 06:24AM BLOOD LD(LDH)-269*
___ 05:53PM BLOOD proBNP-2327*
___ 06:24AM BLOOD Hapto-399*
On Discharge:
___ 07:05AM BLOOD WBC-2.8* RBC-2.21* Hgb-8.1* Hct-24.9*
MCV-113* MCH-36.7* MCHC-32.5 RDW-13.6 RDWSD-56.9* Plt ___
___ 07:05AM BLOOD Glucose-109* UreaN-60* Creat-1.7* Na-137
K-4.6 Cl-100 HCO3-25 AnGap-17
___ 07:05AM BLOOD Calcium-9.2 Phos-4.3 Mg-2.1
Imaging:
___ Hand XRAY
AP, lateral, oblique views of the right hand, as well as lateral
and obliques views of the right wrist were provided. There is a
chronic appearing deformity of the distal radius without
definite signs of acute re-injury. Degenerative changes are
noted at the triscaphe, first CMC joints as well as the MCP, PIP
and DIP joints in a pattern suggestive of osteoarthritis. There
is dorsal soft tissue swelling. Vascular calcification is
present.
IMPRESSION:
Chronic deformity at the distal radius without evidence of acute
fracture or dislocation. Degenerative disease as stated above.
Dorsal soft tissue
swelling.
___ CXR
PA and lateral views of the chest provided. There is an aortic
valvular
stent in place. There is a small left pleural effusion with
basilar
atelectasis. High other congestion is noted without frank
pulmonary edema. Mild scarring in the left suprahilar region is
compatible with an area of post radiation changes adjacent to a
fiducial marker. No pneumothorax. The mediastinal contour
stable. Bony structures appear grossly intact.
IMPRESSION:
As above.
Brief Hospital Course:
Mr. ___ is an ___ with dCHF, AS s/p TAVR, SCLC s/p
cyberknife, chronic hypoxia on home O2, recently admitted for
dCHF exacerbation who presented with low grade fever and right
hand swelling and initially admitted given concern for
cellulitis, ultimately determined to have a gout flare.
# Gout flare: This likely occurred in the setting of
overdiuresis during his prior admission. He was treated with a
short course of prednisone with resolution of his symptoms. He
was not treated with colchicine or NSAIDS given renal
compromise. He was discharged on his home allopurinol, renally
dosed.
# dCHF: He was recently discharged from the hospital after a
dCHF exacerbation. His home torsemide was increased from 20 mg
daily to 30 mg daily during his last admission. He presented
with ___ and ___ elevated BNP and difficult exam it was
initially thought that he was slightly volume overloaded and his
___ was ___ cardiorenal physiology. His renal function worsened
with diuresis suggesting he was actually overdiuresed (this is
also consistent with the rationale for his gout flare). Over the
course of 3 days in the hospital his renal function improved
with holding diuresis. On the day prior to discharge his
torsemide was restarted at a lower dose- 20 mg and reassuringly
his renal function continued to trend toward his baseline. It
appears that 20 mg of torsemide was too low of a dose for him
while 30 mg was too high. He is discharged on an alternating
dosing schedule: Torsemide 30mg 3x per week (MWF) and 20 mg 4x
per week (___). He was counseled by nutrition re: low
sodium diet. He is scheduled for close follow up with his PCP
for repeat labs and weight.
# ___: Initially thought secondary to cardiorenal physiology as
above, though ultimately determined to be secondary to
overdiuresis. Diuretics were held after initial diuresis and
were restarted at a lower dose prior to discharge. His
creatinine trended to baseline on day of discharge. His
medications were renally dosed and he was discharged on a lower
dose of allopurinol per renal function.
# Leukopenia: Mr. ___ white blood cell counts during his
admissions are notable for recurrent episodes of leukopenia.
Unclear if this is related to myelosuppression. He had no
evidence of infection and clinically otherwise appeared well.
# HTN: Well controlled on amlodipine and lisinopril
Transitional Issues:
He is discharged on the following regimen:
Torsemide 30 mg ___
Torsemide 20 mg ___
His WEIGHT ON DISCHARGE: 112.2 kg.
- Please obtain repeat chemistry panel and CBC to ensure
stability of renal function and resolution of leukopenia
- Continue to counsel patient on low sodium diet
Med Rec:
- Discharged on LOWER dose of allopurinol ___ mg daily instead
of 200 mg daily) given compromised renal function
- Discharged on alternating dose of torsemide as above
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Allopurinol ___ mg PO DAILY
2. Amlodipine 10 mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. Atorvastatin 80 mg PO QPM
5. Carvedilol 25 mg PO BID
6. Fluticasone Propionate NASAL 2 SPRY NU QAM
7. Pantoprazole 40 mg PO Q12H
8. Ranitidine 150 mg PO BID
9. Vitamin D ___ UNIT PO DAILY
10. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheezing
11. Ipratropium Bromide MDI 2 PUFF IH QID
12. Lisinopril 20 mg PO DAILY
13. Torsemide 30 mg PO DAILY
Discharge Medications:
1. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheezing
2. Amlodipine 10 mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. Atorvastatin 80 mg PO QPM
5. Carvedilol 25 mg PO BID
6. Fluticasone Propionate NASAL 2 SPRY NU QAM
7. Ipratropium Bromide MDI 2 PUFF IH QID
8. Lisinopril 20 mg PO DAILY
9. Pantoprazole 40 mg PO Q12H
10. Ranitidine 150 mg PO BID
11. Vitamin D ___ UNIT PO DAILY
12. Allopurinol ___ mg PO DAILY
RX *allopurinol ___ mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
13. Torsemide 20 mg PO 4X/WEEK (___)
RX *torsemide 10 mg 2 tablet(s) by mouth 4 times per week Disp
#*32 Tablet Refills:*0
14. Torsemide 30 mg PO 3X/WEEK (___)
RX *torsemide 10 mg 3 tablet(s) by mouth three times per week
Disp #*36 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Gout
___
Acute kidney injury
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. ___,
You came to the hospital with swelling in your hand. This was
thought to be from a gout flare and your symptoms resolved with
steroids. Please continue to take your allopurinol. The dose has
been decreased a little bit because of your kidney function.
During your hospitalization you received Lasix for your heart
failure. This caused your kidney function to worsen. It is now
back to where is was before and this is great news. However, it
is likely that the dose of torsemide you were on from your last
hospitalization was a little bit too high. We will send you home
on a slightly different regimen and it will be very important
for you to follow it:
___: Take THREE pills of torsemide (30 mg)
___: Take TWO pills of torsemide
(20 mg)
Please follow a LOW SODIUM diet as instructed by the
nutritionist.
It will be very important for you to follow up with the
appointments listed below.
It was a pleasure to be a part of your care,
Your ___ treatment team.
Followup Instructions:
___
|
19735459-DS-17
| 19,735,459 | 29,723,717 |
DS
| 17 |
2133-01-22 00:00:00
|
2133-01-24 15:19:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
codeine / Ultram / Plavix
Attending: ___.
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
___ - Thoracentesis by ___, 550cc drained
___ - Thoracoscopy with chest tube placement, Pleurx
placement, and pleurodesis
History of Present Illness:
___ y/o M with history of CAD, AS s/p TAVR, COPD (baseline up to
2L O2 requirement), history of FDG-avid LUL nodule, s/p
radiofrequency ablation of the left upper lobe lesion and
thoracentesis of left pleural effusion on ___ presenting to
___ w/fevers and hypoxemia. Patient found by ___ to be in the
___ O2 sat on 2L and febrile, below baseline of ___ on 2L O2.
In the ED, initial VS were
101.4 99 181/77 22 98% NRB -> 95% on ___ NC. Physical exam
notable for clear lung exam. Labs were notable for elevated
D-Dimer 1323, WBC 7, Hgb 10.5, Cr 1.4, normal lactate, UA with
small leuks/blood.
Imaging notable for CXR with L pleural effusion, no
consolidation/PTX and CTPA negative for PE. Lower extremity US
showed: No evidence of deep venous thrombosis in the left lower
extremity veins. EKG showed sinus tachycardia with RBBB. In the
ED he received:
PO Acetaminophen 1000 mg
IVF 1000 mL NS 250 mL
IVF 250 mL NS 250 mL
PO/NG Atorvastatin 80 mg
PO/NG Carvedilol 25 mg
PO/NG Lisinopril 10 mg
He was admitted to medicine for his hypoxia/fevers.
Vitals prior to transfer:
98.0 89 107/37 20 96% Nasal Cannula (4L)
On arrival to the floor, patient reported SOB that began on
___, along with productive cough non-bloody secretions.
He has chronic orthopnea. Weight has been stable at 246 pounds.
In the AM on exam by accepting team, patient is stable,
breathing comfortably on 4L O2. He denies fever/chills, visual
changes, chest pain, but does have mild left upper shoulder pain
at site of RFA. +constipation.
REVIEW OF SYSTEMS:
As per above, otherwise a 10 point ROS is negative.
Past Medical History:
1. Lung cancer-diag by CXR ___: Squamous cell lung
cancer of the LUL T2aN0M0- PET scan at ___ confirmed FDG avid
nodes that could be consistent with disease however, at least 2
biopsies was negative with positive lymph node sampling.
2. Severe aortic stenosis, s/p TAVR
3. Chronic diastolic congestive heart failure
4. GI bleed, ? ___ syndrome
5. Hypertension
6. Hyperlipidemia, mixed
7. Chronic kidney disease, stage III, baseline Cr 1.4-1.6.
8. History of remote AF/flutter in the ___.
9. Carotid disease:50-69% LICA, <50% ___. S/p CEA
10. OSA on home ___
11. Gout
12. BPH
13. Allergic rhinitis
14. Anti-E antibody, difficult crossmatch
Social History:
___
Family History:
Mother died of MI at age ___. Father died of liver cancer approx
age ___. Brother died of complications from DM (?). Sister is
alive, currently battling breast cancer. Has son and daughter,
who are healthy
Physical Exam:
ADMISSION PHYSICAL EXAM:
============================
98.2-98.6, 127/55, 92, 18, 96% on 4L
GENERAL: NAD, Obese
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM, good dentition
NECK: nontender supple neck, no LAD, difficult to assess JVD
secondary to obesity
CARDIAC: RRR, II/VI systolic murmur, S1/S2, no murmurs, gallops,
or rubs
LUNG: breathing comfortably without use of accessory muscles.
Left lower lobe sounds diminished. No wheezes. RLL with mild
crackles.
ABDOMEN: nondistended, +BS, mildly hyperactive sounds, nontender
in all quadrants, no rebound/guarding, no hepatosplenomegaly
EXTREMITIES: no cyanosis, clubbing or edema, L leg circ > R.
Left lower extremity with trace edema to midshin. Moving all 4
extremities with purpose
PULSES: 2+ DP pulses bilaterally
NEURO: CN grossly intact
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
DISCHARGE PHYSICAL EXAM:
============================
VITALS: 98.1 (Tmax=99) 144/59 75 18 98% on 2L NC
I/O 1020/800
GENERAL: NAD lying in bed
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM, good dentition
NECK: nontender supple neck, no LAD, no JVD.
CARDIAC: RRR, II/VI systolic murmur, S1/S2, no murmurs, gallops,
or rubs
LUNG: breathing comfortably without use of accessory muscles.
Left lower lobe sounds improved from prior. Has left chest tube
and pleurex in place. site of chest tube and pleurex insertion
was not tender
ABDOMEN: nondistended, +BS, mildly hyperactive sounds, nontender
in all quadrants, no rebound/guarding, no hepatosplenomegaly
EXTREMITIES: no cyanosis, clubbing or edema, L leg circ > R.
Left lower extremity with trace -1+ pitting edema to ankles.
Moving all 4 extremities with purpose
PULSES: 2+ DP pulses bilaterally
NEURO: AAOx2-3.
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
Pertinent Results:
ADMISSION LABS:
=================================
___ 03:50PM BLOOD WBC-7.7 RBC-2.78* Hgb-10.5* Hct-32.0*
MCV-115* MCH-37.8* MCHC-32.8 RDW-14.7 RDWSD-63.6* Plt ___
___ 03:50PM BLOOD Neuts-61.5 Lymphs-5.8* Monos-30.8*
Eos-0.1* Baso-0.1 Im ___ AbsNeut-4.74# AbsLymp-0.45*
AbsMono-2.38* AbsEos-0.01* AbsBaso-0.01
___ 05:25AM BLOOD ___ PTT-31.8 ___
___ 03:50PM BLOOD Glucose-124* UreaN-23* Creat-1.4* Na-137
K-4.0 Cl-99 HCO3-28 AnGap-14
___ 03:50PM BLOOD ALT-6 AST-20 AlkPhos-93 TotBili-0.6
___ 03:50PM BLOOD proBNP-1142*
___ 03:50PM BLOOD Calcium-8.8 Phos-2.4*# Mg-1.8
___ 03:50PM BLOOD D-Dimer-1323*
___ 03:57PM BLOOD Lactate-1.3
DISCHARGE LABS:
=================================
___ 05:45AM BLOOD WBC-6.3 RBC-2.03* Hgb-7.6* Hct-23.7*
MCV-117* MCH-37.4* MCHC-32.1 RDW-14.0 RDWSD-59.4* Plt ___
___ 05:45AM BLOOD Glucose-113* UreaN-51* Creat-1.7* Na-134
K-4.2 Cl-94* HCO3-30 AnGap-14
___ 05:45AM BLOOD Calcium-8.5 Phos-3.8 Mg-2.4
MICROBIOLOGY:
=================================
___: Blood cultures x 2 negative
___: Urine culture negative, urine Legionella negative
___ 3:45 pm PLEURAL FLUID THORACENTESIS.
GRAM STAIN (Final ___:
4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES.
NO MICROORGANISMS SEEN.
This is a concentrated smear made by cytospin method, please
refer to
hematology for a quantitative white blood cell count..
FLUID CULTURE (Final ___: NO GROWTH.
ANAEROBIC CULTURE (Final ___: NO GROWTH.
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
___ 4:00 pm TISSUE LEFT PARIETAL PLEURA.
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
TISSUE (Final ___: NO GROWTH.
ANAEROBIC CULTURE (Preliminary): NO GROWTH.
ACID FAST SMEAR (Final ___:
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
ACID FAST CULTURE (Preliminary):
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
POTASSIUM HYDROXIDE PREPARATION (Final ___:
NO FUNGAL ELEMENTS SEEN.
___ 3:57 pm PLEURAL FLUID PLUERAL EFFUSION.
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final ___: NO GROWTH.
ANAEROBIC CULTURE (Preliminary): NO GROWTH.
ACID FAST SMEAR (Final ___:
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
ACID FAST CULTURE (Preliminary):
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
POTASSIUM HYDROXIDE PREPARATION (Final ___:
NO FUNGAL ELEMENTS SEEN.
___: Blood cultures x 2 pending
IMAGING/STUDIES:
=================================
CXR (___):
IMPRESSION:
Left basilar chest tube remains in place with stable appearance
to the left hemithorax with more focal opacity in the left
suprahilar region in an area of recent ablation and a lateral
pleural abnormality which may reflect loculated fluid in this
patient with known lung malignancy. The right lung remains
grossly clear. Heart is unchanged in size. No pulmonary edema.
No pneumothorax.
Cytology (___):
Pleural fluid:
NEGATIVE FOR MALIGNANT CELLS.
- Mesothelial cells, numerous lymphocytes and histiocytes.
CXR: ___:
S a with the study of ___, there is little change. The
degree of left pleural effusion appears stable with underlying
basilar atelectasis but no evidence of pneumothorax. The
opacification in the left perihilar in suprahilar region most
likely reflects the postprocedure ground-glass opacity seen on a
prior CT scan. The cardiac silhouette remains enlarged and there
is indistinctness of pulmonary vessels consistent with elevation
of pulmonary venous pressure.
CXR: ___:
In comparison with the study of ___, there is little
change. There is still a small left pleural effusion with
associated atelectatic changes. Opacification in the left
perihilar and suprahilar region probably reflects the post
procedural ground-glass opacity seen on the CT of ___
after RF ablation. The right lung remains essentially clear.
Thoracentesis: ___:
Ultrasound-guided paracentesis of the left pleural effusion with
removal of
550 mL of clear serosanguineous fluid. Samples were sent for
analysis.
CXR ___:
Slight increase in extent of the pre-existing small left pleural
effusion.
Increase in extent of the retrocardiac atelectasis and the
associated
parenchymal opacity. Mild cardiomegaly persists. The right
lung continues to be normal.
CXR ___: 1. Stable small left pleural effusion.
2. Unchanged rounded opacity adjacent to the clips in the left
upper lobe. No new focal consolidation.
3. No pneumothorax.
CTPA ___:
1. No evidence of pulmonary embolism or acute aortic syndrome.
2. Status post recent RF ablation with new ground-glass opacity
in the left upper lobe, most likely post procedural. No
pneumothorax.
3. Moderate left pleural effusion, decreased since one day
prior.
4. Redemonstration of multiple pulmonary nodules, unchanged
since ___, as well as prominent mediastinal and hilar lymph nodes.
ECHO ___:
The left atrium is mildly dilated. 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 diameters of
aorta at the sinus, ascending and arch levels are normal. A
___ aortic valve bioprosthesis is present. The aortic
valve prosthesis appears well seated, with normal leaflet/disc
motion and transvalvular gradients. A trace anterior
paravalvular aortic valve leak is present. The mitral valve
leaflets are mildly thickened. Trivial mitral regurgitation is
seen. [Due to acoustic shadowing, the severity of mitral
regurgitation may be significantly UNDERestimated.] There is
moderate pulmonary artery systolic hypertension. There is no
pericardial effusion.
IMPRESSION: Well-seated ___ aortic valve prosthesis with
trace paravalvular leak. Symmetric LVH with normal global and
regional biventricular systolic function. Moderate pulmonary
hypertension.
Compared with the prior study (images reviewed) of ___,
the findings are similar.
Brief Hospital Course:
Mr. ___ is a ___ y/o M with squamous cell carcinoma of the
lung, with recent LUL RFA of LUL nodule and thoracentesis of L
pleural effusion on ___ who presented with 1 day of dyspnea,
cough, hypoxia, found to have re-accumulation of left pleural
effusion and a likely inflammatory pneumonitis from the RFA
treatment versus PNA who underwent ___ drainage of recurrent
pleural effusion followed by thoracoscopy and Pleurx catheter
placement.
# Exudative Left Pleural Effusion and Hypoxemia: Patient has
squamous cell carcinoma of the lung, and has had recurrent
exudative pleural effusions. On ___ patient had drainage
by ___ of left pleural effusion and an RFA of a left upper lobe
nodule. Over the next two days prior to this admission, he
developed fevers/malaise, had poor PO intake, and progressive
hypoxemia. His O2 requirement at admission was 4L NC to maintain
saturation of 92-96%. CTA showed no PE but did show
reaccumulation of the left pleural effusion. Patient underwent
___ thoracentesis with removal of 550cc of fluid on
___. He was treated empirically with antibiotics for
several days and was given standing duo-nebs. Fluid studies
showed exudative fluid but cultures remained negative. Cytology
was also negative for malignant cells. Although initially
diuresed for respiratory status, patient was found to be
hypovolemic at his dry weight, likely precipitating ___ (see
below). On ___, the patient had an ultrasound by ___ of
the left lung which showed residual pleural effusion of around
500cc. The patient underwent a thorascopy on ___ with no
complications. During the procedure, 400cc of pleural fluids
were withdrawn, plaques on the parietal pleura were identified
and biopsied (pathology results pending). In addition, a chest
tube and a Pleurx catheter were inserted and pleurodesis was
performed with talc. The chest tube was removed the following
day. He was discharged home with ___ with Pleurx catheter in
place (will be evaluated/removed at IP follow-up visit in two
weeks post-discharge).
Acute Kidney Injury overlying CKD III
Patient has CKD at baseline, and initial creatinine was stable
at 1.5. However, in context of diuresis patient found to have
poor urine output on ___ and likely hypovolemia. Due to
respiratory decompensation he initially received 60mg Lasix, but
was given 1L LR due to the low urine output. Bladder scan showed
less than 100cc in the bladder. He was also restarted on a
regular diet with nutritional supplementation as well.
Differential for the ___ includes hypovolemia (prerenal
azotemia) - particularly given FeUrea of 13.96% (pre-renal), or
hypoxemic ATN (given low O2 saturation prior to admission), or
CIN given approximately 48 hours now since patient's contrast
study. Less likely the patient has an obstructive process given
the negative bladder scan. His creatinine improved and at
discharge was 1.7. His allopurinol dose was modified to 100mg
daily due to CKD.
Macrocytic Anemia
Patient has macrocytic anemia with inappropriately low
reticulocyte count. Iron studies show possible anemia of
inflammatory/chronic disease superimposed on low B12 of 271
(low/intermediate) so MMA was ordered and was normal.
Empirically started high dose Vitamin B12. He will need Vitamin
B12 at 1000 mcg daily for perpetuity.
COPD: Has up to 2L O2 requirement at home. He was switched from
MDI to nebulizers. He may benefit from long acting inhaled
steroid as an outpatient.
Diastolic CHF EF > 55% and AS s/p TAVR
Patient with preserved ejection fraction. CXR does not appear to
show signs of pulmonary edema though patient does endorse
orthopnea though notes his weight has been stable at home.
Weight here is 112 kg and 246 lbs consistent with home reported
weight. Patient is s/p ___ cc IVF in the ED, and an additional
1L on the floor. He was given further careful IVF and monitoring
of PO intake along with holding of his lasix.
Now has his diet broadened and tolerating PO.
- Given ongoing ___ and SIRS, continue to hold torsemide
- Consider restarting torsemide in coming days
#Left lower extremity edema/Increased circumference
Stable. Patient without evidence of DVT on lower extremity US.
D-dimer elevated and PE ruled out with CTA.
# CAD:
Stable. Continued ASA, Atorvastatin and carvedilol.
# HTN:
Stable. Intermittently hypotensive, but likely due to
hypovolemia. Continue holding lisinopril.
Gout:
Stable. Lowered dose from home 200mg to 100mg due to ___.
History of GI bleed/GERD
Stable. Continued home pantoprazole.
Allergic Rhinitis:
Stable. Continue home fluticasone and loratadine
TRANSITIONAL ISSUES:
=======================
# Weight at discharge: 110kg
# Will be seen by IP in two weeks for likely Pleurx removal (see
Pleurx care directions below). They will call him with an
appointment
Pleurodesis PleurX orders: L side
1. Please drain Pleurx every day.
2. Do not drain more than 1000 ml per drainage.
3. Stop draining for pain, chest tightness, or cough.
4. Do not manipulate catheter in any way.
5. Keep a daily log of drainage amount and color, have the
patient bring it with him to his appointment.
6. You may shower with an occlusive dressing
7. If the drainage is less than 50cc for three consecutive
drainages please call the office for further instructions.
8. Please call office with any questions or concerns at
___.
Pleurx catheter sutures to be removed when seen in clinic ___
days post PleurX placement.
Please call ___ if there are any questions.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 80 mg PO QPM
3. Carvedilol 25 mg PO BID
4. Fluticasone Propionate NASAL 2 SPRY NU QAM
5. Ipratropium Bromide MDI 2 PUFF IH QID
6. Lisinopril 10 mg PO DAILY
7. Pantoprazole 40 mg PO Q12H
8. Ranitidine 150 mg PO BID
9. Vitamin D ___ UNIT PO DAILY
10. Allopurinol ___ mg PO DAILY
11. Torsemide 40 mg PO DAILY
12. Oxycodone-Acetaminophen (5mg-325mg) ___ TAB PO Q6H:PRN pain
13. Loratadine 10 mg PO DAILY
Discharge Medications:
1. Allopurinol ___ mg PO DAILY
RX *allopurinol ___ mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 80 mg PO QPM
4. Fluticasone Propionate NASAL 2 SPRY NU QAM
5. Loratadine 10 mg PO DAILY
6. Pantoprazole 40 mg PO Q12H
7. Ranitidine 150 mg PO BID
8. Vitamin D ___ UNIT PO DAILY
9. Cyanocobalamin 1000 mcg PO DAILY
RX *cyanocobalamin (vitamin B-12) 1,000 mcg 1 tablet(s) by mouth
daily Disp #*30 Tablet Refills:*0
10. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*0
11. Polyethylene Glycol 17 g PO DAILY constipation
RX *polyethylene glycol 3350 17 gram 1 powder(s) by mouth daily
Disp #*30 Packet Refills:*0
12. 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
13. Carvedilol 25 mg PO BID
14. Lisinopril 10 mg PO DAILY
15. Torsemide 40 mg PO DAILY
16. Albuterol Inhaler 2 PUFF IH Q4H:PRN dyspnea
RX *albuterol sulfate [ProAir HFA] 90 mcg 2 puff inh every four
(4) hours Disp #*1 Inhaler Refills:*0
17. Ipratropium Bromide MDI 2 PUFF IH Q6H:PRN dyspnea
RX *ipratropium bromide [Atrovent HFA] 17 mcg/actuation 2 puff
inh every six (6) hours Disp #*1 Inhaler Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary:
=================================
Exudative Left Pleural Effusion
Squamous Cell Carcinoma of the Lung
Macrocytic Anemia ___ MDS
Secondary:
==========================
COPD
dCHF (EF>55%) Chronic without exacerbation
CAD
Hypertension
Gout
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 came to ___ with shortness
of breath. You were found to have fluid in your left lung that
returned only two days after being drained by the interventional
radiology team. In addition, you had inflammation from your
radiofrequency ablation procedure on your left lung. These two
things combined made you more short of breath than normal. You
had a repeat drainage of the fluid on ___ and your
breathing improved. On ___ you underwent a procedure
called "thoracoscopy" which involves using a camera to view the
space between your lung and chest wall. During the procedure,
extra fluids around the lung was removed and you were given
medication to seal off the gap between your lungs and chest wall
to prevent future fluids from accumulating. A chest tube and a
Pleurx (both of which are tubes that help drain the fluid around
your lungs) were placed with no complications. Before your
discharge the chest tube was removed but the Pleurx was left in
please. This pleurx needs to be drained every day even if only a
little fluid comes out. Please follow up with Interventional
Pulmonology in ___ weeks to determine when the Pleurx should be
removed. They will call you at home with an appointment.
Meanwhile, after your discharge, please follow the standard
instructions written below for proper care of your Pleurx. Make
sure to take enough pain medication to allow yourself to take
good deep breaths. This is important since shallow breaths may
increase your risk of developing lung infections.
After leaving the hospital it will be very important to see your
primary care doctor, ___, and followup with the
interventional pulmonary teams for follow-up
It has been a pleasure caring for you. We wish you all the best!
Kind regards,
Your ___ Team
Pleurx care instruction after a Pleurodesis: (site: Left side
tube)
1. Please drain Pleurx every day.
2. Do not drain more than 1000 ml per drainage.
3. Stop draining for pain, chest tightness, or cough.
4. Do not manipulate catheter in any way.
5. Keep a daily log of drainage amount and color. Bring the
daily log you to your appointments.
6. You may shower with an occlusive dressing
7. If the drainage is less than 50cc for three consecutive
drainages please call the office for further instructions.
8. Please call office with any questions or concerns at
___.
Pleurx catheter sutures to be removed when seen in clinic ___
days post PleurX placement.
Please call ___ if there are any questions.
Followup Instructions:
___
|
19735459-DS-24
| 19,735,459 | 24,143,593 |
DS
| 24 |
2133-06-23 00:00:00
|
2133-06-23 22:17:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
codeine / Ultram / Plavix
Attending: ___.
Chief Complaint:
fevers
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ yo M with history of squamous cell lung cancer s/p
radiofrequency ablation of LUL, COPD, HFpEF, severe AS s/p TAVR,
Stage III CKD (baseline Cr 1.5) who presents with fever s/p fall
at his rehab facility.
He was discharged ___ to rehab from ___ after admission for
GIB. Per his wife, he was doing well at rehab and was at his
baseline: at baseline he walks with a walker, eating meals by
mouth, and does not require supplemental oxygen, though does
have OSA and has been refusing nighttime CPAP).
His wife, who sees him every day, did not notice anything
different about him on the morning of arrival. He worked ___
and afterwards was trying to get out of bed when he slipped and
fell. He was communicating normally w/his family after the fall
and was able to walk to the stretcher. He was taken to ___
___ where he continued to interact appropriately w/his wife
and providers. He had an initial ABG 7.34 / 57 / 41. Hgb 9.2 and
positive UA (WBC>100, Nitrites neg). He had a negative head CT,
and chest ___ that may represented an increase in opacities in
the lungs that suggest possible pneumonia. He was treated with
ceftriaxone, azithromycin, and vancomycin at 10 ___. Also give 1L
Ns and rectal Tylenol. He is transferred to ___ for further
evaluation.
Mr. ___ has had 5 recent hospital stays since ___ for hypercarbic respiratory failure s/p percutaneous
trach placement on ___ for trach malfunction and ___ with initiation of HD
-___ for MRSA PNA [discharged on doxycycline]). Chest CT
during this admission showed progressive "mass like lesions
growing in the left upper lobe and persistent segmental upper
lobe atelectasis without obvious bronchial obstruction."
-___ for hypercapneic respiratory failure due to trach
malfunction, with trach removal.
-___ for GIB requiring 8U PRBC transfusion, likely due to
AVM. Per discharge summary, long ___ conversation undertaken and
patient chose to remain full code.
In the ED, initial vitals: 97.0 (then febrile to 102.8) 110
113/95 18 98% 6L/min Nasal Cannula
- Exam notable for diffuse wheezing, desatting to ___ on NC
while asleep, and he refused anything over his mouth such as
BiPAP or CPAP.
- Labs were notable for: leukocystosis to 13, hgb 7.2 from 9.1
on discharge, BUN/Cr 43/2.2 from 34/1.4 at last discharge,
lactate 0.7. VBG pH 7.32 pCO2 57 pO2 76 HCO3 31 (baseline pCO2
in ___, positive UA.
- Imaging: CXR from OSH with more confluent LUL consolidation
compared with prior (our read)
- Patient was given: duonebs, methylprednisolone 125 mg, 1L NS,
mag repletion, flagyl.
On arrival to the MICU, he is somnolent, opens eyes to loud
voice and sternal rub only intermittently. As above, his wife
reports he'd been doing well at rehab, ambulating on his own.
He'd had no trouble with his breathing and mental status was at
baseline up until transfer to ___.
Past Medical History:
PAST MEDICAL & SURGICAL HISTORY:
# Lung cancer-diag by CXR ___: Squamous cell lung
cancer of the LUL T2aN0M0- Dr. ___ (___) - s/p XRT
___, and s/p RFA ___
# Percutaneous trach placement ___ for hypercarbic
respiratory failure and narrowing of focal cords, with removal
of trach ___
# Severe aortic stenosis, s/p TAVR in ___
# Chronic diastolic congestive heart failure, EF 75% on ___
# Anemia with recent EGD on ___ showing mild gastritis &
duodenitis, with more recent GIB ___ requiring 8U PRBCs, with
no source localized on scope (likely due to AVM)
# ___ syndrome (angiodysplasia in setting of aortic
stenosis)
# Malnutrition, s/p Dobhoff placement in ___, now tolerating
POs but still getting tube feeds
# H/o vocal cord dysfunction after radiofrequency ablation
# Hypertension
# Hyperlipidemia, mixed
# Chronic kidney disease, stage III, baseline Cr 1.4-1.6.
# History of remote AF/flutter in the ___.
# Carotid disease:50-69% LICA, <50% ___. S/p CEA
# OSA, most recently refusing CPAP
# Gout
# Benign prostatic hyperplasia with indwelling foley
# Anti-E antibody, difficult cross-match
Social History:
___
Family History:
Mother died of MI at age ___. Father died of liver cancer approx
age ___. Brother died of complications from DM (?). Sister is
alive, currently battling breast cancer. Has son and daughter,
who are healthy.
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: Tm 102.8 in ED HRs ___ BPs ___ (MAPs ___ RR
___ spO2 97% on 5L NC
GENERAL: somnolent, barely arousable to sternal rub
HEENT: Atraumatic. Pupils 3cm on r, 2 cm on l, reactive
bilaterally. slightly dry MM.
NECK: supple, JVP difficult to assess but mid to upper neck
LUNGS: diminished breath sounds bilaterally, no frank wheezing,
faint bibasilar rales but difficult to appreciate given poor
respiratory effort. breahting does not appear labored
CV: systolic murmur ___, mechanical sounding s2, no rubs or
gallops
ABD: soft, non-tender, non-distended, bowel sounds present, no
rebound tenderness or guarding, no organomegaly. PEG tube in
place, ~5 mm slight surrounding erythnema w/o any drainage
EXT: Warm, well perfused, 2+ edema to ankles, 1+ edema to upper
calves
SKIN: sacral decub ulcer with surrounding blanching erythema,
does not appear infected. Shallow ulcer over ___ MTP joint of Left
___ toe.
NEURO: somnolent, does not arouse to sternal rub. withdraws to
pain b/l but moreso on the Right. Toes downtgoing bilaterally.
+myoclonus b/l.
ACCESS: 2 PIVs
DISCHARGE
VS: 97.6 147/52 100 16 96%RA 92.8kg (from 93.2kg)
UOP: 3050cc urine yesterday, 925cc so far today
Gen - sitting up in chair, comfortable appearing
Eyes - EOMI, pupils constricted and minimally reactive
ENT - OP clear, MMM
Heart - RRR no mrg
Lungs - CTA bilaterally, no wheezing, crackles, ronchi
Abd - soft nontender, normoactive bowel sounds; PEG c/d/i
Ext - trace edema to ankles
Skin - stage II sacral ulcer (present on admission per report)
Vasc - 1+ DP/radial pulses, PIV x 2
Neuro - AOx3 (full name, ___ in ___, ___, moving all extremities
Psych - appropriate
Pertinent Results:
ADMISSION
___ 12:25AM BLOOD WBC-13.1*# RBC-2.35* Hgb-7.2* Hct-22.8*
MCV-97 MCH-30.6 MCHC-31.6* RDW-17.5* RDWSD-60.8* Plt ___
___ 12:25AM BLOOD Glucose-105* UreaN-43* Creat-2.2* Na-133
K-4.0 Cl-95* HCO3-26 AnGap-16
___ 02:52AM BLOOD ___ pO2-76* pCO2-57* pH-7.32*
calTCO2-31* Base XS-0
DISCHARGE
___ 07:48AM BLOOD WBC-5.0 RBC-2.90* Hgb-9.0* Hct-28.9*
MCV-100* MCH-31.0 MCHC-31.1* RDW-17.4* RDWSD-61.0* Plt ___
___ 07:56AM BLOOD Glucose-106* UreaN-35* Creat-1.4* Na-141
K-4.4 Cl-100 HCO3-31 AnGap-14
___ Urine Culture ___ - > 100k Kleb Pneumo, R to
ampicillin, nitrofurantoin; S to Bactrim, aminoglycoside,
levofloxacin, amp-sulbactam, piptazo, cefazolin, ceftriazone
___ 2:45 am URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
KLEBSIELLA PNEUMONIAE. >100,000 ORGANISMS/ML..
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
KLEBSIELLA PNEUMONIAE
|
AMPICILLIN/SULBACTAM-- 16 I
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- 128 R
PIPERACILLIN/TAZO----- 16 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
___ Opinion CT Head - ___
1. No acute intracranial abnormality on noncontrast head CT on
motion degraded
examination. Specifically no large territory infarct or
intracranial
hemorrhage.
2. No evidence acute calvarial fracture.
3. Additional findings as described above.
CT Chest ___
1. Multifocal bilateral pulmonary opacities are identified. The
pulmonary
lesions in the left upper lobe are slightly larger compared to
___.
Other small pulmonary nodules in the left lung are stable.
Small pulmonary nodules in the right lung are smaller.
Possibility of infection and/or malignancy remains in the
differential. Consider bronchoscopy for further evaluation.
2. Prominent subcentimeter mediastinal lymph nodes are similar
to ___.
3. Moderately severe emphysema.
4. Cholelithiasis.
RECOMMENDATION(S): Consider bronchoscopy.
Brief Hospital Course:
This is an ___ year old male with past medical history squamous
cell lung cancer, aortic stenosis status post TAVR ___,
diastolic CHF, CKD stage 3, OSA frequently refusing CPAP, with
multiple recent admissions most recently for acute GI bleed
secondary to AVM who was admitted to the ICU ___ with
sepsis secondary to klebsiella UTI, ___, clinically improving,
ready for discharge back to rehab
#Severe sepsis / Klebsiella UTI - Patient initially presented
with fever to 102.8, tachycardia, leukocytosis, ___,
hypotension, and altered mental status. CT Chest showed
"Multifocal bilateral pulmonary opacities are identified. The
pulmonary
lesions in the left upper lobe are slightly larger compared to
___.
Other small pulmonary nodules in the left lung are stable.
Small pulmonary
nodules in the right lung are smaller. Possibility of infection
and/or
malignancy remains in the differential. Consider bronchoscopy
for further
evaluation." As below, felt to be progression of cancer and not
infection. Patient respiratory status rapidly improved to room
air over 24 hours. ___ and ___ urine culture returned with
klebsiella. Felt to have had a UTI (rapid improvement in
respiratory status was not felt to be consistent with
infection). Antibiotics were culture-directed and narrowed to
PO ciprofloxacin. Patient continued to improve, last day PO
cipro ___. To reduce risk of future infection, would
attempt trial of void on ___ as below
# Urinary Retention / BPH - Patient with foley placed during
recent admission for urinary retention secondary to BPH; this
admission, patient presented with UTI likely related to his
catheter. Attempted trial of void this admission, but failed
due to retention of >600cc urine. Felt it might relate to
localized inflammation from UTI, and thought patient would
benefit from repeat trial of void once antibiotic course
completed on ___ would be the best way to avoid
recurrent CAUTI. Continued tamsulosin and scheduled for
outpatient urology follow-up in case patient should fail trial
of void at rehab.
# Acute Metabolic Encephalopathy - Very lethargic and confused
on admission; over the course of admission, he slowly improved
with treatment of infection and holding of sedating medications.
Discontinued gabapentin without occurence of pain this
admission--would recommend against restarting
# ___ / CKD stage 3 - Baseline Cr 1.5, admitted with Cr 2.2.
Felt to be prerenal in setting of severe sepsis. Fluid
responsive. Resolved to 1.4 on discharge
# Lung Cancer / CT Abnormality - CT chest this admission showed
"Multifocal bilateral pulmonary opacities are identified. The
pulmonary lesions in the left upper lobe are slightly larger
compared to ___. Other small pulmonary nodules in the left
lung are stable. Small pulmonary nodules in the right lung are
smaller. Possibility of infection and/or malignancy remains in
the differential. Consider bronchoscopy for further evaluation.
Prominent subcentimeter mediastinal lymph nodes are similar to
___. Moderately severe emphysema." Given that by 24 hours
into admission, patient had no respiratory symptoms, these
changes were felt to be unlikely to an acute infectious process.
Discussed with case primary oncologist Dr. ___ agreed and
emphasized importance of oncology follow-up. Patient scheduled
for appointment at time of discharge see below.
# Chronic Diastolic CHF / Hypertension - Weight at last
discharge was 89kg, but was 95kg on transfer out of ICU,
suspected to be from iatrogenic IV fluids. Patient was started
on standing Lasix with stable renal function and improving
weights. Would recommend checking daily weights and following
renal function to determine if it should be continued
indefinitely or discontinued once he reaches dry weight.
Continued statin, amlodipine and metoprolol
# COPD - continued home fluticasone, bronchodilators
# Gout - continued allopurinol
# GERD - continued home famotidine, PPI
# OSA - refused CPAP this admission; monitored with continuous
saturation monitoring and nocturnal O2
# Sacral decubitus ulcer - present on admission; continued wound
care
# Chronic Pain - as above stopped home gabapentin given sedation
as above; no pain symptoms this admission, would not restart it
in the future
Transitional Issues
# Communication - wife ___ (___), son ___
___
# Code - full code confirmed w/HCP ___
- Last day of PO cipro is ___
- Failed trial of void here--in order to decrease his risk of
future UTIs, would re-attempt at completion of PO antibiotic
course ___ in case he fails again, we have scheduled him
for follow-up with ___ Urology as above
- Markedly encephalopathic on admission here prompting cessation
of gabapentin. No issues with pain this admission, would advise
not to restart this medication.
- CT Scan this admission showed "Multifocal bilateral pulmonary
opacities are identified. The pulmonary lesions in the left
upper lobe are slightly larger compared to ___. Other
small pulmonary nodules in the left lung are stable. Small
pulmonary nodules in the right lung are smaller. Possibility of
infection and/or
malignancy remains in the differential. Consider bronchoscopy
for further evaluation." Per discussion with primary oncologist,
given not clinically concerned for infection at this time,
recommended deferring further workup pending outpatient heme/onc
follow-up scheduled ___
- Started standing Lasix this admission; would follow daily
weights and monitor creatinine regularly to guide dosing /
continuation of therapy
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Amlodipine 2.5 mg PO DAILY
3. Cyanocobalamin 1000 mcg PO DAILY
4. FoLIC Acid 1 mg PO DAILY
5. Ipratropium-Albuterol Neb 1 NEB NEB TID SOB, wheeze
6. Multivitamins W/minerals 1 TAB PO DAILY
7. Tamsulosin 0.4 mg PO QHS
8. Vitamin D 1000 UNIT PO DAILY
9. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN SOB/wheezing
10. Allopurinol ___ mg PO DAILY
11. Atorvastatin 40 mg PO QPM
12. darbepoetin alfa in polysorbat 60 mcg/mL injection 1X/WEEK
13. Docusate Sodium 100 mg PO BID
14. Famotidine 20 mg PO DAILY
15. Ferrous Sulfate 325 mg PO DAILY
16. Fluticasone Propionate NASAL 2 SPRY NU DAILY
17. Furosemide 40-60 mg PO DAILY:PRN weight >85 kg
18. Guaifenesin 10 mL PO Q6H:PRN cough/secretion
19. Ipratropium Bromide MDI ___ PUFF IH Q4H:PRN SOB
20. Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY
21. Polyethylene Glycol 17 g PO DAILY constipation
22. polyvinyl alcohol 1.4 % ophthalmic Q4H:PRN
23. Senna 8.6 mg PO DAILY
24. Simethicone 40-80 mg PO QID:PRN cramping
25. Albuterol Inhaler ___ PUFF IH Q4H:PRN Wheeze
26. Metoprolol Succinate XL 50 mg PO NOON
27. Colchicine 0.6 mg PO DAILY
28. Gabapentin 100 mg PO DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Allopurinol ___ mg PO DAILY
3. Amlodipine 2.5 mg PO DAILY
4. Atorvastatin 40 mg PO QPM
5. Docusate Sodium 100 mg PO BID
6. Famotidine 20 mg PO DAILY
7. Fluticasone Propionate NASAL 2 SPRY NU DAILY
8. FoLIC Acid 1 mg PO DAILY
9. Ipratropium-Albuterol Neb 1 NEB NEB TID SOB, wheeze
10. Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY
11. Metoprolol Succinate XL 50 mg PO NOON
12. Multivitamins W/minerals 1 TAB PO DAILY
13. Polyethylene Glycol 17 g PO DAILY constipation
14. Senna 8.6 mg PO DAILY
15. Simethicone 40-80 mg PO QID:PRN cramping
16. Tamsulosin 0.4 mg PO QHS
17. Vitamin D 1000 UNIT PO DAILY
18. Ciprofloxacin HCl 500 mg PO Q12H
last day = ___
19. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN SOB/wheezing
20. Albuterol Inhaler ___ PUFF IH Q4H:PRN Wheeze
21. Cyanocobalamin 1000 mcg PO DAILY
22. darbepoetin alfa in polysorbat 60 mcg/mL injection 1X/WEEK
23. Ferrous Sulfate 325 mg PO DAILY
24. Furosemide 60 mg PO DAILY
25. polyvinyl alcohol 1.4 % ophthalmic Q4H:PRN
Discharge Disposition:
Extended Care
Facility:
___
___ Diagnosis:
# Sepsis / UTI
# Lung Cancer
# Acute metabolic encephalopathy
# Chronic Diastolic CHF / Hypertension
# COPD
# Gout
# GERD
# OSA
# Sacral decubitus ulcer
# Chronic Pain
# BPH / urinary retention
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. ___:
It was a pleasure caring for you at ___. You were admitted
with high fever. You were evaluated by ICU doctors, and found
to have a urinary tract infection. You were started on
antibiotics and improved.
The best way to prevent future infections is to have your
urinary catheter removed. We tried to do this during your
admission, but you retained urine. It is important that speak
to your physician at ___ regarding trying this again. We have
made an appointment for you with a urologist in case you
continue to have urinary retention.
Your CT scan showed possible progression of your cancer. We
discussed this with your oncologist Dr. ___ who agreed
that you should follow-up with her in clinic on ___
Followup Instructions:
___
|
19735459-DS-25
| 19,735,459 | 28,007,893 |
DS
| 25 |
2133-09-08 00:00:00
|
2133-09-09 12:11:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
codeine / Ultram / Plavix
Attending: ___.
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
EGD
Capsule endoscopy
History of Present Illness:
Patient is a ___ yo M with history of squamous cell lung cancer
s/p
radiofrequency ablation of LUL, COPD (on 2L O2 at home), HFpEF,
severe AS s/p TAVR, ___ syndrome (occasionally requiring
multiple units of transfusions, known E antibody positive),
Stage III CKD (baseline Cr 1.5) who presents with acute on
chronic dyspnea.
Patient reports 2 weeks of gradual onset of dyspnea, mostly with
exertion. The dyspnea is associated with a cough (worse than his
usual baseline) that is worsened with recumbent position. No
associated chest pain, diaphoresis, palpitations,
lightheadedness. No leg pain or leg swelling. He was recently
seen at ___ on ___, noted to have class III dyspnea
sxs, but not felt to be cardiac in nature, as AV gradients on
TTE were low with only trace AR.
ROS also positive for generalized weakness, malaise and
intermittent dark stools. He reports he has been having ___
small dark BMs daily, but denies any bright red blood per
rectum. Denies fever, chills, abdominal pain, dysuria.
In the ED, initial VS were: 98.8, 92 142/51 20 90% Nasal
Cannula. On exam, mechanical murmur with mild wheezes and guaiac
positive brown stool. ED labs were notable for: H/H ___ -->
5.8/19.3, INR 1.2, BUN/Cr 37/1.7, Lactate 2.2 TnT 0.05 CXR
showed new mild pulmonary edema and known left upper lobe
opacities. EKG did not show ischemic changes.
Patient was given:
2u prbc
___ 14:16 IV Pantoprazole 40 mg
___ 15:00 IV Piperacillin-Tazobactam 4.5 g
___ 15:43 IV Vancomycin 1000 mg
Transfer VS were: 98.4 81 150/36 18 100% Nasal Cannula
When seen on the floor, reports mild cough and denies dyspnea
when at rest.
Per chart review, he has had 6 recent hospital stays since
___ for hypercarbic respiratory failure s/p percutaneous
trach placement on ___ for trach malfunction and ___ with initiation of HD
-___ for MRSA PNA [discharged on doxycycline]). Chest CT
during this admission showed progressive "mass like lesions
growing in the left upper lobe and persistent segmental upper
lobe atelectasis without obvious bronchial obstruction."
-___ for hypercapneic respiratory failure due to trach
malfunction, with trach removal.
-___ for GIB requiring 8U PRBC transfusion, likely due to
AVM. Per discharge summary, long GOC conversation undertaken and
patient chose to remain full code.
- ___: severe sepsis, klebiella UTI.
REVIEW OF SYSTEMS:
A ten point ROS was conducted and was negative except as above
in the HPI.
Past Medical History:
PAST MEDICAL & SURGICAL HISTORY:
# Lung cancer-diag by CXR ___: Squamous cell lung
cancer of the LUL T2aN0M0- Dr. ___ (ATRIUS) - s/p XRT
___, and s/p RFA ___
# Percutaneous trach placement ___ for hypercarbic
respiratory failure and narrowing of focal cords, with removal
of trach ___
# Severe aortic stenosis, s/p TAVR in ___
# Chronic diastolic congestive heart failure, EF 75% on ___
# Anemia with recent EGD on ___ showing mild gastritis &
duodenitis, with more recent GIB ___ requiring 8U PRBCs, with
no source localized on scope (likely due to AVM)
# ___ syndrome (angiodysplasia in setting of aortic
stenosis)
# Malnutrition, s/p Dobhoff placement in ___, now tolerating
POs but still getting tube feeds
# H/o vocal cord dysfunction after radiofrequency ablation
# Hypertension
# Hyperlipidemia, mixed
# Chronic kidney disease, stage III, baseline Cr 1.4-1.6.
# History of remote AF/flutter in the ___.
# Carotid disease:50-69% LICA, <50% ___. S/p CEA
# OSA, most recently refusing CPAP
# Gout
# Benign prostatic hyperplasia with indwelling foley
# Anti-E antibody, difficult cross-match
Social History:
___
Family History:
Mother died of MI at age ___. Father died of liver cancer approx
age ___. Brother died of complications from DM (?). Sister is
alive, currently battling breast cancer. Has son and daughter,
who are healthy.
Physical Exam:
Gen: NAD, A&O x3, lying in bed
Eyes: EOMI, sclerae anicteric
Neck: elevated JVP 10cm
ENT: MMM, OP clear
Cardiovasc: RRR, mechanical S2, no MRG, full pulses, trace
edema
Resp: normal effort, bibasilar rales, no wheezing, no accessory
muscle use
GI: soft, NT, ND, BS+
MSK: No significant kyphosis. No palpable synovitis.
Skin: No visible rash. No jaundice.
Neuro: AAOx3. No facial droop.
Psych: Full range of affect
Pertinent Results:
___ 07:06PM WBC-4.4 RBC-1.67*# HGB-5.8* HCT-19.3*
MCV-116*# MCH-34.7* MCHC-30.1* RDW-24.3* RDWSD-98.9*
___ 07:06PM PLT COUNT-154
___ 07:06PM ___ PTT-33.0 ___
___ 03:04PM HGB-5.5* calcHCT-17
___ 03:04PM HGB-5.5* calcHCT-17
___ 03:04PM HGB-5.5* calcHCT-17
___ 01:20PM WBC-5.2 RBC-1.02*# HGB-4.0*# HCT-12.9*#
MCV-127*# MCH-39.2*# MCHC-31.0* RDW-19.9* RDWSD-88.9*
___ 01:20PM PLT SMR-NORMAL PLT COUNT-185
CXR:
FINDINGS:
The cardiomediastinal silhouette is accentuated due to AP
technique, likely
stable. New since prior exam is mild pulmonary edema. Left
upper lobe
opacities were better evaluated on prior CT chest from ___. There is
no new superimposed focal lung consolidation. There is no
pneumothorax or
sizable pleural effusion. Surgical clips overlie the left upper
thorax, as on
prior exam. Irregularity of the left upper ribs is unchanged.
IMPRESSION:
1. New mild pulmonary edema.
2. Left upper lobe opacities are re- demonstrated, better
evaluated on prior
CT chest from ___.
EGD:
Impression:Normal mucosa in the whole esophagus
Small hiatal hernia
Angioectasia in the stomach body (thermal therapy)
Small intestine was examined to jejeunum.
Normal mucosa in the to jejeunum
Otherwise normal EGD to jejeunum
Capsule endoscopy: negative
Brief Hospital Course:
Mr. ___ is an ___ yo M with ___ s/p RFA LUL, COPD on 2L 02,
___, severe AS s/p TAVR, ___ syndrome with frequent GI bleeds
requiring transfusional support, CKD III, presents with acute on
chronic dyspnea found to have profound anemia likely to due to
GI bleeding, as well as acute on chronic diastolic CHF
exacerbation.
Acute blood loss anemia due to
Presumed GI bleed
___ syndrome with h/o AVMs
Chronic multifactorial anemia
Patient with known AVMs and bleeding from this. Recent EGD with
enteroscopy without clear source. Colonoscopy with
diverticulosis and polyps. His bleeding was upper given
presumed melena without hematochezia, likely due to AVM. No abd
pain to suggest ulcer or gastritis. Presentation subacute.
Part of his dyspnea is likely related to this. No signs for
hemolysis. He has CKD as well which is likely contributing to
underproduction. EGD ___ with angioectasia, cauterized, but no
active bleeding. Capsule endoscopy performed and no clear
bleeding. He required 4 units of blood and he stabilized. He
was otherwise continued on his home medications. As his
bleeding is due to AVMs and likely to happen, GI recommend close
OP CBC monitoring and repeat capsule endoscopy should he rebleed
Hypoxemia due to
Acute on chronic diastolic CHF with severe AS/TAVR
OSA with pulm HTN
COPD chronic
Patient had subjective subacute dyspnea partially related to
anemia above, and partially due to CHF exacerbation based on
CXR. His dry weight is unclear, though recently he was
discharged with wt of 89kg. His lungs did not suggest COPD
exacerbation. EKG was non-ischemic and he had no chest pain.
He does not use CPAP reliably and he does desat at night. His
recent echo is reassuring in terms of valve function. However,
he has several chronic conditions that can contribute to his
hypoxemia: COPD, CHF, pulm HTN/OSA, SCC. He was discharged with
Lasix 40mg IV BID for several days with improvement in his CXR
and symptoms. His DC weight was 89kg. He was transitioned back
to his home Lasix dose.
Primary HTN:
Continued metoprolol and amlodipine
CKD III: Cr initially at recent baseline but rose with diuresis,
which returned to baseline prior to DC. Close Cr monitoring is
recommended on follow up
SCC: stable
Gout: allopurinol
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Allopurinol ___ mg PO DAILY
3. Amlodipine 2.5 mg PO DAILY
4. Atorvastatin 40 mg PO QPM
5. Docusate Sodium 100 mg PO BID
6. Famotidine 20 mg PO DAILY
7. Fluticasone Propionate NASAL 2 SPRY NU DAILY
8. FoLIC Acid 1 mg PO DAILY
9. Ipratropium-Albuterol Neb 1 NEB NEB TID SOB, wheeze
10. Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY
11. Metoprolol Succinate XL 50 mg PO NOON
12. Multivitamins W/minerals 1 TAB PO DAILY
13. Polyethylene Glycol 17 g PO DAILY constipation
14. Senna 8.6 mg PO DAILY
15. Simethicone 40-80 mg PO QID:PRN cramping
16. Tamsulosin 0.4 mg PO QHS
17. Vitamin D 1000 UNIT PO DAILY
18. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN SOB/wheezing
19. Albuterol Inhaler ___ PUFF IH Q4H:PRN Wheeze
20. Cyanocobalamin 1000 mcg PO DAILY
21. darbepoetin alfa in polysorbat 60 mcg/mL injection 1X/WEEK
22. Ferrous Sulfate 325 mg PO DAILY
23. Furosemide 60 mg PO DAILY
24. polyvinyl alcohol 1.4 % ophthalmic Q4H:PRN
Discharge Medications:
1. Furosemide 60 mg PO DAILY
2. Acetaminophen 650 mg PO Q6H:PRN pain
3. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN SOB/wheezing
4. Albuterol Inhaler ___ PUFF IH Q4H:PRN Wheeze
5. Allopurinol ___ mg PO DAILY
6. Amlodipine 2.5 mg PO DAILY
7. Atorvastatin 40 mg PO QPM
8. Cyanocobalamin 1000 mcg PO DAILY
9. darbepoetin alfa in polysorbat 60 mcg/mL injection 1X/WEEK
10. Docusate Sodium 100 mg PO BID
11. Famotidine 20 mg PO DAILY
12. Ferrous Sulfate 325 mg PO DAILY
13. Fluticasone Propionate NASAL 2 SPRY NU DAILY
14. FoLIC Acid 1 mg PO DAILY
15. Ipratropium-Albuterol Neb 1 NEB NEB TID SOB, wheeze
16. Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY
17. Metoprolol Succinate XL 50 mg PO NOON
18. Multivitamins W/minerals 1 TAB PO DAILY
19. Polyethylene Glycol 17 g PO DAILY constipation
20. polyvinyl alcohol 1.4 % ophthalmic Q4H:PRN
21. Senna 8.6 mg PO DAILY
22. Simethicone 40-80 mg PO QID:PRN cramping
23. Tamsulosin 0.4 mg PO QHS
24. Vitamin D 1000 UNIT PO DAILY
25.Outpatient Lab Work
Please have your CBC, complete blood count, checked on ___ at
PCP follow up, and ___ times monthly thereafter
Discharge Disposition:
Home With Service
Facility:
___
___:
Acute blood loss anemia/GI bleeding due to AVMs
Acute on chronic diastolic CHF
COPD
OSA
CKD III
Primary HTN
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs. Discharge weight 89kg
You were admitted with shortness of breath and fatigue caused by
a recurrent GI bleed. you required blood transfusion,
endoscopy, and capsule endoscopy. No clear bleeding site was
found and your bleeding was likely due to recurrent small
bleeding vessels. Please follow up closely with your doctors
for ___. We recommend frequent monitoring of your
blood counts.
You were also in heart failure and improved with diuretic.
Please continue your home regimen and follow up with your
cardiologist for ongoing care
Followup Instructions:
___
|
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